ERS technical standard on bronchial challenge testing: pathophysiology and methodology of indirect airway challenge testing

Research output: Contribution to journalArticle


Recently, this international task force reported the general considerations for bronchial challenge testing and the performance of the methacholine challenge test, a "direct" airway challenge test. Here, the task force provides an updated description of the pathophysiology and the methods to conduct indirect challenge tests. Because indirect challenge tests trigger airway narrowing through the activation of endogenous pathways that are involved in asthma, indirect challenge tests tend to be specific for asthma and reveal much about the biology of asthma, but may be less sensitive than direct tests for the detection of airway hyperresponsiveness. We provide recommendations for the conduct and interpretation of hyperpnoea challenge tests such as dry air exercise challenge and eucapnic voluntary hyperpnoea that provide a single strong stimulus for airway narrowing. This technical standard expands the recommendations to additional indirect tests such as hypertonic saline, mannitol and adenosine challenge that are incremental tests, but still retain characteristics of other indirect challenges. Assessment of airway hyperresponsiveness, with direct and indirect tests, are valuable tools to understand and to monitor airway function and to characterise the underlying asthma phenotype to guide therapy. The tests should be interpreted within the context of the clinical features of asthma.


  • Teal S. Hallstrand
  • Joerg D. Leuppi
  • Guy Joos
  • Graham L. Hall
  • Kai Håkon Carlsen
  • David A. Kaminsky
  • Allan L. Coates
  • Donald W. Cockcroft
  • Bruce H. Culver
  • Zuzana Diamant
  • Gail M. Gauvreau
  • Ildiko Horvath
  • Frans H.C. de Jongh
  • Beth L. Laube
  • Peter J. Sterk
  • Jack Wanger
External organisations
  • University of Washington
  • University Hospital Basel
  • Ghent University
  • Curtin University
  • University of Oslo
  • University of Vermont
  • University of Toronto
  • Royal University Hospital, Saskatoon
  • University Medical Center Groningen
  • Academic Medical Center of University of Amsterdam (AMC)
  • University of Basel
  • University of Western Australia, Perth
  • Oslo university hospital
  • University of Groningen
  • McMaster University
  • National Korányi Institute for Tuberculosis and Pulmonology, Hungary
  • Medisch Spectrum Twente
  • Johns Hopkins University
  • University of Amsterdam
  • No affiliation available (private)
Research areas and keywords

Subject classification (UKÄ) – MANDATORY

  • Respiratory Medicine and Allergy
Original languageEnglish
JournalThe European respiratory journal
Issue number5
Publication statusPublished - 2018
Publication categoryResearch