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Guilleminault L, Saint-Hilaire A, Favelle O, Caille A, Boissinot E, Henriet A, Diot P, Marchand-Adam S. Can exhaled nitric oxide differentiate causes of pulmonary fibrosis? Respir Med 2013; 107:1789-96. [DOI: 10.1016/j.rmed.2013.07.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2013] [Revised: 07/03/2013] [Accepted: 07/07/2013] [Indexed: 11/28/2022]
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Update on clinical inflammometry for the management of airway diseases. Can Respir J 2013; 20:117-20. [PMID: 23616969 DOI: 10.1155/2013/602936] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Airway inflammation is a central feature of many airway diseases such as asthma, chronic bronchitis, bronchiectasis and chronic cough; therefore, it is only logical that it is measured to optimize its treatment. However, most treatment recommendations, including the use of anti-inflammatory therapies such as corticosteroids, are based on assessments of only airflow and symptoms. Over the past 10 years, methods have been developed to assess airway inflammation relatively noninvasively. Quantitative cell counts in sputum and the fraction of exhaled nitric oxide are the most validated tests. Judicious use of currently available drugs, such as corticosteroids, bronchodilators and antibiotics, and other anti-inflammatory therapies guided by sputum eosinophil and neutrophil counts, have been demonstrated to decrease exacerbations of asthma and chronic obstructive pulmonary disease, ameliorate cough, improve quality of life in patients with these diseases and is cost effective compared with treatment strategies based on guidelines that do not incorporate these measurements. Thus, it is unfortunate that this is not used more widely in the management of airway diseases, particularly in patients with severe asthma and chronic obstructive pulmonary disease who experience frequent exacerbations.
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203
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Hahn YS. Measurements of fractional exhaled nitric oxide in pediatric asthma. KOREAN JOURNAL OF PEDIATRICS 2013; 56:424-30. [PMID: 24244210 PMCID: PMC3827490 DOI: 10.3345/kjp.2013.56.10.424] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 08/27/2013] [Indexed: 01/19/2023]
Abstract
Exhaled nitric oxide (NO) has been extensively investigated as a noninvasive marker of airway inflammation in asthma. The increased NO expression induced by inflammatory mediators in airways can be monitored easily in exhaled air from asthmatic children. Based on the relationship between the increased NO expression and eosinophilic airway inflammation, fractional exhaled nitric oxide (FeNO) measurements become an important adjunct for the evaluation of asthma. In addition, the availability of portable devices makes it possible to measure FeNO more easily and frequently in the routine pediatric practice. Despite various confounding factors affecting its levels, FeNO can be applicable in diagnosing asthma, monitoring treatment response, evaluating asthma control, and predicting asthma exacerbations. Thus, although pulmonary function tests are the standard tools for objective measurements of asthmatic control, FeNO can broaden the way of asthma monitoring and supplement standard clinical asthma care guidelines.
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Affiliation(s)
- Youn-Soo Hahn
- Department of Pediatrics, Chungbuk National University College of Medicine, Cheongju, Korea
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Anti-inflammatory treatment of atopic asthma guided by exhaled nitric oxide: a randomized, controlled trial. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:639-48.e1-8. [PMID: 24565712 DOI: 10.1016/j.jaip.2013.07.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/31/2013] [Revised: 06/24/2013] [Accepted: 07/30/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND Atopic asthma is characterized by Th2 cytokine-driven inflammation of the airway mucosa, which is signaled by the fraction of exhaled nitric oxide (FENO). OBJECTIVE We tested whether an FENO-guided anti-inflammatory treatment algorithm could improve asthma-related quality of life and asthma symptom control, and reduce exacerbations in atopic asthmatics within primary care. METHODS Altogether, 187 patients with asthma and who were nonsmokers (age range, 18-64 years) with perennial allergy and who were on regular inhaled corticosteroid treatment were recruited at 17 primary health care centers, randomly assigned to 2 groups and followed up for 1 year. For the controls (n = 88), FENO measurement was blinded to both operator and patient, and anti-inflammatory treatment was adjusted according to usual care. In the active group (n = 93), treatment was adjusted according to FENO. Questionnaires on asthma-related quality of life (Mini Asthma Quality of Life Questionnaire) and asthma control (Asthma Control Questionnaire) were completed, and asthma events were noted. RESULTS The Asthma Control Questionnaire score change over 1 year improved significantly more in the FENO-guided group (-0.17 [interquartile range {IQR}, -0.67 to 0.17] vs 0 [-0.33 to 0.50]; P = .045), whereas the Mini Asthma Quality of Life Questionnaire score did not (0.23 [IQR, 0.07-0.73] vs 0.07 [IQR, -0.20 to 0.80]; P = .197). The change in Asthma Control Questionnaire was clinically important in subpopulations with poor control at baseline (P = .03). Furthermore, the exacerbation rate (exacerbations/patient/y) was reduced by almost 50% in the FENO-guided group (0.22 [CI, 0.14-0.34] vs 0.41 [CI, 0.29-0.58]; P = .024). Mean overall inhaled corticosteroid use was similar in both groups (P = .95). CONCLUSION Use of FENO to guide anti-inflammatory treatment within primary care significantly reduced the exacerbation rate and improved asthma symptom control without increasing overall inhaled corticosteroid use.
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Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a leading cause of death worldwide and this burden is predicted to increase unless exposure to risk factors is addressed. Diagnosis of COPD is a challenge: COPD is underdiagnosed and frequently misdiagnosed for asthma or other respiratory conditions. Although spirometry is only one parameter for establishing a clinical diagnosis of COPD, lack of routine spirometry is a key cause of COPD misdiagnosis. Differential diagnosis from asthma is essential because the treatment strategies for, and progression and outcomes of, the two conditions vary greatly. AREAS COVERED Here the authors review methods for the differential diagnosis of COPD and asthma; approaches to improve diagnosis, including case-finding and screening; the identification of specific COPD phenotypes and targeted therapy; and the potential role of exhaled biomarkers in the diagnosis of COPD. EXPERT OPINION Methods to diagnose COPD, specifically differential diagnosis from asthma, have improved in recent years. To translate these into clinical practice will require the development of combined guidelines for COPD and asthma that include COPD-asthma overlap syndrome and are based on evidence from randomized controlled trials.
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Affiliation(s)
- David Price
- University of Aberdeen, Academic Primary Care, Division of Applied Health Sciences , Aberdeen , Scotland +44 1223 96 9808 ;
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Hirano T, Matsunaga K, Sugiura H, Minakata Y, Koarai A, Akamatsu K, Ichikawa T, Furukawa K, Ichinose M. Relationship between alveolar nitric oxide concentration in exhaled air and small airway function in COPD. J Breath Res 2013; 7:046002. [DOI: 10.1088/1752-7155/7/4/046002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Rouatbi S, Alqodwa A, Ben Mdella S, Ben Saad H. Fraction of exhaled nitric oxide (FeNO ) norms in healthy North African children 5-16 years old. Pediatr Pulmonol 2013; 48:981-95. [PMID: 23169683 DOI: 10.1002/ppul.22721] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2012] [Accepted: 10/03/2012] [Indexed: 12/18/2022]
Abstract
AIMS (i) To identify factors that influence the FeNO values in healthy North African, Arab children aged 6-16 years; (ii) to test the applicability and reliability of the previously published FeNO norms; and (iii) if needed, to establish FeNO norms in this population, and to prospectively assess its reliability. POPULATION AND METHODS This was a cross-sectional analytical study. A convenience sample of healthy Tunisian children, aged 6-16 years was recruited. First subjects have responded to two questionnaires, and then FeNO levels were measured by an online method with electrochemical analyzer (Medisoft, Sorinnes [Dinant], Belgium). Anthropometric and spirometric data were collected. Simple and a multiple linear regressions were determined. The 95% confidence interval (95% CI) and upper limit of normal (ULN) were defined. RESULTS Two hundred eleven children (107 boys) were retained. Anthropometric data, gender, socioeconomic level, obesity or puberty status, and sports activity were not independent influencing variables. Total sample FeNO data appeared to be influenced only by maximum mid expiratory flow (l sec(-1) ; r(2) = 0.0236, P = 0.0516). For boys, only 1st second forced expiratory volume (l) explains a slight (r(2) = 0.0451) but significant FeNO variability (P = 0.0281). For girls, FeNO was not significantly correlated with any children determined data. For North African/Arab children, FeNO values were significantly lower than in other populations and the available published FeNO norms did not reliably predict FeNO in our population. The mean ± SD (95% CI ULN, minimum-maximum) of FeNO (ppb) for the total sample was 5.0 ± 2.9 (5.4, 1.0-17.0). For North African, Arab children of any age, any FeNO value greater than 17.0 ppb may be considered abnormal. Finally, in an additional group of children prospectively assessed, we found no child with a FeNO higher than 17.0 ppb. CONCLUSION Our FeNO norms enrich the global repository of FeNO norms the pediatrician can use to choose the most appropriate norms based on children's location or ethnicity.
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Affiliation(s)
- Sonia Rouatbi
- Service of Physiology and Functional Explorations, Farhat HACHED Hospital, Sousse, Tunisia; Laboratory of Physiology, Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
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208
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Fujisawa T, Yasui H, Akamatsu T, Hashimoto D, Enomoto N, Inui N, Nakamura Y, Maekawa M, Suda T, Chida K. Alveolar nitric oxide concentration reflects peripheral airway obstruction in stable asthma. Respirology 2013; 18:522-7. [PMID: 23240824 DOI: 10.1111/resp.12031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 09/26/2012] [Accepted: 10/02/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVE Increased fraction of exhaled nitric oxide (FeNO) has been shown to reflect airway inflammation in asthma. Central airway NO flux (J'awNO; nL/s) and peripheral airway/alveolar NO concentration (CANO; ppb) can be calculated separately. CANO has been reported to reflect small airway inflammation. The aim of the present study is to correlate CANO levels with clinical and physiological parameters in patients with stable asthma. METHODS Seventy-three well-controlled asthmatics (mean age 61) were enrolled. Measurement of FeNO (at 50, 100, 150 and 200 mL/s) and pulmonary function test were performed. J'awNO(TMAD) and CANO(TMAD) were calculated and corrected by the trumpet shape of the airway tree and axial back-diffusion (TMAD). RESULTS CANO(TMAD) was significantly correlated with forced expiratory flow between 25-75% of the forced vital capacity (FVC) (FEF(25 -75)), FEF(25 -75) percentage of the predicted value (%pred), forced expiratory flow at 50% of the FVC (FEF(50)) and FEF(50) %pred (R = -0.39 P = 0.002, R = -0.29 P = 0.02, R = -0.39 P = 0.001, R = -0.29 P = 0.02, respectively). CANO(TMAD) was positively correlated with age (R = -0.45 P = 0.0002) and weakly correlated with duration of asthma (R = -0.27 P = 0.03). Forced expiratory volume in 1 s/FVC was negatively correlated with CANO(TMAD), J'awNO(TMAD) and FeNO 50 mL/s. Among these, correlation between forced expiratory volume in 1 s/FVC and FeNO 50 mL/s was the strongest (R = -0.34 P = 0.004). CONCLUSIONS CANO(TMAD) may be a more specific marker of peripheral airway obstruction than FeNO and J'awNO(TMAD) in stable asthma.
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Affiliation(s)
- Tomoyuki Fujisawa
- Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan.
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209
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Breath tests in respiratory and critical care medicine: from research to practice in current perspectives. BIOMED RESEARCH INTERNATIONAL 2013; 2013:702896. [PMID: 24151617 PMCID: PMC3789325 DOI: 10.1155/2013/702896] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 08/12/2013] [Accepted: 08/14/2013] [Indexed: 12/15/2022]
Abstract
Today, exhaled nitric oxide has been studied the most, and most researches have now focused on asthma. More than a thousand different volatile organic compounds have been observed in low concentrations in normal human breath. Alkanes and methylalkanes, the majority of breath volatile organic compounds, have been increasingly used by physicians as a novel method to diagnose many diseases without discomforts of invasive procedures. None of the individual exhaled volatile organic compound alone is specific for disease. Exhaled breath analysis techniques may be available to diagnose and monitor the diseases in home setting when their sensitivity and specificity are improved in the future.
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McCormack MC, Aloe C, Curtin-Brosnan J, Diette GB, Breysse PN, Matsui EC. Guideline-recommended fractional exhaled nitric oxide is a poor predictor of health-care use among inner-city children and adolescents receiving usual asthma care. Chest 2013; 144:923-929. [PMID: 23764806 PMCID: PMC3760744 DOI: 10.1378/chest.12-3098] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Accepted: 05/01/2013] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND American Thoracic Society guidelines support using fractional exhaled nitric oxide (FENO) measurements in patients with asthma and highlight gaps in the evidence base. Little is known about the use of FENO levels to predict asthma exacerbations among high-risk, urban, minority populations receiving usual care. METHODS Children with persistent asthma (n = 138) were enrolled in a prospective, observational cohort study and skin tested at baseline (a wheal ≥ 3 mm indicated a positive skin-prick test). FENO levels, lung function, and asthma-related health-care use were assessed at baseline and every 3 months thereafter for 1 year. Relationships between FENO levels and health-care use in the subsequent 3 months were examined. Final models accounted for repeated outcome measures and were adjusted for age, sex, and lung function. RESULTS The mean age of the children was 11 years (range, 5-17 years), and most were male (57%), black (91%), and atopic (90%). At baseline, the median FENO level was 31.5 parts per billion (interquartile range, 16-61 ppb) and mean FEV1/FVC was 80.7% (SD, ± 9.6%). There were 237 acute asthma-related health-care visits, 105 unscheduled doctor visits, 125 ED visits, and seven hospitalizations during the follow-up period. FENO level was not a significant predictor of acute visits, ED visits, unscheduled doctor visits, or hospitalization in either unadjusted or adjusted analyses. Use of recommended cut points did not improve the predictive value of the FENO level (positive predictive value, 0.6%-32.8%) nor did application of the guideline-based algorithm to assess change over time. CONCLUSIONS FENO level may not be a clinically useful predictor of health-care use for asthma exacerbations in urban minority children with asthma.
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Affiliation(s)
- Meredith C McCormack
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Charles Aloe
- Division of Pediatric Allergy and Immunology, Johns Hopkins University, Baltimore, MD
| | - Jean Curtin-Brosnan
- Division of Pediatric Allergy and Immunology, Johns Hopkins University, Baltimore, MD
| | - Gregory B Diette
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Patrick N Breysse
- Bloomberg School of Public Health, Department of Environmental Health Sciences, Johns Hopkins University, Baltimore, MD
| | - Elizabeth C Matsui
- Division of Pediatric Allergy and Immunology, Johns Hopkins University, Baltimore, MD
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211
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Cutts R, Turner S. Longitudinal measurements of exhaled nitric oxide in children-what is a significant change in FE(NO) ? Pediatr Allergy Immunol 2013; 24:540-8. [PMID: 23902329 DOI: 10.1111/pai.12101] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2013] [Indexed: 12/01/2022]
Abstract
BACKGROUND The principle aim of this study was to describe the variability of exhaled nitric oxide (FE(NO)) concentrations over 10 months in children with and without asthma. METHODS FE(NO) was measured on six occasions at 2-month intervals in a community-based cohort of children with and without asthma. RESULTS There were 178 children recruited, 47 had asthma, mean age 9.6 yr. A total of 851 FE(NO) measurements were made. The change in FE(NO) values was positively associated with the initial FE(NO) concentration (p < 0.001) and duration between paired measurements (p = 0.016) but not asthma diagnosis; there was an interaction between initial FE(NO) and duration between measurements. As an approximate rule-of-thumb, a child's FE(NO) may rise by up to 100% of their current FE(NO) over 2 and 4 months, independent of asthma. CONCLUSIONS Both the baseline FE(NO) and interval between repeated FE(NO) measurements are relevant to FE(NO) values, independent of asthma. These findings may be useful to clinical interpretation of FE(NO) results in children.
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212
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Open access integrated therapeutic and diagnostic platforms for personalized cardiovascular medicine. J Pers Med 2013; 3:203-37. [PMID: 25562653 PMCID: PMC4251391 DOI: 10.3390/jpm3030203] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2013] [Revised: 08/04/2013] [Accepted: 08/10/2013] [Indexed: 12/14/2022] Open
Abstract
It is undeniable that the increasing costs in healthcare are a concern. Although technological advancements have been made in healthcare systems, the return on investment made by governments and payers has been poor. The current model of care is unsustainable and is due for an upgrade. In developed nations, a law of diminishing returns has been noted in population health standards, whilst in the developing world, westernized chronic illnesses, such as diabetes and cardiovascular disease have become emerging problems. The reasons for these trends are complex, multifactorial and not easily reversed. Personalized medicine has the potential to have a significant impact on these issues, but for it to be truly successful, interdisciplinary mass collaboration is required. We propose here a vision for open-access advanced analytics for personalized cardiac diagnostics using imaging, electrocardiography and genomics.
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213
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Leung TF, Ko FWS, Wong GWK. Recent advances in asthma biomarker research. Ther Adv Respir Dis 2013; 7:297-308. [PMID: 23907809 DOI: 10.1177/1753465813496863] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Asthma is characterized by recurrent and reversible airflow obstruction, which is routinely monitored by history and physical examination, spirometry and home peak flow diaries. As airway inflammation is central to asthma pathogenesis, its monitoring should be part of patient management plans. Fractional exhaled nitric oxide level (FeNO) is the most extensively studied biomarker of airway inflammation, and FeNO references were higher in Chinese (Asians) than Whites. Published evidence was inconclusive as to whether FeNO is a useful management strategy for asthma. Other biomarkers include direct (histamine, methacholine) and indirect (adenosine, hypertonic saline) challenges of bronchial hyperresponsiveness (BHR), induced sputum and exhaled breath condensate (EBC). A management strategy that normalized sputum eosinophils among adult patients resulted in reductions of BHR and asthma exacerbations. However, subsequent adult and pediatric studies failed to replicate these benefits. Asthma phenotypes as defined by inflammatory cell populations in sputum were also not stable over a 12-month period. A recent meta-analysis concluded that induced sputum is not accurate enough to be applied in routine monitoring of childhood asthma. There is poor correlation between biomarkers that reflect different asthma dimensions: spirometry (airway caliber), BHR (airway reactivity) and FeNO or induced sputum (airway inflammation). Lastly, EBC is easily obtained noninvasively by cooling expired air. Many biomarkers ranging from acidity (pH), leukotrienes, aldehydes, cytokines to growth factors have been described. However, significant overlap between groups and technical difficulty in measuring low levels of inflammatory molecules are the major obstacles for EBC research. Metabolomics is an emerging analytical method for EBC biomarkers. In conclusion, both FeNO and induced sputum are useful asthma biomarkers. However, they will only form part of the clinical picture. Longitudinal studies with focused hypotheses and well-designed protocols are needed to establish the roles of these biomarkers in asthma management. The measurement of biomarkers in EBC remains a research tool.
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Affiliation(s)
- Ting F Leung
- Department of Pediatrics, The Chinese University of Hong Kong 6/F, Lui Che Woo Clinical Sciences Building, Prince of Wales Hospital, Shatin, Hong Kong SAR, China
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Misso NLA, Thompson PJ. Oxidative stress and antioxidant deficiencies in asthma: potential modification by diet. Redox Rep 2013; 10:247-55. [PMID: 16354413 DOI: 10.1179/135100005x70233] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The lungs of asthmatic patients are exposed to oxidative stress due to the generation of reactive oxygen and nitrogen species as a consequence of chronic airway inflammation. Increased concentrations of NO*, H2O2 and 8-isoprostane have been measured in exhaled breath and induced sputum of asthmatic patients. O2*-, NO*, and halides interact to form highly reactive species such as peroxynitrite and HOBr, which in turn cause nitration and bromination of protein tyrosine residues. Oxidative stress may also reduce glutathione levels and cause inactivation of antioxidant enzymes such as superoxide dismutase, with a consequent increase in apoptosis, shedding of airway epithelial cells and airway remodelling. The oxidant/antioxidant equilibrium in asthmatic patients may be further perturbed by low dietary intakes of the antioxidant vitamins C and E, selenium and flavonoids, with a consequent lowering of the concentrations of these and other non-dietary antioxidants such as bilirubin and albumin in plasma and airway epithelial lining fluid. Although supplementation with vitamins C and E appears to offer protection against the adverse effects of ozone, recent randomised, placebo-controlled trials of vitamin C or E supplements for patients with mild asthma have not shown significant benefits over standard therapy. However, genetic variation in glutathione S-transferase may influence the susceptibility of asthmatic individuals to oxidative stress and the extent to which they are likely to benefit from antioxidant supplementation. Long-term prospective trials are required to determine whether modification of dietary intake will benefit asthma patients and reduce the socio-economic burden of asthma in the community.
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Affiliation(s)
- Neil L A Misso
- Asthma & Allergy Research Institute (Inc) and Centre for Asthma, Allergy & Respiratory Research, The University of Western Australia, Perth, Australia.
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215
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Targeted therapy of bronchitis in obstructive airway diseases. Pharmacol Ther 2013; 140:213-22. [PMID: 23845862 DOI: 10.1016/j.pharmthera.2013.07.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Accepted: 06/17/2013] [Indexed: 12/21/2022]
Abstract
Guidelines for the management of obstructive airway diseases do not emphasize the measurement of bronchitis to indicate appropriate treatments or monitor response to treatment. Bronchitis is the central component of airway diseases and contributes to symptoms, physiological and structural abnormalities. It can be measured directly and reliably by quantitative assay of spontaneous or induced sputum. The measurement is reproducible, valid, and responsive to treatment and to changes in disease status. Bronchitis may be eosinophilic, neutrophilic, mixed, or paucigranulocytic (eosinophils and neutrophils not elevated). Eosinophilic bronchitis is usually a Th2 driven process and therefore a sputum eosinophilia of greater than 3% usually indicates a response to treatment with corticosteroids or novel therapies directed against Th2 cytokines such as IL-4, IL-5 and IL-13. Neutrophilic bronchitis which is a non-Th2 driven disease is generally a predictor of response to antibiotics and may be a predictor to therapies targeted at pathways that lead to neutrophil recruitment such as IL-8 (eg anti-CXCR2), IL-17 (eg anti-IL17) etc. Paucigranulocytic disease may not warrant anti-inflammatory therapy. Several novel monoclonals and small molecule antagonists have been evaluated in clinical trials with variable results and several more are likely to be discovered in the near future. The success of these agents will depend on appropriate patient selection by accurate phenotyping or characterization of bronchitis.
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216
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Gungor AA, Martino BJ, Dupont SC, Kuo L. A human study model for nitric oxide research in sinonasal disease. Am J Otolaryngol 2013; 34:337-44. [PMID: 23398730 DOI: 10.1016/j.amjoto.2013.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 01/08/2013] [Indexed: 12/01/2022]
Abstract
Sinus nitric oxide (NO) measurements present a novel and promising approach to help overcome difficulties and confounding variables associated with nasal NO measurements such as the nasal cycle, ostial patency, and individual contribution to total NO production of each sinus. Conflicting results reported on nasal NO measurements in various sinonasal diseases are presumed to originate from the variable diffusion of sinus NO into the nose where it is measured. This study presents a novel technique and research method for direct measurement of sinus NO. The authors' original technique of individual, non-destructive catheterization of the sinuses through their natural ostia is developed and refined to allow accurate measurements of NO produced in the sinuses. Our study indicates that reproducible catheterization of the sinuses through their natural ostia can be performed in the clinical research setting under local and topical anesthesia. The model can be used to test the effects of various conditions on nasal and sinus NO production in a variety of disease models and the variables affecting sinonasal gas exchange can be differentially studied. Volunteer healthy adult human subjects without nasal allergies are used. An endoscopic nasal exam with topical anesthesia followed by in vitro allergy testing is performed to determine eligibility. Sinus computerized tomography (CT) scans are used to delineate anatomic features and to calculate paranasal sinus volumes. Continuous flow sinus air sampling and NO measurement with a chemiluminescence analyzer is obtained through polyethylene tube catheters (PEC) placed endoscopically into an aerated major paranasal sinus. Catheters are introduced through natural ostia under local and topical anesthesia. Nasal and differential sinus NO measurements are performed.
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Affiliation(s)
- A A Gungor
- Otolaryngology and Pediatrics, LSUHSC, Shreveport, LA 71130, USA.
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217
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Donohue JF, Jain N. Exhaled nitric oxide to predict corticosteroid responsiveness and reduce asthma exacerbation rates. Respir Med 2013; 107:943-52. [DOI: 10.1016/j.rmed.2013.02.018] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 02/13/2013] [Accepted: 02/21/2013] [Indexed: 10/27/2022]
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Aasen TB, Burge PS, Henneberger PK, Schlünssen V, Baur X. Diagnostic approach in cases with suspected work-related asthma. J Occup Med Toxicol 2013; 8:17. [PMID: 23768266 PMCID: PMC3716794 DOI: 10.1186/1745-6673-8-17] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Accepted: 06/10/2013] [Indexed: 11/18/2022] Open
Abstract
Background Work-related asthma (WRA) is a major cause of respiratory disease in modern societies. The diagnosis and consequently an opportunity for prevention are often missed in practice. Methods Based on recent studies and systematic reviews of the literature methods for detection of WRA and identification of specific causes of allergic WRA are discussed. Results and Conclusions All workers should be asked whether symptoms improve on days away from work or on holidays. Positive answers should lead to further investigation. Spirometry and non-specific bronchial responsiveness should be measured, but carefully performed and validly analysed serial peak expiratory flow or forced expiratory volume in one second (FEV1) measurements are more specific and confirm occupational asthma in about 82% of those still exposed to the causative agent. Skin prick testing or specific immunoglobulin E assays are useful to document allergy to high molecular weight allergens. Specific inhalational challenge tests come closest to a gold standard test, but lack standardisation, availability and sensitivity. Supervised workplace challenges can be used when specific challenges are unavailable or the results non-diagnostic, but methodology lacks standardisation. Finally, if the diagnosis remains unclear a follow-up with serial measurements of FEV1 and non-specific bronchial hyperresponsiveness should detect those likely to develop permanent impairment from their occupational exposures.
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Affiliation(s)
- Tor B Aasen
- Department of Occupational Medicine, Haukeland University Hospital, NO-5021 Bergen, Norway.
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Nittner-Marszalska M, Liebhart J, Pawłowicz R, Kazimierczak A, Marszalska H, Kraus-Filarska M, Panaszek B, Dor-Wojnarowska A. Fractioned exhaled nitric oxide (FE(NO)) is not a sufficiently reliable test for monitoring asthma in pregnancy. Nitric Oxide 2013; 33:56-63. [PMID: 23756211 DOI: 10.1016/j.niox.2013.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 05/26/2013] [Accepted: 06/03/2013] [Indexed: 11/30/2022]
Abstract
It has been reported that fractioned exhaled nitric oxide (FENO) can be used for monitoring airway inflammation and for asthma management but conclusions drawn by different researchers are controversial. The aim of our study was to evaluate the clinical usefulness of FENO assessment for monitoring asthma during pregnancy. We monitored 72 pregnant asthmatics aged 18-38years (Me=29 years) who underwent monthly investigations including: the level of asthma control according to GINA (Global Initiative for Asthma), the occurrence of exacerbations, ACT (Asthma Control Test), as well as FENO and spirometry measurements. In 50 women, during all visits, asthma was well-controlled. In the remaining 22 women, asthma was periodically uncontrolled. FENO measured at the beginning of the study did not show significant correlation with retrospectively evaluated asthma severity (r=0.07; p=0.97). An analysis of data collected during all 254 visits showed that FENO correlated significantly but weakly with ACT scores (r=0.25; p=0.0004) and FEV1 (r=0.21; p=0.0014). FENO at consecutive visits in women with well-controlled asthma (N=50) showed large variability expressed by median coefficient of variation (CV)=32.0% (Min 2.4%, Max 121.9%). This concerned both: atopic and nonatopic groups (35.5%; and 26.7%, respectively). Large FENO variability (35.5%) was also found in a subgroup of women (N=11) with ACT=25 constantly throughout the study. FENO measured at visits when women temporarily lost control of asthma (N=22; 38 visits), showed an increasing tendency (64.2 ppb; 9.5 ppb-188.3 ppb), but did not differ significantly (p=0.13) from measurements taken at visits during which asthma was well-controlled (27.6 ppb; 6.2 ppb-103.4 ppb). The comparison of FENO in consecutive months of pregnancy in women who had well-controlled asthma did not show significant differences in FENO values during the time of observation. The assessment of asthma during pregnancy by means of monitoring FENO is of limited practical value due to this parameter's considerable intrasubject variability, regardless of the degree of asthma control.
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Affiliation(s)
- Marita Nittner-Marszalska
- Departament of Internal Diseases, Geriatrics and Allergology Medical University Wrocław, 50-367 Wrocław, Ul. Pasteura 4, Poland
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220
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Gonem S, Raj V, Wardlaw AJ, Pavord ID, Green R, Siddiqui S. Phenotyping airways disease: an A to E approach. Clin Exp Allergy 2013. [PMID: 23181785 DOI: 10.1111/j.1365-2222.2012.04008.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The airway diseases asthma and chronic obstructive pulmonary disease (COPD) are heterogeneous conditions with overlapping pathophysiological and clinical features. It has previously been proposed that this heterogeneity may be characterized in terms of five relatively independent domains labelled from A to E, namely airway hyperresponsiveness (AHR), bronchitis, cough reflex hypersensitivity, damage to the airways and surrounding lung parenchyma, and extrapulmonary factors. Airway hyperresponsiveness occurs in both asthma and COPD, accounting for variable day to day symptoms, although the mechanisms most likely differ between the two conditions. Bronchitis, or airway inflammation, may be predominantly eosinophilic or neutrophilic, with different treatments required for each. Cough reflex hypersensitivity is thought to underlie the chronic dry cough out of proportion to other symptoms that can occur in association with airways disease. Structural changes associated with airway disease (damage) include bronchial wall thickening, airway smooth muscle hypertrophy, bronchiectasis and emphysema. Finally, a variety of extrapulmonary factors may impact upon airway disease, including rhinosinusitis, gastroesophageal reflux disease, obesity and dysfunctional breathing. This article discusses the A to E concept in detail and describes how this framework may be used to assess and treat patients with airway diseases in the clinic.
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Affiliation(s)
- S Gonem
- Department of Infection, Immunity & Inflammation, Institute for Lung Health, University of Leicester, Leicester, UK
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221
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Biomarker surrogates do not accurately predict sputum eosinophil and neutrophil percentages in asthmatic subjects. J Allergy Clin Immunol 2013; 132:72-80. [PMID: 23706399 DOI: 10.1016/j.jaci.2013.03.044] [Citation(s) in RCA: 189] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 03/05/2013] [Accepted: 03/13/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND Sputum eosinophil percentages are a strong predictor of airway inflammation and exacerbations and aid asthma management, whereas sputum neutrophil percentages indicate a different severe asthma phenotype that is potentially less responsive to TH2-targeted therapy. Variables, such as blood eosinophil counts, total IgE levels, fraction of exhaled nitric oxide (Feno) levels, or FEV1 percent predicted, might predict airway eosinophil percentages, whereas age, FEV1 percent predicted, or blood neutrophil counts might predict sputum neutrophil percentages. Availability and ease of measurement are useful characteristics, but accuracy in predicting airway eosinophil and neutrophil percentages either individually or combined is not established. OBJECTIVES We sought to determine whether blood eosinophil counts, Feno levels, and IgE levels accurately predict sputum eosinophil percentages and whether age, FEV1 percent predicted, and blood neutrophil counts accurately predict sputum neutrophil percentages. METHODS Subjects in the Wake Forest Severe Asthma Research Program (n = 328) were characterized by blood and sputum cell counts, health care use, lung function, Feno levels, and IgE levels. Multiple analytic techniques were used. RESULTS Despite significant association with sputum eosinophil percentages, blood eosinophil counts, Feno levels, and total IgE levels did not accurately predict sputum eosinophil percentages, and combinations of these variables did not improve prediction. Age, FEV1 percent predicted, and blood neutrophil counts were similarly unsatisfactory for the prediction of sputum neutrophil percentages. Factor analysis and stepwise selection found Feno levels, IgE levels, and FEV1 percent predicted, but not blood eosinophil counts, correctly predicted 69% of sputum eosinophil percentages of less than 2% or 2% and greater. Likewise, age, asthma duration, and blood neutrophil counts correctly predicted 64% of sputum neutrophil percentages of less than 40% or 40% and greater. A model to predict both sputum eosinophil and neutrophil percentages accurately assigned only 41% of samples. CONCLUSION Despite statistically significant associations, Feno levels, IgE levels, blood eosinophil and neutrophil counts, FEV1 percent predicted, and age are poor surrogates, both separately and combined, for accurately predicting sputum eosinophil and neutrophil percentages.
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222
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Molecular mechanisms of reactive oxygen species-related pulmonary inflammation and asthma. Mol Immunol 2013; 56:57-63. [PMID: 23665383 DOI: 10.1016/j.molimm.2013.04.002] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 04/07/2013] [Indexed: 02/07/2023]
Abstract
Asthma is a highly relevant disorder that can be induced by many environmental factors such as allergens and pollutants. One of the most critical pathological symptoms of asthma is airway inflammation. In order to identify a cause of respiratory inflammation, we thoroughly examine the unique role of reactive oxygen species (ROS). Evidence supports that the inhalation of aggravating compounds such as allergens can promote the increased generation of ROS. Accordingly, ROS have a proven role in the cellular signaling cascades of many respiratory diseases that cause respiratory inflammation, including asthma. Although there is no known cure for asthma, current treatments effectively lessen the inflammation symptom. Based on the investigations of asthma pathogenesis and the mechanism of ROS formation, we have identified several novel anti-inflammatory therapeutic treatments, shedding light on a fundamental understanding for the cure of this disorder. In this review, we will outline the pathogenesis of asthma and its relationship to ROS, oxidative stress, and pulmonary inflammation.
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223
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See KC, Christiani DC. Normal values and thresholds for the clinical interpretation of exhaled nitric oxide levels in the US general population: results from the National Health and Nutrition Examination Survey 2007-2010. Chest 2013; 143:107-116. [PMID: 22628492 DOI: 10.1378/chest.12-0416] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Elevated fractional excretion of exhaled nitric oxide (FENO) reflects airway inflammation, but few studies have established its normal values. This study aims to establish the normal values and thresholds for the clinical interpretation of FENO in the US general population. METHODS Thirteen thousand two hundred seventy-five subjects aged 6 to 80 years sampled for the National Health and Nutrition Examination Survey (NHANES) 2007-2010 underwent interviews, physical examination, and FENO analysis at 50 mL/s using an online chemiluminescence device according to American Thoracic Society/European Respiratory Society guidelines. After excluding subjects with self-reported asthma and subjects with wheeze in the prior 12 months, prediction equations for the natural logarithm (ln) of FENO were constructed using age, sex, ethnicity, height, BMI, active/passive smoke exposure, and hay fever episodes as covariates. RESULTS The fifth to 95th percentile values of FENO were 3.5 to 36.5 parts per billion (ppb) for children < 12 years of age and 3.5 to 39 ppb for subjects 12 to 80 years of age. Using multiple linear regression, prediction equations explained only 10.3% to 15.7% of the variation in the general population. In the general population, 39% to 45% had ln(FENO) levels > 2 SD of the predicted means. When applied to the general population inclusive of subjects who reported asthma but who did not have attacks within the past year, nearly identical results were obtained. CONCLUSIONS Assuming 95% of the healthy US general population had no clinically significant airway inflammation as assessed by FENO, values exceeding the 95th percentiles indicated abnormality and a high risk of airway inflammation. A large variation of normal FENO values existed in the general population, which was poorly predicted by multiple linear regression models.
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Affiliation(s)
- Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore; Harvard School of Public Health, Boston, MA.
| | - David C Christiani
- Harvard School of Public Health, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA; Department of Medicine, Massachusetts General Hospital, Boston, MA
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224
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Glas N, Vergnon JM, Pacheco Y. [Interest for evaluation of bronchial inflammation in asthma]. REVUE DE PNEUMOLOGIE CLINIQUE 2013; 69:76-82. [PMID: 23434035 DOI: 10.1016/j.pneumo.2012.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 09/18/2012] [Accepted: 10/30/2012] [Indexed: 06/01/2023]
Abstract
Asthma is a heterogeneous chronic inflammatory disease. The respiratory functional tests are sometimes insufficient to confirm the diagnosis. Other tools are developed to estimate the bronchial inflammation such as tests of bronchial provocation, measure of exhaled nitric oxide, induced sputum and exhaled breath condensate. This review presents these non-invasive methods, approaches their interests on the identification of the disease and the treatment.
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Affiliation(s)
- N Glas
- Service de Pneumologie et D'oncologie Thoracique, Hôpital Nord, CHU de Saint-Étienne, France.
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225
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Hirano T, Matsunaga K, Sugiura H, Minakata Y, Koarai A, Akamatsu K, Ichikawa T, Furukawa K, Ichinose M. Persistent elevation of exhaled nitric oxide and modification of corticosteroid therapy in asthma. Respir Investig 2013; 51:84-91. [PMID: 23790736 DOI: 10.1016/j.resinv.2013.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 01/04/2013] [Accepted: 01/10/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Persistent airway inflammation, detected by fractional exhaled nitric oxide (FENO), is occasionally observed in asthmatic patients, even in those treated with inhaled corticosteroids (ICS). However, improvement in residual airway inflammation and pulmonary function through modification of corticosteroid therapy has not been proven. METHODS Thirteen asthmatic patients whose FENO levels were over 40 parts per billion (ppb), despite dry-powder ICS therapy, were enrolled. A 3-step change in steroid treatment was undertaken until FENO was less than 40ppb. In the first step, the powder formula was changed to an ultra-fine particle compound as an equipotent ICS dose. In the second step, the ICS dose was doubled. In the third step, oral corticosteroids were added. We measured pulmonary function and FENO and alveolar NO concentrations (CAlvNO). RESULTS Doubling the ICS dose and changing the ICS formula significantly improved FVC (p<0.001), FEV1 (p<0.05), the slope of the single nitrogen washout curve (dN2) (p<0.01), FENO (p<0.001), and CAlvNO (p<0.05), relative to baseline. The reductions in FENO were significantly associated with the improvement in airflow limitation assessed by dN2 (r=0.73, p=0.007). The remaining FENO elevation, even after doubling the ICS dose, did not decrease after oral corticosteroid administration. CONCLUSIONS These results suggest that modification of ICS therapy can suppress residual FENO elevation, and that reduction in FENO levels is associated with improvement in airflow limitation. However, steroid-resistance mechanisms may exist in some asthmatic patients with sustained FENO elevations.
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Affiliation(s)
- Tsunahiko Hirano
- Third Department of Internal Medicine, Wakayama Medical University, School of Medicine, 811-1 Kimiidera, Wakayama 641-0012, Japan
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226
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Simpson JL, Wark PA. The role of exhaled nitric oxide and exhaled breath condensates in evaluating airway inflammation in asthma. ACTA ACUST UNITED AC 2013; 2:607-20. [PMID: 23495773 DOI: 10.1517/17530059.2.6.607] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Airway inflammation is central to the development and progression of asthma. Monitoring airway inflammation can be invasive and technically difficult, making its use limited in clinical practice. Several advances have been made in non-invasive techniques to monitor and measure inflammation from the airways. OBJECTIVE To examine the suitability of exhaled nitric oxide and exhaled breath condensates as diagnostic tools in asthma. METHOD The current literature regarding the use of exhaled nitric oxide and exhaled breath condensate to assess and manage asthma was reviewed. CONCLUSION Exhaled nitric oxide is a clinically useful marker of eosinophilic airway inflammation in asthma. Although showing promise, significant validation and investigation are required before exhaled breath condensate could be utilized in clinical practice.
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Affiliation(s)
- Jodie L Simpson
- NHRMC Centre for Respiratory and Sleep Medicine, Level 3 Hunter Medical Research Institute, John Hunter Hospital, Locked Bag 1 Hunter Region Mail Centre, Newcastle NSW 2310, Australia +61 02 49214965 ; +61 02 49855850 ;
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Nolte H, Pavord I, Backer V, Spector S, Shekar T, Gates D, Nair P, Hargreave F. Dose-dependent anti-inflammatory effect of inhaled mometasone furoate/formoterol in subjects with asthma. Respir Med 2013; 107:656-64. [PMID: 23490226 DOI: 10.1016/j.rmed.2013.02.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 01/28/2013] [Accepted: 02/11/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A well-controlled study in patients with allergic asthma was warranted to assess dose-dependency between fractional concentration of exhaled nitric oxide (FeNO) and sputum eosinophils to a combination of an inhaled corticosteroid plus a long-acting β2-agonist. We sought to characterize the dose-dependency of mometasone furoate/formoterol (MF/F) using FeNO and sputum eosinophil percentage as surrogates of airway inflammation in subjects with allergic asthma. METHODS Following a 2-week, open-label run-in, 93 subjects (≥12 y) using only short-acting beta agonist reliever medication as needed, were randomized to twice daily (BID) placebo; MF/F 100/10 μg, 200/10 μg, or 400/10 μg (via pressurized metered-dose inhaler [MDI]); MF-MDI 200 μg; or MF 200 μg via dry powder inhaler (DPI) during a 2-week, double-blind treatment period. RESULTS All active treatments demonstrated significant percentage reductions from baseline in FeNO compared with placebo at all time points (P ≤ 0.034). At endpoint, mean MF/F treatment group FeNO reductions ranged from -35.3% to -61.4%. Sputum eosinophil percentage reductions from baseline were significant compared with placebo for the MF/F 200/10 μg, MF/F 400/10 μg, and MF-DPI 200 μg groups at endpoint (P ≤ 0.023). Escalating MF/F doses significantly reduced both FeNO (P ≤ 0.001) and sputum eosinophil (P ≤ 0.022) levels in a dose-dependent manner at all time points. All treatments were well tolerated; no serious adverse events were observed. CONCLUSION All 3 MF/F doses demonstrated pronounced, clinically meaningful, dose-dependent reductions in FeNO, with reduced sputum eosinophil levels for MF/F 200/10 μg and MF/F 400/10 μg. These findings suggest both inflammatory markers may be useful in assessing corticosteroid responsiveness in asthma patients, and perhaps identifying the same asthma subphenotype. Clinical Trials.gov: NCT00635882.
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Affiliation(s)
- Hendrik Nolte
- Merck Sharp & Dohme Corp., Whitehouse Station, NJ 08889, USA.
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228
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Kim YH, Kim KW, Baek J, Park HB, Kim H, Song KJ, Lee JM, Sohn MH, Kim KE. Usefulness of impulse oscillometry and fractional exhaled nitric oxide in children with Eosinophilic bronchitis. Pediatr Pulmonol 2013; 48:221-8. [PMID: 22825832 DOI: 10.1002/ppul.22631] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Accepted: 06/08/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Eosinophilic bronchitis (EB) is a common cause of chronic cough. Although EB shares many immunopathologic features with asthma, it does not show airway hyperresponsiveness or reversible airway obstruction by spirometry. OBJECTIVE Compared to healthy children without pulmonary disease, we hypothesized that EB patients would demonstrate abnormal pulmonary function and inflammation with impulse oscillometry (IOS) and fractional exhaled nitric oxide (FeNO), which are more sensitive tests of these parameters than spirometry. METHODS A total of 232 children with asthma, 109 with EB, and 115 control subjects were enrolled. We compared pulmonary function parameters and FeNO levels among the three groups. Additionally, we designated a screening cutoff value of FeNO combined with IOS parameters to distinguish EB from the control group, and identify which children with EB have more asthmatic characteristics. RESULTS By IOS, the bronchodilator response of the EB and asthma groups increased significantly compared to controls for both reactance at 5 Hz (Δ X5) and reactance area (Δ AX) (P < 0.0001). Cutoff values to distinguish EB from controls were a Δ X5 of -20% (sensitivity, 77.5%; specificity, 49.6%), and Δ AX of -30% (sensitivity, 75.0%; specificity, 46.0%), when the FeNO is 20 ppb. CONCLUSIONS Reversible airway obstruction in IOS and elevated FeNO levels can be detected in children with EB. This would support that EB in children shows airway characteristics similar to those of asthma, and that a continuum exists between asthma and EB.
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Affiliation(s)
- Yoon Hee Kim
- Department of Pediatrics and Institute of Allergy, Severance Biomedical Science Institute, Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
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229
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Cristescu SM, Mandon J, Harren FJM, Meriläinen P, Högman M. Methods of NO detection in exhaled breath. J Breath Res 2013; 7:017104. [PMID: 23445766 DOI: 10.1088/1752-7155/7/1/017104] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
There is still an unexplored potential for exhaled nitric oxide (NO) in many clinical applications. This study presents an overview of the currently available methods for monitoring NO in exhaled breath and the use of the modelling of NO production and transport in the lung in clinical practice. Three technologies are described, namely chemiluminescence, electrochemical sensing and laser-based detection with their advantages and limitations. Comparisons are made in terms of sensitivity, time response, size, costs and suitability for clinical purposes. The importance of the flow rate for NO sampling is discussed from the perspective of the recent recommendations for standardized procedures for online and offline NO measurement. The measurement of NO at one flow rate, such as 50 ml s(-1), can neither determine the alveolar site/peripheral contribution nor quantify the difference in NO diffusion from the airways walls. The use of NO modelling (linear or non-linear approach) can solve this problem and provide useful information about the source of NO. This is of great value in diagnostic procedures of respiratory diseases and in treatment with anti-inflammatory drugs.
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Affiliation(s)
- S M Cristescu
- Life Science Trace Gas Facility, Molecular and Laser Physics, Institute for Molecules and Materials, Radboud University, Nijmegen, The Netherlands.
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230
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Bell MC, Busse WW. Severe asthma: an expanding and mounting clinical challenge. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2013; 1:110-21; quiz 122. [PMID: 24565450 DOI: 10.1016/j.jaip.2013.01.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 01/16/2013] [Accepted: 01/18/2013] [Indexed: 12/29/2022]
Abstract
Although all patients with asthma have variable airflow obstruction, airway inflammation, and bronchial hyperresponsiveness, some have disease that is severe in many aspects: persistent airflow obstruction, ongoing symptoms, increased frequency of exacerbations, and, most importantly, a diminished response to medications. A number of definitions have emerged to characterize the clinical features of severe asthma, but a central feature of this phenotype is the need for high doses of medications, especially corticosteroids, in attempts to achieve disease control. The prevalence of severe asthma is also undergoing reevaluation from the usual estimate of 10% to larger numbers on the basis of medication needs and the lack of disease control achieved. At present, the underlying mechanisms of severe asthma are not established but likely reflect a heterogeneous pattern, rather than a single unifying process. Guideline-directed treatment for severe asthma has limits with usual approaches centered on high doses of inhaled corticosteroids, long-acting β-agonists, and trials with omalizumab, the monoclonal antibody to IgE. With the development of approaches to recognize asthma phenotypes with distinct pathogenesis and hence unique therapeutic targets, it is hoped that a personalized strategy in treatment directed toward disease-specific features will improve outcomes for this high-risk, severely affected population of patients.
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Affiliation(s)
- Matthew C Bell
- 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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231
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Muñoz X, Sanchez-Vidaurre S, Roca O, Torres F, Morell F, Cruz MJ. Bronchial inflammation and hyperresponsiveness in well controlled asthma. Clin Exp Allergy 2013; 42:1321-8. [PMID: 22925318 DOI: 10.1111/j.1365-2222.2012.04004.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little research has been devoted to the characteristics of bronchial inflammation in patients with stable, well controlled asthma. OBJECTIVE The aim of this study was to assess the degree and type of airway inflammation and to investigate the relationship between inflammation and bronchial hyperresponsiveness in patients with well controlled asthma. METHODS A cross-sectional study was conducted in 84 adult patients (43 men, mean age 43 years) with documented well controlled asthma. Induced sputum samples were obtained and cell types determined by differential cell count. Spirometry and methacholine challenge testing were performed. Asthma Control Questionnaire (ACQ) was used to assess symptoms. Patients were included if their ACQ score was < 0.75. RESULTS A total of 59 patients had persistent bronchial inflammation: 28 cases were considered eosinophilic, 28 neutrophilic, and 3 mixed. Median (range) percentage of eosinophils was 4% (0-64) in patients testing positive to methacholine challenge (n = 66) and 1% (0-3) in those testing negative (n = 18) (P = 0.003). A positive correlation was found between eosinophil percentage and the methacholine dose/response ratio (r = 0.477, P = 0.0001). The geometric mean (95% CI) of the methacholine PC20 was 1.74 mg/mL (1.04-2.93) in patients with eosinophilic inflammation and 4.14 mg/mL (2.5-6.84) in those with neutrophilic inflammation (P = 0.03). CONCLUSIONS Inflammation and bronchial hyperresponsiveness persist in most patients with well controlled asthma. CLINICAL RELEVANCE The study demonstrates that eosinophilic or neutrophilic inflammation persisted in most well controlled asthma patients despite the fact that their condition was controlled and therefore, measurement of bronchial inflammation seems essential to achieve proper asthma control.
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Affiliation(s)
- X Muñoz
- Pulmonology Service, Medicine Department, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
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232
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Tiev KP, Hua-Huy T, Rivière S, Le-Dong NN, Febvre M, Cabane J, Dinh-Xuan AT. High alveolar concentration of nitric oxide is associated with alveolitis in scleroderma. Nitric Oxide 2013; 28:65-70. [DOI: 10.1016/j.niox.2012.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 09/01/2012] [Accepted: 10/16/2012] [Indexed: 10/27/2022]
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233
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Patrick LM, Demet I, Andreas J, Bruno K, Heinrich WJ, Alexander M. Comparison of treatment guidance based on bronchial responsiveness to mannitol, spirometry or exhaled nitric oxide in stable asthmatic children. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/ojped.2013.34074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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234
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Abstract
Studies have shown that induced sputum can provide information regarding the cellular and molecular processes involved in asthma and other obstructive pulmonary diseases, and can aid in the diagnosis of asthma and in distinguishing asthma from chronic obstructive pulmonary disease in patients who present with evidence for fixed airflow obstruction. Sputum eosinophils are associated with both asthma severity and level of asthma control. By effectively treating sputum eosinophilia, the number of asthma exacerbations can be significantly reduced compared with managing asthma based on symptoms and lung function.
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Affiliation(s)
- Joseph D Spahn
- Ira J. and Jacqueline Neimark Laboratory of Clinical Pharmacology in Pediatrics, National Jewish Health, Denver, CO 80206, USA.
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235
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Greenberger PA. Terminology, close-calls, and bracketology for allergy, asthma, and immunology. Ann Allergy Asthma Immunol 2012; 110:141-5. [PMID: 23548520 DOI: 10.1016/j.anai.2012.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 10/24/2012] [Accepted: 11/01/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Paul A Greenberger
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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236
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Anderson WJ, Short PM, Williamson PA, Lipworth BJ. Inhaled Corticosteroid Dose Response Using Domiciliary Exhaled Nitric Oxide in Persistent Asthma. Chest 2012; 142:1553-1561. [DOI: 10.1378/chest.12-1310] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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237
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238
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Davis BE, Cockcroft DW. Past, present and future uses of methacholine testing. Expert Rev Respir Med 2012; 6:321-9. [PMID: 22788946 DOI: 10.1586/ers.12.29] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Methacholine challenge testing is a valuable diagnostic and research tool used by clinicians to assist in the diagnosis of asthma, and by researchers to understand disease pathophysiology and assess novel therapeutic efficacy. The use of methacholine challenge in asthma relates to its direct effect on airway smooth muscle (i.e., bronchoconstriction) as a measure of airway hyperresponsiveness, a cardinal feature of asthma. Airway hyperresponsiveness has been documented in other airway disorders, including chronic obstructive pulmonary disease, cystic fibrosis and allergic rhinitis; however, there is little clinical application of methacholine challenge in these conditions as a diagnostic or disease management tool. The authors will review the aspects of methacholine challenge testing, as they relate to asthma, and point out its usefulness in clinical research. A brief review of past (historical) uses and speculation as to the future uses of methacholine challenge will also be discussed.
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Affiliation(s)
- Beth E Davis
- Department of Medicine, Division of Respirology, Critical Care and Sleep Medicine, Royal University Hospital, University of Saskatchewan, 103 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada.
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Saito J, Sato S, Fukuhara A, Sato Y, Nikaido T, Inokoshi Y, Fukuhara N, Saito K, Ishii T, Tanino Y, Ishida T, Munakata M. Association of asthma education with asthma control evaluated by asthma control test, FEV1, and fractional exhaled nitric oxide. J Asthma 2012; 50:97-102. [PMID: 23163920 DOI: 10.3109/02770903.2012.741638] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Asthma education is an important adjunct for asthma control although the way asthma education affects asthma outcomes is poorly understood. The asthma control test (ACT), forced expiratory volume in 1 s (FEV(1)), and fractional exhaled nitric oxide (FeNO) have all been used as markers of asthma control. However, the use of FeNO as a surrogate marker remains controversial. OBJECTIVES (i) To examine whether asthma education is associated with asthma control; (ii) to compare absolute levels and changes of ACT, FEV(1), and FeNO over a year; and (iii) to evaluate whether FeNO can be used as an additional marker of asthma control. METHODS Fifty asthmatics with poor adherence (12 mild, 21 moderate, and 17 severe) received asthma education at study entry. Medications were unchanged for the first 3 months, and ACT, FEV(1), and FeNO measurements were recorded at entry, 3, 6, and 12 months. Asthma control was assessed at each visit and patients were categorized as either "stable" or "unstable" asthmatics according to the global initiative for asthma (GINA) guidelines. RESULTS A significant decrease in FeNO and increase in ACT score were noted in the stable asthmatic group at 3 months (p < .001), and this persisted over 12 months. Significant correlations were seen between changes (Δ) in FeNO, ACT, and FEV(1) over time. However, significant correlations between the absolute levels were not maintained over 12 months. A decrease of ≥18.6% in FeNO and a ≥3-point increase in ACT score (sensitivity: 80% and 73.3% and specificity: 83.3% and 87.5%, respectively) were associated with stable asthma control although the absolute levels were not. CONCLUSIONS Asthma education may be useful to achieve stable control. In addition, changes rather than absolute levels of FeNO and ACT may be better markers of asthma control.
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Affiliation(s)
- Junpei Saito
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan.
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240
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Leung J, Nguyen-Traxler A, Lee EM, Yip JS, Weinstock JV, Chan WW, Ngo P, Weinstein BJ, Bonis PA. Assessment of fractionated exhaled nitric oxide as a biomarker for the treatment of eosinophilic esophagitis. Allergy Asthma Proc 2012; 33:519-24. [PMID: 23394511 PMCID: PMC3522397 DOI: 10.2500/aap.2012.33.3606] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Diagnosis of eosinophilic esophagitis (EoE) and determination of response to therapy is based on histological assessment of the esophagus, which requires upper endoscopy. In children, in whom a dietary approach is commonly used, multiple endoscopies are needed, because foods are eliminated and then gradually reintroduced. Ideally, noninvasive methods could supplement or replace upper endoscopy to facilitate management. Fractionated exhaled nitric oxide (FeNO) has been proposed as a useful measure for monitoring disease activity in studies of patients with eosinophil-predominant asthma and in other atopic disorders. Thus, we evaluated whether FeNO levels could be a useful biomarker to assess the response to therapy in EoE patients. This study was designed to determine whether there is a change in FeNO levels during treatment with topical corticosteroids and whether changes correlated with clinical response. This was a prospective, multicenter study that enrolled nonasthmatic patients with established EoE. FeNO levels and symptom scores were measured at baseline, biweekly during 6-week swallowed fluticasone treatment, and 4 weeks posttreatment. Twelve patients completed the trial. We found a statistically significant difference between median pre- and posttreatment FeNO levels [20.3 ppb (16.0 -29.0 ppb) vs 17.6 ppb (11.7 -27.3 ppb), [corrected] p=0.009]. However, neither the pretreatment FeNO level, a change of FeNO level after 2 weeks of treatment, nor the FeNO level at the end of treatment confidently predicted a clinical or histological response. Although our findings suggest nitric oxide possibly has a physiological role in EoE, our observations do not support a role of FeNo determination for management of EoE.
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Affiliation(s)
- John Leung
- Department of Rheumatology, Immunology and Allergy, Harvard Medical School/Massachusetts General Hospital, Boston, MA 02114, USA.
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241
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Ochkur SI, Kim JD, Protheroe CA, Colbert D, Condjella RM, Bersoux S, Helmers RA, Moqbel R, Lacy P, Kelly EA, Jarjour NN, Kern R, Peters A, Schleimer RP, Furuta GT, Nair P, Lee JJ, Lee NA. A sensitive high throughput ELISA for human eosinophil peroxidase: a specific assay to quantify eosinophil degranulation from patient-derived sources. J Immunol Methods 2012; 384:10-20. [PMID: 22750539 PMCID: PMC3432656 DOI: 10.1016/j.jim.2012.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 06/20/2012] [Accepted: 06/20/2012] [Indexed: 11/19/2022]
Abstract
Quantitative high throughput assays of eosinophil-mediated activities in fluid samples from patients in a clinical setting have been limited to ELISA assessments for the presence of the prominent granule ribonucleases, ECP and EDN. However, the demonstration that these ribonucleases are expressed by leukocytes other than eosinophils, as well as cells of non-hematopoietic origin, limits the usefulness of these assays. Two novel monoclonal antibodies recognizing eosinophil peroxidase (EPX) were used to develop an eosinophil-specific and sensitive sandwich ELISA. The sensitivity of this EPX-based ELISA was shown to be similar to that of the commercially available ELISA kits for ECP and EDN. More importantly, evidence is also presented confirming that among these granule protein detection options, EPX-based ELISA is the only eosinophil-specific assay. The utility of this high throughput assay to detect released EPX was shown in ex vivo degranulation studies with isolated human eosinophils. In addition, EPX-based ELISA was used to detect and quantify eosinophil degranulation in several in vivo patient settings, including bronchoalveolar lavage fluid obtained following segmental allergen challenge of subjects with allergic asthma, induced sputum derived from respiratory subjects following hypotonic saline inhalation, and nasal lavage of chronic rhinosinusitis patients. This unique EPX-based ELISA thus provides an eosinophil-specific assay that is sensitive, reproducible, and quantitative. In addition, this assay is adaptable to high throughput formats (e.g., automated assays utilizing microtiter plates) using the diverse patient fluid samples typically available in research and clinical settings.
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Affiliation(s)
- Sergei I. Ochkur
- Division of Pulmonary Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
| | - John Dongil Kim
- Division of Pulmonary Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
- Pulmonary Research Group, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Cheryl A. Protheroe
- Division of Hematology/Oncology, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Dana Colbert
- Division of Hematology/Oncology, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Rachel M. Condjella
- Division of Hematology/Oncology, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Sophie Bersoux
- Division of Primary Care, Department of Internal Medicine, Mayo Clinic Arizona, Scottsdale, AZ
| | - Richard A. Helmers
- Division of Pulmonary Medicine, Department of Critical Care Medicine, Mayo Clinic Arizona, Scottsdale, AZ
| | - Redwan Moqbel
- Department of Immunology, University of Manitoba, Winnipeg, MB, Canada
| | - Paige Lacy
- Pulmonary Research Group, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Elizabeth A. Kelly
- Division of Pulmonary Medicine, Department of Internal Medicine, University of Wisconsin Medical School, Madison, WI
| | - Nizar N. Jarjour
- Division of Pulmonary Medicine, Department of Internal Medicine, University of Wisconsin Medical School, Madison, WI
| | - Robert Kern
- Departments of Medicine and Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Anju Peters
- Departments of Medicine and Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert P. Schleimer
- Departments of Medicine and Otolaryngology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Glenn T. Furuta
- Digestive Health Institute, Section of Pediatric Gastroenterology and Hepatology, Gastrointestinal Eosinophilic Diseases Program, Children's Hospital Colorado, National Jewish Health; Mucosal Inflammation Program, University of Colorado Denver School of Medicine, Aurora CO
| | - Parameswaran Nair
- Division of Respiratory, Department of Internal Medicine, McMaster University, Hamilton, Ontario Canada
| | - James J. Lee
- Division of Pulmonary Medicine, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
| | - Nancy A. Lee
- Division of Hematology/Oncology, Department of Biochemistry and Molecular Biology, Mayo Clinic Arizona, Scottsdale, AZ
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Abstract
With each breath that we exhale, thousands of molecules are expelled in our breath, giving individuals a "breath-print" that can tell a lot about them and their state of health. Breath analysis is rapidly evolving as the new frontier in medical testing. The end of the 20th century and the beginning of the 21st century have arguably witnessed a revolution in our understanding of the constituents of exhaled breath and the development of the field of breath analysis and testing. Thanks to major breakthroughs in new technologies (infrared, electrochemical, chemiluminescence, and others) and the availability of mass spectrometers, the field of breath analysis has made considerable advances in the 21st century. Several methods are now in clinical use or nearly ready to enter that arena. Breath analysis has the potential to offer relatively inexpensive, rapid, noninvasive methods for detecting and/or monitoring a variety of diseases. Breath analysis also has applications in fields beyond medicine, including environmental monitoring, security, and others. This review will focus on exhaled breath as a potential source of biomarkers for medical applications with specific attention to applications (and potential applications) in cardiovascular disease.
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Affiliation(s)
- Frank S Cikach
- Department of Pathobiology/Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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243
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Grob NM, Laskowski D, Dweik RA. A technical report on exhaled nitric oxide measurement: asthma monitoring in athletes. J Breath Res 2012; 2:37027. [PMID: 20622980 DOI: 10.1088/1752-7155/2/3/037027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Exhaled NO (FE(NO)) measurements have been utilized as a marker to diagnose asthma as well as a non-invasive tool for monitoring airway inflammation and the response to anti-inflammatory medications. One area where this non-invasive monitoring may be helpful is for asthmatic athletes as they train for competitive events. We hypothesized that in the course of training an asthmatic individual may experience worsening of lung inflammation reflected in FE(NO) levels that may be too subtle to detect by conventional methods like spirometry. Data were collected from an asthmatic patient (n = 1) over the course of endurance training using both the desktop (NIOX) and the portable NO (MINO) analyzers daily for eight weeks. We found that average NO levels measured in the desktop system correlated well with the two portable analyzers (r(2) =0.73, r(2) = 0.74 p < 0.0001); additionally, there was a strong correlation between the two MINO devices (r(2) = 0.88; p < 0.0001). A strong negative relationship existed between the number of miles run and NO, regardless of the device used. FEV(1) and PEF, however, did not change significantly as the miles run increased. Exercise training in asthmatics was associated with a decrease (improvement) in NO levels but no significant change in FEV(1) and PEF. This suggests that exhaled NO levels may be more sensitive to changes in the airway as a result of exercise than traditional pulmonary function testing.
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Affiliation(s)
- Natalia M Grob
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
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244
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Grob NM, Dweik RA. Exhaled nitric oxide in asthma: progress since the introduction of standardized methodology. J Breath Res 2012; 2:37002. [PMID: 20664809 DOI: 10.1088/1752-7155/2/3/037002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The measurement of nitric oxide (NO) in exhaled breath has given us the ability to learn about and monitor the inflammatory status of the airway through a non-invasive method that is easy to perform and repeat. This has been most useful in the diagnosis and management of asthma and has promised a seemingly unlimited potential for evaluating the airways and how clinical decisions are made (Grob N M and Dweik R A 2008 Chest133 837-9). The exhaled NO field was initially limited, however, due to the absence of standardized methodology. The ATS and ERS jointly released recommendations for standardized methods of measuring and reporting exhaled NO in 1999 that were revised in 2005 (1999 Am. J. Respir. Crit. Care. Med. 160 2104-17; 2005 Am. J. Respir. Crit. Care. Med. 171 912-30). In this paper, we summarize the literature that followed this standardization. We searched the literature for all papers that included the term 'exhaled nitric oxide' and selected those that followed ATS guidelines for online measurement for further review. We also reviewed cut-off values suggested by groups studying exhaled nitric oxide. We found a wide range of NO values reported for normal and asthma populations. The geometric mean for FE(NO) ranged from 10 ppb to 33 ppb in healthy adult control populations. For asthma, the FE(NO) geometric mean ranged from 6 ppb to 98 ppb. This considerable variation likely reflects the different clinical settings and purposes of measurement. Exhaled NO has been used for a multitude of reasons that range from screening, to diagnosis, to monitoring the effect of therapy. The field of exhaled NO has made undeniable progress since the standardization of the measurement methods. Our challenge now is to have guidelines to interpret exhaled NO levels in the appropriate context. As the utility of exhaled NO continues to evolve, it can serve as a good example of the crucial role of the standardization of collection and measurement methods to propel any new test in the right direction as it makes its way from a research tool to a clinically useful test.
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Affiliation(s)
- Natalia M Grob
- Department of Pulmonary, Allergy and Critical Care Medicine/Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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245
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Munder M. Role of arginase in asthma: potential clinical applications. Expert Rev Clin Pharmacol 2012; 3:17-23. [PMID: 22111529 DOI: 10.1586/ecp.09.53] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Allergic asthma is a chronic disease with significant morbidity and mortality. It affects 300 million people worldwide and absorbs a significant amount of the healthcare budget. The predisposition to asthma is dictated by complex genetic regulation, and the asthmatic inflammation itself is characterized by the interplay of various local cells of the bronchial tree and invading inflammatory immune cells. The clinical problems of asthma are owing to intermittent airway hyper-responsiveness that can become chronic in the course of the disease. Histopathologically, infiltration with a variety of inflammatory cells, smooth muscle cell hyperplasia and hypertrophy, goblet cell hyperplasia and subepithelial fibrosis are found in asthmatic inflammatory tissue. This special report sets out to review data on the role of the enzyme arginase and L-arginine metabolism as a unifying element of asthma pathophysiology and as a potential target for future clinical asthma treatment.
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Affiliation(s)
- Markus Munder
- Department of Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany.
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Elhefny A, Mourad S, Morsi TS, Kamel MA, Mahmoud HM. Exhaled breath condensate nitric oxide end products and pH in controlled asthma. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2012. [DOI: 10.1016/j.ejcdt.2012.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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247
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Yoon JY, Woo SI, Kim H, Sun YH, Hahn YS. Fractional exhaled nitric oxide and forced expiratory flow between 25% and 75% of vital capacity in children with controlled asthma. KOREAN JOURNAL OF PEDIATRICS 2012; 55:330-6. [PMID: 23049590 PMCID: PMC3454575 DOI: 10.3345/kjp.2012.55.9.330] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 02/15/2012] [Accepted: 03/23/2012] [Indexed: 11/27/2022]
Abstract
Purpose Fractional exhaled nitric oxide (FeNO) and forced expiratory flow between 25% and 75% of vital capacity (FEF25-75) are not included in routine monitoring of asthma control. We observed changes in FeNO level and FEF25-75 after FeNO-based treatment with inhaled corticosteroid (ICS) in children with controlled asthma (CA). Methods We recruited 148 children with asthma (age, 8 to 16 years) who had maintained asthma control and normal forced expiratory volume in the first second (FEV1) without control medication for ≥3 months. Patients with FeNO levels >25 ppb were allocated to the ICS-treated (FeNO-based management) or untreated group (guideline-based management). Changes in spirometric values and FeNO levels from baseline were evaluated after 6 weeks. Results Ninety-three patients had FeNO levels >25 ppb. These patients had lower FEF25-75% predicted values than those with FeNO levels ≤25 ppb (P<0.01). After 6 weeks, the geometric mean (GM) FeNO level in the ICS-treated group was 45% lower than the baseline value, and the mean percent increase in FEF25-75 was 18.% which was greater than that in other spirometric values. There was a negative correlation between percent changes in FEF25-75 and FeNO (r=-0.368, P=0.001). In contrast, the GM FeNO and spirometric values were not significantly different from the baseline values in the untreated group. Conclusion The anti-inflammatory treatment simultaneously improved the FeNO levels and FEF25-75 in CA patients when their FeNO levels were >25 ppb.
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Affiliation(s)
- Ji-Yong Yoon
- Department of Pediatrics, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
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248
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Calhoun WJ, Ameredes BT, King TS, Icitovic N, Bleecker ER, Castro M, Cherniack RM, Chinchilli VM, Craig T, Denlinger L, DiMango EA, Engle LL, Fahy JV, Grant JA, Israel E, Jarjour N, Kazani SD, Kraft M, Kunselman SJ, Lazarus SC, Lemanske RF, Lugogo N, Martin RJ, Meyers DA, Moore WC, Pascual R, Peters SP, Ramsdell J, Sorkness CA, Sutherland ER, Szefler SJ, Wasserman SI, Walter MJ, Wechsler ME, Boushey HA. Comparison of physician-, biomarker-, and symptom-based strategies for adjustment of inhaled corticosteroid therapy in adults with asthma: the BASALT randomized controlled trial. JAMA 2012; 308:987-97. [PMID: 22968888 PMCID: PMC3697088 DOI: 10.1001/2012.jama.10893] [Citation(s) in RCA: 142] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT No consensus exists for adjusting inhaled corticosteroid therapy in patients with asthma. Approaches include adjustment at outpatient visits guided by physician assessment of asthma control (symptoms, rescue therapy, pulmonary function), based on exhaled nitric oxide, or on a day-to-day basis guided by symptoms. OBJECTIVE To determine if adjustment of inhaled corticosteroid therapy based on exhaled nitric oxide or day-to-day symptoms is superior to guideline-informed, physician assessment-based adjustment in preventing treatment failure in adults with mild to moderate asthma. DESIGN, SETTING, AND PARTICIPANTS A randomized, parallel, 3-group, placebo-controlled, multiply-blinded trial of 342 adults with mild to moderate asthma controlled by low-dose inhaled corticosteroid therapy (n = 114 assigned to physician assessment-based adjustment [101 completed], n = 115 to biomarker-based [exhaled nitric oxide] adjustment [92 completed], and n = 113 to symptom-based adjustment [97 completed]), the Best Adjustment Strategy for Asthma in the Long Term (BASALT) trial was conducted by the Asthma Clinical Research Network at 10 academic medical centers in the United States for 9 months between June 2007 and July 2010. INTERVENTIONS For physician assessment-based adjustment and biomarker-based (exhaled nitric oxide) adjustment, the dose of inhaled corticosteroids was adjusted every 6 weeks; for symptom-based adjustment, inhaled corticosteroids were taken with each albuterol rescue use. MAIN OUTCOME MEASURE The primary outcome was time to treatment failure. RESULTS There were no significant differences in time to treatment failure. The 9-month Kaplan-Meier failure rates were 22% (97.5% CI, 14%-33%; 24 events) for physician assessment-based adjustment, 20% (97.5% CI, 13%-30%; 21 events) for biomarker-based adjustment, and 15% (97.5% CI, 9%-25%; 16 events) for symptom-based adjustment. The hazard ratio for physician assessment-based adjustment vs biomarker-based adjustment was 1.2 (97.5% CI, 0.6-2.3). The hazard ratio for physician assessment-based adjustment vs symptom-based adjustment was 1.6 (97.5% CI, 0.8-3.3). CONCLUSION Among adults with mild to moderate persistent asthma controlled with low-dose inhaled corticosteroid therapy, the use of either biomarker-based or symptom-based adjustment of inhaled corticosteroids was not superior to physician assessment-based adjustment of inhaled corticosteroids in time to treatment failure. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00495157.
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Affiliation(s)
- William J Calhoun
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA.
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Ludviksdottir D, Diamant Z, Alving K, Bjermer L, Malinovschi A. Clinical aspects of using exhaled NO in asthma diagnosis and management. CLINICAL RESPIRATORY JOURNAL 2012; 6:193-207. [DOI: 10.1111/crj.12001] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
| | | | - Kjell Alving
- Department of Women's and Children's Health; Uppsala University; Uppsala; Sweden
| | - Leif Bjermer
- Department of Respiratory Diseases and Allergology; Skane University; Lund; Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology; Uppsala University; Uppsala; Sweden
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250
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Malerba M, Ragnoli B, Radaeli A, Ricciardolo F. Long-Term Adjustment of Stable Asthma Treatment with Fractional Exhaled Nitric Oxide and Sputum Eosinophils. EUR J INFLAMM 2012. [DOI: 10.1177/1721727x1201000314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Current approaches to control asthma do not involve direct assessment of airway inflammation. The aim of this study is to assess whether the therapeutic adjustments of steroid treatment according to a stepwise algorithm based on sputum Eosinophils (sEos) and fractioned exhaled Nitric Oxide (FeNO) were effective in maintaining the stability of a group of stable asthmatic patients during a twelvemonth follow-up. Fourteen asthmatic patients, treated for asthma according to a previously published protocol, were enrolled in the study. The patients underwent clinical evaluation, pulmonary function tests, measuring of airway hyperresponsiveness to methacholine, and determination of FeNO and sEos at visit 1. These procedures were repeated after 6 and 12 months (Visits 2 and 3, respectively). Symptoms score gradually improved during the study (p=0.008), no changes were observed in the frequency of clinical asthma exacerbations or in airway hyperresponsiveness to methacholine. At the end of the study both sEos and FeNO were significantly improved (p=0.011 and p=0.003, respectively) and at visit 3 the median steroid dose was reduced (p=0.039) in accordance with the improving of symptoms score, FeNO and sEos values. A direct relationship was observed between the difference of FeNO values and the difference of sEos registered between visits 1 and 2 (r2=609, p0.001) and between visits 2 and 3 (r2=646, p<0.001). In conclusion, long-term titration of asthma inhaled steroid treatment based on sEos and FeNO values was able to provide long-term clinical stability and improvement to the asthmatic patients studied, without significant increases in the steroid dose.
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Affiliation(s)
- M. Malerba
- Department of Internal Medicine, University of Brescia, Brescia, Italy
| | - B. Ragnoli
- Emergency Department, Spedali Civili di Brescia, Brescia, Italy
| | - A. Radaeli
- Emergency Department, Spedali Civili di Brescia, Brescia, Italy
| | - F.L.M. Ricciardolo
- Division of Respiratory Diseases, Department of Clinical and Biological Science, University of Torino, Torino, Italy
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