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Pesantes E, Hernando R, Lores C, Cámara J, Arévalo E, Lores L. Utility of exhaled nitric oxide to guide mild asthma treatment in atopic patients and its correlation with asthma control test score: a randomized controlled trial. BMC Pulm Med 2024; 24:421. [PMID: 39210358 PMCID: PMC11360837 DOI: 10.1186/s12890-024-03227-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 08/16/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is used for the diagnosis and monitoring of asthma, although its utility to guide treatment and its correlation with other tools is still under discussion. We study the possibility to withdraw inhaled corticosteroid treatment in atopic patients with mild asthma based on the FeNO level, as well as to study its correlation with other clinical control tools. METHODS Prospective and randomized study including atopic patients aged 18 to 65 with mild asthma, stable, on low-dose inhaled corticosteroid (ICS) treatment, who had their treatment withdrawn based on a FeNO level of 40 ppb. Patients were randomized into two groups: control group (treatment with ICS was withdrawn regardless of FeNO level) and experimental group (according to the FeNO levels, patients were assigned to one of two groups: FeNO > 40 ppb on treatment with budesonide 200 mcg every 12 h and SABA on demand; FeNO ≤ 40 ppb only with SABA on demand). Follow-up was conducted for one year, during which medical assessment was performed with FeNO measurements, asthma control test (ACT), lung function tests (FEV1, FEV1/FVC, PEF, and RV/TLC), and recording of the number of exacerbations. RESULTS Ninety-two patients were included, with a mean age of 39.92 years (SD 13.99); 46 patients were assigned to the control group, and 46 patients to the experimental group. The number of exacerbations was similar between the groups (p = 0.301), while the time to the first exacerbation was significantly shorter in the control group (30.86 vs. 99.00 days), p < 0.001, 95% CI (43.332-92.954). Lung function tests (FEV1, FEV1/FVC, PEF, and RV/TLC) showed no differences between the groups (p > 0.05). Both FeNO and ACT showed significant changes in the groups in which ICS was withdrawn (p < 0.05 for both parameters). A significant negative correlation was observed between FeNO and ACT (r = -0.139, p = 0.008). CONCLUSIONS In atopic patients with mild asthma, withdrawal of ICS based on an FeNO of 40 ppb led to worsened symptoms but without changes in lung function tests or an increase in exacerbations. There was a negative correlation between FeNO values and symptomatic control measured by the ACT. TRIAL REGISTRATION Clinical Trial Number: 2012-000372-42. Start Date: 2012-07-23. Trial registered prospectively ( https://www.clinicaltrialsregister.eu/ctr-search/search?query=2012-000372-42 ). This study adheres to CONSORT guidelines of randomised control trials.
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Affiliation(s)
- Edwin Pesantes
- Parc Sanitari Sant Joan de Dèu, Camí Vell de la colonia, 25, Sant Boi de Llobregat, Barcelona, 08830, Spain.
| | - Rosana Hernando
- Parc Sanitari Sant Joan de Dèu, Camí Vell de la colonia, 25, Sant Boi de Llobregat, Barcelona, 08830, Spain
| | - Carmen Lores
- Bellvitge University Hospital,, Barcelona, Spain
| | - Jonathan Cámara
- Parc Sanitari Sant Joan de Dèu, Camí Vell de la colonia, 25, Sant Boi de Llobregat, Barcelona, 08830, Spain
| | - Elías Arévalo
- San Francisco Xavier de Chuquisaca University, Sucre, Bolivia
| | - Luis Lores
- Parc Sanitari Sant Joan de Dèu, Camí Vell de la colonia, 25, Sant Boi de Llobregat, Barcelona, 08830, Spain
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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.
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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
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Kumar R, Gaur S, Agarwal M, Menon B, Goel N, Mrigpuri P, Spalgais S, Priya A, Kumar K, Meena R, Sankararaman N, Verma A, Gupta V, Sonal, Prakash A, Safwan MA, Behera D, Singh A, Arora N, Prasad R, Padukudru M, Kant S, Janmeja A, Mohan A, Jain V, Nagendra Prasad K, Nagaraju K, Goyal M. Indian Guidelines for diagnosis of respiratory allergy. INDIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY 2023. [DOI: 10.4103/0972-6691.367373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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4
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Exhaled Nitric Oxide Level in Pharynx Angioedema. J Clin Med 2022; 11:jcm11030637. [PMID: 35160089 PMCID: PMC8836686 DOI: 10.3390/jcm11030637] [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: 12/18/2021] [Revised: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 01/27/2023] Open
Abstract
Airway inflammation is related to increased nitric oxide production. It can be assessed noninvasively with exhaled nitric oxide measurement. As airway inflammation was supposed to be present in chronic urticaria and angioedema patients we hypothesized increased exhaled nitric oxide in this group. Twenty-six symptomatic chronic urticaria patients with an acute episode of pharynx angioedema (17 women and 9 men, median age 35) were included in the study group. None of the patients reported a history of asthma, allergic rhinitis or cigarette smoking. The control group consisted of 29 non-smoking healthy subjects (19 women and 10 men, median age 22) without any history of atopy. Exhaled nitric oxide measurement was performed in all subjects. Exhaled nitric oxide levels in the angioedema group did not differ statistically significantly from those detected in healthy subjects (15.5 ppb and 17.0 ppb respectively). Our results indicate the lack of airway inflammation in chronic urticaria patients with pharynx angioedema.
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Krantz C, Accordini S, Alving K, Corsico AG, Demoly P, Ferreira DS, Forsberg B, Garcia-Aymerich J, Gislason T, Heinrich J, Jõgi R, Johannessen A, Leynaert B, Marcon A, Martínez-Moratalla Rovira J, Nerpin E, Nowak D, Olin AC, Olivieri M, Pereira-Vega A, Raherison-Semjen C, Real FG, Sigsgaard T, Squillacioti G, Janson C, Malinovschi A. Cross-sectional study on exhaled nitric oxide in relation to upper airway inflammatory disorders with regard to asthma and perennial sensitization. Clin Exp Allergy 2021; 52:297-311. [PMID: 34536262 DOI: 10.1111/cea.14019] [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: 11/30/2020] [Accepted: 09/15/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) is a well-known marker of type-2 inflammation. FeNO is elevated in asthma and allergic rhinitis, with IgE sensitization as a major determinant. OBJECTIVE We aimed to see whether there was an independent association between upper airway inflammatory disorders (UAID) and FeNO, after adjustment for asthma and sensitization, in a multi-centre population-based study. METHODS A total of 741 subjects with current asthma and 4155 non-asthmatic subjects participating in the second follow-up of the European Community Respiratory Health Survey (ECRHS III) underwent FeNO measurements. Sensitization status was based on measurement of IgE against airborne allergens; information on asthma, UAID and medication was collected through interview-led questionnaires. Independent associations between UAID and FeNO were assessed in adjusted multivariate regression models and test for interaction with perennial sensitization and asthma on the relation between UAID and FeNO were made. RESULTS UAID were associated with higher FeNO after adjusting for perennial sensitization, asthma and other confounders: with 4.4 (0.9-7.9) % higher FeNO in relation to current rhinitis and 4.8 (0.7-9.2) % higher FeNO in relation to rhinoconjunctivitis. A significant interaction with perennial sensitization was found in the relationship between current rhinitis and FeNO (p = .03) and between rhinoconjunctivitis and FeNO (p = .03). After stratification by asthma and perennial sensitization, the association between current rhinitis and FeNO remained in non-asthmatic subjects with perennial sensitization, with 12.1 (0.2-25.5) % higher FeNO in subjects with current rhinitis than in those without. CONCLUSIONS & CLINICAL RELEVANCE Current rhinitis and rhinoconjunctivitis was associated with higher FeNO, with an interaction with perennial sensitization. This further highlights the concept of united airway disease, with correlations between symptoms and inflammation in the upper and lower airways and that sensitization needs to be accounted for in the relation between FeNO and rhinitis.
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Affiliation(s)
- Christina Krantz
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Simone Accordini
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Kjell Alving
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Angelo G Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation, Pavia, Italy.,Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Pascal Demoly
- Département de Pneumologie et Addictologie, Centre Hospitalier Universitaire de Montpellier, Montpellier, France.,Hôpital Arnaud de Villeneuve, IDESP, INSERM-Univ Montpellier, Montpellier, France
| | - Diogenes S Ferreira
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia.,Alergia e Imunologia, Complexo Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Bertil Forsberg
- Department of Public Health and Clinical Medicine, Section of Sustainable Health, Umeå University, Umeå, Sweden
| | - Judith Garcia-Aymerich
- ISGlobal, Barcelona, Spain.,Universitat Pompeu Fabra (UPF), Barcelona, Spain.,CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | - Thorarinn Gislason
- Department of Sleep, Landspitali_the National University Hospital, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Joachim Heinrich
- Institute and Clinic for Occupational, Social and Environmental Medicine, LMU University Clinic, Comprehensive Pneumology Center (CPC), Munich, Germany.,German Center for Lung Research (DZL), Gießen, Germany.,Allergy and Lung Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic., Australia
| | - Rain Jõgi
- Lung Clinic, Tartu University Hospital, Tartu, Estonia
| | - Ane Johannessen
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Bénédicte Leynaert
- Université Paris-Saclay, UVSQ, Univ. Paris-Sud, INSERM, Équipe d'Épidémiologie respiratoire intégrative, CESP, Villejuif, France
| | - Alessandro Marcon
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Jesús Martínez-Moratalla Rovira
- Pneumology Service of the University Hospital of Albacete, Albacete, Spain.,Faculty of Medicine of Albacete, Castilla-La Mancha University, Albacete, Spain
| | - Elisabet Nerpin
- Department of Medical Sciences, Respiratory Medicine, Allergy and Sleep, Uppsala University, Uppsala, Sweden.,Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden.,Department of Medicine, Health and Social Studies, Dalarna University, Falun, Sweden
| | - Dennis Nowak
- Institute and Clinic for Occupational, Social and Environmental Medicine, LMU University Clinic, Comprehensive Pneumology Center (CPC), Munich, Germany.,German Center for Lung Research (DZL), Gießen, Germany
| | - Anna-Carin Olin
- Section of Occupational and Environmental Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Mario Olivieri
- Unit of Occupational Medicine, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | | | - Chantal Raherison-Semjen
- Univ. Bordeaux, INSERM, Bordeaux, France.,Service des Maladies Respiratoires, Pole cardio-thoracique, CHU, Bordeaux, France
| | - Francisco Gómez Real
- Research Unit for Health Surveys (RUHS), Department of Clinical Sciences, University of Bergen, Bergen, Norway.,Department of Gynaecology and Obstetrics, Haukeland University Hospital, Bergen, Norway
| | - Torben Sigsgaard
- Department of Public Health, Danish Ramazzini Center, Aarhus University, Aarhus, Denmark
| | - Guilia Squillacioti
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Christer Janson
- Department of Medical Sciences, Respiratory Medicine, Allergy and Sleep, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
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Flashner BM, Rifas-Shiman SL, Oken E, Camargo CA, Platts-Mills TAE, Workman L, Litonjua AA, Gold DR, Rice MB. Contributions of asthma, rhinitis and IgE to exhaled nitric oxide in adolescents. ERJ Open Res 2021; 7:00945-2020. [PMID: 33898613 PMCID: PMC8053905 DOI: 10.1183/23120541.00945-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 03/04/2021] [Indexed: 12/02/2022] Open
Abstract
Exhaled nitric oxide fraction (FeNO) is an indicator of allergic airway inflammation. However, it is unknown how asthma, allergic rhinitis (AR) and allergic sensitisation relate to FeNO, particularly among adolescents and in overlapping conditions. We sought to determine the associations between asthma, AR, and aeroallergen immunoglobulin (Ig)E and FeNO in adolescents. We measured FeNO among 929 adolescents (aged 11–16 years) in Project Viva, an unselected prebirth cohort in Massachusetts, USA. We defined asthma as ever asthma physician diagnosis plus wheezing in the past year or taking asthma medications in the past month, AR as a physician diagnosis of hay fever or AR, and aeroallergen IgE as any IgE >0.35 IU·mL−1 among 592 participants who provided blood samples. We examined associations of asthma, AR and IgE with percent difference in FeNO in linear regression models adjusted for sex, race/ethnicity, age and height, maternal education and smoking during pregnancy, and household/neighbourhood demographics. Asthma (14%) was associated with 97% higher FeNO (95% CI 70–128%), AR (21%) with 45% higher FeNO (95% CI 28–65%), and aeroallergen IgE (58%) with 102% higher FeNO (95% CI 80–126%) compared to those without each condition, respectively. In the absence of asthma or AR, aeroallergen IgE was associated with 75% higher FeNO (95% CI 52–101), while asthma and AR were not associated with FeNO in the absence of IgE. The link between asthma and AR with FeNO is limited to those with IgE-mediated phenotypes. FeNO may be elevated in those with allergic sensitisation alone, even in the absence of asthma or AR. While asthma, allergic rhinitis (AR) and allergic sensitisation are associated with higher FENO, asthma and AR in the absence of aeroallergen IgE are not associated with FENO. When elevated in asthma or AR, FENO suggests allergic sensitisation.https://bit.ly/3bGgr0r
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Affiliation(s)
- Bess M Flashner
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sheryl L Rifas-Shiman
- Division of Chronic Disease Research Across the Lifecourse, Dept of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Emily Oken
- Division of Chronic Disease Research Across the Lifecourse, Dept of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Carlos A Camargo
- Channing Division of Network Medicine, Dept of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Dept of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Thomas A E Platts-Mills
- Dept of Allergy and Immunology, University of Virginia Health System, Charlottesville, VA, USA
| | - Lisa Workman
- Dept of Allergy and Immunology, University of Virginia Health System, Charlottesville, VA, USA
| | - Augusto A Litonjua
- Pediatric Pulmonary Division, Dept of Pediatrics, Golisano Children's Hospital at Strong, University of Rochester Medical Center, Rochester, NY, USA
| | - Diane R Gold
- Channing Division of Network Medicine, Dept of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Dept of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Mary B Rice
- Division of Pulmonary, Critical Care and Sleep Medicine, Dept of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Liu C, Zheng K, Liu X, Zheng M, Liu Z, Wang X, Zhang L. Use of Nasal Nitric Oxide in the Diagnosis of Allergic Rhinitis and Nonallergic Rhinitis in Patients with and without Sinus Inflammation. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1574-1581.e4. [DOI: 10.1016/j.jaip.2019.12.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 12/07/2019] [Accepted: 12/09/2019] [Indexed: 10/25/2022]
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The Pattern of Sensitization Influences Exhaled and Nasal Nitric Oxide Levels in Young Adults. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020. [PMID: 32193864 DOI: 10.1007/5584_2020_509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
Nitric oxide (NO) from upper (nasal NO, nNO) or lower airways (fractional exhaled NO, FeNO) is considered a surrogate marker for Th2-type inflammation, which is influenced by atopy. The aim of this study was to analyze nNO and FeNO in regard to qualitative and quantitative aspects of sensitization. We evaluated 244 non-smoking young adults. All of them were first-year students recruited for a longitudinal study. An inhalation allergy screening tool was used for atopy definition (specific immunoglobulin E (sIgE) to sx1 ≥ 0.35 kU/L), and also sIgE response to three inhalant perennial allergens, house dust mite (HDM, d1), cat (e1), and dog (e5), was determined in the non-pollen season. With respect to sx1, 100 subjects could be classified as atopic. Sensitization to one, two, or three perennial allergens could be demonstrated in 46, 10, and 16 students, respectively. The subjects with positive IgE response to sx1, but not sensitized to HDM, cat, and/or dog, had FeNO levels comparable to those of non-atopic subjects (13.5 vs. 13.0 ppb, respectively; p = 0.485). These levels were significantly lower compared to atopic subjects being sensitized to any perennial allergen (19.0 ppb; p = 0.0003). After grouping the atopic subjects for perennial sensitization patterns, significantly higher FeNO could be detected in subjects with poly-sensitization (n = 26; 26.0 ppb) compared to the mono-sensitized ones (n = 46; 18.0 ppb; p = 0.023). Regarding nNO, no differences could be observed. Applying a two-way ANOVA, we could reveal a significant correlation of specific HDM-IgE CAP-class with FeNO (p < 0.0001) and nNO levels (p = 0.007). Finally, a significant relationship was found between nNO and FeNO for the whole cohort (p < 0.0001). In summary, our findings support the argument that atopy and perennial sensitization should be considered for the interpretation of NO.
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Kalm-Stephens P, Malinovschi A, Janson C, Venge P, Nordvall L, Alving K. Concurrence of elevated FeNO and airway hyperresponsiveness in nonasthmatic adolescents. Pediatr Pulmonol 2020; 55:571-579. [PMID: 31944632 DOI: 10.1002/ppul.24578] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 10/26/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The aim of this study was to investigate airway responsiveness and eosinophil and neutrophil inflammatory markers in clinically confirmed nonasthmatic adolescents with elevated fractional exhaled nitric oxide (FeNO), a marker of type-2 inflammation in the airways. METHODOLOGY A total of 959 subjects from a general population, aged 12 to 15 years, answered a standardised questionnaire and underwent FeNO measurements at a screening visit at school. Adolescents without asthma, who had elevated FeNO (FeNO100 > 15 ppb) (n = 19), and control subjects, with low FeNO (FeNO100 < 5 ppb) and without reported symptoms of asthma or allergy (n = 28), participated in a follow-up study where FeNO50 , airway responsiveness to methacholine (PD20 ), blood eosinophil counts, and serum neutrophil lipocalin (HNL) and myeloperoxidase (MPO) levels were measured. Questionnaire follow-ups were performed 4 and 16 years later. RESULTS Airway responsiveness (PD20 : 6.94 [1.87, 11.39] vs 11.42 [6.33, 59.4] µmol; P < .05) and blood eosinophil counts (0.31 [0.20, 0.44] vs 0.13 [0.1, 0.22] 109 /L; P < .001) (geometric mean [95% CI]) were higher among cases than controls. A significant correlation between blood eosinophils and FeNO was found (rho = 0.41; P = .005). In contrast, serum HNL and MPO were lower in cases than controls (P < .05 both), and there was a negative correlation between HNL and FeNO (r = -0.31; P = .04). At both follow-ups, a higher proportion of subjects reported allergic symptoms compared with baseline (P = .02, P = .01). CONCLUSIONS Elevated FeNO in nonasthmatic adolescents was associated with airway hyperresponsiveness, elevated blood eosinophil counts, and lower systemic activation of neutrophils.
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Affiliation(s)
- Pia Kalm-Stephens
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Christer Janson
- Department of Medical Sciences: Respiratory, Allergy, and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Per Venge
- Department of Medical Sciences: Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Lennart Nordvall
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Kjell Alving
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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10
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Exposure to Household Air Pollution from Biomass Cookstoves and Levels of Fractional Exhaled Nitric Oxide (FeNO) among Honduran Women. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15112544. [PMID: 30428575 PMCID: PMC6267103 DOI: 10.3390/ijerph15112544] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/26/2018] [Accepted: 11/07/2018] [Indexed: 12/14/2022]
Abstract
Household air pollution is estimated to be responsible for nearly three million premature deaths annually. Measuring fractional exhaled nitric oxide (FeNO) may improve the limited understanding of the association of household air pollution and airway inflammation. We evaluated the cross-sectional association of FeNO with exposure to household air pollution (24-h average kitchen and personal fine particulate matter and black carbon; stove type) among 139 women in rural Honduras using traditional stoves or cleaner-burning Justa stoves. We additionally evaluated interaction by age. Results were generally consistent with a null association; we did not observe a consistent pattern for interaction by age. Evidence from ambient and household air pollution regarding FeNO is inconsistent, and may be attributable to differing study populations, exposures, and FeNO measurement procedures (e.g., the flow rate used to measure FeNO).
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11
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Hoyte FCL, Gross LM, Katial RK. Exhaled Nitric Oxide: An Update. Immunol Allergy Clin North Am 2018; 38:573-585. [PMID: 30342580 DOI: 10.1016/j.iac.2018.06.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Fractional concentration of exhaled nitric oxide (FENO) is a biomarker used to identify allergic airway inflammation. Because it is noninvasive and easy to obtain, its utility has been studied in the diagnosis and management of several respiratory diseases. Much of the research has been done in asthma, and many studies support the use of FENO in aiding diagnosing asthma, predicting steroid responsiveness, and preventing exacerbations by guiding medication dosage and assessing adherence.
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Affiliation(s)
- Flavia C L Hoyte
- Division of Allergy and Immunology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA.
| | - Lara M Gross
- Division of Allergy and Immunology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA; Division of Allergy and Clinical Immunology, Department of Medicine, University of Colorado, 13001 E 17th Place, Aurora, CO 80045, USA
| | - Rohit K Katial
- Division of Allergy and Immunology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
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12
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Cheng L, Chen J, Fu Q, He S, Li H, Liu Z, Tan G, Tao Z, Wang D, Wen W, Xu R, Xu Y, Yang Q, Zhang C, Zhang G, Zhang R, Zhang Y, Zhou B, Zhu D, Chen L, Cui X, Deng Y, Guo Z, Huang Z, Huang Z, Li H, Li J, Li W, Li Y, Xi L, Lou H, Lu M, Ouyang Y, Shi W, Tao X, Tian H, Wang C, Wang M, Wang N, Wang X, Xie H, Yu S, Zhao R, Zheng M, Zhou H, Zhu L, Zhang L. Chinese Society of Allergy Guidelines for Diagnosis and Treatment of Allergic Rhinitis. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2018; 10:300-353. [PMID: 29949830 PMCID: PMC6021586 DOI: 10.4168/aair.2018.10.4.300] [Citation(s) in RCA: 190] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/17/2017] [Accepted: 10/05/2017] [Indexed: 11/20/2022]
Abstract
Allergic rhinitis (AR) is a global health problem that causes major illnesses and disabilities worldwide. Epidemiologic studies have demonstrated that the prevalence of AR has increased progressively over the last few decades in more developed countries and currently affects up to 40% of the population worldwide. Likewise, a rising trend of AR has also been observed over the last 2-3 decades in developing countries including China, with the prevalence of AR varying widely in these countries. A survey of self-reported AR over a 6-year period in the general Chinese adult population reported that the standardized prevalence of adult AR increased from 11.1% in 2005 to 17.6% in 2011. An increasing number of Journal Articles and imporclinical trials on the epidemiology, pathophysiologic mechanisms, diagnosis, management and comorbidities of AR in Chinese subjects have been published in international peer-reviewed journals over the past 2 decades, and substantially added to our understanding of this disease as a global problem. Although guidelines for the diagnosis and treatment of AR in Chinese subjects have also been published, they have not been translated into English and therefore not generally accessible for reference to non-Chinese speaking international medical communities. Moreover, methods for the diagnosis and treatment of AR in China have not been standardized entirely and some patients are still treated according to regional preferences. Thus, the present guidelines have been developed by the Chinese Society of Allergy to be accessible to both national and international medical communities involved in the management of AR patients. These guidelines have been prepared in line with existing international guidelines to provide evidence-based recommendations for the diagnosis and management of AR in China.
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Affiliation(s)
- Lei Cheng
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
- International Centre for Allergy Research, Nanjing Medical University, Nanjing, China
| | - Jianjun Chen
- Department of Otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qingling Fu
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shaoheng He
- Allergy and Clinical Immunology Research Centre, the First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Huabin Li
- Department of Otolaryngology Head Neck Surgery, Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Zheng Liu
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guolin Tan
- Department of Otolaryngology Head Neck Surgery, Third Xiangya Hospital, Central South University, Changsha, China
| | - Zezhang Tao
- Department of Otolaryngology-Head and Neck Surgery, Renmin Hospital, Wuhan University, Wuhan, China
| | - Dehui Wang
- Department of Otolaryngology Head Neck Surgery, Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Weiping Wen
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Rui Xu
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yu Xu
- Department of Otolaryngology-Head and Neck Surgery, Renmin Hospital, Wuhan University, Wuhan, China
| | - Qintai Yang
- Department of Otolaryngology Head and Neck Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chonghua Zhang
- Department of Otolaryngology Head Neck Surgery, Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Gehua Zhang
- Department of Otolaryngology Head and Neck Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ruxin Zhang
- Department of Otorhinolaryngology Head and Neck Surgery, Huadong Hospital, Fudan University, Shanghai, China
| | - Yuan Zhang
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
- Department of Allergy, Beijing TongRen Hospital, Capital Medical University, Beijing, China
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Bing Zhou
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Dongdong Zhu
- Department of Otorhinolaryngology Head and Neck Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Luquan Chen
- Department of Traditional Chinese Medicine, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Xinyan Cui
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Yuqin Deng
- Department of Otolaryngology-Head and Neck Surgery, Renmin Hospital, Wuhan University, Wuhan, China
| | - Zhiqiang Guo
- Department of Otorhinolaryngology Head and Neck Surgery, Huadong Hospital, Fudan University, Shanghai, China
| | - Zhenxiao Huang
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Zizhen Huang
- Department of Otolaryngology Head and Neck Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Houyong Li
- Department of Otolaryngology Head Neck Surgery, Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Jingyun Li
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Wenting Li
- Department of Otolaryngology Head and Neck Surgery, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanqing Li
- Department of Otolaryngology Head Neck Surgery, Eye & ENT Hospital of Fudan University, Shanghai, China
| | - Lin Xi
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Hongfei Lou
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Meiping Lu
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Yuhui Ouyang
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Wendan Shi
- Department of Otolaryngology-Head and Neck Surgery, Renmin Hospital, Wuhan University, Wuhan, China
| | - Xiaoyao Tao
- Otorhinolaryngology Hospital, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huiqin Tian
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Chengshuo Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Min Wang
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | - Nan Wang
- Department of Otolaryngology-Head and Neck Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiangdong Wang
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
- Department of Allergy, Beijing TongRen Hospital, Capital Medical University, Beijing, China
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Hui Xie
- Department of Otorhinolaryngology, Affiliated Hospital, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Shaoqing Yu
- Department of Otolaryngology Head and Neck Surgery, Tongji Hospital, Tongji University, Shanghai, China
| | - Renwu Zhao
- Department of Otorhinolaryngology Head and Neck Surgery, Huadong Hospital, Fudan University, Shanghai, China
| | - Ming Zheng
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China
| | - Han Zhou
- Department of Otorhinolaryngology, The First Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Luping Zhu
- Department of Otorhinolaryngology, The Second Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Luo Zhang
- Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
- Department of Allergy, Beijing TongRen Hospital, Capital Medical University, Beijing, China
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing, China.
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13
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Tafuro F, Selis L, Goldoni M, Stendardo M, Mozzoni P, Ridolo E, Boschetto P, Corradi M. Biomarkers of respiratory allergy in laboratory animal care workers: an observational study. Int Arch Occup Environ Health 2018; 91:735-744. [PMID: 29858653 DOI: 10.1007/s00420-018-1321-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 05/22/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Laboratory animal allergy is a highly prevalent occupational disease among exposed workers. The aim of the study was to validate the biomarkers of airway inflammation in laboratory animal (LA) care workers. METHODS All of the participants in this observational study (63 LA care workers and 64 controls) were administered a clinical questionnaire, underwent spirometry and a skin prick or radioallergosorbent test for common and occupational aeroallergens, and the fraction of exhaled nitric oxide (FeNO50), exhaled breath condensate hydrogen peroxide (EBC H2O2) and serum pneumoprotein levels were measured. Multivariate analysis (ANCOVA) was used to assess the interactions of the variables. RESULTS FeNO50 levels correlated with exposure (p = 0.002), sensitisation (p = 0.000) and age (p = 0.001), but there was no interaction between exposure and sensitisation when age was considered in the model (p = 0.146). EBC-H2O2 levels were higher in the sensitised workers than in the sensitised controls [0.14 (0.08-0.29) µM vs 0.07 (0.05-0.12) µM; p < 0.05]. Serum surfactant protein A (SP-A) levels were unaffected by exposure, sensitisation or age, although higher levels were observed in symptomatic workers; however, SP-D levels were influenced by exposure (p = 0.024) and age (p = 0.022), and club cell 16 levels were influenced by sensitisation (p = 0.027) and age (p = 0.019). CONCLUSIONS The presence of the clinical symptoms associated with LA exposure and high FeNO levels should prompt further medical assessments in LA workers. Although EBC-H2O2 levels do not seem to reflect eosinophilic inflammation, serum SP-A levels could be used to monitor progression from rhinitis to asthma.
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Affiliation(s)
- Federica Tafuro
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Luisella Selis
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Matteo Goldoni
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | | | - Paola Mozzoni
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Erminia Ridolo
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Piera Boschetto
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Massimo Corradi
- Department of Medicine and Surgery, University of Parma, Parma, Italy. .,Unit of Occupational Medicine, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43123, Parma, Italy.
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14
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Torén K, Murgia N, Schiöler L, Bake B, Olin AC. Reference values of fractional excretion of exhaled nitric oxide among non-smokers and current smokers. BMC Pulm Med 2017; 17:118. [PMID: 28841881 PMCID: PMC5574203 DOI: 10.1186/s12890-017-0456-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 08/04/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Fractional exhaled nitric oxide (FENO) is used to assess of airway inflammation; diagnose asthma and monitor adherence to advised therapy. Reliable and accurate reference values for FENO are needed for both non-smoking and current smoking adults in the clinical setting. The present study was performed to establish reference adult FENO values among never-smokers, former smokers and current smokers. METHODS FENO was measured in 5265 subjects aged 25-75 years in a general-population study, using a chemiluminescence (Niox ™) analyser according to the guidelines of the American Thoracic Society and the European Respiratory Society. Atopy was based on the presence of immunoglobulin E (IgE) antibodies to common inhalant allergens (measured using Phadiatop® test). Spirometry without bronchodilation was performed and forced vital capacity (FVC), forced expired volume in 1 s (FEV1) and the ratio of FEV1 to FVC values were obtained. After excluding subjects with asthma, chronic bronchitis, spirometric airway obstruction and current cold, 3378 subjects remained. Equations for predictions of FENO values were modelled using nonparametric regression models. RESULTS FENO levels were similar in never-smokers and former smokers, and these two groups were therefore merged into a group termed "non-smokers". Reference equations, including the 5th and 95th percentiles, were generated for female and male non-smokers, based on age, height and atopy. Regression models for current smokers were unstable. Hence, the proposed reference values for current smokers are based on the univariate distribution of FENO and fixed cut-off limits. CONCLUSIONS Reference values for FENO among respiratory healthy non-smokers should be outlined stratified for gender using individual reference values. For current smokers separate cut-off limits are proposed.
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Affiliation(s)
- Kjell Torén
- Section of Occupational and Environmental Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Section of Occupational medicine, Respiratory Diseases and Toxicology University of Perugia, Perugia, Italy
| | - Nicola Murgia
- Section of Occupational and Environmental Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Section of Occupational medicine, Respiratory Diseases and Toxicology University of Perugia, Perugia, Italy
| | - Linus Schiöler
- Section of Occupational and Environmental Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Björn Bake
- Section of Occupational and Environmental Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anna-Carin Olin
- Section of Occupational and Environmental Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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15
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Matulonga B, Rava M, Siroux V, Bernard A, Dumas O, Pin I, Zock JP, Nadif R, Leynaert B, Le Moual N. Women using bleach for home cleaning are at increased risk of non-allergic asthma. Respir Med 2016; 117:264-71. [PMID: 27492540 DOI: 10.1016/j.rmed.2016.06.019] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/10/2016] [Accepted: 06/24/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Bleach is widely used for household cleaning. Although it is recognized that occupational use of bleach may have adverse respiratory health effects, it is unknown whether common domestic use of bleach may be a risk factor for asthma. AIM To assess whether the domestic use of bleach for home cleaning is associated with asthma and other respiratory outcomes. METHODS Questionnaire-based information on respiratory symptoms and cleaning habits and data from skin prick-tests, bronchial responsiveness challenge and white blood cells were analyzed in 607 women participating in the follow-up of the Epidemiological Study on the Genetics and Environment of Asthma (EGEA). Bleach use was evaluated in 3 categories (<1 day/week; 1-3 days/week; 4-7 days/week "frequent"). RESULTS Overall, 37% of the women reported using bleach weekly. Women using bleach frequently (11%) were more likely to have current asthma as compared to non-users (adjusted Odds-Ratio (aOR) = 1.7; 95% Confidence Interval (95%CI) 1.0-3.0). Among women with asthma, frequent use of bleach was significantly associated with higher blood neutrophil cell counts. Bleach use was significantly associated with non-allergic asthma (aOR 3.3; 95%CI 1.5-7.1), and more particularly with non-allergic adult-onset asthma (aOR 4.9; 95%CI 2.0-11.6). Consistently, among women without allergic sensitization, significant positive associations were found between use of bleach and bronchial hyperresponsiveness, asthma like-symptoms and chronic cough. No association was observed for allergic asthma. CONCLUSIONS Frequent use of bleach for home-cleaning is associated with non-allergic adult-onset asthma, elevated neutrophil counts and lower-airway symptoms in women.
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Affiliation(s)
- Bobette Matulonga
- Inserm, UMR 1152, Pathophysiology and Epidemiology of Respiratory Diseases, Epidemiology Team, F-75890, Paris, France; Univ Paris-Saclay, Faculty of Medicine, Kremlin-Bicêtre, France
| | - Marta Rava
- Inserm, U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France; Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France; Genetic and Molecular Epidemiology Group, Spanish National Cancer Research Center (CNIO), Madrid, Spain
| | - Valérie Siroux
- University Grenoble Alpes, IAB, Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, F-38042, Grenoble, France; Inserm U823, IAB, Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, F-38042, Grenoble, France
| | - Alfred Bernard
- Louvain Center for Toxicology and Applied Pharmacology (LTAP), Catholic University of Louvain, 1200, Brussels, Belgium
| | - Orianne Dumas
- Inserm, U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France; Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Isabelle Pin
- University Grenoble Alpes, IAB, Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, F-38042, Grenoble, France; Inserm U823, IAB, Team of Environmental Epidemiology Applied to Reproduction and Respiratory Health, F-38042, Grenoble, France; CHU de Grenoble, La Tronche, F-38043, Grenoble, France
| | - Jan-Paul Zock
- Center for Research in Environmental Epidemiology (CREAL), Barcelona, Spain; Universitat Pompeu Fabra (UPF), Barcelona, Spain; CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain; Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Rachel Nadif
- Inserm, U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France; Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
| | - Bénédicte Leynaert
- Inserm, UMR 1152, Pathophysiology and Epidemiology of Respiratory Diseases, Epidemiology Team, F-75890, Paris, France; University Paris Diderot Paris 7, UMR 1152, F-75890, Paris, France.
| | - Nicole Le Moual
- Inserm, U1168, VIMA: Aging and Chronic Diseases, Epidemiological and Public Health Approaches, F-94807, Villejuif, France; Univ Versailles St-Quentin-en-Yvelines, UMR-S 1168, F-78180, Montigny le Bretonneux, France
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Ricciardolo FL, Sorbello V, Ciprandi G. A pathophysiological approach for FeNO: A biomarker for asthma. Allergol Immunopathol (Madr) 2015; 43:609-16. [PMID: 25796309 DOI: 10.1016/j.aller.2014.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 11/19/2014] [Accepted: 11/25/2014] [Indexed: 10/23/2022]
Abstract
The present review is focused on literature concerning the relevance of fractional exhaled nitric oxide (FeNO) in clinical practice from a pathophysiological point of view. There is increasing evidence that asthma is a heterogeneous pathological condition characterised by different phenotypes/endotypes related to specific biomarkers, including FeNO, helpful to predict therapeutic response in selected asthmatic populations. Nowadays FeNO, a non-invasive biomarker, appears to be useful to foresee asthma developing, to recognise specific asthma phenotypes, like the eosinophilic, to ameliorate asthma diagnosis and management in selected populations and to predict standard corticosteroid and biologic therapy efficacy. In addition, FeNO assessment may also be useful in patients with allergic rhinitis in order to detect the potential involvement of eosinophilic bronchial inflammation in "case finding" subjects at risk of asthma diagnosis. Therefore, it is possible to hypothesise a future with an appropriate use of FeNO by physicians dealing with worrisome clinical issues in specific asthma phenotypes.
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Abstract
OBJECTIVES To investigate the role of storage mites in the development of allergic diseases among ham production workers, and to search for early alterations in lung function tests and early inflammation markers in exhaled air. Respiratory allergies due to storage mites have been reported in people with various occupations but, although such mites are unavoidable when curing ham, there are no published data concerning ham production workers. SETTING Secondary care. DESIGN Experimental cross-sectional study. PARTICIPANTS 220 participants (110 ham production workers and 110 controls) were recruited. PRIMARY AND SECONDARY OUTCOME MEASURES Workers answered a medical questionnaire, and underwent spirometry and fraction of exhaled nitric oxide at 50 mL/s (FeNO₅₀) measurements. Those with allergic symptoms also underwent skin prick tests to determine their sensitisation to airborne allergens. A methacholine test was performed in symptomatic participants when spirometry was normal to assess airways hyper-responsiveness. RESULTS Symptomatic storage mite sensitisation was observed in 16 workers (14.5%) (rhinoconjunctivitis in 15 (63%) and asthma in (4%)) and 2 controls (1.8%; p=0.001). Higher FeNO₅₀ values in exposed symptomatic workers compared with healthy control participants (34.65±7.49 vs 13.29±4.29 ppb; p<0.001) suggested bronchial and nasal involvement, although their lung function parameters were normal. Regardless of exposure, a FeNO₅₀ value of 22.5 ppb seems to be 100% sensitive and 99.4% specific in distinguishing allergic and non-allergic participants. Multivariate analysis of FeNO₅₀ values in the symptomatic participants showed that they were positively influenced by IgE-mediated allergy (p=0.001) and reported symptom severity (p=0.041), and negatively by smoking status (p=0.049). CONCLUSIONS Ham processing workers, as well as workers involved in any meat processing work that includes curing, should be informed about the occupational risk of sensitisation to mites.
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Affiliation(s)
- Federica Tafuro
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Erminia Ridolo
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Matteo Goldoni
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Marcello Montagni
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Antonio Mutti
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Massimo Corradi
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
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Gupta N, Goel N, Kumar R. Correlation of exhaled nitric oxide, nasal nitric oxide and atopic status: A cross-sectional study in bronchial asthma and allergic rhinitis. Lung India 2014; 31:342-7. [PMID: 25378841 PMCID: PMC4220315 DOI: 10.4103/0970-2113.142107] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Objective: Exhaled nitric oxide (FENO) and nasal nitric oxide (n NO) measurement is an area of ongoing research in the study of airway inflammation. The atopic status is known to influence the levels of FENO and n NO. This study was undertaken to study the relationship between nitric oxide measurements in bronchial asthma and allergic rhinitis along with their correlation with atopic profile of Indian population. Materials and Methods: Ninety subjects were recruited for the study comprising of 25 each of bronchial asthma (BA), allergic rhinitis (AR), bronchial asthma with allergic rhinitis (BA-AR) and 15 healthy controls. These were assessed for atopy and exhaled breath analysis of nitric oxide. The measurements of FENO and n NO levels were done using NIOX chemiluminescence analyzer. Atopy was assessed by skin prick testing (SPT) against 58 common aero-allergens and subjects with ≥1 positive SPT were labeled as atopic. Results: The BA-AR and BA groups had higher FENO levels in comparison to the control (P < 0.05) and AR group (P < 0.05). The AR and BA-AR groups had higher n NO levels compared to the control group (P < 0.05) and BA group (P < 0.05). The increasing FENO levels significantly correlated with the increase in the number of allergen sensitization in patients suffering from BA-AR (P < 0.05). However, the BA group showed a weaker positive correlation (P = 0.07). Conclusion: FENO is a non-invasive marker of airway inflammation. Also, FENO levels correlate with presence and degree of atopy in BA and AR. Simultaneously, n NO could be a surrogate marker of rhinitis.
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Affiliation(s)
- Nitesh Gupta
- Department of Respiratory Allergy and Applied Immunology, National Centre of Respiratory Allergy, Asthma and Immunology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Nitin Goel
- Department of Respiratory Allergy and Applied Immunology, National Centre of Respiratory Allergy, Asthma and Immunology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Raj Kumar
- Department of Respiratory Allergy and Applied Immunology, National Centre of Respiratory Allergy, Asthma and Immunology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
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19
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Across-shift changes of exhaled nitric oxide and spirometric indices among cotton textile workers. Int J Occup Med Environ Health 2014; 27:707-15. [PMID: 25168972 DOI: 10.2478/s13382-014-0306-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 06/16/2014] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES For the purpose of evaluation of exhaled NO as an index of airway inflammation, we assessed changes in fractional exhaled NO (FeNO) across a work shift and its relationship with respiratory complaints. MATERIAL AND METHODS Chronic and work-aggravated respiratory complaints were assessed using a questionnaire in 89 male textile workers. FeNO and spirometry were performed before and after a work shift and all the changes were registered. RESULTS A significant increase in FeNO after a work shift was observed. Post-shift FeNO was significantly higher among the subjects with chronic respiratory complaints. There was an obvious decrease in FVC, and FEV1 after a work shift; however, we couldn't find a significant relationship between changes in respiratory parameters and concentration of inhalable dusts. CONCLUSIONS FeNO increase after a work shift along with pulmonary function decrement and higher post-shift FeNO among subjects with respiratory complaints makes across-shift FeNO a non-invasive test for assessment of airway hyper-responsiveness in textile workers.
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Bake B, Viklund E, Olin AC. Effects of pollen season on central and peripheral nitric oxide production in subjects with pollen asthma. Respir Med 2014; 108:1277-83. [PMID: 25052059 DOI: 10.1016/j.rmed.2014.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 06/02/2014] [Accepted: 06/23/2014] [Indexed: 12/26/2022]
Abstract
BACKGROUND Pollen exposure of allergic subjects with asthma causes increased nitric oxide (NO) in exhaled air (FENO) suggestive of increased airway inflammation. It is, however, unclear to what extent NO production in peripheral airways and alveoli are involved. OBJECTIVES The aim of the present investigation was to analyze the relationship between central and peripheral components of FENO to clarify the distribution of pollen induced inflammation in asthma. SUBJECTS AND METHODS 13 pollen allergic non-smoking subjects with mild-intermittent asthma and 12 healthy non-smoking control subjects were examined with spirometry and FENO at flows between 50 and 270 mL/s during and out of pollen season. RESULTS Spirometry was normal and unaffected by season in subjects with asthma as well as controls. Out of season subjects with asthma had significantly higher FENO, elevated airway production (JáwNO) and preacinar/acinar production (CANO) than controls. Pollen exposure resulted in significantly increased FENO and JáwNO but not CANO. FENO among controls were not affected by season. Individual results showed, however, that CANO increased substantially in a few subjects with asthma. The increased CANO in subjects with asthma may be explained by increased NO production in preacinar/acinar airways and back diffusion towards the alveoli. CONCLUSIONS The findings may indicate that subjects with allergic asthma have airway inflammation without alveolar involvement outside the pollen season and pollen exposure causes a further increase of airway inflammation and in a few subjects obstruction of intra acinar airways causing impeded back diffusion. Increased NO production in central airways, unassociated with airway obstruction could be an alternative explanation. These effects were not disclosed by spirometry.
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Affiliation(s)
- Björn Bake
- Occupational and Environmental Medicine, Sahlgrenska Academy at University of Gothenburg, Sweden; Respiratory Medicine and Allergology, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Emilia Viklund
- Occupational and Environmental Medicine, Sahlgrenska Academy at University of Gothenburg, Sweden
| | - Anna-Carin Olin
- Occupational and Environmental Medicine, Sahlgrenska Academy at University of Gothenburg, Sweden; Respiratory Medicine and Allergology, Sahlgrenska Academy at University of Gothenburg, Sweden.
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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.
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Affiliation(s)
- C Krantz
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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22
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Respiratory symptoms, exhaled nitric oxide, and lung function among workers in Tanzanian coffee factories. J Occup Environ Med 2014; 55:544-51. [PMID: 23618889 DOI: 10.1097/jom.0b013e318285f453] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare chronic respiratory symptoms, fractional exhaled nitric oxide (FENO), and lung function between Robusta and Arabica coffee workers and a control group. METHODS Chronic respiratory symptoms were assessed by a questionnaire (n = 138 coffee workers and n = 120 controls). The FENO was measured by NIOX MINO device (Aerocrine AB, Solna, Sweden). Lung function was examined by a portable spirometer. RESULTS Coffee workers had higher prevalence of chronic respiratory and asthma symptoms than controls. Robusta coffee workers were exposed to higher levels of endotoxin and had more asthma symptoms than Arabica coffee workers (38% vs. 18%). Coffee workers had reduced lung function associated with cumulative exposure to total dust and endotoxin. CONCLUSION Work in coffee factories is associated with small but significant lung function impairment. These changes were not associated with the level of FENO.
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Simpson JL, Wark PA. The role of exhaled nitric oxide and exhaled breath condensates in evaluating airway inflammation in asthma. ACTA ACUST UNITED AC 2013; 2:607-20. [PMID: 23495773 DOI: 10.1517/17530059.2.6.607] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Airway inflammation is central to the development and progression of asthma. Monitoring airway inflammation can be invasive and technically difficult, making its use limited in clinical practice. Several advances have been made in non-invasive techniques to monitor and measure inflammation from the airways. OBJECTIVE To examine the suitability of exhaled nitric oxide and exhaled breath condensates as diagnostic tools in asthma. METHOD The current literature regarding the use of exhaled nitric oxide and exhaled breath condensate to assess and manage asthma was reviewed. CONCLUSION Exhaled nitric oxide is a clinically useful marker of eosinophilic airway inflammation in asthma. Although showing promise, significant validation and investigation are required before exhaled breath condensate could be utilized in clinical practice.
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Affiliation(s)
- Jodie L Simpson
- NHRMC Centre for Respiratory and Sleep Medicine, Level 3 Hunter Medical Research Institute, John Hunter Hospital, Locked Bag 1 Hunter Region Mail Centre, Newcastle NSW 2310, Australia +61 02 49214965 ; +61 02 49855850 ;
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Jedrychowski W, Maugeri U, Mroz E, Flak E, Rembiasz M, Jacek R, Sowa A. Fractional exhaled nitric oxide in healthy non-asthmatic 7-year olds and prenatal exposure to polycyclic aromatic hydrocarbons: nested regression analysis. Pediatr Pulmonol 2012; 47:1131-9. [PMID: 22588790 DOI: 10.1002/ppul.22570] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 03/22/2012] [Indexed: 11/12/2022]
Abstract
UNLABELLED The main goal of the study was to assess possible association between transplacental exposure to genotoxic PAH compounds assessed by the cord blood PAH-DNA adducts and fractional exhaled nitric oxide (FeNO) measured in healthy non-asthmatic children at the age of 7 years. The subjects included the subsample of 89 children who took part in the ongoing population based birth cohort study in Krakow and attended FeNO testing. The effect of transplacental PAH exposure was adjusted for potential confounders, such as maternal allergy and children's specific atopy to common domestic allergens. RESULTS FeNO values were significantly elevated in children with higher prenatal PAH exposure (gmean = 7.7 ppb; 95% CI: 5.8-10.2 ppb) compared with those at low exposure level (gmean = 3.8 ppb; 95% CI: 2.3-6.3) (P = 0.011). Children with maternal allergy had also significantly higher mean FeNO values (gmean = 13.7 ppb, 95% CI: 8.8-21.4 ppb) compared with the subjects whose mothers denied allergy (gmean = 5.6 ppb, 95% CI: 4.3-7.3 ppb) (P = 0.012). Similarly, FeNO values in atopic children were higher (gmean = 11.2 ppb; 95% CI: 3.8-32.8 ppb) than in non-atopic individuals (gmean = 6.0 ppb; 95% CI: 4.7-7.7 ppb, P = 0.079). The results of the nested multivariable linear regression analysis showed that both maternal allergy and sensitization of children to domestic aeroallergens jointly explained 10.4% of FeNO variance, however, the additional 10.9% was determined by prenatal PAH exposure. CONCLUSION FeNO is more than a marker useful for screening atopy or symptomatic bronchial inflammation and may also be a proxy for cytokine deregulation and "allergic response" phenotype possibly established in fetal period due to transplacental PAH exposure. Preliminary results of our study should encourage more studies on intrauterine PAH exposure and later respiratory symptoms.
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Affiliation(s)
- Wieslaw Jedrychowski
- Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Krakow, Poland.
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Alexanderson C, Olin AC, Dahlman-Höglund A, Finizia C, Torén K. Nasal nitric oxide in a random sample of adults and its relationship to sensitization, cat allergen, rhinitis, and ambient nitric oxide. Am J Rhinol Allergy 2012; 26:e99-103. [PMID: 22643936 DOI: 10.2500/ajra.2012.26.3777] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is conflicting evidence whether nasal nitric oxide (NO) is associated with current rhinitis and with other possible predictors. Most studies have been performed in clinical cohorts and there is a lack of studies based on a general population sample. The aim of the present study was to investigate predictors for levels of nasal nitric oxide (NO) in a general population. METHODS The population consisted of 357 subjects from Gothenburg participating in the follow-up of the European Respiratory Health Survey in 1999-2001. All subjects completed an extensive respiratory questionnaire. Nasal NO was measured from one nostril at a time with a sampling rate of 50 mL/s for 16 seconds and the nasal NO concentration was determined as the mean value within the plateau phase. Mattress dust samples were collected for cats and mites in a subsample of subjects. Ambient and exhaled NO was also measured. The predictors for nasal NO were analyzed in multiple linear regression models. RESULTS There was no relation between the levels of nasal NO and reporting current rhinitis. Nasal NO was significantly increased among those with high levels of IgE against cats and current smokers had significantly lower nasal NO. There was also a positive association between ambient NO and nasal NO. There were no significant associations between nasal NO and sex, age, or height, or between nasal NO and measured levels of cat antigen. CONCLUSION In this general population sample we found no relation between current rhinitis and nasal NO levels. There was a clear association between sensitization to cat and nasal NO, but there was no relation to current exposure to cat allergen. Our data support that nasal NO has a limited value in monitoring upper airway inflammation.
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Affiliation(s)
- Cecilia Alexanderson
- Division of Otorhinolaryngology, Sahlgrenska University Hospital/Mölndal, Sweden.
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26
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Abstract
Nitric oxide (NO) is now considered an important biomarker for respiratory disease. Studies have confirmed that the fractional concentration of exhaled nitric oxide (FENO) is elevated in the airways of patients who have asthma in comparison with controls. The level of FENO correlates well with the presence and level of inflammation, and decreases with glucocorticoid treatment. NO has potential to be used not only as a diagnostic aid but also as a management tool for assessing severity, monitoring response to therapy, and gaining control of asthma symptoms. This article reviews the biology of NO and its role in respiratory disease.
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Affiliation(s)
- Lora Stewart
- Allergy & Asthma Care and Prevention Center, Lone Tree, CO 80204, USA
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27
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Crane J, Lampshire P, Wickens K, Epton M, Siebers R, Ingham T, Pattemore P, Town I. Asthma, atopy and exhaled nitric oxide in a cohort of 6-yr-old New Zealand children. Pediatr Allergy Immunol 2012; 23:59-64. [PMID: 22104032 DOI: 10.1111/j.1399-3038.2011.01227.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Exhaled nitric oxide has been promoted as a non-invasive measure of airway inflammation, with clinical utility for the diagnosis and management of asthma. AIM We studied associations between exhaled nitric oxide, asthma and atopy in a variety of clinically relevant phenotypes in a cohort of 6-yr-old children. METHOD Asthma was defined using standard questionnaire criteria, atopy was measured using skin prick tests (SPT) and specific IgE to common allergens, and exhaled nitric oxide was measured using a chemiluminescence analyser according to American and European Thoracic Society criteria. RESULTS Exhaled nitric oxide was strongly related to atopy and in particular to sensitization to house dust mites. Children with non-allergic asthma had no increase in exhaled nitric oxide compared with non-asthmatic children. Compared with children who never wheezed both late onset and persistent, wheezing was associated with increased FE(NO), while early transient wheezing was not. Elevated levels of exhaled nitric oxide amongst children with allergic asthma were almost entirely explained by their levels of specific IgE to aeroallergens, predominantly D pteronyssinus. CONCLUSION Airway inflammation as measured by exhaled nitric oxide in young New Zealand children is related to their level of specific IgE to aeroallergens. This has implications for the utility of nitric oxide as a diagnostic and management tool in childhood asthma and for the importance of specific IgE as a marker of asthma severity.
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Affiliation(s)
- Julian Crane
- Wellington Asthma Research Group, Department of Medicine, University of Otago, Wellington, New Zealand.
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Benhamou AH, Koehli A, Rochat I, Inci D, Moeller A, Taramarcaz P, Lauener RP, Eigenmann PA. Exhaled nitric oxide decreases after positive food-allergen challenge. Clin Transl Allergy 2011; 1:14. [PMID: 22409969 PMCID: PMC3339336 DOI: 10.1186/2045-7022-1-14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Accepted: 11/28/2011] [Indexed: 11/28/2022] Open
Abstract
Background Exhaled nitric oxide (FeNO) is a well described marker of airway inflammation in asthma and is also known to increase after chronic exposure to inhaled allergens. It is not known whether monitoring FeNO could be useful during food challenges to detect early or subclinical reactions. Methods Forty children aged 3 to 16 years undergoing an allergen-food challenge at two centres were prospectively recruited for this study. FeNO was assessed before and repeatedly after the food-challenge. Results Data were obtained from a total of 53 challenges (16 positive, 37 negative) and were compared between the two groups. Half of the patients with a positive food challenge exhibited clinical upper respiratory symptoms. The FeNO significantly decreased in 7 of 16 patients with a positive challenge test within 60 to 90 minutes after the first symptoms of an allergic reaction. Conclusion Our results show a significant decrease in FeNO after a positive food challenge suggesting involvement of the lower airways despite absence of clinical and functional changes of lower airways. Prospective blinded studies are needed to confirm these results.
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Affiliation(s)
- Avigael H Benhamou
- Pediatric Allergy Unit, Geneva University Hospitals and University of Geneva, Geneva, Switzerland.
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Ishizuka T, Matsuzaki S, Aoki H, Yatomi M, Kamide Y, Hisada T, Tsuburai T, Dobashi K, Ohshima K, Akiyama K, Mori M. Prevalence of asthma symptoms based on the European Community Respiratory Health Survey questionnaire and FENO in university students: gender differences in symptoms and FENO. Allergy Asthma Clin Immunol 2011; 7:15. [PMID: 21923950 PMCID: PMC3193803 DOI: 10.1186/1710-1492-7-15] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 09/19/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The fractional concentration of nitric oxide in exhaled air (FENO) is used as a biomarker of eosinophilic airway inflammation. FENO is increased in patients with asthma. The relationship between subjective asthma symptoms and airway inflammation is an important issue. We expected that the subjective asthma symptoms in women might be different from those in men. Therefore, we investigated the gender differences of asthma symptoms and FENO in a survey of asthma prevalence in university students. METHODS The information about asthma symptoms was obtained from answers to the European Community Respiratory Health Survey (ECRHS) questionnaire, and FENO was measured by an offline method in 640 students who were informed of this study and consented to participate. RESULTS The prevalence of asthma symptoms on the basis of data obtained from 584 students (266 men and 318 women), ranging in age from 18 to 24 years, was analyzed. Wheeze, chest tightness, an attack of shortness of breath, or an attack of cough within the last year was observed in 13.2% of 584 students. When 38.0 ppb was used as the cut-off value of FENO to make the diagnosis of asthma, the sensitivity was 86.8% and the specificity was 74.0%. FENO was ≥ 38.0 ppb in 32.7% of students. FENO was higher in men than in women. The prevalence of asthma symptoms estimated by considering FENO was 7.2%; the prevalence was greater in men (9.4%) than women (5.3%). A FENO ≥ 38.0 ppb was common in students who reported wheeze, but not in students, especially women, who reported cough attacks. CONCLUSIONS The prevalence of asthma symptoms in university students age 18 to 24 years in Japan was estimated to be 7.2% on the basis of FENO levels as well as subjective symptoms. Gender differences were observed in both FENO levels and asthma symptoms reflecting the presence of eosinophilic airway inflammation. TRIAL REGISTRATION NUMBER UMIN000003244.
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Affiliation(s)
- Tamotsu Ishizuka
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, 3-39-15 Showa-machi, Maebashi 371-8511, Japan.
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Linhares D, Jacinto T, Pereira AM, Fonseca JA. Effects of atopy and rhinitis on exhaled nitric oxide values - a systematic review. Clin Transl Allergy 2011; 1:8. [PMID: 22409776 PMCID: PMC3339369 DOI: 10.1186/2045-7022-1-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 08/17/2011] [Indexed: 11/27/2022] Open
Abstract
Background Atopy and rhinitis are among the factors affecting exhaled nitric oxide (FeNO) values and may contribute to difficulties in the clinical interpretation of FeNO measurements. However, data assessing their effects on FeNO values had never been summarized. This review aims to evaluate the effect of atopy and rhinitis in FeNO values in otherwise healthy individuals. Methods A systematic review was performed in Pubmed, Scopus and ISI Web of Knowledge. A two-step selection process was completed, and from 2357 references 19 were included. The inclusion criteria were: participants without known diseases other than rhinitis; atopy assessement by SPT or Specific IgE; and FeNO measurements according to ATS/ERS recommendations. Results The 8 articles measuring FeNO in children showed higher values in both allergic rhinitis and atopic children when compared with healthy children. The 11 articles performed in adults observed higher FeNO in AR patients comparatively with either healthy or atopic individuals. However, adult healthy and atopic individuals had similar FeNO values. Conclusions FeNO values are higher in individuals with rhinitis and/or atopy without other health problems. These effects are small, seem to be independent and should be further studied using multivariate models. The effect of atopy was observed only in children. The combined effect of atopy and rhinitis produced higher FeNO values in adults. These results support that both atopy and rhinitis should be considered when interpreting or when defining FeNO reference values.
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Affiliation(s)
- Daniela Linhares
- Health Information and Decision Sciences, Faculty of Medicine of University of Porto, Alameda Hernâni Monteiro, 4200-319 Porto, Portugal.
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Acoustic rhinometry, spirometry and nitric oxide in relation to airway allergy and smoking habits in an adolescent cohort. Int J Pediatr Otorhinolaryngol 2011; 75:177-81. [PMID: 21081250 DOI: 10.1016/j.ijporl.2010.10.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Revised: 10/19/2010] [Accepted: 10/24/2010] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study aimed to analyze upper and lower airway function and the impact of smoking habits in a cohort of allergic and healthy adolescents. The influence of smoking habits on the outcomes of rhinitis and asthma is well documented, but only few reports are available showing smoke related upper airway impairment by rhinometric measurements, and none with focus on early changes in adolescents. METHODS A cohort followed from infancy was re-examined at the age of 18 years concerning allergy development. Acoustic rhinometry (VOL2), spirometry (FEV(1)) and measurements of nitric oxide levels from the upper (nNO) and lower airways (eNO) were performed before and after physical exercise, and smoking habits were registered. RESULTS Active smoking habits were reported by 4/21 subjects suffering from allergic rhinitis, by 1/4 from probable allergic rhinitis, by 0/3 subjects with atopic dermatitis and by 2/10 healthy controls. Smoking habits were reported as daily by 2 and occasional by 5 of the 7 active smokers. VOL2 did not increase in smokers after exercise as in non-smokers, resulting in a post-exercise group difference (7.3±1.1cm(3) vs. 8.8±1.5cm(3); p=0.02), and FEV(1) values were lower in smokers compared to non-smokers (89±7% vs. 98±8%; p=0.02). The nNO and eNO levels were, however, only slightly reduced in smokers. Airway allergy was discerned only in subjects with current allergen exposure by increased eNO levels compared to healthy controls (41±44ppb vs. 13±5ppb). The levels of VOL2, nNO and FEV(1) did not differentiate allergic subjects from healthy controls. CONCLUSIONS Low levels of tobacco smoke exposure resulted in reduced airway functions in this adolescent cohort. Acoustic rhinometry and spirometry were found to be more sensitive methods compared to nitric oxide measurements in early detection of airway impairment related to smoke exposure. A possible difference in airway vulnerability between allergic and healthy subjects due to smoke exposure remains to be evaluated in larger study groups.
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Bohadana AB, Hannhart B, Ghezzo H, Teculescu D, Zmirou-Navier D. Exhaled nitric oxide and spirometry in respiratory health surveillance. Occup Med (Lond) 2011; 61:108-14. [PMID: 21285029 DOI: 10.1093/occmed/kqq184] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Exposure to pollutants in bakeries and hairdressing salons can cause airway syndromes varying from bronchial irritation to asthma. Workplace respiratory health surveillance aims to identify possible cases requiring further investigation. AIMS To compare the performance of fractional exhaled nitric oxide (FE(NO)) and spirometry for health surveillance of apprentice bakers (ABs) and apprentice hairdressers (AHDs). Determinants of FE(NO) were also identified. METHODS Symptoms and physician-diagnosed asthma were evaluated by questionnaire. FE(NO) was measured and spirometry was carried out. Subjects with elevated FE(NO) (FE(NO) > upper limit normal), airway obstruction [forced expiratory volume in 1 s (FEV(1))/forced vital capacity (FVC) < 95th percentile] and atopy (history of allergies) were identified. RESULTS A total of 126 apprentices (59 ABs and 67 AHDs) participated. Twenty-nine (23%) apprentices had abnormal tests: 4 had associated high FE(NO) and airway obstruction, while 25 had either high FE(NO) (n = 15) or airway obstruction (n = 10) alone. Compared with ABs (n = 16), AHDs (n = 13) had more asthma (38 versus 0%; P < 0.05) and atopy (62 versus 6%; P < 0.05). There was no difference in symptoms, smoking FE(NO) or airways obstruction. Among 97 subjects with normal tests, no differences existed between ABs (n = 53) and AHDs (n = 44). Average FE(NO) was increased in atopic non-smokers compared with atopic smokers and non-atopic subjects (P < 0.05). Smoking, a history of allergies, FEV(1)/FVC % observed and respiratory symptoms were the main determinants of FE(NO). CONCLUSIONS FE(NO) and spirometry were not overlapping dimensions in ABs and hairdressers, each test contributing unique information on the physiological status of the respiratory system. FE(NO) may provide added information on airway inflammation not provided by spirometry.
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Affiliation(s)
- A B Bohadana
- Department of Environmental Health and Work Health, University of Montreal, Montreal, Quebec H3T 1A8, Canada.
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Berg CM, Thelle DS, Rosengren A, Lissner L, Torén K, Olin AC. Decreased fraction of exhaled nitric oxide in obese subjects with asthma symptoms: data from the population study INTERGENE/ADONIX. Chest 2010; 139:1109-1116. [PMID: 21183611 DOI: 10.1378/chest.10-1299] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Several studies have demonstrated an association between obesity and asthma. However, it is uncertain if fraction of exhaled nitric oxide (Feno), which is used as a marker of airway inflammation, and atopy are associated with BMI. The aim of this study was to examine if obese subjects with asthma symptoms have a different phenotype of asthma than nonobese subjects as indicated by Feno. METHODS The subjects (N = 2,187) consisted of women and men, aged 25 to 74, living in Gothenburg, Sweden, who participated in the randomly selected INTERGENE study cohort. Measurements included anthropometric measures, bioelectric impedance, Feno, pulmonary function, and blood samples for IgE; questionnaires included items on respiratory symptoms. Obesity was defined as BMI ≥ 30 kg/m(2). In this cross-sectional analysis, general linear models were used to analyze how Feno was associated with anthropometry, body composition, wheezing, and atopy. RESULTS In nonobese subjects, wheezing was associated with raised Feno and atopy, whereas in contrast, obese subjects who reported wheezing had lower Feno than obese subjects without wheezing (16.1 vs 19.1 parts per billion, P < .01). The prevalence of atopy was similar in both of those subgroups (25.0% vs 20.7%, P = .4). Similarly, in 395 subjects (19%) who reported wheezing, Feno was negatively associated with BMI, waist-to-hip ratio, and percentage of body fat, whereas no significant relationships were observed in those without respiratory symptoms. CONCLUSIONS Wheezing was significantly associated with reduced Feno in obese subjects, whereas there was a positive association between wheezing and Feno among the nonobese subjects, indicating a possible difference in asthma phenotype, based on body weight.
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Affiliation(s)
- Christina M Berg
- Department of Food and Nutrition, and Sport Science, University of Gothenburg, Gothenburg, Sweden.
| | - Dag S Thelle
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden; Department of Biostatistics, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Annika Rosengren
- Department of Emergency and Cardiovascular Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Lauren Lissner
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Kjell Torén
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
| | - Anna-Carin Olin
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden
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Janson C, Kalm-Stephens P, Foucard T, Alving K, Nordvall SL. Risk factors associated with allergic and non-allergic asthma in adolescents. CLINICAL RESPIRATORY JOURNAL 2010; 1:16-22. [PMID: 20298273 DOI: 10.1111/j.1752-699x.2007.00001.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Risk factors for asthma have been investigated in a large number of studies in adults and children, with little progress in the primary and secondary prevention of asthma. The aim of this investigation was to investigate risk factors associated with allergic and non-allergic asthma in adolescents. METHODS In this study, 959 schoolchildren (13-14 years old) answered a questionnaire and performed exhaled nitric oxide (NO) measurements. All children (n = 238) with reported asthma, asthma-related symptoms and/or increased NO levels were invited to a clinical follow-up which included a physician evaluation and skin-prick testing. RESULTS Asthma was diagnosed in 96 adolescents, whereof half had allergic and half non-allergic asthma. Children with both allergic and non-allergic asthma had a significantly higher body mass index (BMI) (20.8 and 20.7 vs. 19.8 kg/m(2)) (p < 0.05) and a higher prevalence of parental asthma (30% and 32% vs. 16%) (p < 0.05). Early-life infection (otitis and croup) [adjusted odds ratio (OR) (95% confidence interval (CI)): 1.99 (1.02-3.88) and 2.80 (1.44-5.42), respectively], pets during the first year of life [2.17 (1.16-4.04)], window pane condensation [2.45 (1.11-5.40)] and unsatisfactory school cleaning [(2.50 (1.28-4.89)] was associated with non-allergic but not with allergic asthma. CONCLUSION This study indicates the importance of distinguishing between subtypes of asthma when assessing the effect of different risk factors. While the risk of both allergic and non-allergic asthma increased with increasing BMI, associations between early-life and current environmental exposure were primarily found in relation to non-allergic asthma.
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Affiliation(s)
- Christer Janson
- Department of Medical Sciences: Respiratory Medicine and Allergology, Uppsala University, Uppsala, Sweden.
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Tossa P, Paris C, Zmirou-Navier D, Demange V, Acouetey DS, Michaely JP, Bohadana A. Increase in exhaled nitric oxide is associated with bronchial hyperresponsiveness among apprentices. Am J Respir Crit Care Med 2010; 182:738-44. [PMID: 20508219 DOI: 10.1164/rccm.200903-0415oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Airway inflammation is a hallmark of asthma. Several studies have validated the use of the fractional concentration of exhaled nitric oxide (Fe(NO)) as a surrogate marker of airway inflammation in asthma. OBJECTIVES We examined how the change in Fe(NO) levels, since the beginning of occupational exposure, could be associated with the incidence of bronchial hyperresponsiveness (BHR) among baker, pastry maker, and hairdresser apprentices during their 2-year training. METHODS A standardized questionnaire was administered; skin prick tests for common and specific occupational allergens were done; methacholine challenge and measurement of Fe(NO) were performed 6, 12, and 15 months after the first examination. MEASUREMENTS AND MAIN RESULTS Of 441 apprentices initially included, 351 completed the study. The increase in Fe(NO), since the beginning of exposure, was associated with the incidence of BHR (odds ratio, 2.00 [95% confidence interval, 1.21-3.32] per unit increase in log parts per billion) both in atopic and nonatopic subjects. The average increase in Fe(NO) was similar in atopic and nonatopic subjects and was unrelated to past or current smoking habits, sex, or training track. Atopy in bakers/pastry makers and sensitization to alkaline persulfates in hairdressers were also independently associated with the incidence of BHR. BHR occurred sooner among bakers/pastry makers than among hairdressers, but its incidence leveled off later. CONCLUSIONS Our results suggest that measurement of Fe(NO), a simple and reproducible test, could be useful in the screening of BHR in workers newly exposed to agents known to cause occupational asthma.
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Affiliation(s)
- Paul Tossa
- Institut National de Santé et de Recherche Médicale U954, School of Medicine, Vandoeuvre-lès-Nancy, France
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Demange V, Bohadana A, Massin N, Wild P. Exhaled nitric oxide and airway hyperresponsiveness in workers: a preliminary study in lifeguards. BMC Pulm Med 2009; 9:53. [PMID: 20043846 PMCID: PMC2805603 DOI: 10.1186/1471-2466-9-53] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 12/31/2009] [Indexed: 01/16/2023] Open
Abstract
Background Airway inflammation and airway hyperresponsiveness (AHR) are two characteristic features of asthma. Fractional exhaled nitric oxide (FENO) has shown good correlation with AHR in asthmatics. Less information is available about FENO as a marker of inflammation from work exposures. We thus examined the relation between FENO and AHR in lifeguards undergoing exposure to chloramines in indoor pools. Methods 39 lifeguards at six indoor pools were given a respiratory health questionnaire, FENO measurements, spirometry, and a methacholine bronchial challenge (MBC) test. Subjects were labeled MBC+ if the forced expiratory volume (FEV1) fell by 20% or more. The normalized linear dose-response slope (NDRS) was calculated as the percentage fall in FEV1 at the last dose divided by the total dose given. The relation between MBC and FENO was assessed using logistic regression adjusting on confounding factors. The association between NDRS and log-transformed values of FENO was tested in a multiple linear regression model. Results The prevalence of lifeguards MBC+ was 37.5%. In reactors, the median FENO was 18.9 ppb (90% of the predicted value) vs. 12.5 ppb (73% predicted) in non-reactors. FENO values ≥ 60% of predicted values were 80% sensitive and 42% specific to identify subjects MBC+. In the logistic regression model no other factor had an effect on MBC after adjusting for FENO. In the linear regression model, NDRS was significantly predicted by log FENO. Conclusions In lifeguards working in indoor swimming pools, elevated FENO levels are associated with increased airway responsiveness.
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Affiliation(s)
- Valérie Demange
- INRS, Département Epidémiologie en Entreprise, Rue du Morvan, CS 60027, 54519 Vandoeuvre-lès-Nancy Cedex, France.
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Olin AC, Rosengren A, Thelle DS, Lissner L, Torén K. Increased fraction of exhaled nitric oxide predicts new-onset wheeze in a general population. Am J Respir Crit Care Med 2009; 181:324-7. [PMID: 20007926 DOI: 10.1164/rccm.200907-1079oc] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Fraction of exhaled nitric oxide (Fe(NO)) is regarded as a marker of airway inflammation. It is unknown whether increased Fe(NO) in respiratorily healthy subjects increases the risk of developing wheeze. OBJECTIVES To examine if increased levels of Fe(NO) predicts later onset of wheeze. METHODS We followed up 2,200 men and women from a general population-based study. At baseline, the subjects were investigated with questionnaires, blood samples, pulmonary function tests, and Fe(NO). At follow-up 4 years later, all subjects were mailed a respiratory questionnaire. The association between incident wheeze and baseline levels of Fe(NO) over the 90th percentile were evaluated calculating hazard ratios using Cox regression models adjusted for smoking habits, age, height, sex, and atopy. MEASUREMENTS AND MAIN RESULTS The follow-up questionnaire was completed by 1,896 subjects (86.2%). All subjects reporting wheeze, asthma, or asthma symptoms at baseline were excluded resulting in a study population of 1,506 subjects. Of these, 49 subjects reported new-onset wheeze. The median concentration of Fe(NO) at baseline was significantly higher among those with new-onset wheeze (18.8 ppb vs. 15.8 ppb, P = 0.03). In a Cox regression model including all subjects, Fe(NO) over the 90th percentile predicted onset of wheeze (hazard ratio 2.7; 95% confidence interval, 1.4-5.4). In stratified models, this was most apparent among never-smokers and in atopic subjects, for whom the odds ratios were higher. CONCLUSIONS Our results indicate that increased Fe(NO) is associated with an increased risk of developing wheeze. The results also support the hypothesis that increased level of Fe(NO) among subjects without respiratory symptoms is a sign of subclinical airways inflammation.
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Affiliation(s)
- Anna-Carin Olin
- Occupational and Environmental Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg, Sweden.
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Ekroos H, Rouhos A, Pallasaho P, Karjalainen J, Sarna S, Sovijärvi ARA. Equally elevated concentrations of exhaled nitric oxide in nonatopic and low-sensitized atopic asthmatics. Respir Med 2008; 103:152-8. [PMID: 18951776 DOI: 10.1016/j.rmed.2008.03.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2007] [Revised: 03/05/2008] [Accepted: 03/13/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Some studies show concentrations of exhaled nitric oxide (FENO) in nonatopic asthma and in healthy subjects to be similar, but include asthmatics on inhaled steroids, which is likely to interfere with the results. AIM Comparison of FENO between nonatopic asthmatics, low-sensitized and high-sensitized atopic asthmatics, and healthy controls. METHODS We studied 85 non-smoking, steroid-naive young men with recently diagnosed symptomatic asthma and 10 healthy controls. FENO was measured according to European Respiratory Society Guidelines. In skin prick tests of 13 common aeroallergens, subjects with a total sum of prick wheals 3-10mm were regarded as low-sensitized and those with >10mm, as high-sensitized. Flow-volume spirometry, standardized histamine challenge, and an exercise test were also carried out. RESULTS Prick tests revealed 14 subjects to be nonatopic and 71 atopic. In high-sensitized subjects with atopic asthma, the FENO median (25-75 quartiles) was significantly higher, 34.9 (21.3-53.8) parts per billion (ppb), than in subjects with nonatopic asthma, 15.2 (9.7-24.7)ppb (p<0.001), both being significantly higher than in healthy controls, 6.6 (5.2-8.5)ppb (p<0.001). FENO levels were similar in nonatopic and in low-sensitized atopic asthmatics, with no difference between them in bronchial responsiveness to histamine and exercise. CONCLUSION Among steroid-naive young male asthmatics, FENO was equally elevated in nonatopic asthma and in low-sensitized atopic asthma but lower than in those with high-sensitized atopic asthma. These differences in FENO between asthma groups parallel the differences in airway function disturbance in terms of responsiveness to histamine or exercise.
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Affiliation(s)
- Heikki Ekroos
- Division of Clinical Physiology and Nuclear Medicine, Laboratory Department, Helsinki University Hospital, Helsinki, Finland.
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Gabriele C, Hol J, Kerkhof E, Elink Schuurman BEE, Samsom JN, Hop W, Nieuwenhuis EES, de Jongste JC. Fractional exhaled nitric oxide in infants during cow's milk food challenge. Pediatr Allergy Immunol 2008; 19:420-5. [PMID: 18266827 DOI: 10.1111/j.1399-3038.2007.00673.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Cow's milk allergy (CMA) is the most common food allergy in early childhood. The golden standard for the diagnosis of CMA is a food challenge after a period of elimination. Increased levels of fractional exhaled nitric oxide (FE(NO)) have been shown after bronchial allergen provocation. We evaluated whether FE(NO) may also be a predictor of a positive reaction during cow's milk challenge in infants. Forty-four infants [mean age (range): 4.2 (3.7-4.6) months] suspected of CMA underwent an open food challenge with cow's milk formula administered in ascending quantities, starting with 2 ml and then 6, 20, 60 and 200 ml until a clinical reaction occurred. Off-line FE(NO) samples were obtained during tidal breathing by means of a facemask covering infants' nose and mouth. FE(NO) was measured twice before the challenge (baseline), immediately before each new dose of milk and after a positive reaction or after the last dose of milk. Eleven children showed immediate positive clinical responses to cow's milk, whereas 13 infants presented only a late-type reaction. FE(NO) values before or after a positive reaction (either immediate or late) were not different from FE(NO) values at baseline. Baseline FE(NO) in infants with a positive reaction did not differ from FE(NO) in infants without a reaction at any time point. We conclude that FE(NO) values are not predictive and not related to the occurrence of a positive reaction during a cow's milk challenge in infants, suggesting that a positive reaction may not result from eosinophilic activation.
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Affiliation(s)
- Carmelo Gabriele
- Department of Pediatrics, The Generation R Study Group, Erasmus University Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
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Lara A, Khatri SB, Wang Z, Comhair SAA, Xu W, Dweik RA, Bodine M, Levison BS, Hammel J, Bleecker E, Busse W, Calhoun WJ, Castro M, Chung KF, Curran-Everett D, Gaston B, Israel E, Jarjour N, Moore W, Peters SP, Teague WG, Wenzel S, Hazen SL, Erzurum SC. Alterations of the arginine metabolome in asthma. Am J Respir Crit Care Med 2008; 178:673-81. [PMID: 18635886 DOI: 10.1164/rccm.200710-1542oc] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE As the sole nitrogen donor in nitric oxide (NO) synthesis and key intermediate in the urea cycle, arginine and its metabolic pathways are integrally linked to cellular respiration, metabolism, and inflammation. OBJECTIVES We hypothesized that arginine (Arg) bioavailability would be associated with airflow abnormalities and inflammation in subjects with asthma, and would be informative for asthma severity. METHODS Arg bioavailability was assessed in subjects with severe and nonsevere asthma and healthy control subjects by determination of plasma Arg relative to its metabolic products, ornithine and citrulline, and relative to methylarginine inhibitors of NO synthases, and by serum arginase activity. Inflammatory parameters, including fraction of exhaled NO (Fe(NO)), IgE, skin test positivity to allergens, bronchoalveolar lavage, and blood eosinophils, were also evaluated. MEASUREMENTS AND MAIN RESULTS Subjects with asthma had greater Arg bioavailability, but also increased Arg catabolism compared with healthy control subjects, as evidenced by higher levels of Fe(NO) and serum arginase activity. However, Arg bioavailability was positively associated with Fe(NO) only in healthy control subjects; Arg bioavailability was unrelated to Fe(NO) or other inflammatory parameters in severe or nonsevere asthma. Inflammatory parameters were related to airflow obstruction and reactivity in nonsevere asthma, but not in severe asthma. Conversely, Arg bioavailability was related to airflow obstruction in severe asthma, but not in nonsevere asthma. Modeling confirmed that measures of Arg bioavailabilty predict airflow obstruction only in severe asthma. CONCLUSIONS Unlike Fe(NO), Arg bioavailability is not a surrogate measure of inflammation; however, Arg bioavailability is strongly associated with airflow abnormalities in severe asthma.
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Affiliation(s)
- Abigail Lara
- Department of Pathobiology, The Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Rouhos A, Kainu A, Karjalainen J, Lindqvist A, Piirilä P, Sarna S, Haahtela T, Sovijärvi ARA. Atopic sensitization to common allergens without symptoms or signs of airway disorders does not increase exhaled nitric oxide. THE CLINICAL RESPIRATORY JOURNAL 2008; 2:141-8. [PMID: 20298322 PMCID: PMC3272347 DOI: 10.1111/j.1752-699x.2007.00045.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Revised: 11/23/2007] [Accepted: 11/27/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Elevated fractional exhaled nitric oxide (FENO) associates positively with symptomatic atopy among asthmatics and in the general population. It is, however, unclear whether sensitization to common allergens per se- as verified with positive skin prick tests--affects FENO in healthy individuals. OBJECTIVE The aim of this study was to examine the association between FENO and sensitization to common allergens in healthy nonsmoking adults with no signs or symptoms of airway disorders. METHODS FENO measurements (flow rate: 50 mL/s), skin prick tests to common inhalant allergens, structured interviews, spirometry, bronchodilatation tests and bronchial histamine challenges were performed on a randomly selected population of 248 subjects. Seventy-three of them (29%) were nonsmoking asymptomatic adults with no history of asthma, persistent or recurrent upper or lower airway symptoms and no signs of airway disorders in the tests listed above. RESULTS FENO concentrations were similar in skin prick test positive (n = 32) and negative (n = 41) healthy subjects, with median values of 13.2 and 15.5 ppb, respectively (P = 0.304). No correlation appeared between FENO and the number of positive reactions (r = -0.138; P = 0.244), or the total sum of wheal diameters (r = -0.135; P = 0.254). The nonparametric one-tailed 95% upper limits of FENO among skin prick positive and negative healthy nonsmoking subjects were 29 and 31 ppb, respectively. CONCLUSIONS Atopic constitution defined as positive skin prick test results does not increase FENO in healthy nonsmoking adults with no signs or symptoms of airway disorders. This suggests that same reference ranges for FENO can be applied to both skin prick test positive and negative subjects.
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Affiliation(s)
- Annamari Rouhos
- Division of Respiratory Diseases, Department of Medicine, Helsinki University Central Hospital, Helsinki, Finland.
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Bernstein IL, Li JT, Bernstein DI, Hamilton R, Spector SL, Tan R, Sicherer S, Golden DBK, Khan DA, Nicklas RA, Portnoy JM, Blessing-Moore J, Cox L, Lang DM, Oppenheimer J, Randolph CC, Schuller DE, Tilles SA, Wallace DV, Levetin E, Weber R. Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol 2008; 100:S1-148. [PMID: 18431959 DOI: 10.1016/s1081-1206(10)60305-5] [Citation(s) in RCA: 291] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Dressel H, de la Motte D, Reichert J, Ochmann U, Petru R, Angerer P, Holz O, Nowak D, Jörres RA. Exhaled nitric oxide: independent effects of atopy, smoking, respiratory tract infection, gender and height. Respir Med 2008; 102:962-9. [PMID: 18396030 DOI: 10.1016/j.rmed.2008.02.012] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Revised: 12/22/2007] [Accepted: 02/20/2008] [Indexed: 10/22/2022]
Abstract
Measurement of exhaled nitric oxide is widely used in respiratory research and clinical practice, especially in patients with asthma. However, interpretation is often difficult, due to common interfering factors, and little is known about interactions between factors. We assessed the influences and interactions of factors such as smoking, respiratory tract infections and respiratory allergy concerning exhaled nitric oxide values, with the aim to derive a scheme for adjustment. We studied 897 subjects (514 females, 383 males; mean age+/-standard deviation 34.5+/-13.0 years) with and without respiratory allergy (allergic rhinitis and/or asthma), smoking and respiratory tract infection. Logarithmic nitric oxide levels were described by an additive model comprising respiratory allergy, smoking, respiratory tract infection, gender and height (p0.001 each), without significant interaction terms. Geometric mean was 17.5ppb in a healthy female non smoker of height 170cm, whereby respiratory allergy corresponded to a change by factor 1.50, smoking 0.63, infection 1.24, male gender 1.17, and each 10cm increase (decrease) in height to 1.11 (0.90). Factors were virtually identical when excluding asthma and using the category allergic rhinitis instead of respiratory allergy (n=863). Within each category formed by combinations of these different predictors, the range of residual variation was approximately constant. We conclude that the factors influencing exhaled nitric oxide, which we analyzed, act independently of each other. Thus, circumstances such as smoking and respiratory tract infection do not appear to affect the usefulness of exhaled nitric oxide, provided that appropriate factors for adjustment are applied.
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Affiliation(s)
- Holger Dressel
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig-Maximilians-University, Ziemssenstr. 1, 80336 München, Germany.
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Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A, Zuberbier T, Baena-Cagnani CE, Canonica GW, van Weel C, Agache I, Aït-Khaled N, Bachert C, Blaiss MS, Bonini S, Boulet LP, Bousquet PJ, Camargos P, Carlsen KH, Chen Y, Custovic A, Dahl R, Demoly P, Douagui H, Durham SR, van Wijk RG, Kalayci O, Kaliner MA, Kim YY, Kowalski ML, Kuna P, Le LTT, Lemiere C, Li J, Lockey RF, Mavale-Manuel S, Meltzer EO, Mohammad Y, Mullol J, Naclerio R, O'Hehir RE, Ohta K, Ouedraogo S, Palkonen S, Papadopoulos N, Passalacqua G, Pawankar R, Popov TA, Rabe KF, Rosado-Pinto J, Scadding GK, Simons FER, Toskala E, Valovirta E, van Cauwenberge P, Wang DY, Wickman M, Yawn BP, Yorgancioglu A, Yusuf OM, Zar H, Annesi-Maesano I, Bateman ED, Ben Kheder A, Boakye DA, Bouchard J, Burney P, Busse WW, Chan-Yeung M, Chavannes NH, Chuchalin A, Dolen WK, Emuzyte R, Grouse L, Humbert M, Jackson C, Johnston SL, Keith PK, Kemp JP, Klossek JM, Larenas-Linnemann D, Lipworth B, Malo JL, Marshall GD, Naspitz C, Nekam K, Niggemann B, Nizankowska-Mogilnicka E, Okamoto Y, Orru MP, Potter P, Price D, Stoloff SW, Vandenplas O, Viegi G, Williams D. Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update (in collaboration with the World Health Organization, GA(2)LEN and AllerGen). Allergy 2008; 63 Suppl 86:8-160. [PMID: 18331513 DOI: 10.1111/j.1398-9995.2007.01620.x] [Citation(s) in RCA: 3050] [Impact Index Per Article: 190.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
MESH Headings
- Adolescent
- Asthma/epidemiology
- Asthma/etiology
- Asthma/therapy
- Child
- Global Health
- Humans
- Prevalence
- Rhinitis, Allergic, Perennial/complications
- Rhinitis, Allergic, Perennial/diagnosis
- Rhinitis, Allergic, Perennial/epidemiology
- Rhinitis, Allergic, Perennial/therapy
- Rhinitis, Allergic, Seasonal/complications
- Rhinitis, Allergic, Seasonal/diagnosis
- Rhinitis, Allergic, Seasonal/epidemiology
- Rhinitis, Allergic, Seasonal/therapy
- Risk Factors
- World Health Organization
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Affiliation(s)
- J Bousquet
- University Hospital and INSERM, Hôpital Arnaud de Villeneuve, Montpellier, France
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van Asch CJJ, Balemans WAF, Rovers MM, Schilder AGM, van der Ent CK. Atopic disease and exhaled nitric oxide in an unselected population of young adults. Ann Allergy Asthma Immunol 2008; 100:59-65. [PMID: 18254484 DOI: 10.1016/s1081-1206(10)60406-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several studies have reported elevated levels of fractional exhaled nitric oxide (FeNO) in atopic patients, particularly in asthmatic patients, suggesting that FeNO is a marker of bronchial inflammation. However, the independent influence of different atopic entities (eczema, allergic rhinitis, and asthma) on FeNO has never been studied in the general population. OBJECTIVE To study the influence of a questionnaire-based diagnosis of atopic diseases and IgE and lung function measurements on FeNO levels. METHODS This study was part of a follow-up on otitis media of a birth cohort of 1,328 children born in Nijmegen, the Netherlands, between September 1, 1982, and August 31, 1983. Within the birth cohort, the incidence of asthma, allergic rhinitis, and eczema was determined, and off-line FeNO, spirometry, and IgE measurements were performed at the age of 21 years. RESULTS FeNO measurements were successfully performed in 361 participants. Median FeNO levels were significantly higher in those with vs without eczema (23.6 vs 18.0 ppb; P < .0001), those with vs without allergic rhinitis (20.7 vs 17.8 ppb; P = .0001), and those with vs without atopic asthma (23.3 vs 18.1 ppb; P = .02) but not in those with vs without asthma (20.8 vs 18.3 ppb; P = .24). Eczema, allergic rhinitis, smoking, sex, and atopic sensitization appeared to be independently associated with log FeNO in this population sample, whereas (atopic) asthma was not. No effect on FeNO levels was observed for lung function parameters. CONCLUSION Eczema, allergic rhinitis, and atopic status were all independently associated with elevated FeNO levels, whereas (atopic) asthma was not. This finding implies that future studies into the role of FeNO in asthma should consider the influence of atopic disease outside the lungs.
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Affiliation(s)
- Charlotte J J van Asch
- Department of Paediatric Respiratory Medicine, Wilhelmina Children's Hospital, University Medical Centre, Utrecht, the Netherlands
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Bohadana A, Michaely JP, Teculescu D, Wild P. Reproducibility of exhaled nitric oxide in smokers and non-smokers: relevance for longitudinal studies. BMC Pulm Med 2008; 8:4. [PMID: 18304367 PMCID: PMC2292677 DOI: 10.1186/1471-2466-8-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2007] [Accepted: 02/28/2008] [Indexed: 11/10/2022] Open
Abstract
Background Currently, there is much interest in measuring fractional exhaled nitric oxide (FENO) in populations. We evaluated the reproducibility of FENO in healthy subjects and determined the number of subjects necessary to carry out a longitudinal survey of FENO in a population containing smokers and non-smokers, based on the assessed reproducibility. Methods The reproducibility of FENO was examined in 18 healthy smokers and 21 non-smokers. FENO was assessed once at 9 AM on five consecutive days; in the last day this measurement was repeated at 2 PM. Respiratory symptoms and medical history were assessed by questionnaire. The within- and between-session repeatability of FENO and log-transformed FENO was described. The power of a longitudinal study based on a relative increase in FENO was estimated using a bilateral t-test of the log-transformed FENO using the between-session variance of the assay. Results FENO measurements were highly reproducible throughout the study. FENO was significantly higher in males than females regardless of smoking status. FENO was positively associated with height (p < 0.001), gender (p < 0.034), smoking (p < 0.0001) and percent FEV1/FVC (p < 0.001) but not with age (p = 0.987). The between-session standard deviation was roughly constant on the log scale. Assuming the between-session standard deviation is equal to its longitudinal equivalent, either 111 or 29 subjects would be necessary to achieve an 80% power in detecting a 3% or a 10% increase in FENO respectively. Conclusion The good reproducibility of FENO is not influenced by gender or smoking habits. In a well controlled, longitudinal study it should allow detecting even small increases in FENO with a reasonable population size.
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Affiliation(s)
- Abraham Bohadana
- Institut National de la Santé et de la Recherche Médicale, INSERM, ERI 11, 54505 Vandoeuvre - lès-Nancy, France.
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Abstract
Exhaled nitric oxide (FENO) is a noninvasive easily measurable biomarker that is proving to be an excellent surrogate for eosinophilic inflammation in the lungs of patients who have asthma. Although large-scale normative data are still awaited, preliminary studies have shown FENO to be helpful in diagnosing and assessing severity and control for asthma. FENO levels have also proven helpful in diagnosing and managing several other inflammatory lung diseases.
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Affiliation(s)
- Lora Stewart
- National Jewish Medical and Research Center, Division of Allergy and Immunology, 1400 Jackson Street, Denver, CO 80206, USA
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Cruz AA, Popov T, Pawankar R, Annesi-Maesano I, Fokkens W, Kemp J, Ohta K, Price D, Bousquet J. Common characteristics of upper and lower airways in rhinitis and asthma: ARIA update, in collaboration with GA(2)LEN. Allergy 2008; 62 Suppl 84:1-41. [PMID: 17924930 DOI: 10.1111/j.1398-9995.2007.01551.x] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This update aimed to review the new evidence available to support or refute prior Allergic Rhinitis and its Impact on Asthma (ARIA) statements. A Medline search of publications between 2000 and 2005 was conducted, with articles selected by experts. New evidence supports previous ARIA statements, such as: (i) allergic rhinitis (AR) is a risk factor for asthma; (ii) patients with persistent rhinitis should be evaluated for asthma; (iii) most patients with asthma have rhinitis; (iv) a combined strategy should be used to treat the airways and (v) in low- to middle-income countries, a different strategy may be needed. The increased risk of asthma has also been found among sufferers from non-AR. Recent reports show AR is a global problem. Many studies demonstrated parallel increasing prevalence of asthma and rhinitis, but in regions of highest prevalence, it may be reaching a plateau. Factors associated with a reduced risk of asthma and AR have been identified, confirming previous findings of protection related to exposure to infections. Treatment of rhinitis with intranasal glucocorticosteroids, antihistamines, leukotriene antagonists or immunotherapy may reduce morbidity because of asthma. To take advantage of the paradigm of unified airways, there is a need to rationalize diagnosis and treatment to optimize management.
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MESH Headings
- Asthma/economics
- Asthma/epidemiology
- Asthma/physiopathology
- Asthma/therapy
- Humans
- Immunotherapy
- Prevalence
- Rhinitis, Allergic, Perennial/epidemiology
- Rhinitis, Allergic, Perennial/physiopathology
- Rhinitis, Allergic, Perennial/therapy
- Rhinitis, Allergic, Seasonal/epidemiology
- Rhinitis, Allergic, Seasonal/physiopathology
- Rhinitis, Allergic, Seasonal/therapy
- Risk Factors
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Affiliation(s)
- A A Cruz
- ProAR, Programme for Control of Asthma and Allergic Rhinitis in Bahia, Federal University of Bahia School of Medicine, and CNPq, Salvador, Brazil
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49
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Katial R, Stewart L. Exhaled nitric oxide: a test for diagnosis and control of asthma? Curr Allergy Asthma Rep 2008; 7:459-63. [PMID: 17986377 DOI: 10.1007/s11882-007-0070-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The fractional concentration of nitric oxide (FE(NO)) in exhaled breath is a noninvasive marker of airway inflammation in asthma. The precise role of FE(NO) in the asthma management algorithm has not been defined. However, there are compelling data for use of FE(NO) for diagnosing asthma, assessing control and severity, titrating inhaled corticosteroids, and detecting ongoing airway inflammation. This article reviews the biology of nitric oxide in airway pathology and its role in asthma.
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Affiliation(s)
- Rohit Katial
- National Jewish Medical and Research Center, 1400 Jackson Street, Denver, CO 80206, USA.
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50
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Olin AC, Bake B, Torén K. Fraction of exhaled nitric oxide at 50 mL/s: reference values for adult lifelong never-smokers. Chest 2007; 131:1852-6. [PMID: 17565022 DOI: 10.1378/chest.06-2928] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The measurement of fractional exhaled nitric oxide (FENO) is used as a marker of airway inflammation. The aim of this study was to establish reference values of FENO for adults. METHODS FENO at a flow rate of 50 mL/s was analyzed in 3,376 adults using a chemiluminescence analyzer according to American Thoracic Society/European Respiratory Society guidelines. Blood samples were analyzed, and atopy was defined as the presence of specific IgE. All subjects responded to a respiratory questionnaire. Those who had never smoked (n = 1,803) were selected for this study. After the exclusion of subjects with physician-diagnosed asthma, asthma symptoms, ever wheezing, dry cough, or use of inhaled steroids, 1,131 healthy never-smokers remained, including 845 nonatopic and 286 atopic subjects. RESULTS Based on multiple regression modeling, we propose the following reference equation for healthy never-smoking adults: Ln(FENO) = 0.057 + 0.013 x height (in centimeters) + 0.0088 x age (in years). The residual SD was 0.51, and the explanatory value was 9%. In a model, based on nonatopic subjects alone, the reference equation obtained was slightly different, as follows: Ln(FENO) = -0.0026 + 0.013 x height (in centimeters) + 0.010 x age (in years). The residual SD for this equation was 0.48, and the explanatory value was 11%. CONCLUSIONS Normal values of FENO for adults may be predicted on the basis of age and height. However, as the reference equations only account for about 9 to 11% of the variation, the most important information that could be extracted from the study is that the upper limits of FENO range from 24.0 to 54.0 parts per billion, depending on age and height.
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Affiliation(s)
- Anna-Carin Olin
- Department of Occupational and Environmental Medicine, Sahlgrenska University Hospital, Box 414, SE 405 30 Göteborg, Sweden.
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