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over a six month treatment prograrnme, with no colTesponding reduction in those on disodium
cromoglycate (Rytila, Pelkonen et al. 2004). In the 'Childhood Asthma Management
Program' (CAMP) study, IHCS treated patients had a lower sputum percentage of eosinophils
at 0.2Vo versus 0.87o than those treated with nedocromil sodium or placebo. In repeated
sputum inductions during reduction of medication, sputum eosinophil counts predicted an
exacerbation (Covar, Spahn et al. 2004).
1.6.4 (iii) Technical aspects of bronchoscopy, bronchial biopsy, bronchoalveolar lavage
and/or induced sputum
Despite the increasing ability to sample from the lung with the use of bronchoscopy, airway
biopsy, BAL and induced sputum, there remain questions over the success, reproducibility
and the safety of these techniques. To start with, there is significant variability both within
and between biopsy samples even when taken from one individual @ichmond, Booth et al.
1996; Sont, Willems et al. 1997; Jeffery, Laitinen et al. 2000). The parameters from biopsy
measurements are less reproducible than physiological tests, with even diurnal variation in
number and function of inflammatory cells @oulter, Burke et al. 2000). Biopsy specimens are
also likely to be taken from quite different sites, from both proximal and distal airways, which
may not be comparable @alzar, Wenzel et al. 2N2; Boulet 2N2; James and Carroll 2002).
BAL variability was investigated by doing 180 procedures in 2O clinically stable but
symptomatic asthmatic adults. The standard deviation for total cell counts was 78 X 103
cells/ml and for macrophages was 16%o,lymphocytes was l3%o and eosinophils 17o (Ward,
Gardiner et al. 1995; Ruffin 1996). The lavage profile seen in asthma, has also been seen in
allergic rhinitis (Gutierrez, Prieto et al. 1998; Alvarez, Olaguibel et al. 2000; Polosa, Ciamarra
et al. 2000; Boulay and Boulet 200.2; Beeh, Beier et al. 2O03; Wilson, Duong et al. 2005;
Bonay, Neukirch et al. 2006; Hara, Fujimura et al. 2006) and in subjects with atopic
dermatitis (Kyllonen, Malmberg et al. 2006).
The initial success rate of hypertonic saline in obtaining samples in adults was 757o (Pin,
Gibson et al. 1992; Foresi, Irone et al. L997; Hashimoto, Minoguchi et al. 1999) but
improved to 83Vo to 93Vo with refinement of the procedure (Vlachos-Mayer, Irigh et al.
2000; Bartoli, Bacci et al.2OO4). The success of sputum induction in children has been given
as 60 to 74Vo in controls (Wilson N M 2000) and 6IVo to 94Vo in asthmatics (Norzila, Fakes et
al. 2000; Wilson, Bridge et al. 2000; Li, I-ex et al. 2003; Covar, Spahn et al.2004; Rytila,
Pelkonen et al. 2OO4; I-ex, Payne et al. 2005). It is more successful in acute than chronic
asthma (Norzila, Fakes et al. 2000; Rytila, Pelkonen et al.2004) and more successful in the
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