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Fraser A, Simpson R, Turner S. Use of exhaled nitric oxide in the diagnosis and monitoring of childhood asthma: myth or maxim? Breathe (Sheff) 2023; 19:220236. [PMID: 38125803 PMCID: PMC10729813 DOI: 10.1183/20734735.0236-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/14/2023] [Indexed: 12/23/2023] Open
Abstract
Asthma is a common condition in children. This review describes the evidence from the literature and international asthma guidelines for using fractional exhaled nitric oxide (FENO) in the diagnosis and monitoring of childhood asthma. The accuracy of FENO measuring devices could be further improved, the difference in FENO results between devices are equivalent to what is considered a clinically important difference. For diagnosing asthma no guideline currently recommends FENO is used as the first test, but many recommend FENO as part of a series of tests. A cut-off of 35 ppb is widely recommended as being supportive of an asthma diagnosis, but evidence from children at risk of asthma suggests that a lower threshold of 25 ppb may be more appropriate. Nine randomised clinical trials including 1885 children have added FENO to usual asthma care and find that exacerbations are reduced when care is guided by FENO (OR for exacerbation compared to usual care 0.77, 95% CI 0.62-0.94). What is not clear is what cut-off(s) of FENO should be used to trigger a change in treatment. After 30 years of intensive research there is not sufficient evidence to recommend FENO for routine diagnosing and monitoring asthma in children. Educational aims To give the reader an overview of literature that supports and does not support the role of FENO in diagnosing asthma in children.To give the reader an overview of literature that supports and does not support the role of FENO in monitoring asthma in children.To give the reader an understanding of the role of FENO in international guidelines for diagnosing and monitoring asthma in children.
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Affiliation(s)
- Anna Fraser
- Child Health, Women and Children's Division, NHS Grampian, Aberdeen, UK
- Joint first authors
| | - Ruaraidh Simpson
- Child Health, Women and Children's Division, NHS Grampian, Aberdeen, UK
- Joint first authors
| | - Steve Turner
- Child Health, Women and Children's Division, NHS Grampian, Aberdeen, UK
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Ohara Y, Ohara T, Hashimoto K, Hosoya M. Exhaled carbon monoxide levels in infants and toddlers with episodic asthma. Fukushima J Med Sci 2020; 66:78-87. [PMID: 32595177 PMCID: PMC7470756 DOI: 10.5387/fms.2019-02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objective: There are few lung function tests available to evaluate bronchial asthma in infants and toddlers. The objective of this study was to test the hypothesis that the measurement of exhaled carbon monoxide (eCO) levels is applicable to evaluate infants and toddlers with stable asthma and during acute asthma attack. Methods: A one-way valve breath sampling bag was developed to collect the exhaled air of infants and toddlers. A total of 483 infants (under 2 years) and toddlers (2-5 years) were studied; 355 had an established diagnosis of asthma (182 suffering mild asthma attacks and 173 without active asthmatic symptoms), 119 had upper respiratory infection (URI) including acute bronchitis, and 9 were healthy. Results: In infants and toddlers, eCO levels of those with asthma attacks [median (interquartile range) = 2.0 (2.0-3.25) ppm, n=182] were significantly higher than those of subjects with asymptomatic asthma [2.0 (1.0-2.0) ppm, n=173, P < 0.0001], URI [2.0 (1.0-3.0) ppm, n=119, P < 0.0001], and healthy children [1.0 (0.0-1.0) ppm, n=9, P < 0.0001]. In 75 children with asthma petit mal, eCO levels during asthma attacks [3.0 (2.0-4.0) ppm] significantly decreased after therapy [1.0 (1.0-2.0) ppm, P < 0.0001]. In infants and toddlers with an established diagnosis of asthma (n=355), eCO cut-off >2 ppm discriminated asthma attack from an asymptomatic state with a sensitivity of 95.6%, a specificity of 43.3%, and an area under the curve (AUC) of 0.71 (95% CI: 0.65-0.76, P < 0.0001). In 401 infants and toddlers with some respiratory symptoms, of which 285 cases were finally diagnosed as asthma [eCO level = 2.0 (2.0-3.0) ppm] and 116 cases were not asthma [eCO level = 2.0 (1.0-3.0) ppm, P < 0.0001], eCO cut-off >3 ppm supported the final diagnosis of asthma with a sensitivity of 38.9%, a specificity of 74.1%, and AUC of 0.63 (95% CI: 0.56-0.69, P < 0.0001). Conclusion: The measurement of eCO by a novel method is applicable to evaluate asthmatic activity and treatment responsiveness, and to diagnose asthma in infants and toddlers.
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Affiliation(s)
| | - Takahiro Ohara
- Division of Community Medicine, Tohoku Medical and Pharmaceutical University
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Evolution of Airway Inflammation in Preschoolers with Asthma-Results of a Two-Year Longitudinal Study. J Clin Med 2020; 9:jcm9010187. [PMID: 31936693 PMCID: PMC7020050 DOI: 10.3390/jcm9010187] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/04/2020] [Accepted: 01/06/2020] [Indexed: 12/12/2022] Open
Abstract
Fractional exhaled nitric oxide (FeNO) is a non-invasive marker for eosinophilic airway inflammation and has been used for monitoring asthma. Here, we assess the characteristics of FeNO from preschool to school age, in parallel with asthma activity. A total of 167 asthmatic children and 66 healthy, age-matched controls were included in the 2-year prospective PreDicta study evaluating wheeze/asthma persistence in preschool-aged children. Information on asthma/rhinitis activity, infections and atopy was recorded at baseline. Follow-up visits were performed at 6-month intervals, as well as upon exacerbation/cold and 4–6 weeks later in the asthmatic group. We obtained 539 FeNO measurements from asthmatics and 42 from controls. At baseline, FeNO values did not differ between the two groups (median: 3.0 ppb vs. 2.0 ppb, respectively). FeNO values at 6, 12, 18 and 24 months (4.0, CI: 0.0–8.6; 6.0, CI: 2.8–12.0; 8.0, CI: 4.0–14.0; 8.5, CI: 4.4–14.5 ppb, respectively) increased with age (correlation p ≤ 0.001) and atopy (p = 0.03). FeNO was non-significantly increased from baseline to the symptomatic visit, while it decreased after convalescence (p = 0.007). Markers of disease activity, such as wheezing episodes and days with asthma were associated with increased FeNO values during the study (p < 0.05 for all). Age, atopy and disease activity were found to be important FeNO determinants in preschool children. Longitudinal and individualized FeNO assessment may be valuable in monitoring asthmatic children with recurrent wheezing or mild asthma.
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White MP, Kolstad TK, Elliott M, Cochrane ES, Stamey DC, Debley JS. Exhaled Nitric Oxide in Wheezy Infants Predicts Persistent Atopic Asthma and Exacerbations at School Age. J Asthma Allergy 2020; 13:11-22. [PMID: 32021309 PMCID: PMC6954861 DOI: 10.2147/jaa.s227732] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 11/21/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND There are limited data assessing the predictive value of fraction of exhaled nitric oxide (FENO) in infants/toddlers with recurrent wheezing for asthma at school age. OBJECTIVES In a cohort of infants/toddlers with recurrent wheezing determine the predictive values of sedated single-breath FENO (SB-FENO) and awake tidal-breathing mixed-expired FENO (tidal-FENO) for active asthma, severe exacerbations, and lung function at age 6 years. METHODS In 44 infants/toddlers, SB-FENO was measured under sedation at 50 mL/sec in conjunction with forced expiratory flow and volume measurements, and tidal-FENO was measured during awake tidal breathing. Clinical outcomes and lung function were assessed at age 6 years in 36 subjects. RESULTS Enrollment SB-FENO was significantly higher among subjects with active asthma at age 6 years than among subjects without asthma (36.4 vs. 16.9 ppb, p < 0.0001), and the odds of asthma was 7.6 times greater (OR 7.6; 95% CI 1.8-31.6) for every 10 ppb increase in enrollment SB-FENO. A ROC analysis demonstrated that an enrollment SB-FENO > 31.5 ppb predicted active asthma at age 6 years with an area under the curve (AUC) of 0.92 (95% CI: 0.82-1). SB-FENO was also higher among subjects who experienced severe asthma exacerbations during the year preceding age of 6 years. SB-FENO at enrollment and lung function measures at age 6 years were modestly correlated (FEV1: r = -0.4; FEF25-75: r = -0.41; FEV1/FVC ratio: r=-0.46), and SB-FENO was significantly higher among subjects with bronchodilator responsiveness (BDR) at age 6 years. Tidal-FENO was not predictive of active asthma, exacerbations, or lung function at age 6 years. CONCLUSION In wheezy infants/toddlers, SB-FENO was predictive of school-age asthma and associated with lung function measures at age 6 years.
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Affiliation(s)
- Maria P White
- Center for Immunity and Immunotherapies, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Tessa K Kolstad
- Center for Immunity and Immunotherapies, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Molly Elliott
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Elizabeth S Cochrane
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - David C Stamey
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - Jason S Debley
- Center for Immunity and Immunotherapies, Seattle Children’s Research Institute, Seattle, WA, USA
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
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Ferraro VA, Zanconato S, Baraldi E, Carraro S. Nitric Oxide and Biological Mediators in Pediatric Chronic Rhinosinusitis and Asthma. J Clin Med 2019; 8:jcm8111783. [PMID: 31731479 PMCID: PMC6912805 DOI: 10.3390/jcm8111783] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND In the context of the so-called unified airway theory, chronic rhinosinusitis (CRS) and asthma may coexist. The inflammation underlying these conditions can be studied through the aid of biomarkers. Main body: We described the main biological mediators that have been studied in pediatric CRS and asthma, and, according to the available literature, we reported their potential role in the diagnosis and management of these conditions. As for CRS, we discussed the studies that investigated nasal nitric oxide (nNO), pendrin, and periostin. As for asthma, we discussed the role of fractional exhaled nitric oxide (feNO), the role of periostin, and that of biological mediators measured in exhaled breath condensate (EBC) and exhaled air (volatile organic compounds, VOCs). CONCLUSION Among non-invasive biomarkers, nNO seems the most informative in CRS and feNO in asthma. Other biological mediators seem promising, but further studies are needed before they can be applied in clinical practice.
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Abstract
Asthma-like symptoms like wheezing and dyspnea affect 1 in every 3 preschool children. An easily available biomarker that predicts later asthma or unfavorable lung growth in these children may be helpful in targeting the right child with the right drugs and avoiding exposure to potentially harmful drugs in others. The fraction of exhaled nitric oxide (FeNO) has been suggested as a marker of eosinophilic inflammation. FeNO can be measured in a standardized way from the age of 4 but several methods have been developed to measure FeNO also in younger children. Several studies have assessed the predictive value of FeNO in preschool wheezing children for asthma later in life. These studies have shown that FeNO may be helpful in defining different preschool wheezing phenotypes, and in assessing the risk of later asthma or impaired lung growth. However, data are conflicting on the added value over clinical parameters. In two studies in school children, high FeNO was predictive for asthma development during follow up and also predicted lower lung function growth. In school children with respiratory symptoms suggestive of asthma, particularly in atopic children, FeNO has diagnostic value for an asthma diagnosis, mostly for ruling in asthma. There are not enough data to assess if FeNO has a predictive value for lung development in school children.
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Affiliation(s)
- Mariëlle W Pijnenburg
- Division of Respiratory Medicine and Allergology, Department of Pediatrics, Erasmus MC-Sophia, University Medical Center Rotterdam, Rotterdam, Netherlands
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Ferraro V, Carraro S, Bozzetto S, Zanconato S, Baraldi E. Exhaled biomarkers in childhood asthma: old and new approaches. Asthma Res Pract 2018; 4:9. [PMID: 30094051 PMCID: PMC6081883 DOI: 10.1186/s40733-018-0045-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 07/30/2018] [Indexed: 12/21/2022] Open
Abstract
Background Asthma is a chronic condition usually characterized by underlying inflammation. The study of asthmatic inflammation is of the utmost importance for both diagnostic and monitoring purposes. The gold standard for investigating airway inflammation is bronchoscopy, with bronchoalveolar lavage and bronchial biopsy, but the invasiveness of such procedures limits their use in children. For this reason, in the last decades there has been a growing interest for the development of noninvasive methods. Main body In the present review, we describe the most important non-invasive methods for the study of airway inflammation in children, focusing on the measure of the fractional exhaled nitric oxide (feNO), on the measure of the exhaled breath temperature (EBT) and on the analysis of both exhaled breath condensate (EBC) and exhaled air (Volatile Organic Compounds, VOCs), using targeted and untargeted approaches. We summarize what is currently known on the topic of exhaled biomarkers in childhood asthma, with a special emphasis on emerging approaches, underlining the role of exhaled biomarkers in the diagnosis, management and treatment of asthma, and their potential for the development of personalized treatments. Conclusion Among non-invasive methods to study asthma, exhaled breath analysis remains one of the most interesting approaches, feNO and “-omic” sciences seem promising for the purpose of characterizing biomarkers of this disease.
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Affiliation(s)
- Valentina Ferraro
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | - Silvia Carraro
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | - Sara Bozzetto
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | - Stefania Zanconato
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | - Eugenio Baraldi
- Women's and Children's Health Department, University of Padova, Padova, Italy
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Arakawa H, Hamasaki Y, Kohno Y, Ebisawa M, Kondo N, Nishima S, Nishimuta T, Morikawa A. Japanese guidelines for childhood asthma 2017. Allergol Int 2017; 66:190-204. [PMID: 28108245 DOI: 10.1016/j.alit.2016.11.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Indexed: 10/20/2022] Open
Abstract
The Japanese Guideline for the Diagnosis and Treatment of Allergic Diseases 2017 (JAGL 2017) includes a minor revision of the Japanese Pediatric Guideline for the Treatment and Management of Asthma 2012 (JPGL 2012) by the Japanese Society of Pediatric Allergy and Clinical Immunology. The section on child asthma in JAGL 2017 provides information on how to diagnose asthma between infancy and adolescence (0-15 years of age). It makes recommendations for best practices in the management of childhood asthma, including management of acute exacerbations and non-pharmacological and pharmacological management. This guideline will be of interest to non-specialist physicians involved in the care of children with asthma. JAGL differs from the Global Initiative for Asthma Guideline in that JAGL emphasizes diagnosis and early intervention of children with asthma at <2 years or 2-5 years of age. The first choice of treatment depends on the severity and frequency of symptoms. Pharmacological management, including step-up or step-down of drugs used for long-term management based on the status of asthma control levels, is easy to understand; thus, this guideline is suitable for the routine medical care of children with asthma. JAGL also recommends using a control test in children, so that the physician aims for complete control by avoiding exacerbating factors and appropriately using anti-inflammatory drugs (for example, inhaled corticosteroids and leukotriene receptor antagonists).
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Moeller A, Carlsen KH, Sly PD, Baraldi E, Piacentini G, Pavord I, Lex C, Saglani S. Monitoring asthma in childhood: lung function, bronchial responsiveness and inflammation. Eur Respir Rev 2016; 24:204-15. [PMID: 26028633 DOI: 10.1183/16000617.00003914] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
This review focuses on the methods available for measuring reversible airways obstruction, bronchial hyperresponsiveness (BHR) and inflammation as hallmarks of asthma, and their role in monitoring children with asthma. Persistent bronchial obstruction may occur in asymptomatic children and is considered a risk factor for severe asthma episodes and is associated with poor asthma outcome. Annual measurement of forced expiratory volume in 1 s using office based spirometry is considered useful. Other lung function measurements including the assessment of BHR may be reserved for children with possible exercise limitations, poor symptom perception and those not responding to their current treatment or with atypical asthma symptoms, and performed on a higher specialty level. To date, for most methods of measuring lung function there are no proper randomised controlled or large longitudinal studies available to establish their role in asthma management in children. Noninvasive biomarkers for monitoring inflammation in children are available, for example the measurement of exhaled nitric oxide fraction, and the assessment of induced sputum cytology or inflammatory mediators in the exhaled breath condensate. However, their role and usefulness in routine clinical practice to monitor and guide therapy remains unclear, and therefore, their use should be reserved for selected cases.
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Affiliation(s)
- Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | - Kai-Hakon Carlsen
- Dept of Paediatrics, Women and Children's Division, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Peter D Sly
- Queensland Children's Medical Research Institute, The University of Queensland, Brisbane, Australia
| | - Eugenio Baraldi
- Women's and Children's Health Department, Unit of Respiratory Medicine and Allergy, University of Padova, Padova, Italy
| | - Giorgio Piacentini
- Paediatric Section, Dept of Life and Reproduction Sciences, University of Verona, Verona, Italy
| | - Ian Pavord
- Dept of Respiratory Medicine, University of Oxford, NDM Research Building, Oxford, UK
| | - Christiane Lex
- Dept of Paediatric Cardiology and Intensive Care Medicine, Division of Paediatric Respiratory Medicine, University Hospital Goettingen, Goettingen, Germany
| | - Sejal Saglani
- Leukocyte Biology and Respiratory Paediatrics, National Heart and Lung Institute, Imperial College London, London, UK
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Special Considerations for Infants and Young Children. PEDIATRIC ALLERGY: PRINCIPLES AND PRACTICE 2016. [PMCID: PMC7271152 DOI: 10.1016/b978-0-323-29875-9.00032-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Moschino L, Zanconato S, Bozzetto S, Baraldi E, Carraro S. Childhood asthma biomarkers: present knowledge and future steps. Paediatr Respir Rev 2015; 16:205-12. [PMID: 26100359 DOI: 10.1016/j.prrv.2015.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 05/06/2015] [Indexed: 11/28/2022]
Abstract
Asthma represents the most common chronic respiratory disease of childhood. Its current standard diagnosis relies on patient history of symptoms and confirmed expiratory airflow limitation. Nevertheless, the spectrum of asthma in clinical presentation is broad, and both symptoms and lung function may not always reflect the underlying airway inflammation, which can be determined by different pathogenetic mechanisms. For these reasons, the identification of objective biomarkers of asthma, which may guide diagnosis, phenotyping, management and treatment is of great clinical utility and might have a role in the development of personalized therapy. The availability of non-invasive methods to study and monitor disease inflammation is of relevance especially in childhood asthma. In this sense, a promising role might be played by the measurement of exhaled biomarkers, such as exhaled nitric oxide (FE(NO)) and molecules in exhaled breath condensate (EBC). Furthermore, recent studies have shown encouraging results with the application of the novel metabolomic approach to the study of exhaled biomarkers. In this paper the existing knowledge in the field of asthma biomarkers, with a special focus on exhaled biomarkers, will be highlighted.
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Affiliation(s)
- Laura Moschino
- Department of Women's and Children's Health, University of Padova, Padova Italy
| | - Stefania Zanconato
- Department of Women's and Children's Health, University of Padova, Padova Italy
| | - Sara Bozzetto
- Department of Women's and Children's Health, University of Padova, Padova Italy
| | - Eugenio Baraldi
- Department of Women's and Children's Health, University of Padova, Padova Italy
| | - Silvia Carraro
- Department of Women's and Children's Health, University of Padova, Padova Italy.
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Hamasaki Y, Kohno Y, Ebisawa M, Kondo N, Nishima S, Nishimuta T, Morikawa A. Japanese Guideline for Childhood Asthma 2014. Allergol Int 2015; 63:335-356. [PMID: 25178176 DOI: 10.2332/allergolint.14-rai-0767] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Indexed: 11/20/2022] Open
Abstract
The Japanese Guideline for the Diagnosis and Treatment of Allergic Diseases 2013 (JAGL 2013) describes childhood asthma after the Japanese Pediatric Guideline for the Treatment and Management of Asthma 2012 (JPGL 2012) by the Japanese Society of Pediatric Allergy and Clinical Immunology. JAGL 2013 provides information on diagnosis by age group from infancy to puberty (0-15 years of age), treatment for acute exacerbations, long-term management by anti-inflammatory drugs, daily life guidance, and patient education to allow non-specialist physicians to refer to this guideline for routine medical treatment. JAGL differs from the Global Initiative for Asthma Guideline (GINA) in that JAGL emphasizes early diagnosis and intervention at <2 years and 2-5 years of age. A management method, including step-up or step-down of long-term management drugs based on the status of asthma control levels, as in JAGL, is easy to understand, and thus the Guideline is suitable as a frame of reference for routine medical treatment. JAGL has also introduced treatment and management using a control test on children, recommending that the physician aim at complete control by avoiding exacerbation factors and by appropriate use of anti-inflammatory drugs.
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Affiliation(s)
- Yuhei Hamasaki
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | | | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergology and Rheumatology, National Hospital Organization, Sagamihara National Hospital, Kanagawa, Japan
| | - Naomi Kondo
- Department of Pediatrics, Graduate School of Medicine, Gifu University, Gifu, Japan
| | - Sankei Nishima
- National Hospital Organization, Fukuoka National Hospital, Fukuoka, Japan
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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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van der Heijden HHACM, Brouwer ML, Hoekstra F, van der Pol P, Merkus PJFM. Reference values of exhaled nitric oxide in healthy children 1-5 years using off-line tidal breathing. Pediatr Pulmonol 2014; 49:291-5. [PMID: 23532936 DOI: 10.1002/ppul.22796] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 02/10/2013] [Indexed: 11/12/2022]
Abstract
Measurement of the fraction of exhaled nitric oxide (FeNO) is a useful test to diagnose and/or monitor eosinophilic airway inflammation. The off-line tidal breathing method is used for measurements in young children, but reference values for preschool children are scarce. The objective of this study was to establish reference values for FeNO in healthy children 1-5 years old. We included 51 healthy children (23 males), mean age 32.5 months, from the general population and measured FeNO, using an off-line tidal breathing method with a chemiluminescence analyzer. The method proved feasible in 100% of the children. Geometric mean FeNO was 7.1 parts per billion (ppb), 95% confidence interval 2.8-11.5 ppb, with the 95th percentile 22.6 ppb. No significant difference was found between boys and girls, and no correlations were observed between FeNO and age, height, or weight. This study demonstrates that the off-line tidal breathing method is feasible to measure FeNO in preschool children and provides reference values of FeNO in healthy children 1-5 years of age.
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Elliott M, Heltshe SL, Stamey DC, Cochrane ES, Redding GJ, Debley JS. Exhaled nitric oxide predicts persistence of wheezing, exacerbations, and decline in lung function in wheezy infants and toddlers. Clin Exp Allergy 2013; 43:1351-61. [PMID: 24261945 PMCID: PMC3839057 DOI: 10.1111/cea.12171] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Revised: 06/21/2013] [Accepted: 06/23/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND There are limited data assessing the predictive value of fraction of exhaled nitric oxide (FENO ) for persistence of wheezing, exacerbations, or lung function change over time in infants/toddlers with recurrent wheezing. OBJECTIVES In an ongoing longitudinal cohort of infants and toddlers with recurrent wheezing, we compared predictive values of single-breath FENO (SB-FENO ), tidal-breathing mixed expired FENO (tidal-FENO ), bronchodilator responsiveness (BDR) and the Castro-Rodriquez Asthma Predictive Index (API) for persistence of wheezing, exacerbations and lung function change through age 3 years. METHODS Enrolment forced expiratory flows and volumes infant pulmonary function tests (iPFTs) were measured in 44 infants/toddlers using the raised volume rapid thoracoabdominal compression method. SB-FENO was measured at 50 mL/s, and tidal-FENO was measured during awake tidal breathing. Clinical outcomes were assessed at age 3 years in 42 infants. Follow-up iPFTs were completed between ages 2.5-3 years in 32 subjects. RESULTS An enrolment SB-FENO concentration ≥ 30 p.p.b. predicted persistence of wheezing at age 3 years with a sensitivity of 77%, a specificity of 94%, and an area under the curve (AUC) of 0.86 (95% CI: 0.74-0.98). The sensitivity, specificity, positive predictive, and negative predictive values of SB-FENO for persistence of wheezing and exacerbations were superior to tidal-FENO , BDR, and the API. SB-FENO ≥ 30 p.p.b. and tidal-FENO ≥ 7 p.p.b. measured at enrolment was associated with a decline in both FEV0.5 and FEF25-75 between enrolment and age 3 years. CONCLUSIONS In wheezy infants/toddlers, SB-FENO was superior to tidal-FENO , BDR, and the API in predicting future exacerbations and persistence of wheezing at age 3 years. Both SB-FENO and tidal-FENO were associated with lung function decline over time.
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Affiliation(s)
- Molly Elliott
- Department of Pediatrics, Division of Pulmonary Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA
| | - Sonya L. Heltshe
- Department of Pediatrics, Division of Pulmonary Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA
- Center for Clinical and Translational Research. Seattle Children’s Research Institute, Seattle, WA
| | - David C. Stamey
- Department of Pediatrics, Division of Pulmonary Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA
| | - Elizabeth S. Cochrane
- Department of Pediatrics, Division of Pulmonary Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA
| | - Gregory J. Redding
- Department of Pediatrics, Division of Pulmonary Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA
| | - Jason S. Debley
- Department of Pediatrics, Division of Pulmonary Medicine, Seattle Children’s Hospital, University of Washington, Seattle, WA
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Singer F, Luchsinger I, Inci D, Knauer N, Latzin P, Wildhaber JH, Moeller A. Exhaled nitric oxide in symptomatic children at preschool age predicts later asthma. Allergy 2013; 68:531-8. [PMID: 23414302 DOI: 10.1111/all.12127] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2013] [Indexed: 12/31/2022]
Abstract
BACKGROUND Prediction of asthma in young children with respiratory symptoms is hampered by the lack of objective measures applicable in clinical routine. In this prospective study in a preschool children cohort, we assessed whether the fraction of exhaled nitric oxide (FeNO), a biomarker of airway inflammation, is associated with asthma at school age. METHODS At baseline, IgE and eosinophils were measured in the blood, and FeNO was measured offline in 391 children aged 3-47 months with lower airway symptoms. We developed an asthma predictive index (API) including high FeNO as major criterion. At follow-up, primary outcome was physician-diagnosed asthma based on standardized interviews in those children reaching school age (n = 166). RESULTS FeNO was significantly elevated in those children with later asthma (68/166) as compared to children not developing asthma. Median (IQR) FeNO was 10.5 (6.6-17.2) vs. 7.4 (5.3-10.3) ppb. Per 5 ppb FeNO increase, the odds ratio (95% CI) for asthma increased by 2.44 (1.61-3.70) without changing when adjusting for confounders. Using the new API, children scored at risk had 58.0% probability for later asthma, whereas the negative predictive value was 78.2%, which was comparable to the classical API. CONCLUSIONS In this cohort of high-risk preschool children, elevated FeNO is associated with increased risk for school-age asthma. The new API including FeNO identifies children at risk of later asthma comparably to the classical API, but does not require blood sampling.
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Affiliation(s)
- F. Singer
- Division of Respiratory Medicine; University Children's Hospital Bern; University of Bern; Bern; Switzerland
| | - I. Luchsinger
- Division of Respiratory Medicine; University Children′s Hospital Zurich; Zurich; Switzerland
| | - D. Inci
- Division of Respiratory Medicine; University Children's Hospital Bern; University of Bern; Bern; Switzerland
| | - N. Knauer
- Division of Respiratory Medicine; University Children′s Hospital Zurich; Zurich; Switzerland
| | - P. Latzin
- Division of Respiratory Medicine; University Children's Hospital Bern; University of Bern; Bern; Switzerland
| | | | - A. Moeller
- Division of Respiratory Medicine; University Children′s Hospital Zurich; Zurich; Switzerland
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Yoda Y, Otani N, Hasunuma H, Kanegae H, Shima M. Storage conditions for stability of offline measurement of fractional exhaled nitric oxide after collection for epidemiologic research. BMC Pulm Med 2012; 12:68. [PMID: 23116255 PMCID: PMC3515473 DOI: 10.1186/1471-2466-12-68] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 10/29/2012] [Indexed: 11/18/2022] Open
Abstract
Background The measurement of fractional concentration of nitric oxide in exhaled air (FeNO) is valuable for the assessment of airway inflammation. Offline measurement of FeNO has been used in some epidemiologic studies. However, the time course of the changes in FeNO after collection has not been fully clarified. In this study, the effects of storage conditions on the stability of FeNO measurement in exhaled air after collection for epidemiologic research were examined. Methods Exhaled air samples were collected from 48 healthy adults (mean age 43.4 ± 12.1 years) in Mylar bags. FeNO levels in the bags were measured immediately after collection. The bags were then stored at 4°C or room temperature to measure FeNO levels repeatedly for up to 168 hours. Results In the bags stored at room temperature after collection, FeNO levels were stable for 9 hours, but increased starting at 24 hours. FeNO levels remained stable for a long time at 4°C, and they were 99.7% ± 7.7% and 101.3% ± 15.0% relative to the baseline values at 24 and 96 hours, respectively. When the samples were stored at 4°C, FeNO levels gradually decreased with time among the subjects with FeNO ≥ 51 ppb immediately after collection, although there were almost no changes among the other subjects. FeNO levels among current smokers increased even at 4°C, although the values among ex-smokers decreased gradually, and those among nonsmokers remained stable. The rate of increase was significantly higher among current smokers than among nonsmokers and ex-smokers from 9 hours after collection onwards. Conclusions Storage at 4°C could prolong the stability of FeNO levels after collection. This result suggests that valid measurements can be performed within several days if the samples are stored at 4°C. However, the time course of the changes in FeNO levels differed in relation to initial FeNO values and cigarette smoking.
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Affiliation(s)
- Yoshiko Yoda
- Department of Public Health, Hyogo College of Medicine, Mukogawa-cho, Nishinomiya, Hyogo, Japan
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Peña Zarza JA, Osona B, Gil-Sanchez JA, Figuerola J. Exhaled Nitric Oxide in Acute Phase of Bronchiolitis and Its Relation with Episodes of Subsequent Wheezing in Children of Preschool Age. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2012; 25:92-96. [PMID: 22768386 DOI: 10.1089/ped.2011.0127] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 01/10/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND: Fractional exhaled nitric oxide (FENO) levels are increased in children with asthma and in infants with recurrent wheezing, but the role of FENO in the acute phase of bronchiolitis is still not defined. OBJECTIVE: The aim of this study is to evaluate FENO values in the acute phase of bronchiolitis, compare them with healthy infants, and relate those values with the appearance of other wheezing episodes. METHODS: FENO values were determined in infants between 2 months and 2 years affected with RVS bronchiolitis by offline method. The FENO values collected in the acute phase were related with the respiratory clinical symptoms presented in the 2 years following the episode. RESULTS: A total of 30 patients were recruited: 15 in the bronchiolitis group and 15 in the control group. The average of the FENO values in the acute phase was 18.74 ppb (range 2-88) in the bronchiolitis group, and 8.75 ppb (range 2-24) in the control group. However, these results showed no significant statistical differences (p=0.176). Nevertheless, we found a positive correlation between the FENO values and the clinical score (Downes) of the bronchiolitis episode (p=0.023). In infants that presented other wheezing episodes in the 2 years after, the average of FENO in the acute phase of the first episode was 23.1 ppb (average of 10.25 ppb) versus 8.4 ppb (average 5.4 ppb) in the group of patients with no other episodes. The comparison of averages has no statistical significance. CONCLUSION: We found no differences in FENO between infants with bronchiolitis and healthy ones. The FENO values in the acute phase seems to be related to the severity of the disease but do not predict the appearance of wheezing episodes in the following 2 years.
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Comparison of online single-breath vs. online multiple-breath exhaled nitric oxide in school-age children. Pediatr Res 2012; 71:605-11. [PMID: 22322384 DOI: 10.1038/pr.2012.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Standards for online multiple-breath (mb) exhaled nitric oxide (eNO) measurements and studies comparing them with online single-breath (sb) eNO measurements are lacking, although eNOmb requires less cooperation in children at school age or younger. METHODS Online eNOmb and eNOsb were measured in 99 healthy children and (in order to observe higher values) in 21 children with suspected asthma at a median age of 6.1 and 11.7 y, respectively. For eNOmb, we aimed for 20 tidal breathing maneuvers; eNOsb was measured according to standards. The two techniques were compared by standard methods after computing NO output or extrapolating eNOmb to the standard flow of 50 ml/s (eNOmb(50)). RESULTS Measurements were acceptable in 82 (eNOmb) and 81 (eNOsb) children. Paired data were available for 65 children. On a log-log scale, eNOmb(50) (geometric mean ± SD 13.1 ± 15.5 parts per billion, ppb) was correlated with eNOsb (12.5 ± 15.8 ppb), with r(2) = 0.87. The mean difference between eNOsb and eNOmb(50) was -0.7 ppb, with limits of agreement (LOAs) of 4.0 and -5.3 ppb. DISCUSSION Despite its correlation with eNOsb, the LOA range hampers eNOmb use in research, where exact values across the whole range are warranted. However, eNOmb might be an alternative tool especially at preschool age, when cooperation during measurements is crucial.
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Piacentini GL, Cattazzo E, Tezza G, Peroni DG. Exhaled nitric oxide in pediatrics: what is new for practice purposes and clinical research in children? J Breath Res 2012; 6:027103. [PMID: 22523000 DOI: 10.1088/1752-7155/6/2/027103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Fractional exhaled NO (FeNO) is universally considered an indirect marker of eosinophilic airways inflammation, playing an important role in the physiopathology of childhood asthma. Advances in technology and standardization have allowed a wider use of FeNO in clinical practice in children from the age of four years. FeNO measurements add a new dimension to the traditional clinical tools (symptoms scores, lung function tests) in the assessment of asthma. To date a number of studies have suggested a possible use of FeNO in early identification of exacerbation risk and in inhaled corticosteroids titration. The aim of this paper is to address practical issues of interest to paediatric clinicians who are attempting to use FeNO measurements as an adjunctive tool in the diagnosis and management of childhood airway diseases.
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Affiliation(s)
- G L Piacentini
- Faculty of Medicine, Department of Pediatrics, University of Verona, Policlinico GB Rossi, Piazzale L. Scuro 10, Verona, Italy.
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21
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de Broucker V, Hulo S, Cherot-Kornobis N, Lartigau-Sezary I, Matran R, Sobaszek A, Edme JL. Interest of exhaled biomarkers in occupational asthma to latex: a case report. ARCHIVES OF ENVIRONMENTAL & OCCUPATIONAL HEALTH 2012; 67:170-176. [PMID: 22845730 DOI: 10.1080/19338244.2011.619213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
New methods for exploring pulmonary inflammation might be useful: measurements of exhaled nitric oxide (NO) and hydrogen peroxide (H(2)O(2)) in exhaled breath condensate (EBC). The authors describe the application and utility of these methods in a case report of pediatric nurse presenting an occupational asthma to latex. Despite compliance with avoidance measures, respiratory discomfort had worsened during work. Classical tests (spirometry, monitoring of peak expiratory flow) were not contributing to objectify the discomfort. Exhaled NO and H(2)O(2) in EBC increased immediately after work periods, compared with rest periods. Application of these new methods, at the same time, in workplace appears useful in the objective demonstration of a temporal relation between work and respiratory problems. The results allowed the occupational physician to transfer the patient to a new work station more appropriate for her respiratory health status.
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22
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Miraglia Del Giudice M, Marseglia GL, Leonardi S, Tosca MA, Marseglia A, Perrone L, Ciprandi G. Fractional exhaled nitric oxide measurements in rhinitis and asthma in children. Int J Immunopathol Pharmacol 2011; 24:29-32. [PMID: 22032784 DOI: 10.1177/03946320110240s407] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Exaled nitric oxide (FeNO) is considered a good noninvasive marker to assess airway inflammation in asthma and allergic rhinitis. In asthma, exhaled NO is very useful to verify adherence to therapy, and to predict upcoming asthma exacerbations. It has been also proposed that adjusting anti-inflammatory drugs guided by the monitoring of exhaled NO, could improve overall asthma control. Other studies showed increased FeNO levels in subjects with allergic rhinitis.
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23
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Clinical Applications of Pediatric Pulmonary Function Testing: Lung Function in Recurrent Wheezing and Asthma. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2011; 24:69-76. [DOI: 10.1089/ped.2010.0060] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Nishimuta T, Kondo N, Hamasaki Y, Morikawa A, Nishima S. Japanese guideline for childhood asthma. Allergol Int 2011; 60:147-69. [PMID: 21636964 DOI: 10.2332/allergolint.11-rai-0328] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Indexed: 11/20/2022] Open
Abstract
The Japanese Guideline for the Diagnosis and Treatment of Allergic Diseases 2010 (JAGL 2010) describes childhood asthma based on the Japanese Pediatric Guideline for the Treatment and Management of Asthma 2008 (JPGL 2008) published by the Japanese Society of Pediatric Allergy and Clinical Immunology. JAGL 2010 provides information on diagnosis by age groups from infancy to puberty, treatment for acute exacerbations, long-term management by medication, daily life guidance, and patient education to allow physicians, not specialized in childhood asthma, to refer to this guideline for routine medical treatment. JAGL differs from the Global Initiative for Asthma Guideline (GINA) in that the former emphasizes long-term management of childhood asthma based on asthma severity and early diagnosis and intervention at <2 years and 2-5 years of age. However, a management method, including step-up or step-down of long-term management agents based on the status of asthma symptoms, is easy to understand and thus JAGL is suitable for routine medical treatment. JAGL also introduced treatment and management using a control test for children, recommending treatment and management aimed at complete control through avoiding exacerbation factors and appropriate use of antiinflammatory agents.
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Affiliation(s)
- Toshiyuki Nishimuta
- Department of Pediatrics, National Hospital Organization Shimoshizu National Hospital, Chiba, Japan.
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25
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Boon M, Meyts I, Warnier G, Boeck KD. Exhaled Nitric Oxide: Offline Tidal Breathing Measurements Are Feasible in Children and Correlate with Online Single Breath Measurements. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2010. [DOI: 10.1089/ped.2010.0037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mieke Boon
- Department of Pediatric Pulmonology, University Hospitals Leuven, Leuven, Belgium
| | - Isabelle Meyts
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium
| | - Gerda Warnier
- Department of Pediatric Pulmonology, University Hospitals Leuven, Leuven, Belgium
| | - Kris De Boeck
- Department of Pediatric Pulmonology, University Hospitals Leuven, Leuven, Belgium
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26
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Teague WG. Exhaled nitric oxide in wheezy infants: a marker of inflammation determined by airways acidification and S-nitrosothiol degradation? J Allergy Clin Immunol 2010; 125:1235-6. [PMID: 20513520 DOI: 10.1016/j.jaci.2010.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Accepted: 04/20/2010] [Indexed: 11/26/2022]
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de Blic J, Scheinmann P. Asma infantil y del lactante. EMC - PEDIATRÍA 2010; 45:1-20. [PMID: 32308525 PMCID: PMC7158999 DOI: 10.1016/s1245-1789(10)70178-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
El asma es la enfermedad crónica más frecuente de la infancia. El diagnóstico suele ser fácil cuando se producen episodios de disnea espiratoria con sibilancias reversibles de forma espontánea o mediante el uso de broncodilatadores. Las radiografías de tórax, la exploración funcional respiratoria y el estudio alérgico constituyen el aspecto fundamental de las pruebas complementarias necesarias. El tratamiento de la crisis consiste en el uso de β2-adrenérgicos inhalados y, si es necesario, corticoides orales. El tratamiento de fondo tiene como objetivo limitar al máximo los síntomas y restaurar o mantener las funciones pulmonares normales. Se debe adaptar a la gravedad y al control de la enfermedad y los corticoides inhalados tienen un papel de elección.
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Beigelman A, Mauger DT, Phillips BR, Zeiger RS, Taussig LM, Strunk RC, Bacharier LB. Effect of elevated exhaled nitric oxide levels on the risk of respiratory tract illness in preschool-aged children with moderate-to-severe intermittent wheezing. Ann Allergy Asthma Immunol 2009; 103:108-13. [PMID: 19739422 DOI: 10.1016/s1081-1206(10)60162-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The fractional concentration of exhaled nitric oxide (FeNO) is a noninvasive marker for airway inflammation but requires further study in preschool-aged children to determine its clinical relevance. OBJECTIVE To determine whether the risk of respiratory tract illnesses (RTIs), disease burden, and atopic features are related to FeNO in preschool-aged children with moderate-to-severe intermittent wheezing. METHODS We determined FeNO using the off-line tidal breathing technique in 89 children, aged 12 to 59 months, with moderate-to-severe intermittent wheezing. The risk of RTI was determined by comparing participants with a baseline FeNO of greater than the 75th percentile (24.4 ppb) with those with a baseline FeNO at the 75th percentile or lower using Cox regression analysis. RESULTS The risk of RTI was significantly higher in children with an FeNO of greater than 24.4 ppb relative to those with lower FeNO values (adjusted relative risk, 3.80; 95% confidence interval, 1.74-8.22; P < .001). FeNO levels of greater than 24.4 ppb were associated with more positive skin test results to aeroallergens (P = .03) but not with other atopic characteristics or historic parameters of illness burden. CONCLUSIONS An elevated FeNO in preschool-aged children with moderate-to-severe intermittent wheezing was associated with an increased risk of RTI during a 1-year follow-up. In addition, a higher FeNO was associated with aeroallergen sensitization.
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Affiliation(s)
- Avraham Beigelman
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Missouri 63110, USA
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29
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Gabriele C, de Benedictis FM, de Jongste JC. Exhaled nitric oxide measurements in the first 2 years of life: methodological issues, clinical and epidemiological applications. Ital J Pediatr 2009; 35:21. [PMID: 19712438 PMCID: PMC2717974 DOI: 10.1186/1824-7288-35-21] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 07/20/2009] [Indexed: 12/20/2022] Open
Abstract
Fractional exhaled nitric oxide (FeNO) is a useful tool to diagnose and monitor eosinophilic bronchial inflammation in asthmatic children and adults. In children younger than 2 years of age FeNO has been successfully measured both with the tidal breathing and with the single breath techniques. However, there are a number of methodological issues that need to be addressed in order to increase the reproducibility of the FeNO measurements within and between infants. Indeed, a standardized method to measure FeNO in the first 2 years of life would be extremely useful in order to meaningfully interpret FeNO values in this age group. Several factors related to the measurement conditions have been found to influence FeNO, such as expiratory flow, ambient NO and nasal contamination. Furthermore, the exposure to pre- and postnatal risk factors for respiratory morbidity has been shown to influence FeNO values. Therefore, these factors should always be assessed and their association with FeNO values in the specific study population should be evaluated and, eventually, controlled for. There is evidence consistently suggesting that FeNO is increased in infants with family history of atopy/atopic diseases and in infants with recurrent wheezing. These findings could support the hypothesis that eosinophilic bronchial inflammation is present at an early stage in those infants at increased risk of developing persistent respiratory symptoms and asthma. Furthermore, it has been shown that FeNO measurements could represent a useful tool to assess bronchial inflammation in other airways diseases, such as primary ciliary dyskinesia, bronchopulmonary dysplasia and cystic fibrosis. Further studies are needed in order to improve the reproducibility of the measurements, and large prospective studies are warranted in order to evaluate whether FeNO values measured in the first years of life can predict the future development of asthma or other respiratory diseases.
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Affiliation(s)
- Carmelo Gabriele
- Department of Pediatrics, Salesi Children's Hospital, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy.
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30
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de Mir Messa I, Moreno Galdó A, Cobos Barroso N, Gartner S, Martín De Vicente C, Liñán Cortés S. [Exhaled nitric oxide in children under 4 years of age with recurrent bronchitis]. Arch Bronconeumol 2009; 45:442-8. [PMID: 19501946 DOI: 10.1016/j.arbres.2009.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2009] [Revised: 03/25/2009] [Accepted: 04/02/2009] [Indexed: 12/18/2022]
Abstract
BACKGROUND The objective of the study was to assess bronchial inflammation in preschool children with recurrent bronchitis by measuring exhaled nitric oxide. PATIENTS AND METHODS The study included patients under 4 years of age with at least 3 episodes of wheezing in the past year (n=63) and a control group (n=30). Exhaled nitric oxide was measured in samples collected offline during spontaneous tidal breathing with a face mask and stored in Mylar balloons. RESULTS The fractional exhaled nitric oxide concentration (FE(NO)) was higher in the group with bronchitis (mean [SD], 5.3 [1.3] parts per billion [ppb]) than in the control group (4.6 [1.1]ppb) (P=.02). There was a significant difference between the control group and children in the bronchitis group not treated with inhaled corticosteroids (P<.05), but not between controls and corticosteroid-treated patients. A relationship with eosinophil count was observed in that those with higher counts (>400 microL) had higher FE(NO) levels (P<.01). No relationship was observed between FE(NO) and a positive methacholine challenge test. Follow-up lasted at least 20 months. The initial FE(NO) level did not differ significantly according to whether patients were subsequently transient, infrequent, or frequent wheezers (5.2 [0.98]ppb, 5.6 [1.5]ppb, and 4.8 [1.34]ppb, respectively; P=.36). CONCLUSIONS In children under 4 years of age with recurrent wheezing bronchitis who were asymptomatic at study entry, a small increase in FE(NO) was observed although there was a good deal of overlap with the control group.
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Affiliation(s)
- Inés de Mir Messa
- Unidad de Neumología Pediátrica y Fibrosis Quística, Hospital Universitari Vall d'Hebron, Barcelona, España.
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31
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Kwok MY, Walsh-Kelly CM, Gorelick MH. The role of exhaled nitric oxide in evaluation of acute asthma in a pediatric emergency department. Acad Emerg Med 2009; 16:21-8. [PMID: 19055675 DOI: 10.1111/j.1553-2712.2008.00304.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Fractional excretion of nitric oxide (FE(NO)) has been used as a noninvasive marker to assess and manage chronic asthma in adults and children. The aim of this study was to determine the feasibility of obtaining FE(NO) concentrations in children treated in the emergency department (ED) for acute asthma exacerbation and to examine the association between FE(NO) concentrations and other measures of acute asthma severity. METHODS This was a cross-sectional study of a convenience sample of children 2-18 years old who were seen in an urban ED for acute asthma exacerbation. Using a tidal breathing method with real-time display, the authors measured FE(NO) concentrations before and 1 hour after the administration of corticosteroids and at discharge from the ED. Outcome measures included pulmonary index score (PIS), hospital admission, and short-term outcomes (e.g., missed days of school). RESULTS A total of 133 subjects were enrolled. Sixty-eight percent (95% confidence interval [CI] = 60% to 76%) of the subjects provided adequate breaths for FE(NO) measurement. There was no difference in the median initial FE(NO) concentration among subjects, regardless of the severity of their acute asthma. Most subjects showed no change in their FE(NO) concentrations from the start to the end of treatment. FE(NO) concentrations were not significantly associated with other short-term outcomes. CONCLUSIONS Measurement of FE(NO) is difficult for a large proportion of children with acute asthma exacerbation. FE(NO) concentration during an asthma exacerbation does not correlate with other measures of acute severity and has limited utility in the ED management of acute asthma in children.
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Affiliation(s)
- Maria Y Kwok
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.
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32
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Khoo SM, Lim TK. Effects of inhaled versus systemic corticosteroids on exhaled nitric oxide in severe acute asthma. Respir Med 2008; 103:614-20. [PMID: 19022641 DOI: 10.1016/j.rmed.2008.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Revised: 10/08/2008] [Accepted: 10/10/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND There is a paucity of information on the differential effects of systemic versus inhaled corticosteroids on airway inflammation in patients with acute asthma. This study aimed to evaluate the effects of stopping systemic corticosteroids while maintaining the inhaled corticosteroids (ICS) on airway inflammation, lung function and asthma symptoms in patients who had been discharged from hospital after treatment for severe acute asthma. METHODS Twenty-four adult patients with severe exacerbations of asthma were treated with both oral and inhaled corticosteroids after discharge from hospital. Oral corticosteroids were stopped after 1 week. Spirometry, asthma quality of life questionnaire (AQLQ) score and exhaled nitric oxide (NO) were measured at discharge, 1 week, and 2 weeks after discharge. RESULTS Withdrawal of oral corticosteroids resulted in significant rebound in mean exhaled NO by 11.0ppb (95% CI, 4.9-17.1ppb, p<0.001) or 47.7% (95% CI, 22.4-73.1%) despite uninterrupted ICS treatment. The rebound in exhaled NO occurred despite significant improvement in the mean AQLQ score (p=0.006) and frequency of reliever use (p=0.003) and was not associated with significant change in the mean FEV(1) (p=0.64). CONCLUSIONS In patients discharged from hospital after treatment for asthma exacerbations, withdrawal of oral corticosteroids resulted in increase in exhaled NO levels despite continued ICS treatment.
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Affiliation(s)
- See Meng Khoo
- Division of Respiratory and Critical Care Medicine, National University Hospital, Singapore, Singapore.
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Cobos Barroso N, Pérez-Yarza EG, Sardón Prado O, Reverté Bover C, Gartner S, Korta Murua J. [Exhaled nitric oxide in children: a noninvasive marker of airway inflammation]. Arch Bronconeumol 2008; 44:41-51. [PMID: 18221726 DOI: 10.1016/s1579-2129(08)60007-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This article is an academic review of the application in children of the measurement of fractional exhaled nitric oxide (FENO). We outline the joint American Thoracic Society/European Respiratory Society recommendations for online measurement of FENO in both cooperating children and children unable to cooperate, offline measurement with uncontrolled exhalation flow rate, offline measurement with controlled exhalation flow rate using a dynamic flow restrictor, and offline measurement during tidal breathing in children unable to cooperate. This is followed by a review of the normal range of values for single-breath online measurements obtained with a chemiluminescence FENO analyzer (geometric mean, 9.7 parts per billion [ppb]; upper limit of the 95% confidence interval, 25.2 ppb). FENO values above 17 ppb have a sensitivity of 81% and a specificity of 80% for predicting asthma of an eosinophilic phenotype. We discuss the response of FENO values to anti-inflammatory treatment and the use of this marker in the management of asthma. Results obtained with chemiluminescence and portable electrochemical analyzers are compared. The portable devices offer the possibility--in children over 5 years of age--of accurate and universal monitoring of exhaled nitric oxide concentrations, an emerging marker of eosinophilic inflammation in asthma that facilitates diagnosis, monitoring of disease progression, and assessment of response to therapy.
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Affiliation(s)
- Nicolás Cobos Barroso
- Unidad de Neumología Pediátrica y Fibrosis Quística, Hospital Universitario Vall d'Hebron, Barcelona, Spain
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Moeller A, Lehmann A, Knauer N, Albisetti M, Rochat M, Johannes W. Effects of montelukast on subjective and objective outcome measures in preschool asthmatic children. Pediatr Pulmonol 2008; 43:179-86. [PMID: 18085698 DOI: 10.1002/ppul.20753] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
It is well accepted that control of airway inflammation is crucial for overall asthma control. Hence, efficient anti-inflammatory therapy is important for disease control. Therefore, we studied the effect of a treatment with montelukast on subjective and objective measures in preschool asthmatic children with insufficient control of airway inflammation, illustrated by increased fractional exhaled nitric oxide (FeNO). Thirty-one preschool children (2.5-5 years) were included in this study. Children with FeNO > or = 10 ppb at the first visit received montelukast 4 mg as a first line therapy or an add-on therapy to their baseline treatment (group 1). Therapy was not changed at first visit in children with FeNO < 10 ppb (group 2). Symptom scores, FeNO, lung function (forced oscillation, Rrs8Hz) and airway responsiveness to adenosine 5'-monophosphate (AMP) were assessed at visits 1 and 2 eight weeks apart. There was a significant decrease in FeNO (median [interquartile range]; 12.9 [3.7] vs. 7.6 [6.85] ppb, P = 0.011), Rrs8Hz (mean +/- SD; 10.03 +/- 3.1 vs. 8.72 +/- 2.43 hPa.s/L; P = 0.047) and symptom scores (2[2] vs. 1.5[2], P = 0.034) and a significant increase in the provocative AMP dose (2.65 +/- 2.1 vs. 4.54 +/- 1.05; P = 0.015) in group 1 but not in group 2. First line or add-on treatment of oral montelukast in preschool children with mild to moderate asthma and elevated FeNO, decreased levels of FeNO, improved airway responsiveness to AMP, lung function and symptom scores.
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Affiliation(s)
- Alexander Moeller
- Swiss Pediatric Respiratory Research Group, Division of Respiratory Medicine, University Children's Hospital Zurich, Zürich, Switzerland
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35
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Moeller A, Diefenbacher C, Lehmann A, Rochat M, Brooks-Wildhaber J, Hall GL, Wildhaber JH. Exhaled nitric oxide distinguishes between subgroups of preschool children with respiratory symptoms. J Allergy Clin Immunol 2008; 121:705-9. [PMID: 18177695 DOI: 10.1016/j.jaci.2007.11.008] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2007] [Revised: 10/30/2007] [Accepted: 11/01/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND Respiratory symptoms are common in early childhood. The clinical characterization of disease presentation and hence its likely disease progression has so far been proven difficult. OBJECTIVE To investigate whether exhaled nitric oxide (NO) could be helpful to distinguish between subgroups of nonwheezy and wheezy young children less than 4 years of age. METHODS Exhaled NO was measured in 391 children (age 3-47 months) with nonwheezy and wheezy respiratory symptoms. Children were divided into 3 groups: children with recurrent cough but no history of wheeze (group 1), with early recurrent wheeze and a loose index for the prediction of asthma at school age (group 2), and with frequent recurrent wheeze and a stringent index for the prediction of asthma at school age (group 3). RESULTS Children from group 3 showed significantly higher median (interquartile range) fractional exhaled NO (FeNO) levels (11.7 [11.85]) than children from groups 1 (6.5 [5.5]; P < .001) and 2 (6.4 [6.5]; P < .001). No difference in FeNO levels was found between children from groups 1 and 2 (P = .91). CONCLUSION Wheezy young children less than 4 years of age with a stringent index for the prediction of asthma at school age have elevated levels of FeNO compared with children with recurrent wheeze and a loose index for the prediction of asthma at school age or children with recurrent cough.
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Affiliation(s)
- Alexander Moeller
- Swiss Pediatric Respiratory Research Group and Division of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland.
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36
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Cobos Barroso N, Pérez-Yarza EG, Sardón Prado O, Reverté Bover C, Gartner S, Korta Murua J. Óxido nítrico exhalado en niños: un indicador no invasivo de la inflamación de las vías aéreas. Arch Bronconeumol 2008. [DOI: 10.1157/13114655] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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37
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Bacharier LB, Boner A, Carlsen KH, Eigenmann PA, Frischer T, Götz M, Helms PJ, Hunt J, Liu A, Papadopoulos N, Platts-Mills T, Pohunek P, Simons FER, Valovirta E, Wahn U, Wildhaber J. Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report. Allergy 2008; 63:5-34. [PMID: 18053013 DOI: 10.1111/j.1398-9995.2007.01586.x] [Citation(s) in RCA: 367] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Asthma is the leading chronic disease among children in most industrialized countries. However, the evidence base on specific aspects of pediatric asthma, including therapeutic strategies, is limited and no recent international guidelines have focused exclusively on pediatric asthma. As a result, the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma and Immunology nominated expert teams to find a consensus to serve as a guideline for clinical practice in Europe as well as in North America. This consensus report recommends strategies that include pharmacological treatment, allergen and trigger avoidance and asthma education. The report is part of the PRACTALL initiative, which is endorsed by both academies.
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Affiliation(s)
- L B Bacharier
- Department of Pediatrics, Washington University, St Louis, MO, USA
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Pijnenburg MWH, De Jongste JC. Exhaled nitric oxide in childhood asthma: a review. Clin Exp Allergy 2007; 38:246-59. [PMID: 18076708 DOI: 10.1111/j.1365-2222.2007.02897.x] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
As an 'inflammometer', the fraction of nitric oxide in exhaled air (Fe(NO)) is increasingly used in the management of paediatric asthma. Fe(NO) provides us with valuable, additional information regarding the nature of underlying airway inflammation, and complements lung function testing and measurement of airway hyper-reactivity. This review focuses on clinical applications of Fe(NO) in paediatric asthma. First, Fe(NO) provides us with a practical tool to aid in the diagnosis of asthma and distinguish patients who will benefit from inhaled corticosteroids from those who will not. Second, Fe(NO) is helpful in predicting exacerbations, and predicting successful steroid reduction or withdrawal. In atopic asthmatic children Fe(NO) is beneficial in adjusting steroid doses, discerning those patients who require additional therapy from those whose medication dose could feasibly be reduced. In pre-school children Fe(NO) may be of help in the differential diagnosis of respiratory symptoms, and may potentially allow for better targeting and monitoring of anti-inflammatory treatment.
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Affiliation(s)
- M W H Pijnenburg
- Department of Paediatrics/Paediatric Respiratory Medicine, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands.
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39
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McCurdy MR, Bakhirkin Y, Wysocki G, Tittel FK. Performance of an exhaled nitric oxide and carbon dioxide sensor using quantum cascade laser-based integrated cavity output spectroscopy. JOURNAL OF BIOMEDICAL OPTICS 2007; 12:034034. [PMID: 17614742 DOI: 10.1117/1.2747608] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Exhaled nitric oxide (NO) is an important biomarker in asthma and other respiratory disorders. The optical performance of a NOCO(2) sensor employing integrated cavity output spectroscopy (ICOS) with a quantum cascade laser operating at 5.22 microm capable of real-time NO and CO(2) measurements in a single breath cycle is reported. A NO noise-equivalent concentration of 0.4 ppb within a 1-sec integration time is achieved. The off-axis ICOS sensor performance is compared to a chemiluminescent NO analyzer and a nondispersive infrared (NDIR) CO(2) absorption capnograph. Differences between the gas analyzers are assessed by the Bland-Altman method to estimate the expected variability between the gas sensors. The off-axis ICOS sensor measurements are in good agreement with the data acquired with the two commercial gas analyzers. This work demonstrates the performance characteristics and merits of mid-infrared spectroscopy for exhaled breath analysis.
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Affiliation(s)
- Matthew R McCurdy
- Rice University, Rice Quantum Institute, 6100 Main Street, Houston, Texas 77005 and Baylor College of Medicine, Medical Scientist Training Program, 1 Baylor Plaza, Houston, Texas 77030
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40
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Gill M, Graff GR, Adler AJ, Dweik RA. Validation study of fractional exhaled nitric oxide measurements using a handheld monitoring device. J Asthma 2007; 43:731-4. [PMID: 17169823 DOI: 10.1080/02770900601031045] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We tested reproducibility of exhaled nitric oxide (FE(NO)) and inter-operator handling when measured with a handheld device, NIOX MINO. We enrolled 20 volunteers using a priori goals of acceptable reproducibility to be mean within-subject standard deviation less than 3 parts per billion (ppb) for FE(NO) measurements less than 30 ppb, and mean coefficient of variation less than 10% for FE(NO) measurements more than 30 ppb. Seventeen subjects with measurements less than 30 ppb displayed a mean standard deviation of 1.15, and 3 subjects with FE(NO) more than 30 ppb had a mean coefficient of variation of 2.4%. We conclude that NIOX MINO demonstrates excellent reproducibility for all ranges of FE(NO).
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Affiliation(s)
- Michelle Gill
- The Department of Emergency Medicine, Loma Linda University School of Medicine, 11234 Anderson Street, Loma Linda, CA 92354, USA.
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41
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Gabriele C, van der Wiel EC, Nieuwhof EM, Moll HA, Merkus PJFM, de Jongste JC. Methodological aspects of exhaled nitric oxide measurements in infants. Pediatr Allergy Immunol 2007; 18:36-41. [PMID: 17295797 DOI: 10.1111/j.1399-3038.2006.00472.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Guidelines for the measurement of fractional exhaled nitric oxide (FE(NO)) recommend refraining from lung function tests (LFT) and certain foods and beverages before performing FE(NO) measurements, as they may lead to transiently altered FE(NO) levels. Little is known of such factors in infants. The aim of the present study was to evaluate whether forced expiratory maneuvers, sedation, nasal contamination, and breastfeeding affect FE(NO) values in infants. FE(NO) was measured off-line during tidal breathing by means of a facemask covering nose and mouth. FE(NO) measurements were performed in 45 sedated infants (mean age 12.1 months) who underwent LFT because of airway diseases and in 83 unsedated healthy infants (mean age 4.3 months). In infants with airway diseases, no difference was found in FE(NO) values before and 5 min after LFT (n = 19 infants, p = 0.7) and FE(NO) values before sedation did not differ from FE(NO) values during sedation (n = 10 infants, p = 0.2). Oral FE(NO) values were significantly lower than mixed (nasal + oral) FE(NO) (n = 42 infants, p < 0.001). FE(NO) values before and 5 min after breastfeeding were not different (n = 11 healthy infants, p = 0.57). The short-term reproducibility in healthy infants (n = 54) was satisfactory (intraclass correlation coefficient = 0.94). We conclude that, in infants with airway diseases, LFT prior to FE(NO) measurement did not influence FE(NO) values and FE(NO) values did not change after sedation. Oral FE(NO) values were significantly lower than mixed (oral + nasal) FE(NO), and breastfeeding did not influence FE(NO). Short-term reproducibility in awake healthy infants was good.
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Affiliation(s)
- Carmelo Gabriele
- Department of Pediatric Respiratory Medicine, Erasmus Medical Centre, Sophia Chldren's Hospital, Rotterdam, The Netherlands
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42
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Daniel PF, Klug B, Valerius NH. Exhaled nitric oxide in healthy young children during tidal breathing through a facemask. Pediatr Allergy Immunol 2007; 18:42-6. [PMID: 17295798 DOI: 10.1111/j.1399-3038.2006.00473.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of this study was to establish reference values and to examine day-to-day and within-day variations of exhaled nitric oxide (eNO) during tidal breathing in healthy children using a newly described method. Exhaled NO was measured on-line and off-line during tidal breathing through a facemask. In a subgroup of children measurements were repeated during the course of a single day and on the same time on three consecutive days. A total of 133 healthy children were included in the study and measurements were obtained from 121 children aged 2-7 yr (61 boys and 60 girls). The geometric mean eNO concentration and 95% CI was 3.9 (3.5-4.2) parts per billion (p.p.b.) for on-line measurements and 3.0 (2.7-3.3) p.p.b. for off-line measurements. Exhaled NO was independent of gender, age, height and weight. The 95% reference intervals (RI) for on-line and off-line measurements were 1.2-8.2 and 1.3-7.1 p.p.b. respectively. Twenty-three children completed measurements of within-day and day-to-day variations, none of which showed significant variation. In conclusion, the established reference values and data on variability within and between days may facilitate the clinical application for measurement of eNO during tidal breathing in young children.
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Affiliation(s)
- Peter F Daniel
- Department of Pediatrics, Copenhagen University Hospital, Hvidovre, Denmark.
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43
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de Jongste JC. To wheeze or not to wheeze: prospective FENO-typing in early infancy. Am J Respir Crit Care Med 2007; 174:1281-2. [PMID: 17158284 DOI: 10.1164/rccm.200609-1393ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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44
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Taylor DR, Pijnenburg MW, Smith AD, De Jongste JC. Exhaled nitric oxide measurements: clinical application and interpretation. Thorax 2006; 61:817-27. [PMID: 16936238 PMCID: PMC2117092 DOI: 10.1136/thx.2005.056093] [Citation(s) in RCA: 348] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The use of exhaled nitric oxide measurements (F(E)NO) in clinical practice is now coming of age. There are a number of theoretical and practical factors which have brought this about. Firstly, F(E)NO is a good surrogate marker for eosinophilic airway inflammation. High F(E)NO levels may be used to distinguish eosinophilic from non-eosinophilic pathologies. This information complements conventional pulmonary function testing in the assessment of patients with non-specific respiratory symptoms. Secondly, eosinophilic airway inflammation is steroid responsive. There are now sufficient data to justify the claim that F(E)NO measurements may be used successfully to identify and monitor steroid response as well as steroid requirements in the diagnosis and management of airways disease. F(E)NO measurements are also helpful in identifying patients who do/do not require ongoing treatment with inhaled steroids. Thirdly, portable nitric oxide analysers are now available, making routine testing a practical possibility. However, a number of issues still need to be resolved, including the diagnostic role of F(E)NO in preschool children and the use of reference values versus individual F(E)NO profiles in managing patients with difficult or severe asthma.
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Affiliation(s)
- D R Taylor
- Department of Medical and Surgical Sciences, Dunedin School of Medicine, University of Otago, P O Box 913, Dunedin, New Zealand.
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45
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Gabriele C, Nieuwhof EM, Van Der Wiel EC, Hofhuis W, Moll HA, Merkus PJFM, De Jongste JC. Exhaled nitric oxide differentiates airway diseases in the first two years of life. Pediatr Res 2006; 60:461-5. [PMID: 16940253 DOI: 10.1203/01.pdr.0000238242.39881.64] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Fractional exhaled nitric oxide (FE(NO)) levels are increased in children and adults with asthma, whereas low levels have been found in cystic fibrosis and primary ciliary dyskinesia. The aim of this study was to investigate whether FE(NO) measurements could distinguish between children below the age of 2 with different airway diseases. FE(NO) measurements were performed in 118 infants aged between 4.6 and 25.2 mo: 74 infants with recurrent wheezing (RW), 24 with bronchopulmonary dysplasia (BPD), and 20 with cystic fibrosis (CF). FE(NO) was measured also in 100 healthy controls aged between 1.1 and 7.7 mo. Geometric mean (95% confidence interval) FE(NO) values were 10.4 (9.1-12.0) parts per billion (ppb) in healthy infants, 18.6 (15.6-22.2) ppb in wheezy infants, 11.7 (8.2-16.8) ppb in BPD infants and 5.9 (3.4-10.1) ppb in CF infants. FE(NO) in wheezers was higher than in controls, BPD, and CF (p = 0.009, p = 0.038, and p < 0.001, respectively). Atopic wheezers showed higher FE(NO) than nonatopic wheezers (p = 0.04). CF infants had lower FE(NO) than healthy controls and BPD infants (p = 0.003 and p = 0.043, respectively). FE(NO) values in BPD and control infants were not different. We conclude that FE(NO) is helpful to differentiate various airway diseases already in the first 2 y of life.
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Affiliation(s)
- Carmelo Gabriele
- Department of Pediatric Respiratory Medicine, Erasmus Medical Centre/Sophia Children's Hospital, Rotterdam, 3000 CB, the Netherlands
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47
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Xu W, Zheng S, Dweik RA, Erzurum SC. Role of epithelial nitric oxide in airway viral infection. Free Radic Biol Med 2006; 41:19-28. [PMID: 16781449 PMCID: PMC7127628 DOI: 10.1016/j.freeradbiomed.2006.01.037] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2005] [Revised: 01/20/2006] [Accepted: 01/23/2006] [Indexed: 12/13/2022]
Abstract
The airway mucosal epithelium is the first site of virus contact with the host, and the main site of infection and inflammation. Nitric oxide (NO) produced by the airway epithelium is vital to antiviral inflammatory and immune defense in the lung. Multiple mechanisms function coordinately to support high-level basal NO synthesis in healthy airway epithelium and further induction of NO synthesis in the infected airway of normal hosts. Hosts deficient in NO synthesis, such as those patients with cystic fibrosis, have impaired antiviral defense and may benefit from therapies to augment NO levels in the airways.
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Key Words
- balf, bronchoalveolar lavage fluid
- cf, cystic fibrosis
- cgmp, guanosine 3′,5′-cyclic monophosphate
- cmv, cytomegalovirus
- dsrna, double-stranded rna
- epo, eosinophil peroxidase
- gas, γ-activated site
- gsh, reduced glutathione
- hiv, human immunodeficiency virus
- hocl, hypochlorous acid
- hpivs, human parainfluenza viruses
- hrsv, human respiratory syncytial virus
- h2o2, hydrogen peroxide
- irf, interferon regulatory factor
- lpo, lactoperoidase
- mpo, myeloperoxidase
- no3−, nitrate
- no, nitric oxide
- nos, nitric oxide synthases
- no2−, nitrite
- onoo−, peroxynitrite
- pkr, dsrna-activated protein kinase
- poly(ic), polyinosinic-polycytidylic acid
- ros, reactive oxygen species
- o2−, superoxide
- gsno, s-nitrosoglutathione
- ssrna, single-stranded rna
- stat, signal transducer and activator of transcription
- antiviral host defense
- nitric oxide
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Affiliation(s)
- Weiling Xu
- Department of Pathobiology, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Ave., NC 20, Cleveland, OH 44195, USA.
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Shome GP, Starnes JD, Shearer M, Kennedy R, Way A, Arif A, Prabhakar S. Exhaled nitric oxide in asthma: variability, relation to asthma severity, and peripheral blood lymphocyte cytokine expression. J Asthma 2006; 43:95-9. [PMID: 16517424 DOI: 10.1080/02770900500497925] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Exhaled nitric oxide has been used as a means of indirectly measuring the underlying inflammation in asthma. The objectives of the study were to measure exhaled nitric oxide levels in asthma patients and healthy volunteers, to study peripheral blood lymphocyte cytokine expression, and to study the relationship between exhaled nitric oxide and intracellular cytokine expression. Exhaled nitric oxide was elevated in patients with moderate to severe asthma and with treatment decreased in the first week reaching to a near normal level by 4 weeks. Elevated exhaled nitric oxide was associated with decreased IL-4 and IL-13 cytokine expression by CD8 lymphocytes.
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Affiliation(s)
- Goutam P Shome
- Division of Allergy & Immunology, Department of Internal Medicine, Texas Tech University, Health Sciences Center, Lubbock, Texas 79430, USA.
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Abstract
Assessment of airway function is difficult in young children with asthma, and in addition, only reflects the status of the disease at the time of the measurement. Thus, there is increasing interest in monitoring airway inflammation in asthma, which may provide a longer term assessment of disease activity. Most methods of assessing asthmatic inflammation are invasive, and are not feasible in the paediatric population. This review discusses exhaled nitric oxide as a marker of asthmatic inflammation, and compares it with other recognized markers. Exhaled nitric oxide has the potential to become a noninvasive method of assessing asthma control in the paediatric population.
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Mallol J, Andrade R, Auger F, Rodríguez J, Alvarado R, Figueroa L. Wheezing during the first year of life in infants from low-income population: a descriptive study. Allergol Immunopathol (Madr) 2005; 33:257-63. [PMID: 16287544 DOI: 10.1157/13080928] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Recurrent wheezing (RW) plays an important role in the morbidity and mortality of children during the first year of life in developing regions and its actual incidence in those areas is virtually unknown. METHODS AND RESULTS This study describes the occurrence of wheezing during the first year of life in a birth cohort of 188 infants followed monthly and living in a poor urban area in Santiago de Chile. This study showed that 80.3 % of the infants in the cohort had one or more wheezing episode during the first year of life, 43.1 % had RW (3 or more wheezing episodes), 44.1 % had their first wheezing within the first three months of life and 13.3 % had pneumonia (PN). Having one or more episode of wheezing in the first three months of life was the main risk factor for suffering from RW during the first year and RW was a significant risk factor for having PN. CONCLUSIONS This study found a high prevalence of RW in infants from a low-income population during the first year of life with the disease starting very early in their lives, progressing with more frequent episodes and being significantly associated to PN, particularly in the first 6 months of life.
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Affiliation(s)
- J Mallol
- Department of Pediatric Respiratory Medicine, Faculty of Medical Sciences, University of Santiago de Chile (USACH), Hospital CRS El Pino, Santiago, Chile.
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