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Noninvasive Assessment of Airway Alterations in Smokers

The Small Airways Revisited

Respiratory Division, Academic Hospital, Vrije Universiteit Brussel; and Biomedical Physics Laboratory, Université Libre de Bruxelles, Brussels, Belgium

Correspondence and requests for reprints should be addressed to Sylvia Verbanck, AZ-VUB, Consultatie Pneumologie, Laarbeeklaan 101, 1090 Brussels, Belgium. E-mail: sylvia.verbanck{at}az.vub.ac.be

It has been shown that structural changes in small airways of smokers with average smoking histories greater than 35 pack-years could be reflected in the single-breath washout test. The more sophisticated multiple breath washout test (MBW) has the potential to anatomically locate the affected small airways in acinar and conductive lung zones through increased phase III slope indices S_acin and S_cond, respectively. Pulmonary function, S_acin, and S_cond were obtained in 63 normal never-smokers and in 169 smokers classified according to smoking history (< 10 pack-years; 10–20 pack-years; 20–30 pack-years; > 30 pack-years). Compared with never-smokers, significant changes in S_acin (p = 0.02), S_cond (p < 0.001), and diffusing capacity (DL_CO; p < 0.001) were detected from greater than 10 pack-years onwards. Spirometric abnormality was significant only from greater than 20 pack-years onwards. In smokers with greater than 30 pack-years and DL_CO less than 60% predicted, the presence of emphysema resulted in disproportionally larger S_acin than S_cond increases. We conclude that S_cond and S_acin can noninvasively detect airway changes from as early as 10 pack-years onwards, locating the earliest manifestations of smoking-induced small airways alterations around the acinar entrance. In these early stages, the associated DL_CO decrease may be a reflection of ventilation heterogeneity rather than true parenchymal destruction. In more advanced stages of smoking-induced lung disease, differential patterns of S_acin and S_cond are characteristic of the presence of parenchymal destruction in addition to peripheral airways alterations.

Key Words: lung periphery • multiple-breath washout • phase III slope • ventilation distribution

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