Airway response to emotional stimuli in asthma: the role of the cholinergic pathway

Thomas Ritz, Antje Kullowatz, Michael D. Goldman, Hans-Jrgen Smith, Frank Kanniess, Bernhard Dahme and Helgo Magnussen
J Appl Physiol 108:1542-1549, 2010. First published 1 April 2010; doi:10.1152/japplphysiol.00818.2009 You might find this additional info useful... Supplemental material for this article can be found at: http://jap.physiology.org/content/suppl/2010/05/17/japplphysiol.00818.2009.DC1.html This article cites 55 articles, 20 of which can be accessed free at: http://jap.physiology.org/content/108/6/1542.full.html#ref-list-1 This article has been cited by 4 other HighWire hosted articles Stress-Induced Respiratory Pattern Changes in Asthma Thomas Ritz, Erica Simon and Ana F. Trueba Psychosom Med, July , 2011; 73 (6): 514-521. [Abstract] [Full Text] [PDF]
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Asthma nervosa: old concept, new insights J. Douwes, C. Brooks and N. Pearce Eur Respir J, May , 2011; 37 (5): 986-990. [Full Text] [PDF] Treatment adherence and psychosocial factors in severe asthma J.M. Foster, K.L. Lavoie and L-P. Boulet Difficult-to-Treat Severe Asthma, April 5, 2011; 28-49. [Abstract] Acute Stress-induced Increases in Exhaled Nitric Oxide in Asthma and Their Association with Endogenous Cortisol Thomas Ritz, Erica S. Ayala, Ana F. Trueba, Charles D. Vance and Richard J. Auchus AJRCCM, December 30, 2010; 183 (1): 26-30. [Abstract] [Full Text] [PDF] Updated information and services including high resolution figures, can be found at: http://jap.physiology.org/content/108/6/1542.full.html Additional material and information about Journal of Applied Physiology can be found at: http://www.the-aps.org/publications/jappl

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J Appl Physiol 108: 15421549, 2010. First published April 1, 2010; doi:10.1152/japplphysiol.00818.2009.

Airway response to emotional stimuli in asthma: the role of the cholinergic pathway
Thomas Ritz,1 Antje Kullowatz,1 Michael D. Goldman,2, Hans-Jrgen Smith,3 Frank Kanniess,4 Bernhard Dahme,1 and Helgo Magnussen4
Department of Psychology, University of Hamburg, Hamburg, Germany; 2Department of Electrical and Computer Engineering, University of Texas at El Paso, El Paso, Texas; 3CareFusion, Hchberg, Germany; and 4Pulmonary Research Institute at Hospital Grosshansdorf, Center for Pneumology and Thoracic Surgery, Grosshansdorf, Germany
Submitted 27 July 2009; accepted in nal form 29 March 2010
1

Ritz T, Kullowatz A, Goldman MD, Smith H, Kanniess F, Dahme B, Magnussen H. Airway response to emotional stimuli in asthma: the role of the cholinergic pathway. J Appl Physiol 108: 15421549, 2010. First published April 1, 2010; doi:10.1152/japplphysiol.00818.2009.In asthma, airways constrict in response to emotion and stress, but underlying mechanisms, potential extrathoracic contributions, and associations with airway pathophysiology have not been elucidated. We therefore investigated the role of the cholinergic pathway in emotion-induced airway responses in patients with asthma and the association of these responses with airway pathophysiology. Patients with asthma (n 54) and healthy participants (n 25) received either 40 g ipratropium bromide or a placebo in a double-blind doubledummy cross-over design in two laboratory sessions with experimental emotion induction. Stimuli were preevaluated lms and pictures of pleasant, unpleasant, and neutral quality. Respiratory resistance and reactance at 5 and 20 Hz were measured continuously before and during presentations, together with respiration by impedance plethysmography and end-tidal PCO2 by capnometry. In addition, measures of airway inammation (fraction of exhaled nitric oxide), airway hyperreactivity (methacholine challenge), and reversibility of obstruction were obtained. Respiratory resistance at 5 and 20 Hz increased during unpleasant stimuli in asthma patients. This response was blocked by ipratropium bromide and was not substantially associated with asthma severity, airway inammation, hyperreactivity and reversibility, or pattern of ventilation and PCO2. Under the placebo condition, changes in resistance during unpleasant lms were positively correlated with patients reports of psychological asthma triggers. In conclusion, airway constriction to unpleasant stimuli in asthma depends on an intact cholinergic pathway, is largely due to the central airways, and is not substantially associated with other indicators of airway pathology. Its link to the perceived psychological triggers in patients daily lives suggests a physiological basis for emotion-induced asthma. respiratory resistance; emotion; airway hyperreactivity
THE ROLE OF PSYCHOSOCIAL FACTORS in patients with bronchial asthma has been studied extensively, with substantial evidence demonstrating effects on the management of this chronic disease (27, 33, 59). However, the relationship between psychosocial stimuli and the regulation of airway tone is not fully understood. Some studies that used diary-assessment techniques have shown an association between impairment of lung function change or asthma exacerbations and mood states or life events (45, 49). Experimental studies that used emotion induction techniques have suggested a uniform tendency of the airways to constrict during unpleasant stimulation (22, 31, 40,

Deceased March 18, 2010. Address for reprint requests and other correspondence: T. Ritz, Dept. of Psychology, Southern Methodist Univ., PO Box 750442, Dallas, TX 752750442 (e-mail: tritz@smu.edu). 1542

42, 47, 55). However, little is known about the mechanisms underlying emotion-induced airway constriction. Cholinergic effects on muscarinic receptors by vagal motor activity are known to be the major autonomic pathways of bronchoconstriction (3, 9). Early research exploring effects of psychological factors on the airways used the paradigm of bronchoconstrictive suggestion, in which participants inhale an inert substance that is presented as a bronchoconstrictive agent (22). Typically, this paradigm induced bronchoconstriction, which was shown to be abolished by atropine (34), but the extent to which this experimental paradigm informs about emotional processes has remained unclear (7). Exploration of autonomic pathways that mediate emotion-induced bronchoconstriction is also important because such bronchoconstrictions constitute an important paradox (1, 53). Stronger negative emotions such as fear and anger are typically accompanied by a ght-ight pattern with sympathetic activation. Consequently, bronchodilation would be expected if these adrenergic effects predominate in the airways. However, experimental studies using negative emotion induction have so far mostly shown bronchoconstriction (22, 31, 40, 42), which supports clinical and patients reports of emotion-induced asthma symptoms (e.g., Refs. 38, 39, 46). Studies demonstrating respiratory system resistance (Rrs) increases to emotional stimuli have so far not addressed the question of localization of airway constriction. Most importantly, because Rrs is measured with the use of traditional forced oscillation methods for the whole respiratory tract, narrowing of the extrathoracic airways could signicantly contribute to the observed Rrs increases, thus possibly reducing the signicance of ndings for asthmatic bronchoconstriction. However, the use of anticholinergic bronchodilators, such as ipratropium bromide, which block muscarinic receptors in the bronchi (8, 51), could demonstrate the importance of extrathoracic vs. intrathoracic central airway constriction in emotion induction. Because laryngeal constriction relies on nicotinic transmission (57), it would not be affected by blockade with ipratropium. Thus, if emotion-induced airway constriction persisted after blockade by ipratropium, this would be more supportive of a constriction in the extrathoracic airways (such as the larynx), or, alternatively, it would support the notion of peripheral airway constriction. We obtained additional information on the role of the peripheral vs. central airway obstruction in this study by using impulse oscillometry (52), which allows limited inferences on central vs. peripheral airway contributions to any observed resistance change by interpreting the frequency dependence of resistance (18) and the parameters derived from low-frequency reactance.
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In the present study, we explored the effects of experimental emotion induction on Rrs and respiratory system reactance (Xrs) in patients with asthma and in nonasthmatic individuals. We compared the effects of ipratropium bromide with placebo to explore the dependency of Rrs increases on an intact cholinergic pathway. We also investigated whether emotioninduced airway responses are an independent aspect of airway reactivity that would justify adding experimental emotion induction to the variety of direct and indirect airway challenge methods (13, 24). For that, observed airway responses should not be epiphenomena of pathophysiological processes at the organ level, such as nonspecic airway hyperreactivity, reversibility of airway obstruction, or airway inammation, and should not reect respiratory changes that are known to occur in emotion (6, 12, 28). For example, hyperventilation is known to lead to bronchoconstriction in asthma (51), and it has been suspected of being a major mechanism in stress-induced asthma (12, 43). On the other hand, deep breaths can dilate the airways in healthy patients and in patients with milder forms of asthma (50). Experimental studies have been equivocal with regard to ventilatory contributions (47, 48) and the role of nonspecic hyperreactivity to psychologically induced airway constriction (21, 30). No research has explored associations with reversibility and inammatory markers to date.
METHODS

Participants Participants were recruited from the Pulmonary Research Institute at the Hospital Grosshansdorf (Grosshansdorf, Germany) and by advertisements at the University of Hamburg. Inclusion criteria were a diagnosis of asthma (or no lung disease in healthy controls), nonsmoker for at least 6 mo ( 10 life-time pack-years), and current stable mental and physical health. Excluded were individuals who had used oral corticosteroids in the previous 3 mo. This study was approved by our local ethics committees, and participants gave informed consent. Diagnostic evaluations by a pulmonologist included asthma history, physical examination, lung function assessment, methacholine testing, exhaled nitric oxide, and allergy skin testing. Asthma severity was then rated according to relevant guidelines (36). Patients were instructed to stay on a stable dose of their asthma medication during the study. Before each assessment, short-acting bronchodilators were to be discontinued for 6 h, long-acting -agonists for 12 h, and leukotriene inhibitors for 3 days. Inhaled corticosteroids were continued as prescribed if not combined with long-acting -agonists. Mental health was explored by a clinically trained psychologist who used a structured interview (58). Participants with episodes of major depression, high likelihood of suicide, schizophrenia, or substance abuse were excluded. Measurements Impulse oscillometry (IOS MasterScreen, Jaeger/CareFusion) was used to measure Rrs and Xrs and tabulated Rrs at 5 and 20 Hz (Rrs5, Rrs20) and Xrs at 5 and 20 Hz (Xrs5, Xrs20) in an attempt to discriminate between central vs. peripheral resistance (and elastic properties) of the respiratory system. Xrs in the low-frequency range reects elastic properties and primarily peripheral rather than central airway properties, whereas Xrs in the high-frequency range reects primarily the effects of inertial forces in the central airways (52). We also tabulated the integrated low-frequency reactance area (AX), which may be less inuenced by methodological noise than individual values of low-frequency Xrs (16, 17), as well as changes in resonance frequency (fres). In addition, to help distinguish changes in
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the central vs. peripheral airways, we included Rrs5-Rrs20 as a measure of frequency dependence of resistance (15, 18). The impulse oscillometry pneumotachograph was calibrated daily with a 3-liter syringe, after which measurements were taken with a standard reference impedance to ensure stability of pressure channel gain. Chin straps with attached padding to stabilize cheeks were used during the recordings to reduce upper airway shunt. The device had been customized by the manufacturer to accommodate continuous measurements for the maximum duration of stimulus presentation trials in this study (390 s). Artifacts due to swallowing were manually excluded from the analyzed recordings. We performed spirometry (forced expiratory volume in the rst second) using the pneumotachograph, and our test results were compared with patients percent predicted values. The methacholine inhalation test was administered according to a standard protocol (25). Tidal volume (VT) and respiration rate (RR) were measured using a respiratory inductance plethysmograph (LifeShirt System, Vivometrics, Ventura, CA) calibrated with a xed-volume breathing bag of 800 ml. VT and RR measurements failed in one patient due to technical difculties. The end-tidal PCO2 was measured continuously with a side-stream capnometer (Capnocount, Weinmann, Mannheim, Germany). The sampling tube was connected to the impulse oscillometry mouthpiece. This measure was only available for parts of the sample (n 34 patients and n 14 controls). We determined airway inammation by the fraction of exhaled nitric oxide (FeNO, in ppb), using a chemiluminescence analyzer (NIOX; Aerocrine, Solna, Sweden) at the beginning of each session and following relevant guidelines (2). The average of nine consecutive valid breaths was used in the analysis. Physical symptoms (shortness of breath, chest tightness, dizziness, light-headedness, nausea, heart pounding, and weariness) were rated on an 11-point scale (0 10) anchored with not at all and quite strong. For emotional dimensions of unpleasantness-pleasantness and calmness-arousal, nine-point (0 8) bipolar pictorial rating scales were used (20). Ratings of symptoms were incomplete for 1 control participant, and ratings of emotion were incomplete for four patients and three control participants. Before the session, asthma patients also completed a questionnaire on frequency of perceived asthma triggers (Asthma Trigger Inventory) (44, 46), with subscales for psychological triggers, allergens, physical activity, air pollution/irritants, and infection. Experimental Stimuli Participants viewed emotional stimulation material that had been successfully used in previous experimental studies. These materials included two parallel sets of affective picture blocks (9 pictures per block, each shown for 20 s) and preevaluated emotion-evoking lm sequences of a pleasant, neutral, or an unpleasant emotional quality (length of 35 min each) (19, 47). Pictures were selected from the International Affective Picture System (10). (See supplemental data for reference number of pictures. Supplemental data are available in the online version of this article.) Film sequences were extracted from commercially available movies, medical education materials, and archive materials of the University of Hamburg. The following lm sequences were presented: for pleasant, British comedian I and British comedian II; for neutral, screensaver and preparation of a room for a presentation; for unpleasant, hip graft surgery and open heart surgery. The stimulus material was projected onto a screen ( 1.5 1.8 m). The order of lm vs. picture block presentation was counterbalanced in both groups, and the order of individual lms and pictures was randomized within and between sessions across participants. By using two emotion-induction techniques, we sought to control for potential emotion-nonspecic, methodological effects of the induction method.
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Table 1. Basic demographics and lung function for asthma patients and healthy controls
Asthma Patients Healthy Volunteers

Sex, % female Age, years Education, % Abitur Family status, % unmarried FEV1, % predicted Rrs5 change to ipratropium, % of baseline FeNO, ppb Methacholine test, % positive Skin prick test, % positive

64.0 27.5 6.8 86.5 71.2 99.8 13.7 24.0 18.6 49.9 34.1 75.9 98.1

64.8 28.0 6.2 87.0 78.3 107.2 11.0* 10.5 17.6 23.2 25.0 12.0 52.0

Values are means SD. FEV1, forced expiratory volume in the rst second; FeNO, fraction of exhaled nitric oxide; Rrs5, respiratory system resistance at 5 Hz. *P 0.05, P 0.01, P 0.001. German certicate of high school education, guarantees university access.

tions (unpleasant, neutral, pleasant), and two groups (asthma patients, healthy individuals) as independent variables were calculated with resistance, reactance, respiration, and rating scales as dependent variables. For all repeated-measures ANOVAs, Greenhouse-Geisser correction on dfs was performed to account for violations of the sphericity assumption. Partial eta squared ( p2) was used as a measure of effect size. A priori contrasts tested the hypothesis that increases in Rrs5 and Rrs20 were stronger during unpleasant than during neutral stimulations under placebo vs. ipratropium conditions. Additional post hoc comparisons of means were calculated using the NewmanKeuls procedure (P 0.05). For correlations, Spearmans rho was calculated. To estimate the potential clinical relevance of changes in Rrs, we compared results with typical thresholds for just noticeable differences, as found in prior added resistive load studies (14); criteria were 0.076 kPal 1s for asthma patients and 0.061 kPal 1s for controls.
RESULTS

Protocol Subsequent to a diagnostic intake visit, which included skin testing and methacholine challenge, two laboratory visits were scheduled within 3 8 days. Before each presentation protocol, initial impulse oscillometry measurements were taken, and participants were administered a dose of ipratropium bromide (Atrovent, two actuations of 20 g) or placebo delivered by dry powder inhalers under nurse supervision. Both the participants and the experimenter remained blind to the type of substance administered. After a 20-min rest period, a 90-s impulse oscillometry baseline period was recorded, which served to quantify reversibility of constriction [spirometry was not implemented at this point due to the known inuences of the forced expiratory maneuver on airway tone (41)]. Participants then viewed the stimulus material sitting upright in a light- and temperature-controlled room. Physiological measures were recorded continuously before (90 s) and during each presentation. Participants breathed ambient air through a mouthpiece connected to the impulse oscillometry measurement head with a small terminal resistor of 0.1 kPal 1s while their nose was occluded. Participants were instructed to breathe normally, keep their eyes open, and avoid excessive body movements. After each lm and picture block, participants rated their symptoms and emotion. Data Analysis Effects of ipratropium on prestimulation baseline were analyzed with the use of two-way ANOVA with two conditions (ipratropium vs. placebo) and two groups (asthma vs. control), with levels of resistance and reactance as dependent variables. To study effects of emotion induction under ipratropium vs. placebo conditions, difference scores of physiological parameters for each lm and picture block were calculated by subtracting the 90-s premeasurement periods. Four-way repeated-measures ANOVAs with two conditions (ipratropium vs. placebo), two methods (lm, pictures), three emo-

Baseline Sample Characteristics Eighty-two participants were invited to participate; three of these were excluded because of pregnancy (n 1), scheduling problems (n 1), or technical problems (n 1). Thus 79 participants (54 patients with asthma, 25 controls) were included in the nal analysis. In patients, asthma severity was rated as intermittent for 48.1%, mild persistent for 32.5%, and moderate persistent for 20.4%. Forced expiratory volume in the rst second at baseline was lower and the reversibility of Rrs5, the percentage of positive skin tests, and FeNO were higher in patients than in controls (Table 1). Common criteria for hyperresponsiveness in methacholine testing were met by 41 patients and 3 healthy controls. Both groups were equivalent in basic demographics, including age, sex, family status, and educational level. Asthma onset before the age of 17 years was reported by 76% of the patients, seasonal asthma symptoms by 50%, night-time symptoms at least twice monthly by 42.6%, and a family history of atopy by 64.8%. Inhaled corticosteroids were taken by 29.6% of the patients, short-acting bronchodilators by 37%, long-acting bronchodilators by 24.1%, cromoglycate by 20.4%, and other medication (leukotriene inhibitors, antihistaminics, theophylline) by 11.1%. One-third of the patients were not taking anti-asthmatic medication. There were no overall group differences in initial baseline measures (Table 2). Effects of Ipratropium on Prestimulation Baseline Rrs5, Rrs20, and fres were reduced by ipratropium in both groups. Reductions in Rrs5 and fres were particularly seen in the
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Table 2. Results and ANOVA effects (df 1,76) of preexperimental baseline values for Rrs, Xrs, AX, and fres under placebo and ipratropium conditions for asthma patients and healthy controls
Asthma Placebo Ipratropium Placebo Control Ipratropium F Condition
p 2

Group by Condition F
p 2

Rrs5 Rrs20 Xrs5 Xrs20 AX fres

0.448 0.300 0.106 0.104 0.405 10.2

0.18 0.11 0.15 0.06 0.93 4.0

0.366 0.257 0.081 0.122 0.214 9.1

0.12 0.09 0.06 0.06 0.38 2.9

0.416 0.317 0.080 0.104 0.201 9.6

0.12 0.12 0.05 0.08 0.29 3.0

0.383 0.297 0.081 0.112 0.235 9.7

0.11 0.12 0.04 0.07 0.43 4.4

22.17 17.48 1.08 8.53 1.15 4.04*

0.228 0.189 0.014 0.101 0.015 0.052

3.96* 2.24 1.21 0.95 2.68 6.40*

0.050 0.029 0.016 0.012 0.035 0.081

Values are means SD. Rrs20, Rrs at 20 Hz; Xrs5 and Xrs20, respiratory system reactance at 5 and 20 Hz, respectively; AX, reactance area; fres, resonance frequency; 2, partial eta squared. *P 0.05, P 0.01, P 0.001. p J Appl Physiol VOL
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Fig. 1. Changes in respiratory resistance (Rrs) at 5 Hz during emotional stimulation in asthma patients and in healthy controls (average of lm and picture methods).

asthma group. Xrs5 and AX were smaller in magnitude after ipratropium in asthma patients, but changes were not signicant. Effect of Emotion Induction on the Airways and Its Modulation by Ipratropium Bromide Group effects. Patients with asthma showed overall stronger increases in resistance across protocols of both sessions [group effects were F(1,77) 3.96 and 2.62, P 0.050 and 0.109, and p2 0.058 and 0.033, respectively, for Rrs5 and Rrs20, respectively]. Effect of emotion induction. Relatively uniform changes of resistance were observed across the frequency spectrum with emotion induction. Across all conditions and methods, unpleasant stimuli were associated with the strongest increases in resistance, with signicant emotion effects of F(2,154) 13.81 and 12.26, both P 0.001, 0.92 and 0.90, and p2 0.152 and 0.137 for Rrs5 and Rrs20, respectively. Effect of placebo vs. blockade. Increases in Rrs5 during unpleasant stimuli were generally greater under placebo than under ipratropium conditions, as suggested by a signicant condition-by-emotion interaction [F(2,154) 6.04, P 0.003, 0.98, and p2 0.073] (Fig. 1). (See also supplement for more details. Supplemental data are available in the online version of this article.) Both Rrs5 and Rrs20 showed conditionby-emotion-by-group interactions [F(2,154) 2.41 and 3.86, P 0.094 and 0.023, 0.98 and 0.96, and p2 0.030 and 0.048], although the former was only a statistical trend. A priori contrasts suggested that, for asthma patients only, increases in Rrs5 and Rrs20 during unpleasant stimuli were higher than during neutral stimuli under placebo vs. under ipratropium conditions [F(1,77) 14.75 and 6.86, P 0.001 and 0.011, respectively]. Post hoc testing also showed signicantly stronger increases in Rrs5 and Rrs20 during unpleasant stimuli and placebo condition than during any other combination of emotion, condition, and group. After ipratropium, Rrs increases were still visible during unpleasant stimuli but they were not signicant. Healthy participants only showed signicantly or
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marginally (post hoc tests, P 0.11) stronger increases during negative stimuli vs. during neutral and positive stimuli in the placebo condition.1 Figure 2 shows percent changes in Rrs5 and Rrs20 from prestimulus levels for unpleasant stimuli in both groups and the number of participants exceeding typical thresholds for just noticeable differences in prior added resistive load studies. Evidence for central vs. peripheral effects on the airways. Although airway constriction to unpleasant stimuli was observed across impulse frequencies, they were smaller at higher frequencies. Rrs5-Rrs20 showed signicant effects of emotion and condition by emotion [F(2,154) 6.46 and 10.89, P 0.003 and 0.001, both 0.90, and p2 0.077 and 0.124, respectively], with post hoc test showing that increases in Rrs5Rrs20 were greater for unpleasant stimuli under placebo but not under ipratropium conditions. The increase in Rrs5Rrs20 is consistent with the possibility of some increase in peripheral airway resistance. No effects were found for Xrs5. Additional effects were observed for AX, but they did not reect specic changes observed with Rrs for negative stimuli and ipratropium vs. placebo conditions. (See supplement for more details. Supplemental data are available in the online version of this article.) Changes in Emotion and Symptoms Ratings of pleasantness-unpleasantness and calmness-arousal both showed a clear distinction between emotional and neutral stimuli. Additional method-by-emotion effects were due to signicantly greater unpleasantness for unpleasant pictures and greater pleasantness and arousal for pleasant lms. Asthma patients reported signicantly higher overall levels of chest tightness and a tendency toward increased breathlessness and dizziness. Overall, the sensation of dizziness was stronger with ipratropium than with placebo for asthma pa1 As a supplementary analysis, we also calculated a ve-way repeatedmeasures ANOVA, including resistance (Rrs5 and Rrs20) as 2 levels of an additional repeated-measures variable. This analysis yielded a condition by emotion by resistance interaction, which indicated that reductions in resistance during ipratropium were stronger for Rrs5.

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Fig. 2. Percentage of asthma patients and healthy controls exceeding typical thresholds for just noticeable differences (from added resistive load studies) across frequencies during unpleasant stimulation under placebo or cholinergic (ipratropium) blockade. Rrs5 and Rrs20, Rrs at 5 and 20 Hz, respectively. www.jap.org

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tients. Symptoms were generally stronger for unpleasant stimuli than for others, regardless of whether ipratropium or placebo was used. Correlations between emotions or symptoms and Rrs change were not signicant, except for nausea levels, which showed consistently positive associations with Rrs5 and Rrs20 changes in asthma patients. (For more detailed ndings, see supplement. Supplemental data are available in the online version of this article.) Changes in Ventilation PCO2 and RR, but not VT, showed smaller changes to lm than to picture stimulation and emotional qualities. Signicant increases in PCO2 were found that were generally stronger during pictures, as well as increases in RR that were stronger during pleasant and unpleasant lms than during neutral lms. In addition, RR changes were negatively correlated with Rrs5 and Rrs20 for some pleasant and neutral stimulus presentations in healthy participants only. None of the effects reected the increases observed in Rrs5 and Rrs20 during unpleasant stimuli and their attenuation during ipratropium. (See supplement for more detailed ndings. Supplemental data are available in the online version of this article.) Association of Airway Responses with Demographics, Asthma Manifestation, and Medication No signicant associations were found for Rrs5, Rrs10, Xrs5, and AX with age or gender. fres increased more for women than for men [t(49 50) 2.10, 2.40, and 1.98; P 0.041, 0.020, and 0.053, respectively] (see also supplement, available in the online version of this article). Asthma severity and age of asthma onset were not signicantly associated with airway responses, nor was currently prescribed medication (inhaled corticosteroids vs. other medication, short-acting bronchodilator or no medication vs. other medication). Association of Airway Responses with Nonspecic Hyperreactivity, Reversibility, and Airway Inammation In asthma patients, only airway responses to neutral pictures under placebo conditions were negatively associated with methacholine PC20 [r(52) 0.41, P 0.001], where PC20 is the concentration of drug that induces 20% decline in forced expiratory volume in the rst second. The remaining coefcients were not signicant. There were no substantial associations of Rrs5 or Rrs20 changes with reversibility or basal FeNO assessed before each session (for more detailed ndings, see supplement, available in the online version of this article). Association of Airway Responses with Self-Reported Psychological Triggers of Asthma Patients who reported more frequent psychological triggers in their daily lives, as measured by the respective Asthma Trigger Inventory subscale, showed larger increases in Rrs5 and Rrs20 during unpleasant lms under placebo conditions [r(51) 0.39 and 0.34, P 0.008 and 0.013, respectively] (for more detailed ndings, see supplement, available in the online version of this article).
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Airway Response to Emotional Stimulation and Its Attenuation by Ipratropium In this study, we demonstrated airway constriction to unpleasant emotional stimuli in asthma patients, which was attenuated signicantly by cholinergic blockade. Whereas airway constriction to negative stimuli and stress has been shown in asthma patients before (22, 40, 42), this is the rst study to demonstrate an involvement of the cholinergic pathway in such responses. It conrms earlier speculations about involvement of the cholinergic pathway in psychologically induced bronchoconstriction (e.g., Refs. 22, 35). Because stronger airway responses to emotional stimuli were not correlated with methacholine PC20, such responses do not seem to be a function of greater sensitivity of the airways to a normal level of cholinergic stimulation. Rather, stronger centrally mediated vagal excitation would be a more likely explanation for increases in resistance observed during unpleasant stimulation. The alternative explanation that the observed bronchoconstriction might be due to sympathoadrenergic mechanisms is unlikely for the following reasons. First, there is no direct functional sympathetic innervation in humans (3, 9), and, although possible sympathetic modulation of cholinergic activity at the ganglia might occur, its extent is not well explored. Stress-induced sympathetic inuences on the airways would thus mainly cause an effect via circulating epinephrine, which leads to relaxation of the airway smooth muscles. Second, sympathetic withdrawal rather than excitation or reductions in circulating catecholamines rather than increases would need to have occurred under negative emotion induction; however, this is a more unlikely scenario in the arousal of unpleasant affect (5). Third, the abolition of bronchoconstriction to negative emotional stimuli by cholinergic blockade strongly suggests a cholinergic pathway of constriction. The number of asthma patients responding with Rrs5 and Rrs20 increases that approach typical thresholds for just noticeable change [as dened by added resistive load studies (14)] was largely comparable to results shown in earlier research with similar stimulation material (40), with 19% and 13% of patients exceeding such thresholds for lms and pictures, respectively. Research on bronchoconstrictive suggestion has typically found that 20 40% of patients respond to stimulation, depending on samples and varying criteria of clinical signicance. Thus a subset of asthma patients will be particularly susceptible to psychological stimulation. Beyond that, it should be noted that responding was not discrete but a continuous variable. It is conceivable that unpleasant psychosocial situations that only lead to weak airway constrictions may nevertheless contribute to symptoms or asthma exacerbations if these airway constrictions are superimposed on the effects of other bronchoconstricting triggers such as exercise, infections, or allergens. Resistance increases during unpleasant stimuli in healthy controls were similar to results shown in asthma patients, although more marginal in size. In contrast to asthma patients, decreases in resistance were observed during neutral and pleasant stimuli in healthy controls, with a notable consistency and magnitude that exceeded prior ndings (40). Further exploration of underlying mechanisms may yield interesting new
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insights into factors that may dilate the airways in health and disease. Association with Indicators of Airway Pathology, Asthma Severity, and Ventilatory Adjustments Our ndings suggest that stimulation of the airways by experimental emotion induction is a relatively independent challenge procedure that yields an index of airway responsiveness that can be distinguished from indexes of local airway pathophysiology, such as nonspecic hyperresponsiveness (PC20 of methacholine), bronchodilator response to ipratropium, and airway inammation (FeNO). The associations of airway responses to emotional stimuli with these indicators of airway pathophysiology were mostly nonsignicant in asthma patients, under both placebo and blockade conditions. Thus we suggest that emotional responsiveness of the airways in asthma is not just an epiphenomenon of underlying variations in the pathophysiological status of the airways, nor is it strongly linked to asthma severity within the limited range tested here. However, it informs about an aspect of airway reactivity that has relevance to a patients daily life: patients who reported before the experiment that psychological states are more frequently triggering asthma symptoms and exacerbations showed under unblocked conditions stronger responses to emotionally unpleasant lm material. This replicated early ndings with different lm material (46) and provides a physiological basis to frequent claims of emotion- or stress-induced asthma. The fact that these associations were tested between patients does not rule out that changes in life events, stress, and emotion, which may occur within patients over longer periods of time, could be associated with change indexes of airway pathophysiology, such as inammatory status. In one recent study, our group (28) observed that changes in negative stimuli and daily hassles over a 3-mo period were systematically associated with changes in lung function and that this association was mediated by changes in inammation. Thus, although vagal excitation was the major pathway of the observed airway constriction to brief experimental stimuli, certain forms of psychological stress will affect asthma by their effects on airway inammation, a conclusion supported by experimental research with asthma patients (e.g., Refs. 26, 32) and animal models of asthma (e.g., Refs. 23, 37). Short-term bronchoconstriction as observed in this study could add to or interact with the load exerted on the airways by exacerbation of inammation. Patients airway responses to unpleasant stimuli were also not substantially associated with breathing parameters. This would argue against the possibility that Rrs increases were epiphenomena of ventilatory adjustments, but we tested this association only between subjects, not within. It should be noted that some associations were observed in healthy controls during neutral and pleasant pictures, but none explained the pattern of response to unpleasant stimuli. Prior experimental research using lm or picture stimuli has also yielded little consistent evidence for substantial contributions from ventilation (40). Ventilatory adjustments may be a more systematic factor in daily states of emotion or distress that can be more intense than experimentally induced emotional states.
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Localization of Airway Response to Emotional Stimulation The signicant attenuation of airway constriction with ipratropium inhalation suggested that a substantial part of the response can be attributed to the central intrathoracic airways. Extrathoracic airway responses, such as narrowing of the larynx or partial closures of the glottis alone would not have been affected directly by blockade of muscarinic receptors (57). Increases in Rrs were typically observed across the frequency spectrum from 5 to 20 Hz, indicating that the central airways contributed as a main site to the observed constriction during unpleasant stimuli in unblocked conditions. In addition, the substantially larger increases in Rrs5 than in Rrs20 (i.e., increase in Rrs5-Rrs20) and increases in the magnitude of AX suggest that the peripheral airways were also affected by unpleasant stimulation. Because the peripheral airways are less susceptible to ipratropium bromide (3), the small, albeit insignicant, increases shown for unpleasant stimuli under blockade could be attributed to this airway site, to extrathoracic airway contributions, or to incomplete blockade due to variations in inhaler technique. However, even subtle laryngeal aperture changes such as in subvocalization lead to much larger changes in resistance (Goldman, unpublished observations), making this extrathoracic pathway an unlikely contributor to the present ndings. On a cautionary note, inferences about localization are far from perfect with indirect techniques, such as impulse oscillometry used in this study. However, although direct methods may have the potential of yielding more conclusive ndings regarding sites of airway constriction, they can also be expected to interfere substantially with the process of emotional experience and thus compromise the validity of the experimental procedure. Limitations Limitations of this study include the predominance of intermittent to mild persistent asthma in our patient sample. Lung function measures, including basal Rrs, Xrs, and fres, also suggested that asthma was well controlled in these patients; also, one-third of the participants were not taking any antiasthmatic medication. Psychosocial factors have been shown to be important in patients with more difcult or more severe asthma (11, 56). We decided to exclude patients who had more severe asthma and who had recently required systemic corticosteroids because of the profound steroid effects on airway reactivity and inammation. Consequently, generalization of our ndings to severe or uncontrolled asthma is not possible. However, within the restricted range of severity grades sampled in this study, no dependency of emotion-induced airway response on asthma severity was observed. Our sample was also limited with respect to demographic variables in that patients were relatively young and were highly educated on average. Although the ndings in terms of resistance increases during unpleasant stimuli concur with earlier research on samples with different demographics (47), a systematic comparison of emotion-induced airway reactivity across demographic subpopulations of patients would be needed. Finally, because the major focus of this study was on changes in airway mechanics, we had not selected healthy controls for nonatopic status, resulting in half of the control sample presenting with positive allergy skin tests. This may also have affected FeNO values in this sample, which on average slightly exceeded 20
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CHOLINERGIC AIRWAY RESPONSE AND EMOTION 7. Butler C, Steptoe A. Placebo responses: an experimental study of psychophysiological processes in asthmatic volunteers. Br J Clin Psychol 25: 173183, 1986. 8. Campbell SC. Clinical aspects of anticholinergic therapy. Respir Care 45: 864 867, 2000. 9. Canning BJ, Fischer A. Neural regulation of airway smooth muscle tone. Respir Physiol 125: 113127, 2001. 10. Center for the Study of Emotion and Attention. The International Affective Picture System: Digitized Photographs. Gainesville, FL: The Center for Research in Psychophysiology, Univ. of Florida, 1999. 11. Chung KF, Godard P, Adelroth E, Ayres J, Barnes N, Barnes P, Bel E, Burney P, Chanez P, Connett G, Corrigan C, de Blic J, Fabbri L, Holgate ST, Ind P, Joos G, Kerstjens H, Leuenberger P, Lofdahl CG, McKenzie S, Magnussen H, Postma D, Saetta M, Salmeron S, Sterk P. Difcult/therapy-resistant asthma: the need for an integrated approach to dene clinical phenotypes, evaluate risk factors, understand pathophysiology and nd novel therapies. ERS Task Force on Difcult/TherapyResistant Asthma. European Respiratory Society. Eur Respir J 13: 1198 1208, 1999. 12. Clarke PS. Emotional exacerbation in asthma caused by overbreathing. J Asthma 19: 249 251, 1980. 13. Crapo RO, Casaburi R, Coates AL, Enright PL, Hankinson JL, Irvin CG, MacIntyre NR, McKay RT, Wanger JS, Anderson SD, Cockcroft DW, Fish JE, Sterk PJ. Guidelines for methacholine and exercise challenge testing-1999. Am J Respir Crit Care Med 161: 309 329, 2000. 14. Dahme B, Richter R, Mass R. Interoception of respiratory resistance in asthmatic patients. Biol Psychol 42: 215229, 1996. 15. Duiverman EJ, Clment J, van de Woestijne KP, Neijens HJ, van den Bergh AC, Kerrebijn KF. Forced oscillation technique. Reference values for resistance and reactance over a frequency spectrum of 226 Hz in healthy children aged 2.312.5 years. Bull Eur Physiopath Respir 21: 171178, 1985. 16. Goldman MD, Carter R, Klein R, Fritz G, Carter B, Pachucki P. Within and between-day variability of respiratory impedance, using impulse oscillometry in adolescent asthmatics. Pediatr Pulmonol 34: 312 319, 2002. 17. Goldman MD, Saadeh C, Ross D. Clinical applications of forced oscillation to assess peripheral airway function. Respir Physiol Neurobiol 148: 179 194, 2005. 18. Grimby G, Takishima T, Graham W, Macklem P, Mead J. Frequency dependence of ow resistance in patients with obstructive lung disease. J Clin Invest 47: 14551465, 1968. 19. Gross JJ, Levenson RW. Emotion elicitation using lms. Cogn Emot 9: 87108, 1995. 20. Hodes RL, Cook EW 3rd, Lang PJ. Individual differences in autonomic response: conditioned association or conditioned fear? Psychophysiology 22: 545557, 1985. 21. Horton DJ, Suda WL, Kinsman RA, Souhrada J, Spector SL. Bronchoconstrictive suggestion in asthma: a role for airways hyperreactivity and emotions. Am Rev Respir Dis 117: 1029 1038, 1978. 22. Isenberg SA, Lehrer PM, Hochron S. The effects of suggestion and emotional arousal on pulmonary function in asthma: a review and a hypothesis regarding vagal mediation. Psychosom Med 54: 192216, 1992. 23. Joachim RA, Quarcoo D, Arck P, Herz U, Renz H, Klapp B. Stress enhances airway reactivity and airway inammation in an animal model of allergic bronchial asthma. Psychosom Med 65: 811815, 2003. 24. Joos GF, OConnor B, Anderson SD, Chung F, Cockcroft DW, Dahln B, DiMaria G, Foresi A, Hargreave FE, Holgate ST, Inman M, Ltvall J, Magnussen H, Polosa R, Postma DS, Riedler J; ERS Task Force. Indirect airway challenges. Eur Respir J 21: 1050 1068, 2003. 25. Jrres RA, Nowak D, Kirsten D, Grnke L, Magnussen H. A short protocol for methacholine provocation testing adapted to the RosenthalChaidosimeter technique. Chest 111: 866 869, 1997. 26. Kang DH, Coe CL, McCarthy DO, Jarjour NN, Kelly EA, Rodriguez RR, Busse WW. Cytokine proles of stimulated blood lymphocytes in asthmatic and healthy adolescents across the school year. J Interferon Cytokine Res 17: 481487, 1997. 27. Kaugars AS, Klinnert MD, Bender BG. Family inuences on pediatric asthma. J Pediatr Psychol 29: 475491, 2004. 28. Kullowatz A, Roseneld D, Dahme B, Magnussen H, Kanniess F, Ritz T. Effects of stress on lung function in asthma are mediated by changes in airway inammation. Psychosom Med 70: 468 475, 2008. www.jap.org

ppb as the commonly applied threshold for clinically relevant inammation. Similarly, our asthma group also included patients with FeNO or PC20 below the clinical threshold, which could be due to less severe (intermittent) or well-controlled asthma (13). However, wider ranges in FeNO and PC20 values and limited overlap in atopic status and hyperreactivity probably resulted in a more conservative test for differences between patients and healthy controls and for associations between these parameters and emotion-induced airway responsiveness. Recalculation of the analyses with only methacholine-positive patients did not substantially change the main ndings. In conclusion, asthma patients showed signicant airway constriction to unpleasant stimuli, which was signicantly attenuated by anticholinergic bronchodilators. In addition to central cholinergic airway constriction, peripheral airways may also contribute to increased resistance. Up to one-fth of patients showed resistance increases that reached clinically relevant levels if not medicated. These patients did not show systematic ventilatory adjustments, greater airway hyperreactivity, or elevated airway inammation that would explain the magnitude of oscillometric resistance and reactance increases. However, self-report of emotion-induced asthma symptoms in daily life predicted stronger responses to some types of unpleasant stimuli. Patients reports of emotion-induced asthma may well require medical or behavioral management strategies that acknowledge this specic pathway of exaggerated airway response.
ACKNOWLEDGMENTS Present address of T. Ritz: Department of Psychology, Southern Methodist University, Dallas, TX. We thank the staff of the Pulmonary Research Institute at the Hospital Grosshansdorf for assistance with our study. GRANTS This study was funded by a grant from the German Research Society, Deutsche Forschungsgemeinschaft (Project Ri 957/3-1 to T. Ritz). DISCLOSURES Vivometrics (Ventura, CA) provided free equipment support for respiratory inductance plethysmography. M. D. Goldman and H.-J. Smith are or have been involved in developing and marketing of the impulse oscillometry device (Jaeger/CareFusion). M. D. Goldman did consulting work for the company from 2000 to 2003 but had not consulted since then. H.-J. Smith was the key engineer in developing the equipment originally and is now also working in product management and marketing for the company. REFERENCES 1. Alexander AB, Cropp JA, Chai H. Effects of relaxation training on pulmonary mechanics in children with asthma. J Appl Behav Anal 12: 2735, 1979. 2. American Thoracic Society and European Respiratory Society. ATS/ ERSrecommendations for standardized procedures for the online and ofine measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide. Am J Respir Crit Care Med 171: 912930, 2005. 3. Barnes PJ. Neural control of human airways in health and disease. Am Rev Respir Dis 134: 1289 1314, 1986. 4. Barnes PJ. Distribution of receptor targets in the lung. Proc Am Thorac Soc 1: 345351, 2006. 5. Berntson GG, Cacioppo JT. Integrative physiology: homeostasis, allostasis, and the orchestration of systemic physiology. In: Handbook of Psychophysiology (3rd ed.), edited by Cacioppo JT, Tassinary LG, Berntson GG. Cambridge, MA: Cambridge Univ. Press, 2008, p. 231243. 6. Boiten FA. The effects of emotional behaviour on components of the respiratory cycle. Biol Psychol 49: 29 51, 1998. J Appl Physiol VOL

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