Collagen deposition in large airways may not differentiate severe asthma from milder forms of the disease

Chronic airway inflammation and remodeling, including fibrosis, have been proposed as important contributors to asthma pathophysiology. Previous studies of airway fibrosis have been performed mainly in mild and moderate asthmatics at the subepithelial "basement membrane" (SBM) level. The current study was designed to evaluate the large airway SBM thickness and submucosal collagen deposition, as measured by three different collagen staining methods, in endobronchial biopsies from 17 severe, nine moderate, and seven mild asthmatics, as well as eight normal control subjects. Tissue eosinophils and transforming growth factor-beta (TGF-beta) immunoreactivity were also examined. There were no statistically significant differences in the SBM thickness, submucosal collagen deposition, eosinophil numbers, or TGF-beta positive cells among the three groups of asthmatics and the normal control subjects. It was only when examining all asthmatics (n = 33) together, that a modestly thickened SBM (p = 0.04), as evaluated by collagen type III immunostaining, was observed as compared with normal control subjects. Despite this difference, no significant differences were found in the amount of submucosal collagen deposition and the number of eosinophils or TGF-beta expressing cells when comparing total asthmatics and normal control subjects. Additionally, no significant correlations were found between collagen deposition and eosinophil count, TGF-beta expression level, FEV1, or duration of asthma. These results suggest that although increased collagen deposition in the SBM at the large airway level is a characteristic of asthma, it may not explain the differences in severity of asthma.

Factors determining the severity of asthma

Asthma typically can range from a disease of very mild and intermittent symptoms to one of debilitating and life-threatening disease. However, the factors that control these differences remain poorly understood. It is likely that the factors controlling the severity of asthma are many and dependent on each other. Potential factors include: (i) inflammatory; (ii) structural; (iii) hereditary/congenital; (iv) environmental; and (v) psychological/emotional; each potentially interacting and influencing the other. Finally, the question remains as to whether all asthmatics, no matter what their initial severity, potentially can develop severe disease, or whether only a certain subgroup will become severe.

Efficacy, safety, and effects on quality of life of salmeterol versus albuterol in patients with mild to moderate persistent asthma

BACKGROUND

Salmeterol xinafoate is a long-acting, highly selective, beta2-adrenergic agonist that produces bronchodilation and clinically significant improvement in pulmonary function for up to 12 hours in patients with asthma.

OBJECTIVE

To evaluate the impact on asthma-specific quality of life, efficacy, and safety of salmeterol versus albuterol in adult patients with mild-to-moderate persistent asthma.

METHODS

A randomized, double-blind, double-dummy, parallel-group, multicenter study was conducted in 539 adult asthma patients over 12 weeks. Patients were randomized to receive either salmeterol 42 microg via metered-dose inhaler twice daily or albuterol 180 microg four times daily. Upon entry into the study, 46% of patients were being treated with an inhaled corticosteroid and were allowed to continue treatment throughout the study. Pulmonary function and asthma symptoms were monitored daily, and patients completed the Asthma Quality of Life Questionnaire (AQLQ) at baseline and after 4, 8, and 12 weeks of treatment.

RESULTS

Treatment with salmeterol twice daily produced significantly greater improvements from baseline in all quality of life domain ("Activity Limitation," "Asthma Symptoms," "Emotional Function," "Environmental Exposure") scores and in the global AQLQ score at 12 weeks (P < or = .038) compared with albuterol treatment four times daily. Pulmonary function and asthma symptoms were also significantly improved with salmeterol compared with albuterol.

CONCLUSIONS

Salmeterol 42 microg administered twice daily is significantly more effective than albuterol 180 microg four times daily for improving asthma-specific quality of life, controlling asthma symptoms, and improving pulmonary function in patients with mild-to-moderate persistent asthma. Furthermore, those improvements were maintained over a 12-week period.

Immunoaffinity resin for purification of urinary leukotriene E4

Urinary leukotriene E4 (LTE4) has been used as an index of total leukotriene synthesis. A wide variety of methods have been applied to measure LTE4 which has made direct comparison of urinary levels reported by different laboratories difficult. A new peptidoleukotriene immunoaffinity resin was utilized for urinary LTE4 purification in a method that is easy and inexpensive, utilizing commercially available reagents. This method is described and compared to other methods. LTE4 (50-250 pg/mL) added to a urine extract was quantitatively recovered using the immunoaffinity resin. Similarly, LTE4 (50-400 pg/mL) added to urine was recovered between 63 and 76%. The coefficient of variation of samples purified and quantified on the same or on different days ranged from 8-10%. There was a strong correlation (r2 = 0.95) between LTE4 concentrations determined after immunofiltration and immunoaffinity purification. Although there was a good correlation between urinary LTE4 levels measured without purification compared to after immunoaffinity purification, the high y-intercept of 179 indicates the presence of interfering substances in unpurified urine. Urinary LTE4 in normal healthy adults was 80 +/- 7 pg/mg creatinine, similar to that previously reported following HPLC or immunofiltration purification. Urinary LTE4 was also measured in healthy children (age 3-12) and found to be 103 +/- 9.

New approaches to anti-inflammatory therapy for asthma

Currently, corticosteroids are the therapy of choice for the inflammatory component of asthma. This class of drug provides powerful anti-inflammatory effects in most patients; however, these effects are not specific and in some cases may result in serious side effects. Also, many patients have difficulty adhering to therapy with inhaled forms of these drugs, which are administered by metered-dose inhalers up to several times per day. There are several other therapies that provide potential anti-inflammatory effects, but they are of low efficacy, with little definitive anti-inflammatory effect. While efforts are currently under way to improve corticosteroid therapy, other directions include the development of targeted anti-inflammatory agents. For example, the leukotrienes, a family of inflammatory mediators that have been shown to enhance bronchoconstriction and airway mucus secretion, have been the focus of numerous investigations. Specific leukotriene receptor antagonists and synthesis inhibitors have been developed and are currently showing promise in clinical trials; one leukotriene receptor antagonist (zafirlukast) and one 5-lipoxygenase inhibitor (zileuton) were recently approved by the United States Food and Drug Administration for the treatment of asthma.

Bronchoscopic evaluation of severe asthma. Persistent inflammation associated with high dose glucocorticoids

The role of inflammation in the pathogenesis of severe asthma chronically treated with high doses of glucocorticoids is poorly understood. Despite this, treatment has been aimed at advancing anti-inflammatory and immunomodulator therapy. This study was designed to evaluate both the presence and type of airway inflammation in patients with severe asthma. A prospective bronchoscopic study evaluated 14 severe, high-dose oral glucocorticoid dependent asthmatics. Bronchoalveolar lavage fluid was analyzed for cytology and inflammatory mediators. Endobronchial and transbronchial biopsies were performed in selected patients for morphometric evaluation of macrophage/monocytes, neutrophils, eosinophils and lymphocytes. These results were compared with lavage and endo- and transbronchial biopsy studies in normal controls and patients with moderate asthma. The concentration of eosinophils in bronchoalveolar lavage fluid was highest in the moderate asthmatics not on glucocorticoids, with very little difference between normal controls and severe asthmatics (significant difference among the groups, p = 0.007). In contrast, the severe asthmatics demonstrated a twofold higher concentration of neutrophils in lavage than either the mild-moderate asthmatics, or the normal controls (p = 0.032 among the groups, p < 0.05 between the severe asthmatics and both controls). Similar results were obtained in the endobronchial and transbronchial biopsy specimens, which consistently showed significantly higher numbers of neutrophils in the severe asthmatics than in the control groups. The eicosanoid mediators, thromboxane and leukotriene B4, were also highest in the severe asthma group (differences among the groups, p = 0.019 and p = 0.023, respectively). These findings suggest that inflammation remains in severe symptomatic asthmatics despite treatment with high dose glucocorticoids which may be due to the severity of disease, glucocorticoid treatment, or other as yet undefined factors.

Immunofiltration purification for urinary leukotriene E4 quantitation

Leukotriene E4 (LTE4) is a major leukotriene metabolite in urine. Urinary LTE4 concentration is often utilized as an index of total leukotriene synthesis. A novel method employing immunofiltration for the purification of urinary LTE4 was developed. This immunofiltration method is based upon the addition of excess anti-LTE4 antibody to urine which binds LTE4. Separation of bound LTE4 (high M(r)) from high levels of unbound contaminants (low M(r)) is then accomplished by filtration through a 10,000 M(r) cut-off filter. The LTE4-antibody complex is separated by precipitation of the antibody with methanol which is subsequently removed by centrifugation. Following evaporation of the methanol, enzyme immunoassay is utilized for quantitation. This methodology was validated by determining the recovery of tritiated and unlabeled LTE4 added to urine and buffer and by comparison of results obtained with urine samples measured after HPLC purification (correlation r2 = 0.72). Reproducibility of the assay was assessed by analyzing the same sample on two different days (standard deviation of 18%). The mean urinary LTE4 levels in healthy subjects and asthmatics measured utilizing this method were found to be identical to levels determined by HPLC/immunoassay. The ease and accuracy of this assay make it amenable for the analysis of large numbers of samples.

The effect of salmeterol on nocturnal symptoms, airway function, and inflammation in asthma

STUDY OBJECTIVE

To determine the efficacy of salmeterol alone in a group of patients with moderate asthma with nocturnal worsening of symptoms.

DESIGN

Double-blind, randomized, placebo-controlled crossover study.

SETTING

Tertiary care hospital specializing in respiratory diseases.

PARTICIPANTS

Ten patients with nocturnal asthma.

INTERVENTIONS

Subjects were randomized to salmeterol, 100 micrograms twice daily, or placebo for 6 weeks with a 1-week washout between treatment periods. Symptoms, nocturnal awakenings, and beta 2-agonist use were recorded daily. Spirometry was performed at weeks 1 and 6 of each period at bedtime and at 4 AM, and methacholine challenge was performed at 4 AM followed by bronchoscopy with BAL. BAL fluid analysis included cell count and differential count, eosinophil cationic protein, Charcot-Leyden crystal protein, leukotriene B4, and thromboxane B2.

RESULTS

The percentage of nights with awakenings decreased significantly with salmeterol (69.8 +/- 8.7% vs 30.6 +/- 10.8% for placebo and salmeterol, respectively; p = 0.02). The percentage of 24-h days with supplemental inhaled beta 2-agonist use significantly decreased with salmeterol (85.9 +/- 9.4% vs 70.4 +/- 10.1% for placebo and salmeterol, respectively; p = 0.04). There were no significant differences in bronchial reactivity, 4 AM FEV1, overnight percentage change in FEV1, or indexes of airway inflammation.

CONCLUSIONS

Salmeterol alone improves the number of nocturnal awakenings and supplemental 24-h beta 2-agonist use in nocturnal asthma without significantly altering lung function and airway inflammation.

Hyperpnea-induced changes in parenchymal lung mechanics in normal subjects and in asthmatics

The effects of hyperpnea on parenchymal lung mechanics are unknown, but they may contribute to the resultant airflow limitation commonly seen in asthma. To investigate these effects, we measured the following parameters in seven asthmatic and six normal subjects before and after 5 min of hyperpnea: specific conductance, upstream resistance, static compliance, the coefficient of retraction, lung volumes, lung hysteresis, and the ratio of maximal to partial flow rates (the M:P ratio, an indicator of the effect of deep inhalation on airflow, and a measure of relative airway and parenchymal hysteresis). In addition to a central effect on the airways, as shown by significant falls in specific conductance, hyperpnea in asthmatics, but not in normal subjects, resulted in significant increases in residual volume and pressure-volume hysteresis, suggestive of changes in parenchymal lung mechanics. The M:P ratio also increased in the asthmatics, consistent with greater increases in airway than in parenchymal hysteresis after hyperpnea. We conclude that hyperpnea has significant effects on the lung parenchyma that contribute to airflow limitation in asthmatics, and we hypothesize that these effects may be due to alterations in peripheral airway smooth muscle tone and surfactant function.

Arachidonic acid metabolites: mediators of inflammation in asthma

Asthma is increasingly recognized as a mediator-driven inflammatory process in the lungs. The leukotrienes (LTs) and prostaglandins (PGs), two families of proinflammatory mediators arising via arachidonic acid metabolism, have been implicated in the inflammatory cascade that occurs in asthmatic airways. The PG pathway normally maintains a balance in the airways; both PGD2 and thromboxane A2 are bronchoconstrictors, whereas PGE2 and prostacyclin are bronchoprotective. The actions of the LTs, however, appear to be exclusively proinflammatory in nature. The dihydroxy-LT, LTB4, may play an important role in attracting neutrophils and eosinophils into the airways, whereas the sulfidopeptide leukotrienes (LTC4, LTD4, and LTE4) produce effects that are characteristic of asthma, such as potent bronchoconstriction, increased endothelial membrane permeability leading to airway edema, and enhanced secretion of thick, viscous mucus. Given the significant role of the inflammatory process in asthma, newer pharmacologic agents, such as the sulfidopeptide-LT antagonists, zafirlukast, montelukast, and pranlukast and the 5-lipoxygenase (5-LO) inhibitor, zileuton, have been developed with the goal of targeting specific elements of the inflammatory cascade. These drugs appear to represent improvements to the existing therapeutic armamentarium. In addition, the results of clinical trials with these agents have helped to expand our understanding of the pathogenesis of asthma.

Abnormalities of cell and mediator levels in bronchoalveolar lavage fluid of patients with mild asthma

Increases in numbers and the activation state of inflammatory cells are typical findings even in patients with mild asthma. Periods of worsening inflammation are characterized by further changes, such as an increased number of eosinophils in patients with nocturnal asthma, an increased number of lymphocytes and basophils after allergen provocation, and an increased number of neutrophils after exposure to toluene diisocyanate. Correlations of bronchoalveolar lavage (BAL) findings with physiologic changes in patients with asthma are helpful but must be analyzed in the context of the difficulties in absolute quantification of cells and mediators in lavage. Correlations have been reported between BAL mast cells, eosinophils, and eosinophilic cationic protein and methacholine PC20 and FEV1. Correlations of other cell types or mediators with physiologic changes are either controversial (as with lymphocytes and their activation) or nonexistent (as with most mediators that have been measured). Ex vivo mediator production may be a useful measure. The ability to measure peripheral resistance directly at the site of inflammation may become an asset of the endobronchial instillation method. Causality can be proved only by selectively adding or removing certain inflammatory mediators through the use of leukotriene synthesis inhibitors, human grade eicosanoids, specific antagonists, agonists, and humanized antibodies. Of these examples, only leukotriene modulation has been evaluated with BAL in studies with human subjects. Whether inflammation and obstruction in patients with asthma result from the lack of certain mediators and/or an excess of others is unknown.

Arachidonate-induced eicosanoid synthesis in RBL-2H3 cells: stimulation with antigen or A23187 induces prolonged activation of 5-lipoxygenase

We studied the ability of rat basophilic leukemia (RBL-2H3) cells stimulated with either IgE/antigen or calcium ionophore, A23187, to synthesize LTC4 and PGD2 after addition of exogenous arachidonic acid. RBL-2H3 cells preferentially synthesized PGD2 in response to stimulation with low concentrations of antigen or A23187 while higher concentrations also resulted in a marked synthesis of LTC4. The synthesis of LTC4 was dependent upon initial activation of 5-lipoxygenase by IgE/antigen or A23187, since arachidonic acid lone failed to induce LTC4 synthesis. Following the addition of IgE/antigen or A23187 alone, the synthesis of PGD2 and LTC4 was essentially complete by 10 min. To determine whether a limitation of substrate precluded further eicosanoid synthesis, exogenous arachidonic acid was added to washed cells 15-145 min following the initial stimulation with IgE/antigen or A23187, PGD2 and LTC4 synthesis was resumed following the addition of arachidonic acid to washed prestimulated cells, demonstrating that the termination of eicosanoid synthesis in RBL-2H3 cells was nor caused by the inactivation of cyclooxygenase and 5-lipoxygenase. DNP-lysine was added to cells previously stimulated with IgE/antigen to stop receptor aggregation and this greatly inhibited subsequent production of LTC4 following the addition of arachidonic acid, suggesting that ongoing stimulation of Fc epsilon XsRI was required for LTC4 synthesis in this setting. These results indicate that the magnitude of a physiologic stimulus (IgE/antigen) can profoundly affect the arachidonate metabolites produced by mast cells and that the synthesis of these metabolites quickly becomes limited by substrate availability rather than the activity of cyclooxygenase or 5-lipoxygenase.

Zileuton: the first 5-lipoxygenase inhibitor for the treatment of asthma

OBJECTIVE

To introduce and review zileuton, an orally active 5-lipoxygenase inhibitor that represents the first of a new class of medications to be used in the treatment of asthma.

DATA SOURCES

A MEDLINE search (from 1966 to December 1995) was performed to identify pertinent English-language literature.

STUDY SELECTION

Basic science studies on the pharmacokinetics of zileuton, its pathophysiologic effects on asthma, and clinical efficacy trials were reviewed.

DATA EXTRACTION

Clinical trials were emphasized. Studies from ex vivo or animal models of pharmacologic and pharmacodynamic effects were considered for review where no in vivo human data were available.

DATA SYNTHESIS

Zileuton has shown the ability to attenuate induced bronchospasm, produce some degree of bronchodilation, and provide antiinflammatory or steroid-sparing effects with both single doses (800 mg) and chronic treatment (400 and 600 mg qid). Zileuton has been studied in patients requiring daily inhaled beta-adrenergic agonist treatment; however, data from pediatric populations and comparisons with other asthma medications are limited at this time. Adverse effects include dyspepsia and elevated liver enzymes (incidence approximately 3%). One case of jaundice has been reported among the more than 5000 patients treated with zileuton. There is also some concern for drug interactions with hepatically cleared medications, such as theophylline.

CONCLUSIONS

Zileuton represents the first drug of a new treatment category for asthma, the 5-lipoxygenase inhibitors. Some people with asthma may receive considerable benefit, but as it is an entirely new drug entity, zileuton's final place in the hierarchy of asthma medications remains to be determined.

Theophylline: potential antiinflammatory effects in nocturnal asthma

BACKGROUND

Recent information suggests that one of the therapeutic properties of theophylline is an antiinflammatory effect.

OBJECTIVE

We evaluated this potential effect of theophylline in eight patients with nocturnal asthma.

METHODS

The study design was a randomized, double-blind, placebo-controlled crossover of 2-week treatment periods, separated by a 1-week washout period. Spirometry and bronchoscopy were performed.

RESULTS

Theophylline, compared with placebo, significantly improved the overnight decrement in lung function. The higher the nocturnal theophylline level, the greater the improvement in lung function. Theophylline also significantly decreased the percentage of neutrophils in the 4:00 AM bronchoalveolar lavage fluid and stimulated leukotriene B4 levels from macrophages obtained at 4:00 AM. The greater change in neutrophils correlated with increasing serum theophylline concentration. Also, the change in leukotriene B4 production was significantly correlated with the theophylline-induced decrement in lavage granulocytes (neutrophils and eosinophils).

CONCLUSION

This study suggests that one action of theophylline is to alter inflammatory cell number and function in nocturnal asthma and that it may do this through an leukotriene B4-mediated mechanism.

Peripheral airways responsiveness to cool, dry air in normal and asthmatic individuals

Peripheral airways resistance (Rp) has been shown to be increased in asymptomatic asthmatic patients with normal spirometric values, and to be correlated with airways hyperresponsiveness to methacholine. We investigated whether Rp in asthmatic subjects with exercise-induced bronchospasm (EIB) would rise in response to cool, dry air. Using a wedged bronchoscope technique, we challenged an isolated lung segment with high flows (500 to 1,000 ml/min) of cool (22 degrees C) dry 5% CO2 in air for 5 min in eight asthmatic subjects with EIB and eight normal subjects. Baseline Rp and Rp following challenge were measured with saturated air at 37 degrees C at a flow rate of 100 ml/min. Baseline Rp was significantly greater in the asthmatic (0.09; [0.05 to 0.23] cm H2O/ml/min; median [interquartile range]) than in the normal subjects (0.05; [0.03 to 0.07] cm H2O/ml/min) (p = 0.04). The asthmatic, but not the normal subjects, had a significant absolute maximal increase in Rp following cool, dry air (0.10 [0.03 to 0.15] cm H2O/ml/min) (p < 0.01). In the asthmatic subjects, baseline Rp correlated with airways hyperresponsiveness to exercise (r = -0.76, p = 0.03). We conclude that the peripheral airways of asthmatic individuals with EIB are responsive to cool, dry air, and may play an important role in EIB.

Methacholine challenge does not affect bronchoalveolar fluid cell number and many indices of cell function in asthma

Methacholine (MCh) challenge testing is often incorporated into clinical studies prior to performing bronchoscopy as a measure of bronchial hyperresponsiveness (BHR). However, the effect of methacholine on many aspects of bronchoalveolar lavage (BAL) fluid cell count and function have not been fully evaluated. Ten patients with asthma, maintained on inhaled beta 2-agonists, were studied. Each subject underwent two bronchoscopies in a random order, one preceded by methacholine challenge within 30 min of the BAL. The investigators were blinded to the regimen. Several markers of BAL fluid cell number and function were studied: cell count and differential histamine, eosinophil products, including eosinophil cationic protein and Charcot-Leyden crystal protein, macrophage production of thromboxane B2 and leukotriene B4, neutrophil lysozyme and lactoferrin, and lymphocyte typing and activation markers measured via flow cytometry. No significant differences were noted in any of these markers of cell number or function which could be ascribed to methacholine challenge. Thus, methacholine challenge does not appear to affect these markers of cell number and function. These findings indicate that a methacholine challenge can be used as a measure of bronchial hyperresponsiveness within 30 min prior to bronchoscopy without altering bronchoalveolar lavage fluid characteristics.

Effect of 5-lipoxygenase inhibition on bronchoconstriction and airway inflammation in nocturnal asthma

To investigate the contribution of leukotrienes (LTs) to inflammation and bronchoconstriction in nocturnal asthma, we performed a randomized trial in 12 asthmatic patients and 6 normal control subjects. This study involved pulmonary function testing, methacholine challenge, bronchoscopy for cell counts, LT and thromboxane (TX) levels in bronchoalveolar lavage (BAL) fluid, and collection of urine for LTs at 4:00 P.M. and 4:00 A.M. At 4:00 P.M. BAL fluid LTB4 and sulfidopeptide LT levels in asthmatic and control subjects were not statistically different. At 4:00 A.M. alone, LTB4 and cysteinyl LT levels increased to become significantly greater in asthmatic than in control subjects, LTB4 levels correlating significantly (r = -0.66, p < 0.0001) with nocturnal fall in FEV1. Nocturnal asthmatic urinary LTE4 levels were also significantly higher than those of control subjects. The 4:00 A.M. testing was repeated during treatment with a 5-lipoxygenase inhibitor, zileuton. In asthmatic subjects, zileuton decreased BAL fluid LTB4 (p = 0.01) and urinary LTE4 (p = 0.01) while showing a trend for improving nocturnal FEV1 (p = 0.086). These decreases in LTB4 levels and improvement in FVE1 were associated with significant reductions in 4 A.M. BAL fluid and blood eosinophil percentages on zileuton compared with placebo administration. These findings demonstrate the importance of LTs in both the inflammation and the physiology of nocturnal asthma.

Single oral dose of prednisone decreases leukotriene B4 production by alveolar macrophages from patients with nocturnal asthma but not control subjects: relationship to changes in cellular influx and FEV1

BACKGROUND

Nocturnal worsening of asthma is associated with an increase in numbers of airway inflammatory cells during the early morning. However, cell function during the night, with and without administration of steroids, has not been investigated.

OBJECTIVE

This study was designed to determine the effect of prednisone on pulmonary alveolar macrophage production of leukotriene B2 and thromboxane B2 at night and how it relates to changes in pulmonary function and cellular influx.

METHODS

Alveolar macrophages were obtained from patients with nocturnal asthma, patients with nonnocturnal asthma, and normal control subjects at 4:00 AM by bronchoalveolar lavage after administration of placebo and prednisone. Cells were placed in limited cell culture, and eicosanoids were measured from baseline and stimulated cells.

RESULTS

Patients with nocturnal asthma had both a significantly greater fall in forced expiratory volume in 1 second (FEV1) and a greater influx of neutrophils and eosinophils at 4:00 AM than normal subjects after placebo treatment, whereas patients with nonnocturnal asthma had intermediary responses. There was no difference in baseline or stimulated LTB4 production during placebo administration in the three groups. After prednisone treatment, there was an improvement in the nocturnal fall in FEV1 and a significant decrease in the neutrophil influx in patients with nocturnal asthma compared with the other groups. These changes were accompanied by a significant decrease in the stimulated LTB4 production in patients with nocturnal asthma compared with a small increase in both patients with nonnocturnal asthma and normal subjects. Thromboxane B2 production did not change. The decrease in LTB4 production was correlated with the fall in granulocytic cells and improvement in the nocturnal FEV1. However, the two variables with the greatest combined influence on the improvement in FEV1 were the decrease in stimulated LTB4 production and the fall in neutrophil influx.

CONCLUSIONS

We demonstrate for the first time that a single oral dose of prednisone decreases LTB4 production from alveolar macrophages, obtained at night from patients with nocturnal asthma, during a time of known inflammation. Further, this decrease in stimulated production is associated with decreases in cellular influx and improvement in pulmonary function.

Blood and bronchoalveolar lavage endothelin-1 levels in nocturnal asthma

Endothelin-1 (ET-1) is a potent endogenous vasoconstrictor that was recently shown to exhibit bronchoconstrictive properties in vitro. In asthmatic patients, the expression of ET-1 peptide was also shown to be increased in endobronchial biopsies. Thus, we postulated that ET-1 could be higher in subjects with nocturnal asthma. Bronchoalveolar lavage (BAL) fluid levels of ET-1 were measured in 10 subjects with nocturnal asthma and 6 normal volunteers at 0400 h (nighttime groups) and in an additional 7 subjects with nocturnal asthma and 6 control subjects at 1600 h (daytime groups). ET-1 levels were significantly lower in the nighttime asthmatic group (median 39.3 pg/mg protein, 7.3 to 44.0 IQ) than in the nighttime control group (median 77.4 pg/mg protein, 46.8 to 121.9 IQ; p = 0.01) or the daytime asthmatic group (median 56.8 pg/mg protein, 51.6 to 97.4 IQ; p = 0.04). ET-1 levels did not differ significantly between the daytime asthmatic and the daytime control groups or between control groups. Additionally, the overnight reduction in lung function was significantly correlated with lower BAL ET-1 levels (r = 0.57, p = 0.05). These results suggest that ET-1 plays a role in the overnight worsening of asthma and perhaps is more tightly tissue bound, resulting in lower levels of BAL fluid.

Asthma as an inflammatory disease

Asthma has been described primarily as an inflammatory process only in the last 5 to 10 years. Previously, it was thought of primarily as a disease of nerves and smooth muscle. This inflammatory process is now considered to be an immunologically initiated, mediator-driven event. The observation that asthma is associated with an inflammatory process in the lungs has dramatically changed our understanding of the pathophysiology and treatment of this disease. Like many other theories that have undergone a significant change in direction, it is possible that over the next few years the pendulum will begin to swing back. The nerves and smooth muscles may (or may not) be implicated directly again. It is conceivable that in addition to an inflammatory process, underlying alterations in the architecture of the lungs will also be found. These alterations might serve to amplify the effects of inflammation, thereby leading to the clinical manifestations of asthma.

Peritoneal lavage fluid alters patterns of eicosanoid production in murine bone marrow-derived and peritoneal macrophages: dependency on inflammatory state of the peritoneum

Murine resident macrophages produce an abundance of eicosanoids, whereas elicited macrophages produce lesser quantities of eicosanoids in general, and leukotriene C4 (LTC4) and prostacyclin (PGI2) in particular. Macrophage precursors derived from bone marrow cells produce even smaller amounts. We postulated that these differences may be regulated by substances found in the microenvironment of the cell, which may alter arachidonate release from phospholipid and its subsequent metabolism to eicosanoids. To examine if inherent differences in phospholipid availability contributed to the observed differences in eicosanoid synthesis among these three groups of macrophages, we monitored uptake and release of arachidonic acid (AA) in resident and elicited peritoneal macrophages and in bone marrow-derived macrophages (BMDM). Although differences existed in the extent of arachidonate release (37% vs. 22% vs. 27% release), the differences were not enough to explain the much larger differences in eicosanoid production. We therefore determined whether the AA cascade enzymes, including phospholipase A2 (PLA2) were intact by adding exogenous AA to the three cell types. PGI2 synthesis was not significantly increased in either elicited or BMDM. However, the enzymes necessary for LTC4 production appeared intact in elicited cells but not in BMDM. To further characterize the differences in eicosanoid synthesis between resident and elicited peritoneal macrophages and BMDM, we determined if a variety of exogenous substances [growth factors, cytokines, and noninflammatory and inflammatory peritoneal lavage fluid (NPLF and IPLF)] could enhance the production of LTC4 and PGI2 in those macrophage groups. The addition of granulocyte-macrophage colony stimulating factor (GM-CSF) slightly increased LTC4 production by BMDM and elicited macrophages. In contrast, NPLF increased the production of both LTC4 and PGI2 from BMDM, while IPLF had no effect. A similar effect of NPLF was seen on LTC4 (but not PGI2) production from elicited peritoneal cells, while IPLF decreased both LTC4 and PGI2 production from resident peritoneal macrophages. These studies indicate that substances found in the peritoneum of mice can enhance or diminish the production of LTC4 and PGI2 from the macrophage. This regulation appears to depend on the inflammatory state of the peritoneum.

Inactivation of leukotriene C4 in the airways and subsequent urinary leukotriene E4 excretion in normal and asthmatic subjects

Leukotrienes (LT) are synthesized in the lung during asthmatic reactions and mediate certain inflammatory symptoms. Pulmonary metabolism and clearance of exogenously added peptidoleukotrienes were studied in nonasthmatics, asthmatics, and asthmatics challenged with allergen. [3H]LTC4 and [14C]dextran were instilled into the airways, and bronchoalveolar lavage fluid (BALF) was obtained 15 min later. After comparing the [3H]/[14C] ratio of the instilled solution with that in BALF, 77% of LT were found to have been removed from the airways of nonasthmatics, and 72% of unchallenged asthmatics. Allergen administration to asthmatics 1 min before LT instillation inhibited LT transfer out of the airways by 26%, compared with asthmatics not challenged with allergen. This decrease in the removal of LT from the airways during allergic reactions could potentiate the physiologic effects of LT produced in the airways. The predominant LT in BALF was LTE4, constituting 56% of the LT in asthmatics and 61% in nonasthmatics. The percentage of LTE4 in BALF increased to 87% in allergen-stimulated asthmatics (p < 0.05 compared with the two other groups), this again reflecting decreased transfer of LT out of the lung rather than an increase in metabolism. Urinary excretion of LT metabolites occurred rapidly, the majority being excreted excreted within 6 h after instillation. LTE4, the major urinary LT metabolite identified by high-performance liquid chromatography, was a similar percentage concentration in the three groups and, thus, can be accurately used as an index of LT synthesis.

Inflammatory cells and eicosanoid mediators in subjects with late asthmatic responses and increases in airway responsiveness

To determine the relationship of inflammatory cells and eicosanoid mediators to the pathogenesis of the late asthmatic response (LAR) and increases in nonspecific airway responsiveness, we studied bronchoalveolar lavage (BAL) cells and fluid in 27 subjects 12 hours after inhaled antigen challenge. Methacholine challenge was performed before antigen challenge and 24 hours later (12 hours after BAL). Eight subjects had no LAR (-LAR, less than or equal to 10% fall in FEV1), nine subjects had an equivocal LAR (+/- LAR, 11% 25% fall in FEV1), and 10 subjects had a definite LAR (+LAR, greater than 25% fall in FEV1). Subjects developing +LAR had increased airway responsiveness at baseline compared with that of subjects developing an +/- LAR, but not with subjects having -LAR. If airway responsiveness was markedly increased at baseline, further increases after antigen challenge were often not observed. We found that both percent neutrophils and eosinophils increased in BAL as the severity of the LAR increased, but significant differences between the groups with -LAR and +LAR were only observed when both cell types were considered together. In addition, there was a significant correlation between the combined cell percentages and the severity of the LAR as determined by fall in FEV1. Likewise, increases in airway responsiveness were associated with significant increases in both neutrophil and eosinophil numbers, but only neutrophils correlated with the change in airway responsiveness after antigen challenge. However, despite the significant physiologic and cellular differences that we found between our groups, no significant differences could be found in BAL eicosanoid-mediator concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

Urinary leukotriene E4 in patients with asthma. Effect of airways reactivity and sodium cromoglycate

A group of 17 patients with allergic asthma was challenged with aerosolized antigen, and the excretion of the peptidoleukotriene metabolite leukotriene (LT) E4 in the urine was determined as an index of leukotriene synthesis. The allergen challenge caused a drop in FEV1 of 25 to 59% within the first 2 h in all patients. This was associated with an increase in urine LTE4 excretion during the subsequent 12 h. The amount of urinary LTE4 excreted increased from a 12-h baseline level of 46 +/- 6.8 ng to a postallergen challenge level of 92 +/- 13 ng. In a similar experimental protocol methacholine challenge alone did not significantly increase urinary LTE4 excretion. In comparing all individuals as a group, there was no significant positive correlation between the magnitude of the drop in FEV1 during the immediate asthmatic response (IAR) and the increased amount of LTE4 excreted in the urine (p = 0.08). These parameters were still not significantly correlated when airways reactivity (log PC20) was also considered (p = 0.057). However, when each individual was compared to self in the presence and absence of cromoglycate, a significant correlation was found to exist between the drop in FEV1 during the IAR, the excretion of urinary LTE4, and the airways reactivity. No correlation was found between the increase in urine LTE4 excreted during the 12 h following allergen challenge and the severity of late (3 to 12 h) responses to allergen, but there was a significant prolonged (12 to 36 h) elevated urine LTE4 excretion in those patients with the most severe late asthmatic response.(ABSTRACT TRUNCATED AT 250 WORDS)

Bronchoalveolar lavage fluid mediator levels 5 minutes after allergen challenge in atopic subjects with asthma: relationship to the development of late asthmatic responses

Inflammatory mediators have been implicated in the pathogenesis of human asthma and have been demonstrated to increase in bronchoalveolar lavage fluid during the time of the immediate asthmatic response (IAR) after allergen instillation in the lungs. However, the relationship of these mediators, measured early to the late asthmatic response (LAR), airway reactivity, and clinical asthma, is unknown. In the present study, we evaluated mediator levels in bronchoalveolar lavage fluid before and 5 minutes after allergen challenge from three subject groups: atopic subjects without asthma (N = 7), atopic subjects with asthma and without LAR [-) LAR) (N = 6), and atopic subjects with asthma and with LAR [+) LAR) (N = 6). Subjects with asthma were differentiated into subjects with and without LARs based on at least a 15% decrease in FEV1 between 3 to 8 hours postallergen inhalation. The mediators, prostaglandin D2 thromboxane B2 leukotriene C4 (LTC4), and histamine, were measured both before and after allergen instillation. Baseline prechallenge levels were similar, except in the case of LTC4. LTC4 was detectable at baseline significantly more frequently in the atopic subjects with asthma with and without LAR when these subjects were compared to the atopic subjects without asthma (nine of 12 detectable versus one of seven detectable). In all groups, significant increases in mediator levels were observed in the groups with asthma postallergen challenge, compared to the atopic subjects without asthma. Atopic subjects with asthma and without LAR had significantly higher levels of all four mediators after challenge than atopic subjects with asthma and with LAR and atopic subjects without asthma.(ABSTRACT TRUNCATED AT 250 WORDS)

Elevated levels of leukotriene C4 in bronchoalveolar lavage fluid from atopic asthmatics after endobronchial allergen challenge

Sulfidopeptide leukotrienes have been implicated in the pathogenesis of asthma because of their ability to induce bronchospasm, airways hyperreactivity, and increased mucus production. In the present study, the leukotrienes (LT) C4, D4, and E4 were measured in bronchoalveolar lavage fluid (BALF) before and 5 min after endobronchial allergen challenge in four subject groups: nonatopic nonasthmatic, nonatopic asthmatic, atopic nonasthmatic, and atopic asthmatic. As determined by high performance liquid chromatography (HPLC), after allergen challenge, the predominant sulfidopeptide leukotriene found in BALF from atopic asthmatics was LTC4. Smaller amounts of LTD4 and LTE4 were detectable. The baseline level of leukotrienes in the atopic asthmatics was 64 +/- 18 pg/ml, with measurable levels being found in nine of 11 samples. Atopic nonasthmatics had measurable levels in only one of seven baseline samples, whereas five of six nonatopic subjects had undetectable levels. Allergen challenge in atopic asthmatics resulted in significant increases in LTC4 over prechallenge levels (64 +/- 18 to 616 +/- 193 pg/ml) (p less than 0.01) and over levels in the three control groups after challenge (p = 0.0297). The atopic nonasthmatic group also had detectable leukotriene levels after allergen challenge (88 +/- 32 pg/ml), whereas leukotrienes remained undetectable in five of the six nonatopic samples. For comparison, histamine and the prostanoids prostaglandin D2 (PGD2) and thromboxane B2 (TxB2) were also measured in BALF. The levels of all three of these mediators increased in BALF from atopic asthmatics after allergen challenge. After allergen challenge, the best correlation was found between the levels in BALF for the prostanoids PGD2 and TxB2 (r = 0.88).(ABSTRACT TRUNCATED AT 250 WORDS)

Measurement of peptidoleukotrienes in biological fluids

Samples of human bronchoalveolar lavage fluid (BALF) and urine were utilized to demonstrate methods for quantitation and validation of leukotrienes (LTs). These methods utilize an enzyme immunoassay (EIA) that uses commercially available reagents, the antibody recognizing LTC4, LTD4, LTE4, and N-acetyl LTE4. BALF containing epithelial lining fluid was collected from atopic asthmatics both before and 5 min after the subjects had been challenged with a local instillation of allergen into the airways. BALF samples collected without allergen challenge had low levels of immunoreactive LTs, whereas samples collected after allergen were markedly elevated. After high-performance liquid chromatography (HPLC) separation of LTs, EIA revealed the presence of LTC4. The identity was validated by incubating LTC4 with a bovine gamma-glutamyl transpeptidase with dipeptidase activity that converted added [3H]-LTC4 as well as LTC4 immunoreactivity to LTE4. Urine samples collected from six healthy volunteers, one patient with adult respiratory distress syndrome (ARDS), and three patients in status asthmaticus were also analyzed for LTs. After HPLC separation of LTs and quantitation by EIA, urine samples from healthy subjects were found to have low but measurable LTE4. In contrast, the urine samples from the patients in status asthmaticus and from the ARDS patient had large elevations of LTE4 levels compared with healthy subjects. When the HPLC fractions containing [3H]LTE4 and LT immunoreactivity in the ARDS sample were treated with acetic anhydride, HPLC analysis indicated that both radiolabel and immunoreactivity now eluted at the retention time of N-acetyl LTE4, the derivatized product of LTE4. The methods described are relatively easy and can be used to measure and validate the existence of peptidoleukotrienes in biological samples.

Spectrum of prostanoid release after bronchoalveolar allergen challenge in atopic asthmatics and in control groups. An alteration in the ratio of bronchoconstrictive to bronchoprotective mediators

Prostanoids have been implicated in the pathogenesis of asthma because of their potential role in the modulation of airway tone. In the present study, the bronchoconstrictors prostaglandin D2 (PGD2) and thromboxane (TX), and those prostanoids able to protect against bronchoconstriction, prostaglandin E2 (PGE2), and the stable metabolite of prostacyclin, 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha), were measured in bronchoalveolar lavage fluid (BALF) before and 5 min after endobronchial allergen challenge in four subject groups: nonatopic nonasthmatics (n = 6), nonatopic asthmatics (n = 3), atopic nonasthmatics (n = 9), and atopic asthmatics (n = 8). There were no significant differences in prechallenge prostanoid levels between the four groups, with the potentially bronchoprotective mediators present in highest concentration. Allergen challenge in atopic asthmatics resulted in significant increases (p less than 0.05) in PGD2 (97.4 +/- 19.4 to 1,053.2 +/- 338.6 pg/ml, mean +/- SEM) and TX (45.5 +/- 7.5 to 150.7 +/- 37.8 pg/ml) over prechallenge levels and control groups. Similarly, histamine increased in the atopic asthmatics after challenge (0.36 +/- 0.22 to 6.84 +/- 1.86 ng/ml; p less than 0.05). Atopic nonasthmatics had slight increases in PGD2 (96.9 +/- 25.4 to 219.7 +/- 47.5 pg/ml; p greater than 0.1) after challenge, whereas PGD2 and TX did not change in nonatopic subjects. A significant positive correlation was found between histamine, PGD2, and TX levels after challenge among all groups (p less than 0.001). There were no significant changes among the four groups after allergen challenge in 6-keto-PGF1 alpha or PGE2.(ABSTRACT TRUNCATED AT 250 WORDS)

Activation of pulmonary mast cells by bronchoalveolar allergen challenge. In vivo release of histamine and tryptase in atopic subjects with and without asthma

Human mast cells likely play a significant role in human asthma. In the present study, concentrations of tryptase and histamine in bronchoalveolar lavage fluid (BALF) were used as indicators of pulmonary mast cell activation. BALF was obtained before and after endobronchial allergen challenge and assessed for mediator content and cell composition in 4 subject groups: nonatopic nonasthmatics (Group 1, n = 7), nonatopic asthmatics (Group 2, n = 3), atopic nonasthmatics (Group 3, n = 7), and atopic asthmatics (Group 4, n = 7). Before challenge, histamine concentrations were not different between the 4 groups, whereas tryptase concentrations were significantly greater in the atopic asthmatics than in each of the other groups (p less than 0.04). Allergen challenge in atopic asthmatics resulted in significant increases above baseline in mean +/- SD histamine (0.7 +/- 7.1 to 2.8 +/- 2.0 ng/ml) and tryptase (2.0 +/- 1.7 to 10.1 +/- 8.2 ng/ml) concentrations in BALF (p less than 0.03). Atopic nonasthmatics also had increases above baseline in histamine (0.2 +/- 0.2 to 1.2 +/- 1.4 ng/ml) and tryptase (0.5 +/- 0.4 to 1.4 +/- 1.03 ng/ml) concentrations after allergen challenge (p less than 0.05). Though the histamine values were not significantly different between atopic nonasthmatics and atopic asthmatics after allergen challenge, tryptase concentrations were markedly higher in the atopic asthmatic group. The numbers, as well as the predominance of the T mast cell type in atopic asthmatics and nonasthmatics, were no different from controls. In nonatopic subjects, regardless of asthmatic state, histamine or tryptase concentrations were not altered by allergen challenge.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of two indices of glycemic control in diabetic subjects: glycosylated serum protein and hemoglobin

Glycosylated serum protein (GSP) and glycosylated hemoglobin (GHb) were measured in 263 insulin-dependent and 41 non-insulin-dependent diabetic subjects. Both indices provided useful information in type II diabetes, but were extremely poor in judging control in type I diabetes. In both groups, there was poor correlation of the fasting serum glucose with either GSP or GHb. Only 4% of type I diabetic subjects had normal values for both GSP and GHb. Of subjects with elevated GSP, 98% had elevated GHb; 25% of subjects with elevated GHb values had normal values for GSP.

Effect of lesions of the locus coeruleus complex on the circadian rhythm of plasma corticosterone in the mouse

An apparently transient elevation of basal morning (08.00 h) plasma corticosterone levels in male mice was found 48 h after bilateral electrolytic lesions of the brainstem locus coeruleus complex but was not observed 6 weeks after lesioning.