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Pavord ID, Casale TB, Corren J, FitzGerald MJ, Deniz Y, Altincatal A, Gall R, Pandit-Abid N, Radwan A, Jacob-Nara JA, Rowe PJ, Busse WW. Dupilumab Reduces Exacerbations Independent of Changes in Biomarkers in Moderate-to-Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1763-1772. [PMID: 38555079 DOI: 10.1016/j.jaip.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 03/11/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Changes from baseline in fractional exhaled nitric oxide (FeNO) and blood eosinophil count (Eos) may be related to efficacy outcomes in dupilumab-treated patients with moderate-to-severe asthma. OBJECTIVE This post hoc analysis investigated biomarker changes in placebo- and dupilumab-treated patients with uncontrolled moderate-to-severe asthma enrolled in QUEST (NCT02414854). METHODS Spline analyses of annualized severe exacerbation rate (AER) and change from baseline in pre-bronchodilator (BD) forced expiratory volume in 1 second (FEV1) at week 52 were performed as a function of the fold change in FeNO at week 52 and the maximum fold change in Eos over weeks 0-12 (also change from baseline in pre-BD FEV1 at week 12). RESULTS The combined placebo and dupilumab groups comprised 638 and 1264 patients, respectively. FeNO levels declined rapidly by week 2 and then gradually to week 52 in patients treated with dupilumab versus placebo; Eos, after initially increasing with dupilumab, declined slightly from baseline in both treatment groups. AER during QUEST showed no significant association with the change in biomarkers in either treatment group. The change from baseline in pre-BD FEV1 at week 52 was inversely associated with the fold change in FeNO in both groups, with a significant difference between the dupilumab and placebo curves (P = .014), and was positively associated with the fold change in Eos in both groups (P = .022). CONCLUSIONS Relative changes in FeNO and Eos were not associated with AER, regardless of treatment arm. However, changes in both biomarkers showed a predictive value for lung function improvement; for FeNO, this was specific to the dupilumab treatment arm.
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Affiliation(s)
- Ian D Pavord
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom.
| | - Thomas B Casale
- Division of Allergy and Immunology, University of South Florida, Tampa, Fla
| | - Jonathan Corren
- David Geffen School of Medicine, University of California, Los Angeles, CA
| | | | - Yamo Deniz
- Regeneron Pharmaceuticals, Inc, Tarrytown, NY
| | | | | | | | - Amr Radwan
- Regeneron Pharmaceuticals, Inc, Tarrytown, NY
| | | | | | - William W Busse
- UW Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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Li S, Dong J, Li A, Yang Q, Xiong X, Xie X, Zhang Y. The role of 14-3-3β in acute asthma in children and analysis of the risk factors for asthma exacerbation. J Asthma 2024:1-10. [PMID: 38767583 DOI: 10.1080/02770903.2024.2355238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 05/10/2024] [Indexed: 05/22/2024]
Abstract
OBJECTIVE To investigate the role of 14-3-3β in acute asthma exacerbations in children and analyze the risk factors for asthma exacerbations. METHODS This study recruited 101 children with acute asthma exacerbations, 101 children with stable asthma, and 65 healthy children. Serum 14-3-3β was compared among the three groups. Factors such as asthma family history, skin prick test, serum-specific IgE test, coinfections, and clinical indicators (FeNO, FEV1, white blood cells, eosinophils, and serum IgE level) were compared between the asthma groups. Risk factors associated with acute asthma exacerbations were identified using multivariate logistic regression models. ROC curve was drawn to determine the diagnostic sensitivity and specificity of 14-3-3β. RESULTS Serum 14-3-3β was significantly greater in the acute asthma group than in the stable asthma and control groups. Serum 14-3-3β was higher in severe acute asthma group than in mild-moderate asthma group. There were no significant differences in serum 14-3-3β levels between stable asthma and control groups (p > .05). Multivariate logistic regression analysis revealed that serum 14-3-3β level, FeNO, coinfection, and FEV1 z-score significantly increased the odds of acute asthma exacerbations in children. The optimal 14-3-3β cutoff value (39.79 ng/mL), had a sensitivity of 69.3% and specificity of 94.1% for predicting acute asthma exacerbations. CONCLUSIONS 14-3-3β is elevated in children with acute exacerbations of asthma, and increases with exacerbation severity. 14-3-3β, FeNO, FEV1, and coinfection could be independent risk factors for predicting asthma exacerbations. The optimal 14-3-3β cutoff value for predicting asthma exacerbations was 39.79 ng/mL.
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Affiliation(s)
- Shufang Li
- Department of Pediatrics, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Pediatric Clinical Research Center, Zhengzhou, China
- Henan Key Laboratory of Child Brain Injury, Zhengzhou, China
- Institute of Neuroscience of Zhengzhou University, Zhengzhou, China
| | - Junjun Dong
- Department of Pediatrics, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Aijun Li
- Department of Pediatrics, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Qiuyan Yang
- Department of Pediatrics, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Pediatric Clinical Research Center, Zhengzhou, China
- Henan Key Laboratory of Child Brain Injury, Zhengzhou, China
- Institute of Neuroscience of Zhengzhou University, Zhengzhou, China
| | - Xiaoman Xiong
- Department of Pediatrics, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xueli Xie
- Department of Pediatrics, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanli Zhang
- Department of Pediatrics, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Henan Pediatric Clinical Research Center, Zhengzhou, China
- Henan Key Laboratory of Child Brain Injury, Zhengzhou, China
- Institute of Neuroscience of Zhengzhou University, Zhengzhou, China
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Siora A, Vontetsianos A, Chynkiamis N, Anagnostopoulou C, Bartziokas K, Anagnostopoulos N, Rovina N, Bakakos P, Papaioannou AI. Small airways in asthma: From inflammation and pathophysiology to treatment response. Respir Med 2024; 222:107532. [PMID: 38228215 DOI: 10.1016/j.rmed.2024.107532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/02/2024] [Accepted: 01/13/2024] [Indexed: 01/18/2024]
Abstract
Small airways are characterized as those with an inner diameter less than 2 mm and constitute a major site of pathology and inflammation in asthma disease. It is estimated that small airways dysfunction may occur before the emergence of noticeable symptoms, spirometric abnormalities and imaging findings, thus characterizing them as "the quiet or silent zone" of the lungs. Despite their importance, measuring and quantifying small airways dysfunction presents a considerable challenge due to their inaccessibility in usual functional measurements, primarily due to their size and peripheral localization. Several pulmonary function tests have been proposed for the assessment of the small airways, including impulse oscillometry, nitrogen washout, body plethysmography, as well as imaging methods. Nevertheless, none of these methods has been established as the definitive "gold standard," thus, a combination of them should be used for an effective assessment of the small airways. Widely used asthma treatments seem to also affect several parameters of the small airways. Emerging biologic treatments show promising results in reducing small airways inflammation and remodelling, providing evidence for potential alterations in the disease's progression and outcomes. These novel therapies have implications not only in the clinical aspects of asthma but also in its inflammatory and functional aspects.
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Affiliation(s)
- Anastasia Siora
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece.
| | - Angelos Vontetsianos
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
| | - Nikolaos Chynkiamis
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
| | - Christina Anagnostopoulou
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
| | | | - Nektarios Anagnostopoulos
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
| | - Nikoletta Rovina
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
| | - Petros Bakakos
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
| | - Andriana I Papaioannou
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
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Ragnoli B, Radaeli A, Pochetti P, Kette S, Morjaria J, Malerba M. Fractional nitric oxide measurement in exhaled air (FeNO): perspectives in the management of respiratory diseases. Ther Adv Chronic Dis 2023; 14:20406223231190480. [PMID: 37538344 PMCID: PMC10395178 DOI: 10.1177/20406223231190480] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 07/03/2023] [Indexed: 08/05/2023] Open
Abstract
Exhaled nitric oxide (NO) production, upregulated by inflammatory cytokines and mediators in central and peripheral airways, can be easily and non-invasively detected in exhaled air in asthma and other respiratory conditions as a promising tool for disease monitoring. The American Thoracic Society and European Respiratory Society released recommendations that standardize the measurement of the fractional exhaled NO (FeNO). In asthma, increased FeNO reflects eosinophilic-mediated inflammatory pathways and, as a biomarker of T2 inflammation can be used to identify asthma T2 phenotype. In this setting its measurement has shown to be an important tool especially in the diagnostic process, in the assessment and evaluation of poor adherence or predicting positive response to inhaled corticosteroids treatment, in phenotyping severe asthma patients and as a biomarker to predict the response to biologic treatments. The discovery of the role of NO in the pathogenesis of different diseases affecting the airways and the possibility to estimate the predominant site of increased NO production has provided new insight on its regulatory role in the airways, making it suitable for a potential extended use in clinical practice for different pulmonary diseases, even though its role remains less clear than in asthma. Monitoring FeNO in pulmonary obstructive lung diseases including chronic bronchitis and emphysema, interstitial lung diseases, obstructive sleep apnea and other pulmonary diseases is still under debate but has opened up a window to the role NO may play in the management of these diseases. The use of FeNO is reliable, cost effective and recommendable in both adults and children, and should be implemented in the management of patients with asthma and other respiratory conditions.
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Affiliation(s)
| | | | | | - Stefano Kette
- Respiratory Unit, S. Andrea Hospital, Vercelli, Italy
| | - Jaymin Morjaria
- Department of Respiratory Medicine, Harefield Hospital, Guy’s & St Thomas’ NHS Foundation Trust, Harefield, UK
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Wu Y, Huang M, Zhong J, Lu Y, Gan K, Yang R, Liu Y, Li J, Chen J. The clinical efficacy of type 2 monoclonal antibodies in eosinophil-associated chronic airway diseases: a meta-analysis. Front Immunol 2023; 14:1089710. [PMID: 37114057 PMCID: PMC10126252 DOI: 10.3389/fimmu.2023.1089710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 03/22/2023] [Indexed: 04/29/2023] Open
Abstract
Background Anti-type 2 inflammation therapy has been proposed as a treatment strategy for eosinophil-associated chronic airway disorders that could reduce exacerbations and improve lung function. We performed a meta-analysis of randomized controlled trials to assess the effectiveness of type 2 monoclonal antibodies (anti-T2s) for eosinophil-associated chronic airway disorders. Methods PubMed, Embase, Web of Science, and Cochrane Library were searched from their inception to 21 August 2022. Randomized clinical trials evaluating the effectiveness of anti-T2s versus placebo in the treatment of chronic airway diseases were selected. The outcomes were exacerbation rate and change in pre-bronchodilator forced expiratory volume in 1 s (FEV1) from baseline. The Cochrane Risk of Bias Assessment Tool 1.0 was used to evaluate the risk of bias, and the random-effects or fixed-effect model were used to pool the data. Results Thirty-eight articles concerning forty-one randomized clinical trials with 17,115 patients were included. Compared with placebo, anti-T2s therapy yielded a significant reduction in exacerbation rate in COPD and asthma (Rate Ratio (RR)=0.89, 95%CI, 0.83-0.95, I2 = 29.4%; RR= 0.59, 95%CI, 0.52-0.68, I2 = 83.9%, respectively) and improvement in FEV1 in asthma (Standard Mean Difference (SMD)=0.09, 95%CI, 0.08-0.11, I2 = 42.6%). Anti-T2s therapy had no effect on FEV1 improvement in COPD (SMD=0.05, 95%CI, -0.01-0.10, I2 = 69.8%). Conclusion Despite inconsistent findings across trials, anti-T2s had a positive overall impact on patients' exacerbation rate in asthma and COPD and FEV1 in asthma. Anti-T2s may be effective in treating chronic airway illnesses related to eosinophils. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022362280.
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Affiliation(s)
- Yuan Wu
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Mengfen Huang
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jinyao Zhong
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yue Lu
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Kao Gan
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
| | - Rongyuan Yang
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
- Guangzhou Key Laboratory of Traditional Chinese Medicine for Prevention and Treatment of Emerging Infectious Diseases, Guangzhou, China
| | - Yuntao Liu
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
- Guangzhou Key Laboratory of Traditional Chinese Medicine for Prevention and Treatment of Emerging Infectious Diseases, Guangzhou, China
| | - Jiqiang Li
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
- Guangzhou Key Laboratory of Traditional Chinese Medicine for Prevention and Treatment of Emerging Infectious Diseases, Guangzhou, China
| | - Jiankun Chen
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou, China
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, China
- Guangzhou Key Laboratory of Traditional Chinese Medicine for Prevention and Treatment of Emerging Infectious Diseases, Guangzhou, China
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Baseline FeNO Independently Predicts the Dupilumab Response in Patients With Moderate-to-Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 11:1213-1220.e2. [PMID: 36535524 DOI: 10.1016/j.jaip.2022.11.043] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/23/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND FeNO may have a role as both a prognostic and predictive biomarker in combination with eosinophils for assessing responsiveness to some biological therapies. OBJECTIVE We evaluated the value of baseline FeNO, adjusted for baseline blood eosinophil levels and other clinical characteristics, as an independent predictor of treatment response to dupilumab in patients with uncontrolled moderate-to-severe asthma. METHODS We performed a post hoc analysis of LIBERTY ASTHMA QUEST (NCT02414854), a phase 3, double-blind study in patients aged 12 years and older with uncontrolled moderate-to-severe asthma, who received dupilumab 200 or 300 mg, or placebo every 2 weeks up to 52 weeks. We assessed the annualized event rate of severe exacerbations and least-squares mean change from baseline in prebronchodilator FEV1 at weeks 12 and 52 in relationship to baseline FeNO, adjusted for eosinophils and other clinical characteristics. RESULTS The annualized event rate increased with increasing baseline FeNO in placebo and decreased in dupilumab groups. The relative risk of severe exacerbations was 22·7%, 58·3%, and 69·3% lower for dupilumab versus placebo for the FeNO less than 25, 25 to less than 50, and 50 and greater parts per billion subgroups. The magnitude of FEV1 improvement increased with higher baseline FeNO for dupilumab and was consistent across the continuum of FeNO levels in placebo. Both findings were independent of blood eosinophil levels. Significant differences were observed between FeNO subgroups. CONCLUSIONS Increased baseline FeNO was associated with greater clinical effects in dupilumab versus placebo independently of eosinophil levels and other clinical characteristics.
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[History of atopy reduces predictive value of fractional exhaled nitric oxide for eosinophilic airway inflammation in chronic cough]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2022; 42:1470-1475. [PMID: 36329580 PMCID: PMC9637498 DOI: 10.12122/j.issn.1673-4254.2022.10.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
OBJECTIVE To investigate the impact of a history of atopy on the value of fractional exhaled nitric oxide (FENO) for predicting sputum eosinophils in patients with chronic cough. METHODS A total of 868 patients with persistent cough lasting more than 3 weeks without pulmonary infection were enrolled, including 119 patients with subacute cough (defined as cough lasting 3-8 weeks) and 749 with chronic cough (longer than 8 weeks). The predictive value of FENO level for sputum eosinophilia was analyzed using receiver-operating characteristic (ROC) curve analysis, and the area under the curve (AUC) was calculated. The atopy status of the patients was determined by screening for history of allergy, hay fever, or animal or food allergies. RESULTS Of the 868 patients enrolled, 173 patients (19.9%) had eosinophilic airway inflammation (EAI). In the overall patients, the median (Q1, Q3) FENO level was 18 (12, 35) ppb, ranging from 5 to 300 ppb. The patients with chronic cough and a positive history of atopy had a higher median FENO level than those without atopy (24 [13, 50] vs 18 [11, 34]; Z=2.25, P= 0.029), and FENO level was significantly correlated with EAI (r=0.281, P < 0.001). The AUCs of FENO for diagnosis of airway eosinophilia in patients with atopy and those without atopy were 0.677 (95% CI: 0.548-0.806) and 0.708 (95% CI: 0.660-0.756), respectively. The optimal cut-off value of FENO for diagnosing EAI was higher in patients with atopy than in those without atopy (72 vs 28.5 ppb). CONCLUSION A history of atopy reduces the predictive value of FENO level for EAI in patients with chronic cough, suggesting the importance of examining the atopic status when interpreting test results of FENO.
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Marcos MC, Cisneros Serrano C. What is the added value of FeNO as T2 biomarker? FRONTIERS IN ALLERGY 2022; 3:957106. [PMID: 36032508 PMCID: PMC9403133 DOI: 10.3389/falgy.2022.957106] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/20/2022] [Indexed: 11/17/2022] Open
Abstract
There is increasing evidence about the role of nitric oxide in type 2 (T2) immune response. Fraction of exhaled nitric oxide (FeNO) is a product of airways inflammation and it is increased in patients with asthma. Since Gustaffson published the first article about this biomarker in the 1990s, interest has continued to grow. Compared with other T2 biomarkers such as blood eosinophil count, induced sputum, or serum periostin, FeNO has some remarkable advantages, including its not invasive nature, easy repeatability, and possibility to be performed even in patients with severe airway obstruction. It is considered as an indicator of T2 inflammation and, by the same token, a useful predictor for inhaled steroid response. It is difficult to determine the utility of nitric oxide (NO) for initial asthma diagnosis. In such a heterogenous disease, a single parameter would probably not be enough to provide a complete picture. There is also an important variability among authors concerning FeNO cutoff values and the percentage of sensibility and specificity for diagnosis. Its high specificity indicates a potential role to “rule in” asthma; however, its lower sensibility could suggest a lower capacity to “rule out” this pathology. For this reason, if a diagnosis of asthma is being considered, FeNO should be considered along with other tests. FeNO has also shown its utility to detect response to steroids, adherence to treatment, and risk of exacerbation. Even though there is not enough quality of evidence to establish overall conclusions, FeNO could be an alternative procedure to diagnose or exclude asthma and also a predictive tool in asthma treated with corticosteroids.
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Park JS, Suh DI, Song DJ, Baek HS, Shin M, Yoo Y, Kwon JW, Jang GC, Yang HJ, Lee E, Kim HS, Seo JH, Woo SI, Kim HY, Shin YH, Lee JS, Yoon J, Jung S, Han M, Eom E, Yu J, Kim WK, Lim DH, Kim JT. Longitudinal asthma exacerbation phenotypes in the Korean childhood asthma study cohort. Pediatr Allergy Immunol 2022; 33. [PMID: 35470936 DOI: 10.1111/pai.13772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/23/2022] [Accepted: 03/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Asthma exacerbation (AE) leads to social and economic costs and long-term adverse outcomes. We aimed to predict exacerbation-prone asthma (EPA) in children. METHODS The Korean childhood Asthma Study (KAS) is a prospective nationwide pediatric asthma cohort of children aged 5-15 years followed every 6 months. Patients with AE during the 6 months prior to all three visits, with AE prior to one or two visits, and without AE prior to any visit were defined as having EPA, exacerbation-intermittent asthma (EIA), and exacerbation-resistant asthma (ERA), respectively. Risk factors and prediction models of EPA were explored. RESULTS Of the 497 patients who completed three visits, 42%, 18%, and 15% had exacerbations prior to visits 1, 2, and 3 and 5%, 47%, and 48% had EPA, EIA, and ERA, respectively. Univariate and multivariable logistic regression revealed forced expiratory volume in 1 s (FEV1) z-score, forced vital capacity (FVC) z-score, white blood cell (WBC) count, and asthma control test (ACT) score as relevant EPA risk factors. The EPA prediction model comprised FVC z-score, WBC count, ACT score, sex, and parental education level (area under the receiver operating characteristic curve [AUROC] 0.841 [95% confidence interval (CI): 0.728-0.954]). CONCLUSION With appropriate management, AE decreases over time, but persistent AEs may occur. Apart from asthma control level, baseline lung function and WBC count predicted EPA.
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Affiliation(s)
- Ji Soo Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Dae Jin Song
- Department of Pediatrics, Korea University College of Medicine, Seoul, South Korea
| | - Hey-Sung Baek
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Meeyong Shin
- Department of Pediatrics, Soonchunhyang University School of Medicine, Bucheon, South Korea
| | - Young Yoo
- Department of Pediatrics, Korea University Anam Hospital, Seoul, South Korea
| | - Ji-Won Kwon
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Gwang Cheon Jang
- Department of Pediatrics, National Health Insurance Service Ilsan Hospital, Ilsan, South Korea
| | - Hyeon-Jong Yang
- Department of Pediatrics, Pediatric Allergy and Respiratory Center, Soonchunhyang University College of Medicine, Seoul, South Korea
| | - Eun Lee
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Hwan Soo Kim
- Department of Pediatrics, School of Medicine, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, South Korea
| | - Ju-Hee Seo
- Department of Pediatrics, Dankook University Hospital, Cheonan, South Korea
| | - Sung-Il Woo
- Department of Pediatrics, College of Medicine, Chungbuk National University, Cheongju, South Korea
| | - Hyung Young Kim
- Department of Pediatrics, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Youn Ho Shin
- Department of Pediatrics, Gangnam CHA Medical Center, CHA University School of Medicine, Seoul, South Korea
| | - Ju Suk Lee
- Department of Pediatrics, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, South Korea
| | - Jisun Yoon
- Department of Pediatrics, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Sungsu Jung
- Department of Pediatrics, Pusan National University Children's Hospital, Pusan National University School of Medicine, Yangsan, South Korea
| | - Minkyu Han
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, South Korea
| | - Eunjin Eom
- Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jinho Yu
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Woo Kyung Kim
- Department of Pediatrics, Inje University Seoul Paik Hospital, Seoul, South Korea
| | - Dae Hyun Lim
- Department of Pediatrics, School of Medicine, Inha University, Incheon, South Korea
| | - Jin Tack Kim
- Department of Pediatrics, School of Medicine, Uijeongbu St. Mary's Hospital, The Catholic University of Korea, Uijeongbu, South Korea
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Loewenthal L, Menzies-Gow A. FeNO in Asthma. Semin Respir Crit Care Med 2022; 43:635-645. [DOI: 10.1055/s-0042-1743290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
AbstractAsthma is a common disease affecting 350 million people worldwide, which is characterized by airways inflammation and hyperreactivity. Historically diagnosis and treatment have been mainly based on symptoms, which have the potential to result in misdiagnosis and inappropriate treatment. Nitric oxide (NO) is exhaled in human breath and is a marker of airways inflammation. Levels of NO are increased in the exhaled breath of patients with type 2 asthma and fractional exhaled nitric oxide (FeNO) provides an objective biomarker of airway inflammation. FeNO testing is an accessible, noninvasive, and easy-to-use test. Cut-off values have been established by the American Thoracic Society (ATS), the Global Initiative for Asthma (GINA), and the National Institute for Health and Care Excellence (NICE) but vary between guidance. FeNO levels have been shown to be predictive of blood and sputum eosinophil levels but should not be used in isolation and current guidance emphasizes the importance of incorporating clinical symptoms and testing when utilizing FeNO results. The inclusion of FeNO testing can increase diagnostic accuracy of asthma, while high levels in asthmatic patients can help predict response to inhaled corticosteroids (ICS) and suppression of levels with ICS to monitor adherence. FeNO levels are also a predictor of asthma risk with increased exacerbation rates and accelerated decline in lung function associated with high levels as well as having an emerging role in predicting response to some biologic therapies in severe asthma. FeNO testing is cost-effective and has been shown, when combined with clinical assessment, to improve asthma management.
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Affiliation(s)
- Lola Loewenthal
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Andrew Menzies-Gow
- Department of Respiratory Medicine, Royal Brompton and Harefield Hospitals, London, United Kingdom
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Using FeNO Measurement in Clinical Asthma Management. Chest 2021; 161:906-917. [PMID: 34673021 DOI: 10.1016/j.chest.2021.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 09/30/2021] [Accepted: 10/10/2021] [Indexed: 11/24/2022] Open
Abstract
Asthma is a common and heterogeneous disease, characterised by lower airway inflammation and airflow limitation. Critical factors in asthma management include establishing an accurate diagnosis and ensuring appropriate selection and dosage of anti-inflammatory therapies. The majority of asthma patients exhibit type 2 (T2) inflammation, with increased interleukin (IL)-4, IL-5, and IL-13 signalling, often with associated eosinophilia. Identifying lower airway eosinophilia with sputum induction improves asthma outcomes, but is time consuming and costly. Increased T2-inflammation leads to upregulation of nitric oxide (NO) release into the airway, with increasing fractional exhaled NO (FeNO) reflecting greater T2-inflammation. FeNO can be easily and quickly measured in the clinic, offering a point of care surrogate measure of the degree of lower airway inflammation. FeNO testing can be used to help confirm an asthma diagnosis, to guide inhaled corticosteroid therapy, to assess adherence to treatment, and to aid selection of appropriate biologic therapy. However, FeNO levels may also be influenced by a variety of intrinsic and extrinsic factors other than asthma, including nasal polyposis and cigarette smoking, and must be interpreted in the broader clinical context rather than viewed in isolation. This review discusses the clinical application of FeNO measurement in asthma care, from diagnosis to treatment selection, and describes its place in current international expert guidelines.
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12
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Trevor J, Lugogo N, Carr W, Moore WC, Soong W, Panettieri RA, Desai P, Trudo F, Ambrose CS. Exacerbations in US Severe Asthma: Incidence, Characteristics, Predictors, and Effects of Biologic Treatments. Ann Allergy Asthma Immunol 2021; 127:579-587.e1. [PMID: 34273485 DOI: 10.1016/j.anai.2021.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 07/06/2021] [Accepted: 07/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with severe asthma (SA) have a heightened risk of exacerbations, including hospitalization. The real-world, specialist-verified incidence and characteristics of exacerbations among patients with SA in the United States (US) have not been described. OBJECTIVE To describe the real-world incidence, characteristics, and predictors of exacerbations among patients with SA in the US. METHODS CHRONICLE is an ongoing observational study of specialist-treated US adults with SA receiving biologic treatment or maintenance systemic corticosteroids (SCS), or uncontrolled by high-dosage inhaled corticosteroids with additional controllers. For patients enrolled February 2018 to February 2020, annualized rates and characteristics of exacerbation-related events were summarized by treatment category for 12 months before enrollment and after enrollment through the latest data collection. Results were further analyzed for subgroups of interest. RESULTS Among 1884 enrolled patients, 53.5% and 12.3% experienced an exacerbation and asthma hospitalization, respectively (0.81 and 0.14 per person-year). Of all exacerbations, 36%, 9%, and 15% required an unscheduled healthcare provider visit, emergency department visit without hospitalization, and hospitalization, respectively. Among patients not receiving biologics or SCS, higher blood eosinophil count, higher fractional exhaled nitric oxide, and lower total immunoglobulin E level were associated with higher exacerbation rates. Exacerbation rates decreased after starting or switching biologics (n = 1299). Multivariate analyses of enrolled patients showed prior-year exacerbations/hospitalizations, lack of asthma control, and geographic region also predicted event risk. CONCLUSION In this real-world cohort of specialist-treated US adults with SA, there was a substantial burden of exacerbations and associated healthcare resource utilization. Patients receiving biologics had a lower exacerbation burden.
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Affiliation(s)
| | | | - Warner Carr
- Allergy & Asthma Associates of Southern California, Mission Viejo, California
| | - Wendy C Moore
- Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Weily Soong
- University of Alabama at Birmingham, Birmingham, Alabama
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13
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Busse WW, Wenzel SE, Casale TB, FitzGerald JM, Rice MS, Daizadeh N, Deniz Y, Patel N, Harel S, Rowe PJ, Graham NMH, O'Riordan T, Pavord ID. Baseline FeNO as a prognostic biomarker for subsequent severe asthma exacerbations in patients with uncontrolled, moderate-to-severe asthma receiving placebo in the LIBERTY ASTHMA QUEST study: a post-hoc analysis. THE LANCET RESPIRATORY MEDICINE 2021; 9:1165-1173. [PMID: 34181876 DOI: 10.1016/s2213-2600(21)00124-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 02/03/2021] [Accepted: 02/23/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) has potential as a prognostic biomarker in asthma, but its prognostic value among other recognised indicators is unclear. We assessed the added prognostic value of baseline FeNO to blood eosinophil count and prior severe asthma exacerbations for subsequent exacerbations. METHODS In this post-hoc analysis of the 52-week, double-blind, phase 3 LIBERTY ASTHMA QUEST study, we identified 620 patients with moderate-to-severe asthma who were randomly assigned to placebo; had uncontrolled asthma with inhaled glucocorticoids plus up to two controllers; one or more exacerbations in the previous year; FEV1 percent predicted 40-80%; FEV1 reversibility of 12% or higher and 200 mL; Asthma Control Questionnaire (ACQ-5) score of 1·5 or higher; and complete data on baseline type 2 biomarkers (FeNO, eosinophils, and total IgE) with no baseline minimum requirement. Annualised severe exacerbation rate was assessed by baseline FeNO (<25 ppb, ≥25 to <50 ppb, ≥50 ppb; negative binomial model) and cross-classified by baseline blood eosinophils (<150 cells per μL, ≥150 to <300 cells per μL, ≥300 cells per μL) and prior exacerbations (one, two or more), all adjusted for baseline ACQ-5, postbronchodilator FEV1, and other clinical characteristics. Post-hoc analyses were done in the intention-to-treat population. The LIBERTY ASTHMA QUEST STUDY is registered on ClinicalTrials.gov, NCT02414854, and is complete. FINDINGS Patients with baseline FeNO of 50 ppb or higher (n=144) had a 1·54-times higher exacerbation rate than patients with FeNO of less than 25 ppb (n=291; relative risk 1·54 [95% CI 1·11-2·14]; p=0·0097). Patients with baseline FeNO of 25 to <50 ppb (n=185) had a 1·33-times higher exacerbation rate than patients with FeNO of less than 25 ppb (1·33 [0·99-1·78]; p=0·0572). Patients with baseline FeNO of 25 ppb or higher, a blood eosinophil count of 150 cells per μL or higher, and two or more prior exacerbations (n=157) had an exacerbation rate 3·62-times higher than patients with FeNO of less than 25 ppb, a blood eosinophil count of less than 150 cells per μL, and one prior exacerbation (n=116; 3·62 [1·67-7·81]; p=0·0011). INTERPRETATION In uncontrolled, moderate-to-severe asthma, higher baseline FeNO levels were associated with greater risk of severe asthma exacerbations, particularly in combination with elevated eosinophil count and prior exacerbations, supporting the added value of FeNO as a prognostic biomarker. Further research is needed to confirm FeNO as an independent predictor for asthma exacerbations. FUNDING Sanofi and Regeneron Pharmaceuticals.
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Affiliation(s)
- William W Busse
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Sally E Wenzel
- Asthma Institute at the University of Pittsburgh Medical Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Thomas B Casale
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | | | | | | | - Yamo Deniz
- Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | | | - Sivan Harel
- Regeneron Pharmaceuticals, Tarrytown, NY, USA
| | | | | | | | - Ian D Pavord
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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14
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Lehtimäki L, Karvonen T, Högman M. Clinical Values of Nitric Oxide Parameters from the Respiratory System. Curr Med Chem 2021; 27:7189-7199. [PMID: 32493184 DOI: 10.2174/0929867327666200603141847] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/24/2020] [Accepted: 03/16/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FENO) concentration reliably reflects central airway inflammation, but it is not sensitive to changes in the NO dynamics in the lung periphery. By measuring FENO at several different flow rates one can estimate alveolar NO concentration (CANO), bronchial NO flux (JawNO), bronchial wall NO concentration (CawNO) and the bronchial diffusivity of NO (DawNO). OBJECTIVE We aimed to describe the current knowledge and clinical relevance of NO parameters in different pulmonary diseases. METHODS We conducted a systematic literature search to identify publications reporting NO parameters in subjects with pulmonary or systemic diseases affecting the respiratory tract. A narrative review was created for those with clinical relevance. RESULTS Estimation of pulmonary NO parameters allows for differentiation between central and peripheral inflammation and a more precise analysis of central airway NO output. CANO seems to be a promising marker of parenchymal inflammation in interstitial lung diseases and also a marker of tissue damage and altered gas diffusion in chronic obstructive pulmonary disease and systemic diseases affecting the lung. In asthma, CANO can detect small airway involvement left undetected by ordinary FENO measurement. Additionally, CawNO and DawNO can be used in asthma to assess if FENO is increased due to enhanced inflammatory activity (increased CawNO) or tissue changes related to bronchial remodelling (altered DawNO). CONCLUSION NO parameters may be useful for diagnosis, prediction of disease progression and prediction of treatment responses in different parenchymal lung and airway diseases. Formal trials to test the added clinical value of NO parameters are needed.
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Affiliation(s)
- Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland,Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Tuomas Karvonen
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Marieann Högman
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, S-75185 Uppsala, Sweden
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15
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Menzella F, Galeone C, Ghidoni G, Ruggiero P, D'Amato M, Fontana M, Facciolongo N. The pharmacoeconomics of the state-of-the-art drug treatments for asthma: a systematic review. Multidiscip Respir Med 2021; 16:787. [PMID: 34557301 PMCID: PMC8404525 DOI: 10.4081/mrm.2021.787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 06/30/2021] [Indexed: 11/23/2022] Open
Abstract
Asthma is a chronic disease characterized by significant morbidities and mortality, with a large impact on socio-economic resources and a considerable burden on health-care systems. In the standard care of asthma, inhaled corticosteroids (ICS) associated with long-acting β-adrenoceptor agonists (LABA) are a reliable and often cost-effective choice, especially if based on the single inhaler therapy (SIT) strategy; however, in a subset of patients it is not possible to reach an adequate asthma control. In these cases, it is possible to resort to other pharmacologic options, including corticosteroids (OCS) or biologics. Unfortunately, OCS are associated with important side effects, whilst monoclonal antibodies (mAbs) allow excellent results, even if far more expensive. Up to now, the economic impact of asthma has not been compared with equivalent indicators in several studies. In fact, a significant heterogeneity of the cost analysis is evident in literature, for which the assessment of the real cost-effectiveness of asthma therapies is remarkably complex. To maximize the cost-effectiveness of asthma strategies, especially of biologics, attention must be paid on phenotyping and identification of predictors of response. Several studies were included, involving comparative analysis of drug treatments for asthma, comparative analysis of the costs and consequences of therapies, measurement and evaluation of direct drug costs, and the reduction of health service use. The initial research identified 389 articles, classified by titles and abstracts. A total of 311 articles were excluded as irrelevant and 78 articles were selected. Pharmacoeconomic studies on asthma therapies often report conflicting data also due to heterogeneous indicators and different populations examined. A careful evaluation of the existing literature is extremely important, because the scenario is remarkably complex, with an attempt to homogenize and interpret available data. Based on these studies, the improvement of prescriptive appropriateness and the reduction of the use of healthcare resources thanks to controller medications and to innovative therapies such as biologics partially reduce the economic burden of these treatments. A multidisciplinary stakeholder approach can also be extremely helpful in deciding between the available options and thus optimizing healthcare resources.
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Affiliation(s)
- Francesco Menzella
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia
| | - Carla Galeone
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia
| | - Giulia Ghidoni
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia
| | - Patrizia Ruggiero
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia
| | - Maria D'Amato
- Department of Pneumology, AO "Dei Colli", University of Naples Federico II, Naples, Italy
| | - Matteo Fontana
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia
| | - Nicola Facciolongo
- Pneumology Unit, Arcispedale Santa Maria Nuova, Azienda USL di Reggio Emilia IRCCS, Reggio Emilia
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16
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Galiniak S, Rachel M. Comparison of fractional exhaled nitric oxide in asthmatics with and without allergic rhinitis. Biomarkers 2021; 26:174-183. [PMID: 33435738 DOI: 10.1080/1354750x.2020.1871410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
PURPOSE OF THE STUDY The aim of this study was to measure the concentration of FeNO in asthmatics with and without allergic rhinitis (AR) and to determine usefulness of the test in the assessment of asthma control in the Polish population. The next objective of this study was to estimate the cut-off point of FeNO which might be a good indicator of uncontrolled asthma. MATERIALS AND METHODS The measurements were taken using the Hyp'Air FeNO in 303 adult patients with asthma, AR, comorbid AR and asthma, and non-diseased volunteers. RESULTS FeNO level in healthy adults was similar to the FeNO concentration in AR as well as controlled asthmatic patients without and with AR. Patients with partly controlled and uncontrolled asthma with and without AR had higher FeNO (>60 ppb) levels when compared to adults with controlled disease. The optimal cut-off point of FeNO > 46 ppb and FeNO > 33 ppb was estimated for identification of uncontrolled asthmatics without and with AR, respectively. CONCLUSION In conclusion, we found a significant correlation between the FeNO concentration and the level of asthma symptom control in asthmatic patients with and without AR.
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Affiliation(s)
| | - Marta Rachel
- Medical College of Rzeszów University, Rzeszów, Poland.,Allergology Department, Provincial Hospital No 2, Rzeszów, Poland
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17
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Pérez de Llano L, Blanco Cid N, Martin Robles I, Golpe R, Castro-Añon O, Dacal Rivas D. Regarding the role of F ENO in predicting failure after ICS reduction in mild-to-moderate asthma patients. Eur Respir J 2020; 56:56/2/2002375. [PMID: 32820023 DOI: 10.1183/13993003.02375-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 06/29/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Luis Pérez de Llano
- Pneumology Service, Hospital Lucus Augusti, EOXI Lugo, Cervo e Monforte, Lugo, Spain
| | - Nagore Blanco Cid
- Pneumology Service, Hospital Lucus Augusti, EOXI Lugo, Cervo e Monforte, Lugo, Spain
| | - Irene Martin Robles
- Pneumology Service, Hospital Lucus Augusti, EOXI Lugo, Cervo e Monforte, Lugo, Spain
| | - Rafael Golpe
- Pneumology Service, Hospital Lucus Augusti, EOXI Lugo, Cervo e Monforte, Lugo, Spain
| | - Olalla Castro-Añon
- Pneumology Service, Hospital Lucus Augusti, EOXI Lugo, Cervo e Monforte, Lugo, Spain
| | - David Dacal Rivas
- Pneumology Service, Hospital Lucus Augusti, EOXI Lugo, Cervo e Monforte, Lugo, Spain
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18
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Wang K, Verbakel JY, Oke J, Fleming-Nouri A, Harada N, Atsuta R, Fujisawa T, Kawayama T, Inoue H, Lazarus S, Szefler S, Martinez FD, Shaw D, Pavord ID, Thomas M. Using fractional exhaled nitric oxide to guide step-down treatment decisions in asthma: practical considerations. Eur Respir J 2020; 56:56/2/2002809. [PMID: 32820024 DOI: 10.1183/13993003.02809-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 07/16/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Kay Wang
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jan Y Verbakel
- KU Leuven, Dept of Public Health and Primary Care, Leuven, Belgium
| | - Jason Oke
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Norihiro Harada
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Ryo Atsuta
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Tomoyuki Fujisawa
- Second Division Dept of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Kurume University School of Medicine, Kurume, Japan
| | - Hiromasa Inoue
- Dept of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Stephen Lazarus
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
| | - Stanley Szefler
- Children's Hospital Colorado, The Breathing Institute, Dept of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Fernando D Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Dominick Shaw
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Ian D Pavord
- Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Mike Thomas
- Primary Care, Population Sciences and Medical Education (PPM), University of Southampton, Southampton, UK
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19
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Petralia LS, Bahl A, Peverall R, Richmond G, Couper JH, Hancock G, Robbins PA, Ritchie GAD. Accurate real-time F ENO expirograms using complementary optical sensors. J Breath Res 2020; 14:047102. [PMID: 32531773 DOI: 10.1088/1752-7163/ab9c31] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
The fraction of exhaled nitric oxide (FENO) is an important biomarker for the diagnosis and management of asthma and other pulmonary diseases associated with airway inflammation. In this study we report on a novel method for accurate, highly time-resolved, real time detection of FENO at the mouth. The experimental arrangement is based on a combination of optical sensors for the determination of the temporal profile of exhaled NO and CO2 concentrations. Breath CO2 and exhalation flow are measured at the mouth using diode laser absorption spectroscopy (at 2 μm) and differential pressure sensing, respectively. NO is determined in a sidestream configuration using a quantum cascade laser based, cavity-enhanced absorption cell (at 5.2 μm) which simultaneously measures sidestream CO2. The at-mouth and sidestream CO2 measurements are used to enable the deconvolution of the sidestream NO measurement back to the at-mouth location. All measurements have a time resolution of 0.1 s, limited by the requirement of a reasonable limit of detection for the NO measurement, which on this timescale is 4.7 ppb (2 σ). Using this methodology, NO expirograms (FENOgrams) were measured and compared for eight healthy volunteers. The FENOgrams appear to differ qualitatively between individuals and the hope is that the dynamic information encoded in these FENOgrams will provide valuable additional insight into the location of the inflammation in the airways and potentially predict a response to therapy. A validation of the measurements at low-time resolution is provided by checking that results from previous studies that used a two-compartment model of NO production can be reproduced using our technology.
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Affiliation(s)
- Lorenzo S Petralia
- Department of Chemistry, Physical and Theoretical Chemistry Laboratory, University of Oxford, Oxford, United Kingdom
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20
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Wang K, Verbakel JY, Oke J, Fleming-Nouri A, Brewin J, Roberts N, Harada N, Atsuta R, Takahashi K, Mori K, Fujisawa T, Shirai T, Kawayama T, Inoue H, Lazarus S, Szefler S, Martinez F, Shaw D, Pavord ID, Thomas M. Using fractional exhaled nitric oxide to guide step-down treatment decisions in patients with asthma: a systematic review and individual patient data meta-analysis. Eur Respir J 2020; 55:13993003.02150-2019. [PMID: 32139458 DOI: 10.1183/13993003.02150-2019] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/13/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND High exhaled nitric oxide fraction (F ENO) levels are associated with greater risk of asthma exacerbation. However, it is not clear how F ENO can be used to guide safe reductions in inhaled corticosteroid (ICS) doses in asthma patients. This study assesses the ability of F ENO to guide ICS reductions. METHODS Systematic searching of electronic databases identified prospective observational studies and randomised controlled trials which recruited participants with mild-to-moderate asthma aged ≥12 years and measured F ENO before reducing ICS. We performed multilevel mixed-effects logistic regression in relation to acute exacerbations and estimated each participant's exacerbation risk using our logistic regression model. RESULTS We included data from seven out of eight eligible studies, representing 384 participants. ICS doses were halved in four studies and withdrawn in three studies. A baseline F ENO measurement of ≥50 ppb was associated with increased risk of exacerbations (crude OR 3.14, 95% CI 1.41-7.00, p=0.005; adjusted OR 3.08, 95% CI 1.36-6.98, p=0.007) and corresponded to an estimated exacerbation risk cut-off of 15%. Reducing ICS when estimated exacerbation risk was <15% versus <10% would result in fewer patients remaining on the same ICS dose (40 (10.4%) out of 384 versus 141 (36.7%) out of 384), but similar proportions of patients avoiding exacerbations (222 (91.4%) out of 243, 95% CI 87.1-94.6% versus 311 (90.4%) out of 344, 95% CI 86.8-93.3%). CONCLUSION In patients with mild-to-moderate asthma, gradual ICS reduction when F ENO is <50 ppb may help decrease ICS use without increasing exacerbations. Future research should aim to validate these findings in larger populations.
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Affiliation(s)
- Kay Wang
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jan Y Verbakel
- KU Leuven, Dept of Public Health and Primary Care, Leuven, Belgium
| | - Jason Oke
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Josh Brewin
- Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Norihiro Harada
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Ryo Atsuta
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Kazuhisa Takahashi
- Dept of Respiratory Medicine, Juntendo University Faculty of Medicine and Graduate School of Medicine, Tokyo, Japan
| | - Kazutaka Mori
- Second Division Dept of Internal Medicine, Hamamatsu University School of Medicine, Hammamatsu, Japan
| | - Tomoyuki Fujisawa
- Second Division Dept of Internal Medicine, Hamamatsu University School of Medicine, Hammamatsu, Japan
| | - Toshihiro Shirai
- Dept of Respiratory Medicine, Shizuoka General Hospital, Shizuoka, Japan
| | - Tomotaka Kawayama
- Division of Respirology, Neurology, and Rheumatology, Kurume University School of Medicine, Kurume, Japan
| | - Hiromasa Inoue
- Dept of Pulmonary Medicine, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Stephen Lazarus
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco, CA, USA
| | - Stanley Szefler
- Children's Hospital Colorado, The Breathing Institute, Dept of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Fernando Martinez
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
| | - Dominick Shaw
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, UK
| | - Ian D Pavord
- Oxford Respiratory NIHR BRC and Respiratory Medicine Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Mike Thomas
- Primary Care, Population Sciences and Medical Education (PPM), University of Southampton, Southampton, UK
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21
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Colas L, Hassoun D, Magnan A. Needs for Systems Approaches to Better Treat Individuals With Severe Asthma: Predicting Phenotypes and Responses to Treatments. Front Med (Lausanne) 2020; 7:98. [PMID: 32296705 PMCID: PMC7137032 DOI: 10.3389/fmed.2020.00098] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 03/05/2020] [Indexed: 01/19/2023] Open
Abstract
Asthma is a frequent heterogeneous multifactorial chronic disease whose severe forms remain largely uncontrolled despite the availability of many drugs and educational therapy. Several phenotypes and endotypes of severe asthma have been described over the last two decades. Typical type-2-immunity-driven asthma remains the most frequent phenotype, and several targeted therapies have been developed and are now available. On the contrary, non-type-2 immunity-driven severe asthma is less understood and still requires efficient innovative therapies. A personalized approach would allow improving asthma control with the help of robust biomarkers able to predict phenotypes/endotypes, exacerbations, response to targeted treatments and, in the future, possible curative options. Some data from large multicenter cohorts have emerged in recent years, especially in transcriptomics. These data have to be integrated and reproduced longitudinally to provide a systems approach for asthma care. In this focused review, the needs for such an approach and the available data will be reviewed as well as the next steps for achieving personalized medicine in asthma.
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Affiliation(s)
- Luc Colas
- Nantes Université, CHU de Nantes, Plateforme Transversale d'Allergologie, Nantes, France.,Nantes Université, INSERM UMR 1087, CNRS UMR 6291, Nantes, France.,Nantes Université, Centre de Recherche en Transplantation et Immunologie UMR1064, INSERM, Nantes, France
| | - Dorian Hassoun
- Nantes Université, INSERM UMR 1087, CNRS UMR 6291, Nantes, France.,Nantes Université, CHU de Nantes, Service de Pneumologie, Nantes, France
| | - Antoine Magnan
- Nantes Université, INSERM UMR 1087, CNRS UMR 6291, Nantes, France.,Nantes Université, CHU de Nantes, Service de Pneumologie, Nantes, France
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22
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Menzies-Gow A, Mansur AH, Brightling CE. Clinical utility of fractional exhaled nitric oxide in severe asthma management. Eur Respir J 2020; 55:13993003.01633-2019. [PMID: 31949116 DOI: 10.1183/13993003.01633-2019] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/25/2019] [Indexed: 02/06/2023]
Abstract
Asthma is a chronic inflammatory disease of the airways, affecting over 350 million people worldwide and placing a significant burden on healthcare providers and wider society. Approximately 5-10% of asthma patients are diagnosed with severe asthma and typically are associated with increased risk of hospitalisation from exacerbations, increased morbidity, mortality and higher asthma-associated healthcare costs. Nitric oxide (NO) is an important regulator of immune responses and is a product of inflammation in the airways that is over-produced in asthma. Fractional exhaled NO (F eNO) is predominantly used as a predictor of response to inhaled corticosteroids (ICSs), to monitor adherence and as a diagnostic tool in ICS-naïve patients. In the UK, the National Institute for Health and Care Excellence (NICE) guidelines recommend the use of F eNO for the initial diagnosis of patients with suspected asthma. In the USA, American Thoracic Society (ATS) guidelines recommend F eNO as part of the initial diagnosis of asthma and for monitoring of airway inflammation. F eNO has also been shown to be a predictive factor for asthma exacerbations, with higher levels being associated with a greater number of exacerbations. In addition, higher levels of F eNO have been shown to be associated with a decline in lung function. F eNO testing is a cost-effective procedure and has been shown to improve patient management when combined with standard assessment methods. Recent evidence suggests that F eNO may also be useful as a surrogate biomarker for the assessment and management of severe asthma and to predict responsiveness to some biological therapies.
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Affiliation(s)
| | - Adel H Mansur
- Dept of Respiratory Medicine, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Christopher E Brightling
- Institute for Lung Health, NIHR Leicester Biomedical Research Centre, Dept of Respiratory Sciences, University of Leicester, Leicester, UK
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Blöndal V, Sundbom F, Borres MP, Högman M, Alving K, Malinovschi A, Janson C. Study of atopic multimorbidity in subjects with rhinitis using multiplex allergen component analysis. Clin Transl Allergy 2020; 10:6. [PMID: 32110380 PMCID: PMC7033937 DOI: 10.1186/s13601-020-0311-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 02/06/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Rhinitis is a common problem within the population. Many subjects with rhinitis also have atopic multimorbidity, such as asthma and eczema. The purpose of this investigation was to compare subjects with only rhinitis to those that have rhinitis, asthma and/or eczema in relation to immunoglobulin E (IgE) sensitization, inflammatory markers, family history, lung function and body mass index (BMI). METHODS A total of 216 adult subjects with rhinitis from the European Community Respiratory Health Survey II were investigated with multiplex component allergen analysis (103 allergen components), total IgE, C-reactive protein, eosinophilic cationic protein, fractional exhaled nitric oxide and spirometry. Rhinitis, eczema, asthma and parental allergy were questionnaire-assessed. RESULTS Of the 216 participants with rhinitis, 89 also had asthma and/or eczema. Participants with rhinitis that also had asthma or eczema were more likely to be IgE-sensitized (3.44, odds ratio, OR: 95% CI 1.62-7.30, adjusted for sex, age, mother's allergy, total IgE and forced expiratory volume (FEV1)). The number of IgE-positive components was independently associated with atopic multimorbidity (1.11, OR: 95% Cl 1.01-1.21) adjusted for sex, age, mother's allergy, total IgE and FEV1. When analysing different types of sensitization, the strongest association with atopic multimorbidity was found in participants that were IgE-sensitized both to perennial and seasonal allergens (4.50, OR: 95% CI 1.61-12.5). Maternal allergy (2.75, OR: 95% CI 1.15-4.46), high total IgE (2.38, OR: 95% CI 1.21-4.67) and lower FEV1 (0.73, OR: 95% CI 0.58-0.93) were also independently associated with atopic multimorbidity, while no association was found with any of the other inflammatory markers. CONCLUSION IgE polysensitization, to perennial and seasonal allergens, and levels of total IgE seem to be the main determinants of atopic multimorbidity in subjects with rhinitis. This indicates that disease-modifying treatment that targets IgE sensitization may be of value when decreasing the risk of developing atopic multimorbidity.
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Affiliation(s)
- Viiu Blöndal
- Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
- Department of Medical Sciences, Lung Allergy and Sleep Research, Uppsala University Hospital, Uppsala University, 751 85 Uppsala, Sweden
| | - Fredrik Sundbom
- Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Magnus P. Borres
- Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- Thermo Fischer Scientific, Uppsala, Sweden
| | - Marieann Högman
- Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Kjell Alving
- Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Christer Janson
- Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
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24
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Heffler E, Carpagnano GE, Favero E, Guida G, Maniscalco M, Motta A, Paoletti G, Rolla G, Baraldi E, Pezzella V, Piacentini G, Nardini S. Fractional Exhaled Nitric Oxide (FENO) in the management of asthma: a position paper of the Italian Respiratory Society (SIP/IRS) and Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC). Multidiscip Respir Med 2020; 15:36. [PMID: 32269772 PMCID: PMC7137762 DOI: 10.4081/mrm.2020.36] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/05/2020] [Indexed: 02/08/2023] Open
Abstract
Asthma prevalence in Italy is on the rise and is estimated to be over 6% of the general population. The diagnosis of asthma can be challenging and elusive, especially in children and the last two decades has brought evidences that asthma is not a single disease but consists of various phenotypes. Symptoms can be underestimated by the patient or underreported to the clinician and physical signs can be scanty. Usual objective measures, like spirometry, are necessary but sometimes not significant. Despite proper treatment, asthma can be a very severe condition (even leading to death), however new drugs have recently become available which can be very effective in its control. Since asthma is currently thought to be caused by inflammation, a direct measure of the latter can be of paramount importance. For this purpose, the measurement of Fractional Exhaled Nitric Oxide (FENO) has been used since the early years of the current century as a non-invasive, easy-to-assess tool useful for diagnosing and managing asthma. This SIP-IRS/SIAAIC Position Paper is a narrative review which summarizes the evidence behind the usefulness of FENO in the diagnosis, management and phenotypization of asthma.
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Affiliation(s)
- Enrico Heffler
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano (MI).,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI)
| | - Giovanna Elisiana Carpagnano
- Department of Medical and Surgical Sciences, University of Foggia; Section of Respiratory Diseases, Hospital d'Avanzo, Foggia
| | - Elisabetta Favero
- Department of Medicine-DIMED, Immunological and Respiratory Rare Disease, Allergologic Clinic Ca' Foncello Hospital, Treviso
| | - Giuseppe Guida
- Allergy and Pneumology Unit, A.O. S. Croce e Carle, Cuneo
| | - Mauro Maniscalco
- Respiratory Rehabilitation Unit, ICS Maugeri, Institute of Telese Terme IRCCS
| | - Andrea Motta
- Institute of Biomolecular Chemistry, National Research Council, Pozzuoli (NA)
| | - Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center IRCCS, Rozzano (MI).,Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI)
| | - Giovanni Rolla
- Allergy and Clinical Immunology, University of Turin and A.O. Mauriziano, Turin
| | - Eugenio Baraldi
- Department of Woman's and Child's Health, University Hospital of Padua
| | - Vincenza Pezzella
- Department of Woman, Child and of General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples
| | - Giorgio Piacentini
- Paediatric Section, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona
| | - Stefano Nardini
- Italian Respiratory Society-Società Italiana di Pneumologia, Milan, Italy
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25
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Lin H, Wang X. The effects of gasotransmitters on bronchopulmonary dysplasia. Eur J Pharmacol 2020; 873:172983. [PMID: 32017936 DOI: 10.1016/j.ejphar.2020.172983] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 01/22/2020] [Accepted: 01/31/2020] [Indexed: 02/06/2023]
Abstract
Bronchopulmonary dysplasia (BPD), which remains a major clinical problem for preterm infants, is caused mainly by hyperoxia, mechanical ventilation and inflammation. Many approaches have been developed with the aim of decreasing the incidence of or alleviating BPD, but effective methods are still lacking. Gasotransmitters, a type of small gas molecule that can be generated endogenously, exert a protective effect against BPD-associated lung injury; nitric oxide (NO), carbon monoxide (CO) and hydrogen sulfide (H2S) are three such gasotransmitters. The protective effects of NO have been extensively studied in animal models of BPD, but the results of these studies are inconsistent with those of clinical trials. NO inhalation seems to have no effect on BPD, although side effects have been reported. NO inhalation is not recommended for BPD treatment in preterm infants, except those with severe pulmonary hypertension. Both CO and H2S decreased lung injury in BPD rodent models in preclinical studies. Another small gas molecule, hydrogen, exerts a protective effect against BPD. The nuclear factor erythroid-derived 2 (Nrf2)/heme oxygenase-1 (HO-1) axis seems to play a central role in the protective effect of these gasotransmitters on BPD. Gasotransmitters play important roles in mammals, but further clinical trials are needed to explore their effects on BPD.
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Affiliation(s)
- Hai Lin
- Department of Traditional Chinese Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Xinbao Wang
- Department of Pediatrics, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China.
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26
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de Jong CCM, Pedersen ES, Goutaki M, Trachsel D, Barben J, Kuehni CE. Do clinical investigations predict long-term wheeze? A follow-up of pediatric respiratory outpatients. Pediatr Pulmonol 2019; 54:1156-1161. [PMID: 31026385 DOI: 10.1002/ppul.24347] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/26/2019] [Accepted: 04/12/2019] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The contribution of clinical investigations to prediction of long-term outcomes of children investigated for asthma is unclear. AIM We performed a broad range of clinical tests and investigated whether they helped to predict long-term wheeze among children referred for evaluation of possible asthma. METHODS We studied children aged 6 to 16 years referred to two Swiss pulmonary outpatient clinics with a history of wheeze, dyspnea, or cough in 2007. The initial assessment included spirometry, fractional exhaled nitric oxide, skin prick tests, and bronchial provocation tests by exercise, methacholine, and mannitol. Respiratory symptoms were assessed with questionnaires at baseline and at follow-up 7 years later. Associations between baseline factors and wheeze at follow-up were investigated by logistic regression. RESULTS At baseline, 111 children were examined in 2007. After 7 years, 85 (77%) completed the follow-up questionnaire, among whom 61 (72%) had wheeze at baseline, while at follow-up 39 (46%) reported wheeze. Adjusting for age and sex, the following characteristics predicted wheeze at adolescence: wheeze triggered by pets (odds ratio, 4.2; 95% CI, 1.2-14.8), pollen (2.8, 1.1-7.0), and exercise (3.1, 1.2-8.0). Of the clinical tests, only a positive exercise test (3.2, 1.1-9.7) predicted wheeze at adolescence. CONCLUSION Reported exercise-induced wheeze and wheeze triggered by pets or pollen were important predictors of wheeze persistence into adolescence. None of the clinical tests predicted wheeze more strongly than reported symptoms. Clinical tests might be important for asthma diagnosis but medical history is more helpful in predicting prognosis in children referred for asthma.
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Affiliation(s)
- Carmen C M de Jong
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Eva Sl Pedersen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Myrofora Goutaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Daniel Trachsel
- Paediatric Respiratory Medicine, Children's University Hospital of Basel, Basel, Switzerland
| | - Juerg Barben
- Paediatric Respiratory Medicine, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland.,Children's University Hospital of Bern, University of Bern, Bern, Switzerland
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Saito J, Kikuchi M, Fukuhara A, Sato S, Rikimaru M, Suzuki Y, Uematsu M, Fukuhara N, Kawamata T, Umeda T, Togawa R, Sato Y, Koizumi T, Hirai K, Minemura H, Nikaido T, Kanazawa K, Tanino Y, Shibata Y, Munakata M. Comparison of fractional exhaled nitric oxide levels measured by different analyzers produced by different manufacturers. J Asthma 2019; 57:1216-1226. [PMID: 31288573 DOI: 10.1080/02770903.2019.1642351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: Fractional exhaled nitric oxide (FeNO) is widely used as a biomarker of allergic airway inflammation. At present, both stationary chemiluminescence and portable electrochemical analyzers produced by different manufacturers are available. However, it remains debatable whether those analyzers are comparable to each other. We compare FeNO levels obtained by different analyzers.Methods: For the first study, 153 subjects were enrolled to compare differences in FeNO levels measured using three analyzers (NA623NP®, NObreath®, and NIOX MINO®) which were produced by different manufacturers. For the second study, 30 subjects were recruited to compare FeNO levels obtained by the two analyzers (NIOX MINO® and NIOX VERO®) produced by the same manufacturer. FeNO was measured twice using each analyzer in random order.Results: FeNO levels obtained using the NIOX MINO® and NObreath® were more variable than those measured using the NA623NP®. There were strong positive correlations in FeNO levels measured by the NA623NP®, NIOX MINO®, and NObreath® (p < 0.001). The NA623NP® and NIOX MINO® provided the highest and lowest FeNO levels, respectively; whereas, those obtained by NObreath® were intermediate. No significant differences were observed in FeNO levels obtained using the NIOX MINO® and NIOX VERO®.Conclusions: FeNO levels measured by the NIOX MINO® and NIOX VERO®, both of which were produced by the same manufacturer, have comparability. However, significant differences in FeNO levels exist when measured by analyzers manufactured by different manufacturers. This should be taken into account for FeNO measurement.
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Affiliation(s)
- Junpei Saito
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Masami Kikuchi
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Atsuro Fukuhara
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Suguru Sato
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Mami Rikimaru
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yasuhito Suzuki
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Manabu Uematsu
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Naoko Fukuhara
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takaya Kawamata
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takeshi Umeda
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Ryuichi Togawa
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yuki Sato
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Tatsuhiko Koizumi
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Kenichiro Hirai
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Hiroyuki Minemura
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takefumi Nikaido
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Kenya Kanazawa
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yoshinori Tanino
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Yoko Shibata
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Mitsuru Munakata
- Department of Pulmonary Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan
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Ahovuo-Saloranta A, Csonka P, Lehtimäki L. Basic characteristics and clinical value of FeNO in smoking asthmatics-a systematic review. J Breath Res 2019; 13:034003. [PMID: 30861509 DOI: 10.1088/1752-7163/ab0ece] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Fractional exhaled nitric oxide (FeNO) reflects eosinophilic airway inflammation and it can be used to diagnose and phenotype asthma and predict treatment responses. However, smoking decreases FeNO and it is not clear if FeNO has clinical value in smoking subjects with asthma. We conducted a systematic review focusing on four basic characteristics and five clinical questions on using FeNO in smokers with asthma. At least two authors independently screened search results, extracted data and assessed the quality of the included studies. Data were synthesised mainly by qualitative methods. Twenty-two studies were included. FeNO is lower in smoking than in non-smoking asthmatics, but importantly FeNO is higher in untreated smoking asthmatics than in healthy smokers. Information was incomplete but there is some indication that FeNO might be useful in detecting eosinophilic airway inflammation and in diagnosing asthma in smoking subjects. There was no data available to four of the five clinical questions. In conclusion, at the moment there is insufficient data to give specific guidelines on using FeNO in smoking subjects, but although smoking decreases FeNO it does not seem to make FeNO measurement redundant. FeNO is also associated with asthma in smokers and current results encourage conducting clinical trials on FeNO in smokers with asthma.
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29
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Powitz F. [Asthma - Update 2019]. MMW Fortschr Med 2019; 161:45-55. [PMID: 30912087 DOI: 10.1007/s15006-019-0010-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Frank Powitz
- Pneumologie Elisenhof, Prielmayerstr. 3, D-80335, München, Deutschland.
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30
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Zeiger RS, Schatz M, Yang SJ, Chen W. Fractional Exhaled Nitric Oxide-Assisted Management of Uncontrolled Persistent Asthma: A Real-World Prospective Observational Study. Perm J 2019; 23:18-109. [PMID: 31050641 PMCID: PMC6499115 DOI: 10.7812/tpp/18-109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
CONTEXT The utility of fractional exhaled nitric oxide (FeNO) measurement in real-world asthma management requires investigation. OBJECTIVE To determine whether FeNO-assisted care added to standard asthma management improves asthma control in a managed care organization. DESIGN Prospective observational study in patients aged 12 years and older with uncontrolled persistent asthma identified during a scheduled visit to an Allergy Department that routinely used FeNO (FeNO-assisted care, n = 426) vs visits to 4 Allergy Departments that did not, but followed routine guideline-based care (standard care, n = 925). The FeNO-assisted care was based on FeNO level, asthma control status, and step-care level. MAIN OUTCOME MEASURES Composite primary outcome was 1 or more asthma exacerbations or 7 or more dispensed canisters containing short-acting β2-agonists in the follow-up year. Inverse probability of treatment weighting propensity scoring balanced covariates, and multivariable regression analyses compared outcomes between groups. RESULTS Compared with standard care, FeNO-assisted care was not associated with reducing the primary composite outcome (adjusted risk ratio = 0.94, 95% confidence interval = 0.69-1.29, p = 0.71), nor with a reduction in asthma exacerbations or dispensing of 7 or more short-acting β2-agonist canisters as separate outcomes. In an atopic subgroup with aeroallergen sensitization, the composite outcome was similar between groups, but the rate of asthma exacerbations was lower with FeNO-assisted treatment (adjusted rate ratio = 0.67, 95% confidence interval = 0.49-0.91, p = 0.01). CONCLUSION These findings suggest future studies of FeNO-assisted care should be directed at the atopic phenotype.
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Affiliation(s)
- Robert Stephen Zeiger
- Department of Allergy, Clairemont Mesa Medical Center, San Diego, CA
- Kaiser Permanente Southern California Research and Evaluation, Pasadena
| | - Michael Schatz
- Department of Allergy, Clairemont Mesa Medical Center, San Diego, CA
| | - Su-Jau Yang
- Kaiser Permanente Southern California Research and Evaluation, Pasadena
| | - Wansu Chen
- Kaiser Permanente Southern California Research and Evaluation, Pasadena
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31
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Gallucci M, Carbonara P, Pacilli AMG, di Palmo E, Ricci G, Nava S. Use of Symptoms Scores, Spirometry, and Other Pulmonary Function Testing for Asthma Monitoring. Front Pediatr 2019; 7:54. [PMID: 30891435 PMCID: PMC6413670 DOI: 10.3389/fped.2019.00054] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 02/11/2019] [Indexed: 01/09/2023] Open
Abstract
Asthma is a global problem affecting millions of people all over the world. Monitoring of asthma both in children and in adulthood is an indispensable tool for the optimal disease management and for the maintenance of clinical stability. To date, several resources are available to assess the asthma control, first is the monitoring of symptoms, both through periodic follow-up visits and through specific quality of life measures addressed to the patient in first person or to parents. Clinical monitoring is not always sufficient to predict the risk of future exacerbations, which is why further instrumental examinations are available including lung function tests, the assessment of bronchial hyper-reactivity and bronchial inflammation. All these tools may help in quantifying the future risk for each patient and therefore they potentially may change the natural history of asthmatic disease. The monitoring of asthma in children as in adults is certainly linked by many aspects, however the asthmatic child is a future asthmatic adult and it is precisely during childhood and adolescence that we should implement all the efforts and strategies to prevent the progression of the disease and the subsequent impairment of lung function. For these reasons, asthma monitoring plays a crucial role and must be particularly close and careful. In this paper, we evaluate several tools currently available for asthma monitoring, focusing on current recommendations emerging from various guidelines and especially on the differences between the monitoring in pediatric age and adulthood.
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Affiliation(s)
- Marcella Gallucci
- Department of Pediatrics, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Paolo Carbonara
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), University of Bologna, Alma Mater Studiorum, Bologna, Italy
| | - Angela Maria Grazia Pacilli
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), University of Bologna, Alma Mater Studiorum, Bologna, Italy
| | - Emanuela di Palmo
- Department of Pediatrics, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giampaolo Ricci
- Department of Pediatrics, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Stefano Nava
- Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), University of Bologna, Alma Mater Studiorum, Bologna, Italy
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Kasuga S, Kabata D, Sakaguchi T, Kudoh S, Nishigaki S, Higa Y, Fujikawa S, Fujitani H, Shintani A, Hamazaki T, Shintaku H. Usefulness of serum biopterin as a predictive biomarker for childhood asthma control: A prospective cohort study. Allergol Int 2019; 68:96-100. [PMID: 30297096 DOI: 10.1016/j.alit.2018.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 06/14/2018] [Accepted: 08/01/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Pteridines are metabolites of tetrahydrobiopterin, which serves as co-enzyme of nitric oxide synthase. We sought to investigate the usefulness of pteridines as biomarkers for childhood asthma control. METHODS We conducted a single-center prospective cohort study involving 168 asthmatic children aged 4-17 years who visited the periodical asthma checkup program. Serum neopterin and biopterin levels were measured as pteridines at each visit along with measurement of FeNO, respiratory function tests, nasal eosinophil test, blood eosinophil count, and IgE level. We calculated coefficients for relation between pteridines and asthma control, which was assessed by questionnaires (JPAC: Japanese Pediatric Asthma Control Program). RESULTS A total of 168 participants aged 10.3 ± 3.39 years (mean ± SD) with asthma were recruited. The participants in this study contained 58 patients (34.5%) of complete-controlled based on JPAC, 132 patients (76.0%) of well-controlled group based on GINA. FeNO and serum neopterin level did not correlate with following period's JPAC scores. In contrast, serum biopterin level significantly correlated with following period's JPAC total score (Coefficients 0.398; 95% CI 0.164 to 0.632; p value 0.001) and frequency of wheezing during exercise (Coefficients 0.272; 95% CI 0.217 to 0.328; p value < 0.001). CONCLUSIONS We found serum biopterin effected the following period's control status of asthmatic children, thus monitoring biopterin level will be a useful for management of asthma to adjust treatment.
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Affiliation(s)
- Saki Kasuga
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tomoko Sakaguchi
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Satoshi Kudoh
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Satsuki Nishigaki
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yusuke Higa
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shiori Fujikawa
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroko Fujitani
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takashi Hamazaki
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Haruo Shintaku
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
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Pérez de Llano L, García-Rivero JL, Urrutia I, Martínez-Moragón E, Ramos J, Cebollero P, Carballada F, Blanco-Aparicio M, Vennera MDC, Merino M, Torralba-García Y, Plaza V. A Simple Score for Future Risk Prediction in Patients with Controlled Asthma Who Undergo a Guidelines-Based Step-Down Strategy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:1214-1221.e3. [PMID: 30368006 DOI: 10.1016/j.jaip.2018.10.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 10/13/2018] [Accepted: 10/15/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND The minimum controlling dose of treatment must be established in patients with asthma, but the outcome of step-down is unpredictable. OBJECTIVE To identify factors associated with risk of control loss when stepping down asthma treatment and to develop a score to predict this risk. METHODS A prospective, multicenter study including adults with well-controlled asthma was performed. Treatment was stepped up or stepped down over a 12-month period to maintain asthma control. We determined associations between clinical and functional variables and step-down failure. Finally, we derived a score to predict loss of control in 1 cohort and validated it in an independent cohort. RESULTS The derivation cohort consisted of 228 patients; 218 completed at least 1 step-down episode and a total of 495 step-down episodes were evaluated. A medical-record documented postbronchodilator spirometry result of <70% forced expiratory volume in 1 second (FEV1)/forced vital capacity (odds ratio [OR] = 2.08; 95% confidence interval [CI]: 1.26-3.43), current FEV1 < 80% (OR = 1.80; 95% CI: 1.03-3.14), ≥1 severe exacerbation in the previous 12 months (OR = 2.43; 95% CI: 1.48-4.01), and Asthma Control Test score < 25 (OR = 2.30; 95% CI: 1.35-3.92) were independently associated with failure. The score showed an area under the curve of 0.690 (95% CI: 0.633-0.747; P < .05) in the derivation cohort and 0.76 (95% CI: 0.643-0.882; P < .001) in a validation cohort of 114 patients. A score <4.5 implies a low risk of failure (<20%), whereas a score >8 implies a high risk (>40%). CONCLUSION This score can facilitate the prediction of step-down failure before medication taper in patients with well-controlled asthma.
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Affiliation(s)
| | | | - Isabel Urrutia
- Pneumology Service, Hospital de Galdakao, Bizkaia, Spain
| | | | - Jacinto Ramos
- Pneumology Service, Complejo Asistencial de Salamanca, Salamanca, València, Spain
| | - Pilar Cebollero
- Pneumology Service, Complejo Hospitalario de Navarra, Navarra, Spain
| | | | - Marina Blanco-Aparicio
- Pneumology Service, Complexo Hospitalario Universitario A Coruña (CHUAC), A Coruña, Spain
| | - María Del Carmen Vennera
- Servei de Pneumologia i Allèrgia Respiratòria, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - María Merino
- Health Outcomes Research Department, Weber, Economía y Salud, Madrid, Spain
| | - Yolanda Torralba-García
- Servei de Pneumologia i Allèrgia Respiratòria, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Vicente Plaza
- Department of Respiratory Medicine, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomédica Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Department of Medicine, Barcelona, Spain
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Ciprandi G, Gallo F, Cirillo I. Asthma symptom perception does not relate with type-2 bronchial inflammation. REVUE FRANCAISE D ALLERGOLOGIE 2018. [DOI: 10.1016/j.reval.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Lassmann-Klee PG, Lindholm T, Metsälä M, Halonen L, Sovijärvi ARA, Piirilä P. Reduction of F ENO by tap water and carbonated water mouthwashes: magnitude and time course. Scandinavian Journal of Clinical and Laboratory Investigation 2018; 78:153-156. [PMID: 29304558 DOI: 10.1080/00365513.2017.1419574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Fractional exhaled nitric oxide (FENO) assesses eosinophilic inflammation of the airways, but FENO values are also influenced by oral nitric oxide (NO). The aim of this pilot study was to measure FENO and compare the effect of two different mouthwashes on FENO and analyse the duration of the effect. FENO was measured in 12 randomized volunteers (healthy or asthmatic subjects) with a NIOX VERO® analyser at an expiratory flow rate of 50 mL/s. After a baseline measurement, a mouthwash was performed either with tap water or carbonated water and was measured during 20 min in 2 min intervals. The procedure was repeated with the other mouthwash. We found that both mouthwashes reduced FENO immediately at the beginning compared to the baseline (p < .001). The carbonated water mouthwash effect lasted 12 min (p ranging from <0.001 to <0.05). The tap water mouthwash reduced FENO statistically significantly only for 2 min compared with the baseline. We conclude that a single carbonated water mouthwash can significantly reduce the oropharyngeal NO contribution during a 12 min time interval.
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Affiliation(s)
- Paul Guenther Lassmann-Klee
- a Unit of Clinical Physiology , Helsinki University Central Hospital, University of Helsinki , Helsinki , Finland
| | - Tuula Lindholm
- b Laboratory of Clinical Physiology , Finnish Institute of Occupational Health , Helsinki , Finland
| | - Markus Metsälä
- c Department of Chemistry , University of Helsinki , Helsinki , Finland
| | - Lauri Halonen
- c Department of Chemistry , University of Helsinki , Helsinki , Finland
| | - Anssi Raimo Antero Sovijärvi
- a Unit of Clinical Physiology , Helsinki University Central Hospital, University of Helsinki , Helsinki , Finland
| | - Päivi Piirilä
- a Unit of Clinical Physiology , Helsinki University Central Hospital, University of Helsinki , Helsinki , Finland
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Backman K, Ollikainen H, Piippo-Savolainen E, Nuolivirta K, Korppi M. Asthma and lung function in adulthood after a viral wheezing episode in early childhood. Clin Exp Allergy 2017; 48:138-146. [PMID: 29143374 DOI: 10.1111/cea.13062] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 11/08/2017] [Accepted: 11/10/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Viral aetiology of infection has a significant role in the long-term outcome of early-childhood wheezing. OBJECTIVE This study examines asthma and lung function in adulthood after early-childhood wheezing induced by respiratory syncytial virus (RSV) and rhinovirus (RV). METHODS A total of 100 children were hospitalized for a wheezing episode at less than 24 months of age from 1992 to 1993 in Kuopio University Hospital (Finland). Adenovirus, influenza A and B virus, parainfluenza (1-3) virus, and RSV were tested on admission using antigen detection and antibody assays, and RSV and RV were tested by polymerase chain reaction (PCR). In 2010, 49 cases and 60 population controls attended a follow-up study, which included spirometry with bronchodilation test and fractionally exhaled nitric oxide (FENO ) measurements. RESULTS Current asthma was present in 64% of the cases with RV-induced wheezing (OR 17.0 [95%CI 3.9-75.3] vs controls), in 43% of the cases with RSV-induced wheezing episode (6.1 [1.5-24.9] vs controls), and in 12% of the controls. The RV group showed significantly higher mean FENO values than the RSV group and controls. RV-positive cases had lower MEF50 before bronchodilation and higher MEF50, FEV1, and FEV1/FVC bronchodilation responses than controls. RSV-positive cases had lower FVC than controls before bronchodilation. CONCLUSION Cases with RV- and RSV-induced early-childhood wheezing had increased risk for asthma in adulthood, and RV-positive cases had significantly higher FENO values than RSV-positive cases and controls. Compared to controls, RV-positive cases showed more bronchial reactivity, and RSV-positive cases showed lower FVC before bronchodilation in lung function testing. CLINICAL RELEVANCE Children with RV- or RSV-induced wheezing in early childhood have an increased risk for asthma and lung function abnormalities in adulthood.
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Affiliation(s)
- K Backman
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - H Ollikainen
- Child Welfare Clinic and School Health Care, Health Care Center, Pediatrics, Kuopio, Finland
| | | | - K Nuolivirta
- Department of Pediatrics, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - M Korppi
- Pediatric Research Centre, Tampere University and Tampere University Hospital, Tampere, Finland
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Fractional exhaled nitric oxide, methacholine, or forced expiratory flow between 25% and 75%: What's better in the daily clinical practice? Ann Allergy Asthma Immunol 2017; 118:235. [PMID: 28153082 DOI: 10.1016/j.anai.2016.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 11/04/2016] [Indexed: 11/22/2022]
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Martins C, Silva D, Severo M, Rufo J, Paciência I, Madureira J, Padrão P, Moreira P, Delgado L, Oliveira Fernandes E, Barros H, Malmberg P, Moreira A. Spirometry-adjusted fraction of exhaled nitric oxide increases accuracy for assessment of asthma control in children. Pediatr Allergy Immunol 2017; 28:754-762. [PMID: 28892559 DOI: 10.1111/pai.12803] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/06/2017] [Indexed: 12/12/2022]
Abstract
Spirometry and exhaled nitric oxide are two important complimentary tools to identify and assess asthma control in children. We aimed to determine the ability of a new suggested spirometry-adjusted fraction of exhaled nitric oxide (NO) index in doing that. A random sample of 1602 schoolchildren were screened by a health questionnaire, skin prick tests, spirometry with bronchodilation and exhaled NO. A total of 662 children were included with median (IQR) exhaled NO 11(14) ppb. Receiver operating characteristic (ROC) curves using exhaled NO equations from Malmberg, Kovesi and Buchvald, and spirometry-adjusted fraction of exhaled NO values were applied to identify asthmatic children and uncontrolled asthma. Receiver operating characteristic (ROC) curves failed to identify asthmatic children (all AUC < 0.700). Spirometry-adjusted fraction of exhaled NO/FEV1 (AUC = 0.712; P = .010) and NO/FEF25%-75% (AUC = 0.735 P = .004) had a fair and increased ability to identify uncontrolled disease compared with exhaled NO (AUC = 0.707; P = .011) or the Malmberg equation (AUC = 0.701; P = .014). Sensitivity and specificity identifying non-controlled asthma were 59% and 81%, respectively, for the cut-off value of 9.7 ppb/L for exhaled NO/FEV1 , and 40% and 100% for 15.7 ppb/L/s for exhaled NO/FEF25%-75% . Exhaled NO did not allow to identify childhood asthma. Spirometry-adjusted fraction of exhaled NO performed better-assessing asthma control in children. Thus, although more validation studies are needed, we suggest its use in epidemiological studies to assess asthma control.
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Affiliation(s)
- Carla Martins
- Department of Immunoallergology, Centro Hospitalar de São João, Porto, Portugal
| | - Diana Silva
- Department of Immunoallergology, Centro Hospitalar de São João, Porto, Portugal.,Faculty of Medicine, Basic and Clinical Immunology, University of Porto, Porto, Portugal
| | - Milton Severo
- Faculty of Medicine, Basic and Clinical Immunology, University of Porto, Porto, Portugal.,Institute of Public Health, University of Porto, Porto, Portugal
| | - João Rufo
- Faculty of Medicine, Basic and Clinical Immunology, University of Porto, Porto, Portugal.,Institute of Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - Inês Paciência
- Faculty of Medicine, Basic and Clinical Immunology, University of Porto, Porto, Portugal.,Institute of Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - Joana Madureira
- Institute of Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - Patrícia Padrão
- Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal
| | - Pedro Moreira
- Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal
| | - Luís Delgado
- Department of Immunoallergology, Centro Hospitalar de São João, Porto, Portugal.,Faculty of Medicine, Basic and Clinical Immunology, University of Porto, Porto, Portugal
| | | | - Henrique Barros
- Faculty of Medicine, Basic and Clinical Immunology, University of Porto, Porto, Portugal.,Institute of Public Health, University of Porto, Porto, Portugal
| | - Pekka Malmberg
- Department of Allergology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - André Moreira
- Department of Immunoallergology, Centro Hospitalar de São João, Porto, Portugal.,Faculty of Medicine, Basic and Clinical Immunology, University of Porto, Porto, Portugal.,Institute of Public Health, University of Porto, Porto, Portugal.,Faculty of Nutrition and Food Sciences, University of Porto, Porto, Portugal
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Karvonen T, Kankaanranta H, Saarelainen S, Moilanen E, Lehtimäki L. Comparison of feasibility and estimates of central and peripheral nitric oxide parameters by different mathematical models. J Breath Res 2017; 11:047102. [DOI: 10.1088/1752-7163/aa7cc0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Horváth I, Barnes PJ, Loukides S, Sterk PJ, Högman M, Olin AC, Amann A, Antus B, Baraldi E, Bikov A, Boots AW, Bos LD, Brinkman P, Bucca C, Carpagnano GE, Corradi M, Cristescu S, de Jongste JC, Dinh-Xuan AT, Dompeling E, Fens N, Fowler S, Hohlfeld JM, Holz O, Jöbsis Q, Van De Kant K, Knobel HH, Kostikas K, Lehtimäki L, Lundberg J, Montuschi P, Van Muylem A, Pennazza G, Reinhold P, Ricciardolo FLM, Rosias P, Santonico M, van der Schee MP, van Schooten FJ, Spanevello A, Tonia T, Vink TJ. A European Respiratory Society technical standard: exhaled biomarkers in lung disease. Eur Respir J 2017; 49:49/4/1600965. [PMID: 28446552 DOI: 10.1183/13993003.00965-2016] [Citation(s) in RCA: 375] [Impact Index Per Article: 53.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 01/09/2017] [Indexed: 12/19/2022]
Abstract
Breath tests cover the fraction of nitric oxide in expired gas (FeNO), volatile organic compounds (VOCs), variables in exhaled breath condensate (EBC) and other measurements. For EBC and for FeNO, official recommendations for standardised procedures are more than 10 years old and there is none for exhaled VOCs and particles. The aim of this document is to provide technical standards and recommendations for sample collection and analytic approaches and to highlight future research priorities in the field. For EBC and FeNO, new developments and advances in technology have been evaluated in the current document. This report is not intended to provide clinical guidance on disease diagnosis and management.Clinicians and researchers with expertise in exhaled biomarkers were invited to participate. Published studies regarding methodology of breath tests were selected, discussed and evaluated in a consensus-based manner by the Task Force members.Recommendations for standardisation of sampling, analysing and reporting of data and suggestions for research to cover gaps in the evidence have been created and summarised.Application of breath biomarker measurement in a standardised manner will provide comparable results, thereby facilitating the potential use of these biomarkers in clinical practice.
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Affiliation(s)
- Ildiko Horváth
- Dept of Pulmonology, National Korányi Institute of Pulmonology, Budapest, Hungary
| | - Peter J Barnes
- National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, UK
| | | | - Peter J Sterk
- Dept of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Marieann Högman
- Centre for Research & Development, Uppsala University/Gävleborg County Council, Gävle, Sweden
| | - Anna-Carin Olin
- Occupational and Environmental Medicine, Sahlgrenska Academy and University Hospital, Goteborg, Sweden
| | - Anton Amann
- Innsbruck Medical University, Innsbruck, Austria
| | - Balazs Antus
- Dept of Pathophysiology, National Korányi Institute of Pulmonology, Budapest, Hungary
| | | | - Andras Bikov
- Dept of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Agnes W Boots
- Dept of Pharmacology and Toxicology, University of Maastricht, Maastricht, The Netherlands
| | - Lieuwe D Bos
- Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Paul Brinkman
- Dept of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Caterina Bucca
- Biomedical Sciences and Human Oncology, Universita' di Torino, Turin, Italy
| | | | | | - Simona Cristescu
- Dept of Molecular and Laser Physics, Institute for Molecules and Materials, Radboud University, Nijmegen, The Netherlands
| | - Johan C de Jongste
- Dept of Pediatrics/Respiratory Medicine, Erasmus MC-Sophia Childrens' Hospital, Rotterdam, The Netherlands
| | | | - Edward Dompeling
- Dept of Paediatrics/Family Medicine Research School CAPHRI, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Niki Fens
- Dept of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Stephen Fowler
- Respiratory Research Group, University of Manchester Wythenshawe Hospital, Manchester, UK
| | - Jens M Hohlfeld
- Clinical Airway Research, Fraunhofer Institute of Toxicology and Experimental Medicine (ITEM), Hannover, Germany.,Medizinische Hochschule Hannover, Hannover, Germany
| | - Olaf Holz
- Clinical Airway Research, Fraunhofer Institute of Toxicology and Experimental Medicine (ITEM), Hannover, Germany
| | - Quirijn Jöbsis
- Department of Paediatric Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Kim Van De Kant
- Dept of Paediatrics/Family Medicine Research School CAPHRI, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Hugo H Knobel
- Philips Research, High Tech Campus 11, Eindhoven, The Netherlands
| | | | | | - Jon Lundberg
- Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Paolo Montuschi
- Pharmacology, Catholic University of the Sacred Heart, Rome, Italy
| | - Alain Van Muylem
- Hopital Erasme Cliniques Universitaires de Bruxelles, Bruxelles, Belgium
| | - Giorgio Pennazza
- Faculty of Engineering, University Campus Bio-Medico, Rome, Italy
| | - Petra Reinhold
- Institute of Molecular Pathogenesis, Friedrich Loeffler Institut, Jena, Germany
| | - Fabio L M Ricciardolo
- Clinic of Respiratory Disease, Dept of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Philippe Rosias
- Dept of Paediatrics/Family Medicine Research School CAPHRI, Maastricht University Medical Centre, Maastricht, The Netherlands.,Dept of Pediatrics, Maasland Hospital, Sittard, The Netherlands
| | - Marco Santonico
- Faculty of Engineering, University Campus Bio-Medico, Rome, Italy
| | - Marc P van der Schee
- Dept of Respiratory Medicine, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - Thomy Tonia
- European Respiratory Society, Lausanne, Switzerland
| | - Teunis J Vink
- Philips Research, High Tech Campus 11, Eindhoven, The Netherlands
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Högman M, Lehtimäki L, Dinh-Xuan AT. Utilising exhaled nitric oxide information to enhance diagnosis and therapy of respiratory disease - current evidence for clinical practice and proposals to improve the methodology. Expert Rev Respir Med 2017; 11:101-109. [PMID: 28076986 DOI: 10.1080/17476348.2017.1281746] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION A non-invasive tool to diagnose respiratory diseases and to follow treatment has long been looked-for. Exhaled nitric oxide (NO) is a promising marker of inflammation in asthma but nearly 25-years of research has shown that it works in only certain endotypes of asthma. The modelling of NO dynamics of the lung can give more information than a single FENO value. Areas covered: The estimation of the NO production in the conducting airways and in the gas exchange area has given new insight of the NO production in diseases beyond asthma. In this article, we discuss the importance of methodology for NO measurement in the exhaled breath and the indication of applying this technique to detect respiratory disorders. This narrative review is an attempt to examine and discuss the physiological basis underlying exhaled NO measurements and the clinical evidence of the usefulness of this method in asthma and various other respiratory disorders. Expert commentary: Estimation of the NO parameters would aid in our understanding of the NO dynamics of the lung and thereby give more knowledge how to interpret the measured FENO value in clinical practice.
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Affiliation(s)
- Marieann Högman
- a Department of Medical Sciences, Lung- Allergy- and Sleep Research , Uppsala University , Uppsala , Sweden
| | - Lauri Lehtimäki
- b Allergy Centre , Tampere University Hospital , Tampere , Finland.,c Medical School , University of Tampere , Tampere , Finland
| | - Anh Tuan Dinh-Xuan
- d Department of Respiratory Physiology , Cochin Hospital & Paris Descartes University , Paris , France
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