CT (HRCT) HRCT NFA HRCT NFA NFA NFA. ( ) (>6mo) 36% 70% 100% NFA (P <0.05) NFA (CT) (bronchial wall thickening)

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1 CT Young-Mok Lee, MD, PhD; Jai-Soung Park, MD, PhD; Jung-Hwa Hwang, MD, PhD; Sung-Woo Park, MD; Soo-taek Uh, MD, PhD; Yong-Hoon Kim, MD, PhD; and Choon-Sik Park, MD, PhD CT (HRCT) (NFA) NFA HRCT NFA HRCT NFA 16 NFA 16 HRCT ( ) ( ) (>6mo) 36% 70% 100% NFA NFA (P <0.05) 7 NFA 5 NFA HRCT NFA (P<0.05) NFA NFA NFA NFA (bronchial wall thickening) (CT) (nearfatal asthma) (small airway) [1, ] 1y [3] CHEST

2 NFA HRCT [,5] NFA NFA HRCT (near-fatal asthma NFA) HRCT 6 mo [6, 7] [8, 9] NFA NFA NFA 0 16 CT (high-resolution CT HRCT) [13] FEV 1 >15% ( ) ( ) <10mg/mL ( FEV 1 0% ) ) ( ) [10] HRCT HRCT [1] ( 1 1 ) [11] HRCT ( 10 NFA ) [1] NFA [1] ( 3 16 ) ICU NFA NFA Paco >5 mm Hg (5.9kPa) 38 mm Hg Pao <60mmHg From the Asthma and Allergy Research Group (Drs. Lee, S-W Park, Uh, Kim, and C-S Park), Department of Radiology (Drs. J-S Park and Hwang), Soonchunhyang University Hospital, Seoul and Bucheon, Korea. Correspondence to: Choon-Sik Park, MD, Professor, Division of Allergy and Respiratory Medicine, Soonchunhyang University Hospital, 117 Jung-Dong, Wonmi-Gu, Bucheon, Gyeonggi-Do 0-767, Republic of Korea; schalr@schbc.ac.kr (7.9 kpa) mm Hg [3, 1] <7d NFA 7d ( mg/kg ) ( 5mg/kg) β ( ) 7 NFA 57

3 HRCT HRCT h Chai [15] -50 HU HRCT -700 HU FEV 1 0% HU NFA 6wk HRCT (bronchial wall index BWI) ( ) () wk (3) () (5) (6) ( 1) Fleischner [16] 1 ( HRCT <10HU) (1 mm 10 mm ) HRCT (CT-W000 Hitachi Medical Tokyo Japan) 10 kv CT 00 ma 1 s mm 1cm 0 mm A B 1 9 ( 1) HRCT A HRCT ( ) ( 1) B HRCT ( ) CHEST

4 BWI ( / ) [17] 1.5 mm (SPSS / PC WIN 8.0 package; SPSS; Chicago, IL) <1.5 x ± s x CT [18] CT 5 Mann-Wnitney U Wilcoxon Spearman FEV 1 6 ( BWI 1/3 /3 ) HRCT (0 HRCT 1 1% 5% 6% 50% 3 51% 75% 76% 100% ) [19, 0] 1 FEV 1 ( ) 3 1( P <0.05) NFA 0 1 Paco < ( ) mm Hg ( ) kpa > mm Hg ( kpa) Paco (7.9 8.) mm Hg (6. 1.) kpa HRCT mm Hg (.6 7. kpa) HRCT 76% 71% 1 1 ( ) ( ) 3 ( ) / / 7/7 7 / 3 5 / / 5 / y FEV 1 /% FEV 1 /% / µg x ± s () x 3 P<

5 BWI A B C ( 1) ( ) NFA ( 3) BWI (A) (B) (C) NS P >0.05 () (3) P < P <0.05 8% 76% % κ > HRCT κ FEV 1 ( ) [1] BWI (0.5 BWI 1 FEV 1 ( 6.3) BWI ) (r =-0.78 P <0.01) BWI FEV 1 ( ) ( ) (P < 0.05) FEV 1 ( A) ( ) ( ) NFA (100%) 1 36% 70% 6 1 mo ( 3 1 ( P<0.05) 1 ( B) % (1 11 ) 80.6% (10 8 ) % (16 13 ) 0% ( ( ) ( C) 3 1 HRCT FEV BWI ( ) P<0.01 ) CHEST

6 ) HRCT (P <0.05 3D) HRCT HRCT ( ) (. 0. HRCT 7 mo ( ) ( P >0.05 3E 16.8 mo) HRCT 1 3 F) 1 BWI (57 85) (1 3 11) ( ) (P <0.05) HRCT 3 µg/d >1 ( 3E) 1 <0% BWI ( ( 3B) ) ( ) ( 3C F) ( P <0.05 3A B) 1 ( P >0.05 3C) 3 BWI ( ) HRCT P<0.05 P<0.05 NS BWI A 0 B 0 C P<0.05 NS NS D 0 E 0 F 3 1 (A B C) 3 (D E F) 16.8 mo (7 mo) HRCT BWI NS P>

7 BWI FEV 1 NFA [31] Lucidarme [3] 10 BWI HRCT Lynch [] 10% Grenier [3] Harmanci [] 0% NFA BWI 36% 70% Awadh [1] BWI [ ] [33] HRCT Dunnill [6, 3] 10 mm HRCT HRCT 0% [35] [10, 35, 36] FEV 1 BWI [11, 37] [5, 6] BWI [7, 8] NFA ( ) [8, 8, 9] NFA FEV 1 NFA ( ) [30] [7 9] [8] NFA HRCT [38] NFA HRCT Paganin [10, 35] NFA HRCT Paganin [10 35] CT 1 wk CHEST

8 [39] 9 7 Strunk RC, et al. JAMA 1985;5: Castro M, et al. J Asthma 001;38: Dunnill MS. J Clin Pathol 1960;13:7 33 (6 mo) 7 James AL, et al. Am Rev Respir Dis 1989;139: 6 8 Carroll N, et al. Am Rev Respir Dis 1993;17: Carroll N, et al. Eur Respir J 1996;9: Paganin F, et al. Am Rev Respir Dis 199;16: NFA NFA 11 Kasahara K, et al. Thorax 00;57: 6 1 Awadh N, et al. Thorax 1998;53:8 53 [0 1] No Chai H, et al. J Allergy Clin Immunol 1975;56: % 16 Austin JH, et al. Radiology 1996;00: NFA 100%NFA (0 ) NFA NFA 18 McNamara AE, et al. J Appl Physiol 199;73: Jensen SP, et al. Clin Radiol 00;57: NFA NFA 0 Hansell DM, et al. Radiology 199;193: CT: Appleton & Lange, 1990;58 59 Lynch DA, et al. Radiology 1993;188: Grenier P, et al. Eur Radiol 1996;6: % HRCT 6 Jeffery P. Am Rev Respir Dis 1991;13: NFA HRCT 8 Kraft M. Eur Respir J 1999;1: NFA NFA NFA NFA NFA Wilkins, 001; Sly RM, et al. Ann Allergy Asthma Immunol 1997;78:37 35 McFadden ER Jr, et al. Ann Intern Med 1997;17: Molfino NA. Near-fatal asthma. In: Hall JB, et al, eds. Acute asthma: assessment and management. NY: McGraw-Hill, 000; 13 American Thoracic Society. Am Rev Respir Dis 1987;136:5 1 National Institutes of Health. Global strategy for asthma management and prevention, NHLBI / WHO workshop report, Bethesda, MD: National Heart, Lung, and Blood Institute, 00; publication 17 Boulet LP, et al. Am J Respir Crit Care Med 1995;15: Dawson-Saunders B, et al. Basic and clinical biostatistics. Norwalk, Harmanci E, et al. Respiration 00;69:0 6 5 Hogg JC, et al. Postmortem pathology. In: Barnes PJ, et al, eds. Asthma. Philadelphia, PA: Lippincott-Raven, 1997; Hamid Q, et al. J Allergy Clin Immunol 1997;100: 51 9 Kuwano K, et al. Am Rev Respir Dis 1993;18: Wiggs BR, et al. Am Rev Respir Dis 199;15: Webb WR, et al. High resolution computed tomography findings of lung disease. In: Webb WR, et al, eds. High resolution computed tomography of the lung. 3rd ed. PA: Lippincott William & 3 Lucidarme O, et al. Radiology 000;16: Molet S, et al. Role of airway remodeling in severe asthma. In: Szefler SJ, et al, eds. Severe asthma: pathogenesis and clinical management. nd ed. NY: Marcel Dekker, 001; Dunnill MS, et al. Thorax 1969;: Paganin F, et al. Am J Respir Crit Care Med 1996;153: James A, et al. Chest 1995;107(3 Suppl):110S 578

9 37 Gono H, et al. Eur Respir J 003;: Bousquet J, et al. Am J Respir Crit Care Med 000;161: Hoshino M, et al. J Allergy Clin Immunol 1999;10: Claman DM, et al. J Allergy Clin Immunol 199;9: Fahy JV, et al. Eur Respir J 1998;11:10 17 CHEST 00;16: CHEST No CHEST E. Failure to receive pneumococcal vaccination. In a recent large study of nursing home residents, the history of pneumococcal vaccination failed to provide protection form the development of a first episode of pneumonia (choice E). Because the study did not cover the effect of vaccine on subsequent episodes of pneumonia, it still possible that the pneumococcal vaccine might have some protective effect against invasive pneumococcal disease, but previous prospective studies have clearly shown that the elderly frequently failed to develop adequate antibody titers to the vaccine strains. To this date, the state of pneumococcal vaccination in the elderly is open to question. A conjugate pneumococcal vaccine is currently undergoing clinical trials and it may prove to be effective. In the same study age (by decades), male gender and swallowing difficulty were predictive for the development of the first episode of pneumonia (choices A, C, and D), while having been vaccinated against influenza was protective (choice B). CHEST