1
|
Mehra R, Tjurmina OA, Ajijola OA, Arora R, Bolser DC, Chapleau MW, Chen PS, Clancy CE, Delisle BP, Gold MR, Goldberger JJ, Goldstein DS, Habecker BA, Handoko ML, Harvey R, Hummel JP, Hund T, Meyer C, Redline S, Ripplinger CM, Simon MA, Somers VK, Stavrakis S, Taylor-Clark T, Undem BJ, Verrier RL, Zucker IH, Sopko G, Shivkumar K. Research Opportunities in Autonomic Neural Mechanisms of Cardiopulmonary Regulation: A Report From the National Heart, Lung, and Blood Institute and the National Institutes of Health Office of the Director Workshop. JACC Basic Transl Sci 2022; 7:265-293. [PMID: 35411324 PMCID: PMC8993767 DOI: 10.1016/j.jacbts.2021.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 12/22/2022]
Abstract
This virtual workshop was convened by the National Heart, Lung, and Blood Institute, in partnership with the Office of Strategic Coordination of the Office of the National Institutes of Health Director, and held September 2 to 3, 2020. The intent was to assemble a multidisciplinary group of experts in basic, translational, and clinical research in neuroscience and cardiopulmonary disorders to identify knowledge gaps, guide future research efforts, and foster multidisciplinary collaborations pertaining to autonomic neural mechanisms of cardiopulmonary regulation. The group critically evaluated the current state of knowledge of the roles that the autonomic nervous system plays in regulation of cardiopulmonary function in health and in pathophysiology of arrhythmias, heart failure, sleep and circadian dysfunction, and breathing disorders. Opportunities to leverage the Common Fund's SPARC (Stimulating Peripheral Activity to Relieve Conditions) program were characterized as related to nonpharmacologic neuromodulation and device-based therapies. Common themes discussed include knowledge gaps, research priorities, and approaches to develop novel predictive markers of autonomic dysfunction. Approaches to precisely target neural pathophysiological mechanisms to herald new therapies for arrhythmias, heart failure, sleep and circadian rhythm physiology, and breathing disorders were also detailed.
Collapse
Key Words
- ACE, angiotensin-converting enzyme
- AD, autonomic dysregulation
- AF, atrial fibrillation
- ANS, autonomic nervous system
- Ach, acetylcholine
- CNS, central nervous system
- COPD, chronic obstructive pulmonary disease
- CSA, central sleep apnea
- CVD, cardiovascular disease
- ECG, electrocardiogram
- EV, extracellular vesicle
- GP, ganglionated plexi
- HF, heart failure
- HFpEF, heart failure with preserved ejection fraction
- HFrEF, heart failure with reduced ejection fraction
- HRV, heart rate variability
- LQT, long QT
- MI, myocardial infarction
- NE, norepinephrine
- NHLBI, National Heart, Lung, and Blood Institute
- NPY, neuropeptide Y
- NREM, non-rapid eye movement
- OSA, obstructive sleep apnea
- PAH, pulmonary arterial hypertension
- PV, pulmonary vein
- REM, rapid eye movement
- RV, right ventricular
- SCD, sudden cardiac death
- SDB, sleep disordered breathing
- SNA, sympathetic nerve activity
- SNSA, sympathetic nervous system activity
- TLD, targeted lung denervation
- asthma
- atrial fibrillation
- autonomic nervous system
- cardiopulmonary
- chronic obstructive pulmonary disease
- circadian
- heart failure
- pulmonary arterial hypertension
- sleep apnea
- ventricular arrhythmia
Collapse
Affiliation(s)
- Reena Mehra
- Cleveland Clinic, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Olga A. Tjurmina
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | | | - Rishi Arora
- Feinberg School of Medicine at Northwestern University, Chicago, Illinois, USA
| | | | - Mark W. Chapleau
- University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | | | | | | | - Michael R. Gold
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - David S. Goldstein
- National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA
| | - Beth A. Habecker
- Oregon Health and Science University School of Medicine, Portland, Oregon, USA
| | - M. Louis Handoko
- Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | | | - James P. Hummel
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | | | | | | | - Marc A. Simon
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- University of California-San Francisco, San Francisco, California, USA
| | | | - Stavros Stavrakis
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | | | | | - Richard L. Verrier
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - George Sopko
- National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | | |
Collapse
|
2
|
Nguyen VN, Chavannes NH. Correlation between fractional exhaled nitric oxide and Asthma Control Test score and spirometry parameters in on-treatment-asthmatics in Ho Chi Minh City. J Thorac Dis 2020; 12:2197-2209. [PMID: 32642125 PMCID: PMC7330382 DOI: 10.21037/jtd.2020.04.01] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Background Although fractional exhaled nitric oxide (FeNO) is a reliable and easily applied marker of airway inflammation in asthma, the relationship between FeNO and indicators of asthma control [Asthma Control Test (ACT) score] and/or severity (spirometry parameters) remains unclear. This study aims to determine possible correlations between FeNO and ACT score; and between FeNO and spirometry parameters. Methods A cross-sectional study with convenience sampling was conducted among ambulatory patients in the Asthma & COPD clinic at the University Medical Center, Ho Chi Minh City from March 2016 to March 2017. Using measurement of FeNO, the ACT questionnaire and a spirometry test, correlations were determined between FeNO and the ACT score and spirometry parameters. Results Four hundred and ten asthmatic patients (mean age 42 years; 65% female) were included and analyzed; their mean time since onset of asthma was 9.5 years. All patients were treated following step 2 to 4 of GINA guidelines. Mean (SD) FeNO was 29.5 (24.4) parts per billion (ppb) and mean (SD) ACT score was 20.5 (40). A significant difference in FeNO values was found among the three groups with different asthma control levels categorized according to the ACT score (P=0.001) but was not found among the three groups with different asthma treatment levels (P=0.425). FeNO was significantly inversely correlated with the ACT score (Spearman’s r =−0.224, P<0.001) and with spirometry parameters indicate airway obstruction such as predicted FEV1, FEV1/FVC, predicted PEF and predicted FEF25–75% with Spearman’s r were −0.187; −0.143; −0.091 and −0.195, respectively (all P<0.05), whereas no correlation between FeNO and FVC—an indicator of airway restriction—was found. Conclusions In these asthmatic patients in Vietnam, an inverse correlation was found between FeNO and the ACT score and between FeNO and spirometry indicators of airway obstruction. Therefore, FeNO may be a useful tool in asthma management.
Collapse
Affiliation(s)
- Vinh Nhu Nguyen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.,Department of Family Medicine, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam.,Department of Respiratory Functional Exploration, University Medical Center, Ho Chi Minh City, Vietnam
| | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
3
|
Application of Inflammatory Markers in Induced Sputum in Stable Chronic Obstructive Pulmonary Disease Patients with Positive Bronchodilation Tests. Curr Med Sci 2019; 39:560-567. [PMID: 31346991 DOI: 10.1007/s11596-019-2074-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 05/21/2019] [Indexed: 01/02/2023]
Abstract
Positive bronchodilation (BD) tests can be noticed in some stable chronic obstructive pulmonary disease (COPD) patients. The characteristics of airway inflammation in this entity remain unclear. Our study aimed to identify the characteristics of airway inflammation in stable COPD patients with positive BD tests. The airway inflammation was assessed in 88 patients with stable COPD using the examination of induced sputum in the aftermath of lung function and BD tests. Cellular counts and the levels of molecular markers including eosinophil cationic protein (ECP), myeloperoxidase (MPO), interleukin-5 (IL-5), and IL-8 were assayed by Wright's stain, Immuno-CAP system, and ELISA, RT-PCR. Among the 88 patients with stable COPD, 20 (22.7%) showed positive BD tests. The values of eosinophils (4.7%±3.4%) and ECP (90.1±41.6 ng/mL) in induced sputum in stable COPD patients with positive BD tests were markedly elevated as compared with those in stable COPD patients with negative BD tests or in healthy controls (all P>0.05), but significantly lower than those in asthmatic patients (all P<0.01). The IL-5 in sputum supernatant was significantly decreased in stable COPD patients with positive BD tests as compared with the patients with asthma (12.5±7.8 vs. 48.2±26.0 ng/mL;.P<0.01). However, healthy controls exhibited similar concentrations of IL-5 in induced sputum with patients with stable COPD, whether with positive or negative BD tests (all P>0.05). Moreover, the values of neutrophils (61.8%±15.1%), MPO (574.0±111.8 ng/mL), and IL-8 (32.6±13.4 ng/mL) in induced sputum in stable COPD patients with positive BD tests were significantly higher than those in asthmatics or normal controls (all P<0.01). However, the values of the above inflammatory markers in induced sputum were similar among stable COPD patients with positive or negative BD tests (all P>0.05). The stable COPD patients with positive BD tests may present not only eosinophilic airway inflammation but also neutrophilic airway inflammation.
Collapse
|
4
|
Comberiati P, Katial RK, Covar RA. Bronchoprovocation Testing in Asthma: An Update. Immunol Allergy Clin North Am 2019; 38:545-571. [PMID: 30342579 DOI: 10.1016/j.iac.2018.06.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Bronchial hyperresponsiveness (BHR) is defined as a heightened bronchoconstrictive response to airway stimuli. It complements the cardinal features in asthma, such as variable or reversible airflow limitation and airway inflammation. Although BHR is considered a pathophysiologic hallmark of asthma, it should be acknowledged that this property of the airway is dynamic, because its severity and even presence can vary over time with disease activity, triggers or specific exposure, and with treatment. In addition, it is important to recognize that there is a component that is not reflective of a specific disease entity.
Collapse
Affiliation(s)
- Pasquale Comberiati
- Department of Clinical and Experimental Medicine, Section of Paediatrics, University of Pisa, 56126 Pisa, Italy; Department of Clinical Immunology and Allergology, I.M. Sechenov First Moscow State Medical University, 119991 Moscow, Russia
| | - Rohit K Katial
- National Jewish Health, 1400 Jackson Street (J321), Denver, CO 80206, USA
| | - Ronina A Covar
- National Jewish Health, 1400 Jackson Street (J321), Denver, CO 80206, USA.
| |
Collapse
|
5
|
Asthma control in preschool children with small airway function as measured by IOS and fractional exhaled nitric oxide. Respir Med 2018; 145:8-13. [PMID: 30509720 DOI: 10.1016/j.rmed.2018.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 09/04/2018] [Accepted: 10/10/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVE This study investigated the accuracy of impulse oscillometry (IOS) combined with fractional exhaled nitric oxide (FeNO) to assess asthma control among preschool children. METHODS A total of 79 preschool children(3-6 year old) with asthma and 25 healthy preschool children who visited a paediatrician were enrolled in this study. All of the children were tested for allergens, respiratory system resistance (at 5 and 20 Hz [R5, R20]), respiratory system reactance (at 5 Hz [X5]), the resonant frequency of reactance (Fres), and the area under the reactance curve (between 5 Hz and Fres (reactance area [AX]) using IOS and FeNO. A paediatric respiratory specialist who was unaware of the IOS and FeNO results assigned children with asthma to either the asthma-controlled group (n = 27) or the asthma-uncontrolled group (n = 52) based on the Global Initiative for Asthma (GINA) criteria. A healthy control group (n = 25) was also included. The relationships between the FeNO and IOS values as well as the asthma control of the three groups were analysed, and the areas under the curve (AUCs) were calculated for each measure. RESULTS (1) During the controlled group, means±standard deviations of AX, R5-20, R5, X5 and FeNO were 26.15 ± 7.534, 3.52 ± 1.311,9.97 ± 1.576,-3.85 ± 0.572,-3.85 ± 0.572. During the uncontrolled group, means±standard deviations of AX,R5-20,R5,X5 and FeNO were 38.34 ± 13.563,5.36 ± 1.545,11.41 ± 2.029,-5.07 ± 1.554,36.40 ± 21.07. Among preschool children, significant differences were observed between the controlled and uncontrolled group with regard to the small airway functional parameters (AX, R5-20, R5, and X5) and FeNO(P <0.05).(2) A receiver operating characteristic (ROC) analysis showed that the AUCs were 0.786 for FeNO alone, 0.751 for X5 alone, and 0.866 for X5 combined with FeNO (cut-off value: 27 ppb). CONCLUSION FeNO combined with the small airway function parameter X5 accurately assessed asthma control among preschool children.
Collapse
|
6
|
Thomas B, Chay OM, Allen JC, Chiang ASX, Pugalenthi A, Goh A, Wong P, Teo AH, Tan SG, Teoh OH. Concordance between bronchial hyperresponsiveness, fractional exhaled nitric oxide, and asthma control in children. Pediatr Pulmonol 2016; 51:1004-1009. [PMID: 27074221 DOI: 10.1002/ppul.23426] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 02/16/2016] [Accepted: 02/24/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Previous studies on association between level of asthma control, markers of airway inflammation and the degree of bronchial hyperresponsiveness (BHR) have yielded conflicting results. Our aim was to determine the presence and severity of BHR and the concordance between BHR, asthma control, and fractional exhaled nitric oxide (FeNO) in children with asthma on therapy. METHODS In this cross-sectional observational study, children (aged 6-18 years) with asthma on British Thoracic Society (BTS) treatment steps 2 or 3, underwent comprehensive assessment of their asthma control (clinical assessment, spirometry, asthma control test [ACT], Pediatric Asthma Quality of Life Questionnaire [PAQLQ]), measurement of FeNO and BHR (using mannitol dry powder bronchial challenge test [MCT], Aridol™, Pharmaxis, Australia). RESULTS Fifty-seven children (63% male) were studied. Twenty-seven children were on BTS treatment step 2 and 30 were on step 3. Overall, 25 out of 57 (43.8%) children had positive MCT. Of note, 9 out of 27 (33.3%) children with clinically controlled asthma had positive MCT. Analyses of pair-wise agreement between MCT (positive or negative), FeNO (>25 or ≤25 ppb) and clinical assessment of asthma control (controlled or partially controlled/uncontrolled) showed poor agreement between these measures. CONCLUSIONS A substantial proportion of children with asthma have persistent BHR despite good clinical control. The concordance between clinical assessment of asthma control, BHR and FeNO was observed to be poor. Our findings raise concerns in the context of emerging evidence for the role of bronchoconstriction in inducing epithelial stress that may drive airway remodeling in asthma. Pediatr Pulmonol. 2016;51:1004-1009. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Biju Thomas
- Department of Pediatric Respiratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore. , .,Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857, Singapore. ,
| | - Oh Moh Chay
- Department of Pediatric Respiratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore.,Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857, Singapore
| | - John C Allen
- Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857, Singapore
| | - Andrea Shu Xian Chiang
- Department of Pediatric Respiratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore
| | - Arun Pugalenthi
- Department of Pediatric Respiratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore.,Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857, Singapore
| | - Anne Goh
- Department of Pediatric Respiratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore.,Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857, Singapore
| | - Petrina Wong
- Department of Pediatric Respiratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore
| | - Ai Huay Teo
- Department of Pediatric Respiratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore
| | - Soh Gin Tan
- Department of Pediatric Respiratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore
| | - Oon Hoe Teoh
- Department of Pediatric Respiratory Medicine, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore 229899, Singapore.,Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857, Singapore
| |
Collapse
|
7
|
Galera R, Casitas R, Martínez-Cerón E, Romero D, García-Río F. Does airway hyperresponsiveness monitoring lead to improved asthma control? Clin Exp Allergy 2016; 45:1396-405. [PMID: 25817630 DOI: 10.1111/cea.12539] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The current guidelines recommend an approach to asthma management based on asthma control, rather than asthma severity. Although several specific questionnaires have been developed and control criteria have been established based on clinical guidelines, the evaluation of asthma control is still not optimal. In general, these indicators provide adequate assessment of current control, but they are more limited when estimating future risk. There is much evidence demonstrating the persistence of airway inflammation and airway hyperresponsiveness (AHR) in patients with total control. Therefore, the objective of this review was to analyse the possible role of AHR monitoring as an instrument for assessing asthma control. We will evaluate its capacity as an indicator for future risk, both for estimating the possibility of clinical deterioration and loss of lung function or exacerbations. Furthermore, its relationship with inhaled corticosteroid treatment will be analysed, while emphasizing its capacity for predicting response and adjusting dosage, as well as information about the capability of AHR for monitoring treatment. Last of all, we will discuss the main limitations and emerging opportunities of AHR as an assessment instrument for asthma control.
Collapse
Affiliation(s)
- R Galera
- Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - R Casitas
- Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - E Martínez-Cerón
- Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - D Romero
- Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - F García-Río
- Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain.,Universidad Autónoma de Madrid, Madrid, Spain.,CIBER de Enfermedades Respiratorias, Madrid, Spain
| |
Collapse
|
8
|
Muñoz X, Bustamante V, Lopez-Campos JL, Cruz MJ, Barreiro E. Usefulness of noninvasive methods for the study of bronchial inflammation in the control of patients with asthma. Int Arch Allergy Immunol 2015; 166:1-12. [PMID: 25765083 DOI: 10.1159/000371849] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Bronchial asthma is one of the most prevalent respiratory conditions. Although it is defined as an inflammatory disease, the current guidelines for both diagnosis and follow-up of patients are based only on clinical and lung function parameters. Current research is focused on finding markers that can accurately predict future risk, and on assessing the ability of these markers to guide medical treatment and thus improve prognosis. The use of noninvasive methods to study airway inflammation is gaining increasing support. The study of eosinophils in induced sputum has proved useful for the diagnosis of asthma; however, its clinical implementation is complex. Some studies have shown that the measurement of exhaled nitric oxide (FeNO) may also be useful to establish disease phenotypes and improve control. Others have found that the measurement of pH and certain markers of oxidative stress, cytokines and prostanoids in exhaled breath condensate (EBC) may also be useful as well as the measurement of the temperature of exhaled breath and the analysis of volatile organic compounds (VOCs). In conclusion, since asthma is an inflammatory disease, it seems appropriate to try to control it through the study of airway inflammation using noninvasive methods. In this regard, the analysis of induced sputum cells has proved very useful, although the clinical implementation of this technique seems difficult. Other techniques such as temperature measurement, the analysis of FeNO, the analysis of the VOCs in exhaled breath, or the study of certain biomarkers in EBC require further study in order to determine their clinical applicability.
Collapse
Affiliation(s)
- Xavier Muñoz
- Pulmonology Service, Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | | | | | | | | |
Collapse
|
9
|
Park HW, Jung JW, Kim KM, Kim TW, Lee SH, Lee CH, Goo JM, Min KU, Cho SH. Xenon ventilation computed tomography and the management of asthma in the elderly. Respirology 2014; 19:389-95. [PMID: 24512222 DOI: 10.1111/resp.12242] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Revised: 12/19/2012] [Accepted: 11/12/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Xenon ventilation computed tomography (CT) has shown potential in assessing the regional ventilation status in subjects with asthma. The purpose of this study was to evaluate the usefulness of xenon ventilation CT in the management of asthma in the elderly. METHODS Treatment-naïve asthmatics aged 65 years or older were recruited. Before initiation of medication, spirometry with bronchodilator (BD) reversibility, questionnaires to assess the severity of symptoms including a visual analogue scale (VAS), tests to evaluate cognitive function and mood, and xenon ventilation CT were performed. Xenon gas trapping (XT) on xenon ventilation CT represents an area where inhaled xenon gas was not expired and was trapped. Symptoms and lung functions were measured again after the 12-week treatment. RESULTS A total of 30 elderly asthmatics were enrolled. The severity of dyspnoea measured by the VAS showed a significant correlation with the total number of areas of XT on the xenon ventilation CT taken in the pre-BD wash-out phase (r = -0.723, P < 0.001). The total number of areas of XT significantly decreased after BD inhalation, and differences in the total number of areas of XT (between the pre- and post-BD wash-out phases) at baseline showed significant correlations with the per cent increases in forced expiratory volume in 1 s after subsequent anti-asthma treatment (r = -0.775, P < 0.001). CONCLUSIONS Xenon ventilation CT may be an objective and promising tool in the measurement of dyspnoea and prediction of the treatment response in elderly asthmatics.
Collapse
Affiliation(s)
- Heung-Woo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Diamant Z, Tufvesson E, Bjermer L. Which biomarkers are effective for identifying Th2-driven inflammation in asthma? Curr Allergy Asthma Rep 2014; 13:477-86. [PMID: 23918590 DOI: 10.1007/s11882-013-0376-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Recognition of asthma as a heterogeneous disease revealed different potential molecular targets and urged the development of targeted, customized treatment modalities. Evidence was provided for different inflammatory subsets of asthma and more recently, further refined to T helper (Th)2-high and Th2-low subphenotypes with different responsiveness to standard and targeted pharmacotherapy. Given these differences in immunology and pathophysiology, proof of concept studies of novel treatment modalities for asthma should be performed in adequate, well-defined phenotypes. In this review, we describe both existing and novel biomarkers of Th2-inflammation in asthma that can be applied to classify asthma subphenotypes in clinical studies and for treatment monitoring.
Collapse
Affiliation(s)
- Zuzana Diamant
- Institute for Clinical Science, Department of Respiratory Medicine and Allergology, Skane University Hospital, Lund University, Klinikgatan 18, S-221 85, Lund, Sweden,
| | | | | |
Collapse
|
11
|
Hancox RJ, Subbarao P, Sears MR. Relevance of birth cohorts to assessment of asthma persistence. Curr Allergy Asthma Rep 2013; 12:175-84. [PMID: 22415313 DOI: 10.1007/s11882-012-0255-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The definition of persistent asthma in longitudinal studies reflects symptoms reported at every assessment with no substantive asymptomatic periods. Early-childhood wheezing may be transient, especially if it is of viral etiology. Longitudinal studies provide greater opportunity to confirm the diagnosis by variability of symptoms, objective measurements, and therapeutic responses. Several clinical phenotypes of childhood asthma have been identified, with general consistency between cohorts. Persistent wheezing is often associated with loss of lung function, which is evident from early-childhood and related to persistent inflammation and airway hyperresponsiveness. Female sex, atopy, airway responsiveness, and personal smoking, but not exposure to environmental tobacco smoke, are risk factors for persistence of childhood asthma into adulthood. The effect of breastfeeding remains controversial, but gene-environment interactions may partly explain outcomes. Understanding the natural history and underlying causes of asthma may lead to development of strategies for primary prevention.
Collapse
Affiliation(s)
- Robert J Hancox
- Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, New Zealand.
| | | | | |
Collapse
|
12
|
Muñoz X, Sanchez-Vidaurre S, Roca O, Torres F, Morell F, Cruz MJ. Bronchial inflammation and hyperresponsiveness in well controlled asthma. Clin Exp Allergy 2013; 42:1321-8. [PMID: 22925318 DOI: 10.1111/j.1365-2222.2012.04004.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little research has been devoted to the characteristics of bronchial inflammation in patients with stable, well controlled asthma. OBJECTIVE The aim of this study was to assess the degree and type of airway inflammation and to investigate the relationship between inflammation and bronchial hyperresponsiveness in patients with well controlled asthma. METHODS A cross-sectional study was conducted in 84 adult patients (43 men, mean age 43 years) with documented well controlled asthma. Induced sputum samples were obtained and cell types determined by differential cell count. Spirometry and methacholine challenge testing were performed. Asthma Control Questionnaire (ACQ) was used to assess symptoms. Patients were included if their ACQ score was < 0.75. RESULTS A total of 59 patients had persistent bronchial inflammation: 28 cases were considered eosinophilic, 28 neutrophilic, and 3 mixed. Median (range) percentage of eosinophils was 4% (0-64) in patients testing positive to methacholine challenge (n = 66) and 1% (0-3) in those testing negative (n = 18) (P = 0.003). A positive correlation was found between eosinophil percentage and the methacholine dose/response ratio (r = 0.477, P = 0.0001). The geometric mean (95% CI) of the methacholine PC20 was 1.74 mg/mL (1.04-2.93) in patients with eosinophilic inflammation and 4.14 mg/mL (2.5-6.84) in those with neutrophilic inflammation (P = 0.03). CONCLUSIONS Inflammation and bronchial hyperresponsiveness persist in most patients with well controlled asthma. CLINICAL RELEVANCE The study demonstrates that eosinophilic or neutrophilic inflammation persisted in most well controlled asthma patients despite the fact that their condition was controlled and therefore, measurement of bronchial inflammation seems essential to achieve proper asthma control.
Collapse
Affiliation(s)
- X Muñoz
- Pulmonology Service, Medicine Department, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | | | | | | | | | | |
Collapse
|
13
|
Efficacy of theophylline plus salmeterol/fluticasone propionate combination therapy in patients with asthma. Respir Med 2013; 107:347-54. [PMID: 23290154 DOI: 10.1016/j.rmed.2012.12.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 11/29/2012] [Accepted: 12/05/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To compare the efficacy of theophylline plus salmeterol/fluticasone propionate combination product (SFC) with SFC plus placebo in asthmatic patients. METHODS In this randomized, stratified, parallel-group study, 325 patients were randomized to receive either 200 mg theophylline plus 50/250 μg SFC or placebo tablet plus 50/250 μg SFC twice daily for 24 weeks. Outcome variables included the level of asthma control (assessed by the Asthma Control Test) and the number of patients experiencing ≥1 exacerbations during the 24-week treatment period. Testing of lung function as well as measurement of the levels of inflammatory markers in induced sputum was performed. RESULTS There were significantly fewer patients with ≥1 asthma exacerbation in the theophylline plus SFC group (29.6%) when compared with the SFC plus placebo group (46.9%) (p = 0.004). Theophylline plus SFC improved the FEF(25-75%) value, which indicates enhanced small airway function, to a greater extent than SFC plus placebo (66.9 ± 18.8% and 57.4 ± 17.6%, respectively; p < 0.001). A significant decrease in eosinophil count and concentration of eosinophil cationic protein in induced sputum was also seen in the theophylline plus SFC group when compared with the SFC plus placebo group (4.1 ± 2.2% and 6.3 ± 2.7%, 63.6 ± 39.5 μg/L and 89.4 ± 45.6 μg/L, respectively; all p < 0.01). CONCLUSION The combination of theophylline plus SFC may provide greater protection against asthma exacerbations, and its administration is accompanied by significant improvements in small airway function and airway inflammation.
Collapse
|
14
|
Davis BE, Cockcroft DW. Past, present and future uses of methacholine testing. Expert Rev Respir Med 2012; 6:321-9. [PMID: 22788946 DOI: 10.1586/ers.12.29] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Methacholine challenge testing is a valuable diagnostic and research tool used by clinicians to assist in the diagnosis of asthma, and by researchers to understand disease pathophysiology and assess novel therapeutic efficacy. The use of methacholine challenge in asthma relates to its direct effect on airway smooth muscle (i.e., bronchoconstriction) as a measure of airway hyperresponsiveness, a cardinal feature of asthma. Airway hyperresponsiveness has been documented in other airway disorders, including chronic obstructive pulmonary disease, cystic fibrosis and allergic rhinitis; however, there is little clinical application of methacholine challenge in these conditions as a diagnostic or disease management tool. The authors will review the aspects of methacholine challenge testing, as they relate to asthma, and point out its usefulness in clinical research. A brief review of past (historical) uses and speculation as to the future uses of methacholine challenge will also be discussed.
Collapse
Affiliation(s)
- Beth E Davis
- Department of Medicine, Division of Respirology, Critical Care and Sleep Medicine, Royal University Hospital, University of Saskatchewan, 103 Hospital Drive, Saskatoon, SK, S7N 0W8, Canada.
| | | |
Collapse
|
15
|
Farah CS, King GG, Brown NJ, Peters MJ, Berend N, Salome CM. Ventilation heterogeneity predicts asthma control in adults following inhaled corticosteroid dose titration. J Allergy Clin Immunol 2012; 130:61-8. [DOI: 10.1016/j.jaci.2012.02.015] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 02/03/2012] [Accepted: 02/16/2012] [Indexed: 10/28/2022]
|
16
|
Farah CS, King GG, Brown NJ, Downie SR, Kermode JA, Hardaker KM, Peters MJ, Berend N, Salome CM. The role of the small airways in the clinical expression of asthma in adults. J Allergy Clin Immunol 2012; 129:381-7, 387.e1. [DOI: 10.1016/j.jaci.2011.11.017] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 10/21/2011] [Accepted: 11/16/2011] [Indexed: 11/16/2022]
|
17
|
Bora M, Alpaydin AO, Yorgancioglu A, Akkas G, Isisag A, Coskun AS, Celik P. Does asthma control as assessed by the asthma control test reflect airway inflammation? Multidiscip Respir Med 2011; 6:291-8. [PMID: 22958759 PMCID: PMC3463081 DOI: 10.1186/2049-6958-6-5-291] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2011] [Accepted: 05/06/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND AND AIMS The treatment of asthmatic patients is particularly focused on the control of symptoms as well as functional and inflammatory parameters. In our study, we investigated the relationship between the asthma control test (ACT) which evaluates symptoms and airway inflammation and functional parameters. MATERIALS AND METHODS Stable asthmatic patients admitted to our pulmonary outpatient clinic were enrolled in the study consecutively and underwent the ACT, pulmonary function tests and methacholine bronchial provocation test (MBPT). Additionally, fractional exhaled nitric oxide level (FeNO) and induced sputum cell distribution were assessed. All these parameters were re-evaluated at the third month after adjusting medications of the patients according to baseline ACT scores. RESULTS Of the 101 patients screened, we analyzed 83 who proceeded to the follow up visit. At the baseline visit, 8 were totally controlled, 36 partially controlled and 39 uncontrolled according to ACT. At the follow up visit, 10 were totally controlled, 39 partially controlled and 34 uncontrolled. Comparison of the two visits in terms of all parameters revealed significant reductions only in the percentages of patients with MBPT positivity (p = 0.029) and FeNO levels > 20 ppb (p = 0.025) at follow up. The percentages of patients with FeNO > 20 ppb, MBPT positivity, induced sputum eosinophilia or induced sputum neutrophilia did not show significant differences between totally controlled, partially controlled and uncontrolled groups at both baseline and follow up visits. CONCLUSION Although the ACT scores did not show significant correlations with the airway inflammation parameters tested in this study, a marked reduction in the percentage of patients with MBPT positivity and FeNO > 20 ppb at follow up may suggest the importance of the control concept in the management of asthma.
Collapse
Affiliation(s)
- Mine Bora
- Celal Bayar University Medical Faculty, Department of Pulmonary Diseases, Manisa, Turkey.
| | | | | | | | | | | | | |
Collapse
|
18
|
Abstract
Exercise-induced bronchoconstriction (EIB) is common in individuals with asthma, and may be observed even in the absence of a clinical diagnosis of asthma. Exercise-induced bronchoconstriction can be diagnosed via standardized exercise protocols, and anti-inflammatory therapy with inhaled corticosteroids (ICS) is often warranted. Exercise-related symptoms are commonly reported in primary care; however, access to standardized exercise protocols to assess EIB are often restricted because of the need for specialized equipment, as well as time constraints. Symptoms and lung function remain the most accessible indicators of EIB, yet these are poor predictors of its presence and severity. Evidence suggests that exercise causes the airways to narrow as a result of the osmotic and thermal consequences of respiratory water loss. The increase in airway osmolarity leads to the release of bronchoconstricting mediators (eg, histamine, prostaglandins, leukotrienes) from inflammatory cells (eg, mast cells and eosinophils). The objective assessment of EIB suggests the presence of airway inflammation, which is sensitive to ICS in association with a responsive airway smooth muscle. Surrogate tests for EIB, such as eucapnic voluntary hyperpnea or the osmotic challenge tests, cause airway narrowing via a similar mechanism, and a response indicates likely benefit from ICS therapy. The complete inhibition of EIB with ICS therapy in individuals with asthma may be a useful marker of control of airway pathology. Furthermore, inhibition of EIB provides additional, useful information regarding the identification of clinical control based on symptoms and lung function. This article explores the inflammatory basis of EIB in asthma as well as the effect of ICS on the pathophysiology of EIB.
Collapse
Affiliation(s)
- John D Brannan
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, New South Wales, Australia.
| | | |
Collapse
|
19
|
Brannan JD. Bronchial hyperresponsiveness in the assessment of asthma control: Airway hyperresponsiveness in asthma: its measurement and clinical significance. Chest 2010; 138:11S-17S. [PMID: 20668013 DOI: 10.1378/chest.10-0231] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
The two key pathophysiologic features of asthma are bronchial hyperresponsiveness (BHR) and airway inflammation. Symptoms and lung function are the most accessible clinical markers for the diagnosis of asthma as well as for assessing asthma control using the most effective treatment of asthma, inhaled corticosteroids (ICS). However, BHR and inflammation usually take longer to resolve using ICS compared with symptoms and lung function. BHR can be assessed using "direct" stimuli that act on the airway smooth muscle (eg, methacholine) or "indirect" stimuli that require the presence of airway inflammation (eg, exercise, osmotic stimuli). Although there are practical limitations in using BHR to assess asthma control, efforts have been made to make BHR more accessible and standardized. Some studies have demonstrated that treatment aimed to decrease BHR with direct stimuli can lead to improved asthma control; however, it often results in the use of higher doses of ICS. Furthermore, BHR to direct stimuli does not usually resolve using ICS because of a fixed component. By contrast, BHR with an indirect stimulus indicates a responsive smooth muscle that occurs only in the presence of inflammation sensitive to ICS (eg, mast cells, eosinophils). BHR to indirect stimuli does resolve using ICS. Because ICS target both key pathophysiologic features of asthma, assessing indirect BHR in the presence of ICS will identify resolution or persistence of BHR and airway inflammation. This may provide a more clinically relevant marker for asthma control that may also lead to improving the clinical usefulness of ICS.
Collapse
Affiliation(s)
- John D Brannan
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, NSW, Australia.
| |
Collapse
|