Perception of Bronchoconstriction in
Mehmet Ekici, M.D.,1Alpaslan Apan, M.D.,2
Aydanur Ekici, M.D.,3and A. Kemal Erdemog ˘lu, M.D.4
Departments of1Chest Diseases,2Anaesthesiology, and4Neurology,
Faculty of Medicine, Kigri igkkale University, Kiri i
3Department of Chest Diseases, Kigri igkkale State Hospital, Kiri i
The impaired perception of bronchoconstriction in asthmatic patients may
increase the risk of severe exacerbation. To characterize the perception of
bronchoconstriction in elderly asthma patients, we compared the perception
in older patients with that of younger patients. To determine the influence of
perception of long-standing diseases, we further evaluated the perception in
early-onset elderly asthma patients and in late-onset elderly asthma patients.
The study group consisted of 80 stable asthmatic patients. The patients were
grouped according to their age (group 1, <60 years, n¼37; group 2, ?60
years, n¼43). Each group was separated into two subgroups according to the
duration of symptoms (late-onset asthma 1A and 2A, <5 years, early-onset
asthma 1B and 2B, ?5 years). A histamine inhalation test was performed for
each patient. Dyspnea was assessed by modified Borg scale. The Borg score in
forced expiratory volume in 1sec (FEV1) reduction by 20% was determined as
perception score 20 (PS20). The mean perception scores of the elderly asthmatic
patients were significantly lower than those of the younger asthmatic patients
(group 1, PS20¼2.35?0.17; group 2, PS20¼1.37?0.12; p<0.0001). The
differences of mean perception score (PS20) between early- and late-onset
subgroups were insignificant (1A, 2.63?0.30 and IB, 2.07?0.16; p¼0.101;
2A, 1.36?0.19 and 2B, 1.59?0.120; p¼0.91). The mean perception
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Journal of Asthma, 38(8), 691–696 (2001)
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scores of male asthmatic patients were significantly lower than those of female
patients (p¼0.03). There was a correlation between PS20 and %FEV1 in
the younger group (r¼0.392, p¼0.02), but not in the elderly group (r¼139,
p¼0.375). The correlation between PS20 and PD20 in both younger and
elderly group was insignificant (p>0.05). Elderly asthmatics perceive less
intense respiratory distress for a decrease of 20% in FEV1than do younger
asthmatics. This underperception of bronchoconstriction may result in a
delay in medical care during an acute asthmatic episode. Thus, we strongly
recommend that elderly asthmatic patients should be followed up more frequently
KEY WORDS: Asthma;Borg scale;
Asthma is common in old age and carries signifi-
cant morbidity and mortality (1,2). Incontrovertible
evidence exists that there is a progressive and strik-
ingly increased mortality from bronchial asthma (3).
This increased mortality has primarily affected the
group over age 65 years (4). In the elderly asthmatic
patients, the diagnostic evaluation is usually limited
and substantial variation in the diagnosis and man-
agement of asthma is demonstrated (5). Elderly
asthmatics complain less than younger asthmatics
with the same degree of bronchoconstriction (6).
The elderly asthmatics have less marked tachycardia
and pulsus paradoxus compared to the younger
patients for similar degrees of airways obstruction
and arterial blood gas abnormalities during acute
exacerbation of asthma. Assessment confined to
physical examination would, therefore, lead to
underestimation of the severity of their asthma (7).
Because asthma in the elderly may cause obstructive
ventilatory dysfunction in the stable state, respira-
tory failure might easily develop, even during
mild attacks (8). Asthma in the elderly remains
optimally treated (9,10). To the authors’ knowledge,
there are no studies in the literature investigating
whether the perception of bronchoconstriction in
elderly asthmatic patients with late-onset disease
differs from that of elderly patients with early-onset
The aim of the present study was to compare
awareness of acute bronchoconstriction provoked
by inhaled histamine in elderly and young asth-
matics, as well as in early- and late-onset asthmatic
subgroups in the elderly group.
The present study included 80 asthmatic patients
who were followed in the Respiratory Disease Clinics
of both K|r|kkale State Hospital and K|r|kkale
University Hospital. Patients were consecutively
recruited during an 8-month period. Asthma diagno-
sis was made according to the American Thoracic
Society criteria (11). Patients consisted of 65 women
and 15 men and mean age was 53.8?1.6 years. All
patients were nonsmokers or ex-smokers (for more
than 24 months, with less than 5 pack-years). The
following conditions were taken as exclusion criteria:
cardiac disorder, cognitive impairment, treatment
with systemic corticosteroids, or respiratory tract
infection in the previous 4 weeks. All patients used
inhaled b2-agonist and 69 patients used inhaled ste-
roid. Detailed physical examination and spirometric
measurements were obtained from each patient. The
symptom score of asthma was determined for each
Patients were divided into two groups according
to their age: those<60 years old were placed in
group 1; those ?60 years old constituted group 2.
Each group was further divided into two subgroups
according to their symptoms period: group A had
symptoms <5 years and group B had symptoms
for ?5 years.
A histamine (H) inhalation test was performed
on patients to determine the level of bronchial
hyperreactivity. Prior to testing, inhaled and oral
bronchodilators were withheld for at least 12hr.
Corticosteroids were not withheld. Histamine solu-
tion (Sigma, Diesenhofen, Germany) was prepared in
sterile isotonic saline. H challenge test was perform-
ed according to the standardized procedure (12).
692Ekici et al.
Pulmonary function was measured by a flow-sensing
spirometer connected to a computer for data analy-
sis (Jeager, Wuerzburg, Germany). Each subject
inhaled doubling increasing concentrations of H
(0.03–16mg/mL), nebulized by a dosimeter with an
output of 9?0.3mL/puff (Dosimeter APS Pro,
Jeager), until forced expiratory volume in1sec(FEV1)
was reduced by 20% from baseline values. Bron-
chial response to H was expressed as the provoca-
tive dose causing a 20% decrease in FEV1(PD20in
mg/mL), and was calculated using the same compu-
ter program (LAB, version 4.3, Jeager).
During the H test, intensity of breathlessness was
estimated before each FEV1 measurement with a
modified Borg scale labeled from 0 (no symptom)
to 10 (maximum bearable). Patients were asked to
select the appropriate definition at the time of the
test to determine their breathlessness. Patients were
completely free to decide their own self-scores.
Patients were cautioned to determine only their
breathlessness and to disregard any irritation of the
nose or throat during the scoring. The perception
score corresponding to a decrease in FEV1by 20%
(PS20) was calculated by linear interpolation of the
last two points on the perception/decrease in the
FEV1curve of the H challenge test (13).
The independent samples t-test was used to com-
pare the clinical parameters (PS20, PD20, gender,
and FEV1as the percent of predicted) on subgroups
and groups of young and elderly asthmatic patients.
Pearson correlation analysis was used to evaluate
the relationship among PS20, FEV1, and PD20 on
subgroups of young and elderly asthmatic patients.
A p value <0.05 was considered to be significant.
Demographic and spirometric data from patients
are presented in Table 1.
The mean perception scores of elderly asthmatic
patients were significantly lower than those of
the younger asthmatic patients (group 1, PS20¼
According to the age groups, the difference of
mean perception scores (PS20) between early- and
late-onset subgroups was insignificant (group 1A,
2.63?0.29, and group 1B, 2.07?0.16; p¼0.101;
group 2A, 1.36?0.19, and group 2B, 1.39?0.12,
p¼0.907) (Fig. 1).
The mean perception scores of male asthmatic
patients were significantly lower than those of
female patients (male PS20, 1.31?0.13, n¼15;
female PS20, 1.94?0.13, n¼65; p¼0.030). There
was correlation between PS20and %FEV1(r¼0.39,
p¼0.017) in the younger group (Fig. 2), but not in
the elderly group (r¼139, p¼0.375) (Fig. 3).
The correlation between PS20 and PD20 in
both younger and elderly groups was insignificant
(group 1, r¼?0.072, p¼0.671; group 2, r¼0.083,
n¼37;group 2, PS20¼1.37?0.12,
In our study, elderly asthmatics perceived less
breathlessness for a decrease of 20% in FEV1than
did younger asthmatics. In a review of the liter-
ature, there is no sufficient investigation about
Clinical Features of the Patients
Group 1 ( <60 year)Group 2 (?60 year)
Duration of symptom, (year)
The results are presented as mean±standard error.
Bronchoconstriction in Elderly Asthmatics 693
perception of acute bronchoconstriction in elderly
asthmatic patients. Connolly et al. (14) found that
elderly asthmatic patients were less aware of acute
bronchoconstriction than were young asthmatic
patients. Marks et al. (15), using three different ago-
nists to induce bronchoconstriction, reached the
same conclusion in comparing young and elderly
asthmatics. Weiner et al. (6) reported that elderly
asthmatics complained less than younger asthmatics
for the same degree of bronchoconstriction. The
perception of dyspnea is impaired in the elderly, a
fact that may be related to the higher rate of mor-
tality from asthma among elderly patients than
among those who are younger (16). The perceptual
sensitivity of inspiratory and expiratory resistive
loads is less in the elderly than in the younger
patients. Thus, the decreasing exponent for estima-
tion of the magnitude of respiratory loads may be
caused by age-related changes on the integration of
sensory inputs within the central nervous system
(17). The impairment in perception may be more
central, and there is some evidence for impairment
in central processing with age (18). In a prospective
study in which the study group was mainly younger
than 60 years, it was demonstrated that 15% of the
patients were unable to sense the presence of
marked airways obstruction (FEV1 less than 50%
of the predicted normal value) and the results
did not differ by age (19). In a study conducted by
Bijl-Hofland et al. (20), where the subjects were
aged between 16 and 60 years, authors did not
find any influence of age on the degree of percep-
tiveness in patients. A possible reason for the differ-
ent results is the chosen age distribution in the
We classified the patients into two groups as
early- and late-onset and the perception was not
found to be different between groups. In the litera-
ture, we did not find any studies investigating the
between late- and early-onset asthma in the elderly.
There was no relation described between awareness
Figure 1. The mean of PS20and subgroups.
percent predicted in the younger group.
The relationship between PS20 and FEV1 as
percent predicted in the elderly group.
The relationship between PS20 and FEV1 as
694 Ekici et al.
scores and duration of asthma in either asthmatic
patients overall or in the elderly or young asthmatic
patients (10). In addition, it was found that both
long-standing elderly asthmatics and recent-onset
elderly asthmatics were indistinguishable by symp-
toms and medication requirements (21,22). In con-
trast to these studies, Weiner et al. reported that
older patients with long-standing disease com-
plained less frequently than older patients with a
recent-onset disease. Patients with prolonged and
more consistent airflow obstruction usually adapt to
the sensation of dyspnea (6). The present study
demonstrates that age itself in elderly asthmatics is
an important factor for impaired perception, but
not the chronicity of the disease.
We observed, like Janson-Bjerklie et al. (23) and
Brand et al. (24) but in contrast to Quirk et al. (25)
and Rubinfeld et al. (19), that females reported
greater dyspnea than males.
Although an important correlation was found
between perception score with FEV1in the younger
group, no correlation was observed for the elderly
group. In addition, the present study failed to show
any correlation between H dose and perception score
on both groups. Bijl-Hofland et al. (20) and Burdon
et al. (26) demonstrated that the perception of
breathlessness during bronchoconstriction is corre-
lated with FEV1 and PC20. It was also concluded
that temporal adaptation may only be relevant in the
age range 16–60 years, and the impaired perception
in older patients may be caused by many other para-
meters (20). Other studies indicated that broncho-
constriction is less well perceived by patients with
severe asthma as compared to patients with mild
asthma (27,28). Turcotte et al. (29) found that
poorly perceived late asthmatic responses are due to
the temporal adaptation to the slow and progressive
Boulet et al. (13) showed that hypoperceivers or
hyperperceivers in a hyperreactive population were
similar for age, sex, baseline FEV1, and PC20.
The majority of studies described above, which were
performed mainly on younger subjects, indicated
bronchoconstriction. Results in the younger asth-
matic group were partly consistent with the present
study. Thus, FEV1was a predictor of perception of
bronchoconstriction in the younger asthmatic group
in our study.
The perception of bronchoconstriction was mainly
influenced by age, but not by duration of disease
in the elderly asthmatics. The severity of acute
bronchoconstriction in elderly patients may not be
realized because of impaired perception. This can
increase the risk of severe asthmatic attack and
therefore it may delay the appropriate therapy.
Elderly patients have to be followed more carefully
than their younger counterparts. They should be
educated for self-management and should be moni-
tored at home with a peak flow meter. We conclude
that these are the most appropriate precautions.
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a Random Population
696Ekici et al.
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