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BACKGROUND In a previous work we have demonstrated that the use of an indirect stimulus such as ultrasonically nebulized distilled water (UNDW, "fog") challenge, in addition to methacholine, in the assessment of occupational asthma due to TDI improves our ability in detecting sensitized subjects. OBJECTIVE In the present study we aimed to determine the validity of "fog" in the assessment of occupational asthma induced by various low molecular weight substances. METHODS Fourty subjects exposed to low molecular weight substances with work-related respiratory symptoms underwent methacholine, UNDW and specific bronchial challenge tests. Diagnosis of occupational asthma was made in 20 of 40 patients who developed bronchoconstrictive responses to the specific challenges (reactors). Sensitivity and specificity of UNDW alone, of methacholine alone, and of the combination of the two tests were determined at two different cutpoints of PD20FEV1 of methacholine, with the results of the specific challenge as the "gold standard". RESULTS Frequency and severity of bronchial hyperresponsiveness both to UNDW and to methacholine were significantly higher in reactors than in nonreactors. Ultrasonically nebulized distilled water had higher specificity (80% versus 60%) but lower sensitivity (65% versus 75% to 90%) than methacholine. As compared with methacholine alone, the combination in series of the two challenges (both challenges positive) substantially improved specificity (85% versus 60%). CONCLUSIONS In conclusion, in the assessment of low molecular weight chemical-induced asthma diagnosed with the specific challenge as the "gold standard," UNDW challenge proves more specific than methacholine for occupational asthma, but it is considerably less sensitive. The combination of the two challenges results in very high sensitivity and high specificity for occupational asthma, therefore, although further investigations are required for the definitive diagnosis, it should be regarded as a useful means to confirm objectively a suggestive history.
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