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Matsunaga K, Kuwahira I, Hanaoka M, Saito J, Tsuburai T, Fukunaga K, Matsumoto H, Sugiura H, Ichinose M. An official JRS statement: The principles of fractional exhaled nitric oxide (FeNO) measurement and interpretation of the results in clinical practice. Respir Investig 2020; 59:34-52. [PMID: 32773326 DOI: 10.1016/j.resinv.2020.05.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/20/2020] [Accepted: 05/08/2020] [Indexed: 12/22/2022]
Abstract
Nitric oxide (NO) is produced in the body and has been shown to have diverse actions in the abundance of research that has been performed on it since the 1970s, leading to Furchgott, Murad, and Ignarro receiving the Nobel Prize in Physiology or Medicine in 1998. NO is produced by nitric oxide synthase (NOS). NOS is broadly distributed, being found in the nerves, blood vessels, airway epithelium, and inflammatory cells. In asthma, inflammatory cytokines induce NOS activity in the airway epithelium and inflammatory cells, producing large amounts of NO. Measurement of fractional exhaled nitric oxide (FeNO) is a simple, safe, and quantitative method of assessing airway inflammation. The FeNO measurement method has been standardized and, in recent years, this noninvasive test has been broadly used to support the diagnosis of asthma, monitor airway inflammation, and detect asthma overlap in chronic obstructive pulmonary disease (COPD) patients. Since the normal upper limit of FeNO for healthy Japanese adults is 37 ppb, values of 35 ppb or more are likely to be interpreted as a signature of inflammatory condition presenting features with asthma, and this value is used in clinical practice. Research is also underway for clinical application of these measurements in other respiratory diseases such as COPD and interstitial lung disease. Currently, there remains some confusion regarding the significance of these measurements and the interpretation of the results. This statement is designed to provide a simple explanation including the principles of FeNO measurements, the measurement methods, and the interpretation of the measurement results.
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Affiliation(s)
- Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Yamaguchi University, Ube, Japan.
| | - Ichiro Kuwahira
- Department of Pulmonary Medicine, Tokai University Tokyo Hospital, Tokyo, Japan
| | - Masayuki Hanaoka
- First Department of Internal Medicine, Shinshu University, Matsumoto, Japan
| | - Junpei Saito
- Department of Pulmonary Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takahiro Tsuburai
- Division of Respiratory Diseases, Saint Marianna University Yokohama City Seibu Hospital, Yokohama, Japan
| | - Koichi Fukunaga
- Division of Pulmonary Medicine, Department of Medicine, Keio University, Tokyo, Japan
| | - Hisako Matsumoto
- Department of Respiratory Medicine, Kyoto University, Kyoto, Japan
| | - Hisatoshi Sugiura
- Department of Respiratory Medicine, Tohoku University, Sendai, Japan
| | - Masakazu Ichinose
- Department of Respiratory Medicine, Tohoku University, Sendai, Japan
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Winkler A, Kahnert K, Behr J, Neurohr C, Kneidinger N, Hatz R, Dressel H, Radtke T, Jörres RA. Combined diffusing capacity for nitric oxide and carbon monoxide as predictor of bronchiolitis obliterans syndrome following lung transplantation. Respir Res 2018; 19:171. [PMID: 30200966 PMCID: PMC6131787 DOI: 10.1186/s12931-018-0881-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a need for non-invasive parameters that are sensitive to the development of the bronchiolitis obliterans syndrome (BOS) in lung transplantation (LTx) patients. We studied whether the pulmonary diffusing capacity for inhaled nitric oxide is capable of detecting BOS stages. METHODS Sixty-one LTx patients were included into this cross-sectional study (19/29/7/3/3 in BOS stages 0/0-p/1/2/3). For analysis stages 0/0-p versus 1/2/3 ("BOS binary-early"), and stages 0/0-p/1 versus 2/3 ("BOS binary-late") were summarized. Measurements of the combined diffusing capacity for nitric oxide (DLNO) and carbon monoxide (DLCO) were compared with spirometry and bodyplethysmography, and their relative importance was evaluated by discriminant analysis. RESULTS Regarding the recognition of "BOS binary-early", among spirometric parameters forced expiratory volume in 1 s (FEV1) was best, among bodyplethysmographic parameters airway resistance, and among diffusing parameters DLNO. Regarding "BOS binary-late", DLNO was inferior to bodyplethysmographic parameters. CONCLUSION Although the study comprised only measurements at a single time point and no follow-up, DLNO outperformed FEV1, the time course of which is used in detecting BOS. Together with its pathophysiological plausibility, this result suggests that the measurement of DLNO, possibly over time, could be an easily applicable tool for the monitoring of LTx patients and should be evaluated in larger studies.
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Affiliation(s)
- Anna Winkler
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Comprehensive Pneumology Center Munich (CPC-M), Ludwig-Maximilians-Universität München, Munich, Germany
| | - Kathrin Kahnert
- Department of Internal Medicine V, University of Munich (LMU), Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), Ziemssenstr. 1, 80336, Munich, Germany.
| | - Jürgen Behr
- Department of Internal Medicine V, University of Munich (LMU), Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), Ziemssenstr. 1, 80336, Munich, Germany
| | - Claus Neurohr
- Robert-Bosch-Hospital, Klinik Schillerhöhe, Gerlingen, Germany
| | - Nikolaus Kneidinger
- Department of Internal Medicine V, University of Munich (LMU), Comprehensive Pneumology Center, Member of the German Center for Lung Research (DZL), Ziemssenstr. 1, 80336, Munich, Germany
| | - Rudolf Hatz
- Department of Thoracic Surgery, University of Munich (LMU), Munich, Germany
| | - Holger Dressel
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
- Division of Occupational and Environmental Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Thomas Radtke
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
- Division of Occupational and Environmental Medicine, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Rudolf A Jörres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Comprehensive Pneumology Center Munich (CPC-M), Ludwig-Maximilians-Universität München, Munich, Germany
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Schmitzer M, Winter H, Kneidinger N, Meimarakis G, Dick A, Schramm R, Klotz LV, Preissler G, Strobl N, von Dossow V, Schneider C, Weig T, Hatz R, Kauke T. Persistence of de novo donor specific HLA-Antibodies after lung transplantation: a potential marker of decreased patient survival. HLA 2018; 92:24-32. [PMID: 29888557 DOI: 10.1111/tan.13306] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/23/2018] [Accepted: 06/07/2018] [Indexed: 01/08/2023]
Abstract
The impact of de novo donor-specific anti-HLA antibodies (DSA) on outcomes in lung transplantation is still a matter of debate. We hypothesize that differentiating DSA by persistent and transient appearance may offer an additional risk assessment. The clinical relevance of HLA-antibodies was investigated prospectively in 72 recipients with a median follow-up period of 21 months. The presence of HLA-antibodies was analysed by single antigen bead assay prior to and after (3 weeks, 3, 6, 12 and 18 months) transplantation. In 23 patients (32%) de novo DSA were detected. In 10 of these patients (44%) DSA persisted throughout the follow-up period whereas 13 of these patients (56%) had transient DSA. There was a trend towards lower one-year-survival in DSA positive compared to DSA negative patients (83% versus 94%; p=0.199). Remarkably, patients with persistent DSA had significantly reduced survival (one-year survival 60%) compared with both patients without DSA and those with transient DSA (p=0.005). Persistent DSA represented an independent prognostic factor for reduced overall survival in multivariate analysis (HR 8.3, 95% CI 1.8-37.0; p=0.006). Persistence of DSA during the first year after transplantation seems to be more harmful for lung allograft function than transiently detected DSA at an early stage. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- M Schmitzer
- Department of Thoracic Surgery at that time
- Department of Internal Medicine V, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL)
| | - H Winter
- Department of Thoracic Surgery at that time
- Department of Thoracic Surgery, University Hospital Heidelberg
| | - N Kneidinger
- Department of Internal Medicine V, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL)
| | - G Meimarakis
- Department of Vascular and Endovascular Surgery Klinikum Landshut
| | - A Dick
- Laboratory for Immunogenetics, Department of Transfusion Medicine
| | - R Schramm
- Department of Cardiac Surgery at that time
- Department of Thoracic and Cardiovascular Surgery, University Hospital of the Ruhr-University of Bochum
| | - L V Klotz
- Comprehensive Pneumology Center Munich (CPC-M), Institute of Lung Biology and Disease, Helmholtz Zentrum München; Member of the German Center for Lung Research (DZL) at that time
- Department of Thoracic Surgery, University Hospital Heidelberg
| | | | - N Strobl
- Department of Thoracic Surgery at that time
| | - V von Dossow
- Department of Anaesthesiology at that time, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich
- Anaesthesiology, HDZ Bad Oeynhausen, University Hospital of the Ruhr-University of Bochum Munich Lung Transplant Group (MLTP)
| | | | - T Weig
- Department of Anaesthesiology at that time, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich
| | - R Hatz
- Department of Thoracic Surgery at that time
| | - T Kauke
- Department of Thoracic Surgery at that time
- Laboratory for Immunogenetics, Department of Transfusion Medicine
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Köktürk N, Yıldırım F, Aydoğdu M, Akı ŞZ, Yeğin ZA, Özkurt ZN, Suyanı E, Kıvılcım Oğuzülgen İ, Türköz Sucak G. Is It Possible to Predict Pulmonary Complications and Mortality in Hematopoietic Stem Cell Transplantation Recipients from Pre-Transplantation Exhaled Nitric Oxide Levels? Turk J Haematol 2016; 33:34-40. [PMID: 26376938 PMCID: PMC4805335 DOI: 10.4274/tjh.2014.0159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Chemo/radiotherapy-induced free oxygen radicals and reactive oxygen derivatives contribute to the development of early and late transplantation-related pulmonary and extra-pulmonary complications in hematopoietic stem cell transplantation (HSCT) recipients. It has been proposed that an increase in fractional exhaled nitric oxide (FeNO) level indicates oxidative stress and inflammation in the airways. The aim of this prospective study is to evaluate the pre-transplantation FeNO levels in HSCT patients and to search for its role in predicting post-transplantation pulmonary complications and mortality. MATERIALS AND METHODS HSCT patients were included in the study prospectively between October 2009 and July 2011. Pre-transplantation FeNO levels were measured with a NIOX MINO® device prior to conditioning regimens. All patients were monitored prospectively for post-transplantation pulmonary complications with medical history, physical examination, chest X-ray, and pulmonary function tests. RESULTS A total of 56 patients (33 autologous, 23 allogeneic) with mean age of 45±13 years were included in the study, among whom 40 (71%) were male. Pre-transplantation FeNO level of the whole study group was found to be 24±13 (mean ± standard deviation) parts per billion (ppb). The FeNO level in allogeneic HSCT recipients was 19±6 ppb while it was 27±15 ppb in autologous HSCT recipients (p=0.042). No significant correlation was found between the pre-transplantation chemotherapy and radiotherapy protocols and baseline FeNO levels (p>0.05). Post-transplantation pulmonary toxicity was identified in 12 (21%) patients and no significant relationship was found between baseline FeNO levels and pulmonary toxicity. The survival rate of the whole study group for 1 year after transplantation was 70%. No significant relationship was identified between baseline FeNO values and survival (FeNO 19±7 ppb in patients who died and 26±15 ppb in the survivors; p=0.114). CONCLUSION Pre-transplantation FeNO measurement does not seem to have a role in predicting post-transplantation pulmonary complications and mortality.
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Affiliation(s)
| | - Fatma Yıldırım
- Gazi University Faculty of Medicine, Department of Pulmonary Medicine, Ankara, Turkey. Phone: +90 312 202 61 19 E-mail:
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Yu J. Postinfectious bronchiolitis obliterans in children: lessons from bronchiolitis obliterans after lung transplantation and hematopoietic stem cell transplantation. KOREAN JOURNAL OF PEDIATRICS 2015; 58:459-65. [PMID: 26770220 PMCID: PMC4705325 DOI: 10.3345/kjp.2015.58.12.459] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 06/13/2015] [Indexed: 11/27/2022]
Abstract
Postinfectious bronchiolitis obliterans (PIBO) is an irreversible obstructive lung disease characterized by subepithelial inflammation and fibrotic narrowing of the bronchioles after lower respiratory tract infection during childhood, especially early childhood. Although diagnosis of PIBO should be confirmed by histopathology, it is generally based on history and clinical findings. Irreversible airway obstruction is demonstrated by decreased forced expiratory volume in 1 second with an absent bronchodilator response, and by mosaic perfusion, air trapping, and/or bronchiectasis on computed tomography images. However, lung function tests using spirometry are not feasible in young children, and most cases of PIBO develop during early childhood. Further studies focused on obtaining serial measurements of lung function in infants and toddlers with a risk of bronchiolitis obliterans (BO) after lower respiratory tract infection are therefore needed. Although an optimal treatment for PIBO has not been established, corticosteroids have been used to target the inflammatory component. Other treatment modalities for BO after lung transplantation or hematopoietic stem cell transplantation have been studied in clinical trials, and the results can be extrapolated for the treatment of PIBO. Lung transplantation remains the final option for children with PIBO who have progressed to end-stage lung disease.
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Affiliation(s)
- Jinho Yu
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Elbahlawan L, Srinivasan A, Morrison RR. A Critical Care and Transplantation-Based Approach to Acute Respiratory Failure after Hematopoietic Stem Cell Transplantation in Children. Biol Blood Marrow Transplant 2015; 22:617-626. [PMID: 26409244 PMCID: PMC5033513 DOI: 10.1016/j.bbmt.2015.09.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 09/16/2015] [Indexed: 12/11/2022]
Abstract
Acute respiratory failure contributes significantly to nonrelapse mortality after allogeneic hematopoietic stem cell transplantation. Although there is a trend of improved survival over time, mortality remains unacceptably high. An understanding of the pathophysiology of early respiratory failure, opportunities for targeted therapy, assessment of the patient at risk, optimal use of noninvasive positive pressure ventilation, strategies to improve alveolar recruitment, appropriate fluid management, care of the patient with chronic lung disease, and importantly, a team approach between critical care and transplantation services may improve outcomes. Outcomes from acute respiratory failure after hematopoietic stem cell transplantation remain unacceptably high. The review focuses on strategies to improve these outcomes.
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Affiliation(s)
- Lama Elbahlawan
- Department of Pediatric Medicine, Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Ashok Srinivasan
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee.,Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - R Ray Morrison
- Department of Pediatric Medicine, Division of Critical Care, St. Jude Children's Research Hospital, Memphis, Tennessee.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
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7
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Cameli P, Bargagli E, Fossi A, Bennett D, Voltolini L, Refini R, Gotti G, Rottoli P. Exhaled nitric oxide and carbon monoxide in lung transplanted patients. Respir Med 2015. [DOI: 10.1016/j.rmed.2015.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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8
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Malinovschi A, Ludviksdottir D, Tufvesson E, Rolla G, Bjermer L, Alving K, Diamant Z. Application of nitric oxide measurements in clinical conditions beyond asthma. Eur Clin Respir J 2015; 2:28517. [PMID: 26672962 PMCID: PMC4653314 DOI: 10.3402/ecrj.v2.28517] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 07/05/2015] [Indexed: 02/01/2023] Open
Abstract
Fractional exhaled nitric oxide (FeNO) is a convenient, non-invasive method for the assessment of active, mainly Th2-driven, airway inflammation, which is sensitive to treatment with standard anti-inflammatory therapy. Consequently, FeNO serves as a valued tool to aid diagnosis and monitoring in several asthma phenotypes. More recently, FeNO has been evaluated in several other respiratory, infectious, and/or immunological conditions. In this short review, we provide an overview of several clinical studies and discuss the status of potential applications of NO measurements in clinical conditions beyond asthma.
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Affiliation(s)
- Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden;
| | - Dora Ludviksdottir
- Department of Respiratory Medicine and Sleep, Landspitali University Hospital, Reykjavik, Iceland
| | - Ellen Tufvesson
- Department of Respiratory Medicine and Allergology, Institute for Clinical Science, Lund University, Lund, Sweden
| | - Giovanni Rolla
- Department of Medical Sciences, Allergology and Clinical Immunology, University of Torino, Torino, Italy
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Institute for Clinical Science, Lund University, Lund, Sweden
| | - Kjell Alving
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Zuzana Diamant
- Department of Respiratory Medicine and Allergology, Institute for Clinical Science, Lund University, Lund, Sweden.,Department of Clinical Pharmacy & Pharmacology, University Medical Centre Groningen, Groningen, The Netherlands.,Department of General Practice, University Medical Centre Groningen, Groningen, The Netherlands.,QPS Netherlands, Groningen, The Netherlands
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Kauke T, Kneidinger N, Martin B, Dick A, Schneider C, Schramm R, Meimarakis G, Preissler G, Eickelberg O, von Dossow V, Behr J, Hatz R, Neurohr C, Winter H. Bronchiolitis obliterans syndrome due to donor-specific HLA-antibodies. ACTA ACUST UNITED AC 2015. [PMID: 26204790 DOI: 10.1111/tan.12626] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Chronic lung allograft dysfunction (CLAD) is a limiting factor for long-term survival in lung transplant recipients. Donor-specific human leukocyte antigen (HLA)-antibodies (DSA) have been suggested as potential risk factors for CLAD. However, their impact on clinical outcome following lung transplantation remains controversial. We performed a single-center study of 120 lung transplant recipients transplanted between 2006 and 2011. Patient sera were investigated before and after transplantation. The sera were screened by means of Luminex(®) technology (Luminex Inc., Austin, TX, USA) for IgG-HLA-class I and class II antibodies (ab). Using single antigen beads, DSA were identified and correlated retrospectively with clinical parameters. After transplantation 39 out of 120 patients (32.5%) were positive for HLA-ab. The incidence of de novo DSA formation was 27 of 120 patients (22.5%). Eleven of 27 (41%) of de novo DSA-positive patients developed BOS compared to 13 of 93 (14%) DSA-negative patients (p = 0.002). Furthermore, the generation of de novo DSA was independently associated with the development of BOS in multivariable analysis [hazard ration (HR) 2.5, 95% confidence interval (CI) 1.0-6.08; p = 0.046). Our results indicate that de novo DSA are associated with the development of BOS after lung transplantation. Monitoring of HLA-ab after transplantation is useful for identifying high-risk patients and offers an opportunity for early therapeutic intervention.
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Affiliation(s)
- T Kauke
- Laboratory for Immunogenetics, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany.,Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - N Kneidinger
- Department of Internal Medicine V, University Hospital Grosshadern, Ludwig-Maximilians-University, and Asklepios Fachkliniken München-Gauting, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - B Martin
- Department of Internal Medicine V, University Hospital Grosshadern, Ludwig-Maximilians-University, and Asklepios Fachkliniken München-Gauting, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - A Dick
- Laboratory for Immunogenetics, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - C Schneider
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - R Schramm
- Department of Cardiac Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - G Meimarakis
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - G Preissler
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - O Eickelberg
- Comprehensive Pneumology Center Munich (CPC-M), Institute of Lung Biology and Disease, Helmholtz Zentrum München, Member of the German Center for Lung Research (DZL), Munich, Germany
| | - V von Dossow
- Department of Anaesthesiology, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich Lung Transplant Group (MLTP), Munich, Germany
| | - J Behr
- Department of Internal Medicine V, University Hospital Grosshadern, Ludwig-Maximilians-University, and Asklepios Fachkliniken München-Gauting, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - R Hatz
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
| | - C Neurohr
- Department of Internal Medicine V, University Hospital Grosshadern, Ludwig-Maximilians-University, and Asklepios Fachkliniken München-Gauting, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - H Winter
- Department of General, Visceral, Transplantation, Vascular and Thoracic Surgery, University Hospital Grosshadern, Ludwig-Maximilians-University, Munich, Germany
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Rosewich M, Zissler UM, Kheiri T, Voss S, Eickmeier O, Schulze J, Herrmann E, Dücker RP, Schubert R, Zielen S. Airway inflammation in children and adolescents with bronchiolitis obliterans. Cytokine 2015; 73:156-62. [PMID: 25748838 DOI: 10.1016/j.cyto.2014.10.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 09/22/2014] [Accepted: 10/28/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Airway inflammation plays a major role in the progression of chronic lung diseases. The features of airway inflammation are not well defined among patients with cases of bronchiolitis obliterans (BO) that began in childhood. OBJECTIVES To investigate the sputum cell and cytokine profiles of stable cases of BO regarding lung function and the involvement of small airway disease (SAD). METHODS Twenty patients with BO (median age=14.5, range=7-23years) and 22 healthy controls (median age=16.5years, range=7-24years) were investigated. Lung function parameters and bronchial reversibility testing as well as sputum cell and cytokine profiles (IL-1β, IL-6, IL-8, TNF-α, IL-5, IFN-γ, and NFκB regulation) were analysed using quantitative RT-PCR and cytometric bead assay (CBA) in induced sputum. RESULTS Patients with BO had significantly lower lung function values, including FVC, forced expiratory volume (FEV1), the Tiffeneau index (FEV1/VC), and MEF25, but increased functional residual capacity (RV/TLC) values. Bronchial reversibility was found in five patients (25%). Moreover, airway inflammation (as indicated by total cells, neutrophils, IL-1β, IL-6, IL-8, TNF-α, and NFκB) was significantly increased among patients with BO compared with controls. CONCLUSIONS BO is predominantly a neutrophilic disease of the small bronchioles featuring elevated levels of pro-inflammatory cytokines leading to tissue remodelling and fibrosis of the small airways. Future therapies for patients with BO should more efficiently target the small airways.
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Affiliation(s)
- Martin Rosewich
- Department of Paediatric Pulmonology, Allergy and Cystic Fibrosis, Children's Hospital, Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany.
| | - Ulrich M Zissler
- Center of Allergy and Environment (ZAUM), Technical University and Helmholtz Center Munich, Germany
| | - Tanja Kheiri
- Department of Paediatric Pulmonology, Allergy and Cystic Fibrosis, Children's Hospital, Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Sandra Voss
- Department of Paediatric Pulmonology, Allergy and Cystic Fibrosis, Children's Hospital, Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Olaf Eickmeier
- Department of Paediatric Pulmonology, Allergy and Cystic Fibrosis, Children's Hospital, Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Johannes Schulze
- Department of Paediatric Pulmonology, Allergy and Cystic Fibrosis, Children's Hospital, Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Ruth Pia Dücker
- Department of Paediatric Pulmonology, Allergy and Cystic Fibrosis, Children's Hospital, Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Ralf Schubert
- Department of Paediatric Pulmonology, Allergy and Cystic Fibrosis, Children's Hospital, Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Stefan Zielen
- Department of Paediatric Pulmonology, Allergy and Cystic Fibrosis, Children's Hospital, Goethe-University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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Fractional Exhaled Nitric Oxide: Indications and Interpretation. DIAGNOSTIC TESTS IN PEDIATRIC PULMONOLOGY 2015. [DOI: 10.1007/978-1-4939-1801-0_14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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12
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Serial monitoring of exhaled nitric oxide in lung transplant recipients. J Heart Lung Transplant 2014; 34:557-62. [PMID: 25447582 DOI: 10.1016/j.healun.2014.09.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 08/19/2014] [Accepted: 09/19/2014] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Exhaled nitric oxide (FeNO), a marker of airway inflammation, is often elevated in lung transplant recipients (LTxRs) with acute rejection or infection. Isolated measurements in the setting of bronchiolitis obliterans syndrome have been variable. We sought to assess the utility of serial FeNO in predicting chronic allograft dysfunction or the presence of acute rejection or infection. METHODS Eighty-six LTxRs underwent 325 serial FeNO measurements at an expiratory flow rate of 50 ml/s. The change in FeNO (ΔFeNO) between two measurements obtained during a stable state (ΔFeNO-SS) was compared with ΔFeNO, where the first measurement was taken during a stable state and the second during an unstable state (defined as a subsequent decline in FEV1 > 10% over 3 months [ΔFeNO-SU]) or an acute complication (acute rejection, lymphocytic bronchiolitis or acute infection [ΔFeNO-SAC]). The median follow-up time after the baseline FeNO was 10 (range 3 to 25) months. RESULTS ΔFeNO-SS in 117 FeNO pairs was similar to ΔFeNO-SU in 26 pairs (2.1 ± 3 ppb vs 2.3 ± 4 ppb; p = 0.2). ΔFeNO-SAC in 17 pairs was markedly increased (27 ± 20 ppb; p < 0.001 vs ΔFeNO-SS). The area under the receiver-operating characteristic curve for ΔFeNO in detecting an acute complication was 0.93 (p < 0.001). By applying a cut-off of >10 ppb, the sensitivity and specificity was 82% and 100%, respectively, with positive and negative predictive values of 100% and 97.5%. CONCLUSIONS Changes in FeNO may serve as a useful adjunct in the detection of acute complications after lung transplantation. In this limited analysis, ΔFeNO was not predictive of a subsequent decline in allograft function.
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Galbán CJ, Boes JL, Bule M, Kitko CL, Couriel DR, Johnson TD, Lama V, Telenga ED, van den Berge M, Rehemtulla A, Kazerooni EA, Ponkowski MJ, Ross BD, Yanik GA. Parametric response mapping as an indicator of bronchiolitis obliterans syndrome after hematopoietic stem cell transplantation. Biol Blood Marrow Transplant 2014; 20:1592-8. [PMID: 24954547 DOI: 10.1016/j.bbmt.2014.06.014] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Accepted: 06/10/2014] [Indexed: 12/21/2022]
Abstract
The management of bronchiolitis obliterans syndrome (BOS) after hematopoietic cell transplantation presents many challenges, both diagnostically and therapeutically. We developed a computed tomography (CT) voxel-wise methodology termed parametric response mapping (PRM) that quantifies normal parenchyma, functional small airway disease (PRM(fSAD)), emphysema, and parenchymal disease as relative lung volumes. We now investigate the use of PRM as an imaging biomarker in the diagnosis of BOS. PRM was applied to CT data from 4 patient cohorts: acute infection (n = 11), BOS at onset (n = 34), BOS plus infection (n = 9), and age-matched, nontransplant control subjects (n = 23). Pulmonary function tests and bronchoalveolar lavage were used for group classification. Mean values for PRM(fSAD) were significantly greater in patients with BOS (38% ± 2%) when compared with those with infection alone (17% ± 4%, P < .0001) and age-matched control subjects (8.4% ± 1%, P < .0001). Patients with BOS had similar PRM(fSAD) profiles, whether a concurrent infection was present or not. An optimal cut-point for PRM(fSAD) of 28% of the total lung volume was identified, with values >28% highly indicative of BOS occurrence. PRM may provide a major advance in our ability to identify the small airway obstruction that characterizes BOS, even in the presence of concurrent infection.
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Affiliation(s)
- Craig J Galbán
- Department of Radiology, University of Michigan, Ann Arbor, Michigan.
| | - Jennifer L Boes
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Maria Bule
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Carrie L Kitko
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan
| | - Daniel R Couriel
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Timothy D Johnson
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Vihba Lama
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Eef D Telenga
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Maarten van den Berge
- Department of Pulmonary Diseases, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Alnawaz Rehemtulla
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Ella A Kazerooni
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Michael J Ponkowski
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan
| | - Brian D Ross
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Gregory A Yanik
- Blood and Marrow Transplant Program, University of Michigan, Ann Arbor, Michigan; Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Donohue JF, Jain N. Exhaled nitric oxide to predict corticosteroid responsiveness and reduce asthma exacerbation rates. Respir Med 2013; 107:943-52. [DOI: 10.1016/j.rmed.2013.02.018] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 02/13/2013] [Accepted: 02/21/2013] [Indexed: 10/27/2022]
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Jungraithmayr W, Jang JH, Schrepfer S, Inci I, Weder W. Small Animal Models of Experimental Obliterative Bronchiolitis. Am J Respir Cell Mol Biol 2013; 48:675-84. [DOI: 10.1165/rcmb.2012-0379tr] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Kovacs D, Bikov A, Losonczy G, Murakozy G, Horvath I. Follow up of lung transplant recipients using an electronic nose. J Breath Res 2013; 7:017117. [DOI: 10.1088/1752-7155/7/1/017117] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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17
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Bronchiolitis obliterans after allogeneic hematopoietic SCT: further insight—new perspectives? Bone Marrow Transplant 2013; 48:1224-9. [DOI: 10.1038/bmt.2013.17] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Revised: 01/16/2013] [Accepted: 01/23/2013] [Indexed: 01/11/2023]
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Manna A, Caffarelli C, Varini M, Dascola CP, Montella S, Maglione M, Sperlì F, Santamaria F. Clinical application of exhaled nitric oxide measurement in pediatric lung diseases. Ital J Pediatr 2012; 38:74. [PMID: 23273317 PMCID: PMC3545741 DOI: 10.1186/1824-7288-38-74] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 12/19/2012] [Indexed: 12/18/2022] Open
Abstract
Fractional exhaled nitric oxide (FeNO) is a non invasive method for assessing the inflammatory status of children with airway disease. Different ways to measure FeNO levels are currently available. The possibility of measuring FeNO levels in an office setting even in young children, and the commercial availability of portable devices, support the routine use of FeNO determination in the daily pediatric practice. Although many confounding factors may affect its measurement, FeNO is now widely used in the management of children with asthma, and seems to provide significantly higher diagnostic accuracy than lung function or bronchial challenge tests. The role of FeNO in airway infection (e.g. viral bronchiolitis and common acquired pneumonia), in bronchiectasis, or in cases with diffuse lung disease is less clear. This review focuses on the most recent advances and the current clinical applications of FeNO measurement in pediatric lung disease.
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Affiliation(s)
- Angelo Manna
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
| | - Carlo Caffarelli
- Department of Pediatrics, University Hospital of Parma, Parma, Italy
| | - Margherita Varini
- Department of Pediatrics, University Hospital of Parma, Parma, Italy
| | | | - Silvia Montella
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
| | - Marco Maglione
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
| | - Francesco Sperlì
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
| | - Francesca Santamaria
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
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Spitale N, Popat N, McIvor A. Update on exhaled nitric oxide in pulmonary disease. Expert Rev Respir Med 2012; 6:105-15. [PMID: 22283583 DOI: 10.1586/ers.12.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The ability to assess the inflammatory status of a patient's airway using a noninvasive method is the ideal situation for clinicians. Owing in part to the relationship between the levels of exhaled nitric oxide to inflammation and the ease of the technique, the measurement of the fraction of exhaled nitric oxide (F(E)NO) has achieved considerable attention, particularly with respect to asthma. A multitude of studies have shown that when measured in exhaled air, this unique molecule has the potential to have both diagnostic and therapeutic roles in the clinical setting for many pulmonary diseases. The incorporation of F(E)NO into asthma management and treatment algorithms may help shed further insight on the current control and future risk of patients. Research is ongoing to determine the biology and the benefits of the use of F(E)NO in respiratory conditions in addition to asthma. This review will briefly outline the pathophysiology of nitric oxide, the measurement of F(E)NO and the potential clinical uses of F(E)NO in asthma and a number of other respiratory diseases. Despite its promise, until further research is conducted, the use of F(E)NO cannot be recommended for routine clinical management of respiratory diseases at present, but should be considered as an adjuvant to help guide therapy in certain patients with asthma and in those with eosinophilic bronchitis.
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Affiliation(s)
- Naomi Spitale
- Division of Respirology, Department of Medicine, The Ottawa Hospital, ON, Canada
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Fazekas T, Eickhoff P, Lawitschka A, Knotek B, Pötschger U, Peters C. Exhaled nitric oxide and pulmonary complications after paediatric stem cell transplantation. Eur J Pediatr 2012; 171:1095-101. [PMID: 22350283 PMCID: PMC7102378 DOI: 10.1007/s00431-012-1692-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 02/02/2012] [Indexed: 11/25/2022]
Abstract
UNLABELLED Pulmonary complications are major causes of morbidity and mortality after haematopoietic stem cell transplantation (HSCT). We hypothesise that elevated exhaled nitric oxide (FeNO) levels early after HSCT in children are predictive for pulmonary complications. The present prospective study included 30 children (age, 4-18 years) before HSCT. FeNO levels were evaluated 10 days before transplant, at day 0, day +28 and day +60 after HSCT. During the follow-up period until day +100, pulmonary complications and lung function were assessed. Before HSCT, the mean FeNO levels were comparable in children with or without post-transplant pulmonary complications. However, they differed at day 0 and day +28 with a mean of 7 (±1.95) and 13 (±3.44) ppb at day 0 and a mean of 13 (±3.44) and 14 (±3.57) ppb at day +28, respectively. CONCLUSION Children with pulmonary complications after day +28 have higher mean FeNO levels 28 days after HSCT than children without later pulmonary complications. Therefore, FeNO could be an important diagnostic tool for hyperinflammatory response in bronchial epithelium after paediatric HSCT.
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Affiliation(s)
- T Fazekas
- St. Anna Children's Hospital, Kinderspitalgasse 6, 1090, Vienna, Austria.
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Antus B, Barta I, Csiszer E. Exhaled nitric oxide in diagnosis of bronchiolitis obliterans syndrome in lung transplant recipients: possible limitations. Am J Transplant 2011; 11:2774-5; author reply 2776-7. [PMID: 22054303 DOI: 10.1111/j.1600-6143.2011.03780.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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