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Matsunaga K, Kuwahira I, Hanaoka M, Saito J, Tsuburai T, Fukunaga K, Matsumoto H, Sugiura H, Ichinose M. An official JRS statement: The principles of fractional exhaled nitric oxide (FeNO) measurement and interpretation of the results in clinical practice. Respir Investig 2020; 59:34-52. [PMID: 32773326 DOI: 10.1016/j.resinv.2020.05.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/20/2020] [Accepted: 05/08/2020] [Indexed: 12/22/2022]
Abstract
Nitric oxide (NO) is produced in the body and has been shown to have diverse actions in the abundance of research that has been performed on it since the 1970s, leading to Furchgott, Murad, and Ignarro receiving the Nobel Prize in Physiology or Medicine in 1998. NO is produced by nitric oxide synthase (NOS). NOS is broadly distributed, being found in the nerves, blood vessels, airway epithelium, and inflammatory cells. In asthma, inflammatory cytokines induce NOS activity in the airway epithelium and inflammatory cells, producing large amounts of NO. Measurement of fractional exhaled nitric oxide (FeNO) is a simple, safe, and quantitative method of assessing airway inflammation. The FeNO measurement method has been standardized and, in recent years, this noninvasive test has been broadly used to support the diagnosis of asthma, monitor airway inflammation, and detect asthma overlap in chronic obstructive pulmonary disease (COPD) patients. Since the normal upper limit of FeNO for healthy Japanese adults is 37 ppb, values of 35 ppb or more are likely to be interpreted as a signature of inflammatory condition presenting features with asthma, and this value is used in clinical practice. Research is also underway for clinical application of these measurements in other respiratory diseases such as COPD and interstitial lung disease. Currently, there remains some confusion regarding the significance of these measurements and the interpretation of the results. This statement is designed to provide a simple explanation including the principles of FeNO measurements, the measurement methods, and the interpretation of the measurement results.
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Affiliation(s)
- Kazuto Matsunaga
- Department of Respiratory Medicine and Infectious Disease, Yamaguchi University, Ube, Japan.
| | - Ichiro Kuwahira
- Department of Pulmonary Medicine, Tokai University Tokyo Hospital, Tokyo, Japan
| | - Masayuki Hanaoka
- First Department of Internal Medicine, Shinshu University, Matsumoto, Japan
| | - Junpei Saito
- Department of Pulmonary Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takahiro Tsuburai
- Division of Respiratory Diseases, Saint Marianna University Yokohama City Seibu Hospital, Yokohama, Japan
| | - Koichi Fukunaga
- Division of Pulmonary Medicine, Department of Medicine, Keio University, Tokyo, Japan
| | - Hisako Matsumoto
- Department of Respiratory Medicine, Kyoto University, Kyoto, Japan
| | - Hisatoshi Sugiura
- Department of Respiratory Medicine, Tohoku University, Sendai, Japan
| | - Masakazu Ichinose
- Department of Respiratory Medicine, Tohoku University, Sendai, Japan
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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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Chan M, Krakowski AC, Leong C, Naheedy J, Hagood J. Minocycline-Induced Eosinophilic Pneumonia in a Pediatric Patient. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2018. [DOI: 10.1089/ped.2017.0832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Affiliation(s)
- Marilynn Chan
- Department of Pediatric Pulmonology, University of California San Diego and Rady Children's Hospital of San Diego, San Diego, California
| | - Andrew C. Krakowski
- Department of Pediatric Pulmonology, University of California San Diego and Rady Children's Hospital of San Diego, San Diego, California
- Department of Pediatric Dermatology, DermOne, LLC, West Conshohocken, Pennsylvania
| | - Curtis Leong
- Department of Pediatric Pulmonology, University of California San Diego and Rady Children's Hospital of San Diego, San Diego, California
- Department of General Pediatrics, Kaiser Permanente, San Diego, California
| | - John Naheedy
- Department of Pediatric Pulmonology, University of California San Diego and Rady Children's Hospital of San Diego, San Diego, California
| | - James Hagood
- Department of Pediatric Pulmonology, University of California San Diego and Rady Children's Hospital of San Diego, San Diego, California
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Shrestha SK, Shrestha S, Sharma L, Pant S, Neopane A. Comparison of fractional exhaled nitric oxide levels in chronic obstructive pulmonary disease, bronchial asthma and healthy subjects of Nepal. J Breath Res 2017; 11:047101. [PMID: 28686173 DOI: 10.1088/1752-7163/aa7e63] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Fractional exhaled nitric oxide levels in exhaled breath can indicate ongoing eosinophilic airway inflammation, specifically in asthma. But its utility is being explored for central airway inflammations, including chronic obstructive pulmonary disease. Normal levels of fractional exhaled nitric oxide (FENO50) have been defined in different studies but not in Nepal. This study compares FENO50 levels in normal subjects, asthma and chronic obstructive pulmonary disease. METHODS Single breath estimation of FENO50 was measured by a handheld electrochemical sensor-based device in normal non-smoking adults (n = 106), clinically controlled asthma (n = 106) and stable chronic obstructive pulmonary disease (n = 106). RESULTS The geometric mean for FENO50 was 14 parts per billion (ppb) with a median of 16 ppb, first quartile at 11 ppb and third quartile at 20 ppb in normal non-smoking adults. The values were 31 ppb (geometric mean), 34 ppb (median), 17 ppb (first quartile) and 79 ppb (third quartile) in clinically controlled asthma. Similarly the values were 10 ppb (geometric mean), 11 ppb (median), 6 ppb (first quartile) and 17 ppb (third quartile) in stable chronic obstructive airway disease. The log-transformed data showed significantly higher FENO50 levels in the asthma group compared with the normal (p < 0.001) and chronic obstructive airway disease (p < 0.001). However, levels were similar between healthy and chronic obstructive airway disease groups (p = 0.08). CONCLUSIONS FENO50 levels were higher in bronchial asthma (despite disease control) than in normal non-smoking adults and subjects with stable chronic obstructive pulmonary disease. Levels of FENO50 were similar between the chronic obstructive airway disease and normal groups.
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Affiliation(s)
- Sanjeet Krishna Shrestha
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
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Oishi K, Hirano T, Suetake R, Ohata S, Yamaji Y, Ito K, Edakuni N, Matsunaga K. Exhaled nitric oxide measurements in patients with acute-onset interstitial lung disease. J Breath Res 2017; 11:036001. [DOI: 10.1088/1752-7163/aa6c4b] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Kara PH, Urnal R, Unluer EE. A must diagnosis of persistent cough: chronic eosinophilic pneumonia (Carrington disease). Am J Emerg Med 2016; 34:1734.e5-6. [PMID: 26782801 DOI: 10.1016/j.ajem.2015.12.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/18/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
- Pinar Hanife Kara
- Izmir Katip Celebi University, Ataturk Research and Training Hospital, Department of Emergency Medicine, 35360, Izmir, Turkey.
| | - Rifat Urnal
- Izmir Katip Celebi University, Ataturk Research and Training Hospital, Department of Emergency Medicine, 35360, Izmir, Turkey.
| | - Erden Erol Unluer
- Izmir Katip Celebi University, Ataturk Research and Training Hospital, Department of Emergency Medicine, 35360, Izmir, Turkey.
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Pi X, Wang C, Li Y, Zheng J, Cui Y, Guo L, Lin Z, Zhang X, Li E. Preoperative FeNO as a screening indicator of pulmonary complications after abdominal surgery in patients over 60 years old. J Breath Res 2015; 9:036004. [PMID: 25992977 DOI: 10.1088/1752-7155/9/3/036004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The incidence of pulmonary complications after abdominal surgery is higher than that of cardiac complications. The perioperative factors currently used to assess the risk of postoperative pulmonary complications (PPCs) are imperfect. FeNO is a marker of respiratory system disease related to the airway inflammatory response and bronchial hyperresponsiveness; it may be a new indicator to screen PPCs. A total of 162 patients over 60 years old scheduled for major abdominal surgery under general anesthesia were chosen to measure their preoperative FeNO level. Statistical analyses including the receiver operating characteristic (ROC) and general linear regression were used to analyze the relationships of FeNO with PPCs and other parameters. The medians and quartiles of preoperative FeNO were 14.33 (9.67-21.10) ppb; the geometric mean was 14.25 ppb. Preoperative FeNO correlated to age (P < 0.05), and the coefficient of association was 0.267. ROC curve analysis of FeNO and PPCs resulted in a high probability with an area under the curve of 0.747 (p = 0.001, 95% confidence interval =0.602-0.893). The cut-off level was 30.2 ppb, with 47.06% sensitivity and 93.10% specificity. The positive predictive value of the cut-off was 42.11% and negative predictive value was 93.70%. OR value was 10.83. The magnitude of FeNO in the PPCs group was larger than that in the non-PPCs groups 26.20 (11.55 - 39.20) versus 13.50 (9.55-20.00); p = 0.008). Preoperative FeNO levels may be used to screen the patients over 60 years old undergoing abdominal surgery with a lower probability to suffer PPCs whoes FeNO values less than 30.2 ppb.
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Affiliation(s)
- Xin Pi
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
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