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Sarikloglou E, Fouzas S, Paraskakis E. Prediction of Asthma Exacerbations in Children. J Pers Med 2023; 14:20. [PMID: 38248721 PMCID: PMC10820562 DOI: 10.3390/jpm14010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 12/17/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Asthma exacerbations are common in asthmatic children, even among those with good disease control. Asthma attacks result in the children and their parents missing school and work days; limit the patient's social and physical activities; and lead to emergency department visits, hospital admissions, or even fatal events. Thus, the prompt identification of asthmatic children at risk for exacerbation is crucial, as it may allow for proactive measures that could prevent these episodes. Children prone to asthma exacerbation are a heterogeneous group; various demographic factors such as younger age, ethnic group, low family income, clinical parameters (history of an exacerbation in the past 12 months, poor asthma control, poor adherence to treatment, comorbidities), Th2 inflammation, and environmental exposures (pollutants, stress, viral and bacterial pathogens) determine the risk of a future exacerbation and should be carefully considered. This paper aims to review the existing evidence regarding the predictors of asthma exacerbations in children and offer practical monitoring guidance for promptly recognizing patients at risk.
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Affiliation(s)
| | - Sotirios Fouzas
- Department of Pediatrics, University of Patras Medical School, 26504 Patras, Greece;
| | - Emmanouil Paraskakis
- Paediatric Respiratory Unit, Paediatric Department, University of Crete, 71500 Heraklion, Greece
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Pifferi M, Boner AL, Gracci S, Fonnesu R, Maj D, Donzelli G, Michelucci A, Cangiotti A, Bertini V, Valetto A, Caligo MA, Miccoli M, Peroni D, Bush A. Longitudinal Nitric Oxide Levels and Infections by Ultrastructure and Genotype in Primary Ciliary Dyskinesia. Chest 2022; 162:1265-1276. [PMID: 35777446 DOI: 10.1016/j.chest.2022.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 06/12/2022] [Accepted: 06/18/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We hypothesized that differences in nasal nitric oxide (nNO) and fractional exhaled nitric oxide (Feno) relate to prognosis in primary ciliary dyskinesia (PCD). RESEARCH QUESTION What is the relationship between baseline values and longitudinal evolution of nNO and Feno and ultrastructure, genotype, and respiratory infections in PCD? STUDY DESIGN AND METHODS Prospective, longitudinal, single-center study in adults and children evaluated biannually for up to 10 years. We compared cross-sectional and longitudinal values of nNO and Feno in ultrastructural (inner dynein arm [IDA] and microtubular disorganization [MTD]) and genetic (CCDC39 and CCDC40) groups known to have worse pulmonary function with patients within the ultrastructural and genetic groups with a better prognosis. Linear mixed-effects models were used to evaluate longitudinal associations. RESULTS One hundred forty-one patients with PCD underwent 1,014 visits. At enrollment, no differences were found in children in nNO or Feno between the IDA and MTD group and the other ultrastructural groups. In adults, nNO (P = .038) and Feno (P = .032) were significantly lower in the IDA and MTD group than in all other combined ultrastructural groups. Feno values were significantly lower in the CCDC39 and CCDC40 group than in the DNAH5 and DNAH11 combined genotype group (P = .033) and in all other genotypes (P = .032). The IDA and MTD group showed a significant decline in nNO with age (P < .01) compared with other ultrastructural groups who showed stable levels. The CCDC39 and CCDC40 group showed the steepest decline in nNO over time (P < .01) compared with all other genotypes. A higher nNO was associated with lower likelihood of any positive bacterial isolate from the lower respiratory tract (P = .008). Changes in Feno over time did not differ between structural groups or genotypes. INTERPRETATION Lower nNO in patients with PCD with genetic and ultrastructural changes associated with greater lung function decline may be related to worse prognosis, but whether a low nNO is causal needs further study. If lower nNO directly results in a poorer prognosis, strategies augmenting upper airway nitric oxide production may be worth evaluating.
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Affiliation(s)
- Massimo Pifferi
- Department of Paediatrics, University Hospital of Pisa, Pisa, Italy.
| | - Attilio L Boner
- Department of Paediatrics, University Hospital of Verona, Verona, Italy
| | - Serena Gracci
- Department of Paediatrics, University Hospital of Pisa, Pisa, Italy
| | - Rossella Fonnesu
- Department of Paediatrics, University Hospital of Pisa, Pisa, Italy
| | - Debora Maj
- Department of Paediatrics, University Hospital of Pisa, Pisa, Italy
| | - Gabriele Donzelli
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Angela Michelucci
- Laboratory of Molecular Genetics, University Hospital of Pisa, Pisa, Italy
| | - Angela Cangiotti
- Electron Microscopy Unit, University Hospital of Ancona, Ancona, Italy
| | - Veronica Bertini
- Section of Cytogenetics, University Hospital of Pisa, Pisa, Italy
| | - Angelo Valetto
- Section of Cytogenetics, University Hospital of Pisa, Pisa, Italy
| | | | - Mario Miccoli
- Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - Diego Peroni
- Department of Paediatrics, University Hospital of Pisa, Pisa, Italy
| | - Andrew Bush
- Imperial College and Royal Brompton Hospital, London, England
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3
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Han SM, Hwang CS, Jeon HJ, Lee HY, Cho HJ, Park DJ. Three Cases of Primary Ciliary Dyskinesia Combined With Reduced Exhaled Nitric Oxide. Ann Otol Rhinol Laryngol 2019; 128:1081-1085. [PMID: 31271036 DOI: 10.1177/0003489419861119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The diagnosis of primary ciliary dyskinesia (PCD) is often delayed in part related to the limitations of the available diagnostic tests. We present 3 cases of PCD diagnosed using an exhaled nitric oxide (eNO) measurement. METHODS Three cases with a clinical phenotype consistent with PCD were evaluated using an eNO assay with additional transmission electron microscopy (TEM) and/or genetic panel testing. RESULTS One male and 2 female patients presented with common symptoms included recurrent respiratory infection from early childhood and a history of neonatal respiratory distress as term newborn. Two of them had situs inversus totalis. Fractional eNO measurement revealed extremely low NO levels, and subsequently, TEM analysis confirmed ciliary ultrastructural defects in all patients. One patient had compound heterozygous mutation of the PCD-causative gene (DNAH5) identified using next generation sequencing. CONCLUSION Our report stresses the reliability of eNO measurement in the diagnosis of PCD, accompanied by clinical phenotypes and additional diagnostic tools, such as TEM analysis and genetic testing.
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Affiliation(s)
- Sung Min Han
- Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, South Korea
| | - Chi Sang Hwang
- Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, South Korea
| | - Hyun Jong Jeon
- Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, South Korea
| | - Ho Young Lee
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyung-Ju Cho
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong-Joon Park
- Department of Otorhinolaryngology, Yonsei University Wonju College of Medicine, South Korea
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Halbeisen FS, Jose A, de Jong C, Nyilas S, Latzin P, Kuehni CE, Goutaki M. Spirometric indices in primary ciliary dyskinesia: systematic review and meta-analysis. ERJ Open Res 2019; 5:00231-2018. [PMID: 31111042 PMCID: PMC6513038 DOI: 10.1183/23120541.00231-2018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/28/2019] [Indexed: 12/19/2022] Open
Abstract
Primary ciliary dyskinesia (PCD) is a genetic, heterogeneous disease caused by dysfunction of cilia. Evidence is sparse and reports of lung function in PCD patients range from normal to severe impairment. This systematic review and meta-analysis of studies of lung function in PCD patients examines the spirometric indices of PCD patients and differences by age group and sex. We searched PubMed, Embase and Scopus for studies that described lung function in 10 or more patients with PCD. We performed meta-analyses and meta-regression to explain heterogeneity. We included 24 studies, ranging from 13 to 158 patients per study. The most commonly reported spirometric indices were forced expiratory volume in 1 s (FEV1) and forced vital capacity presented as mean and standard deviation of percent predicted values. We found considerable heterogeneity for both parameters (I2=94–96%). The heterogeneity remained when we stratified the analysis by age; however, FEV1 in adult patients was lower. Even after taking into account explanatory factors, the largest part of the between-studies variance remained unexplained. Heterogeneity could be explained by genetic differences between study populations, methodological factors related to the variability of study inclusion criteria or details on the performance and evaluation of lung function measurements that we could not account for. Prospective studies therefore need to use standardised protocols and international reference values. These results underline the possibility of distinct PCD phenotypes as in other chronic respiratory diseases. Detailed characterisation of these phenotypes and related genotypes is needed in order to better understand the natural history of PCD. Spirometric indices of PCD patients vary between published studies, which suggests not only the possibility of methodological differences between centres but also real differences in disease expression based on genotype–phenotype associationshttp://ow.ly/wopw30nYaJo
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Affiliation(s)
- Florian S Halbeisen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Anu Jose
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Carmen de Jong
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Sylvia Nyilas
- Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland.,Dept of Diagnostic, Interventional and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Philipp Latzin
- Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Myrofora Goutaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Paediatric Respiratory Medicine, Children's University Hospital of Bern, University of Bern, Bern, Switzerland
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Cohen RT, Rodeghier M, Kirkham FJ, Rosen CL, Kirkby J, DeBaun MR, Strunk RC. Exhaled nitric oxide: Not associated with asthma, symptoms, or spirometry in children with sickle cell anemia. J Allergy Clin Immunol 2016; 138:1338-1343.e4. [PMID: 27521278 PMCID: PMC5330622 DOI: 10.1016/j.jaci.2016.06.043] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 05/25/2016] [Accepted: 06/13/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND The significance of fractional exhaled nitric oxide (Feno) levels in children with sickle cell anemia (SCA) is unclear, but increased levels can be associated with features of asthma and thus increased morbidity. OBJECTIVES We sought to determine factors associated with Feno and whether Feno levels are associated with increased rates of acute chest syndrome (ACS) and pain. METHODS All participants had SCA, were part of the prospective observational Sleep and Asthma Cohort study, and had the following assessments: Feno levels, spirometry, blood samples analyzed for hemoglobin, white blood cell counts, eosinophil counts and total serum IgE levels, questionnaires about child medical and family history, and review of medical records. RESULTS The analytic sample included 131 children with SCA (median age, 11.2 years; age range, 6-18 years) followed for a mean of 16.2 years, including a mean of 5.1 years after baseline Feno data measurements. In multivariable analyses higher Feno levels were associated with ln(IgE) levels (P < .001) and the highest quartile of peripheral eosinophil counts (P = .03) but not wheezing symptoms, baseline spirometric indices, or response to bronchodilator. Multivariable analyses identified that the incident rate of ACS was associated with ln(Feno) levels (P = .03), as well as male sex (P = .025), wheezing causing shortness of breath (P = .002), and ACS at less than 4 years of age (P < .001). Feno levels were not associated with future pain episodes. CONCLUSIONS Steady-state Feno levels were not associated with an asthma diagnosis, wheezing symptoms, lung function measures, or prior sickle cell morbidity but were associated with markers of atopy and increased risk of future ACS events.
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Affiliation(s)
- Robyn T. Cohen
- Department of Pediatrics, Boston University School of Medicine, Boston, MA, USA
| | | | - Fenella J. Kirkham
- Neurosciences Unit, University College London, Institute of Child Health, London, United Kingdom
| | - Carol L. Rosen
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jane Kirkby
- Portex Respiratory Unit, University College London, Institute of Child Health, London, UK
| | - Michael R. DeBaun
- Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Robert C. Strunk
- Division of Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
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Goez HR, Scott O, Al-Jabri B, Prowse M, Beaudoin W, Hall S, Mehta V, Amirav I. Decreased Levels of Nasal Nitric Oxide in Children With Midline Neuroanatomical Anomalies: A Possible Connection Between Ciliary Dysfunction and Isolated Nervous System Defects. Pediatr Neurol 2015; 53:324-9. [PMID: 26255753 DOI: 10.1016/j.pediatrneurol.2015.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/06/2015] [Accepted: 07/07/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Given the involvement of cilia in midline neurodevelopment, we set to determine whether children with midline neuroanatomical defects have increased prevalence of ciliary dysfunction, using nasal nitric oxide measurement, a screening test for primary ciliary dyskinesia. STUDY DESIGN We measured the nasal nitric oxide levels of 26 children ages 6-17, with congenital midline central nervous system defects, who are otherwise healthy. We evaluated the effect of variables including: age, gender, and anomaly (brain, spinal cord, or combined) on our measurements. We compared our results with the previously established normal range (153.6-509.9 nL/min) and to the cutoff for children with primary ciliary dyskinesia (77 nL/min). RESULTS The overall range for nasal nitric oxide in our cohort was 56.5-334.7 nL/min, with age, gender, and anomaly not having a significant effect. The overall mean, 217.7 nL/min, was significantly lower than the preestablished mean in normal children, 314.51 nL/min (P < 0.01). Four patients (15.4%) had nitric oxide levels below the lower end of normal, with two (7.7%) having values below the cutoff for primary ciliary dyskinesia. CONCLUSIONS This is the first study to report a possible association between ciliary dysfunction and isolated congenital midline neuroanatomical defects, not in the context of any known syndrome. We suggest that genes known to cause isolated central nervous system defects may also be involved in the function of cilia. Longitudinal studies are required to investigate whether, in children with abnormal measurements, nasal nitric oxide levels normalize over time, and whether these children suffer from any respiratory sequelae.
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Affiliation(s)
- Helly Rachel Goez
- Division of Pediatric Neurology, Stollery Children's Hospital, Edmonton, Alberta, Canada.
| | - Ori Scott
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Basma Al-Jabri
- Department of Pediatrics, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | - Matthew Prowse
- Department of Pediatrics, Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
| | - Wendy Beaudoin
- Division of Pediatric Neurosurgery, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Stacey Hall
- Division of Pediatric Neurosurgery, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Vivek Mehta
- Division of Pediatric Neurosurgery, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Israel Amirav
- Division of Pediatric Respirology, Stollery Children's Hospital, Edmonton, Alberta, Canada
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7
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Smith CM, Fadaee-Shohada MJ, Sawhney R, Baker N, Williams G, Hirst RA, Andrew PW, O'Callaghan C. Ciliated cultures from patients with primary ciliary dyskinesia do not produce nitric oxide or inducible nitric oxide synthase during early infection. Chest 2014; 144:1671-1676. [PMID: 24189859 DOI: 10.1378/chest.13-0159] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The mechanism behind why patients with primary ciliary dyskinesia (PCD) exhibit low nasal and exhaled nitric oxide (NO) remains unknown. One hypothesis is that reduced NO biosynthesis is caused by a defect in one or more NO synthases (NOSs). In healthy cells, the biosynthesis of NO is increased following exposure to respiratory pathogens. Here, we aimed to investigate whether ciliated epithelial cells from patients with PCD increase NO production following pneumococcal infection. METHODS Human respiratory epithelium was cultured to a basal or ciliated cell phenotype using submerged or air-liquid interface cultures, respectively. Cells were exposed to media or pneumococci until cells became damaged (< 4 h). Apical fluids were collected prior and following infection, and NO production was determined using chemiluminescence. NOS gene expression was determined using real-time quantitative polymerase chain reaction. RESULTS Levels of NO and NOS2 gene expression increased significantly following infection of healthy ciliated epithelial cells but not basal cells. No increase in NO was seen in ciliated cell cultures from patients with PCD, and NOS2 gene expression remained unchanged from baseline. CONCLUSIONS These results suggest that the biosynthesis of NO in ciliated cells from patients with PCD is abnormal following early bacterial challenge, suggesting an abnormality in the function of inducible NOS in PCD.
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Affiliation(s)
- Claire M Smith
- Department of Respiratory Medicine, Portex Unit, Institute of Child Health, UCL, and Great Ormond Street Hospital for Children NHS Foundation Trust, London; Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, England
| | - Mina J Fadaee-Shohada
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, England
| | - Rounak Sawhney
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, England
| | - Norman Baker
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, England
| | - Gwyneth Williams
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, England
| | - Robert A Hirst
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, England
| | - Peter W Andrew
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, England
| | - Christopher O'Callaghan
- Department of Respiratory Medicine, Portex Unit, Institute of Child Health, UCL, and Great Ormond Street Hospital for Children NHS Foundation Trust, London; Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, England.
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Mosquera RA, Samuels CL, Harris TS, Yadav A, Hashmi SS, Knight MS, Koenig MK. Decreased exhaled nitric oxide levels in patients with mitochondrial disorders. Open Respir Med J 2013; 7:67-70. [PMID: 23935767 PMCID: PMC3735920 DOI: 10.2174/1874306401307010067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Revised: 06/05/2013] [Accepted: 07/08/2013] [Indexed: 11/22/2022] Open
Abstract
Background: Nitric oxide (NO) deficiency may occur in mitochondrial disorders (MD) and can contribute to the pathogenesis of the disease. It is difficult and invasive to measure systemic nitric oxide. NO is formed in the lungs and can be detected in expired air. Currently, hand-held fractional exhaled nitric oxide (FeNO) measurement devices are available enabling a fast in-office analysis of this non-invasive test. It was postulated that FeNO levels might be reduced in MD. Methods: Sixteen subjects with definite MD by modified Walker criteria (4 to 30 years of age) and sixteen healthy control subjects of similar age, race and body mass index (BMI) underwent measurement of FeNO in accordance with the American Thoracic Society guidelines. Results: Sixteen patient-control pairs were recruited. The median FeNO level was 6.5 ppm (IQR: 4-9.5) and 10.5 ppm (IQR: 8-20.5) in the MD and control groups, respectively. In 13 pairs (81%), the FeNO levels were lower in the MD cases than in the matched controls (p=0.021). Eleven (69%) cases had very low FeNO levels (≤7ppm) compared to only 1 control (p=0.001). All cases with enzymatic deficiencies in complex I had FeNO ≤7ppm. Conclusions: Single-breath exhaled nitric oxide recordings were decreased in patients with MD. This pilot study suggests that hand-held FeNO measurements could be an attractive non-invasive indicator of MD. In addition, measurement of FeNO could be used as a parameter to monitor therapeutic response in this population.
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Affiliation(s)
- Ricardo A Mosquera
- University of Texas Health Science Center at Houston (UTHealth), School of Medicine, Department of Pediatric Pulmonary, Houston, Texas, USA
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Walker WT, Liew A, Harris A, Cole J, Lucas JS. Upper and lower airway nitric oxide levels in primary ciliary dyskinesia, cystic fibrosis and asthma. Respir Med 2013; 107:380-6. [PMID: 23290188 DOI: 10.1016/j.rmed.2012.11.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 11/26/2012] [Accepted: 11/28/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Patients with primary ciliary dyskinesia (PCD) have abnormal ciliary function and low nitric oxide levels. Nitric oxide (NO) biosynthesis is dependent on nitric oxide synthases (NOS). Cilia line the bronchial but not the alveolar epithelium. It has been hypothesised that NOS function relies on normal ciliary function and that in PCD bronchial but not alveolar NO might therefore be reduced. The aim of this study was to assess bronchial and alveolar NO levels primarily comparing healthy children to PCD and secondarily to cystic fibrosis (CF) and asthmatic children. METHODS Multiple flow-rate fractional exhaled and nasal NO measurements were performed using a NIOX(®) Flex NO analyser (Aerocrine, Sweden) in children with PCD (n = 14), asthma (n = 18), CF (n = 12) and healthy controls (n = 18). Alveolar and bronchial NO levels were derived using a model of pulmonary NO exchange-dynamics. RESULTS Both the bronchial and alveolar NO were significantly lower in PCD than healthy controls (mean (SD) 264 (209) picolitres/second (pl/s) vs. 720 (514) pl/s, p = 0.024 and 1.7 (0.8) parts per billion (ppb) vs. 3.5 (1.3) ppb, p = 0.001 respectively.) In asthmatics bronchial NO was found to be significantly higher than in healthy controls and in children with CF alveolar NO was significantly lower (2100 (1935) pl/s, p = 0.045 and 2.5 (1.2) ppb, p = 0.034 respectively.) CONCLUSION Our findings do not support the hypothesis that NOS and ciliary function are coupled instead suggesting a more generalised mechanism for the low levels of NO seen in PCD. Our findings in CF and asthma corroborate evidence that these are diseases of the lung peripheries and bronchi respectively.
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Affiliation(s)
- W T Walker
- Primary Ciliary Dyskinesia Centre, Southampton NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
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Manna A, Caffarelli C, Varini M, Dascola CP, Montella S, Maglione M, Sperlì F, Santamaria F. Clinical application of exhaled nitric oxide measurement in pediatric lung diseases. Ital J Pediatr 2012; 38:74. [PMID: 23273317 PMCID: PMC3545741 DOI: 10.1186/1824-7288-38-74] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 12/19/2012] [Indexed: 12/18/2022] Open
Abstract
Fractional exhaled nitric oxide (FeNO) is a non invasive method for assessing the inflammatory status of children with airway disease. Different ways to measure FeNO levels are currently available. The possibility of measuring FeNO levels in an office setting even in young children, and the commercial availability of portable devices, support the routine use of FeNO determination in the daily pediatric practice. Although many confounding factors may affect its measurement, FeNO is now widely used in the management of children with asthma, and seems to provide significantly higher diagnostic accuracy than lung function or bronchial challenge tests. The role of FeNO in airway infection (e.g. viral bronchiolitis and common acquired pneumonia), in bronchiectasis, or in cases with diffuse lung disease is less clear. This review focuses on the most recent advances and the current clinical applications of FeNO measurement in pediatric lung disease.
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Affiliation(s)
- Angelo Manna
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
| | - Carlo Caffarelli
- Department of Pediatrics, University Hospital of Parma, Parma, Italy
| | - Margherita Varini
- Department of Pediatrics, University Hospital of Parma, Parma, Italy
| | | | - Silvia Montella
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
| | - Marco Maglione
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
| | - Francesco Sperlì
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
| | - Francesca Santamaria
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
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Breath biomarkers in diagnosis of pulmonary diseases. Clin Chim Acta 2012; 413:1770-80. [PMID: 22796631 DOI: 10.1016/j.cca.2012.07.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 05/20/2012] [Accepted: 07/05/2012] [Indexed: 12/29/2022]
Abstract
Breath analysis provides a convenient and simple alternative to traditional specimen testing in clinical laboratory diagnosis. As such, substantial research has been devoted to the analysis and identification of breath biomarkers. Development of new analytes enhances the desirability of breath analysis especially for patients who monitor daily biochemical parameters. Elucidating the physiologic significance of volatile substances in breath is essential for clinical use. This review describes the use of breath biomarkers in diagnosis of asthma, chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), lung cancer, as well as other pulmonary diseases. A number of breath biomarkers in lung pathophysiology will be described including nitric oxide (NO), carbon monoxide (CO), hydrogen peroxide (H₂O₂) and other hydrocarbons.
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Spitale N, Popat N, McIvor A. Update on exhaled nitric oxide in pulmonary disease. Expert Rev Respir Med 2012; 6:105-15. [PMID: 22283583 DOI: 10.1586/ers.12.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The ability to assess the inflammatory status of a patient's airway using a noninvasive method is the ideal situation for clinicians. Owing in part to the relationship between the levels of exhaled nitric oxide to inflammation and the ease of the technique, the measurement of the fraction of exhaled nitric oxide (F(E)NO) has achieved considerable attention, particularly with respect to asthma. A multitude of studies have shown that when measured in exhaled air, this unique molecule has the potential to have both diagnostic and therapeutic roles in the clinical setting for many pulmonary diseases. The incorporation of F(E)NO into asthma management and treatment algorithms may help shed further insight on the current control and future risk of patients. Research is ongoing to determine the biology and the benefits of the use of F(E)NO in respiratory conditions in addition to asthma. This review will briefly outline the pathophysiology of nitric oxide, the measurement of F(E)NO and the potential clinical uses of F(E)NO in asthma and a number of other respiratory diseases. Despite its promise, until further research is conducted, the use of F(E)NO cannot be recommended for routine clinical management of respiratory diseases at present, but should be considered as an adjuvant to help guide therapy in certain patients with asthma and in those with eosinophilic bronchitis.
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Affiliation(s)
- Naomi Spitale
- Division of Respirology, Department of Medicine, The Ottawa Hospital, ON, Canada
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Piacentini GL, Cattazzo E, Tezza G, Peroni DG. Exhaled nitric oxide in pediatrics: what is new for practice purposes and clinical research in children? J Breath Res 2012; 6:027103. [PMID: 22523000 DOI: 10.1088/1752-7155/6/2/027103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Fractional exhaled NO (FeNO) is universally considered an indirect marker of eosinophilic airways inflammation, playing an important role in the physiopathology of childhood asthma. Advances in technology and standardization have allowed a wider use of FeNO in clinical practice in children from the age of four years. FeNO measurements add a new dimension to the traditional clinical tools (symptoms scores, lung function tests) in the assessment of asthma. To date a number of studies have suggested a possible use of FeNO in early identification of exacerbation risk and in inhaled corticosteroids titration. The aim of this paper is to address practical issues of interest to paediatric clinicians who are attempting to use FeNO measurements as an adjunctive tool in the diagnosis and management of childhood airway diseases.
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Affiliation(s)
- G L Piacentini
- Faculty of Medicine, Department of Pediatrics, University of Verona, Policlinico GB Rossi, Piazzale L. Scuro 10, Verona, Italy.
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Radhakrishnan DK, Bendiak GN, Mateos-Corral D, Al-Saleh S, Bhattacharjee R, Kirby-Allen M, Grasemann H. Lower airway nitric oxide is increased in children with sickle cell disease. J Pediatr 2012; 160:93-7. [PMID: 21868036 DOI: 10.1016/j.jpeds.2011.06.048] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 05/16/2011] [Accepted: 06/29/2011] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine alveolar and airways nitric oxide (NO) levels in children with sickle cell disease (SCD). STUDY DESIGN Multiple flows fractional exhaled NO (FE(NO)), bronchial NO flux (J'aw(NO)), and alveolar NO concentration (Ca(NO)) were determined prospectively in 16 non-atopic children with SCD in a tertiary ambulatory clinic and compared with those in 10 children with primary ciliary dyskinesia and 22 healthy control subjects. Differences in FE(NO), J'aw(NO), and Ca(NO) were compared with mixed model analysis and Mann-Whitney tests. RESULTS Children with SCD had reference range FE(NO) at 50 mL/sec, but FE(NO) was elevated across all flows compared with healthy control subjects (mean difference=2.10±0.91 parts per billion, P=.03). Subjects with SCD had increased J'aw(NO) (1177±533 picoliters per second versus 833±343 picolitres per second, P=.03), and Ca(NO) was no different from control subjects. In contrast, children with primary ciliary dyskinesia had decreased FE(NO) (mean difference=3.36±1.24 parts per billion, P<.01) and J'aw(NO) (507±259 picoliters per second versus 833±343 picoliters per second, P<.01). CONCLUSIONS Lower airways NO is increased in children with SCD. Elevation of J'aw(NO) may represent dysregulation of NO metabolism or subclinical airways inflammation.
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Malinovschi A, Henrohn D, Eriksson A, Lundberg JO, Alving K, Wikström G. Increased plasma and salivary nitrite and decreased bronchial contribution to exhaled NO in pulmonary arterial hypertension. Eur J Clin Invest 2011; 41:889-97. [PMID: 21554268 DOI: 10.1111/j.1365-2362.2011.02488.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Conflicting results on exhaled NO in pulmonary hypertension (PH) exist. Therefore, we analysed exhaled NO, as well as systemic and local nitrite, a possible alternative source of NO, in PH with regard to PH aetiology. METHODS Exhaled NO at multiple flow-rates, as well as plasma and salivary nitrite and nitrate, was measured in 22 patients with PH and 21 healthy controls. Alveolar NO (Calv(NO) ) and bronchial flux (J'aw(NO) ) were calculated using the slope-intercept model. Patients with PH were subdivided into pulmonary arterial hypertension (PAH) and PH WHO Groups II-IV, according to the WHO clinical classification of PH. RESULTS Exhaled NO was reduced at flow-rates in the range of 20-200 mL s(-1) in patients with PAH (n=13) vs. PH WHO Group II-IV (n=9) (P<0·05 all). Patients with PAH had higher Calv(NO) than healthy controls [2·61 (2·23, 3·36) vs. 1.97ppb (1·22, 2·49), P=0·03] and similar to PH WHO Group II-IV (P=0·51). Patients with PAH had lower J'aw(NO) than patients with PH WHO Group II-IV or healthy controls [430 (371, 702) vs. 807 (557, 993) or 731pLs(-1) (580, 818), P<0·05 both]. Subjects with PAH were characterized by higher levels of salivary and plasma nitrite than healthy controls (P<0·05 both). CONCLUSIONS Patients with PAH have lower bronchial NO flux compared to healthy controls and patients with PH WHO Group II-IV along with elevated salivary and plasma nitrite compared to controls. This implies reduced bronchial NO synthase-derived NO formation in PAH. Increased alveolar NO levels were found in subjects with PH compared to controls, especially in subjects with PAH. This may reflect NO diffusion disturbances in the alveoli.
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Affiliation(s)
- Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden.
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Olm MAK, Kögler JE, Macchione M, Shoemark A, Saldiva PHN, Rodrigues JC. Primary ciliary dyskinesia: evaluation using cilia beat frequency assessment via spectral analysis of digital microscopy images. J Appl Physiol (1985) 2011; 111:295-302. [PMID: 21551013 DOI: 10.1152/japplphysiol.00629.2010] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Ciliary beat frequency (CBF) measurements provide valuable information for diagnosing of primary ciliary dyskinesia (PCD). We developed a system for measuring CBF, used it in association with electron microscopy to diagnose PCD, and then analyzed characteristics of PCD patients. The CBF measurement system was based on power spectra measured through digital imaging. Twenty-four patients suspected of having PCD (age 1-19 yr) were selected from a group of 75 children and adolescents with pneumopathies of unknown causes. Ten healthy, nonsmoking volunteers (age ≥ 17 yr) served as a control group. Nasal brush samples were collected, and CBF and electron microscopy were performed. PCD was diagnosed in 12 patients: 5 had radial spoke defects, 3 showed absent central microtubule pairs with transposition, 2 had outer dynein arm defects, 1 had a shortened outer dynein arm, and 1 had a normal ultrastructure. Previous studies have reported that the most common cilia defects are in the dynein arm. As expected, the mean CBF was higher in the control group (P < 0.001) and patients with normal ultrastructure (P < 0.002), than in those diagnosed with cilia ultrastructural defects (i.e., PCD patients). An obstructive ventilatory pattern was observed in 70% of the PCD patients who underwent pulmonary function tests. All PCD patients presented bronchial wall thickening on chest computed tomography scans. The protocol and diagnostic techniques employed allowed us to diagnose PCD in 16% of patients in this study.
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Affiliation(s)
- Mary A K Olm
- Pediatric Pneumology Unit, Child Institute, Faculty of Medicine, University of São Paulo, São Paulo, SP, Brazil.
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Abba AA. Exhaled nitric oxide in diagnosis and management of respiratory diseases. Ann Thorac Med 2009; 4:173-81. [PMID: 19881162 PMCID: PMC2801041 DOI: 10.4103/1817-1737.56009] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Accepted: 07/10/2009] [Indexed: 11/05/2022] Open
Abstract
The analysis of biomarkers in exhaled breath constituents has recently become of great interest in the diagnosis, treatment and monitoring of many respiratory conditions. Of particular interest is the measurement of fractional exhaled nitric oxide (FENO) in breath. Its measurement is noninvasive, easy and reproducible. The technique has recently been standardized by both American Thoracic Society and European Respiratory Society. The availability of cheap, portable and reliable equipment has made the assay possible in clinics by general physicians and, in the near future, at home by patients. The concentration of exhaled nitric oxide is markedly elevated in bronchial asthma and is positively related to the degree of esinophilic inflammation. Its measurement can be used in the diagnosis of bronchial asthma and titration of dose of steroids as well as to identify steroid responsive patients in chronic obstructive pulmonary disease. In primary ciliary dyskinesia, nasal NO is diagnostically low and of considerable value in diagnosis. Among lung transplant recipients, FENO can be of great value in the early detection of infection, bronchioloitis obliterans syndrome and rejection. This review discusses the biology, factors affecting measurement, and clinical application of FENO in the diagnosis and management of respiratory diseases.
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Affiliation(s)
- Abdullah A Abba
- Department of Medicine, College of Medicine and King Khalid University Hospital, Riyadh, Saudi Arabia.
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Shoemark A, Wilson R. Bronchial and peripheral airway nitric oxide in primary ciliary dyskinesia and bronchiectasis. Respir Med 2009; 103:700-6. [DOI: 10.1016/j.rmed.2008.12.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Revised: 12/01/2008] [Accepted: 12/02/2008] [Indexed: 12/17/2022]
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