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Marcuccio G, Ambrosino P, Merola C, Manzo F, Motta A, Rea G, Cantone E, Maniscalco M. Clinical Applications of Nasal Nitric Oxide in Allergic Rhinitis: A Review of the Literature. J Clin Med 2023; 12:5081. [PMID: 37568482 PMCID: PMC10420175 DOI: 10.3390/jcm12155081] [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: 07/12/2023] [Revised: 07/25/2023] [Accepted: 07/31/2023] [Indexed: 08/13/2023] Open
Abstract
Allergic rhinitis, a common allergic disease affecting a significant number of individuals worldwide, is observed in 25% of children and 40% of adults, with its highest occurrence between the ages of 20 and 40. Its pathogenesis, like other allergic diseases, involves innate and adaptive immune responses, characterized by immunologic hypersensitivity to environmental substances. This response is mediated by type 2 immunity. Within type 2 allergic diseases, certain molecules have been identified as clinical biomarkers that contribute to diagnosis, prognosis, and therapy monitoring. Among these biomarkers, nitric oxide has shown to play a key role in various physiological and pathological processes, including neurotransmission, immunity, inflammation, regulation of mucus and cilia, inhibition of microorganisms, and tumor cell growth. Therefore, measurement of nasal nitric oxide has been proposed as an objective method for monitoring airway obstruction and inflammation in different settings (community, hospital, rehabilitation) and in various clinical conditions, including upper airways diseases of the nose and paranasal sinuses. The purpose of this review is to analyze the potential mechanisms contributing to the production of nasal nitric oxide in allergic rhinitis and other related health issues. Additionally, this review aims to identify potential implications for future research, treatment strategies, and long-term management of symptoms.
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Affiliation(s)
- Giuseppina Marcuccio
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy; (G.M.); (C.M.)
| | - Pasquale Ambrosino
- Istituti Clinici Scientifici Maugeri IRCCS, Directorate of Telese Terme Institute, 82037 Telese Terme, Italy;
| | - Claudia Merola
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy; (G.M.); (C.M.)
| | - Fabio Manzo
- Fleming Clinical Laboratory, 81020 Casapulla, Italy;
| | - Andrea Motta
- Institute of Biomolecular Chemistry, National Research Council, 00185 Pozzuoli, Italy;
| | - Gaetano Rea
- Department of Radiology, Monaldi Hospital, AO dei Colli, 80131 Naples, Italy
| | - Elena Cantone
- Department of Neuroscience, Reproductive and Odontostomatological Sciences—ENT Section, University of Naples Federico II, 80138 Naples, Italy;
| | - Mauro Maniscalco
- Istituti Clinici Scientifici Maugeri IRCCS, Pulmonary Rehabilitation Unit of Telese Terme Institute, 82037 Telese Terme, Italy; (G.M.); (C.M.)
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80138 Naples, Italy
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Jeong JH. Nasal Nitric Oxide in the Upper Airway Inflammatory Diseases. JOURNAL OF RHINOLOGY 2021. [DOI: 10.18787/jr.2021.00361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Exhaled nitric oxide (eNO) from the lower respiratory tract is used commonly in diagnosis and treatment monitoring of asthma patients. However, nasal nitric oxide (nNO) has not been widely used in patients with upper airway inflammatory diseases due to its lack of standardized measurement methods. Nasal nitric oxide is produced mainly by the paranasal sinus mucosa and partially by the nasal mucosa and increases with inflammation. Nasal nitric oxide not only locally supports the defensive mechanism of the upper respiratory tract, but also remotely controls pulmonary function by acting as an aerocrine. Nasal NO can be affected by various physiologic and pathologic factors of the upper respiratory tract. This article will review the origin of nNO, its function, various measurement methods, and difference in presentation among upper respiratory tract inflammatory diseases such as allergic rhinitis, upper respiratory tract infection, nasal polyp, rhinosinusitis, primary ciliary dyskinesia, cystic fibrosis, Young’s syndrome, diffuse panbronchiolitis, empty nose syndrome, and obstructive sleep apnea. Future studies should identify the mechanism of action of nNO in various upper respiratory tract inflammatory diseases and obtain highly reproducible normal values of nNO based on a standardized measurement method with a deeper understanding of factors affecting nNO. Then, nNO will be useful for more rapid and simpler diagnosis of various upper respiratory tract diseases and for monitoring their treatment.
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Kawasumi T, Takeno S, Ishikawa C, Takahara D, Taruya T, Takemoto K, Hamamoto T, Ishino T, Ueda T. The Functional Diversity of Nitric Oxide Synthase Isoforms in Human Nose and Paranasal Sinuses: Contrasting Pathophysiological Aspects in Nasal Allergy and Chronic Rhinosinusitis. Int J Mol Sci 2021; 22:ijms22147561. [PMID: 34299181 PMCID: PMC8304068 DOI: 10.3390/ijms22147561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/09/2021] [Accepted: 07/13/2021] [Indexed: 12/20/2022] Open
Abstract
The human paranasal sinuses are the major source of intrinsic nitric oxide (NO) production in the human airway. NO plays several roles in the maintenance of physiological homeostasis and the regulation of airway inflammation through the expression of three NO synthase (NOS) isoforms. Measuring NO levels can contribute to the diagnosis and assessment of allergic rhinitis (AR) and chronic rhinosinusitis (CRS). In symptomatic AR patients, pro-inflammatory cytokines upregulate the expression of inducible NOS (iNOS) in the inferior turbinate. Excessive amounts of NO cause oxidative damage to cellular components, leading to the deposition of cytotoxic substances. CRS phenotype and endotype classifications have provided insights into modern treatment strategies. Analyses of the production of sinus NO and its metabolites revealed pathobiological diversity that can be exploited for useful biomarkers. Measuring nasal NO based on different NOS activities is a potent tool for specific interventions targeting molecular pathways underlying CRS endotype-specific inflammation. We provide a comprehensive review of the functional diversity of NOS isoforms in the human sinonasal system in relation to these two major nasal disorders' pathologies. The regulatory mechanisms of NOS expression associated with the substrate bioavailability indicate the involvement of both type 1 and type 2 immune responses.
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Affiliation(s)
| | - Sachio Takeno
- Correspondence: ; Tel.: +81-82-257-5252; Fax: +81-82-257-5254
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Tiotiu A, Novakova P, Guillermo G, Correira de Sousa J, Braido F. Management of adult asthma and chronic rhinitis as one airway disease. Expert Rev Respir Med 2021; 15:1135-1147. [PMID: 34030569 DOI: 10.1080/17476348.2021.1932470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Chronic rhinitis is defined as nasal inflammation with the presence of minimum two symptoms such as nasal obstruction, rhinorrhea, sneezing and/or itching one hour daily for a minimum of 12 weeks/year. According their etiology, four groups of rhinitis are described: allergic, infectious, non-allergic non-infectious and mixed.Chronic rhinitis is frequently associated with asthma, shares similar mechanisms of the pathogenesis and has a negative impact of its outcomes sustaining the concept of unified airways disease.Areas covered: The present review summarizes the complex relationship between chronic rhinitis and asthma on the basis of recent epidemiological data, clinical characteristics, diagnosis and therapeutic management. All four groups are discussed with the impact of their specific treatment on asthma outcomes. Some medications are common for chronic rhinitis and asthma while others are more specific but able to treat the associated comorbidity.Expert opinion: The systematic assessment of chronic rhinitis in patients with asthma and its specific treatment improves both disease outcomes. Conversely, several therapies of asthma demonstrated beneficial effects on chronic rhinitis. Treating both diseases at the same time by only one medication is an interesting option to explore in the future in order to limit drugs administration, related costs and side effects.
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Affiliation(s)
- Angelica Tiotiu
- Department of Pulmonology, University Hospital of Nancy, France; 9 Rue Du Morvan, Vandoeuvre-lès-Nancy, France.,Development, Adaptation and Disadvantage. Cardiorespiratory Regulations and Motor Control (EA 3450 DevAH), University of Lorraine, - Vandoeuvre-lès-Nancy, France
| | - Plamena Novakova
- ;department of Allergology, Medical University of Sofia, University Hospital "Alexandrovska"; 1, Sofia, Bulgaria
| | - Guidos Guillermo
- Department of Immunology, School of Medicine, Instituto Politecnico Nacional, Gustavo A. Madero, Ciudad De México, CDMX, Mexico
| | - Jaime Correira de Sousa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal. ICVS/3B's - PT Government Associate Laboratory, Braga/Guimarães, Portugal; Campus De, Braga, Portugal
| | - Fulvio Braido
- Allergy and Respiratory Diseases Department, University of Genoa, Genova GE, Italy
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Tiotiu A, Novakova P, Baiardini I, Bikov A, Chong-Neto H, de-Sousa JC, Emelyanov A, Heffler E, Fogelbach GG, Kowal K, Labor M, Mihaicuta S, Nedeva D, Novakova S, Steiropoulos P, Ansotegui IJ, Bernstein JA, Boulet LP, Canonica GW, Dubuske L, Nunes C, Ivancevich JC, Santus P, Rosario N, Perazzo T, Braido F. Manifesto on united airways diseases (UAD): an Interasma (global asthma association - GAA) document. J Asthma 2021; 59:639-654. [PMID: 33492196 DOI: 10.1080/02770903.2021.1879130] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The large amount of evidence and the renewed interest in upper and lower airways involvement in infectious and inflammatory diseases has led Interasma (Global Asthma Association) to take a position on United Airways Diseases (UAD). METHODS Starting from an extensive literature review, Interasma executive committee discussed and approved this Manifesto developed by Interasma scientific network (INES) members. RESULTS The manifesto describes the evidence gathered to date and defines, states, advocates, and proposes issues on UAD (rhinitis, rhinosinusitis and nasal polyposis), and concomitant/comorbid lower airways disorders (asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea) with the aim of challenging assumptions, fostering commitment, and bringing about change. UAD refers to clinical pictures characterized by the coexistence of upper and lower airways involvement, driven by a common pathophysiological mechanism, leading to a greater burden on patient's health status and requiring an integrated diagnostic and therapeutic plan. The high prevalence of UAD must be taken into account. Upper and lower airways diseases influence disease control and patient's quality of life. CONCLUSIONS Patients with UAD need to have a timely and adequate diagnosis, treatment, and, when recommended, referral for management in a specialized center. Diagnostic testing including skin prick or serum specific IgE, lung function, fractional exhaled nitric oxide (FeNO), polysomnography, allergen-specific immunotherapies, biological therapies and home based continuous positive airway pressure (CPAP) whenever these are recommended, should be part of the management plan for UAD. Education of medical students, physicians, health professionals, patients and caregivers on the UAD is needed.
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Affiliation(s)
- Angelica Tiotiu
- Department of Pulmonology, University Hospital of Nancy, Nancy, France.,EA 3450 DevAH - Development, Adaptation and Disadvantage, Cardiorespiratory Regulations and Motor Control, University of Lorraine, Nancy, France
| | - Plamena Novakova
- Clinic of Clinical Allergy, Medical University Sofia, Sofia, Bulgaria
| | - Ilaria Baiardini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Andras Bikov
- Manchester University NHS Foundation Trust, Manchester, United Kingdom.,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - Herberto Chong-Neto
- Division of Allergy and Immunology, Department of Pediatrics, Federal University of Paraná, Curitiba, Brazil
| | - Jaime Correia- de-Sousa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Alexander Emelyanov
- Department of Respiratory Medicine, North-Western Medical University named after I.I.Mechnikov, St-Petersburg, Russia
| | - Enrico Heffler
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Personalized Medicine, Asthma & Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, MI, Italy
| | - Guillermo Guidos Fogelbach
- Clinic of Clinical Allergy, Medical University Sofia, Sofia, Bulgaria.,Instituto Politécnico Nacional, Escuela Nacional de Medicina y Homeopatía, Laboratorio de Bioquímica Estructural, Ciudad de México, México
| | - Krzysztof Kowal
- Department of Allergology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | | | - Stefan Mihaicuta
- Pulmonology Department, Cardio Prevent Foundation, University of Medicine and Pharmacy "Dr Victor Babes", Timisoara, Romania
| | - Denislava Nedeva
- Clinic of Clinical Allergy, Medical University Sofia, Sofia, Bulgaria
| | - Sylvia Novakova
- Allergy Unit of Internal Consulting Department, University Hospital "St. George", Plovdiv, Bulgaria
| | - Paschalis Steiropoulos
- Department of Respiratory Medicine, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section University of Cincinnati, Cincinnati, OH, USA
| | | | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Personalized Medicine, Asthma & Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, MI, Italy
| | - Lawrence Dubuske
- Division of Allergy and Immunology, Department of Internal Medicine, George Washington University School of Medicine and Health Sciences, George Washington University Medical Faculty Associates, Washington, DC, USA
| | - Carlos Nunes
- Centro de ImmunoAlergologia de Algarve, Porto, Portugal
| | - Juan Carlos Ivancevich
- Immunology Department, Faculty of Medicine, del Salvador University, Buenos Aires, Argentina
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences, University of Milan, Division of Respiratory Diseases "L. Sacco" Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | | | - Tommaso Perazzo
- Department of Internal Medicine, University of Genoa, Genova, Italy
| | - Fulvio Braido
- Department of Internal Medicine, University of Genoa, Genova, Italy.,Respiratory Unit for Continuity of Care IRCCS, Ospedale Policlinico San Martino, Genova, Italy
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Zhu M, Gao X, Zhu Z, Hu X, Zhou H, Liu J. The roles of nasal nitric oxide in diagnosis and endotypes of chronic rhinosinusitis with nasal polyps. J Otolaryngol Head Neck Surg 2020; 49:68. [PMID: 32962755 PMCID: PMC7507626 DOI: 10.1186/s40463-020-00465-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 09/11/2020] [Indexed: 01/17/2023] Open
Abstract
Background Chronic rhinosinusitis with polyps (CRSwNP) is a global health concern. Nasal nitric oxide (nNO), a clinical biomarker, have been studied to assess the presence of airway mucosal inflammation. This study aimed to clarify the roles of nNO in diagnosis and endotypes of CRSwNP. Methods Eighty-two CRSwNP patients and thirty healthy volunteers were recruited for this study. The patients were classified into eosinophilic CRSwNP (Eos CRSwNP) and non⁃eosinophilic CRSwNP (Non-Eos CRSwNP) endotypes by tissue eosinophil percentage. nNO levels were measured with an electrochemical sensor-based device. nNO levels and clinical factors were compared among the groups. Receiver-operating characteristic (ROC) curve and logistic regression analyses were performed to evaluate the predictive ability of the nNO for diagnosis and endotypes of CRSwNP. Results Eos CRSwNP patients(143.9 ± 106.2, ppb) had lower nNO levels than Non-Eos CRSwNP(228.3 ± 109.2, ppb, p = 0.013) and healthy subjects(366.5 ± 88, ppb, p < 0.0001). Patients with atopy exhibited significantly higher levers of nNO compared with patients without atopy (p < 0.05). For Eos CRSwNP diagnosis, nNO had high predictive value for Eos CRSwNP (AUC: 0.939; sensitivity: 76.74%; specificity: 96.67%; cut-off value: 231 ppb, p < 0.001). Furthermore, nNO levels were associated with CRSwNP endotypes (odds ratio: 1.010; 95% confidence interval: 1.003, 1.016%; p = 0.002). When the nNO concentration was 158 ppb, we could discriminate Eos CRSwNP from Non-Eos CRSwNP (AUC = 0.710, sensitivity: 76.92%; specificity, 60.47%, P = 0.001). After it was combinated by nNO, peripheral blood eosinophil count (PEAC) and VAS score, the AUC was increased to 0.894 (95%CI = 0.807 to 0.951, p < 0.0001, sensitivity:76.74%, specificity: 89.74%). Conclusions nNO may have potential for non-invasive diagnosis and endotype of CRSwNP. nNO combined with PEAC and VAS score may be a good diagnostic tool for endotyps of Eos CRSwNP. However, the atopic status of the patients influenced the levels of nNO.
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Affiliation(s)
- Mengdi Zhu
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Soochow University, Shi'zi Road 188, Suzhou, 215006, China
| | - Xuehuan Gao
- Department of Environmental Health, School of Public Health, Fudan University, Shanghai, China
| | - Zhuang Zhu
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xiaoqing Hu
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Soochow University, Shi'zi Road 188, Suzhou, 215006, China
| | - Hui Zhou
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Soochow University, Shi'zi Road 188, Suzhou, 215006, China.
| | - Jisheng Liu
- Department of Otorhinolaryngology Head and Neck Surgery, The First Affiliated Hospital of Soochow University, Shi'zi Road 188, Suzhou, 215006, China.
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Ambrosino P, Parrella P, Formisano R, Papa A, Spedicato GA, Di Minno MND, Motta A, Maniscalco M. Clinical application of nasal nitric oxide measurement in allergic rhinitis: A systematic review and meta-analysis. Ann Allergy Asthma Immunol 2020; 125:447-459.e5. [PMID: 32663599 DOI: 10.1016/j.anai.2020.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 06/19/2020] [Accepted: 07/06/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Nasal nitric oxide (nNO) is considered a biomarker of nasal inflammation. OBJECTIVE To perform a systematic review with meta-analysis and meta-regressions on the association between nNO levels and allergic rhinitis (AR). METHODS PubMed, Web of Science, Scopus, and EMBASE databases were systematically searched. Differences between cases and controls were expressed as standardized mean differences (SMD) with 95% confidence intervals (CI). RESULTS Overall, 39 articles were included: 30 containing data on nNO measured by nasal aspiration (1881 patients with AR and 1337 controls) and 12 assessing nNO by nasal exhalation (525 patients with AR and 350 controls). Compared with controls, AR presented significantly higher nNO values both during nasal aspiration (SMD, 1.309; 95% CI, 0.841-1.777; P < .001) and nasal exhalation (SMD, 0.708; 95% CI, 0.303-1.114; P = .001). Sensitivity and subgroup analyses confirmed that the results for the evaluated outcomes were not affected by the presence of clinical confounding factors (asthma, nasal polyps, inhaled corticosteroids, smoking history), this being valid for both perennial and seasonal diseases during exposure to allergens. For the aspiration method, meta-regressions indicated that older age and a better pulmonary function were associated with a lower difference in nNO levels between patients with AR and controls, whereas an increasing aspiration flow was associated with a high effect size. CONCLUSION nNO levels are higher in AR, particularly when using high aspiration flows and in younger patients, who often perceive this condition as a source of disability. Further studies are needed to evaluate the usefulness of this biomarker for monitoring airway disorders and optimizing strategies in different settings (community, hospital, rehabilitation).
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Affiliation(s)
| | - Paolo Parrella
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | | | - Antimo Papa
- Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
| | | | | | - Andrea Motta
- Institute of Biomolecular Chemistry, National Research Council, Pozzuoli, Naples, Italy
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