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Fu Y, Jia W, Zhang N, Wang Z, Zhang N, Wang T, Zhang N, Xu J, Yang X, Zhang Q, Li C, Zhang X, Yang W, Han B, Zhang L, Tang N, Bai Z. Sources, trigger points, and effect size of associations between PM 2.5-bound polycyclic aromatic hydrocarbons (PAHs) and fractional exhaled nitric oxide (FeNO): A panel study with 16 follow-up visits over 4 years. CHEMOSPHERE 2024; 360:142459. [PMID: 38810807 DOI: 10.1016/j.chemosphere.2024.142459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 05/03/2024] [Accepted: 05/25/2024] [Indexed: 05/31/2024]
Abstract
Exposure to fine particulate matter (PM2.5) is a significant concern for respiratory health. However, the sources, trigger points, and effect size of specific associations between PM2.5 components, particularly polycyclic aromatic hydrocarbons (PAHs) and the airway inflammatory marker fractional exhaled nitric oxide (FeNO) have not been fully explored. In this study, 69 healthy college students were enrolled and followed up 16 times from 2014 to 2018. Individual FeNO was measured and ambient air PM2.5 samples were collected for 7 consecutive days before each follow-up. PAHs were quantified using Gas Chromatography-Mass Spectrometry. Linear mixed-effect regression models were employed to evaluate the associations between PM2.5-bound PAHs and FeNO. Additionally, PMF (Positive Matrix Factorization) was utilized to identify sources of PM2.5-bound PAHs and assess their impact on FeNO. Throughout the study, the average (SD) of ΣPAHs concentrations was 78.50 (128.9) ng/m3. PM2.5 and PM2.5-bound PAHs were significantly associated with FeNO at various lag days. Single-day lag analyses revealed maximum effects of PM2.5 on FeNO, with an increase of 7.71% (95% CI: 4.67%, 10.83%) per interquartile range (IQR) (48.10 μg/m3) increase of PM2.5 at lag2, and ΣPAHs showed a maximum elevation in FeNO of 6.40% (95% CI: 2.33%, 10.63%) at lag4 per IQR (57.39 ng/m3) increase. Individual PAHs exhibited diversity peak effects on FeNO at lag3 (6 of 17), lag4 (9 of 17) in the single-day model, and lag0-5 (8 of 17) (from lag0-1 to lag0-6) in the cumulative model. Source apportionment indicated coal combustion as the primary contributor (accounting for 30.7%). However, a maximum effect on FeNO (an increase of 21.57% (95% CI: 13.58%, 30.13%) per IQR increase) was observed with traffic emissions at lag4. The findings imply that strategic regulation of particular sources of PAHs, like traffic emissions, during specific periods could significantly contribute to safeguarding public health.
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Affiliation(s)
- Yucong Fu
- Department of Occupational and Environmental Health, School of Public Health, Tianjin Medical University, Tianjin, 300070, China; Tianjin Key Laboratory of Environment, Nutrition, and Public Health, Tianjin Medical University, Tianjin, 300070, China; Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, 300070, China
| | - Wenhui Jia
- Department of Occupational and Environmental Health, School of Public Health, Tianjin Medical University, Tianjin, 300070, China; Tianjin Key Laboratory of Environment, Nutrition, and Public Health, Tianjin Medical University, Tianjin, 300070, China; Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, 300070, China; Department of Nutrition and Food Science, School of Public Health, Tianjin Medical University, Tianjin, 300070, China
| | - Ningyu Zhang
- Department of Occupational and Environmental Health, School of Public Health, Tianjin Medical University, Tianjin, 300070, China; Tianjin Key Laboratory of Environment, Nutrition, and Public Health, Tianjin Medical University, Tianjin, 300070, China; Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, 300070, China
| | - Zhiyu Wang
- Department of Occupational and Environmental Health, School of Public Health, Tianjin Medical University, Tianjin, 300070, China; Tianjin Key Laboratory of Environment, Nutrition, and Public Health, Tianjin Medical University, Tianjin, 300070, China; Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, 300070, China
| | - Nan Zhang
- Department of Occupational and Environmental Health, School of Public Health, Tianjin Medical University, Tianjin, 300070, China; Tianjin Key Laboratory of Environment, Nutrition, and Public Health, Tianjin Medical University, Tianjin, 300070, China; Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, 300070, China
| | - Tong Wang
- Department of Occupational and Environmental Health, School of Public Health, Tianjin Medical University, Tianjin, 300070, China; Tianjin Key Laboratory of Environment, Nutrition, and Public Health, Tianjin Medical University, Tianjin, 300070, China; Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, 300070, China
| | - Nan Zhang
- State Key Laboratory of Environmental Criteria and Risk Assessment, Chinese Research Academy of Environmental Sciences, Beijing, 100012, China
| | - Jia Xu
- State Key Laboratory of Environmental Criteria and Risk Assessment, Chinese Research Academy of Environmental Sciences, Beijing, 100012, China
| | - Xueli Yang
- Department of Occupational and Environmental Health, School of Public Health, Tianjin Medical University, Tianjin, 300070, China; Tianjin Key Laboratory of Environment, Nutrition, and Public Health, Tianjin Medical University, Tianjin, 300070, China; Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, 300070, China
| | - Qiang Zhang
- Department of Occupational and Environmental Health, School of Public Health, Tianjin Medical University, Tianjin, 300070, China; Tianjin Key Laboratory of Environment, Nutrition, and Public Health, Tianjin Medical University, Tianjin, 300070, China; Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, 300070, China
| | - Changping Li
- Epidemiology and Biostatistics Institute, School of Public Health, Tianjin Medical University, Tianjin, 300070, China
| | - Xumei Zhang
- Tianjin Key Laboratory of Environment, Nutrition, and Public Health, Tianjin Medical University, Tianjin, 300070, China; Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, 300070, China; Department of Nutrition and Food Science, School of Public Health, Tianjin Medical University, Tianjin, 300070, China
| | - Wen Yang
- State Key Laboratory of Environmental Criteria and Risk Assessment, Chinese Research Academy of Environmental Sciences, Beijing, 100012, China
| | - Bin Han
- State Key Laboratory of Environmental Criteria and Risk Assessment, Chinese Research Academy of Environmental Sciences, Beijing, 100012, China
| | - Liwen Zhang
- Department of Occupational and Environmental Health, School of Public Health, Tianjin Medical University, Tianjin, 300070, China; Tianjin Key Laboratory of Environment, Nutrition, and Public Health, Tianjin Medical University, Tianjin, 300070, China; Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, 300070, China.
| | - Naijun Tang
- Department of Occupational and Environmental Health, School of Public Health, Tianjin Medical University, Tianjin, 300070, China; Tianjin Key Laboratory of Environment, Nutrition, and Public Health, Tianjin Medical University, Tianjin, 300070, China; Center for International Collaborative Research on Environment, Nutrition and Public Health, Tianjin, 300070, China
| | - Zhipeng Bai
- State Key Laboratory of Environmental Criteria and Risk Assessment, Chinese Research Academy of Environmental Sciences, Beijing, 100012, China
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Ji N, Baptista A, Yu CH, Cepeda C, Green F, Greenberg M, Mincey IC, Ohman-Strickland P, Fiedler N, Kipen HM, Laumbach RJ. Traffic-related air pollution, chronic stress, and changes in exhaled nitric oxide and lung function among a panel of children with asthma living in an underresourced community. THE SCIENCE OF THE TOTAL ENVIRONMENT 2024; 912:168984. [PMID: 38040352 DOI: 10.1016/j.scitotenv.2023.168984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/24/2023] [Accepted: 11/27/2023] [Indexed: 12/03/2023]
Abstract
We examined associations between short-term exposure to traffic-related air pollutants (TRAP) and airway inflammation and lung function in children with asthma, and whether these associations are modified by chronic psychological stress. Residents of underresourced port-adjacent communities in New Jersey were concerned about the cumulative impacts of exposure to TRAP, particularly diesel-engine truck emissions, and stress on exacerbation of asthma among children. Children with asthma aged 9-14 (n = 35) were recruited from non-smoking households. We measured each participant's (1) continuous personal exposure to black carbon (BC, a surrogate of TRAP) at 1-min intervals, (2) 24-h integrated personal exposure to nitrogen dioxide (NO2), (3) daily fractional exhaled nitric oxide (FeNO), and (4) lung function for up to 30 consecutive days. Personal BC was recorded by micro-aethalometers. We measured daily FeNO using the NIOX MINO, forced expiratory volume in one second (FEV1), and forced vital capacity (FVC) using Easy One Frontline spirometers. Chronic stress was measured with the UCLA Life Stress Interview for Children. The association was examined using linear mixed-effect models. In the fully adjusted model, an interquartile range (IQR) increase in BC at lag 0-6 h before the FeNO measurement was associated with 8 % (95 % CI: 3 % - 12 %) increase in FeNO, whereas an IQR increase in BC at lag 7-12 h and lag 0-24 h were associated with 6 % (95 % CI: 2 % - 11 %) and 7 % (2 % - 12 %) FeNO increases, respectively. There were no significant lung function changes per IQR increase in BC. No interactions were observed between chronic stress and BC on FeNO. Chronic stress was negatively associated with individual average FeNO levels. Our findings suggest that higher levels of BC exposure within the prior 24 h increased airway inflammation levels in children with asthma, with the strongest effect observed within the first 6 h.
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Affiliation(s)
- N Ji
- Rutgers, The State University of New Jersey, Piscataway, NJ, United States of America
| | - A Baptista
- The New School, New York, NY, United States of America
| | - C H Yu
- Rutgers, The State University of New Jersey, Piscataway, NJ, United States of America; New Jersey Department of Health, Trenton, NJ, United States of America
| | - C Cepeda
- Rutgers, The State University of New Jersey, Piscataway, NJ, United States of America
| | - F Green
- Rutgers, The State University of New Jersey, Piscataway, NJ, United States of America
| | - M Greenberg
- The New School, New York, NY, United States of America
| | - I Colon Mincey
- Ironbound Community Corporation, Newark, NJ, United States of America
| | - P Ohman-Strickland
- Rutgers, The State University of New Jersey, Piscataway, NJ, United States of America
| | - N Fiedler
- Rutgers, The State University of New Jersey, Piscataway, NJ, United States of America
| | - H M Kipen
- Rutgers, The State University of New Jersey, Piscataway, NJ, United States of America
| | - R J Laumbach
- Rutgers, The State University of New Jersey, Piscataway, NJ, United States of America.
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Michils A, Akset M, Haccuria A, Perez-Bogerd S, Malinovschi A, Van Muylem A. The Impact of Airway Obstruction on Feno Values in Asthma Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:111-117. [PMID: 37634805 DOI: 10.1016/j.jaip.2023.08.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 07/20/2023] [Accepted: 08/16/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Exhaled nitric oxide (Feno) is used as a marker of type-2 airway inflammation in asthma management. Studies with airway challenges demonstrated that a reduction in airway caliber decreases Feno levels. OBJECTIVE To evaluate the impact of airway caliber reduction occurring spontaneously in patients with asthma on Feno values in daily clinical practice. METHODS In this post hoc analysis, Feno, FEV1, and asthma control questionnaire scores were recorded on each visit for 120 (1073 visits) adult patients with asthma. Blood eosinophils were measured intermittently. The intraindividual relationship between Feno and FEV1 was evaluated via a linear mixed model. The determinants of the individual mean Feno were measured by a stepwise multivariate linear model including individual mean FEV1, inhaled corticosteroid dose, asthma control questionnaire score, and blood eosinophils. RESULTS Variations in the negative Feno-FEV1 relationship within individuals at different times were significantly determined by the individual's mean FEV1. This relationship did not hold for individuals above the 75th and below the 25th quartiles. The best explanatory variables for individual mean Feno were FEV1 (+4.3 parts per billion/10%pred) and blood eosinophil count (+1 part per billion per 100 cells/mm3). DISCUSSION In the presence of variable degrees of heterogeneous patterns of airway inflammation, airway caliber is shown to be an independent and significant determinant of Feno when measured in patients with asthma. We would propose a +4-parts-per-billion correction factor to the measured Feno value for each 10% reduction below 100% predicted FEV1. Doing this should improve the rigor of interpretation of Feno as an indicator of type-2 inflammation in patients with low FEV1.
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Affiliation(s)
- Alain Michils
- Chest Department, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Maud Akset
- Chest Department, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Amaryllis Haccuria
- Chest Department, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Silvia Perez-Bogerd
- Chest Department, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - Andreï Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Alain Van Muylem
- Chest Department, Erasme University Hospital, Université libre de Bruxelles, Brussels, Belgium.
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Ko FWS, Chan KP, Ng JKC, Ngai JCL, Yip WH, Lo RLP, Chan TO, Hui DSC. 1-Year Prospective Study of the Relationship of Serial Exhaled Nitric Oxide Level and Asthma Control. J Asthma Allergy 2023; 16:725-734. [PMID: 37469451 PMCID: PMC10353557 DOI: 10.2147/jaa.s417117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 06/30/2023] [Indexed: 07/21/2023] Open
Abstract
Background and Objective Previous studies found that the fractional nitric oxide concentration in exhaled breath (FeNO) levels in healthy Chinese adults was higher than in White adults. More understanding of serial changes of FeNO levels with asthma control in a real-life clinical setting would be important to explore the utility of this biomarker in routine asthma management. This study assessed the FeNO levels of Chinese asthma subjects with different levels of asthma control and the serial changes with respect to the changes in asthma control over 1 year. Methods A 12-month prospective study (subjects recruited between November 2019 and January 2021) with serial measurement of FeNO levels at baseline, 4, 8 and 12 months. Asthma control was assessed by the Global Initiative for Asthma classification, Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ). Results Altogether, 136 subjects (mean age 51.51±15.09 years, 46[33.8%] male) had successful baseline FeNO measurements. At baseline, the FeNO levels did not show a statistically significant difference for controlled, partly controlled and uncontrolled asthma according to GINA classification, ACT and ACQ. FeNO levels decreased with improving asthma control and stayed at similar levels with unchanged or worsening asthma control for all subjects. For subjects with baseline blood eosinophil levels ≥300 cells/µL(n=59), FeNO levels decreased with improving asthma control, stayed similar without change for asthma control and increased with worsening asthma control. Receiver operating characteristic (ROC) analysis with the highest area under curve (AUC) for changes in FeNO levels for improving asthma control was between ≤ -10 to -25 ppb at various time points in the 12-month study. Conclusion Changes in FeNO levels over time were associated with changes in clinical asthma control, particularly in those with higher blood eosinophil count and are likely more useful than a single time point measurement in managing asthma.
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Affiliation(s)
- Fanny Wai San Ko
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Ka Pang Chan
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Joyce Ka Ching Ng
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Jenny C L Ngai
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Wing Ho Yip
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Rachel Lai Ping Lo
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - Tat On Chan
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, People’s Republic of China
| | - David Shu Cheong Hui
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong, People’s Republic of China
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McClean N, Hasday JD, Shapiro P. Progress in the development of kinase inhibitors for treating asthma and COPD. ADVANCES IN PHARMACOLOGY (SAN DIEGO, CALIF.) 2023; 98:145-178. [PMID: 37524486 DOI: 10.1016/bs.apha.2023.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Current therapies to mitigate inflammatory responses involved in airway remodeling and associated pathological features of asthma and chronic obstructive pulmonary disease (COPD) are limited and largely ineffective. Inflammation and the release of cytokines and growth factors activate kinase signaling pathways that mediate changes in airway mesenchymal cells such as airway smooth muscle cells and lung fibroblasts. Proliferative and secretory changes in mesenchymal cells exacerbate the inflammatory response and promote airway remodeling, which is often characterized by increased airway smooth muscle mass, airway hyperreactivity, increased mucus secretion, and lung fibrosis. Thus, inhibition of relevant kinases has been viewed as a potential therapeutic approach to mitigate the debilitating and, thus far, irreversible airway remodeling that occurs in asthma and COPD. Despite FDA approval of several kinase inhibitors for the treatment of proliferative disorders, such as cancer and inflammation associated with rheumatoid arthritis and ulcerative colitis, none of these drugs have been approved to treat asthma or COPD. This review will provide a brief overview of the role kinases play in the pathology of asthma and COPD and an update on the status of kinase inhibitors currently in clinical trials for the treatment of obstructive pulmonary disease. In addition, potential issues associated with the current kinase inhibitors, which have limited their success as therapeutic agents in treating asthma or COPD, and alternative approaches to target kinase functions will be discussed.
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Affiliation(s)
- Nathaniel McClean
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, MD, United States
| | - Jeffery D Hasday
- Department of Medicine, Division of Pulmonary Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Paul Shapiro
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, MD, United States.
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Crespo-Lessmann A, Curto E, Mateus Medina EF, Palones E, Belda Soler A, Sánchez Maza S, Soto-Retes L, Plaza V. Characteristics of Induced-Sputum Inflammatory Phenotypes in Adults with Asthma: Predictors of Bronchial Eosinophilia. J Asthma Allergy 2023; 16:95-103. [PMID: 36699564 PMCID: PMC9869783 DOI: 10.2147/jaa.s389402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/19/2022] [Indexed: 01/19/2023] Open
Abstract
Purpose The objectives of this study were, for patients attending a specialist asthma clinic at a tertiary care hospital, to determine, from sputum induction (SI), proportions of bronchial inflammatory phenotypes, demographic, clinical and functional characteristics of each phenotype, and the most accessible non-invasive inflammatory marker that best discriminates between phenotypes. Patients and Methods Included were 96 patients with asthma, attending a specialist asthma clinic at a tertiary care hospital, who underwent testing as follows: SI, spirometry, fractional exhaled nitric oxide (FeNO), blood eosinophilia, total immunoglobulin E (IgE), and a skin prick test. Results SI phenotypes were 46.9% eosinophilic, 33.3% paucigranulocytic, 15.6% neutrophilic, and 4.2% mixed. No significantly different clinical or functional characteristics were observed between the phenotypes. A positive correlation was observed between SI eosinophilia and both emergency visits in the last 12 months (p = 0.041; r = 0.214) and FeNO values (p = 0.000; r = 0.368). Blood eosinophilia correlated with SI eosinophilia (p = 0.001; r = 0.362) and was the best predictor of bronchial eosinophilia, followed by FeNO, and total blood IgE (area under the receiver operating characteristic curve (AUC-ROC) 72%, 65%, and 53%, respectively), although precision was only fair. Conclusion In consultations for severe asthma, the most frequent phenotype was eosinophilic. Peripheral blood eosinophilia is a reliable marker for discriminating between different bronchial inflammatory phenotypes, is useful in enabling doctors to select a suitable biologic treatment and so prevent asthma exacerbation, and is a better predictor of bronchial eosinophilia than FeNO and IgE values.
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Affiliation(s)
- Astrid Crespo-Lessmann
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d’Investigació Biomédica Sant Pau, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elena Curto
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d’Investigació Biomédica Sant Pau, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eder Freddy Mateus Medina
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d’Investigació Biomédica Sant Pau, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Esther Palones
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d’Investigació Biomédica Sant Pau, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alicia Belda Soler
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d’Investigació Biomédica Sant Pau, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Soraya Sánchez Maza
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d’Investigació Biomédica Sant Pau, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Lorena Soto-Retes
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d’Investigació Biomédica Sant Pau, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Vicente Plaza
- Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Institut d’Investigació Biomédica Sant Pau, Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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Guida G, Bagnasco D, Carriero V, Bertolini F, Ricciardolo FLM, Nicola S, Brussino L, Nappi E, Paoletti G, Canonica GW, Heffler E. Critical evaluation of asthma biomarkers in clinical practice. Front Med (Lausanne) 2022; 9:969243. [PMID: 36300189 PMCID: PMC9588982 DOI: 10.3389/fmed.2022.969243] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
The advent of personalized medicine has revolutionized the whole approach to the management of asthma, representing the essential basis for future developments. The cornerstones of personalized medicine are the highest precision in diagnosis, individualized prediction of disease evolution, and patient-tailored treatment. To this aim, enormous efforts have been established to discover biomarkers able to predict patients' phenotypes according to clinical, functional, and bio-humoral traits. Biomarkers are objectively measured characteristics used as indicators of biological or pathogenic processes or clinical responses to specific therapeutic interventions. The diagnosis of type-2 asthma, prediction of response to type-2 targeted treatments, and evaluation of the risk of exacerbation and lung function impairment have been associated with biomarkers detectable either in peripheral blood or in airway samples. The surrogate nature of serum biomarkers, set up to be less invasive than sputum analysis or bronchial biopsies, has shown several limits concerning their clinical applicability. Routinely used biomarkers, like peripheral eosinophilia, total IgE, or exhaled nitric oxide, result, even when combined, to be not completely satisfactory in segregating different type-2 asthma phenotypes, particularly in the context of severe asthma where the choice among different biologics is compelling. Moreover, the type-2 low fraction of patients is not only an orphan of biological treatments but is at risk of being misdiagnosed due to the low negative predictive value of type-2 high biomarkers. Sputum inflammatory cell analysis, considered the highest specific biomarker in discriminating eosinophilic inflammation in asthma, and therefore elected as the gold standard in clinical trials and research models, demonstrated many limits in clinical applicability. Many factors may influence the measure of these biomarkers, such as corticosteroid intake, comorbidities, and environmental exposures or habits. Not least, biomarkers variability over time is a confounding factor leading to wrong clinical choices. In this narrative review, we try to explore many aspects concerning the role of routinely used biomarkers in asthma, applying a critical view over the "state of the art" and contemporarily offering an overview of the most recent evidence in this field.
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Affiliation(s)
- Giuseppe Guida
- Severe Asthma and Rare Lung Disease Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Turin, Italy
| | - Diego Bagnasco
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, Department of Internal Medicine (DIMI), University of Genoa, Genoa, Italy
| | - Vitina Carriero
- Severe Asthma and Rare Lung Disease Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Turin, Italy
| | - Francesca Bertolini
- Severe Asthma and Rare Lung Disease Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Turin, Italy
| | - Fabio Luigi Massimo Ricciardolo
- Severe Asthma and Rare Lung Disease Unit, Department of Clinical and Biological Sciences, San Luigi Gonzaga University Hospital, University of Torino, Turin, Italy
| | - Stefania Nicola
- Allergy and Immunology, AO Mauriziano Hospital, University of Turin, Turin, Italy
| | - Luisa Brussino
- Allergy and Immunology, AO Mauriziano Hospital, University of Turin, Turin, Italy
| | - Emanuele Nappi
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giovanni Paoletti
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giorgio Walter Canonica
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Enrico Heffler
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Understanding the Cellular Sources of the Fractional Exhaled Nitric Oxide (FeNO) and Its Role as a Biomarker of Type 2 Inflammation in Asthma. BIOMED RESEARCH INTERNATIONAL 2022; 2022:5753524. [PMID: 35547356 PMCID: PMC9085317 DOI: 10.1155/2022/5753524] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 11/18/2022]
Abstract
Fractional exhaled nitric oxide (FeNO) has gained great clinical importance as a biomarker of type 2 inflammation in chronic airway diseases such as asthma. FeNO originates primarily in the bronchial epithelium and is produced in large quantities by the enzyme inducible nitric oxide synthase (iNOS). It should be noted that nitric oxide (NO) produced at femtomolar to picomolar levels is fundamental for respiratory physiology. This basal production is induced in the bronchial epithelium by interferon gamma (IFNγ) via Janus kinases (JAK)/STAT-1 signaling. However, when there is an increase in the expression of type 2 inflammatory cytokines such as IL-4 and IL-13, the STAT-6 pathway is activated, leading to overexpression of iNOS and consequently to an overproduction of airway NO. Increased NO levels contributes to bronchial hyperreactivity and mucus hypersecretion, increases vascular permeability, reduces ciliary heartbeat, and promotes free radical production, airway inflammation, and tissue damage. In asthmatic patients, FeNO levels usually rise above 25 parts per billion (ppb) and its follow-up helps to define asthma phenotype and to monitor the effectiveness of corticosteroid treatment and adherence to treatment. FeNO is also very useful to identify those severe asthma patients that might benefit of personalized therapies with monoclonal antibodies. In this review, we revised the cellular and molecular mechanisms of NO production in the airway and its relevance as a biomarker of type 2 inflammation in asthma.
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Rouadi PW, Idriss SA, Bousquet J, Laidlaw TM, Azar CR, Al-Ahmad MS, Yañez A, Al-Nesf MAY, Nsouli TM, Bahna SL, Abou-Jaoude E, Zaitoun FH, Hadi UM, Hellings PW, Scadding GK, Smith PK, Morais-Almeida M, Maximiliano Gómez R, Gonzalez Diaz SN, Klimek L, Juvelekian GS, Riachy MA, Canonica GW, Peden D, Wong GW, Sublett J, Bernstein JA, Wang L, Tanno LK, Chikhladze M, Levin M, Chang YS, Martin BL, Caraballo L, Custovic A, Ortego-Martell JA, Lesslar OJ, Jensen-Jarolim E, Ebisawa M, Fiocchi A, Ansotegui IJ. WAO-ARIA consensus on chronic cough - Part III: Management strategies in primary and cough-specialty care. Updates in COVID-19. World Allergy Organ J 2022; 15:100649. [PMID: 35600836 PMCID: PMC9117692 DOI: 10.1016/j.waojou.2022.100649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/18/2022] Open
Abstract
Background Chronic cough management necessitates a clear integrated care pathway approach. Primary care physicians initially encounter the majority of chronic cough patients, yet their role in proper management can prove challenging due to limited access to advanced diagnostic testing. A multidisciplinary approach involving otolaryngologists and chest physicians, allergists, and gastroenterologists, among others, is central to the optimal diagnosis and treatment of conditions which underly or worsen cough. These include infectious and inflammatory, upper and lower airway pathologies, or gastro-esophageal reflux. Despite the wide armamentarium of ancillary testing conducted in cough multidisciplinary care, such management can improve cough but seldom resolves it completely. This can be due partly to the limited data on the role of tests (eg, spirometry, exhaled nitric oxide), as well as classical pharmacotherapy conducted in multidisciplinary specialties for chronic cough. Other important factors include presence of multiple concomitant cough trigger mechanisms and the central neuronal complexity of chronic cough. Subsequent management conducted by cough specialists aims at control of cough refractory to prior interventions and includes cough-specific behavioral counseling and pharmacotherapy with neuromodulators, among others. Preliminary data on the role of neuromodulators in a proof-of-concept manner are encouraging but lack strong evidence on efficacy and safety. Objectives The World Allergy Organization (WAO)/Allergic Rhinitis and its Impact on Asthma (ARIA) Joint Committee on Chronic Cough reviewed the recent literature on management of chronic cough in primary, multidisciplinary, and cough-specialty care. Knowledge gaps in diagnostic testing, classical and neuromodulator pharmacotherapy, in addition to behavioral therapy of chronic cough were also analyzed. Outcomes This third part of the WAO/ARIA consensus on chronic cough suggests a management algorithm of chronic cough in an integrated care pathway approach. Insights into the inherent limitations of multidisciplinary cough diagnostic testing, efficacy and safety of currently available antitussive pharmacotherapy, or the recently recognized behavioral therapy, can significantly improve the standards of care in patients with chronic cough.
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Affiliation(s)
- Philip W. Rouadi
- Department of Otolaryngology – Head and Neck Surgery, Eye and Ear University Hospital, Beirut, Lebanon
- Ear, Nose and Throat Department, Dar Al Shifa Hospital, Hawally, Kuwait
| | - Samar A. Idriss
- Department of Otolaryngology – Head and Neck Surgery, Eye and Ear University Hospital, Beirut, Lebanon
- Department of Audiology and Otoneurological Evaluation, Edouard Herriot Hospital, Lyon, France
| | - Jean Bousquet
- Hospital Charité, Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Dermatology and Allergy, Comprehensive Allergy Center, Berlin Institute of Health, Berlin, Germany
- Macvia France, Montpellier France
- Université Montpellier, Montpellier, France
| | - Tanya M. Laidlaw
- Department of Medicine, Harvard Medical School, Division of Allergy and Clinical Immunology, Brigham and Women's Hospital Boston, Massachusetts, USA
| | - Cecilio R. Azar
- Department of Gastroenterology, American University of Beirut Medical Center (AUBMC), Beirut, Lebanon
- Department of Gastroenterology, Middle East Institute of Health (MEIH), Beirut, Lebanon
- Department of Gastroenterology, Clemenceau Medical Center (CMC), Beirut, Lebanon
| | - Mona S. Al-Ahmad
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait
| | - Anahi Yañez
- INAER - Investigaciones en Alergia y Enfermedades Respiratorias, Buenos Aires, Argentina
| | - Maryam Ali Y. Al-Nesf
- Allergy and Immunology Section, Department of Medicine, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | | | - Sami L. Bahna
- Allergy & Immunology Section, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | | | - Fares H. Zaitoun
- Department of Allergy Otolaryngology, LAU-RIZK Medical Center, Beirut, Lebanon
| | - Usamah M. Hadi
- Clinical Professor Department of Otolaryngology Head and Neck Surgery, American University of Beirut, Lebanon
| | - Peter W. Hellings
- KU Leuven Department of Microbiology, Immunology and Transplantation, Laboratory of Allergy and Clinical Immunology, Leuven, Belgium
- University Hospitals Leuven, Department of Otorhinolaryngology, Leuven, Belgium
- University Hospital Ghent, Department of Otorhinolaryngology, Laboratory of Upper Airways Research, Ghent, Belgium
- Academic Medical Center, University of Amsterdam, Department of Otorhinolaryngology, Amsterdam, the Netherlands
| | | | - Peter K. Smith
- Clinical Medicine Griffith University, Southport Qld, 4215, Australia
| | | | | | - Sandra N. Gonzalez Diaz
- Universidad Autónoma de Nuevo León, Hospital Universitario and Facultad de Medicina, Monterrey, Nuevo León, Mexico
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Georges S. Juvelekian
- Department of Pulmonary, Critical Care and Sleep Medicine at Saint George Hospital University Medical Center, Beirut, Lebanon
| | - Moussa A. Riachy
- Department of Pulmonary and Critical Care, Hôtel-Dieu de France university Hospital, Beirut, Lebanon
| | - Giorgio Walter Canonica
- Humanitas University & Personalized Medicine Asthma & Allergy Clinic-Humanitas Research Hospital-IRCCS-Milano Italy
| | - David Peden
- UNC Center for Environmental Medicine, Asthma, and Lung Biology, Division of Allergy, Immunology and Rheumatology, Department of Pediatrics UNC School of Medicine, USA
| | - Gary W.K. Wong
- Department of Pediatrics, Chinese University of Hong Kong, Hong Kong, China
| | - James Sublett
- Department of Pediatrics, Section of Allergy and Immunology, University of Louisville School of Medicine, 9800 Shelbyville Rd, Louisville, KY, USA
| | - Jonathan A. Bernstein
- University of Cincinnati College of Medicine, Department of Internal Medicine, Division of Immunology/Allergy Section, Cincinnati, OH, USA
| | - Lianglu Wang
- Department of Allergy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment of Allergic Disease, State Key Laboratory of Complex Severe and Rare Diseases, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Beijing, 100730, China
| | - Luciana K. Tanno
- Université Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA-11, INSERM University of Montpellier, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Manana Chikhladze
- Medical Faculty at Akaki Tsereteli State University, National Institute of Allergy, Asthma & Clinical Immunology, KuTaisi, Tskaltubo, Georgia
| | - Michael Levin
- Division of Paediatric Allergology, Department of Paediatrics, University of Cape Town, South Africa
| | - Yoon-Seok Chang
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea
| | - Bryan L. Martin
- Department of Otolaryngology, Division of Allergy & Immunology, The Ohio State University, Columbus, OH, USA
| | - Luis Caraballo
- Institute for Immunological Research, University of Cartagena. Cartagena de Indias, Colombia
| | - Adnan Custovic
- National Heart and Lund Institute, Imperial College London, UK
| | | | | | - Erika Jensen-Jarolim
- Institute of Pathophysiology and Allergy Research, Center of Pathophysiology, Infectiology and Immunology, Medical University Vienna, Austria
- The interuniversity Messerli Research Institute, Medical University Vienna and University of Veterinary Medicine, Vienna, Austria
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Alessandro Fiocchi
- Translational Pediatric Research Area, Allergic Diseases Research Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Holy See
| | - Ignacio J. Ansotegui
- Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain
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10
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Diamant N, Amirav I, Armoni-Domany K, Sadot E, Shapira U, Cahal M, Be'er M, Rochman M, Lavie M. High fractional exhaled nitric oxide levels in asthma patients: Does size matter? Pediatr Pulmonol 2021; 56:1449-1454. [PMID: 33730452 DOI: 10.1002/ppul.25333] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 02/13/2021] [Accepted: 02/15/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is a biomarker for eosinophilic inflammation used for diagnosis and monitoring of asthma. High FeNO indicates significant airway eosinophilia and steroid-responsive airway inflammation. Some children with asthma have extremely high FeNO levels, but whether these levels represent a different asthma phenotype compared with those with mildly elevated FeNO is unclear. The objective of this study is to investigate whether the extent of high FeNO levels correlates with clinical phenotype, asthma control, comorbidity, and pulmonary function test (PFT) findings in children with asthma. METHODS Anthropometric data, daytime and nighttime symptoms, controller treatment, comorbidity, and PFT findings were retrieved from the Pediatric Pulmonology Unit database (2014-2020) and correlated with FeNO levels in pediatric asthma patients with high FeNO levels. RESULTS Two-hundred children and adolescents with high FeNO levels (range 36-227 ppb) were included. Within this range, higher FeNO levels positively correlated with increased daytime and nighttime symptoms (p = .013 and p = .01, respectively) and poorly controlled asthma (p = .034). A FeNO level of ≥80 ppb was the cutoff for significantly more severe daytime and nighttime symptoms and very poorly controlled asthma compared with levels <80 ppb (p = .004, p = .005, and p = .036, respectively). No correlation was found between FeNO and controller treatment, comorbidity, and PFT performance. CONCLUSION In pediatric asthma patients, high FeNO levels correlate with increased symptom severity and poor asthma control. A FeNO level of ≥80 ppb may serve as an objective indicator for severe asthma.
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Affiliation(s)
- Nir Diamant
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Israel Amirav
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Keren Armoni-Domany
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efraim Sadot
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Udi Shapira
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Cahal
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moria Be'er
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mika Rochman
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moran Lavie
- Pediatric Pulmonology Unit, Dana-Dwek Children's Hospital, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel, affiliated to The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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11
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Braithwaite IE, Cai F, Tom JA, Galanter JM, Owen RP, Zhu R, Williams M, McGregor AG, Eliahu A, Durk MR, Dengler HS, Zak M, Kenny JR, Wilson ME, Beasley R, Chen H. Inhaled JAK inhibitor GDC-0214 reduces exhaled nitric oxide in patients with mild asthma: A randomized, controlled, proof-of-activity trial. J Allergy Clin Immunol 2021; 148:783-789. [PMID: 33744327 DOI: 10.1016/j.jaci.2021.02.042] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/01/2021] [Accepted: 02/23/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The Janus kinase (JAK) pathway mediates the activity of many asthma-relevant cytokines, including IL-4 and IL-13. GDC-0214 is a potent, inhaled, small-molecule JAK inhibitor being developed for the treatment of asthma. OBJECTIVE We sought to determine whether GDC-0214 reduces fractional exhaled nitric oxide (Feno), a JAK1-dependent biomarker of airway inflammation, in patients with mild asthma. METHODS We conducted a double-blind, randomized, placebo-controlled, phase 1 proof-of-activity study in adults with mild asthma and Feno higher than 40 parts per billion (ppb). Subjects were randomized 2:1 (GDC-0214:placebo) into 4 sequential ascending-dose cohorts (1 mg once daily [QD], 4 mg QD, 15 mg QD, or 15 mg twice daily). All subjects received 4 days of blinded placebo, then 10 days of either active drug or placebo. The primary outcome was placebo-corrected percent reduction in Feno from baseline to day 14. Baseline was defined as the average Feno during the blinded placebo period. Pharmacokinetics, safety, and tolerability were also assessed. RESULTS Thirty-six subjects (mean age, 28 years; 54% females) were enrolled. Mean Feno at baseline across all subjects was 93 ± 43 ppb. At day 14, placebo-corrected difference in Feno was -23% (95% CI, -37.3 to -9) for 15 mg QD and -42% (95% CI, -57 to -27.4) for 15 mg twice daily. Higher plasma exposure was associated with greater Feno reduction. No dose-limiting adverse events, serious adverse events, or treatment discontinuations occurred. There were no major imbalances in adverse events or laboratory findings, or evidence of systemic JAK inhibition. CONCLUSIONS GDC-0214, an inhaled JAK inhibitor, caused dose-dependent reductions in Feno in mild asthma and was well tolerated without evidence of systemic toxicity.
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Affiliation(s)
| | - Fang Cai
- Genentech, Inc, South San Francisco, Calif
| | | | | | | | - Rui Zhu
- Genentech, Inc, South San Francisco, Calif
| | - Mathew Williams
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Avi Eliahu
- Genentech, Inc, South San Francisco, Calif
| | | | | | - Mark Zak
- Genentech, Inc, South San Francisco, Calif
| | | | | | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
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12
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Ulrik CS, Lange P, Hilberg O. Fractional exhaled nitric oxide as a determinant for the clinical course of asthma: a systematic review. Eur Clin Respir J 2021; 8:1891725. [PMID: 33708363 PMCID: PMC7919904 DOI: 10.1080/20018525.2021.1891725] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Precision medicine means linking the right patient to the right management strategy including best possible pharmacological therapy, considering the individual variability of the disease characteristics, type of inflammation, genes, environment, and lifestyle. For heterogenous diseases such as asthma, reliable biomarkers are needed to facilitate the best possible disease control and reduce the risk of side effects. The present review examines fractional exhaled nitric oxide (FeNO) as a guide for the management strategy of asthma and predictor of its clinical course. Method: The literature included was identified by searching the PubMed database using specific key words and MeSH terms. Studies were not excluded based on their design alone. The search resulted in 212 hits, of which 35 articles were included in this review. Results: Several studies support a potential role for high FeNO levels as a prognostic biomarker for accelerated lung function decline in adults with newly diagnosed asthma. Furthermore, studies report an association between high FeNO levels and excess decline in FEV1 in adults with long-standing moderate to severe asthma despite optimised therapy, whereas the findings for patients with less severe disease are conflicting. Applying a FeNO-based management algorithm reduces the exacerbation rate in adults with asthma. Similar observations are seen in children, though based on fewer studies. The available studies provide evidence that the level of FeNO may be useful as a predictor of subsequent loss of asthma control in adults, though the evidence is somewhat conflicting in children and young adults. Conclusion: The present review provides evidence of the prognostic value of FeNO as a surrogate biomarker for type 2 inflammation in the airways. FeNO is likely to emerge as an important biomarker in monitoring and tailoring modern asthma treatment, either alone or in combination with other biomarkers.
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Affiliation(s)
- Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark and Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter Lange
- Section of Epidemiology, Department of Public Health, Medical Department, Herlev-Gentofte Hospital, University of Copenhagen, DK-1014 Copenhagen K, Denmark, Herlev, Denmark
| | - Ole Hilberg
- Department of Medicine, Vejle Hospital, Southern Denmark University Hospital, Denmark
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13
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Ji N, Fang M, Baptista A, Cepeda C, Greenberg M, Mincey IC, Ohman-Strickland P, Haynes F, Fiedler N, Kipen HM, Laumbach RJ. Exposure to traffic-related air pollution and changes in exhaled nitric oxide and DNA methylation in arginase and nitric oxide synthase in children with asthma. Environ Health 2021; 20:12. [PMID: 33573660 PMCID: PMC7879528 DOI: 10.1186/s12940-020-00678-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/13/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Traffic-related air pollution (TRAP) has been associated with increased risk of airway inflammation in children with asthma. While epigenetic changes could potentially modulate TRAP-induced inflammatory responses, few studies have assessed the temporal pattern of exposure to TRAP, epigenetic changes and inflammation in children with asthma. Our goal was to test the time-lag patterns of personal exposure to TRAP, airway inflammation (measured as fractional exhaled nitric oxide, FeNO), and DNA methylation in the promoter regions of genes involved in nitric oxide synthesis among children with asthma. METHODS We measured personal exposure to black carbon (BC) and FeNO for up to 30 days in a panel of children with asthma. We collected 90 buccal cell samples for DNA methylation analysis from 18 children (5 per child). Methylation in promoter regions of nitric oxide synthase (NOS1, NOS2A, NOS3) and arginase (ARG1, ARG2) was assessed by bisulfite pyrosequencing. Linear-mixed effect models were used to test the associations of BC at different lag periods, percent DNA methylation at each site and FeNO level. RESULTS Exposure to BC was positively associated with FeNO, and negatively associated with DNA methylation in NOS3. We found strongest association between FeNO and BC at lag 0-6 h while strongest associations between methylation at positions 1 and 2 in NOS3 and BC were at lag 13-24 h and lag 0-24 h, respectively. The strengths of associations were attenuated at longer lag periods. No significant associations between exposure to TRAP and methylation levels in other NOS and ARG isoforms were observed. CONCLUSIONS Exposure to TRAP was associated with higher levels of FeNO and lower levels of DNA methylation in the promoter regions of the NOS3 gene, indicating that DNA methylation of the NOS3 gene could be an important epigenetic mechanism in physiological responses to TRAP in children with asthma.
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Affiliation(s)
- N Ji
- Rutgers, The State University of New Jersey, 170 Frelinghuysen Rd, Room 204, Piscataway, NJ, 08854, USA
| | - M Fang
- Rutgers, The State University of New Jersey, 170 Frelinghuysen Rd, Room 204, Piscataway, NJ, 08854, USA
| | | | - C Cepeda
- Rutgers, The State University of New Jersey, 170 Frelinghuysen Rd, Room 204, Piscataway, NJ, 08854, USA
| | | | | | - P Ohman-Strickland
- Rutgers, The State University of New Jersey, 170 Frelinghuysen Rd, Room 204, Piscataway, NJ, 08854, USA
| | - F Haynes
- Rutgers, The State University of New Jersey, 170 Frelinghuysen Rd, Room 204, Piscataway, NJ, 08854, USA
| | - N Fiedler
- Rutgers, The State University of New Jersey, 170 Frelinghuysen Rd, Room 204, Piscataway, NJ, 08854, USA
| | - H M Kipen
- Rutgers, The State University of New Jersey, 170 Frelinghuysen Rd, Room 204, Piscataway, NJ, 08854, USA
| | - R J Laumbach
- Rutgers, The State University of New Jersey, 170 Frelinghuysen Rd, Room 204, Piscataway, NJ, 08854, USA.
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14
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Abe Y, Suzuki M, Kimura H, Shimizu K, Makita H, Nishimura M, Konno S. Annual Fractional Exhaled Nitric Oxide Measurements and Exacerbations in Severe Asthma. J Asthma Allergy 2020; 13:731-741. [PMID: 33380812 PMCID: PMC7769199 DOI: 10.2147/jaa.s289592] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/10/2020] [Indexed: 12/15/2022] Open
Abstract
Purpose Fractional exhaled nitric oxide (FENO) reflects eosinophilic inflammation of the airways. However, the significance of longitudinal assessment of FENO, including its variability, in the clinical course of severe asthma remains unclear. The aim of this study is to examine the association between long-term changes in FENO and the development of exacerbations in severe asthma. Patients and Methods Among the severe asthma patients enrolled in the Hokkaido Severe Asthma Cohort Study, 100 patients with severe asthma who completed a 3-year follow-up in which FENO was measured annually were included. According to the FENO level at baseline, 1 year, and 2 years, the patients were classified into three groups: the sustained high group (≥50 ppb at all three visits), the sustained low group (<25 ppb at all three visits), and the intermediate group (other). Subjects in the intermediate group were further classified into two groups based on the median value of the coefficient of variation (CV) of FENO during the 3 years (high CV and low CV intermediate groups). Results The sustained high group experienced shorter exacerbation-free survival and more frequent exacerbations than the sustained low group (median number of exacerbation events, 3 vs 0, p = 0.01). In the intermediate group, the high CV group experienced shorter exacerbation-free survival than the low CV group, and the CV of FENO was an independent contributing factor to the development of exacerbations. Conclusion Persistence of FENO above 50 ppb over the years as well as the presence of large variations in FENO levels was associated with the development of exacerbations in patients with severe asthma.
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Affiliation(s)
- Yuki Abe
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-ku, Sapporo 060-8638, Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-ku, Sapporo 060-8638, Japan
| | - Hirokazu Kimura
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-ku, Sapporo 060-8638, Japan
| | - Kaoruko Shimizu
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-ku, Sapporo 060-8638, Japan
| | - Hironi Makita
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-ku, Sapporo 060-8638, Japan
| | - Masaharu Nishimura
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-ku, Sapporo 060-8638, Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-ku, Sapporo 060-8638, Japan
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15
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Gaisberger M, Wass RE, Dobias H, Grabcanovic-Musija F, Weiss G, Lamprecht B, Kaiser B, Studnicka M, Hartl A. Acute Exposure to Environmental Tobacco Smoke: A Controlled Study in Adults with Asthma. Respiration 2020; 99:1-8. [PMID: 33296904 DOI: 10.1159/000508397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 05/02/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Short-term, indoor exposure to environmental tobacco smoke (ETS) is still highly prevalent; however, little is known about the acute lung response in adult asthma. OBJECTIVES We investigated whether acute, experimental ETS exposure influences symptoms, lung function, and inflammatory parameters. METHODS Human subjects with asthma (n = 23) were exposed for 180 min to either room air or ETS at 250, 450, or 850 µg/m3. Respiratory symptoms, lung function, and exhaled nitric oxide (FeNO) were measured. Additionally, blood samples were analyzed for pro- and anti-inflammatory cytokines. RESULTS Humans with asthma demonstrate an increase in respiratory symptoms at all levels of ETS exposure, while the forced expiratory volume in 1 s (FEV1) and FeNO decrease with increasing ETS. The anti-inflammatory cytokine interleukin (IL)-10 increases at intermediate ETS concentrations, whereas tumor necrosis factor (TNF)-α and IL-8 increase only at the highest ETS concentration. CONCLUSION Following 180 min of acute, experimental ETS exposure, we observed a significant increase in respiratory symptoms, a decrease in lung function, and an increase in inflammatory cytokines, indicating an acute lung response in asthma.
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Affiliation(s)
- Martin Gaisberger
- Institute of Physiology and Pathophysiology, Paracelsus Medical University, Salzburg, Austria
- Gastein Research Institute, Paracelsus Medical University, Salzburg, Austria
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Salzburg, Austria
| | - Romana Elisabeth Wass
- Department of Pneumology, Paracelsus Medical University, Salzburg, Austria
- Department of Pulmonary Medicine, General Hospital Linz (AKH), Linz, Austria
| | - Heidemarie Dobias
- Institute of Physiology and Pathophysiology, Paracelsus Medical University, Salzburg, Austria
- Gastein Research Institute, Paracelsus Medical University, Salzburg, Austria
- Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Salzburg, Austria
| | | | - Gertraud Weiss
- Department of Pneumology, Paracelsus Medical University, Salzburg, Austria
| | - Bernd Lamprecht
- Department of Pulmonary Medicine, General Hospital Linz (AKH), Linz, Austria
| | - Bernhard Kaiser
- Department for Statistics, University of Linz, Linz, Austria
| | - Michael Studnicka
- Department of Pneumology, Paracelsus Medical University, Salzburg, Austria,
| | - Arnulf Hartl
- Institute of Ecomedicine, Paracelsus Medical University, Salzburg, Austria
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16
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Boer S, Honkoop PJ, Loijmans RJB, Snoeck-Stroband JB, Assendelft WJJ, Schermer TRJ, Sont JK. Personalised exhaled nitric oxygen fraction ( F ENO)-driven asthma management in primary care: a F ENO subgroup analysis of the ACCURATE trial. ERJ Open Res 2020; 6:00351-2019. [PMID: 32963989 PMCID: PMC7487343 DOI: 10.1183/23120541.00351-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/24/2020] [Indexed: 01/19/2023] Open
Abstract
Background The aim of this study was to identify patients who benefit most from exhaled nitric oxide fraction (FENO)-driven asthma management in primary care, based on prespecified subgroups with different levels of FENO. Methods We used data from 179 adults with asthma from a 12-month primary care randomised controlled trial with 3-monthly assessments of FENO, asthma control, medication usage, costs of medication, severe asthma exacerbations and quality of life. In the original study, patients were randomised to either a symptom-driven treatment strategy (controlled asthma (Ca) strategy) or a FENO+symptom-driven strategy (FCa). In both groups, patients were categorised by their baseline level of FENO as low (<25 ppb), intermediate (25–50 ppb) and high (>50 ppb). At 12 months, we compared, for each prespecified FENO subgroup, asthma control, asthma-related quality of life, medication usage, and costs of medication between the Ca and FCa strategy. Results We found a difference between the Ca and FCa strategy for the mean dosage of beclomethasone strategy of 223 µg (95% CI 6–439), p=0.04) and for the total costs of asthma medication a mean reduction of US$159 (95% CI US$33–285), p=0.03) in patients with a low baseline FENO level. No differences were found for asthma control, severe asthma exacerbations and asthma-related quality of life in patients with a low baseline FENO level. Furthermore, in patients with intermediate or high level of FENO, no differences were found. Conclusions In primary care, FENO-driven asthma management is effective in patients with a low FENO level, for whom it is possible to down-titrate medication, while preserving asthma control and quality of life. In primary care, FENO-driven asthma management is effective in patients with a low FENO, for whom it is possible to down-titrate medication while preserving asthma control and quality of lifehttps://bit.ly/2wC25N7d
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Affiliation(s)
- Suzanne Boer
- Dept of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands.,Dept of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Persijn J Honkoop
- Dept of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - Rik J B Loijmans
- Dept of General Practice, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jiska B Snoeck-Stroband
- Dept of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - Willem J J Assendelft
- Dept of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tjard R J Schermer
- Dept of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jacob K Sont
- Dept of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
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17
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Exhaled nitric oxide and its predictive power related to lung function and bronchial inflammation. Biochem Pharmacol 2020; 179:114101. [DOI: 10.1016/j.bcp.2020.114101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 11/22/2022]
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18
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Seposo X, Ueda K, Sugata S, Yoshino A, Takami A. Short-term effects of air pollution on daily single- and co-morbidity cardiorespiratory outpatient visits. THE SCIENCE OF THE TOTAL ENVIRONMENT 2020; 729:138934. [PMID: 32371210 DOI: 10.1016/j.scitotenv.2020.138934] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 04/21/2020] [Accepted: 04/21/2020] [Indexed: 04/14/2023]
Abstract
Several studies have noted that the existence of comorbidities lead to an increase in the risk of premature mortality and morbidity. Most of the studies examining the effects of air pollution on comorbidity visits were from Northern American countries, with scarce literature from Asia. This study contributes to existing, yet limited understanding of air pollution-comorbidity by examining the effects of daily air pollutants on outpatient single morbidity and comorbid cardiorespiratory visits in Japan. A total of 1,452,505 outpatient cardiorespiratory visits were recorded among the 21 Japanese cities from 2013 to 2016. Daily outpatient cardiorespiratory visit data were obtained from a health insurance claims database managed by the Japan Medical Data Center Co., Ltd. (JMDC). A time-stratified case crossover analysis coupled with Generalized Additive Mixed Model was used to analyze the association of daily air pollutants (particulate matter 2.5 μm or less in diameter, ozone and nitrogen dioxide) on daily single (respiratory and cardiovascular) and comorbidity health outcomes. We further examined single and cumulative effects for 0-3 and 0-14 lag periods. Ozone, NO2, and PM2.5 were positively associated with cardiorespiratory visits in either shorter or longer lags, with more apparent comorbidity associations with NO2 exposure. A 10-unit increase in NO2, after adjusting for ozone, was associated with a 2.24% (95% CI: 1.34-3.15) and 6.49% (95% CI: 5.00-8.01) increase in comorbidity visit at Lag 0 (of Lag 0-3) and cumulative lag 0-3, respectively. Our results contribute to existing evidence suggesting that short-term and extended exposure to air pollution elicit health risks on cardiovascular, respiratory and comorbid clinic visits. Exposure to NO2, in particular, was associated with increase in the risk of single and comorbidity cardiorespiratory visits. Results can be potentially utilized for both individual health (e.g. risk population health management) and health facility management (e.g. health visit influx determination).
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Affiliation(s)
- Xerxes Seposo
- School of Tropical Medicine and Global Health, Nagasaki University, Japan.
| | - Kayo Ueda
- Environmental Health Division, Department of Environmental Engineering, Graduate School of Engineering, Kyoto University, Japan; Environmental Health Sciences, Department of Global Ecology, Graduate School of Global Environmental Studies, Kyoto University, Japan
| | - Seiji Sugata
- Center for Regional Environmental Research, National Institute for Environmental Studies, Japan
| | - Ayako Yoshino
- Center for Regional Environmental Research, National Institute for Environmental Studies, Japan
| | - Akinori Takami
- Center for Regional Environmental Research, National Institute for Environmental Studies, Japan
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19
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Comberiati P, Peroni D, Malka-Rais J, Morganti R, Spahn JD. Fractional exhaled nitric oxide response to oral corticosteroids in children with mild-to-moderate asthma: Influence of race. Ann Allergy Asthma Immunol 2020; 125:440-446.e1. [PMID: 32621994 DOI: 10.1016/j.anai.2020.06.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/11/2020] [Accepted: 06/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is a noninvasive biomarker of type 2 asthma that can predict response to inhaled corticosteroid therapy. Little is known regarding the magnitude of FeNO reduction after an oral corticosteroid (OCS) course, and less is known whether there are differential responses based on race in children with mild-to-moderate asthma. OBJECTIVE To assess the effect of a short course of OCS on FeNO in children with asthma and to determine whether the effect is influenced by race. METHODS Children presenting with an acute asthma exacerbation, who had a FeNO measurement within the past 6 months when clinically stable, were enrolled. Spirometry and FeNO were obtained at the time of exacerbation and after a short course of prednisone. RESULTS A total of 92 children were identified (aged 11 ± 3.3 years; white, n = 46 [50%], Hispanics, n = 30 [33%], African Americans [AAs], n = 16 [7%]). At baseline, AAs were more atopic and had higher mean FeNO values than both white (48.9 vs 25.6 ppb; P < .05) and Hispanic children (22.5 ppb; P < .05), despite being prescribed similar inhaled corticosteroid doses. During the exacerbation, AAs had the highest FeNO values, whereas there was no difference in lung function between AAs and non-AAs. After prednisone therapy, there was a 56.6% reduction in FeNO, and although AAs maintained the highest FeNO levels, the relative reduction was similar between AAs and non-AAs (53.9% vs 57.8%, respectively). CONCLUSION FeNO levels reduced by more than 50% after an OCS course. African American children had a greater degree of type 2-driven airway inflammation at baseline, during an exacerbation and after a short course of OCS, compared with non-AAs, although the relative reduction in FeNO was similar between the groups.
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Affiliation(s)
- Pasquale Comberiati
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy; Department of Clinical Immunology and Allergology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia.
| | - Diego Peroni
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy
| | - Jonathan Malka-Rais
- Pediatric Associates, Division of Allergy and Immunology, Plantation, Florida
| | | | - Joseph D Spahn
- Allergy and Immunology Center, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, Division of Allergy and Immunology, National Jewish Health, Denver, Colorado
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20
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Bonini M, Di Paolo M, Bagnasco D, Baiardini I, Braido F, Caminati M, Carpagnano E, Contoli M, Corsico A, Del Giacco S, Heffler E, Lombardi C, Menichini I, Milanese M, Scichilone N, Senna G, Canonica GW. Minimal clinically important difference for asthma endpoints: an expert consensus report. Eur Respir Rev 2020; 29:29/156/190137. [PMID: 32499305 PMCID: PMC9488652 DOI: 10.1183/16000617.0137-2019] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/09/2020] [Indexed: 02/02/2023] Open
Abstract
Minimal clinically important difference (MCID) can be defined as the smallest change or difference in an outcome measure that is perceived as beneficial and would lead to a change in the patient's medical management. The aim of the current expert consensus report is to provide a “state-of-the-art” review of the currently available literature evidence about MCID for end-points to monitor asthma control, in order to facilitate optimal disease management and identify unmet needs in the field to guide future research. A series of MCID cut-offs are currently available in literature and validated among populations of asthmatic patients, with most of the evidence focusing on outcomes as patient reported outcomes, lung function and exercise tolerance. On the contrary, only scant and partial data are available for inflammatory biomarkers. These clearly represent the most interesting target for future development in diagnosis and clinical management of asthma, particularly in view of the several biologic drugs in the pipeline, for which regulatory agencies will soon require personalised proof of efficacy and treatment response predictors. Minimal clinically important difference (MCID) cut-offs in asthma are validated for patient reported outcomes and lung function, but not for inflammatory biomarkers. MCID represents a key target for future development in asthma management. http://bit.ly/33hcWIe
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Affiliation(s)
- Matteo Bonini
- National Heart and Lung Institute, Royal Brompton Hospital & Imperial College London, London, UK.,UOC Pneumologia, Istituto di Medicina Interna, F. Policlinico Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marcello Di Paolo
- National Heart and Lung Institute, Royal Brompton Hospital & Imperial College London, London, UK
| | - Diego Bagnasco
- Allergy and Respiratory diseases, University of Genoa, Dept of Internal Medicine (DiMI), Ospedale Policlinico San Martino, Genoa, Italy
| | - Ilaria Baiardini
- Dept of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Fulvio Braido
- Allergy and Respiratory diseases, University of Genoa, Dept of Internal Medicine (DiMI), Ospedale Policlinico San Martino, Genoa, Italy
| | - Marco Caminati
- Dept of Medicine, University of Verona, Verona, Italy.,Asthma Center and Allergy Unit, Verona University Hospital, Verona, Italy
| | - Elisiana Carpagnano
- Division of Respiratory Diseases, Dept of Medical and Surgical Sciences, University of Foggia, Italy
| | - Marco Contoli
- Section of Internal and Cardiorespiratory Medicine, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Angelo Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation - Dept of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Stefano Del Giacco
- Dept of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy - Humanitas Research Hospital, Rozzano, Italy
| | - Carlo Lombardi
- Departmental Unit of Pneumology & Allergology, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Ilaria Menichini
- Dept of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Science, "Sapienza" University, Rome, Italy
| | | | - Nicola Scichilone
- AOUP Policlinico Universitario, DIBIMIS, Università di Palermo, Palermo, Italy
| | - Gianenrico Senna
- Dept of Medicine, University of Verona, Verona, Italy.,Asthma Center and Allergy Unit, Verona University Hospital, Verona, Italy
| | - Giorgio W Canonica
- Personalized Medicine, Asthma and Allergy - Humanitas Research Hospital, Rozzano, Italy
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21
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Wang K, Verbakel JY, Oke J, Fleming-Nouri A, Brewin J, Roberts N, Harada N, Atsuta R, Takahashi K, Mori K, Fujisawa T, Shirai T, Kawayama T, Inoue H, Lazarus S, Szefler S, Martinez F, Shaw D, Pavord ID, Thomas M. Using fractional exhaled nitric oxide to guide step-down treatment decisions in patients with asthma: a systematic review and individual patient data meta-analysis. Eur Respir J 2020; 55:13993003.02150-2019. [PMID: 32139458 DOI: 10.1183/13993003.02150-2019] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND High exhaled nitric oxide fraction (F ENO) levels are associated with greater risk of asthma exacerbation. However, it is not clear how F ENO can be used to guide safe reductions in inhaled corticosteroid (ICS) doses in asthma patients. This study assesses the ability of F ENO to guide ICS reductions. METHODS Systematic searching of electronic databases identified prospective observational studies and randomised controlled trials which recruited participants with mild-to-moderate asthma aged ≥12 years and measured F ENO before reducing ICS. We performed multilevel mixed-effects logistic regression in relation to acute exacerbations and estimated each participant's exacerbation risk using our logistic regression model. RESULTS We included data from seven out of eight eligible studies, representing 384 participants. ICS doses were halved in four studies and withdrawn in three studies. A baseline F ENO measurement of ≥50 ppb was associated with increased risk of exacerbations (crude OR 3.14, 95% CI 1.41-7.00, p=0.005; adjusted OR 3.08, 95% CI 1.36-6.98, p=0.007) and corresponded to an estimated exacerbation risk cut-off of 15%. Reducing ICS when estimated exacerbation risk was <15% versus <10% would result in fewer patients remaining on the same ICS dose (40 (10.4%) out of 384 versus 141 (36.7%) out of 384), but similar proportions of patients avoiding exacerbations (222 (91.4%) out of 243, 95% CI 87.1-94.6% versus 311 (90.4%) out of 344, 95% CI 86.8-93.3%). CONCLUSION In patients with mild-to-moderate asthma, gradual ICS reduction when F ENO is <50 ppb may help decrease ICS use without increasing exacerbations. Future research should aim to validate these findings in larger populations.
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Affiliation(s)
- Kay Wang
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jan Y Verbakel
- KU Leuven, Dept of Public Health and Primary Care, Leuven, Belgium
| | - Jason Oke
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Josh Brewin
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Norihiro Harada
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Ryo Atsuta
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Kazuhisa Takahashi
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Kazutaka Mori
- Second Division Dept of Internal Medicine, Hamamatsu University School of Medicine, Hammamatsu, Japan
| | - Tomoyuki Fujisawa
- Second Division Dept of Internal Medicine, Hamamatsu University School of Medicine, Hammamatsu, Japan
| | - Toshihiro Shirai
- Dept of Respiratory Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Kurume University School of Medicine, Kurume, Japan
| | - Hiromasa Inoue
- Dept of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Stephen Lazarus
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
| | - Stanley Szefler
- Children's Hospital Colorado, The Breathing Institute, Dept of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Fernando Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Dominick Shaw
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Ian D Pavord
- Oxford Respiratory NIHR BRC and Respiratory Medicine Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Mike Thomas
- Primary Care, Population Sciences and Medical Education (PPM), University of Southampton, Southampton, UK
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22
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Ciprandi G, Marseglia GL, Ricciardolo FLM, Tosca MA. Pragmatic Markers in the Management of Asthma: A Real-World-Based Approach. CHILDREN-BASEL 2020; 7:children7050048. [PMID: 32443418 PMCID: PMC7278574 DOI: 10.3390/children7050048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 12/11/2022]
Abstract
Bronchial hyperreactivity, reversible airflow limitation and chronic airway inflammation characterize asthma pathophysiology. Personalized medicine, i.e., a tailored management approach, is appropriate for asthma management and is based on the identification of peculiar phenotypes and endotypes. Biomarkers are necessary for defining phenotypes and endotypes. Several biomarkers have been described in asthma, but most of them are experimental and/or not commonly available. The current paper will, therefore, present pragmatic biomarkers useful for asthma management that are available in daily clinical practice. In this regard, eosinophil assessment and serum allergen-specific IgE assay are the most reliable biomarkers. Lung function, mainly concerning forced expiratory flow at 25-755 of vital capacity (FEF25-75), and nasal cytology may be envisaged as ancillary biomarkers in asthma management. In conclusion, biomarkers have clinical relevance in asthma concerning both the endotype definition and the personalization of the therapy.
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Affiliation(s)
- Giorgio Ciprandi
- Allergy Clinic, Casa di Cura Villa Montallegro, Via P. Boselli 5, 16146 Genoa, Italy
- Correspondence:
| | - Gian Luigi Marseglia
- Pediatric Clinic, Department of Pediatrics, Fondazione IRCCS Policlinico San Matteo, University of Pavia, 27100 Pavia, Italy;
| | - Fabio Luigi Massimo Ricciardolo
- Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga University Hospital, 10043 Turin, Italy;
| | - Maria Angela Tosca
- Pediatric Allergy Center, Istituto Giannina Gaslini, 16100 Genoa, Italy;
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23
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Back HM, Lee JB, Kim A, Park SJ, Kim J, Chae JW, Sheen SS, Kagan L, Park HS, Ye YM, Yun HY. Exposure-Response and Clinical Outcome Modeling of Inhaled Budesonide/Formoterol Combination in Asthma Patients. Pharmaceutics 2020; 12:pharmaceutics12040336. [PMID: 32283726 PMCID: PMC7238265 DOI: 10.3390/pharmaceutics12040336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 11/18/2022] Open
Abstract
Exposure-response and clinical outcome (CO) model for inhaled budesonide/formoterol was developed to quantify the relationship among pharmacokinetics (PK), pharmacodynamics (PD) and CO of the drugs and evaluate the covariate effect on model parameters. Sputum eosinophils cationic proteins (ECP) and forced expiratory volume (FEV1) were selected as PD markers and asthma control score was used as a clinical outcome. One- and two-compartment models were used to describe the PK of budesonide and formoterol, respectively. The indirect response model (IDR) was used to describe the PD effect for ECP and FEV1. In addition, the symptomatic effect on the disease progression model for CO was connected with IDR on each PD response. The slope for the effect of ECP and FEV1 to disease progression were estimated as 0.00008 and 0.644, respectively. Total five covariates (ex. ADRB2 genotype etc.) were searched using a stepwise covariate modeling method, however, there was no significant covariate effect. The results from the simulation study were showed that a 1 puff b.i.d. had a comparable effect of asthma control with a 2 puff b.i.d. As a result, the 1 puff b.i.d. of combination drug could be suggested as a standardized dose to minimize the side effects and obtain desired control of disease compared to the 2 puff b.i.d.
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Affiliation(s)
- Hyun-moon Back
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA; (H.-m.B.); (J.B.L.); (L.K.)
- Center of Excellence in Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA
| | - Jong Bong Lee
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA; (H.-m.B.); (J.B.L.); (L.K.)
| | - Anhye Kim
- Department of Clinical Pharmacology and Therapeutics, CHA Bundang Medical Center, CHA University, Seongnam, Gyeonggi-do 13496, Korea;
| | - Seon-Jong Park
- College of Pharmacy, Chungnam National University, Daejeon 34134, Korea; (S.-J.P.); (J.K.); (J.-w.C.)
| | - Junyeong Kim
- College of Pharmacy, Chungnam National University, Daejeon 34134, Korea; (S.-J.P.); (J.K.); (J.-w.C.)
| | - Jung-woo Chae
- College of Pharmacy, Chungnam National University, Daejeon 34134, Korea; (S.-J.P.); (J.K.); (J.-w.C.)
| | - Seung Soo Sheen
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Gyeonggi-do 16499, Korea;
| | - Leonid Kagan
- Department of Pharmaceutics, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA; (H.-m.B.); (J.B.L.); (L.K.)
- Center of Excellence in Pharmaceutical Translational Research and Education, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ 08854, USA
| | - Hae-Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Gyeonggi-do 16499, Korea;
| | - Young-Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Gyeonggi-do 16499, Korea;
- Correspondence: (Y.-M.Y.); (H.-y.Y.)
| | - Hwi-yeol Yun
- College of Pharmacy, Chungnam National University, Daejeon 34134, Korea; (S.-J.P.); (J.K.); (J.-w.C.)
- Correspondence: (Y.-M.Y.); (H.-y.Y.)
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24
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Heffler E, Carpagnano GE, Favero E, Guida G, Maniscalco M, Motta A, Paoletti G, Rolla G, Baraldi E, Pezzella V, Piacentini G, Nardini S. Fractional Exhaled Nitric Oxide (FENO) in the management of asthma: a position paper of the Italian Respiratory Society (SIP/IRS) and Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC). Multidiscip Respir Med 2020; 15:36. [PMID: 32269772 PMCID: PMC7137762 DOI: 10.4081/mrm.2020.36] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/05/2020] [Indexed: 02/08/2023] Open
Abstract
Asthma prevalence in Italy is on the rise and is estimated to be over 6% of the general population. The diagnosis of asthma can be challenging and elusive, especially in children and the last two decades has brought evidences that asthma is not a single disease but consists of various phenotypes. Symptoms can be underestimated by the patient or underreported to the clinician and physical signs can be scanty. Usual objective measures, like spirometry, are necessary but sometimes not significant. Despite proper treatment, asthma can be a very severe condition (even leading to death), however new drugs have recently become available which can be very effective in its control. Since asthma is currently thought to be caused by inflammation, a direct measure of the latter can be of paramount importance. For this purpose, the measurement of Fractional Exhaled Nitric Oxide (FENO) has been used since the early years of the current century as a non-invasive, easy-to-assess tool useful for diagnosing and managing asthma. This SIP-IRS/SIAAIC Position Paper is a narrative review which summarizes the evidence behind the usefulness of FENO in the diagnosis, management and phenotypization of asthma.
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Affiliation(s)
- Enrico Heffler
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano (MI).,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI)
| | - Giovanna Elisiana Carpagnano
- Department of Medical and Surgical Sciences, University of Foggia; Section of Respiratory Diseases, Hospital d'Avanzo, Foggia
| | - Elisabetta Favero
- Department of Medicine-DIMED, Immunological and Respiratory Rare Disease, Allergologic Clinic Ca' Foncello Hospital, Treviso
| | - Giuseppe Guida
- Allergy and Pneumology Unit, A.O. S. Croce e Carle, Cuneo
| | - Mauro Maniscalco
- Respiratory Rehabilitation Unit, ICS Maugeri, Institute of Telese Terme IRCCS
| | - Andrea Motta
- Institute of Biomolecular Chemistry, National Research Council, Pozzuoli (NA)
| | - Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano (MI).,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI)
| | - Giovanni Rolla
- Allergy and Clinical Immunology, University of Turin and A.O. Mauriziano, Turin
| | - Eugenio Baraldi
- Department of Woman's and Child's Health, University Hospital of Padua
| | - Vincenza Pezzella
- Department of Woman, Child and of General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples
| | - Giorgio Piacentini
- Paediatric Section, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona
| | - Stefano Nardini
- Italian Respiratory Society-Società Italiana di Pneumologia, Milan, Italy
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25
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Huang T, Liu B, Yang D, Liu C. Fractional exhaled nitric oxide measurement: Comparison between the Sunvou-CA2122 analyzer and the NIOX VERO analyzer. J Asthma 2019; 58:52-59. [PMID: 31512532 DOI: 10.1080/02770903.2019.1658206] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Fractional exhaled nitric oxide (FeNO) has been developed as a useful marker for eosinophilic airway inflammation and is widely used in clinical practice due to its convenience and noninvasiveness. There are two NO analyzers commonly used in China: the Sunvou-CA2122 Analyzer (NOS) and the NIOX VERO Analyzer (NOV). However, the relationships between the two devices have not yet been reported. The aim of our study was to determine the correlation and differences in the FeNO levels measured by the two devices. METHODS FeNO levels were measured by both NOS and NOV in 107 adult patients with asthma. The asthma control test (ACT) score and lung function were also evaluated. This study was registered in the Chinese Clinical Trial Registry (http://www.chictr.org.cn). RESULTS NOS yielded generally higher FeNO values than NOV [median (range): 87.0 (16 ∼ 276) vs 58.0 (9 ∼ 228); p < .001], and the difference increased with increasing FeNO levels. There was a high degree of correlation between FeNO values obtained with both devices (r s = 0.878, p < .001). However, the Bland-Altman plot showed a low degree of agreement, with a mean difference of -0.16 between logFeNONOS and logFeNONOV (95% CI: -0.45 ∼ 0.14). The conversion equation was calculated as follows: logFeNONOS= 0.027 + 0.904× logFeNONOV. CONCLUSION This was the first report to compare FeNO levels measured by NOS and NOV, showing a strongly positive correlation and a low degree of consistency between the two devices. Further prospective studies are required to verify our conclusions and determine the validity of the equation.
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Affiliation(s)
- Tingxuan Huang
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu, China
| | - Bicui Liu
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu, China.,Respiratory Department, Minda Hospital of Hubei Minzu University, Enshi, China
| | - Dan Yang
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu, China
| | - Chuntao Liu
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu, China
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Acute Severe Asthma in Adolescent and Adult Patients: Current Perspectives on Assessment and Management. J Clin Med 2019; 8:jcm8091283. [PMID: 31443563 PMCID: PMC6780340 DOI: 10.3390/jcm8091283] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 08/09/2019] [Accepted: 08/19/2019] [Indexed: 02/06/2023] Open
Abstract
Asthma is a chronic airway inflammatory disease that is associated with variable expiratory flow, variable respiratory symptoms, and exacerbations which sometimes require hospitalization or may be fatal. It is not only patients with severe and poorly controlled asthma that are at risk for an acute severe exacerbation, but this has also been observed in patients with otherwise mild or moderate asthma. This review discusses current aspects on the pathogenesis and pathophysiology of acute severe asthma exacerbations and provides the current perspectives on the management of acute severe asthma attacks in the emergency department and the intensive care unit.
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Phenotypes favoring fractional exhaled nitric oxide discordance vs guideline-based uncontrolled asthma. Ann Allergy Asthma Immunol 2019; 123:193-200. [PMID: 31108180 DOI: 10.1016/j.anai.2019.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 05/07/2019] [Accepted: 05/11/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite potential value of identification of allergic inflammation with fractional exhaled nitric oxide (FeNO) in managing asthma, randomized clinical trials have not consistently shown better outcomes compared with guideline management alone. OBJECTIVE To assess the effectiveness of FeNO vs non-FeNO-based therapeutic algorithms in managing asthma, and the phenotypic profile associated with FeNO >35 ppb yet well controlled by guidelines, as a potential model to predict better FeNO-based algorithm outcomes. METHODS This is a randomized controlled study (RCT) in 88 high-risk children with asthma 7 to 18 years of age across 352 visits over a 1-year period. Generalized estimating equations analysis assessed algorithm group differences in outcomes and characteristics associated with higher odds uncontrolled by FeNO alone in the treatment decision algorithm. RESULTS The FeNO treatment algorithm did not show superiority in reducing exacerbations and morbidity (P > .05). Phenotypes that more than doubled the odds FeNO alone identified uncontrolled asthma included adolescence, non-adherence, high atopy (>6+), and baseline FeNO >35 ppb, whereas obesity, FEF25-75% < 65% predicted, and bronchodilator response >10% decreased the odds. Uncontrolled asthma by FeNO alone (F) vs guidelines alone (G) showed overall F/G > 1.0 in adolescents, but <1.0 in younger patients unless the FeNO threshold was reduced to >20 ppb. CONCLUSION Our study suggests that age and phenotypes play a key role in FeNO discordance compared with the conventional guideline-based uncontrolled asthma. The FeNO-based therapeutic algorithm, if confirmed further, could provide the clinician with an effective asthma management tool. The clinical implication could improve future FeNO-based RCTs and treatment decision algorithms in managing asthma by considering phenotypes and age-dependent FeNO thresholds.
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Chang DV, Teper A, Balinotti J, Castro Simonelli C, Garcia-Bournissen F, Kofman C. Exhaled nitric oxide predicts loss of asthma control in children after inhaled corticosteroids withdrawal. Pediatr Pulmonol 2019; 54:537-543. [PMID: 30688035 DOI: 10.1002/ppul.24268] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 01/02/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND Exhaled nitric oxide (eNO) has been proposed for monitoring airway inflammation, diagnosis, and prediction of steroid responsiveness in asthma. However, its utility after elective suspension of asthma medication is still unclear. We aimed to determine the association between eNO values and the subsequent loss of asthma control (LAC) in asymptomatic asthmatic children after inhaled corticosteroids (ICS) withdrawal. METHODS We conducted a prospective observational cohort study. Forty-two children (23 boys), mean age 11 years, with clinically controlled asthma, according to GINA guidelines, and receiving low-dose of ICS (budesonide 200 μg/day or equivalent) were included immediately after the withdrawal of ICS. eNO, Asthma Control Test (ACT) and spirometry were monthly assessed, during 54 weeks or until the presence of at least one of the following criteria of LAC: 1) asthma exacerbation, 2) obstructive spirometric pattern, 3) ACT ≤ 19. RESULTS eNO baseline geometric mean (eNOb ), measured 4 weeks after discontinuation of ICS, was 23.7 ppb (SD: 1.16). An eNOb cutoff point of 21.8 ppb was determined to better discriminate between high and low eNO groups. Twenty-five subjects (71.4%) had LAC. High eNOb was associated to LAC (OR: 9.01; 95CI: 1.10-74.26). In addition, LAC occurred earlier in high eNOb than in low eNOb patients (8 vs 28 weeks, respectively; P = 0.017). CONCLUSIONS Our findings suggest that eNO predicts loss of asthma control and may contribute for clinical follow up decisions during childhood asthma after ICS withdrawal.
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Affiliation(s)
- Daniel V Chang
- Centro Respiratorio Dr. Alberto Álvarez, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Alejandro Teper
- Centro Respiratorio Dr. Alberto Álvarez, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Juan Balinotti
- Centro Respiratorio Dr. Alberto Álvarez, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Argentina
| | | | | | - Carlos Kofman
- Centro Respiratorio Dr. Alberto Álvarez, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
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Maniscalco M, Fuschillo S, Gaudiosi C, De Felice A, Martucci M, Motta A. Exhaled and nasal nitric oxide measurement in the evaluation of chronic cough. Nitric Oxide 2018; 83:19-23. [PMID: 30557619 DOI: 10.1016/j.niox.2018.12.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 11/22/2018] [Accepted: 12/13/2018] [Indexed: 12/12/2022]
Abstract
Chronic cough is one of the most common and troublesome nonspecific respiratory symptom for which patients seek a general practitioner and specialist advice. It is conventionally defined as a cough lasting for more than 8 weeks. Exhaled nitric oxide has proven to be a specific biomarker capable to discriminate between differential diagnoses of chronic cough and simultaneously provide information about the response to specific treatment. In this review, we will discuss the potential use of exhaled and nasal nitric oxide in the diagnosis of chronic chough.
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Affiliation(s)
- Mauro Maniscalco
- Pulmonary Rehabilitation Unit, ICS Maugeri SpA SB, Institute of Telese Terme, Benevento, Italy.
| | - Salvatore Fuschillo
- Pulmonary Rehabilitation Unit, ICS Maugeri SpA SB, Institute of Telese Terme, Benevento, Italy
| | - Carlo Gaudiosi
- Pulmonary Rehabilitation Unit, ICS Maugeri SpA SB, Institute of Telese Terme, Benevento, Italy
| | - Alberto De Felice
- Pulmonary Rehabilitation Unit, ICS Maugeri SpA SB, Institute of Telese Terme, Benevento, Italy
| | - Michele Martucci
- Pulmonary Rehabilitation Unit, ICS Maugeri SpA SB, Institute of Telese Terme, Benevento, Italy
| | - Andrea Motta
- Institute of Biomolecular Chemistry, National Research Council, 80078, Pozzuoli, Naples, Italy
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Omalizumab for Severe Asthma: Beyond Allergic Asthma. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3254094. [PMID: 30310816 PMCID: PMC6166383 DOI: 10.1155/2018/3254094] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/18/2018] [Indexed: 11/28/2022]
Abstract
Different subsets of asthma patients may be recognized according to the exposure trigger and the frequency and severity of clinical signs and symptoms. Regarding the exposure trigger, generally asthma can be classified as allergic (or atopic) and nonallergic (or nonatopic). Allergic and nonallergic asthma are distinguished by the presence or absence of clinical allergic reaction and in vitro IgE response to specific aeroallergens. The mechanisms of allergic asthma have been extensively studied with major advances in the last two decades. Nonallergic asthma is characterized by its apparent independence from allergen exposure and sensitization and a higher degree of severity, but little is known regarding the underlying mechanisms. Clinically, allergic and nonallergic asthma are virtually indistinguishable in exacerbations, although exacerbation following allergen exposure is typical of allergic asthma. Although they both show several distinct clinical phenotypes and different biomarkers, there are no ideal biomarkers to stratify asthma phenotypes and guide therapy in clinical practice. Nevertheless, some biomarkers may be helpful to select subsets of atopic patients which might benefit from biologic agents, such as omalizumab. Patients with severe asthma, uncontrolled besides optimal treatment, notwithstanding nonatopic, may also benefit from omalizumab therapy, although currently there are no randomized double-blind placebo controlled clinical trials to support this suggestion. However, omalizumab discontinuation according to each patient's response to therapy and pharmacoeconomical analysis are questions that remain to be answered.
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Jalota L, Allison DR, Prajapati V, Vempilly JJ, Jain VV. Ability of Exhaled Nitric Oxide to Discriminate for Airflow Obstruction Among Frequent Exacerbators of Clinically Diagnosed Asthma. Lung 2018; 196:455-462. [PMID: 29916097 DOI: 10.1007/s00408-018-0132-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 06/11/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Fraction of exhaled nitric oxide (FENO) has been proposed as a non-invasive biomarker for allergic inflammation seen in asthma. Many asthmatics in clinical practice have never had spirometry and recent data report misdiagnoses in patients with physician diagnosed (PD) asthma. The aim of this study was to assess the ability of FENO to discriminate between those with and without airflow obstruction (AO) among patients with PD-asthma. METHODS Frequent exacerbators of PD-asthma (with 2 or more asthma exacerbations leading to emergency room visit or hospitalization within last 12 months) were enrolled. All patients underwent diagnostic evaluations including spirometry, FENO testing and serum immunoglobulin (IgE) and eosinophils. Serial spirometry and methacholine challenge testing (MCT) were performed as indicated. AO was defined by a decreased FEV1/FVC ratio (< 70% and/or < LLN), or a positive MCT. RESULTS Of the 222 patients with PD-asthma, AO was found in 136 (vs. 86 without AO). 81.6% of patients with AO and 66.2% without AO completed FENO testing. There was no significant difference in the mean FENO levels among patients with or without AO (40.8 vs. 30.4 ppb, P = 0.10). Likewise, there was no difference in the serum IgE levels and serum eosinophils. CONCLUSIONS Our analyses suggest that FENO levels do not help discriminate between those with and without AO in patients with PD-asthma. Patients who experience symptoms of asthma may have elevated FENO levels above the suggested cut points of 20-25 ppb. Objective confirmation of AO should be considered in all patients with PD-asthma, irrespective of FENO levels.
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Affiliation(s)
- Leena Jalota
- Division of Pulmonary and Critical Care, University of California, San Francisco-Fresno, 155 N Fresno St, Fresno, CA, 93701, USA
- Department of Internal Medicine, University of California, San Francisco-Fresno, 155 N Fresno St, Fresno, CA, 93701, USA
| | - D Richard Allison
- Division of Pulmonary and Critical Care, University of California, San Francisco-Fresno, 155 N Fresno St, Fresno, CA, 93701, USA
- Department of Internal Medicine, University of California, San Francisco-Fresno, 155 N Fresno St, Fresno, CA, 93701, USA
- Community Regional Medical Center, Fresno, CA, USA
| | - Vinisha Prajapati
- Division of Pulmonary and Critical Care, University of California, San Francisco-Fresno, 155 N Fresno St, Fresno, CA, 93701, USA
- Department of Internal Medicine, University of California, San Francisco-Fresno, 155 N Fresno St, Fresno, CA, 93701, USA
| | - Jose J Vempilly
- Division of Pulmonary and Critical Care, University of California, San Francisco-Fresno, 155 N Fresno St, Fresno, CA, 93701, USA
- Department of Internal Medicine, University of California, San Francisco-Fresno, 155 N Fresno St, Fresno, CA, 93701, USA
| | - Vipul V Jain
- Division of Pulmonary and Critical Care, University of California, San Francisco-Fresno, 155 N Fresno St, Fresno, CA, 93701, USA.
- Department of Internal Medicine, University of California, San Francisco-Fresno, 155 N Fresno St, Fresno, CA, 93701, USA.
- Community Regional Medical Center, Fresno, CA, USA.
- Chronic Lung Disease Program, University of California, San Francisco, Fresno, 2823, Fresno St, Suite A, Fresno, CA, 93721, USA.
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Amat F, Labbé A. Biomarkers for severe allergic asthma in children: could they be useful to guide disease control and use of omalizumab? Expert Rev Respir Med 2018; 12:475-482. [PMID: 29741411 DOI: 10.1080/17476348.2018.1475233] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Although symptom controls in asthmatic children can be achieved through compliant use of conventional medication, some children have uncontrolled severe persistent asthma, especially if they are allergic. For these children, omalizumab (approved by the EMA and FDA in children aged > 6 years) could be a therapeutic option. However, response to omalizumab varies from one child to another. Predictive biomarkers of omalizumab effectiveness could be useful to monitor response to treatment. Area covered: The authors searched in the PubMed database for publications related to the use of biomarkers in allergic asthma. Supported by their own experience in phenotyping asthma in children, they analyzed whether these biomarkers could be useful in assessing response to omalizumab. Expert commentary: Th2 inflammation in children with allergic asthma can be assessed by measuring several biomarkers (blood eosinophil, serum ECP or periostin, FeNO). While a single measurement may be insufficient, a combination of biomarkers assessments may improve the follow-up of children treated by omalizumab.
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Affiliation(s)
- Flore Amat
- a Department of Allergology-Centre de l'Asthme et des Allergies, Hôpital d'Enfants Armand Trousseau, Assistance Publique-Hôpitaux de Paris; UPMC Univ Paris 06,Sorbonne Universités; Equipe EPAR , Institut Pierre Louis d'Epidémiologie et de Santé Publique , Paris , France
| | - André Labbé
- b Pediatric Emergency Department , CHU , Clermont-Ferrand , France
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Day DB, Xiang J, Mo J, Clyde MA, Weschler CJ, Li F, Gong J, Chung M, Zhang Y, Zhang J(J. Combined use of an electrostatic precipitator and a high-efficiency particulate air filter in building ventilation systems: Effects on cardiorespiratory health indicators in healthy adults. INDOOR AIR 2018; 28:360-372. [PMID: 29288500 PMCID: PMC5903943 DOI: 10.1111/ina.12447] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Accepted: 12/19/2017] [Indexed: 05/08/2023]
Abstract
High-efficiency particulate air (HEPA) filtration in combination with an electrostatic precipitator (ESP) can be a cost-effective approach to reducing indoor particulate exposure, but ESPs produce ozone. The health effect of combined ESP-HEPA filtration has not been examined. We conducted an intervention study in 89 volunteers. At baseline, the air-handling units of offices and residences for all subjects were comprised of coarse, ESP, and HEPA filtration. During the 5-week long intervention, the subjects were split into 2 groups, 1 with just the ESP removed and the other with both the ESP and HEPA removed. Each subject was measured for cardiopulmonary risk indicators once at baseline, twice during the intervention, and once 2 weeks after baseline conditions were restored. Measured indoor and outdoor PM2.5 and ozone concentrations, coupled with time-activity data, were used to calculate exposures. Removal of HEPA filters increased 24-hour mean PM2.5 exposure by 38 (95% CI: 31, 45) μg/m3 . Removal of ESPs decreased 24-hour mean ozone exposure by 2.2 (2.0, 2.5) ppb. No biomarkers were significantly associated with HEPA filter removal. In contrast, ESP removal was associated with a -16.1% (-21.5%, -10.4%) change in plasma-soluble P-selectin and a -3.0% (-5.1%, -0.8%) change in systolic blood pressure, suggesting reduced cardiovascular risks.
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Affiliation(s)
- Drew B Day
- Global Health Institute and Nicholas School of the Environment, Duke University, Box 90328, Durham, NC 27708, USA
| | - Jianbang Xiang
- Department of Building Science, Tsinghua University, Beijing 100084, China
- Beijing Key Laboratory of Indoor Air Quality Evaluation and Control, Beijing 100084, China
| | - Jinhan Mo
- Department of Building Science, Tsinghua University, Beijing 100084, China
- Beijing Key Laboratory of Indoor Air Quality Evaluation and Control, Beijing 100084, China
| | - Merlise A Clyde
- Department of Statistical Science, Duke University, 214A Old Chemistry Building, Box 90251, Durham, NC 27708, USA
| | - Charles J Weschler
- Department of Building Science, Tsinghua University, Beijing 100084, China
- Beijing Key Laboratory of Indoor Air Quality Evaluation and Control, Beijing 100084, China
- Environmental and Occupational Health Sciences Institute, Rutgers University, Robert Wood Johnson Medical School, Room N100, 675 Hoes Lane West, Piscataway, NJ 08854, USA
| | - Feng Li
- Department of Respiratory Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, 100 Haining Road, Shanghai, China 200080
| | - Jicheng Gong
- Department of Environmental Science, Peking University, 116 Old Geosciences Building, Beijing, China 100871
| | - Mingkei Chung
- Department of Biomedical Informatics, Harvard Medical School, Harvard University, 10 Shattuck Street, Boston, MA 02115, USA
| | - Yinping Zhang
- Department of Building Science, Tsinghua University, Beijing 100084, China
- Beijing Key Laboratory of Indoor Air Quality Evaluation and Control, Beijing 100084, China
| | - Junfeng (Jim) Zhang
- Global Health Institute and Nicholas School of the Environment, Duke University, Box 90328, Durham, NC 27708, USA
- Department of Environmental Science, Peking University, 116 Old Geosciences Building, Beijing, China 100871
- Duke Kunshan University, No. 8 Duke Avenue, Kunshan, Jiangsu Province, China 215316
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Abstract
PURPOSE OF REVIEW The inflammatory makeup of severe asthma is heterogeneous. Identification of the predominant cellular endotype via biomarkers can aid in the selection of more advanced therapies. This review is clinically focused on how to use these biomarkers to help select between biologic agents and/or bronchial thermoplasty. RECENT FINDINGS Several Th2 biomarkers exist for the detection of eosinophilic disease; however, the best biomarker for clinical practice is debatable depending upon local resources. Currently, there are three federal drug agency-approved biologic agents (omalizumab, mepolizumab and reslizumab) to treat severe asthma with frequent exacerbations despite standard medical therapy. Several others are either in clinical trials or in the development phase for the treatment of eosinophilic asthma. To date, agents targeting neutrophilic inflammation have been largely unsuccessful. Bronchial thermoplasty has emerged as an option for the treatment of severe asthma. SUMMARY The appropriate selection of patients through the use of eosinophilic biomarkers has led to significant reductions in exacerbations with the use of mAb therapy. Bronchial thermoplasty has also shown reductions in asthma exacerbations and improved quality of life; however, it is unclear which patients may respond best to this intervention.
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Kim H, Ellis AK, Fischer D, Noseworthy M, Olivenstein R, Chapman KR, Lee J. Asthma biomarkers in the age of biologics. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2017; 13:48. [PMID: 29176991 PMCID: PMC5691861 DOI: 10.1186/s13223-017-0219-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/25/2017] [Indexed: 02/08/2023]
Abstract
The heterogeneous nature of asthma has been understood for decades, but the precise categorization of asthma has taken on new clinical importance in the era of specific biologic therapy. The simple categories of allergic and non-allergic asthma have given way to more precise phenotypes that hint at underlying biologic mechanisms of variable airflow limitation and airways inflammation. Understanding these mechanisms is of particular importance for the approximately 10% of patients with severe asthma. Biomarkers that aid in phenotyping allow physicians to "personalize" treatment with targeted biologic agents. Unfortunately, testing for these biomarkers is not routine in patients whose asthma is refractory to standard therapy. Scientific advances in the recognition of sensitive and specific biomarkers are steadily outpacing the clinical availability of reliable and non-invasive assessment methods designed for the prompt and specific diagnosis, classification, treatment, and monitoring of severe asthma patients. This article provides a practical overview of current biomarkers and testing methods for prompt, effective management of patients with severe asthma that is refractory to standard therapy.
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Affiliation(s)
- Harold Kim
- Division of Clinical Immunology & Allergy, Department of Medicine, Western University, 1151 Richmond St, London, ON N6A 5C1 Canada
- Division of Clinical Immunology & Allergy, Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1 Canada
| | - Anne K. Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen’s University, 15 Arch Street, Kingston, ON K7L 3N6 Canada
- Department of Biomedical and Molecular Sciences, School of Medicine, Queen’s University, Kingston, ON Canada
| | - David Fischer
- Division of Clinical Immunology & Allergy, Department of Medicine, Western University, 1151 Richmond St, London, ON N6A 5C1 Canada
- Canadian Society of Allergy and Clinical Immunology, P.O. Box 51045, Orleans, ON K1E 3W4 Canada
| | - Mary Noseworthy
- Alberta Children’s Hospital, University of Calgary, 2500 University Dr. NW, Calgary, AB T2N 1N4 Canada
| | - Ron Olivenstein
- Division of Respiratory Medicine, Faculty of Medicine, McGill University, 3605 Rue De la Montagne, Montreal, QC H3G 2M1 Canada
- Acute Care Division, Montreal Chest Institute, 1001 Décarie Blvd, Montreal, QC H4A 3J1 Canada
| | - Kenneth R. Chapman
- Asthma and Airway Centre, Toronto Western Hospital, University Health Network, 399 Bathurst Street, Toronto, ON M5T 2S8 Canada
- Division of Respirology, Department of Medicine, University of Toronto, 1 King’s College Circle, #3172, Toronto, ON M5S 1A8 Canada
| | - Jason Lee
- Toronto Allergy and Asthma Centre, 123 Edward St, Toronto, ON M5G 1E2 Canada
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, 30 Bond St, Toronto, ON M5B 1W8 Canada
- Department of Surgery, School of Medicine, University of Toronto, 1 King’s College Circle, #3172, Toronto, ON M5S 1A8 Canada
- Evidence Based Medical Educator Inc., 123 Edward St., Suite 920, Toronto, ON M5G 1E2 Canada
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Day DB, Xiang J, Mo J, Li F, Chung M, Gong J, Weschler CJ, Ohman-Strickland PA, Sundell J, Weng W, Zhang Y, Zhang J(J. Association of Ozone Exposure With Cardiorespiratory Pathophysiologic Mechanisms in Healthy Adults. JAMA Intern Med 2017; 177:1344-1353. [PMID: 28715576 PMCID: PMC5710579 DOI: 10.1001/jamainternmed.2017.2842] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 04/25/2017] [Indexed: 01/08/2023]
Abstract
Importance Exposure to ozone has been associated with cardiovascular mortality, but the underlying biological mechanisms are not yet understood. Objective To examine the association between ozone exposure and cardiopulmonary pathophysiologic mechanisms. Design, Setting, and Participants A longitudinal study involving 89 healthy adult participants living on a work campus in Changsha City, China, was conducted from December 1, 2014, to January 31, 2015. This unique quasiexperimental setting allowed for better characterization of air pollutant exposure effects because the participants spent most of their time in controlled indoor environments. Concentrations of indoor and outdoor ozone, along with the copollutants particulate matter, nitrogen dioxide, and sulfur dioxide, were monitored throughout the study period and then combined with time-activity information and filtration conditions of each residence and office to estimate 24-hour and 2-week combined indoor and outdoor mean exposure concentrations. Associations between each exposure measure and outcome measure were analyzed using single-pollutant and 2-pollutant linear mixed models controlling for ambient temperature, secondhand smoke exposure, and personal-level time-varying covariates. Main Outcomes and Measures Biomarkers indicative of inflammation and oxidative stress, arterial stiffness, blood pressure, thrombotic factors, and spirometry were measured at 4 sessions. Results Of the 89 participants, 25 (28%) were women and the mean (SD) age was 31.5 (7.6) years. The 24-hour ozone exposure concentrations ranged from 1.4 to 19.4 parts per billion (ppb), corresponding to outdoor concentrations ranging from 4.3 to 47.9 ppb. Within this range, in models controlling for a second copollutant and other potential confounders, a 10-ppb increase in 24-hour ozone was associated with mean increases of 36.3% (95% CI, 29.9%-43.0%) in the level of platelet activation marker soluble P-selectin, 2.8% (95% CI, 0.6%-5.1%) in diastolic blood pressure, 18.1% (95% CI, 4.5%-33.5%) in pulmonary inflammation markers fractional exhaled nitric oxide, and 31.0% (95% CI, 0.2%-71.1%) in exhaled breath condensate nitrite and nitrate as well as a -9.5% (95% CI, -17.7% to -1.4%) decrease in arterial stiffness marker augmentation index. A 10-ppb increase in 2-week ozone was associated with increases of 61.1% (95% CI, 37.8%-88.2%) in soluble P-selectin level and 126.2% (95% CI, 12.1%-356.2%) in exhaled breath condensate nitrite and nitrate level. Other measured biomarkers, including spirometry, showed no significant associations with either 24-hour ozone or 2-week ozone exposures. Conclusions and Relevance Short-term ozone exposure at levels not associated with lung function changes was associated with platelet activation and blood pressure increases, suggesting a possible mechanism by which ozone may affect cardiovascular health.
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Affiliation(s)
- Drew B. Day
- Global Health Institute, Nicholas School of the Environment, Duke University, Durham, North Carolina
| | - Jianbang Xiang
- Department of Building Science, Tsinghua University, Beijing, China
- Beijing Key Laboratory of Indoor Air Quality Evaluation and Control, Beijing, China
| | - Jinhan Mo
- Department of Building Science, Tsinghua University, Beijing, China
- Beijing Key Laboratory of Indoor Air Quality Evaluation and Control, Beijing, China
| | - Feng Li
- Department of Respiratory Medicine, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Mingkei Chung
- Global Health Research Center, Duke Kunshan University, Kunshan, Jiangsu Province, China
| | - Jicheng Gong
- Global Health Institute, Nicholas School of the Environment, Duke University, Durham, North Carolina
- College of Environmental Sciences and Engineering and Beijing Innovation Center for Engineering Science and Advanced Technology, Peking University, Beijing, China
| | - Charles J. Weschler
- Department of Building Science, Tsinghua University, Beijing, China
- Beijing Key Laboratory of Indoor Air Quality Evaluation and Control, Beijing, China
- Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, New Jersey
| | | | - Jan Sundell
- Department of Building Science, Tsinghua University, Beijing, China
| | - Wenguo Weng
- Institute of Public Safety Research, Department of Engineering Physics, Tsinghua University, Beijing, China
| | - Yinping Zhang
- Department of Building Science, Tsinghua University, Beijing, China
- Beijing Key Laboratory of Indoor Air Quality Evaluation and Control, Beijing, China
| | - Junfeng (Jim) Zhang
- Global Health Institute, Nicholas School of the Environment, Duke University, Durham, North Carolina
- Global Health Research Center, Duke Kunshan University, Kunshan, Jiangsu Province, China
- College of Environmental Sciences and Engineering and Beijing Innovation Center for Engineering Science and Advanced Technology, Peking University, Beijing, China
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Menou A, Babeanu D, Paruit HN, Ordureau A, Guillard S, Chambellan A. Normal values of offline exhaled and nasal nitric oxide in healthy children and teens using chemiluminescence. J Breath Res 2017; 11:036008. [PMID: 28579561 DOI: 10.1088/1752-7163/aa76ef] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Nitric oxide (NO) can be used to detect respiratory or ciliary diseases. Fractional exhaled nitric oxide (FeNO) measurement can reflect ongoing eosinophilic airway inflammation and has a diagnostic utility as a test for asthma screening and follow-up while nasal nitric oxide (nNO) is a valuable screening tool for the diagnosis of primary ciliary dyskinesia. The possibility of collecting airway gas samples in an offline manner offers the advantage to extend these measures and improve the screening and management of these diseases, but normal values from healthy children and teens remain sparse. METHODS Samples were consecutively collected using the offline method for eNO and nNO chemiluminescence measurement in 88 and 31 healthy children and teens, respectively. Offline eNO measurement was also performed in 30 consecutive children with naïve asthma and/or respiratory allergy. RESULTS The normal offline eNO value was determined by the following regression equation -8.206 + 0.176 × height. The upper limit of the norm for the offline eNO value was 27.4 parts per billion (ppb). A separate analysis was performed in children, pre-teens and teens, for which offline eNO was 13.6 ± 4.7 ppb, 16.3 ± 13.7 ppb and 20.0 ± 7.2 ppb, respectively. The optimal cut-off value of the offline eNO to predict asthma or respiratory allergies was 23.3 ppb, with a sensitivity and specificity of 77% and 91%, respectively. Mean offline nNO was determined at 660 ppb with the lower limit of the norm at 197 ppb. CONCLUSION The use of offline eNO and nNO normal values should favour the widespread screening of respiratory diseases in children of school age in their usual environment.
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Affiliation(s)
- A Menou
- Faculte des Sciences, Université de Nantes, Nantes, France
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Berry A, Busse WW. Biomarkers in asthmatic patients: Has their time come to direct treatment? J Allergy Clin Immunol 2017; 137:1317-24. [PMID: 27155028 DOI: 10.1016/j.jaci.2016.03.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Revised: 03/01/2016] [Accepted: 03/10/2016] [Indexed: 01/09/2023]
Abstract
Asthma is a heterogeneous disease with multiple phenotypes that have variable risk factors and responses to therapeutics. Mild-to-moderate asthma often responds to traditional medications, whereas severe disease can be refractory to inhaled corticosteroids, long-acting β-agonists, and leukotriene receptor antagonists. There is robust research into the variable phenotypes of asthma. Biomarkers help define the specific pathophysiology of different asthma phenotypes and identify potential therapeutic targets. The following review will discuss the current use of biomarkers for the diagnosis of asthma, triaging the severity of a patient's disease, and the potential efficacy of treatments. This information can be used to define certain patient populations that are more likely to respond to inhaled corticosteroids or biologics. As knowledge of patient phenotypes and endotypes and biological agents to target specific classes of asthma emerge, the ability to provide personalized care to asthmatic patients will follow.
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Affiliation(s)
- Alalia Berry
- Department of Medicine, Section of Allergy Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - William W Busse
- Department of Medicine, Section of Allergy Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
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Chen E, Miller GE, Shalowitz MU, Story RE, Levine CS, Hayen R, Sbihi H, Brauer M. Difficult Family Relationships, Residential Greenspace, and Childhood Asthma. Pediatrics 2017; 139:peds.2016-3056. [PMID: 28280210 PMCID: PMC5369675 DOI: 10.1542/peds.2016-3056] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Both the social environment and the physical environment are increasingly recognized as important to childhood diseases such as asthma. This study tested a novel hypothesis: that living in areas high in greenspace may help buffer the effects of difficult family relationships for children with asthma. METHODS A total of 150 children (ages 9-17), physician-diagnosed with asthma, participated in this study. To assess difficulties in parent-child relationships, parents and children completed measures of harsh/inconsistent parenting and parental hostility. Residential greenspace was calculated by using satellite-derived Normalized Difference Vegetation Index with a buffer of 250 m around the residential address. Outcomes included both clinical and biological measures: asthma control and functional limitations, as well as airway inflammation (fractional concentration of exhaled nitric oxide) and glucocorticoid receptor expression in T-helper cells. RESULTS After controlling for potential confounding variables, including family income, child demographics, and child medical variables, few main effects were found. However, interactions between residential greenspace and difficult family relationships were found for asthma control (P = .02), asthma functional limitations (P = .04), airway inflammation (P = .007), and the abundance of glucocorticoid receptor in T-helper cells (P = .05). These interactions were all in a direction such that as the quality of parent-child relationships improved, greenspace became more strongly associated with better asthma outcomes. CONCLUSIONS These findings suggest synergistic effects of positive environments across the physical and social domains. Children with asthma appear to benefit the most when they both live in high greenspace areas and have positive family relationships.
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Affiliation(s)
- Edith Chen
- Institute for Policy Research and Department of Psychology, Northwestern University, Evanston, Illinois;
| | - Gregory E. Miller
- Institute for Policy Research and Department of Psychology, Northwestern University, Evanston, Illinois
| | | | - Rachel E. Story
- Department of Medicine, NorthShore University HealthSystem, Evanston, Illinois; and
| | - Cynthia S. Levine
- Institute for Policy Research and Department of Psychology, Northwestern University, Evanston, Illinois
| | - Robin Hayen
- Institute for Policy Research and Department of Psychology, Northwestern University, Evanston, Illinois
| | - Hind Sbihi
- University of British Columbia, School of Population and Public Health, Vancouver, British Columbia, Canada
| | - Michael Brauer
- University of British Columbia, School of Population and Public Health, Vancouver, British Columbia, Canada
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Van Iterson EH, Snyder EM, Johnson BD. The Influence of 17 Hours of Normobaric Hypoxia on Parallel Adjustments in Exhaled Nitric Oxide and Airway Function in Lowland Healthy Adults. High Alt Med Biol 2017; 18:1-10. [PMID: 28135110 DOI: 10.1089/ham.2016.0086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Van Iterson, Erik H., Eric M. Snyder, and Bruce D. Johnson. The influence of 17 hours of normobaric hypoxia on parallel adjustments in exhaled nitric oxide and airway function in lowland healthy adults. High Alt Med Biol. 18:1-10, 2017.-Currently, there is a disparate understanding of the role that normobaric hypoxia plays in affecting nitric oxide (NO) measured in exhaled air (eNO) and airway function in lowland healthy adults. Compared to normobaric normoxia, this study aimed to test the effect of 17 hours of normobaric hypoxia on relationships between eNO and airway function in healthy adults. In a crossover study including 2 separate visits, 26 lowland healthy Caucasian adults performed eNO and pulmonary function tests on visit 1 in normobaric normoxia, while repeating all tests on visit 2 following 17 hours of normobaric hypoxia (12.5% O2). Compared to normobaric normoxia, eNO (29 ± 24 vs. 36 ± 28 ppb), forced expiratory volume in one second (FEV1) (4.1 ± 0.7 vs. 4.3 ± 0.8 L), mean forced expiratory flow between 25% and 75% FVC (FEF25-75) (3.9 ± 1.0 vs. 4.2 ± 1.2 L/s), and forced expiratory flow at 75% FVC (FEF75) (2.0 ± 0.7 vs. 2.3 ± 0.8 L/s) increased in normobaric hypoxia, respectively (all p < 0.05). Correlations at normoxia between eNO and FEV1 (r = 0.39 vs. 0.44), FEF25-75 (r = 0.51 vs. 0.51), and FEF75 (r = 0.53 vs. 0.55) persisted as both parameters increased in hypoxia, respectively. For the first time, these data suggest that 17 hours of hypoxic breathing in the absence of low ambient pressure contribute to increased eNO and airway function in lowland healthy adults.
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Affiliation(s)
- Erik H Van Iterson
- 1 Department of Cardiovascular Diseases, Mayo Clinic College of Medicine , Rochester, Minnesota
| | - Eric M Snyder
- 2 Department of Kinesiology, University of Minnesota , Minneapolis, Minnesota
| | - Bruce D Johnson
- 1 Department of Cardiovascular Diseases, Mayo Clinic College of Medicine , Rochester, Minnesota
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Kwon JW, Song WJ, Kim MH, Lim KH, Yang MS, Jung JW, Lee J, Suh DI, Shin YS, Kim SH, Kim SH, Lee BJ, Cho SH. The KAAACI Standardization Committee Report on the procedure and application of fractional exhaled nitric oxide measurement. ALLERGY ASTHMA & RESPIRATORY DISEASE 2017. [DOI: 10.4168/aard.2017.5.4.185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jae-Woo Kwon
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Woo-Jung Song
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Min-Hye Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyung-Hwan Lim
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - Min-Suk Yang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jeongmin Lee
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Yoo Seob Shin
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Byung-Jae Lee
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Abstract
Asthma affects an estimated 7 million children and causes significant health care and disease burden. The most recent iteration of the National Heart, Lung and Blood Institute asthma guidelines, the Expert Panel Report 3, emphasizes the assessment and monitoring of asthma control in the management of asthma. Asthma control refers to the degree to which the manifestations of asthma are minimized by therapeutic interventions and the goals of therapy are met. Although assessment of asthma severity is used to guide initiation of therapy, monitoring of asthma control helps determine whether therapy should be maintained or adjusted. The nuances of estimation of asthma control include understanding concepts of current impairment and future risk and incorporating their measurement into clinical practice. Impairment is assessed on the basis of frequency and intensity of symptoms, variations in lung function, and limitations of daily activities. "Risk" refers to the likelihood of exacerbations, progressive loss of lung function, or adverse effects from medications. Currently available ambulatory tools to measure asthma control range are subjective measures, such as patient-reported composite asthma control score instruments or objective measures of lung function, airway hyperreactivity, and biomarkers. Because asthma control exhibits short- and long-term variability, health care providers need to be vigilant regarding the fluctuations in the factors that can create discordance between subjective and objective assessment of asthma control. Familiarity with the properties, application, and relative value of these measures will enable health care providers to choose the optimal set of measures that will adhere to national standards of care and ensure delivery of high-quality care customized to their patients.
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Kavitha V, Mohan A, Madan K, Hadda V, Khilnani GC, Guleria R. Fractional exhaled nitric oxide is a useful adjunctive modality for monitoring bronchial asthma. Lung India 2017; 34:132-137. [PMID: 28360460 PMCID: PMC5351354 DOI: 10.4103/0970-2113.201322] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background and Objective: To evaluate the utility of fractional exhaled nitric oxide (FeNO) in monitoring asthma control. Materials and Methods: Steroid naïve nonsmoking asthmatics were recruited and followed for 6–8 weeks on standard treatment. Serial measurements of FeNO, peak expiratory flow rate (PEFR) variability, forced expiratory volume in 1 s (FEV1), bronchodilator reversibility (BDR), and asthma control test (ACT) score were measured at baseline and after 6–8 weeks of treatment. Results: One hundred and fifty-one patients were recruited over an 18-month period. These comprised 79 males (52.3%) with mean (standard deviation) age of 34.2 (11.6). Mean (SD) FeNO levels at baseline and after therapy were 45.4 (35.9) and 38.4 (23.7) ppb, respectively (P = 0.01). Baseline FeNO correlated strongly with FEV1 (r = −0.78, P < 0.001), ACT score (r = −0.76, P < 0.001), PEFR variability (r = −0.74, P < 0.001), and moderately with BDR (r = 0.50, P < 0.001). After treatment with inhaled steroids, the correlation remained strong with ACT score (r = −0.68, P < 0.001) but weakened with PEFR variability (r = −0.34, P = 0.01) and FEV1 (r = −0.36, P = 0.01). Conclusions: FeNO may be useful as an adjunctive noninvasive modality to assess asthma control in both steroid naïve asthmatics and asthmatics on treatment. However, the suboptimal sensitivity and specificity may limit its utility as a point-of-care single monitoring tool.
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Affiliation(s)
- Venkatnarayan Kavitha
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Anant Mohan
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - G C Khilnani
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary Medicine and Sleep Disorders, All India Institute of Medical Sciences, New Delhi, India
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NIOX VERO: Individualized Asthma Management in Clinical Practice. Pulm Ther 2016. [DOI: 10.1007/s41030-016-0018-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Neelamegan R, Saka V, Tamilarasu K, Rajaram M, Selvarajan S, Chandrasekaran A. Clinical Utility of Fractional exhaled Nitric Oxide (FeNO) as a Biomarker to Predict Severity of Disease and Response to Inhaled Corticosteroid (ICS) in Asthma Patients. J Clin Diagn Res 2016; 10:FC01-FC06. [PMID: 28208871 DOI: 10.7860/jcdr/2016/20656.8950] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 08/17/2016] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Bronchial asthma is a common chronic inflammatory airway disease diagnosed and is based on symptomatic history and Pulmonary Function Tests (PFT). Fractional exhaled Nitric Oxide (FeNO) is exclusively a non-invasive biomarker of on-going eosinophilic airway inflammation which remains unpredictable only with PFTs. FeNO measurement is recommended in predicting asthma severity and Inhaled Corticosteroid (ICS) response but further research is required to understand its clinical utility and agreement with current recommendations in a specific population. AIM To estimate FeNO levels in Tamilian patients with mild-to-moderate persistent asthma and to correlate with disease severity and ICS response. MATERIALS AND METHODS The study was a prospective cohort with a single group of 102 persistent asthma patients under standard ICS regimen for 8 weeks (follow-up period). PFT and FeNO were measured using portable spirometry and chemiluminescence based exhaled breath analyser, at baseline and during follow-up visits. Based on PFT and FeNO parameters, the study population was sub-grouped with respect to asthma severity (as mild, moderate and moderately severe), FeNO cut-off (> or < 50ppb) and ICS response classification (good vs poor ICS responders). RESULTS Significant decrease in mean FeNO levels were found in mild, moderate and moderately severe asthmatic groups following ICS treatment (90.15±27.36, 75.74±31.98 and 77.18±32.79 ppb) compared to similar baseline FeNO levels (103.03±34.08, 91.38±37.60 and 97.90±43.84 ppb) in all the above groups. Similarly, significant decrease in mean FeNO levels was found - FeNO>50ppb, good and poor ICS responders groups, in post- ICS treatment (89.63±24.04, 77.90±31.12 and 86.49±32.57 ppb) compared to baseline levels (110.183±1.23, 97.12±42.04 and 99.68±34.71 ppb). CONCLUSION The observed baseline FeNO values in all groups as stated above did not show significant difference to differentiate asthma severity or ICS responders groups. The present study results do not support the predictive association of baseline FeNO levels with asthma severity and future ICS response, but the decrements in FeNO levels on ICS treatment, supports its clinical utility in monitoring of ongoing airway inflammation and understanding treatment response rate.
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Affiliation(s)
| | - Vinodkumar Saka
- Professor and Head, Department of Pulmonary Medicine, JIPMER , Puducherry, India
| | | | - Manju Rajaram
- Associate Professor, Department of Pulmonary Medicine, JIPMER , Puducherry, India
| | - Sandhiya Selvarajan
- Assistant Professor, Department of Clinical Pharmacology, JIPMER , Puducherry, India
| | - Adithan Chandrasekaran
- Director, CIDRF, MGMCRI, Puducherry and Retd. Senior Professor and Head, Department of Clinical Pharmacology, JIPMER , Puducherry, India
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Abstract
BACKGROUND Asthma guidelines aim to guide health practitioners to optimise treatment for patients to minimise symptoms, improve or maintain good lung function, and prevent acute exacerbations. The principle of asthma guidelines is based on a step-up or step-down regimen of asthma medications to maximise health using minimum doses. Fractional exhaled nitric oxide (FeNO) is a marker of eosinophilic inflammation and tailoring asthma medications in accordance to airway eosinophilic levels may improve asthma outcomes such as indices of control or reduce exacerbations, or both. OBJECTIVES To evaluate the efficacy of tailoring asthma interventions based on fractional exhaled nitric oxide (FeNO), in comparison to not using FeNO, that is, management based on clinical symptoms (with or without spirometry/peak flow) or asthma guidelines (or both), for asthma-related outcomes in children. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and reference lists of articles. The last searches were in June 2016. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing adjustment of asthma medications based on FeNO levels compared to those not using FeNO, that is, management based on clinical symptoms or asthma guidelines (or both) involving children. DATA COLLECTION AND ANALYSIS We reviewed results of searches against predetermined criteria for inclusion. Two review authors independently selected relevant studies, assessed trial quality and extracted data. We contacted study authors for further information with responses provided from three. MAIN RESULTS The review included nine studies; these studies differed in a variety of ways including definition of asthma exacerbations, FeNO cut-off levels used (12 parts per billion (ppb) to 30 ppb), the way in which FeNO was used to adjust therapy and duration of study (6 to 12 months). Of 1426 children randomised, 1329 completed the studies. The inclusion criteria for the participants in each study varied but all had a diagnosis of asthma. There was a significant difference in the number of children having one or more asthma exacerbations over the study period, they were significantly lower in the FeNO group in comparison to the control group (odds ratio (OR) 0.58, 95% confidence interval (CI) 0.45 to 0.75; 1279 participants; 8 studies). The number needed to treat for an additional beneficial outcome (NNTB) over 52 weeks was 9 (95% CI 6 to 15). There was no difference between the groups when comparing exacerbation rates (mean difference (MD) -0.37, 95% CI -0.8 to 0.06; 736 participants; 4 studies; I2 = 67%). The number of children in the FeNO group requiring oral corticosteroid courses was lower in comparison to the children in the control group (OR 0.63, 95% CI 0.48 to 0.83; 1169 participants; 7 studies; I2 = 0%). There was no statistically significant difference between the groups for exacerbations requiring hospitalisation (OR 0.75, 95% CI 0.41 to 1.36; 1110 participants; 6 studies; I2 = 0%). There were no significant differences between the groups for any of the secondary outcomes (forced expiratory volume in one second (FEV1), FeNO levels, symptom scores or inhaled corticosteroid doses at final visit). The included studies recorded no adverse events.Three studies had inadequate blinding and were thus considered to have a high risk of bias. However, when these studies were removed in subgroup analysis, the difference between the groups for the primary outcome (exacerbations) remained statistically significant. The GRADE quality of the evidence ranged from moderate (for the outcome 'Number of participants who had one or more exacerbations over the study period') to very low (for the outcome 'Exacerbation rates'), based on lack of blinding, statistical heterogeneity and imprecision. AUTHORS' CONCLUSIONS In this updated review with five new included studies, tailoring asthma medications based on FeNO levels (in comparison with primarily guideline management) significantly decreased the number of children who had one or more exacerbations over the study period but did not impact on the day-to-day clinical symptoms or inhaled corticosteroid doses. Therefore, the use of FeNO to guide asthma therapy in children may be beneficial in a subset of children, it cannot be universally recommended for all children with asthma.Further RCTs need to be conducted and these should encompass different asthma severities, different settings including primary care and less affluent settings, and consider different FeNO cut-offs.
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Affiliation(s)
- Helen L Petsky
- Griffith UniversitySchool of Nursing and Midwifery, Griffith University and Menzies Health Institute QueenslandBrisbaneQueenslandAustralia
| | - Kayleigh M Kew
- BMJBritish Medical Journal Technology Assessment Group (BMJ‐TAG)BMA HouseTavistock SquareLondonUKWC1H 9JR
| | - Anne B Chang
- Menzies School of Health Research, Charles Darwin UniversityChild Health DivisionPO Box 41096DarwinNorthern TerritoriesAustralia0811
- Queensland University of TechnologyInstitute of Health and Biomedical InnovationBrisbaneAustralia
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Kim JK, Jung JY, Kim H, Eom SY, Hahn YS. Combined use of fractional exhaled nitric oxide and bronchodilator response in predicting future loss of asthma control among children with atopic asthma. Respirology 2016; 22:466-472. [PMID: 27783458 DOI: 10.1111/resp.12934] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 08/12/2016] [Accepted: 08/19/2016] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Recognition of patients at risk of asthma exacerbation is important for future asthma care and improved outcome. The aim of the present study was to see whether measurements of bronchodilator response (BDR) and fractional exhaled nitric oxide (FeNO) in combination provide prognostic information superior to either measurement alone in children with atopic asthma. METHODS A total of 201 atopic children aged 8-16 years with intermittent or mild persistent asthma were included. Pulmonary function tests including BDR and FeNO were serially monitored 10 times or more over 2 years when subjects were not receiving controller medications. After completion of monitoring, 1-year observation for a loss of asthma control was performed. RESULTS During the monitoring period, positive BDRs (≥12% in forced expiratory volume in 1 s (FEV1 ) from pre-bronchodilator value) and FeNO higher than 35 parts per billion (ppb) were observed at least once in 59% and 77% of participants. When analysed as continuous variables, both BDR (hazard ratio (HR): 1.21; 95% CI: 1.04-1.41; P = 0.014) and FeNO (HR: 1.27; 95% CI: 1.09-1.49; P = 0.003) were associated with increased risks for a control loss. Compared with patients showing either positive BDRs (HR: 3.19; 95% CI: 1.05-9.64) or FeNO higher than 35 ppb (HR: 4.70; 95% CI: 1.68-13.11), patients with both findings (HR: 7.08; 95% CI: 2.57-19.49) had greater risks for a control loss. CONCLUSION These data support that combined use of BDR and FeNO measurements can modify predictive risk obtained from either measurement alone.
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Affiliation(s)
- Je-Kyung Kim
- Department of Pediatrics, Chungbuk National University, Cheongju, Republic of Korea
| | - Jae-Yub Jung
- Department of Pediatrics, Chungbuk National University, Cheongju, Republic of Korea
| | - Heon Kim
- Department of Preventive Medicine, College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Republic of Korea
| | - Sang-Yong Eom
- Department of Preventive Medicine, College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Republic of Korea
| | - Youn-Soo Hahn
- Department of Pediatrics, Chungbuk National University, Cheongju, Republic of Korea
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Petsky HL, Kew KM, Turner C, Chang AB. Exhaled nitric oxide levels to guide treatment for adults with asthma. Cochrane Database Syst Rev 2016; 9:CD011440. [PMID: 27580628 PMCID: PMC6457753 DOI: 10.1002/14651858.cd011440.pub2] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Asthma guidelines aim to guide health practitioners to optimise treatment for patients so as to minimise symptoms, improve or maintain good lung function, and prevent acute exacerbations or flare-ups. The principle of asthma guidelines is based on a step-up or step-down regimen of asthma medications to maximise good health outcomes using minimum medications. Asthma maintenance therapies reduce airway inflammation that is usually eosinophilic. Tailoring asthma medications in accordance with airway eosinophilic levels may improve asthma outcomes such as indices of control or reduce exacerbations or both. Fractional exhaled nitric oxide (FeNO) is a marker of eosinophilic inflammation, and as it is easy to measure, has an advantage over other measurements of eosinophilic inflammation (for example sputum eosinophils). OBJECTIVES To evaluate the efficacy of tailoring asthma interventions based on exhaled nitric oxide (FeNO), in comparison to not using FeNO, that is management based on clinical symptoms (with or without spirometry/peak flow) or asthma guidelines or both, for asthma-related outcomes in adults. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and reference lists of articles. The last searches were undertaken in June 2016. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing adjustment of asthma medications based on exhaled nitric oxide levels compared to not using FeNO, that is management based on clinical symptoms (with or without spirometry/peak flow) or asthma guidelines or both. DATA COLLECTION AND ANALYSIS We reviewed results of searches against predetermined criteria for inclusion. We independently selected relevant studies in duplicate. Two review authors independently assessed trial quality and extracted data. We contacted study authors for further information, receiving responses from four. MAIN RESULTS We included seven adult studies; these studies differed in a variety of ways including definition of asthma exacerbations, FeNO cutoff levels used (15 to 35 ppb), the way in which FeNO was used to adjust therapy, and duration of study (4 to 12 months). Of 1700 randomised participants, 1546 completed the trials. The mean ages of the participants ranged from 28 to 54 years old. The inclusion criteria for the participants in each study varied, but all had a diagnosis of asthma and required asthma medications. In the meta-analysis, there was a significant difference in the primary outcome of asthma exacerbations between the groups, favouring the FeNO group. The number of people having one or more asthma exacerbations was significantly lower in the FeNO group compared to the control group (odds ratio (OR) 0.60, 95% confidence interval (CI) 0.43 to 0.84). The number needed to treat to benefit (NNTB) over 52 weeks was 12 (95% CI 8 to 32). Those in the FeNO group were also significantly more likely to have a lower exacerbation rate than the controls (rate ratio 0.59, 95% CI 0.45 to 0.77). However, we did not find a difference between the groups for exacerbations requiring hospitalisation (OR 0.14, 95% CI 0.01 to 2.67) or rescue oral corticosteroids (OR 0.86, 95% CI 0.50 to 1.48). There was also no significant difference between groups for any of the secondary outcomes (FEV1, FeNO levels, symptoms scores, or inhaled corticosteroid doses at final visit).We considered three included studies that had inadequate blinding to have a high risk of bias. However, when these studies were excluded from the meta-analysis, the difference between the groups for the primary outcomes (exacerbations) remained statistically significant. The GRADE quality of the evidence ranged from moderate (for the outcome 'exacerbations') to very low (for the outcome 'inhaled corticosteroid dose at final visit') based on the lack of blinding and statistical heterogeneity. Six of the seven studies were industry supported, but the company had no role in the study design or data analyses. AUTHORS' CONCLUSIONS With new studies included since the last version of this review, which included adults and children, this updated meta-analysis in adults with asthma showed that tailoring asthma medications based on FeNO levels (compared with primarily on clinical symptoms) decreased the frequency of asthma exacerbations but did not impact on day-to-day clinical symptoms, end-of-study FeNO levels, or inhaled corticosteroid dose. Thus, the universal use of FeNO to help guide therapy in adults with asthma cannot be advocated. As the main benefit shown in the studies in this review was a reduction in asthma exacerbations, the intervention may be most useful in adults who have frequent exacerbations. Further RCTs encompassing different asthma severity, ethnic groups in less affluent settings, and taking into account different FeNO cutoffs are required.
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Affiliation(s)
- Helen L Petsky
- Queensland University of TechnologyInstitute of Health and Biomedical InnovationBrisbaneQueenslandAustralia
| | - Kayleigh M Kew
- St George's, University of LondonPopulation Health Research InstituteCranmer TerraceLondonUKSW17 0RE
| | - Cathy Turner
- The University of QueenslandSchool of Nursing, Midwifery & Social WorkBrisbaneQueenslandAustralia
| | - Anne B Chang
- Queensland University of TechnologyInstitute of Health and Biomedical InnovationBrisbaneQueenslandAustralia
- Menzies School of Health Research, Charles Darwin UniversityChild Health DivisionPO Box 41096DarwinNorthern TerritoriesAustralia0811
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Nickels AS, Lim KG. Evaluation of exhaled nitric oxide's ability to predict methacholine challenge in adults with nonobstructive spirometry. Ann Allergy Asthma Immunol 2016; 117:365-369.e1. [PMID: 27566860 DOI: 10.1016/j.anai.2016.07.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/19/2016] [Accepted: 07/25/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Compared with methacholine challenge, exhaled nitric oxide is less expensive, is performed as a simpler point-of-care maneuver, and may provide treatment guiding information. OBJECTIVE To determine whether exhaled nitric oxide levels can predict the outcome of methacholine challenge in patients without obvious baseline obstruction. METHODS This retrospective database and medical record review included adults presenting to a tertiary care center from November 1, 2009, through August 31, 2013, who underwent methacholine challenge and exhaled nitric oxide measurement within 2 weeks of each other. Database extraction identified age, sex, body mass index, baseline corticosteroid use, testing indication, forced expiratory volume in 1 second (FEV1), and testing results. Individuals taking corticosteroid-containing medication or who had an FEV1 less than the lower limit of normal at baseline were excluded. RESULTS A total of 1,322 individuals were identified, with 774 meeting the eligibility criteria. A total of 123 methacholine challenges (16%) had positive results. Fractional exhaled nitric oxide was statistically higher in those with positive methacholine challenge results (mean [SD], 41.9 [54.5] ppb vs 25.2 [19.7] ppb; P < .01). Receiver operating characteristic curve revealed an area under the curve of 0.572 (P < .01), suggesting a poor correlation between exhaled nitric oxide level and methacholine challenge outcome. Fractional exhaled nitric oxide of greater than 50 ppb has a sensitivity, specificity, positive predictive value, and negative predictive value of 12%, 89%, 17%, and 84%, respectively, for a positive methacholine challenge result. CONCLUSION In this large, retrospective cohort of corticosteroid-naive pulmonary patients with normal FEV1 on baseline spirometry, exhaled nitric oxide poorly predicts the outcome of a methacholine challenge.
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Affiliation(s)
- Andrew S Nickels
- Division of Allergy, Pulmonary, and Critical Care, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Allergy, Immunology, and Pulmonary, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Kaiser G Lim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
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50
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Oliver BGG, Black J. Asthma: Airways That Are Hyperactive by Design. Am J Respir Crit Care Med 2016; 193:596-8. [PMID: 26977964 DOI: 10.1164/rccm.201511-2204ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Brian G G Oliver
- 1 Centre for Health Technologies and.,2 School of Life Sciences University of Technology Sydney Sydney, Australia and.,3 Woolcock Institute of Medical Research The University of Sydney Sydney, Australia
| | - Judy Black
- 3 Woolcock Institute of Medical Research The University of Sydney Sydney, Australia
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