1
|
Murugesan N, Saxena D, Dileep A, Adrish M, Hanania NA. Update on the Role of FeNO in Asthma Management. Diagnostics (Basel) 2023; 13:diagnostics13081428. [PMID: 37189529 DOI: 10.3390/diagnostics13081428] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
Asthma is a heterogenous disorder characterized by presence of different phenotypes and endotypes. Up to 10% of the individuals suffer from severe asthma and are at increased risk of morbidity and mortality. Fractional exhaled nitric oxide (FeNO) is a cost-effective, point of care biomarker that is used to detect type 2 airway inflammation. Guidelines have proposed to measure FeNO as an adjunct to diagnostic evaluation in individuals with suspected asthma and to monitor airway inflammation. FeNO has lower sensitivity, suggesting that it may not be a good biomarker to rule out asthma. FeNO may also be used to predict response to inhaled corticosteroids, predict adherence and deciding on biologic therapy. Higher levels of FeNO have been associated with lower lung function and increased risk for future asthma exacerbations and its predictive value increases when combined with other standard measurements of asthma assessment.
Collapse
Affiliation(s)
- Neveda Murugesan
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Damini Saxena
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Arundhati Dileep
- Division of Pulmonary & Critical Care Medicine, Bronx Care Health System, Bronx, NY 10457, USA
| | - Muhammad Adrish
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Nicola A Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| |
Collapse
|
2
|
Benedict JJ, Lelegren M, Han JK, Lam K. Nasal Nitric Oxide as a Biomarker in the Diagnosis and Treatment of Sinonasal Inflammatory Diseases: A Review of the Literature. Ann Otol Rhinol Laryngol 2023; 132:460-469. [PMID: 35549446 DOI: 10.1177/00034894221093890] [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: 11/17/2022]
Abstract
OBJECTIVE To critically review the literature on nasal nitric oxide (nNO) and its current clinical and research applicability in the diagnosis and treatment of different sinonasal inflammatory diseases, including acute bacterial rhinosinusitis (ABRS), allergic rhinitis (AR), and chronic rhinosinusitis (CRS). METHODS A search of the PubMed database was conducted to include articles on nNO and sinonasal diseases from January 2003 to January 2020. All article titles and abstracts were reviewed to assess their relevance to nNO and ABRS, AR, or CRS. After selection of the manuscripts, full-text reviews were performed to synthesize current understandings of nNO and its applications to the various sinonasal inflammatory diseases. RESULTS A total of 79 relevant studies from an initial 559 articles were identified using our focused search and review criteria. nNO has been consistently shown to be decreased in ABRS and CRS, especially in cases with nasal polyps. While AR is associated with elevations in nNO, nNO levels have also been found to be lower in AR cases with higher symptom severity. The obstruction of the paranasal sinuses is speculated to be an important variable in the relationship between nNO and the sinonasal diseases. Treatment of these diseases appears to affect nNO through the reduction of inflammatory disease burden and also mitigation of sinus obstruction. CONCLUSION nNO has been of increasing interest to researchers and clinicians over the last decade. The most compelling data for nNO as a clinical tool involve CRS. nNO can be used as a marker of ostiomeatal complex patency. Variations in measurement techniques and technology continue to impede standardized interpretation and implementation of nNO as a biomarker for sinonasal inflammatory diseases.
Collapse
Affiliation(s)
- Jacob J Benedict
- Department of Otolaryngology - Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Matthew Lelegren
- Department of Otolaryngology - Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Joseph K Han
- Department of Otolaryngology - Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Kent Lam
- Department of Otolaryngology - Head and Neck Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| |
Collapse
|
3
|
Paoletti G, Melone G, Guida G, Pirola F, Malvezzi L, Pelaia C, Mariani A, Racca F, Malipiero G, Ferri S, Puggioni F, Spriano G, Canonica GW, Heffler E. Extended nitric oxide analysis in patients with chronic rhinosinusitis with nasal polyps, with or without associated asthma. J Breath Res 2020; 15:016007. [PMID: 33065563 DOI: 10.1088/1752-7163/abc234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex inflammatory disease highly impacting patient's quality of life, and associated with lower airway inflammation often evolving into asthma. Exhaled nitric oxide (FENO) is a non-invasive tool to assess Type 2 airway inflammation and its extended analysis allows to differentiate between alveolar concentration (CalvNO) and bronchial output (JawNO). It is also possible to assess the sino-nasal production of nitric oxide (nNO). We studied extended nitric oxide production in patients with CRSwNP with or without associated asthma. Consecutive adult patients with CRSwNP, with or without asthma, and 15 healthy controls were enrolled. Exclusion criteria were: smoking, uncontrolled asthma, recent upper or lower airway infections and oral corticosteroid therapy in the 4 weeks preceding clinical evaluation. Patients' demographic and clinical data were collected; patients underwent pulmonary function tests and extended nitric oxide analysis including nasal nNO assessment. A total of 125 subjects were enrolled (15 healthy controls; 69 with CRSwNP and asthma, and 41 with CRSwNP only). FENO, JawNO and CalvNO values were higher, while nNO was lower, in all patients with CRSwNP compared to healthy controls; no difference was found in CalvNO between patients with concomitant asthma and non-asthmatic subjects; in asthmatic patients, FENO and JawNO were significantly higher, while nNO values was lower, compared to patients with CRSwNP only. These results suggest that CRSwNP could be the first manifestation of a more complex systemic inflammatory pathology driven by Type 2 inflammation. An 'inflammatory gradient' hypothesis could describe a pattern of inflammation in CRSwNP patients that starts distally in the alveoli. Finally, our study indirectly reinforces the concept that novel biological drugs could become valid therapeutic options for nasal polyposis.
Collapse
Affiliation(s)
- Giovanni Paoletti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy. Personalized Medicine, Asthma and Allergy - Humanitas Clinical and Research Center IRCCS, Rozzano, MI Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
4
|
Krantz C, Janson C, Alving K, Malinovschi A. Nasal nitric oxide in relation to asthma characteristics in a longitudinal asthma cohort study. Nitric Oxide 2020; 106:1-8. [PMID: 33045328 DOI: 10.1016/j.niox.2020.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 06/27/2020] [Accepted: 09/22/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Cross-sectional studies report relations between low nasal nitric oxide (nNO) and poor asthma control and between low nNO and chronic rhinosinusitis (CRS). In our cohort study, we studied if changes in nNO related to changes in asthma control, symptoms of CRS, or asthma or rhinitis medication. METHODS A total of 196 subjects with predominantly mild to moderate asthma, aged 10-35 years, performed nNO measurements at both baseline and follow-up after a median of 43 (range 23-65) months. Asthma control, CRS symptoms, and medication, were questionnaire-assessed at both timepoints. IgE sensitisation against aeroallergens was quantified at baseline. RESULTS There was an increase in nNO between baseline and follow-up (764 ± 269 ppb vs. 855 ± 288 ppb, p < 0.001). When adjusted for covariates, a larger increase in nNO was found in subjects sensitised to perennial aeroallergens than those not sensitised (92 (16-167) ppb), as well as in subjects with daily use of inhaled corticosteroids (ICS) at baseline but not at follow-up than those on ICS daily at both timepoints (146 (51-242) ppb). In the same model, subjects using nasal steroids daily at both timepoints had decreased nNO compared with those without such treatment at both timepoints (-185 (-321-(-48)) ppb). No relations between changes in nNO levels and changes in asthma control or symptoms of CRS were found. CONCLUSION Longitudinal changes in nNO were not related to changes in asthma control, but were related to changes in asthma or rhinitis medication.
Collapse
Affiliation(s)
- Christina Krantz
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| | - Christer Janson
- Department of Medical Sciences, Respiratory Medicine and Allergology, Uppsala University, Uppsala, Sweden.
| | - Kjell Alving
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden.
| |
Collapse
|
5
|
Heffler E, Saccheri F, Bartezaghi M, Canonica GW. Effectiveness of omalizumab in patients with severe allergic asthma with and without chronic rhinosinusitis with nasal polyps: a PROXIMA study post hoc analysis. Clin Transl Allergy 2020; 10:25. [PMID: 32607141 PMCID: PMC7318524 DOI: 10.1186/s13601-020-00330-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 06/11/2020] [Indexed: 12/17/2022] Open
Abstract
Background A significant proportion of patients with severe asthma may also suffer from nasal polyposis, which is commonly defined as chronic rhinosinusitis with nasal polyps (CRSwNP), the presence of which may adversely affect asthma treatment outcomes. The biologic agent omalizumab is effective as add-on therapy in patients with severe allergic asthma. The aim of this post hoc analysis of the PROXIMA study was to compare the efficacy of omalizumab between patients with severe allergic asthma, with and without comorbid CRSwNP. Methods PROXIMA was a prospective observational 2-part study conducted in Italy in adult patients with severe allergic asthma, where, in the second part, patients eligible for add-on omalizumab initiated treatment for 12 months. Patient baseline data such as comorbidities and history of exacerbations were collected. Outcomes were asthma control (Asthma Control Questionnaire [ACQ]), lung function (forced expiratory volume in 1 s [FEV1]) and exacerbation rate. The post hoc analysis compared these outcomes between the cohort with comorbid CRSwNP and the cohort without CRSwNP. Results Of 123 patients included in this analysis, 17 (13.8%) were in the CRSwNP cohort. There was no significant difference between cohorts in baseline clinical characteristics or in change from baseline at 12 months in ACQ values, % of predicted FEV1 or annual asthma exacerbation rate, although results were numerically in favor of the CRSwNP cohort versus the non-CRSwNP cohort. The proportion of patients who achieved an improvement in all three outcomes was numerically greater in the CRSwNP cohort (35.7% vs 23.0%). Conclusions In an observational real-world setting, add-on omalizumab for severe allergic asthma was effective in improving asthma control, lung function and in reducing exacerbations, including in those patients with CRSwNP.
Collapse
Affiliation(s)
- Enrico Heffler
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, 20089 Rozzano, MI Italy.,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Mi Italy
| | - Fabiana Saccheri
- Medical & Scientific Department, Novartis Farma SpA, Origgio, Italy
| | - Marta Bartezaghi
- Medical & Scientific Department, Novartis Farma SpA, Origgio, Italy
| | - Giorgio Walter Canonica
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Via Alessandro Manzoni 56, 20089 Rozzano, MI Italy.,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele, Mi Italy
| |
Collapse
|
6
|
Galiniak S, Biesiadecki M, Aebisher D, Rachel M. Nasal nitric oxide in upper airways in children with asthma and allergic rhinitis. Adv Med Sci 2020; 65:127-133. [PMID: 31927424 DOI: 10.1016/j.advms.2019.11.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 07/09/2019] [Accepted: 11/18/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE The aim of this study is to compare levels of nasal nitric oxide (nNO) in pediatric patients with respiratory diseases. MATERIALS AND METHODS nNO was measured by an electrochemical analyzer in 179 patients aged 7-15 with asthma, allergic rhinitis or with asthma and allergic rhinitis and in healthy children recruited from a local allergology clinic. Correlations between nNO levels and patient clinical parameters were assessed. RESULTS nNO was significantly higher in patients with allergic rhinitis (2316.3 ± 442.33 ppb, p < 0.001) as well as with asthma and allergic rhinitis (2399.9 ± 446.73 ppb, p < 0.001) compared to asthmatic and healthy children (1066.4 ± 416.75; 836.2 ± 333.47 ppb, respectively). A receiver operating characteristic curve analysis revealed that a cut-off value of 1545 ppb nNO and 1459 ppb nNO has sensitivity of 100% and specificity of 100% in distinguishing allergic rhinitis and combined asthma and allergic rhinitis from healthy subjects. A positive correlation between nNO and age and height was determined only in groups of healthy controls. We found no association between nNO level and clinical parameters including percent of eosinophils and total IgE. CONCLUSION Levels of nNO are currently measured by different analyzers and with different methods, so assessment of nNO is in need of standardization improvement to become a more reliable tool. However, because it is cheap, painless and fast, it may be helpful in combination with recognition of clinical symptoms and typical diagnostic methods, especially in estimation of inflammation.
Collapse
Affiliation(s)
| | | | - David Aebisher
- Faculty of Medicine, Rzeszów University, Rzeszów, Poland
| | - Marta Rachel
- Faculty of Medicine, Rzeszów University, Rzeszów, Poland; Allergology Outpatient Department, Provincial Hospital No 2, Rzeszow, Poland
| |
Collapse
|
7
|
Heffler E, Carpagnano GE, Favero E, Guida G, Maniscalco M, Motta A, Paoletti G, Rolla G, Baraldi E, Pezzella V, Piacentini G, Nardini S. Fractional Exhaled Nitric Oxide (FENO) in the management of asthma: a position paper of the Italian Respiratory Society (SIP/IRS) and Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC). Multidiscip Respir Med 2020; 15:36. [PMID: 32269772 PMCID: PMC7137762 DOI: 10.4081/mrm.2020.36] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/05/2020] [Indexed: 02/08/2023] Open
Abstract
Asthma prevalence in Italy is on the rise and is estimated to be over 6% of the general population. The diagnosis of asthma can be challenging and elusive, especially in children and the last two decades has brought evidences that asthma is not a single disease but consists of various phenotypes. Symptoms can be underestimated by the patient or underreported to the clinician and physical signs can be scanty. Usual objective measures, like spirometry, are necessary but sometimes not significant. Despite proper treatment, asthma can be a very severe condition (even leading to death), however new drugs have recently become available which can be very effective in its control. Since asthma is currently thought to be caused by inflammation, a direct measure of the latter can be of paramount importance. For this purpose, the measurement of Fractional Exhaled Nitric Oxide (FENO) has been used since the early years of the current century as a non-invasive, easy-to-assess tool useful for diagnosing and managing asthma. This SIP-IRS/SIAAIC Position Paper is a narrative review which summarizes the evidence behind the usefulness of FENO in the diagnosis, management and phenotypization of asthma.
Collapse
Affiliation(s)
- Enrico Heffler
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano (MI).,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI)
| | - Giovanna Elisiana Carpagnano
- Department of Medical and Surgical Sciences, University of Foggia; Section of Respiratory Diseases, Hospital d'Avanzo, Foggia
| | - Elisabetta Favero
- Department of Medicine-DIMED, Immunological and Respiratory Rare Disease, Allergologic Clinic Ca' Foncello Hospital, Treviso
| | - Giuseppe Guida
- Allergy and Pneumology Unit, A.O. S. Croce e Carle, Cuneo
| | - Mauro Maniscalco
- Respiratory Rehabilitation Unit, ICS Maugeri, Institute of Telese Terme IRCCS
| | - Andrea Motta
- Institute of Biomolecular Chemistry, National Research Council, Pozzuoli (NA)
| | - Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano (MI).,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI)
| | - Giovanni Rolla
- Allergy and Clinical Immunology, University of Turin and A.O. Mauriziano, Turin
| | - Eugenio Baraldi
- Department of Woman's and Child's Health, University Hospital of Padua
| | - Vincenza Pezzella
- Department of Woman, Child and of General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples
| | - Giorgio Piacentini
- Paediatric Section, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona
| | - Stefano Nardini
- Italian Respiratory Society-Società Italiana di Pneumologia, Milan, Italy
| |
Collapse
|
8
|
Nasal Nitric Oxide in Chronic Rhinosinusitis with or without Nasal Polyps: A Systematic Review with Meta-Analysis. J Clin Med 2020; 9:jcm9010200. [PMID: 31940834 PMCID: PMC7020063 DOI: 10.3390/jcm9010200] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/07/2020] [Accepted: 01/08/2020] [Indexed: 12/13/2022] Open
Abstract
Background and Aims: There has been a recent growing interest in the role of nasal nitric oxide (nNO) as a biomarker for osteomeatal complex obstruction in paranasal sinus diseases. By using meta-analysis, we systematically reviewed the literature to establish the possible link between nNO concentration and chronic rhinosinusitis with nasal polyps (CRSwNP) or without (CRSsNP). Methods: We systematically searched the EMBASE, PubMed, Scopus, and Web of Science databases for related studies. Differences between controls and cases were reported as standardized mean difference (SMD), with 95% confidence intervals (95% CI), using the random-effects method. Results: We selected 23 articles for the final analysis: 15 with data on 461 CRSwNP patients and 384 healthy controls, 10 with data on 183 CRSsNP patients and 260 controls, and 14 studies on 372 CRSwNP and 297 CRSsNP patients. CRSwNP patients showed significantly lower nNO values when compared to both healthy controls (SMD: −1.495; 95% CI: −2.135, −0.854; p < 0.0001) and CRSsNP patients (SMD: −1.448; 95% CI: −2.046, −0.850; p < 0.0001). Sensitivity and subgroup analyses confirmed the results, which were further refined by regression models. They showed that an increasing aspiration flow is related to a greater difference in nNO levels between cases and control subjects. We also documented lower nNO levels in CRSsNP patients with respect to controls (SMD: −0.696; 95% CI: −1.189, −0.202; p = 0.006), being this result no longer significant when excluding patients in therapy with intranasal corticosteroids. As shown by regression models, the increased Lund–Mackay score indicates a high effect size. Conclusions: nNO levels are significantly lower in CRSwNP, especially when using higher aspiration flows. Additional studies are needed to define one single standardized method and normal reference values for nNO.
Collapse
|
9
|
Marone G, Granata F, Pucino V, Pecoraro A, Heffler E, Loffredo S, Scadding GW, Varricchi G. The Intriguing Role of Interleukin 13 in the Pathophysiology of Asthma. Front Pharmacol 2019; 10:1387. [PMID: 31866859 PMCID: PMC6908970 DOI: 10.3389/fphar.2019.01387] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/31/2019] [Indexed: 12/22/2022] Open
Abstract
Approximately 5–10% of asthmatic patients worldwide suffer from severe asthma. Experimental and clinical studies have demonstrated that IL-13 is an important cytokine in chronic airways inflammation. IL-13 is involved in Th2 inflammation and has been identified as a possible therapeutic target in the treatment of asthma. Two different human monoclonal antibodies (mAbs) anti-IL-13 (tralokinumab and lebrikizumab) block binding and signaling of IL-13 to its receptors, IL-13Rα1 and IL-13Rα2. Several randomized, double-blind, placebo-controlled multicenter studies have evaluated the safety and efficacy of tralokinumab and lebrikizumab in the treatment of adult patients with severe asthma, but all have failed to meet their primary endpoints. No serious adverse events related to the treatment with these anti-IL-13 mAbs have been reported in these studies. These negative clinical results contrast with positive findings from blocking IL-13 signaling in experimental models of asthma, raising doubts about the transferrable value of some models. Interestingly, dupilumab, a mAb which blocks both IL-4 and IL-13 signaling reduces exacerbation rates and improves lung function in severe asthmatics. These results suggest that IL-4 and IL-13 share some, but not all functional activities in airway inflammation. Tralokinumab might show efficacy in a highly selected cohort of asthmatics characterized by overexpression of IL-13.
Collapse
Affiliation(s)
- Giancarlo Marone
- Department of Public Health, University of Naples Federico II, Naples, Italy.,Azienda Ospedaliera Ospedali dei Colli, Monaldi Hospital Pharmacy, Naples, Italy
| | - Francescopaolo Granata
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, University of Naples Federico II, Naples, Italy
| | - Valentina Pucino
- College of Medical and Dental Sciences, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Antonio Pecoraro
- Immunodeficiency Centre for Wales, University Hospital of Wales, Cardiff, United Kingdom
| | - Enrico Heffler
- Personalized Medicine, Asthma, and Allergy, Humanitas Clinical and Research Center, IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Stefania Loffredo
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, University of Naples Federico II, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
| | - Guy W Scadding
- Allergy and Clinical Immunology, Imperial College, National Heart and Lung Institute, London, United Kingdom
| | - Gilda Varricchi
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy.,WAO Center of Excellence, University of Naples Federico II, Naples, Italy.,Institute of Experimental Endocrinology and Oncology "G. Salvatore" (IEOS), National Research Council (CNR), Naples, Italy
| |
Collapse
|
10
|
Wen YS, Lin CY, Yang KD, Hung CH, Chang YJ, Tsai YG. Nasal nitric oxide is a useful biomarker for acute unilateral maxillary sinusitis in pediatric allergic rhinitis: A prospective observational cohort study. World Allergy Organ J 2019; 12:100027. [PMID: 31193296 PMCID: PMC6526296 DOI: 10.1016/j.waojou.2019.100027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Revised: 03/08/2019] [Accepted: 03/15/2019] [Indexed: 12/19/2022] Open
Abstract
Background Nasal nitric oxide (nNO) could be a biomarker for nasal passage inflammation and sinus ostial patency. We have aimed to investigate the nNO concentration and the effect of antibiotic therapy in children with perennial allergic rhinitis (PAR) children with/without acute bacterial sinusitis. Methods We enrolled a cohort of 90 and 31 children with PAR, without and with acute unilateral maxillary sinusitis, and 79 normal children. Acute bacterial maxillary sinusitis was diagnosed based on clinical signs and symptoms, radiographic examination and nasal fibroendoscopy. Rhinitis control assessment test (RCAT), rhinomanometry, nNO and fractional exhaled NO (FENO) measurements were performed before and 2 weeks after antibiotic therapy. Results We found significantly higher mean nNO levels, FENO values, and total nasal resistance in children with PAR than in normal children (p < 0.05). Acute unilateral maxillary sinusitis was associated with lower lesion-side nNO levels, higher FENO values, total nasal resistance, and poor RCAT scores (p < 0.05). In multivariate analysis, age, IgE, and acute maxillary sinusitis were significant factors influencing nNO levels in children with PAR. The lesion-side nNO levels, FENO values, total nasal resistance, and RCAT scores were reversed after antibiotic therapy (p < 0.05). The lesion-side nNO levels were significantly correlated to nasal obstructive scores (r = 0.59, p < 0.05) and expiratory nasal resistance (r = -0.54, p < 0.05) in the acute maxillary sinusitis. A cut-off nNO value of 538 ppb showed 100% sensitivity and 94.9% specificity, to predict PAR from normal children. An nNO value of 462 ppb showed 100% sensitivity and 100% specificity to discriminate between the lesion-side and the unaffected sinus-side in PAR children with acute unilateral maxillary sinusitis. Conclusions We conclude that the obstruction of NO from the sinus into the nasal passage is the likely explanation for the decreased lesion-side nNO levels in acute unilateral maxillary sinusitis. nNO is a non-invasive biomarker with high sensitivity to diagnose and monitor treatment responses of PAR patients with acute rhinosinusitis. Both nNO and FENO levels return to baseline following antibiotic therapy, supporting the "one airway one disease" concept.
Collapse
Affiliation(s)
- Yung-Sung Wen
- Department of Otorhinolaryngology, Head and Neck Surgery, Changhua Christian Hospital, Changhua, Taiwan.,Department of Otorhinolaryngology, Head and Neck Surgery, Yunlin Christian Hospital, Xiluo, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Ching-Yuang Lin
- Clinical Immunological Center and College of Medicine, China Medical University Hospital, Taiwan
| | - Kuender D Yang
- Departments of Pediatrics, Mackay Memorial Hospital, and Institute of Biomedical Sciences, Mackay Medical College, Taipei, Taiwan
| | | | - Yu-Jun Chang
- Epidemiology and Biostatistics Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Yi-Giien Tsai
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan.,School of Medicine, Kaohsiung Medical University, Taiwan.,Department of Pediatrics, Changhua Christian Children Hospital, Changhua, Taiwan
| |
Collapse
|
11
|
Abstract
PURPOSE OF REVIEW In this review, we herein describe the progress in management of severe asthma, evolving from a 'blockbuster approach' to a more personalized approach targeted to the utilization of endotype-driven therapies. RECENT FINDINGS Severe asthma characterization in phenotypes and endotypes, by means of specific biomarkers, have led to the dichotomization of the concepts of 'personalized medicine' and 'precision medicine', which are often used as synonyms, but actually have conceptual differences in meaning. The recent contribute of the omic sciences (i.e. proteomics, transcriptomics, metabolomics, genomics, …) has brought this initially theoretic evolution into a more concrete level. SUMMARY This step-by-step transition would bring to a better approach to severe asthmatic patients as the personalization of their therapeutic strategy would bring to a better patient selection, a more precise endotype-driven treatment, and hopefully to better results in terms of reduction of exacerbation rates, symptoms, pulmonary function and quality of life.
Collapse
|
12
|
Asano T, Takemura M, Kanemitsu Y, Yokota M, Fukumitsu K, Takeda N, Ichikawa H, Hijikata H, Uemura T, Takakuwa O, Ohkubo H, Maeno K, Ito Y, Oguri T, Nakamura A, Maki Y, Nakamura Y, Suzuki M, Niimi A. Combined measurements of fractional exhaled nitric oxide and nasal nitric oxide levels for assessing upper airway diseases in asthmatic patients. J Asthma 2017; 55:300-309. [PMID: 28513250 DOI: 10.1080/02770903.2017.1332203] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Despite the close linkage between rhinitis, chronic rhinosinusitis (CRS) and asthma, relevant biomarkers of both upper and lower airway inflammation are rare. METHODS Patients with asthma (without upper airway disease [UAD; n = 24], with rhinitis [n = 25], CRS [n = 24], and nasal polyps [n = 2]), isolated rhinitis (n = 13), isolated CRS (n = 13), and 10 healthy controls were prospectively recruited. Fractional exhaled nitric oxide (NO) levels at 50 mL/s (FeNO50), nasal NO levels, Lund-Macay-scores of sinus computed tomography and an asthma control questionnaire (ACQ) were evaluated. RESULTS Asthma was associated with higher FeNO50 levels irrespective of the UAD category. FeNO50 levels were higher in asthmatics with CRS (median: 54.0 ppb) than those with rhinitis (35.2 ppb, p = 0.02) and those without UAD (34.3 ppb, p = 0.002). Nasal NO levels were higher in rhinitis patients than other UAD categories, irrespective of the asthma concomitance. Nasal NO levels were higher in asthmatics with rhinitis (112.8 ppb) than those without UAD (67.2 ppb, p = 0.001) and those with CRS (57.6 ppb, p < 0.0001). A receiver-operating-characteristic curve analysis for detecting comorbid allergic rhinitis (AR) in asthmatics showed a high area under the curve (0.87). Nasal NO levels were positively correlated with FeNO50 levels (ρ = 0.56, p = 0.003) in asthmatics with rhinitis. In contrast, they were negatively correlated with the Lund-Macay (ρ = -0.46, p = 0.03) and ACQ scores (ρ = -0.52, p = 0.009) in asthmatics with CRS. CONCLUSIONS Higher nasal NO levels reflect the presence of AR, irrespective of asthma concomitance. Higher FeNO50 levels reflect the presence of CRS and asthma. These NO measurements are useful for assessing comorbid UAD in asthmatics.
Collapse
Affiliation(s)
- Takamitsu Asano
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Masaya Takemura
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Yoshihiro Kanemitsu
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Makoto Yokota
- b Department of Otorhinolaryngology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Kensuke Fukumitsu
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Norihisa Takeda
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Hiroya Ichikawa
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Hisatoshi Hijikata
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Takehiro Uemura
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Osamu Takakuwa
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Hirotsugu Ohkubo
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Ken Maeno
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Yutaka Ito
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Tetsuya Oguri
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Atsushi Nakamura
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Yumi Maki
- c Department of Radiology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Yoshihisa Nakamura
- b Department of Otorhinolaryngology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Motohiko Suzuki
- b Department of Otorhinolaryngology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| | - Akio Niimi
- a Department of Respiratory Medicine, Allergy and Clinical Immunology , Nagoya City University Graduate School of Medical Sciences , Nagoya-City , Japan
| |
Collapse
|
13
|
Abstract
BACKGROUND Ciliopathies refer to a wide variety of diseases in which mutations in the genes encoding proteins involved in ciliogenesis or protein transport to the primary cilia play pathogenetic roles, and in such diseases, retinal involvement may be present. Nitric oxide (NO) plays an important role in airway physiology, including regulation of ciliary motility and host defense. In primary ciliary dyskinesia, a syndromic ciliopathy, nasal NO (nNO) levels were reported to be extremely low compared with controls, possibly reflecting molecular defects leading to structural and functional ciliary abnormalities. We investigated whether decreased nitric levels were also present in patients with retinal inherited dystrophies. METHODS Nasal NO was measured in a group of patients with syndromic and nonsyndromic inherited retinal dystrophies. RESULTS Patients with inherited retinal dystrophies, both syndromic and nonsyndromic, had mean nNO levels that were lower than healthy controls. Seven patients had particularly low levels of nNO: 3 patients with retinitis pigmentosa and 4 individual patients with Mainzer-Saldino syndrome, Bardet-Biedl syndrome, Usher syndrome, and cone-rod disease. CONCLUSIONS These findings provide evidence that there is an underlying abnormal ciliary function involving the nasal epithelium in some patients with inherited retinal dystrophies.
Collapse
|
14
|
Heffler E, Crimi N. Asthma control and bronchodilator response. Respir Med 2016; 116:109. [PMID: 27211114 DOI: 10.1016/j.rmed.2016.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 05/09/2016] [Accepted: 05/14/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Enrico Heffler
- Respiratory Diseases and Allergology, Dept. Clinical and Experimental Medicine, University of Catania, Italy.
| | - Nunzio Crimi
- Respiratory Diseases and Allergology, Dept. Clinical and Experimental Medicine, University of Catania, Italy
| |
Collapse
|
15
|
Ricciardolo F, Sorbello V, Bellezza Fontana R, Schiavetti I, Ciprandi G. Exhaled nitric oxide in relation to asthma control: A real-life survey. Allergol Immunopathol (Madr) 2016; 44:197-205. [PMID: 26589339 DOI: 10.1016/j.aller.2015.05.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 05/16/2015] [Accepted: 05/26/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Asthma is characterised by chronic airway inflammation, a complex cascade of events, mostly sustained by eosinophil recruitment and activation. Fractional exhaled nitric oxide (FeNO) is a surrogate marker of airway inflammation closely associated with bronchial eosinophilia. FeNO is used to define asthma phenotype, to assess eosinophilic inflammatory severity and to predict corticosteroid responsiveness. OBJECTIVE The aim of this study was to investigate whether FeNO may be associated with some clinical and functional factors in asthmatics evaluated in a real life setting. METHODS Globally 363 patients (150 males, mean age 46.3 years) with asthma were consecutively evaluated. The following parameters were assessed: history, including comorbidities, physical examination, body mass index (BMI), lung function, asthma control grade, asthma control test (ACT), and FeNO. RESULTS FeNO values were significantly higher in patients with poorly controlled asthma (p<0.01), asthma symptoms (p=0.015), wheezing (p<0.001), rhinitis diagnosis, (p=0.049) and rhinitis symptoms (p=0.019), but lower in patients with GERD (p=0.024) and pneumonia history (p=0.048). FeNO values increased in patients with the lowest corticosteroid dose (p=0.031). FeNO values>25ppb were associated with poorly controlled asthma (OR 3.71), asthma signs (OR 3.5) and symptoms (OR 1.79). A FeNO value cut-off of 29.9ppb was fairly predictive of (AUC 0.7) poorly controlled asthma. CONCLUSIONS FeNO assessment in clinical practice may be a useful tool for monitoring asthmatics as it is associated with several clinical factors, including asthma control.
Collapse
|
16
|
Malinovschi A, Ludviksdottir D, Tufvesson E, Rolla G, Bjermer L, Alving K, Diamant Z. Application of nitric oxide measurements in clinical conditions beyond asthma. Eur Clin Respir J 2015; 2:28517. [PMID: 26672962 PMCID: PMC4653314 DOI: 10.3402/ecrj.v2.28517] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 07/05/2015] [Indexed: 02/01/2023] Open
Abstract
Fractional exhaled nitric oxide (FeNO) is a convenient, non-invasive method for the assessment of active, mainly Th2-driven, airway inflammation, which is sensitive to treatment with standard anti-inflammatory therapy. Consequently, FeNO serves as a valued tool to aid diagnosis and monitoring in several asthma phenotypes. More recently, FeNO has been evaluated in several other respiratory, infectious, and/or immunological conditions. In this short review, we provide an overview of several clinical studies and discuss the status of potential applications of NO measurements in clinical conditions beyond asthma.
Collapse
Affiliation(s)
- Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden;
| | - Dora Ludviksdottir
- Department of Respiratory Medicine and Sleep, Landspitali University Hospital, Reykjavik, Iceland
| | - Ellen Tufvesson
- Department of Respiratory Medicine and Allergology, Institute for Clinical Science, Lund University, Lund, Sweden
| | - Giovanni Rolla
- Department of Medical Sciences, Allergology and Clinical Immunology, University of Torino, Torino, Italy
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Institute for Clinical Science, Lund University, Lund, Sweden
| | - Kjell Alving
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Zuzana Diamant
- Department of Respiratory Medicine and Allergology, Institute for Clinical Science, Lund University, Lund, Sweden.,Department of Clinical Pharmacy & Pharmacology, University Medical Centre Groningen, Groningen, The Netherlands.,Department of General Practice, University Medical Centre Groningen, Groningen, The Netherlands.,QPS Netherlands, Groningen, The Netherlands
| |
Collapse
|
17
|
Durmaz D, Göksu E, Kılıç T, Özbudak Ö, Eray O. The Role of Nitric Oxide In Predicting Revisit of Patients With Exacerbated Chronic Obstructive Pulmonary Disease. J Emerg Med 2015; 48:247-53. [DOI: 10.1016/j.jemermed.2014.06.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 02/24/2014] [Accepted: 06/30/2014] [Indexed: 11/30/2022]
|
18
|
Krantz C, Janson C, Borres MP, Nordvall L, Alving K, Malinovschi A. Nasal nitric oxide is associated with exhaled NO, bronchial responsiveness and poor asthma control. J Breath Res 2014; 8:026002. [PMID: 24674999 DOI: 10.1088/1752-7155/8/2/026002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The fraction of exhaled nitric oxide (FeNO) is an established marker of airway inflammation in asthma. Nasal nitric oxide (nNO) has initially been regarded as a promising marker of inflammation of nasal mucosa. However, due to its dual origins, paranasal sinuses and nasal mucosa, the clinical use of nNO is controversial. There is an inflammatory link between inflammation in the upper and lower airways within the united airways' paradigm, but the study of the clinical value of nNO in asthma has been limited. The objective of this study is to analyse nNO in asthmatics and its relationship to FeNO, bronchial hyperresponsiveness, allergic sensitization and asthma control. A total of 371 children and young adults from an asthma cohort were included in this study, which performed measurements of nNO (through aspiration at 5 mL s(-1)), FeNO, bronchial responsiveness to methacholine, blood eosinophil count (B-Eos) and IgE sensitization. The asthma control test (ACT) and a questionnaire regarding medical treatment, symptoms of asthma, rhinitis and chronic rhinosinusitis were completed by all subjects. An association was found between higher nNO levels and increased bronchial responsiveness (p < 0.001), FeNO (p < 0.001) and B-Eos (p = 0.002). Sensitization to furry animals related to higher levels of nNO (p < 0.001). Subjects with poorly controlled asthma (ACT < 15) had lower levels of nNO than subjects with a higher ACT score (619 ± 278 ppb, versus 807 ± 274 ppb, p = 0.002). Loss of smell showed the strongest association with lower nNO levels among the upper airway symptoms recorded. In patients with asthma, nNO was positively correlated with exhaled NO, bronchial responsiveness and asthma control. This study suggests clinical utility of nNO in subjects with asthma, but in order to get better understanding of the nNO determinants, simultaneous mapping of upper airway comorbidities by clinical examination is appropriate.
Collapse
Affiliation(s)
- C Krantz
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | | | | | | | | | | |
Collapse
|
19
|
Amann A, Mochalski P, Ruzsanyi V, Broza YY, Haick H. Assessment of the exhalation kinetics of volatile cancer biomarkers based on their physicochemical properties. J Breath Res 2014; 8:016003. [PMID: 24566039 DOI: 10.1088/1752-7155/8/1/016003] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The current review provides an assessment of the exhalation kinetics of volatile organic compounds (VOCs) that have been linked with cancer. Towards this end, we evaluate various physicochemical properties, such as 'breath:air' and 'blood:fat' partition coefficients, of 112 VOCs that have been suggested over the past decade as potential markers of cancer. With these data, we show that the cancer VOC concentrations in the blood and in the fat span over 12 and 8 orders of magnitude, respectively, in order to provide a specific counterpart concentration in the exhaled breath (e.g., 1 ppb). This finding suggests that these 112 different compounds have different storage compartments in the body and that their exhalation kinetics depends on one or a combination of the following factors: (i) the VOC concentrations in different parts of the body; (ii) the VOC synthesis and metabolism rates; (iii) the partition coefficients between tissue(s), blood and air; and (iv) the VOCs' diffusion constants. Based on this analysis, we discuss how this knowledge allows modeling and simulating the behavior of a specific VOC under different sampling protocols (with and without exertion of effort). We end this review by a brief discussion on the potential role of these scenarios in screening and therapeutic monitoring of cancer.
Collapse
Affiliation(s)
- Anton Amann
- Breath Research Institute, Leopold-Franzens University of Innsbruck, 6850 Dornbirn, Austria. Department of Anesthesiology and Critical Care Medicine, Innsbruck Medical University, 6020 Innsbruck, Austria
| | | | | | | | | |
Collapse
|