Using fractional exhaled nitric oxide (FeNO) to diagnose steroid-responsive disease and guide asthma management in routine care

Change is in the air: key questions on the 'Treatable Traits' model for chronic airway diseases in primary care

Despite great advancements in the treatment of chronic airway diseases, improvements in morbidity and mortality have stalled in recent years. Asthma and chronic obstructive pulmonary disease are complex and heterogeneous diseases that require tailored management based on individual patient characteristics and needs. The Treatable Traits (TTs) approach aims to personalise and improve patient care through the identification and targeting of clinically relevant and modifiable pulmonary, extra-pulmonary and behavioural traits. In this article, we outline the rationale for TTs-based management and provide practical guidance for its application in primary care. To aid implementation, seven potential 'prime' traits are proposed: airflow obstruction, eosinophilic inflammation, adherence, inhaler technique, smoking, low body mass index/obesity and anxiety and depression-selected for their prevalence, recognisability and feasibility of use. Some of the key questions among healthcare professionals, that may be roadblocks to widespread application of a TTs model of care, are also addressed.

Cost-Effectiveness of Fractional Exhaled Nitric Oxide Suppression Testing as an Adherence Screening Tool Among Patients With Difficult-to-Control Asthma

BACKGROUND

Approximately 50% of adults on long-term asthma medication are nonadherent. Current methods to detect nonadherence have had limited effect. Fractional exhaled nitric oxide suppression testing (FeNOSuppT) has demonstrated clinical effectiveness as an adherence screening tool to detect poor adherence to inhaled corticosteroids in difficult-to-control asthma prior to initiation of expensive biologic therapy.

OBJECTIVE

Estimate the cost effectiveness and budget impact of FeNOSuppT as a screen prior to the initiation of biologic therapy among U.S. adults with difficult-to-control asthma and high fractional exhaled nitric oxide (≥45 ppb).

METHODS

A decision tree simulated the progression of a cohort of patients over a 1-year time horizon into 1 of 3 states ([1] discharged from or [2] remain in specialist care; or [3] progress to biologics). Two strategies, with and without FeNOSuppT, were examined and the incremental net monetary benefit estimated using a discount rate of 3% and a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY). Sensitivity analysis and a budget impact analysis were also undertaken.

RESULTS

In the baseline scenario, FeNOSuppT prior to the initiation of biologic therapy was associated with lower costs ($4,435/patient) and fewer QALYs (0.0023 QALY/patient) compared with no FeNOSuppT over 1 year and was considered cost effective (incremental net monetary benefit = $4,207). The FeNOSuppT was consistently found to be cost effective across a range of scenarios and in deterministic and probabilistic sensitivity analyses. Assuming differential levels of FeNOSuppT uptake (20%-100%), this was associated with budget savings ranging from USD $5 million to $27 million.

CONCLUSIONS

The FeNOSuppT is likely to be cost effective as a protocol-driven, objective, biomarker-based tool for identifying nonadherence in difficult-to-control asthma. This cost effectiveness is driven by cost savings from patients not progressing to expensive biologic therapy.

Comparison of National and Global Asthma Management Guiding Documents

Asthma is a common chronic disease that affects both adults and children, and that continues to have a high economic burden. Asthma management guidelines were first developed nearly 30 years ago to standardize care, maintain asthma control, improve quality of life, maintain normal lung function, prevent exacerbations, and prevent asthma mortality. The two most common asthma guidelines used today were developed by the National Asthma Education and Prevention Program (NAEPP) Expert Panel Working Group and the Global Initiative for Asthma Science Committee. Both guiding documents use scientific methodology to standardize their approach for formulating recommendations based on pertinent literature. Before the 2020 National Asthma Education and Prevention Program (Expert Panel Report 4), nothing had been released since the 2007 guidelines, whereas the Global Initiative for Asthma publishes updates annually. Although each of these asthma strategies is similar, there are some noted differences. Over the years, the focus of asthma treatment has shifted from acute to chronic management. Frontline respiratory therapists and other health-care providers should have a good understanding of these 2 guiding references and how they can impact acute and chronic asthma management. The primary focus of this narrative is to look at the similarities and differences of these 2 guiding documents as they pertain to the 6 key questions identified by the Expert Panel of the National Asthma Education and Prevention Program.

Correlation of fraction of exhaled nitric oxide with asthma control test and asthma severity in diagnosed cases of asthma

Background

Fraction of NO in exhaled air (FENO) has emerged as a simple, non-invasive, sensitive marker of airway inflammation in asthma diagnosis and management. Correlation studies of FENO with clinical grades of asthma and symptom burden are sparse, more so in Indian population. Hence, this study was carried out in Indian subjects to evaluate FENO correlation with asthma severity.

Methods

The study was performed on 52 proven cases of asthma in the age group of 17-90 years in period of December 2016 to May 2018. All the subjects had assessment in the form of Asthma Control Test (ACT)questionnaire, FENO parts per billion measurement with a portable NO analyzer (NIOX MINO Airway Inflammation Monitor; Aerocrine) and spirometry. Statistical analysis was presented in the form of percentage (%) and mean.

Results

Of a total of 52 asthma cases, 27 (51.9%) were male cases while 25 (48.1%) were female cases. Study population ranged from 17 to 82 years. Subjects categorized into 03 categories of asthma severity based on their treatment step. ACT score of ranged between 11 and 25 with a mean value of 20.27 and standard deviation of 3.73. No significant correlation was found between FENO and ACT (r) = -0.177, P-value = 0.210 (>0.05). Significant correlation between FENO and different grades of asthma severity was found with p-value 0.032 (<0.05).

Conclusion

Asthma severity as assessed by the step of treatment is correlated well with FENO value in an asthmatic individual to maintain the controlled asthma status. FENO and ACT were found to have no correlation.

Overview of recent advancements in asthma management

Asthma is a common but complex heterogenous inflammatory airway disorder. Despite significant developments in our understanding of the pathophysiology and treatment of asthma, it remains a major cause of mortality and morbidity. Optimal management involves addressing modifiable risk factors, titration of inhaled pharmacotherapy in a stepwise approach and, in severe disease, consideration of biologic agents. Appreciation of the clinical characteristics of asthma and recognition of the immune pathways involved has allowed the development of phenotypic and endotypic subtypes of asthma to be better defined. This has revolutionised asthma management, allowing risk stratification of patients, targeted use of biologic agents to modify cytokine responses that drive asthma and improved patient outcomes. Patient education and engagement are critical to the management of this disease in an era of personalised medicine and a rapidly changing global environment.

Severe asthma treatment patterns: A multicenter observational study in the Gulf region

Background

Methods

Results

Conclusions

How to use the fractional exhaled nitric oxide test

Measurement of fractional exhaled nitric oxide (FeNO) has become a mainstream, NICE-recommended, objective test of asthma severity. We explore the uses and practical issues with the FeNO test using clinically relevant questions for general paediatricians.

Effect of cigarette smoking on smoking biomarkers, blood pressure and blood lipid levels among Sri Lankan male smokers

Study purpose

The aim of this study was to determine the fractional exhaled nitric oxide (FeNO) levels, exhaled breath carbon monoxide (eCO) levels, blood pressure, blood lipid levels between smokers and non-smokers and to determine the association of smoking intensity with the above parameters.

Methods

This descriptive study was conducted in selected periurban areas of the Colombo District, Sri Lanka. Adult male current tobacco smokers (n=360), aged between 21 and 60 years were studied and compared with anthropometrically matched male non-smokers (n=180). Data were collected by interviewer-administered questionnaire, clinical assessment and measurement of FeNO by FENO monitor and eCO bySmokerlyser.

Results

Smokers had significantly lower mean FeNO levels and higher mean eCO values compared with non-smokers. Presentation of palpitations was higher among the smokers and a significantly positive correlation was identified between palpitations and eCO levels. There was a significantly positive correlation between the systolic blood pressure of smokers with the duration of smoking (DS), Brinkman Index (BI), Body Mass Index (BMI) and there was a significantly negative correlation with FeNO levels. The mean arterial pressure was positively correlated with the DS, BI and BMI. There was a significantly negative correlation between FeNO and the number of cigarettes smoked per day, DS and BI of smokers. Significantly higher total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), very LDL-C, TC: HDL ratio and low high density lipoprotein cholesterol (HDL-C) level was observed among smokers compared with the non-smokers.

Conclusions

Tobacco smoking was found to impact blood pressure and serum lipid levels thus enhancing the cardiovascular risk among smokers. The levels of eCO and FeNO are useful biomarkers for determining the intensity of smoking. The results indicate the necessity for urgent measures to stop cigarette smoking in Sri Lanka.

Breath Biomarkers in Diagnostic Applications

The detection of chemical compounds in exhaled human breath presents an opportunity to determine physiological state, diagnose disease or assess environmental exposure. Recent advancements in metabolomics research have led to improved capabilities to explore human metabolic profiles in breath. Despite some notable challenges in sampling and analysis, exhaled breath represents a desirable medium for metabolomics applications, foremost due to its non-invasive, convenient and practically limitless availability. Several breath-based tests that target either endogenous or exogenous gas-phase compounds are currently established and are in practical and/or clinical use. This review outlines the concept of breath analysis in the context of these unique tests and their applications. The respective breath biomarkers targeted in each test are discussed in relation to their physiological production in the human body and the development and implementation of the associated tests. The paper concludes with a brief insight into prospective tests and an outlook of the future direction of breath research.

Pro: Access to advanced therapies for severe asthma should be restricted to patients with satisfactory adherence to maintenance treatment

Inhaled corticosteroids (ICS) are the core component of asthma treatment and the only maintenance therapy known to prevent asthma death. There is currently no evidence that biologics prevent asthma death in people with asthma, and as such, biologics cannot be recommended as an alternative to ICS therapy. Taking the time to assess adherence and provide interventions and education to support patients in asthma self-management has been shown to improve patient outcomes. It is therefore our responsibility as healthcare professionals to ensure that patients are supported, educated and motivated to adhere to ICS therapy before progressing to biologic therapies.

ICS save lives. It is therefore our responsibility as healthcare professionals to ensure that patients are supported, educated and motivated to improve poor ICS adherence before treatment is further escalated to biologic therapy. https://bit.ly/3o2q26i

A systematic review of the diagnostic accuracy of volatile organic compounds in airway diseases and their relation to markers of type-2 inflammation

BACKGROUND

Asthma and COPD continue to cause considerable diagnostic and treatment stratification challenges. Volatile organic compounds (VOCs) have been proposed as feasible diagnostic and monitoring biomarkers in airway diseases.

AIMS

To 1) conduct a systematic review evaluating the diagnostic accuracy of VOCs in diagnosing airway diseases; 2) understand the relationship between reported VOCs and biomarkers of type-2 inflammation; 3) assess the standardisation of reporting according to STARD and TRIPOD criteria; 4) review current methods of breath sampling and analysis.

METHODS

A PRISMA-oriented systematic search was conducted (January 1997 to December 2020). Search terms included: "asthma", "volatile organic compound(s)", "VOC" and "COPD". Two independent reviewers examined the extracted titles against review objectives.

RESULTS

44 full-text papers were included; 40/44 studies were cross-sectional and four studies were interventional in design; 17/44 studies used sensor-array technologies (e.g. eNose). Cross-study comparison was not possible across identified studies due to the heterogeneity in design. The commonest airway diseases differentiating VOCs belonged to carbonyl-containing classes (i.e. aldehydes, esters and ketones) and hydrocarbons (i.e. alkanes and alkenes). Although individual markers that are associated with clinical biomarkers of type-2 inflammation were recognised (i.e. ethane and 3,7-dimethylnonane for asthma and α-methylstyrene and decane for COPD), these were not consistently identified across studies. Only 3/44 reported following STARD or TRIPOD criteria for diagnostic accuracy and multivariate reporting, respectively.

CONCLUSIONS

Breath VOCs show promise as diagnostic biomarkers of airway diseases and for type-2 inflammation profiling. However, future studies should focus on transparent reporting of diagnostic accuracy and multivariate models and continue to focus on chemical identification of volatile metabolites.

Predicting Treatment Outcomes Using Explainable Machine Learning in Children with Asthma

Asthma in children is a heterogeneous disease manifested by various phenotypes and endotypes. The level of disease control, as well as the effectiveness of anti-inflammatory treatment, is variable and inadequate in a significant portion of patients. By applying machine learning algorithms, we aimed to predict the treatment success in a pediatric asthma cohort and to identify the key variables for understanding the underlying mechanisms. We predicted the treatment outcomes in children with mild to severe asthma (N = 365), according to changes in asthma control, lung function (FEV1 and MEF50) and FENO values after 6 months of controller medication use, using Random Forest and AdaBoost classifiers. The highest prediction power is achieved for control- and, to a lower extent, for FENO-related treatment outcomes, especially in younger children. The most predictive variables for asthma control are related to asthma severity and the total IgE, which were also predictive for FENO-based outcomes. MEF50-related treatment outcomes were better predicted than the FEV1-based response, and one of the best predictive variables for this response was hsCRP, emphasizing the involvement of the distal airways in childhood asthma. Our results suggest that asthma control- and FENO-based outcomes can be more accurately predicted using machine learning than the outcomes according to FEV1 and MEF50. This supports the symptom control-based asthma management approach and its complementary FENO-guided tool in children. T2-high asthma seemed to respond best to the anti-inflammatory treatment. The results of this study in predicting the treatment success will help to enable treatment optimization and to implement the concept of precision medicine in pediatric asthma treatment.

The role of nitric oxide in ocular surface physiology and pathophysiology

Nitric oxide (NO) has a wide array of biological functions including the regulation of vascular tone, neurotransmission, immunomodulation, stimulation of proinflammatory cytokine expression and antimicrobial action. These functions may depend on the type of isoform that is responsible for the synthesis of NO. NO is found in various ocular tissues playing a pivotal role in physiological mechanisms, namely regulating vascular tone in the uvea, retinal blood circulation, aqueous humor dynamics, neurotransmission and phototransduction in retinal layers. Unregulated production of NO in ocular tissues may result in production of toxic superoxide free radicals that participate in ocular diseases such as endotoxin-induced uveitis, ischemic proliferative retinopathy and neurotoxicity of optic nerve head in glaucoma. However, the role of NO on the ocular surface in mediating physiology and pathophysiological processes is not fully understood. Moreover, methods used to measure levels of NO in the biological samples of the ocular surface are not well established due to its rapid oxidation. The purpose of this review is to highlight the role of NO in the physiology and pathophysiology of ocular surface and propose suitable techniques to measure NO levels in ocular surface tissues and tears. This will improve the understanding of NO's role in ocular surface biology and the development of new NO-based therapies to treat various ocular surface diseases. Further, this review summarizes the biochemistry underpinning NO's antimicrobial action.

The value of small airway function parameters and fractional exhaled nitric oxide for predicting positive methacholine challenge test in asthmatics of different ages with FEV1 ≥ 80% predicted

Background

Small airway function parameters (SAFPs) combined with fractional exhaled nitric oxide (FeNO) can predict a positive methacholine challenge test (MCT) for asthma diagnosis. However, their predictive utility in patients with forced expiratory volume in one second (FEV₁) ≥80% predicted within different age ranges remains unclear. This study aimed to assess the utility of SAFPs, alone or combined with FeNO, to predict a positive MCT in patients in two age groups (<55 and ≥55 years) with asthma‐suggestive symptoms and FEV₁ ≥80% predicted.

Methods

We enrolled 846 Chinese patients with suspected asthma and standard spirometry, FeNO, and MCT findings. Using the area under the curves (AUCs), the utility of SAFPs, alone or combined with FeNO, for predicting a positive MCT was analyzed in a discovery (n = 534) and validation cohort (n = 312) in both age groups with FEV₁ ≥80% predicted.

Results

In the discovery cohort, the optimal cut‐off values for predicting a positive MCT in patients aged <55 years (74.2% and 74.9% for forced expiratory flow (FEF)_50% and FEF_25%–75%, respectively) were higher than those in patients aged ≥55 years (65.0% and 62.9% for FEF_50%, FEF_25%–75%, respectively). However, the optimal FeNO value in patients aged <55 years (43 ppb) was lower than that in patients aged ≥55 years (48 ppb). FeNO combined with SAFPs (FEF_50%, FEF_25%–75%) significantly increased the AUCs in both groups (≥55 years [0.851 for FEF_50% and 0.844 for FEF_25%–75%]; <55 years [0.865 for FEF_50% and 0.883 for FEF_25%–75%]) compared with a single parameter (p < 0.05). These findings were confirmed in the validation cohort. Compared with patients ≥55 years, those aged <55 years had higher and lower optimal cut‐off values for SAFPs and FeNO, respectively. The AUCs of FeNO combined with SAFPs for predicting a positive MCT for asthma diagnosis were significantly higher than those of the individual parameters (p < 0.05) in both age groups.

Conclusions

There were age‐group differences in the utility of SAFPs combined with FeNO for predicting a positive MCT. Patients with an asthma‐suggestive history and a normal FEV₁ should be stratified by age when using SAFPs combined with FeNO to predict a positive MCT.

Assessment of adherence to corticosteroids in asthma by drug monitoring or fractional exhaled nitric oxide: A literature review

Background

Although the efficacy of corticosteroid treatment in controlling asthma is widely accepted, its effectiveness is undermined by poor adherence. However, the optimal method for measuring adherence to asthma therapy remains unclear.

Objective

To perform a review of the literature reporting biological, objective methods for assessing adherence to inhaled or oral corticosteroids in asthma; we included studies reporting direct measurement of exogenous corticosteroids in blood, or the effect of adherence on exhaled nitric oxide.

Design

We searched three databases MEDLINE (using both PubMed and Ovid), the Cumulative Index of Nursing and Allied Health Literature (CINAHL) and Web of Science for articles published between January 1975 and July 2020. Quality of the studies was assessed using the National Institute of Health checklist.

Results

From 2850 screened articles, 26 fulfilled the inclusion criteria. Measurement of blood prednisolone with or without cortisol was used in eight studies as a measure of oral corticosteroid adherence, and fractional exhaled nitric oxide (FeNO) in 17 studies for inhaled corticosteroid adherence. Inhaled corticosteroids were measured directly in the blood in one study. By direct measurement of drug levels in the blood, adherence rates to oral corticosteroids ranged from 47% to 92%, although the performance and timing of the test were often not known, making interpretation of findings and serum prednisolone concentrations difficult. FeNO is generally lower in adherent than non‐adherent patients, but no absolute cut‐off can be proposed based on the available data. However, a fall in FeNO following supervised inhaled corticosteroid dosing could indicate previous poor adherence.

Conclusions and Clinical Relevance

Despite prednisolone and cortisol levels commonly being used as adherence markers in clinical practice, further work is required to assess the influence of the dose and timing on blood levels. The promising findings of FeNO suppression testing should be explored in further prospective studies.

Fractional Exhaled Nitric Oxide as an Inflammatory Biomarker in Chronic Obstructive Pulmonary Disease (COPD) with or without Concurrent Diagnosis of Asthma: The Canadian Cohort Obstructive Lung Disease (CanCOLD)

We studied whether fractional exhaled nitric oxide (F _ENO) can differentiate chronic obstructive pulmonary disease (COPD) with concurrent diagnosis of asthma from COPD-only as well as its ability to predict disease severity and progression. This study was embedded in the Canadian Cohort Obstructive Lung Disease (CanCOLD). Subjects of ≥40 years old completed F _ENO measurements were subdivided into four groups, including COPD (N = 86 [COPD-only (N = 35) and COPD with concurrent diagnosis of asthma (N = 51)], healthy (N = 72), and at risk (N = 151). Three of the most common clinical definitions were used for characterizing COPD with concurrent diagnosis of asthma: 1) atopy and self-reported physician diagnosis of asthma, 2) ≥12% and ≥200 ml post-bronchodilator FEV1; 3) self-reported physician diagnosis of asthma. F _ENO values were classified using quartiles and the American Thoracic Society (ATS) guideline 2011. Compared to COPD-only, more COPD with concurrent diagnosis of asthma had a significant F _ENO50 level of [Formula: see text] 33.5 ppb (fourth quartile) than COPD-only (p = 0.045, 0.011, and 0.006, for definition 1, 2, and 3, respectively). Considering the ATS guideline 2011, fewer COPD with concurrent diagnosis of asthma had F _ENO50 < 25 than COPD-only, which was statistically significant with definition 1 and 3 (p = 0.038 and 0.026, respectively). F _ENO as a biomarker has the potential to be used as a complementary value for differentiating COPD with concurrent diagnosis of asthma from COPD-only. Further studies should be conducted on validated definitions of COPD with concurrent diagnosis of asthma, which may include a reference to the type of airway inflammation in addition to the clinical definition.

Improving primary care management of asthma: do we know what really works?

Asthma imposes a substantial burden on individuals and societies. Patients with asthma need high-quality primary care management; however, evidence suggests the quality of this care can be highly variable. Here we identify and report factors contributing to high-quality management. Twelve primary care global asthma experts, representing nine countries, identified key factors. A literature review (past 10 years) was performed to validate or refute the expert viewpoint. Key driving factors identified were: policy, clinical guidelines, rewards for performance, practice organisation and workforce. Further analysis established the relevant factor components. Review evidence supported the validity of each driver; however, impact on patient outcomes was uncertain. Single interventions (e.g. healthcare practitioner education) showed little effect; interventions driven by national policy (e.g. incentive schemes and teamworking) were more effective. The panel's opinion, supported by literature review, concluded that multiple primary care interventions offer greater benefit than any single intervention in asthma management.

Clinical utility of fractional exhaled nitric oxide in severe asthma management

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.

Immunological biomarkers in severe asthma

Severe asthma is heterogeneous in its clinical presentation, underlying pathophysiology, course and response to therapy. Clinical and physiological assessment of severe asthma is often inadequate in predicting underlying disease mechanisms and or response to medications. With the emergence of novel targeted therapies in severe asthma, the need for reproducible, easily measured biomarkers became obvious but only few are currently available for clinical use. These biomarkers along with the clinical presentation of the patient play an important role in identifying phenotypes and endotypes, predicting the clinical course and prognosis and improving the precision therapeutic approach to asthma.

Association of elevated fractional exhaled nitric oxide concentration and blood eosinophil count with severe asthma exacerbations

Background

Blood eosinophil count (BEC) and fractional exhaled nitric oxide (FeNO) concentration are established biomarkers in asthma, associated particularly with the risk of exacerbations. We evaluated the relationship of BEC and FeNO as complementary and independent biomarkers of severe asthma exacerbations.

Methods

This observational study included data from the Optimum Patient Care Research Database. Asthma patients (18–80 years) with valid continuous data for 1 year before FeNO reading, ≥ 1 inhaled corticosteroid prescription, and BEC recorded ≤ 5 years before FeNO reading were separated into cohorts. Categorisation 1 was based on the American Thoracic Society criteria for elevated FeNO concentration (high: ≥ 50 ppb; non-high: < 25 ppb) and BEC (high: ≥ 0.300 × 10⁹ cells/L; non-high: < 0.300 × 10⁹ cells/L). Categorisation 2 (FeNO concentration, high: ≥ 35 ppb; non-high: < 35 ppb) was based on prior research. Reference groups included patients with neither biomarker raised.

Results

In categorisation 1, patients with either high FeNO or high BEC (n = 200) had a numerically greater exacerbation rate (unadjusted rate ratio, 1.31 [95% confidence interval: 0.97, 1.76]) compared with patients in the reference group. Combination of high FeNO and high BEC (n = 27) resulted in a significantly greater exacerbation rate (3.67 [1.49, 9.04]). Similarly, for categorisation 2, when both biomarkers were raised (n = 53), a significantly greater exacerbation rate was observed (1.72 [1.00, 2.93]).

Conclusion

The combination of high FeNO and high BEC was associated with significantly increased severe exacerbation rates in the year preceding FeNO reading, suggesting that combining FeNO and BEC measurements in primary care may identify asthma patients at risk of exacerbations.

Electronic supplementary material

The online version of this article (10.1186/s13601-019-0282-7) contains supplementary material, which is available to authorized users.

Improvement of asthma control after laser acupuncture and its impact on exhaled 8-isoprostane as an oxidative biomarker in chronic bronchial asthma

Traditional medicine may not control bronchial asthma. Many patients have uncontrolled symptoms and the underlying ongoing inflammation is persistent.

OBJECTIVE

to assess efficacy of laser acupuncture in improving asthma symptoms and underlying oxidative stress through monitoring exhaled 8-isoprostane.

METHOD

48 asthmatic (case group) received successive low level laser acupuncture sessions to stimulate acupoints for chronic asthma and 24 asthmatics received deactivated laser acupuncture sessions (control group). Asthma symptoms, asthma control questionnaire, concentration of 8-Isoprostane in exhaled breath condensate and airway resistance were assessed before and after laser acupuncture therapy.

RESULTS

After the completion of the course of laser acupuncture therapy, we observed significant improvement of asthma symptoms. Asthma control questionnaire improved from 9.7 ± 3.3 to 21.8 ± 3.6 (p 0.001). EBC 8-Isoprostane dropped from 14.7 ± 5.4 to 8.1 ± 5.0 (p 0.001). The airway resistance at R5 and R20 significantly decreased from 116.6 ± 25.8 & 124.5 ± 31.2 to 101.5 ± 25.6 &110.9 ± 29.9 respectively (p 0.001). Control patients who received sham acupuncture therapy did not show such improvement.

CONCLUSION

Laser acupuncture is an effective modality in treating bronchial asthma as evidenced by improved symptoms, airway resistance, and oxidative biomarkers.

Clinical utility of ultrahigh fractional exhaled nitric oxide in predicting bronchial hyperresponsiveness in patients with suspected asthma

BACKGROUND

Fractional exhaled nitric oxide (FeNO) is a non-invasive biomarker for airway eosinophilic inflammation. However, the clinical value of ultrahigh FeNO (≥100 parts per billion (ppb)) in predicting asthma is never explored. We aimed to investigate the value of ultrahigh FeNO as a predictor of bronchial hyperresponsiveness (BHR), an important index for asthma diagnosis.

METHODS

A retrospective cohort study was conducted on 259 patients with suspected asthma who received the examination of FeNO, spirometry, bronchial provocation test (BPT) and differential cell count of induced sputum. Patients were stratified by FeNO value: ultrahigh (group A:≥100 ppb), high (group B: 50-99 ppb), intermediate (group C: 26-49 ppb) and normal (group D:≤25 ppb). The positive rates of BPT and sputum eosinophils percentage (Eos%) were compared among four cohorts. The correlations between FeNO and sputum Eos% were measured.

RESULTS

A significant higher positive rate of BPT was observed in group A (90.91%) than all others (B: 51.43%, C: 31.43%, D: 28.13%, all p<0.01). Referring to group D, the ORs of positive BPT in groups A, B and C were 26.84, 2.84 and 1.05. Sputum Eos% in group A (19.75 (7.00, 46.25)) is higher than that in others (B: 3.50 (1.00, 12.75), C: 1.13 (0.06,3.50), D: 0.50 (0.00, 2.13)). FeNO correlates with sputum Eos% in groups A and B, but not group C or D.

CONCLUSIONS

Ultrahigh FeNO correlates with BHR and could serve as a practical alternative to methacholine challenge to support an asthma diagnosis in patients with suspected asthma in primary care.

[Correlation of fractional exhaled nitric oxide in the upper and lower airways with the level of asthma control]

OBJECTIVE

To study the clinical value of combined measurement of fractional exhaled nitric oxide (FeNO) and nasal fractional exhaled nitric oxide (FnNO) and its correlation with the level of asthma control.

METHODS

A total of 120 children who were diagnosed with asthma from January to June, 2018 and were in the chronic persistent stage were enrolled as subjects. The childhood asthma control test (C-ACT) was performed for all the 120 children. According to the C-ACT score, these children were divided into 4 groups: complete control group with a C-ACT score of >23, partial control group with a C-ACT score of 20-23, and uncontrolled group with a C-ACT score of ≤19 (n=40 each). According to the presence or absence of allergic rhinitis, they were divided into 2 groups: non-rhinitis group with 55 children and rhinitis group with 65 children. A total of 40 children who underwent physical examination during the same period of time were enrolled as the control group. FeNO and FnNO levels were measured for all the 120 children.

RESULTS

The uncontrolled group had the highest level of FeNO, followed by the partial control group and the complete control group (P<0.05). The uncontrolled and partial control groups had a significantly higher level of FeNO than the control group (P<0.05). The uncontrolled and partial control groups had a significantly higher level of FnNO than the complete control and control groups (P<0.05). The rhinitis group had significantly higher FeNO and FnNO levels than the non-rhinitis group (P<0.05).

CONCLUSIONS

FeNO can be used to assess the level of asthma control in children, and its combination with FnNO may be useful for the evaluation of the degree of inflammation in the upper and lower airways and provide a basis for the combined treatment of the upper and lower airways.

Acute Effects of Air Pollution and Noise from Road Traffic in a Panel of Young Healthy Adults

Panel studies are an efficient means to assess short-term effects of air pollution and other time-varying environmental exposures. Repeated examinations of volunteers allow for an in-depth analysis of physiological responses supporting the biological interpretation of environmental impacts. Twenty-four healthy students walked for 1 h at a minimum of four separate occasions under each of the following four settings: along a busy road, along a busy road wearing ear plugs, in a park, and in a park but exposed to traffic noise (65 dB) through headphones. Particle mass (PM_2.5, PM₁), particle number, and noise levels were measured throughout each walk. Lung function and exhaled nitrogen oxide (NO) were measured before, immediately after, 1 h after, and approximately 24 h after each walk. Blood pressure and heart rate variability were measured every 15 min during each walk. Recorded air pollution levels were found to correlate with reduced lung function. The effects were clearly significant for end-expiratory flows and remained visible up to 24 h after exposure. While immediate increases in airway resistance could be interpreted as protective (muscular) responses to particulate air pollution, the persisting effects indicate an induced inflammatory reaction. Noise levels reduced systolic blood pressure and heart rate variability. Maybe due to the small sample size, no effects were visible per specific setting (road vs. park).

Fractional Exhaled Nitric Oxide-Assisted Management of Uncontrolled Persistent Asthma: A Real-World Prospective Observational Study

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.

Measurement of fractional exhaled nitric oxide in real-world clinical practice alters asthma treatment decisions

BACKGROUND

Assessment of asthma using clinical measures alone often fails to detect underlying airway inflammation. Fractional exhaled nitric oxide (FeNO) is a recognized biomarker of type 2 airway inflammation in asthma. Measurement of FeNO is instrumental in the assessment and management of patients with corticosteroid-sensitive asthma.

OBJECTIVE

To determine the impact of measuring FeNO on asthma management in real-world clinical practices.

METHODS

Clinicians from 337 US practices performed a clinical assessment and recorded treatment plans before and after measuring FeNO in 7,901 patients with asthma. Airway inflammation was classified as low, intermediate, or high according to the clinician's usual procedures, including clinical examination, spirometry, and symptoms. Clinicians recorded asthma medication plans, indicating medications to be initiated, continued, or stopped. FeNO measurement was performed, followed by documentation of any change(s) in the treatment plans based on the FeNO value (eg, initiating new medications or changing the dose of or discontinuing existing medications).

RESULTS

Clinical assessment was concordant with FeNO measurement in only 56% of cases, matching FeNO more frequently in patients with low inflammation (64%) vs high inflammation (34%). After FeNO measurement, clinicians modified their treatment plan in 31% and altered prescriptions for inhaled corticosteroids in 90% of cases. Inhaled corticosteroids were initiated or their dose increased in 66% of patients with high inflammation but discontinued or their dose decreased in only 9% of patients with low inflammation.

CONCLUSION

Measurement of FeNO enabled clinicians to assess underlying airway inflammation, leading to a significant revision of their treatment plans compared with real-world clinical assessment of asthma alone.

Relationship of Inhaled Corticosteroid Adherence to Asthma Exacerbations in Patients with Moderate-to-Severe Asthma

BACKGROUND

Patients with asthma and elevated blood eosinophils are at increased risk of severe exacerbations. Management of these patients should consider nonadherence to inhaled corticosteroid (ICS) therapy as a factor for increased exacerbation risk.

OBJECTIVE

The objective of this study was to investigate whether poor adherence to ICS therapy explains the occurrence of asthma exacerbations in patients with elevated blood eosinophil levels.

METHODS

This historical cohort study identified patients within the Optimum Patient Care Research Database, aged 18 years or more, at Global Initiative for Asthma step 3 or 4, with 2 or more ICS prescriptions during the year before the clinical review. Patient characteristics and adherence (based on prescription refills and patient self-report) for ICS therapy were analyzed for those with elevated (>400 cells/μL) or normal (≤400 cells/μL) blood eosinophils.

RESULTS

We studied 7195 patients (66% female, mean age 60 years) with median eosinophil count of 200 cells/μL and found 81% to be not fully adherent to ICS therapy. A total of 1031 patients (14%) had elevated blood eosinophil counts (58% female, mean age 60 years), 83% of whom were not fully adherent to ICS. An increased proportion of adherent patients in the elevated blood eosinophil group had 2 or more exacerbations (14.0% vs 7.2%; P = .003) and uncontrolled asthma (73% vs 60.8%; P = .004) as compared with non-fully adherent patients.

CONCLUSIONS

Approximately 1 in 7 patients had elevated eosinophils. Adherence to ICS therapy was not associated with decreased exacerbations for these patients. Additional therapy should be considered for these patients, such as biologics, which have been previously shown to improve control in severe uncontrolled eosinophilic asthma.

Associations between occupational inhalation risks and FeNO levels in airway obstruction patients: results from the National Health and Nutrition Examination Survey, 2007-2012

Purpose

To investigate associations between occupational inhalation risks and fractional exhaled nitric oxide (FeNO) levels in patients with chronic obstructive pulmonary disease (COPD).

Patients and methods

Data of 16,486 subjects who had undergone spirometry with pre-bronchodilator and post-bronchodilator lung function assessment were retrieved from the National Health and Nutrition Examination Survey, 2007–2012 database. After excluding 2,638 subjects with missing spirometry values, data of 13,336 subjects were included for analysis. Factors associated with occupational inhalation, FeNO levels and COPD were analyzed using logistic regression analysis.

Results

COPD was associated with occupational exposures to mineral dusts, organic dusts, exhaust fumes, other fumes, and second-hand smoking (P<0.05). Long-term exposure to these occupational hazards carried significantly higher risk for subjects with COPD than for controls (crude odds ratios [ORs]: mineral dusts: 2.364, organic dusts: 2.427, exhaust fumes: 2.728, other fumes: 2.144). In subgroup analysis, COPD correlated positively with long-term exposures to organic dusts and exhaust fumes in subjects with FeNO ≤50 ppb (ORs 1.361 and 1.314, respectively); conversely, COPD correlated negatively with intermediate to long-term exposures to organic dusts and exhaust fumes in those with FeNO >50 ppb (ORs 0.058 and 0.210, respectively).

Conclusion

Occupational exposures to airborne pollutants carries higher risk of COPD than non-exposure and the risk is higher the longer the duration of exposure. Exposure–response relationships are inconsistent in subjects with suspected asthmatic airway inflammation (FeNO ≥50 ppb). More careful risk assessment is needed in occupational inhalation exposure, since COPD with asthmatic airway inflammation, or asthma-COPD overlapping syndrome, may have the distinguishing features of both COPD and asthma.

[Clinical significance of fractional exhaled nitric oxide combined with in vitro allergen test in identifying children at a high risk of asthma among those with recurrent wheezing]

OBJECTIVE

To investigate the clinical value of combined determination of in vitro allergens and fractional exhaled nitric oxide (FeNO) in indentifying children at a high risk of asthma among those with recurrent wheezing.

METHODS

A total of 148 children with recurrent wheezing (0.5-6 years old) were enrolled as study subjects, and 80 healthy children who underwent physical examination were enrolled as the control group. Pharmacia UniCAP immunoassay analyzer was used to measure specific immunoglobulin E (sIgE). Nano Coulomb Nitric Oxide Analyzer was used to measure FeNO. The asthma predictive index (API) was evaluated.

RESULTS

The recurrent wheezing group had a significantly higher proportion of children with positive sIgE than the control group [68.9% (102/148) vs 11.3% (9/80); P<0.05]. The recurrent wheezing group also had significantly higher levels and positive rate of FeNO than the control group (P<0.05). The overall positive rate of API in children with wheezing was 32.4%, and the API-positive children had a significantly higher FeNO value than the API-negative children (51±6 ppb vs 13±5 ppb; P<0.05). The detection rate of API was 40.2% (41/102) in positive-sIgE children and 50.1% (38/73) in FeNO-positive children, and there was no significant difference between these two groups. The children with positive sIgE and FeNO had a significantly higher detection rate of API (81.4%) than those with positive sIgE or FeNO (P<0.05).

CONCLUSIONS

Combined determination of FeNO and in vitro allergens is more sensitive in detecting children at a high risk of asthma than FeNO or in vitro allergens determination alone and provides a good method for early identification, diagnosis, and intervention of asthma in children.

[Application of pulmonary function and fractional exhaled nitric oxide tests in the standardized management of bronchial asthma in children]

OBJECTIVE

To investigate the changes of pulmonary function and fractional exhaled nitric oxide (FeNO) in the standardized treatment of bronchial asthma in children.

METHODS

A total of 254 children who were newly diagnosed with acute exacerbation of bronchial asthma were selected as asthma group, and they were divided into two subgroups: asthma with concurrent rhinitis and asthma without concurrent rhinitis. All patients received the standardized management and treatment for one year. The pulmonary function parameters included forced expiratory volume in one second (FEV1), peak expiratory flow (PEF), maximal mid-expiratory flow (MMEF), and mid-expiratory flow at 25%, 50%, and 75% of vital capacity (MEF25, MEF50, and MEF75). The FeNO levels were measured before treatment and at 3, 6, 9, and 12 months after treatment. Another 62 healthy children were selected as the control group, and the pulmonary function and FeNO levels were measured only once.

RESULTS

During one year of standardized treatment, FEV1, PEF, MMEF, MEF25, MEF50, and MEF75 gradually increased, and FeNO levels gradually decreased (P<0.05). Indicators of large airway function, such as FEV1 and PEF, almost returned to normal after 6 months of treatment; indicators of small airway function, such as MMEF, MEF25, MEF50, and MEF75 almost returned to normal after 9 months of treatment; there were no significant differences in the above indices between the asthma group and the control group after one year of treatment (P>0.05). However, the asthma group had a significantly higher FeNO levels than the control group after one year of treatment (P<0.05). The asthmatic patients with concurrent rhinitis had significantly higher FeNO levels than those without concurrent rhinitis before treatment and 3 months after treatment (P<0.05). Before treatment, there was a significant negative correlation between FeNO levels and pulmonary function parameters (P<0.05).

CONCLUSIONS

With the standardized treatment of bronchial asthma in children, pulmonary function parameters gradually increase and FeNO levels gradually decrease. The recovery of large airway function occurs earlier than the recovery of small airway function. Furthermore, the effect of rhinitis on airway responsiveness should be noted.

[Application of pulmonary function and fractional exhaled nitric oxide tests in the standardized management of bronchial asthma in children]

OBJECTIVE

To investigate the changes of pulmonary function and fractional exhaled nitric oxide (FeNO) in the standardized treatment of bronchial asthma in children.

METHODS

A total of 254 children who were newly diagnosed with acute exacerbation of bronchial asthma were selected as asthma group, and they were divided into two subgroups: asthma with concurrent rhinitis and asthma without concurrent rhinitis. All patients received the standardized management and treatment for one year. The pulmonary function parameters included forced expiratory volume in one second (FEV1), peak expiratory flow (PEF), maximal mid-expiratory flow (MMEF), and mid-expiratory flow at 25%, 50%, and 75% of vital capacity (MEF25, MEF50, and MEF75). The FeNO levels were measured before treatment and at 3, 6, 9, and 12 months after treatment. Another 62 healthy children were selected as the control group, and the pulmonary function and FeNO levels were measured only once.

RESULTS

During one year of standardized treatment, FEV1, PEF, MMEF, MEF25, MEF50, and MEF75 gradually increased, and FeNO levels gradually decreased (P<0.05). Indicators of large airway function, such as FEV1 and PEF, almost returned to normal after 6 months of treatment; indicators of small airway function, such as MMEF, MEF25, MEF50, and MEF75 almost returned to normal after 9 months of treatment; there were no significant differences in the above indices between the asthma group and the control group after one year of treatment (P>0.05). However, the asthma group had a significantly higher FeNO levels than the control group after one year of treatment (P<0.05). The asthmatic patients with concurrent rhinitis had significantly higher FeNO levels than those without concurrent rhinitis before treatment and 3 months after treatment (P<0.05). Before treatment, there was a significant negative correlation between FeNO levels and pulmonary function parameters (P<0.05).

CONCLUSIONS

With the standardized treatment of bronchial asthma in children, pulmonary function parameters gradually increase and FeNO levels gradually decrease. The recovery of large airway function occurs earlier than the recovery of small airway function. Furthermore, the effect of rhinitis on airway responsiveness should be noted.

Association between fractional exhaled nitric oxide and clinical characteristics and outcomes in patients with subacute cough

OBJECTIVES

To investigate the relationships between fractional exhaled nitric oxide (FENO) and clinical characteristics and outcomes in patients with subacute cough.

METHODS

Patients with subacute cough (n = 189) after upper respiratory tract infection were enrolled in this single-center prospective study, and were divided into low-FENO (<25 ppb) and high-FENO groups (≥25 ppb). Empirical therapies (without inhaled or systemic corticosteroids) were prescribed based on clinical experience and follow-up until the disease course reached 8 weeks. FENO values, cough symptom scores (CSS), and Leicester Cough Questionnaire (LCQ) scores were obtained, analyzed, and compared between two groups of patients.

RESULTS

The low-FENO and high-FENO groups comprised 136 and 53 patients, respectively. The multiple regression analysis showed that blood eosinophil count and gender were independent factors for elevated FENO (β = 1.38, 0.25, respectively). LCQ scores, total CSS, and daytime CSS were comparable between the low-FENO and high-FENO groups. The nighttime CSS of the high-FENO group were significantly higher than that of the low-FENO group (P = .03). The CSS and LCQ score were improved in both groups but were comparable between groups after 10 days treatment.

CONCLUSIONS

Patients with subacute cough and high-FENO levels have more severe nocturnal cough than those of patients with low-FENO levels. However, FENO levels do not appear to correlate with the clinical outcomes or treatment response. The significance of FENO in the management of subacute cough needs to be further evaluated, at least in the current empirical treatment without corticosteroids.

Use of electronic medical records and biomarkers to manage risk and resource efficiencies

The migration from paper to electronic medical records (EMRs) was motivated by the administrative need to record, retrieve and process increasing amounts of clinical data in the 1980s. In the intervening period, there has been growing recognition of the potential of such records for achieving care efficiencies, informing clinical decision making and real-life research. EMRs can be used to characterise patient groups, management approaches and differential outcomes. Characterisation can also help with identification of potential biomarkers for future risk determination and likely treatment response. The future heralds even greater opportunities through integration of clinical records and a range of technology-based solutions within a more complete electronic health record (EHR). Through application of algorithms based on identified risk predictors and disease determinants, clinical records could also be used to enable risk stratification of patients to optimise targeted interventions, conserving resources to achieve individual patient and system-wide benefit. In this review, we reflect on the evolution of the EMR and EHR and discuss current and emerging opportunities, particularly with respect to biomarkers and targeting of innovative biologic interventions. We also consider some of the critical issues associated with realising the potential of the EHR as a clinical aid and research tool in an age of emerging technologies.​​​​.

Clinically relevant outcome measures for new therapies of asthma using pharmaceutical and biologic agents

PURPOSE OF REVIEW

To determine the benefits of new asthma drugs or therapies, they should be assessed with regard to their effects on relevant clinical outcomes.

RECENT FINDINGS

The most frequently used outcomes have been symptoms, rescue medication needs and pulmonary function tests, although others such as quality of life, exacerbations and impairment of activities have also been identified as important ones. Improvements in our understanding of basic mechanisms of asthma have led to the development of new sets of outcomes including inflammatory markers and a rapidly increasing number of biomarkers, which however require validation, and assessment of their clinical usefulness. Many studies have not only looked at induced sputum cell differentials or FENO to phenotype asthma but also as treatment efficacy markers. Periostin is considered a marker of TH2-induced airway inflammation and a predictor of response to drugs such as anti-IL13 and omalizumab, although at the individual level, such prediction remains imperfect.

SUMMARY

There is a need to develop new markers of activity of the disease, with a prognostic value with regard to the benefits of new treatments.

Effect of once-daily generic ciclesonide on exhaled nitric oxide in atopic children with persistent asthma

BACKGROUND

Ciclesonide (CIC) is an effective inhaled corticosteroid for treating asthmatic children. However, its effect on airway inflammation assessed by the fraction of exhaled nitric oxide (FENO) in children with persistent asthma is virtually unknown. We aimed to assess the effect of once-daily generic CIC, 80 or 160 μg, on FENO, lung function, asthma control and bronchial hyperresponsiveness, in atopic children with persistent asthma.

METHODS

This was a 12-week, randomised, double-blind, parallel-group study. Sixty children with mild-to-moderate persistent asthma were recruited. Changes in FENO, asthma control score, lung function (FEV1) and bronchial hyperresponsiveness to methacholine (BHR) were used to assess the effects of both CIC doses. Non-normally distributed variables were log-transformed to approximate normality, and parametric tests were used for comparisons within and between groups at baseline and after 12 weeks of treatment.

RESULTS

In the CIC 80 μg group, FENO decreased from 45.0 ppb (95% CI 37.8-53.7) to 32.7 ppb (95% CI 21.0-47.3) at the end of study (P=0.021), whereas in the CIC 160 μg group, FENO decreased from 47.3 ppb (95% CI 40.4-55.3) to 30.5 ppb (95% CI 24.1-38.7) (P<0.001). The difference between groups in FENO at the end of study was not significant (P=0.693). There was a significant improvement of asthma control with both CIC doses but there was no significant change in BHR or FEV1 in either group.

CONCLUSION

Once-daily generic ciclesonide (80 μg or 160 μg), for 12 weeks, is effective to improve airway inflammation and asthma control in atopic children with persistent asthma.

Comorbidity in severe asthma requiring systemic corticosteroid therapy: cross-sectional data from the Optimum Patient Care Research Database and the British Thoracic Difficult Asthma Registry

OBJECTIVE

To determine the prevalence of systemic corticosteroid-induced morbidity in severe asthma.

DESIGN

Cross-sectional observational study.

SETTING

The primary care Optimum Patient Care Research Database and the British Thoracic Society Difficult Asthma Registry.

PARTICIPANTS

Optimum Patient Care Research Database (7195 subjects in three age- and gender-matched groups)-severe asthma (Global Initiative for Asthma (GINA) treatment step 5 with four or more prescriptions/year of oral corticosteroids, n=808), mild/moderate asthma (GINA treatment step 2/3, n=3975) and non-asthma controls (n=2412). 770 subjects with severe asthma from the British Thoracic Society Difficult Asthma Registry (442 receiving daily oral corticosteroids to maintain disease control).

MAIN OUTCOME MEASURES

Prevalence rates of morbidities associated with systemic steroid exposure were evaluated and reported separately for each group.

RESULTS

748/808 (93%) subjects with severe asthma had one or more condition linked to systemic corticosteroid exposure (mild/moderate asthma 3109/3975 (78%), non-asthma controls 1548/2412 (64%); p<0.001 for severe asthma versus non-asthma controls). Compared with mild/moderate asthma, morbidity rates for severe asthma were significantly higher for conditions associated with systemic steroid exposure (type II diabetes 10% vs 7%, OR=1.46 (95% CI 1.11 to 1.91), p<0.01; osteoporosis 16% vs 4%, OR=5.23, (95% CI 3.97 to 6.89), p<0.001; dyspeptic disorders (including gastric/duodenal ulceration) 65% vs 34%, OR=3.99, (95% CI 3.37 to 4.72), p<0.001; cataracts 9% vs 5%, OR=1.89, (95% CI 1.39 to 2.56), p<0.001). In the British Thoracic Society Difficult Asthma Registry similar prevalence rates were found, although, additionally, high rates of osteopenia (35%) and obstructive sleep apnoea (11%) were identified.

CONCLUSIONS

Oral corticosteroid-related adverse events are common in severe asthma. New treatments which reduce exposure to oral corticosteroids may reduce the prevalence of these conditions and this should be considered in cost-effectiveness analyses of these new treatments.

Breath analysis as a potential and non-invasive frontier in disease diagnosis: an overview

Currently, a small number of diseases, particularly cardiovascular (CVDs), oncologic (ODs), neurodegenerative (NDDs), chronic respiratory diseases, as well as diabetes, form a severe burden to most of the countries worldwide. Hence, there is an urgent need for development of efficient diagnostic tools, particularly those enabling reliable detection of diseases, at their early stages, preferably using non-invasive approaches. Breath analysis is a non-invasive approach relying only on the characterisation of volatile composition of the exhaled breath (EB) that in turn reflects the volatile composition of the bloodstream and airways and therefore the status and condition of the whole organism metabolism. Advanced sampling procedures (solid-phase and needle traps microextraction) coupled with modern analytical technologies (proton transfer reaction mass spectrometry, selected ion flow tube mass spectrometry, ion mobility spectrometry, e-noses, etc.) allow the characterisation of EB composition to an unprecedented level. However, a key challenge in EB analysis is the proper statistical analysis and interpretation of the large and heterogeneous datasets obtained from EB research. There is no standard statistical framework/protocol yet available in literature that can be used for EB data analysis towards discovery of biomarkers for use in a typical clinical setup. Nevertheless, EB analysis has immense potential towards development of biomarkers for the early disease diagnosis of diseases.

The effect of the novel phosphodiesterase-4 inhibitor MEM 1414 on the allergen induced responses in mild asthma

Background

Inhaled allergen challenge is a standard method to study airway responses to inflammatory provocation and evaluate the therapeutic potential of novel anti-inflammatory compounds in asthma. MEM 1414 is a novel oral PDE4 inhibitor with high affinity and selectivity creating the potential for an improved side effect profile vs non-selective PDE inhibitors. We evaluated the tolerability and effect of MEM 1414 on airway responses in mild asthmatics.

Methods

A randomised double blind placebo controlled cross over study in two centres, in which sixteen steroid naïve atopic asthmatics were challenged with inhaled allergen. Subjects were dosed with MEM 1414 (600 mg) or placebo, twice daily orally for 7 days. Allergen challenge was performed on day 6 (2 hours post-dose), and methacholine responsiveness was measured 24 hours post allergen (day 7). Biomarkers of drug effects using ex vivo LPS stimulation of whole blood production of interleukin (IL)-6 and leukotriene (LT)-B4 and fractional exhaled nitric oxide (FeNO) were measured on day 6 (0, 2 and 8 hours post-dose). Plasma pharmacokinetics were measured on days 1, 6 and 7. The primary endpoint was the effect on late asthmatic response to allergen.

Results

Treatment with MEM 1414 abrogated the late phase response with a mean difference in FEV₁ (LAR 3–10 hours) of 104 ml (25%) vs placebo (p < 0.005), with no effect on the early response. Biomarker responses were also attenuated with MEM 1414 treatment with reductions in LPS-stimulated whole blood assays for TNFα at 8 hours (p < 0.03) and LTB₄ at 24 hours (p = 0.0808) with no change in the IL-6 response. The MEM 1414 treatment phase was associated with higher incidence of nausea (6/16 MEM 1414 vs 2/16 placebo) and vomiting (3/16 vs 0/16 placebo).

Conclusions

Oral MEM 1414, a novel PDE4 inhibitor, significantly reduces the late response following inhaled allergen challenge. MEM 1414 also inhibited whole blood assays of cytokine production from inflammatory cells. MEM 1414 was associated with a typical adverse event profile of PDE4 inhibitors, namely nausea and vomiting although these were mild side effects.

Trial registration number

Current controlled trials ISRCTN48047493.

Challenges and limitations of testing efficacy of aerosol device delivery in young children

An increasing number of medical conditions are chronically or acutely managed with some form of aerosolized therapy. Due to the benefit of directly administering medications to the intended site of action, there is great interest in evaluating treatments for aerosol use. One of the major challenges in selecting and testing new drug-device combinations in children is the uncertainty regarding the appropriate outcome measure to choose. In studies involving adult patients, typically exacerbations of disease or airflow obstruction are assessed as endpoints in drug trials or device assessment. However, in young children, choosing endpoints to assess efficacy is difficult due to the potential lack of sensitive, noninvasive endpoints that are easily performed across sites. In this review, we discuss the challenges and limitations of selecting clinical endpoints for drug-device trials in the youngest population, with a focus on novel emerging technologies. This article provides an overview of preschool and infant pulmonary function testing, multiple-breath washout, imaging techniques including computed tomography and magnetic resonance imaging, flexible bronchoscopy in children, mucociliary clearance scans, and exhaled breath condensate.