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Kumar R, Gaur S, Agarwal M, Menon B, Goel N, Mrigpuri P, Spalgais S, Priya A, Kumar K, Meena R, Sankararaman N, Verma A, Gupta V, Sonal, Prakash A, Safwan MA, Behera D, Singh A, Arora N, Prasad R, Padukudru M, Kant S, Janmeja A, Mohan A, Jain V, Nagendra Prasad K, Nagaraju K, Goyal M. Indian Guidelines for diagnosis of respiratory allergy. INDIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY 2023. [DOI: 10.4103/0972-6691.367373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Louis R, Satia I, Ojanguren I, Schleich F, Bonini M, Tonia T, Rigau D, Ten Brinke A, Buhl R, Loukides S, Kocks JWH, Boulet LP, Bourdin A, Coleman C, Needham K, Thomas M, Idzko M, Papi A, Porsbjerg C, Schuermans D, Soriano JB, Usmani OS. European Respiratory Society Guidelines for the Diagnosis of Asthma in Adults. Eur Respir J 2022; 60:2101585. [PMID: 35169025 DOI: 10.1183/13993003.01585-2021] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 01/10/2022] [Indexed: 12/20/2022]
Abstract
Although asthma is very common affecting 5-10% of the population, the diagnosis of asthma in adults remains a challenge in the real world that results in both over- and under-diagnosis. A task force (TF) was set up by the European Respiratory Society to systematically review the literature on the diagnostic accuracy of tests used to diagnose asthma in adult patients and provide recommendation for clinical practice.The TF defined eight PICO (Population, Index, Comparator, and Outcome) questions that were assessed using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach, The TF utilised the outcomes to develop an evidenced-based diagnostic algorithm, with recommendations for a pragmatic guideline for everyday practice that was directed by real-life patient experiences.The TF support the initial use of spirometry followed, and if airway obstruction is present, by bronchodilator reversibility testing. If initial spirometry fails to show obstruction, further tests should be performed in the following order: FeNO, PEF variability or in secondary care, bronchial challenge. We present the thresholds for each test that are compatible with a diagnosis of asthma in the presence of current symptoms.The TF reinforce the priority to undertake spirometry and recognise the value of measuring blood eosinophils and serum IgE to phenotype the patient. Measuring gas trapping by body plethysmography in patients with preserved FEV1/FVC ratio deserves further attention. The TF draw attention on the difficulty of making a correct diagnosis in patients already receiving inhaled corticosteroids, the comorbidities that may obscure the diagnosis, the importance of phenotyping, and the necessity to consider the patient experience in the diagnostic process.
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Affiliation(s)
- Renaud Louis
- CHU de Liege University Hospital Centre Ville, Liege, Belgium
- First author, Task force chair
| | - Imran Satia
- McMaster University, Hamilton, Canada
- All authors contributed equally
| | - Inigo Ojanguren
- Vall d'Hebron University Hospital Barcelona, Barcelona, Spain
- All authors contributed equally
| | - Florence Schleich
- Department of Pulmonary Medicine, University of Liege, Liège, Belgium
- All authors contributed equally
| | - Matteo Bonini
- Sapienza University of Rome, Rome, Italy
- All authors contributed equally
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - David Rigau
- Iberoamerican Cochrane Centre, Barcelona, Spain
| | - Anne Ten Brinke
- CHU de Liege University Hospital Centre Ville, Liege, Belgium
| | - Roland Buhl
- Pulmonary Department, Mainz University Hospital, Mainz, Germany
| | | | | | - Louis-Philippe Boulet
- Pneumologie, Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Quebec, Canada
| | | | | | | | - Mike Thomas
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK
| | - Marco Idzko
- Department of Respiratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Alberto Papi
- Respiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Celeste Porsbjerg
- Respiratory Medicine, Copenhagen University Hospital Bispebjerg, Copenhagen NV, Denmark
| | - Daniel Schuermans
- Respiratory Division, Academic Hospital UZBrussel, Brussels, Belgium
| | - Joan B Soriano
- Universidad Autónoma de Madrid, Hospital Universitario de la Princesa, Madrid, Spain
| | - Omar S Usmani
- Asthma Lab, National Heart and Lung Institute, London, UK
- Corresponding author, Task force co-chair
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Pignatti P, Visca D, Loukides S, Märtson AG, Alffenaar JWC, Migliori GB, Spanevello A. A snapshot of exhaled nitric oxide and asthma characteristics: experience from high to low income countries. Pulmonology 2020; 28:44-58. [PMID: 33358001 DOI: 10.1016/j.pulmoe.2020.10.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/30/2020] [Accepted: 10/31/2020] [Indexed: 12/30/2022] Open
Abstract
Nitric oxide is a gas produced in the airways of asthmatic subjects and related to T2 inflammation. It can be measured as fractional nitric oxide (FeNO) in the exhaled air and used as a non-invasive, easy to evaluate, rapid marker. It is now widely used in many settings to determine airway inflammation. The aim of this narrative review is to report relationship between FeNO and the physiopathologic characteristics of asthmatic patients. Factors affecting FeNO levels have also been analysed as well as the impact of corticosteroid, target therapies and rehabilitation programs. Considering the availability of the test, spreading this methodology to low income countries has also been considered as a possibility for evaluating airway inflammation and monitoring adherence to inhaled corticosteroid therapy. PubMed data search has been performed restricted to English language papers. Research was limited to studies in adults unless studies in children were the only ones reported for a particular issue. This revision could be useful to summarize the role of FeNO in relation to asthma characteristics and help in the use of FeNO in different clinical settings particularly in low income countries.
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Affiliation(s)
- Patrizia Pignatti
- Allergy and Immunology Unit, Istituti Clinici Scientifici Maugeri IRCCS Pavia, Italy.
| | - Dina Visca
- Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italy and Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy
| | - Stelios Loukides
- 2nd Respiratory Medicine Department, National and Kapodistrian University of Athens Medical School, Attikon University Hospital, Athens, Greece
| | - Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, The Netherlands
| | - Jan-Willem C Alffenaar
- Sydney Pharmacy School, University of Sydney, Sydney, New South Wales, Australia; Westmead Hospital, Sydney, Australia; Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | - Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | - Antonio Spanevello
- Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italy and Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Varese-Como, Italy
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Parallel gradients in F ENO and in the prevalences of asthma and atopy in adult general populations of Sweden, Finland and Estonia - A Nordic EpiLung study. Respir Med 2020; 173:106160. [PMID: 33011446 DOI: 10.1016/j.rmed.2020.106160] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/18/2020] [Accepted: 09/15/2020] [Indexed: 11/23/2022]
Abstract
The prevalence of asthma is higher in Sweden and Finland than in neighbouring eastern countries including Estonia. Corresponding difference in bronchial eosinophilic inflammation could be studied by FENO measurements. We aimed to compare FENO in adult general populations of Sweden, Finland, and Estonia, to test the plausibility of the west-east disparity hypothesis of allergic diseases. We conducted clinical interviews (N = 2658) with participants randomly selected from the general populations in Sweden (Stockholm and Örebro), Finland (Helsinki), and Estonia (Narva and Saaremaa), and performed FENO (n = 1498) and skin prick tests (SPT) in 1997-2003. The median (interquartile range) of FENO (ppb) was 15.5 (9.3) in Sweden, 15.4 (13.6) in Finland and 12.5 (9.6) in Estonia. We found the lowest median FENO values in the Estonian centres Saaremaa 13.1 (9.5) and Narva 11.8 (8.6). In the pooled population, asthma was associated with FENO ≥25 ppb, odds ratio (OR) 3.91 (95% confidence intervals: 2.29-6.32) after adjusting for SPT result, smoking, gender and study centre. A positive SPT test increased the likelihood of asthma OR 3.19 (2.02-5.11). Compared to Saaremaa, the likelihood of having asthma was higher in Helsinki OR 2.40 (1.04-6.02), Narva OR 2.45 (1.05-6.19), Örebro OR 3.38 (1.59-8.09), and Stockholm OR 5.54 (2.18-14.79). There was a higher prevalence of asthma and allergic airway inflammation in adult general populations of Sweden and Finland compared to those of Estonia. Atopy and elevated FENO level were independently associated with an increased risk of asthma. In conclusion, the findings support the earlier west-east disparity hypothesis of allergic diseases.
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FeNO for Asthma Diagnosis in Adults: More Lights Than Shadows. Arch Bronconeumol 2020; 57:85-86. [PMID: 32456799 DOI: 10.1016/j.arbres.2020.03.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/18/2020] [Accepted: 03/21/2020] [Indexed: 11/24/2022]
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A Role for Alveolar Exhaled Nitric Oxide Measurement in the Diagnosis of Hepatopulmonary Syndrome. J Clin Gastroenterol 2020; 54:278-283. [PMID: 31306341 DOI: 10.1097/mcg.0000000000001246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GOALS The authors sought to characterize predominantly alveolar exhaled nitric oxide (eNO) in hepatopulmonary syndrome (HPS) compared with non-HPS, changes after liver transplantation, and diagnostic properties. BACKGROUND HPS is defined by liver disease, intrapulmonary vascular dilatations (IPVDs), and hypoxemia. Rat models and small human studies suggest that NO overproduction may cause IPVDs. STUDY A retrospective review of the Canadian HPS Database (2007 to 2017) and prospective eNO measurement (main outcome) in healthy controls (measurement expiratory flow, 200 mL/s). HPS was defined as: (1) liver disease; (2) contrast echocardiography consistent with IPVDs; and (3) partial pressure of arterial oxygen <70 mm Hg with alveolar-arterial gradient >20 mm Hg; subclinical HPS as criteria (1) and (2) only; and no HPS as criterion (1) only. Current smokers and subjects with asthma or pulmonary hypertension were excluded. A linear mixed effects model was used to compare eNO between groups and before and after transplantation. RESULTS eNO was 10.4±0.7 ppb in HPS (n=26); 8.3±0.6 ppb in subclinical HPS (n=38); 7.1±1.0 ppb in no HPS (n=15); and 5.6±0.7 ppb in controls (n=30) (P<0.001). eNO decreased from 10.9±0.8 ppb preliver to 6.3±0.8 ppb postliver transplant (n=6 HPS, 6 subclinical HPS) (P<0.001). eNO <6 ppb was 84.4% (73.1% to 92.2%) sensitive and ≥12 ppb was 78.1% (69.4% to 85.3%) specific for HPS (vs. subclinical HPS). CONCLUSIONS HPS subjects have higher alveolar eNO than non-HPS subjects, levels normalize with liver transplantation. Applying eNO cutoff values may aid in HPS diagnosis.
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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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Sano H, Tomita K, Sano A, Saeki S, Nishikawa Y, Nishiyama O, Iwanaga T, Tohda Y. Accuracy of objective tests for diagnosing adult asthma in symptomatic patients: A systematic literature review and hierarchical Bayesian latent-class meta-analysis. Allergol Int 2019; 68:191-198. [PMID: 30309809 DOI: 10.1016/j.alit.2018.08.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/13/2018] [Accepted: 08/20/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We obtain summary estimates of the accuracy of additional objective tests for the diagnosis of adult asthma using systematic review and meta-analysis of diagnostic test accuracy studies. METHODS Medline, Embase, and other relevant electronic databases were searched for papers published between January 1989 and December 2016. Studies were included if they evaluated the diagnostic accuracy of objective tests, including airway reversibility (AR), airway hyperresponsiveness (AHR), and fractionated exhaled nitric oxide (FeNO) for the diagnosis of adult asthma in patients with symptoms suggestive of asthma. If papers were assessed appropriate using the adapted QUADAS-2 tool, meta-analysis was conducted using the hierarchical bivariate model. This hierarchical model accounts for both within and between study variability. RESULTS Sixteen studies reported the performance of the evaluated objective tests at presentation. For diagnosis of adult asthma, overall sensitivity and specificity for AR were 0.39 (95% confidence interval [CI] 0.18 to 0.66) and 0.95 (95% CI 0.86 to 1.00); for AHR, 0.86 (95% CI 0.61 to 1.00) and 0.95 (95% CI 0.77 to 1.00); for FeNO, 0.65 (95% CI 0.53 to 0.77) and 0.83 (95% CI 0.75 to 0.90). Comprehensive comparison of three diagnostic tools for adult asthma using the back-calculated likelihood rate (LR) showed that AR and AHR corresponded to a higher LR+, and AHR gave a lower LR-. CONCLUSIONS In the current situation of no gold standard for diagnosis of adult asthma, AR and AHR are appropriate for ruling-in the true diagnosis, and AHR is superior for ruling-out a diagnosis. Since each objective test had a specific characteristic, it should be chosen depending on the situation, such as the capacity of the institution and the conditions of patients.
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Affiliation(s)
- Hiroyuki Sano
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Katsuyuki Tomita
- Department of Respiratory Medicine, Yonago Medical Centre, Tottori, Japan.
| | - Akiko Sano
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Shou Saeki
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Yusaku Nishikawa
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Osamu Nishiyama
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Takashi Iwanaga
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Yuji Tohda
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osaka, Japan
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A novel statistical model for analyzing data of a systematic review generates optimal cutoff values for fractional exhaled nitric oxide for asthma diagnosis. J Clin Epidemiol 2017; 92:69-78. [PMID: 28916487 DOI: 10.1016/j.jclinepi.2017.09.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 08/22/2017] [Accepted: 09/01/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Measurement of fractional exhaled nitric oxide (FENO) might substitute bronchial provocation for diagnosing asthma. However, optimal FENO thresholds for diagnosing asthma remain unclear. We reanalyzed data collected for a systematic review investigating the diagnostic accuracy of FENO measurement to exploit all available thresholds under consideration of pretest probabilities using a newly developed statistical model. STUDY DESIGN AND SETTING One hundred and fifty data sets for a total of 53 different cutoffs extracted from 26 studies with 4,518 participants were analyzed with the multiple thresholds model. This model allows identifying thresholds at which the test is likely to perform best. RESULTS Diagnosing asthma might only be possible in a meaningful manner when the pretest probability of asthma is at least 30%. In that case, FENO > 50 ppb leads to a positive predictive value of 0.76 [95% confidence interval (CI): 0.29-0.96]. Excluding asthma might only be possible, when the pretest probability of asthma is 30% at maximum. Then, FENO < 20 ppb leads to a negative predictive value of 0.86 (95% CI 0.66-0.95). CONCLUSION The multiple thresholds model generates a more comprehensive and more clinically useful picture of the effects of different thresholds, which facilitates the determination of optimal thresholds for diagnosing or excluding asthma with FENO measurement.
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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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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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Abstract
OBJECTIVE Summarize developed evidence-based diagnostic and treatment guidelines for work-related asthma (WRA). METHODS Comprehensive literature reviews conducted with article critiquing and grading. Guidelines developed by a multidisciplinary expert panel and peer-reviewed. RESULTS Evidence supports spirometric testing as an essential early test. Serial peak expiratory flow rates measurement is moderately recommended for employees diagnosed with asthma to establish work-relatedness. Bronchial provocation testing is moderately recommended. IgE and skin prick testing for specific high-molecular weight (HMW) antigens are highly recommended. IgG testing for HMW antigens, IgE testing for low-molecular weight antigens, and nitric oxide testing for diagnosis are not recommended. Removal from exposure is associated with the highest probability of improvement, but may not lead to complete recovery. CONCLUSION Quality evidence supports these clinical practice recommendations. The guidelines may be useful to providers who diagnose and/or treat WRA.
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Karrasch S, Linde K, Rücker G, Sommer H, Karsch-Völk M, Kleijnen J, Jörres RA, Schneider A. Accuracy of FENO for diagnosing asthma: a systematic review. Thorax 2016; 72:109-116. [PMID: 27388487 DOI: 10.1136/thoraxjnl-2016-208704] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/02/2016] [Indexed: 01/14/2023]
Abstract
BACKGROUND Measurement of FENO might substitute bronchial provocation for diagnosing asthma. We aimed to investigate the diagnostic accuracy of FENO measurement compared with established reference standard. METHODS Systematic review and diagnostic meta-analysis. Data sources were Medline, Embase and Scopus up to 29 November 2015. Sensitivity and specificity were estimated using a bivariate model. Additionally, summary receiver-operating characteristic curves were estimated. RESULTS 26 studies with 4518 participants (median 113) were included. Risk of bias was considered low for six of seven items in five studies and for five items in seven studies. The overall sensitivity in the meta-analysis was 0.65 (95% CI 0.58 to 0.72), the overall specificity 0.82 (0.76 to 0.86), the diagnostic OR 9.23 (6.55 to 13.01) and the area under the curve 0.80 (0.77 to 0.85). In meta-regression analyses, higher cut-off values were associated with increasing specificity (OR 1.46 per 10 ppb increase in cut-off) while there was no association with sensitivity. Sensitivities varied significantly within the different FENO devices, but not specificities. Neither prevalence, age, use of bronchoprovocation in >90% of participants or as exclusive reference standard test, nor risk of bias were significantly associated with diagnostic accuracy. CONCLUSIONS There appears to be a fair accuracy of FENO for making the diagnosis of asthma. The overall specificity was higher than sensitivity, which indicates a higher diagnostic potential for ruling in than for ruling out the diagnosis of asthma.
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Affiliation(s)
- Stefan Karrasch
- Institute of General Practice, University Hospital Klinikum rechts der Isar, Technische Universität München, Munich, Germany.,Institute of Epidemiology I, Helmholtz Zentrum München-German Research Center for Environmental Health, Munich, Germany.,Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig-Maximilians-Universität, Munich, Germany
| | - Klaus Linde
- Institute of General Practice, University Hospital Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Gerta Rücker
- Institute for Medical Biometry and Statistics, Medical Center-University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Harriet Sommer
- Institute for Medical Biometry and Statistics, Medical Center-University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marlies Karsch-Völk
- Institute of General Practice, University Hospital Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Jos Kleijnen
- Kleijnen Systematic Reviews Ltd, Escrick, York, UK.,School for Public Health and Primary Care (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Rudolf A Jörres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig-Maximilians-Universität, Munich, Germany
| | - Antonius Schneider
- Institute of General Practice, University Hospital Klinikum rechts der Isar, Technische Universität München, Munich, Germany
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Biomarkers Guided Treatment Strategies in Adult Patients with Asthma: Ready for the Clinical Field? Arch Immunol Ther Exp (Warsz) 2016; 65:1-9. [PMID: 27271573 DOI: 10.1007/s00005-016-0407-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/14/2016] [Indexed: 10/21/2022]
Abstract
Asthma is a chronic inflammatory airways disorder mainly characterized by heterogeneity. In the more severe forms, a discordance often exists between symptoms and inflammation. Difficulty in managing asthma derives partly from the multiple phenotypes existing and our inability to recognize them. The use of non-invasive, with main representative the fraction of exhaled nitric oxide, or semi-invasive techniques such as induced sputum are effective tools that can help us to guide asthma treatment. In the latest years, several serum biomarkers related to asthmatic inflammation have been used for the better recognition of asthma sub-phenotypes to achieve optimization of therapy and disease outcome. In patients with mild-moderate asthma, as well as patients with more severe asthma, the use of blood eosinophils revealed an acceptable accuracy for the prediction of airway eosinophilia indicating that in future studies may facilitate both individualized treatment and management of asthma. None of the above techniques have been incorporated in clinical practice although sputum eosinophils can be used in patients with severe asthma particularly in specialized centers with great experience. Of great interest are blood eosinophils since current data support their role either as tool for treatment selections or/and as a biomarker of airway eosinophilia.
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Karampitsakos T, Gourgoulianis KI. Asthma-COPD Overlap Syndrome (ACOS): Single disease entity or not? Could exhaled nitric oxide be a useful biomarker for the differentiation of ACOS, asthma and COPD? Med Hypotheses 2016; 91:20-23. [PMID: 27142135 DOI: 10.1016/j.mehy.2016.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/02/2016] [Accepted: 04/07/2016] [Indexed: 01/05/2023]
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) represent two major public health problems. However, there is a significant proportion of patients with a mixed asthma-COPD phenotype. This condition is defined as asthma-COPD overlap syndrome (ACOS). Since there are no internationally accepted criteria for the diagnosis of that syndrome, its management remains difficult. Given the fact that patients with ACOS have an increased risk of exacerbation and hospitalization, there is a pressing need for a more targeted approach and better management. We propose that fractional exhaled nitric oxide (FeNO), a marker of eosinophilic inflammation, could help clinicians differentiate ACOS from asthma and COPD. We evaluate this hypothesis, using data derived from the existing literature.
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Affiliation(s)
- Theodoros Karampitsakos
- Academic Department of Pneumonology, Hospital for Diseases of the Chest, "Sotiria", Medical School, University of Athens, Messogion Avenue 152, Athens 11527, Greece.
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Guo Z, Wang Y, Xing G, Wang X. Diagnostic accuracy of fractional exhaled nitric oxide in asthma: a systematic review and meta-analysis of prospective studies. J Asthma 2016; 53:404-12. [PMID: 26796787 DOI: 10.3109/02770903.2015.1101132] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Fractional exhaled nitric oxide (FeNO) has been proposed as a non-invasive measure of airway inflammation in asthma. However, its accuracy for the diagnosis of asthma in different populations is not completely clear. The aim of this study was to investigate the accuracy of FeNO measurement for the diagnosis of asthma through a systematic review and meta-analysis of prospective studies. METHODS A systematic search current to July 2014 was performed in Pubmed, EMBASE, Medline, the Cochrane databases, CNKI, Wanfang and Weipu to find relevant studies. All prospective studies on the use of FeNO for the diagnosis of asthma were included. RESULTS Twenty-five studies including 3983 subjects were analyzed. The pooled sensitivity, specificity and diagnostic odds ratio (DOR) for the entire population was 72% (95% CI, 70-74%), 78% (95% CI, 76-80%) and 15.92 (95% CI, 10.70-23.68), respectively. The area under the summary receiver operating characteristic (sROC) curves revealed a receiver-operating characteristic of 0.88. In subgroup analysis, the DOR for patients using corticosteroids, as well as those for steroid-naïve, non-smoking, smoking, chronic cough and allergic rhinitis patients were 4.47 (95% CI, 3.39-5.90), 21.40 (95% CI, 15.38-29.76), 19.84 (95% CI, 15.63-25.19), 5.41 (95% CI, 2.97-9.86), 35.36 (95% CI, 23.90-52.29), and 2.99 (95% CI, 0.85-10.45), respectively. CONCLUSION FeNO is accurate for the diagnosis of asthma in steroid-naive or non-smoking patients, particularly in chronic cough patients.
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Affiliation(s)
- Zhi Guo
- a Department of Pulmonary Diseases , Jinan Military General Hospital , Jinan , Shandong , China
| | - Ying Wang
- a Department of Pulmonary Diseases , Jinan Military General Hospital , Jinan , Shandong , China
| | - Guohong Xing
- a Department of Pulmonary Diseases , Jinan Military General Hospital , Jinan , Shandong , China
| | - Xin Wang
- a Department of Pulmonary Diseases , Jinan Military General Hospital , Jinan , Shandong , China
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Rawy AM, Mansour AI. Fraction of exhaled nitric oxide measurement as a biomarker in asthma and COPD compared with local and systemic inflammatory markers. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2015. [DOI: 10.1016/j.ejcdt.2014.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Shirai T, Mochizuki E, Asada K, Suda T. Pollen count and exhaled nitric oxide levels in a seasonal allergic rhinitis patient. Respirol Case Rep 2014; 2:113-5. [PMID: 25473586 PMCID: PMC4184743 DOI: 10.1002/rcr2.68] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 07/15/2014] [Accepted: 07/22/2014] [Indexed: 11/30/2022] Open
Abstract
The subject was a 52-year-old man with Japanese cedar pollinosis, which developed between February and May. He had no history of asthma and was an ex-smoker. He underwent fractional exhaled nitric oxide (FeNO) measurements twice a week from 2010 to 2012. The pollen counts in 2010 were the lowest during the last decade, and the FeNO level was less than 30 ppb for the whole year. In contrast, the mean pollen count in 2011 was very high and the patient’s FeNO level rose to more than 100 ppb. The mean pollen count in 2012 was comparable with that of 2010; however, high counts were detected in April and May, and the FeNO level rose to 70 ppb during the latter stages of the pollen season. These results indicate that pollen counts should be taken into consideration during the interpretation of FeNO data in asthma or allergic rhinitis.
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Affiliation(s)
- Toshihiro Shirai
- Department of Respiratory Medicine, Shizuoka General Hospital Shizuoka, Japan
| | - Eisuke Mochizuki
- Department of Respiratory Medicine, Shizuoka General Hospital Shizuoka, Japan
| | - Kazuhiro Asada
- Department of Respiratory Medicine, Shizuoka General Hospital Shizuoka, Japan
| | - Takafumi Suda
- Second Department of Internal Medicine, Hamamatsu University School of Medicine Hamamatsu, Japan
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Tajiri T, Niimi A, Matsumoto H, Ito I, Oguma T, Otsuka K, Takeda T, Nakaji H, Inoue H, Iwata T, Nagasaki T, Mishima M. Prevalence and clinical relevance of allergic rhinitis in patients with classic asthma and cough variant asthma. ACTA ACUST UNITED AC 2013; 87:211-8. [PMID: 24401902 DOI: 10.1159/000355706] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 09/16/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND A clinically relevant relationship between classic asthma and allergic rhinitis has been reported. However, the possible link between cough variant asthma (CVA) and allergic rhinitis remains unknown. OBJECTIVES To clarify the prevalence and clinical relevance of perennial allergic rhinitis or seasonal allergic rhinitis in CVA patients compared to classic asthma patients. METHODS We retrospectively studied adult patients with classic asthma (n = 190) and those with CVA (n = 83). The prevalence of perennial allergic rhinitis or seasonal allergic rhinitis and associations of concomitant perennial or seasonal allergic rhinitis with asthma severity, forced expiratory volume in 1 s (% predicted), fractional exhaled nitric oxide (FeNO) levels, and eosinophil proportions in sputum and blood were analyzed in the two groups. RESULTS The prevalence of perennial allergic rhinitis and/or seasonal allergic rhinitis was significantly higher in classic asthma patients than in CVA patients (all p < 0.05). Concomitant perennial allergic rhinitis was associated with higher FeNO levels and eosinophil proportions in sputum and blood in classic asthma patients (p = 0.035, p = 0.036, and p = 0.008, respectively) and with higher asthma severity, FeNO levels, and sputum eosinophil proportions in CVA patients (p = 0.031, p = 0.007, and p = 0.010, respectively). Concomitant seasonal allergic rhinitis was only associated with higher sputum eosinophil proportions in CVA patients with active rhinitis symptoms during the sensitized pollen season (p = 0.025). CONCLUSIONS Perennial allergic rhinitis may be relevant for CVA patients as well as classic asthma patients by consistently augmenting eosinophilic lower airway inflammation.
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Affiliation(s)
- Tomoko Tajiri
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Breath tests in respiratory and critical care medicine: from research to practice in current perspectives. BIOMED RESEARCH INTERNATIONAL 2013; 2013:702896. [PMID: 24151617 PMCID: PMC3789325 DOI: 10.1155/2013/702896] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 08/12/2013] [Accepted: 08/14/2013] [Indexed: 12/15/2022]
Abstract
Today, exhaled nitric oxide has been studied the most, and most researches have now focused on asthma. More than a thousand different volatile organic compounds have been observed in low concentrations in normal human breath. Alkanes and methylalkanes, the majority of breath volatile organic compounds, have been increasingly used by physicians as a novel method to diagnose many diseases without discomforts of invasive procedures. None of the individual exhaled volatile organic compound alone is specific for disease. Exhaled breath analysis techniques may be available to diagnose and monitor the diseases in home setting when their sensitivity and specificity are improved in the future.
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Katsoulis K, Ganavias L, Michailopoulos P, Bikas C, Dinapogias E, Kontakiotis T, Kostikas K, Loukides S. Exhaled nitric oxide as screening tool in subjects with suspected asthma without reversibility. Int Arch Allergy Immunol 2013; 162:58-64. [PMID: 23816757 DOI: 10.1159/000350221] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2012] [Accepted: 02/18/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND As fractional exhaled nitric oxide (FeNO) has been evaluated only in certain settings for asthma diagnosis, we investigated whether FeNO values could predict positive methacholine challenge testing (expressed as PD20) in subjects with suspected asthma but without spirometric reversibility. METHODS Subjects with asthma-like symptoms and negative bronchodilation test were initially evaluated to undergo FeNO measurement and methacholine bronchial challenge. Diagnostic performance of FeNO to predict PD20 to methacholine <800 μg was examined by constructing receiver-operating characteristic curves. RESULTS A total of 112 subjects met the inclusion criteria. In all subjects, FeNO >32 ppb was associated with a sensitivity of 0.47 and a specificity of 0.85 for the identification of the PD20 <800 μg (AUC = 0.691, 95% CI = 0.6-0.775, p = 0.00002). In smokers, FeNO >11 ppb was associated with a sensitivity of 0.85 and a specificity of 0.5 for the identification of PD20 <800 μg (AUC = 0.625, 95% CI = 0.45-0.772, p = 0.18), while in atopics a FeNO level >26 ppb was associated with a sensitivity of 0.55 and a specificity of 0.85 (AUC = 0.677, 95% CI = 0.53-0.8, p = 0.02). CONCLUSIONS In subjects with symptoms compatible with asthma but without spirometric reversibility, specific cutoff levels for FeNO levels significantly predict the positive methacholine challenge, with significant confounding factors being atopy and current smoking.
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Affiliation(s)
- K Katsoulis
- Pulmonary Department, 424 General Army Hospital, Thessaloniki, Greece
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22
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Role of exhaled nitric oxide as a predictor of atopy. Respir Res 2013; 14:48. [PMID: 23639047 PMCID: PMC3654880 DOI: 10.1186/1465-9921-14-48] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Accepted: 04/26/2013] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND The fractional exhaled nitric oxide (FeNO) is a quantitative, noninvasive and safe measure of airways inflammation that may complement the assessment of asthma. Elevations of FeNO have recently been found to correlate with allergic sensitization. Therefore, FeNO may be a useful predictor of atopy in the general population. We sought to determine the diagnostic accuracy of FeNO in predicting atopy in a population-based study. METHODS We conducted a cross-sectional study in an age- and sex- stratified random sample of 13 to 15 year-olds in two communities in Peru. We asked participants about asthma symptoms, environmental exposures and sociodemographics, and underwent spirometry, assessment of FeNO and an allergy skin test. We used multivariable logistic regression to model the odds of atopy as a function of FeNO, and calculated area-under-the-curves (AUC) to determine the diagnostic accuracy of FeNO as a predictor of atopy. RESULTS Of 1441 recruited participants, 1119 (83%) completed all evaluations. Mean FeNO was 17.6 ppb (SD=0.6) in atopics and 11.6 ppb (SD=0.8) in non-atopics (p<0.001). In multivariable analyses, a FeNO>20 ppb was associated with an increase in the odds of atopy in non-asthmatics (OR=5.3, 95% CI 3.3 to 8.5) and asthmatics (OR=16.2, 95% CI 3.4 to 77.5). A FeNO>20 ppb was the best predictor for atopy with an AUC of 68% (95% CI 64% to 69%). Stratified by asthma, the AUC was 65% (95% CI 61% to 69%) in non-asthmatics and 82% (95% CI 71% to 91%) in asthmatics. CONCLUSIONS FeNO had limited accuracy to identify atopy among the general population; however, it may be a useful indicator of atopic phenotype among asthmatics.
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Kostikas K, Minas M, Nikolaou E, Papaioannou AI, Liakos P, Gougoura S, Gourgoulianis KI, Dinas PC, Metsios GS, Jamurtas AZ, Flouris AD, Koutedakis Y. Secondhand smoke exposure induces acutely airway acidification and oxidative stress. Respir Med 2012; 107:172-9. [PMID: 23218453 DOI: 10.1016/j.rmed.2012.10.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 10/27/2012] [Accepted: 10/30/2012] [Indexed: 10/27/2022]
Abstract
Previous studies have shown that secondhand smoke induces lung function impairment and increases proinflammatory cytokines. The aim of the present study was to evaluate the acute effects of secondhand smoke on airway acidification and airway oxidative stress in never-smokers. In a randomized controlled cross-over trial, 18 young healthy never-smokers were assessed at baseline and 0, 30, 60, 120, 180 and 240 min after one-hour secondhand smoke exposure at bar/restaurant levels. Exhaled NO and CO measurements, exhaled breath condensate collection (for pH, H(2)O(2) and NO(2)(-)/NO(3)(-) measurements) and spirometry were performed at all time-points. Secondhand smoke exposure induced increases in serum cotinine and exhaled CO that persisted until 240 min. Exhaled breath condensate pH decreased immediately after exposure (p < 0.001) and returned to baseline by 180 min, whereas H(2)O(2) increased at 120 min and remained increased at 240 min (p = 0.001). No changes in exhaled NO and NO(2)/NO(3) were observed, while decreases in FEV(1) (p < 0.001) and FEV(1)/FVC (p < 0.001) were observed after exposure and returned to baseline by 180 min. A 1-h exposure to secondhand smoke induced airway acidification and increased airway oxidative stress, accompanied by significant impairment of lung function. Despite the reversal in EBC pH and lung function, airway oxidative stress remained increased 4 h after the exposure. Clinical trial registration number (EudraCT): 2009-013545-28.
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Affiliation(s)
- Konstantinos Kostikas
- Respiratory Medicine Department, University of Thessaly Medical School, Larissa, Greece.
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Increased levels of osteopontin in sputum supernatant of smoking asthmatics. Cytokine 2012; 61:251-5. [PMID: 23098767 DOI: 10.1016/j.cyto.2012.10.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 09/19/2012] [Accepted: 10/01/2012] [Indexed: 12/21/2022]
Abstract
Smoking may modify the inflammatory pattern of the asthmatic airways. Osteopontin (OPN) has been associated with inflammation and fibrosis. In asthma, sputum levels of OPN are elevated and have been related to the underlying severity and to mediators expressing remodeling and inflammation. To evaluate the levels of OPN in sputum supernatants of asthmatic patients and to investigate the possible role of smoking as well as associations with mediators and cells involved in the inflammatory and remodeling process. We studied 103 asthma patients (49 smokers) and 40 healthy subjects (20 smokers) who underwent lung function tests, bronchial hyperresponsiveness to methacholine, and sputum induction for cell count identification and measurement of OPN, TGF-β1, IL-8, IL-13 and ECP in sputum supernatants. The concentrations of all mediators were measured using enzyme immunoassays. OPN levels (pg/ml) were significantly higher in smoking asthmatics compared to non-smoking asthmatics, and both non-smoking and smoking controls [median (interquartile ranges) 1120 (651,1817) vs. 197 (118,341) vs. 50 (42,70) vs. 102 (77,110) pg/ml, respectively; p<0.001]. Regression analysis provided significant associations between OPN and sputum neutrophils, IL-8 and TGF-β1, the most significant being the one with TGF-β1. These associations were present only in smoking asthmatics. Smoking habit significantly affects sputum OPN levels in asthma. The associations of OPN with sputum neutrophils, TGF-β1 and IL-8 in smoking asthmatics suggest a possible role for OPN in the neutrophilic inflammation and remodeling process in this phenotype of asthma.
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Malinovschi A, Backer V, Harving H, Porsbjerg C. The value of exhaled nitric oxide to identify asthma in smoking patients with asthma-like symptoms. Respir Med 2012; 106:794-801. [PMID: 22405608 DOI: 10.1016/j.rmed.2012.02.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2011] [Revised: 02/13/2012] [Accepted: 02/17/2012] [Indexed: 01/13/2023]
Abstract
BACKGROUND The fraction of nitric oxide in exhaled air (FeNO) is used in asthma diagnosis and management. Smoking reduces FeNO and 20-35% of asthmatics are smoking. However no guidelines exist on the diagnostic value of FeNO in smokers. Therefore we assessed the value of FeNO to diagnose asthma in a population of subjects with asthma-like symptoms and different smoking habits. METHODS Measurements of FeNO, lung function, bronchial responsiveness and allergy testing were performed in 282 subjects (108 never-, 62 ex- and 112 current smokers) aged 14-44 years, with symptoms suggestive of asthma. These subjects were a subset of subjects reporting respiratory symptoms (n = 686) in a random population sample (n = 10,400). RESULTS A diagnosis of asthma was given to 96 of the 282 subjects. Subjects with asthma had higher FeNO levels than subjects with non-specific asthma symptoms in all three smoking strata (p < 0.001), with a percentual increase of FeNO by 76% in never-, 71% in ex- and 60% in current smokers. The area under the ROC-curve was similar in never-, ex- and current smokers (0.72 vs. 0.74 vs. 0.70). The cut-offs were approximately 30% lower for either 90% specificity (22 vs. 31 ppb) or 90% sensitivity (7 vs. 10 ppb) in current vs. never-smokers. CONCLUSIONS FeNO could differentiate asthmatic subjects from non-asthmatic subjects with asthma-like symptoms equally well in both never- and current smokers within a random population sample. The FeNO cut-off levels needed in order to achieve high sensitivity or specificity were lower in current smokers.
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Affiliation(s)
- Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden.
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Hillas G, Kostikas K, Mantzouranis K, Bessa V, Kontogianni K, Papadaki G, Papiris S, Alchanatis M, Loukides S, Bakakos P. Exhaled nitric oxide and exhaled breath condensate pH as predictors of sputum cell counts in optimally treated asthmatic smokers. Respirology 2011; 16:811-8. [PMID: 21545371 DOI: 10.1111/j.1440-1843.2011.01984.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Smoking is thought to modify the pattern of airway inflammation. Induced sputum provides useful information on cellular phenotype in inflammatory airways disorders; however, it is time-consuming and difficult to implement in everyday clinical practice. The aim of this study was to determine whether exhaled NO (FeNO) and exhaled breath condensate (EBC) pH differed in asthmatic smokers compared with asthmatic non-smokers and healthy subjects, and to evaluate the performance of FeNO and EBC pH for predicting the cellular phenotype of induced sputum. METHODS Asthmatic smokers (n = 40) and non-smoking asthmatic patients (n = 43) were recruited for the study. Healthy smoking (n = 30) or non-smoking (n = 30) subjects served as controls. FeNO and EBC pH were measured and all subjects underwent sputum induction for assessment of cell counts. RESULTS EBC pH was significantly lower in asthmatic smokers compared with non-smokers (P < 0.01). FeNO levels were also significantly lower in asthmatic smokers compared with non-smokers (P < 0.001). EBC pH was inversely associated with sputum eosinophils in both asthmatic smokers and non-smokers (P < 0.001), whereas it was inversely associated with sputum neutrophils only in asthmatic smokers (P < 0.001). FeNO was positively associated with sputum eosinophils both in asthmatic smokers and non-smokers (P < 0.001) but was not associated with sputum neutrophils. In asthmatic smokers, FeNO was a better predictor of sputum eosinophilia, whereas EBC pH was a better predictor of sputum neutrophilia. A combination of FeNO ≤ 14 ppb together with EBC pH > 7.20 predicted the paucigranulocytic induced sputum phenotype. CONCLUSIONS EBC pH and FeNO levels were significantly lower in asthmatic smokers compared with non-smokers. Combined specific cut-off levels for FeNO and EBC pH may predict the paucigranulocytic phenotype in asthmatic smokers.
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Affiliation(s)
- Georgios Hillas
- First Respiratory Medicine Department, University of Athens Medical School, Sotiria Chest Diseases Hospital, Athens, Greece
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Matsunaga K, Hirano T, Akamatsu K, Koarai A, Sugiura H, Minakata Y, Ichinose M. Exhaled nitric oxide cutoff values for asthma diagnosis according to rhinitis and smoking status in Japanese subjects. Allergol Int 2011; 60:331-7. [PMID: 21502803 DOI: 10.2332/allergolint.10-oa-0277] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Accepted: 12/03/2010] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Measurement of the exhaled nitric oxide fraction (FE(NO)) has been proposed as a useful diagnostic test for asthma. However, most of the data concerning the FE(NO) cutoff values for the diagnosis of asthma have not yet examined using standard procedures. Furthermore, there is no detailed study that investigated the cutoff values that takes into account patient factors that influence the FE(NO) levels. METHODS FE(NO) was measured in 142 steroid-naive asthmatics and 224 control subjects using an online electrochemical nitric oxide analyzer in accordance with the current guidelines. Subjects without respiratory symptoms and normal spirometric parameters were included in the control group. Asthma was diagnosed on the basis of the presence of significant airway reversibility and/or airway hyperresponsiveness during clinical follow up 6 months after FE(NO) measurements. RESULTS FE(NO) was significantly higher in asthmatic patients compared with control subjects (p < 0.01). Based on all study subjects, the receiver operating characteristic curves indicated that the cutoff value of FE(NO) 22 parts per billion (ppb) was associated with the highest combination of sensitivity (90.8%) and specificity (83.9%). Multivariate analysis showed allergic rhinitis, current smoking, and asthma were significant factors influencing the FE(NO) levels. The cutoff values of FE(NO) to discriminate asthma from non-asthma ranged from 18 to 28 ppb depending on rhinitis and smoking status. CONCLUSIONS The cutoff values presented may be useful for the interpretation of FE(NO) values in the clinical practice.
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Affiliation(s)
- Kazuto Matsunaga
- Third Department of Internal Medicine, Wakayama Medical University, School of Medicine, Japan
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Linhares D, Jacinto T, Pereira AM, Fonseca JA. Effects of atopy and rhinitis on exhaled nitric oxide values - a systematic review. Clin Transl Allergy 2011; 1:8. [PMID: 22409776 PMCID: PMC3339369 DOI: 10.1186/2045-7022-1-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 08/17/2011] [Indexed: 11/27/2022] Open
Abstract
Background Atopy and rhinitis are among the factors affecting exhaled nitric oxide (FeNO) values and may contribute to difficulties in the clinical interpretation of FeNO measurements. However, data assessing their effects on FeNO values had never been summarized. This review aims to evaluate the effect of atopy and rhinitis in FeNO values in otherwise healthy individuals. Methods A systematic review was performed in Pubmed, Scopus and ISI Web of Knowledge. A two-step selection process was completed, and from 2357 references 19 were included. The inclusion criteria were: participants without known diseases other than rhinitis; atopy assessement by SPT or Specific IgE; and FeNO measurements according to ATS/ERS recommendations. Results The 8 articles measuring FeNO in children showed higher values in both allergic rhinitis and atopic children when compared with healthy children. The 11 articles performed in adults observed higher FeNO in AR patients comparatively with either healthy or atopic individuals. However, adult healthy and atopic individuals had similar FeNO values. Conclusions FeNO values are higher in individuals with rhinitis and/or atopy without other health problems. These effects are small, seem to be independent and should be further studied using multivariate models. The effect of atopy was observed only in children. The combined effect of atopy and rhinitis produced higher FeNO values in adults. These results support that both atopy and rhinitis should be considered when interpreting or when defining FeNO reference values.
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Affiliation(s)
- Daniela Linhares
- Health Information and Decision Sciences, Faculty of Medicine of University of Porto, Alameda Hernâni Monteiro, 4200-319 Porto, Portugal.
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Bohadana AB, Hannhart B, Ghezzo H, Teculescu D, Zmirou-Navier D. Exhaled nitric oxide and spirometry in respiratory health surveillance. Occup Med (Lond) 2011; 61:108-14. [PMID: 21285029 DOI: 10.1093/occmed/kqq184] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Exposure to pollutants in bakeries and hairdressing salons can cause airway syndromes varying from bronchial irritation to asthma. Workplace respiratory health surveillance aims to identify possible cases requiring further investigation. AIMS To compare the performance of fractional exhaled nitric oxide (FE(NO)) and spirometry for health surveillance of apprentice bakers (ABs) and apprentice hairdressers (AHDs). Determinants of FE(NO) were also identified. METHODS Symptoms and physician-diagnosed asthma were evaluated by questionnaire. FE(NO) was measured and spirometry was carried out. Subjects with elevated FE(NO) (FE(NO) > upper limit normal), airway obstruction [forced expiratory volume in 1 s (FEV(1))/forced vital capacity (FVC) < 95th percentile] and atopy (history of allergies) were identified. RESULTS A total of 126 apprentices (59 ABs and 67 AHDs) participated. Twenty-nine (23%) apprentices had abnormal tests: 4 had associated high FE(NO) and airway obstruction, while 25 had either high FE(NO) (n = 15) or airway obstruction (n = 10) alone. Compared with ABs (n = 16), AHDs (n = 13) had more asthma (38 versus 0%; P < 0.05) and atopy (62 versus 6%; P < 0.05). There was no difference in symptoms, smoking FE(NO) or airways obstruction. Among 97 subjects with normal tests, no differences existed between ABs (n = 53) and AHDs (n = 44). Average FE(NO) was increased in atopic non-smokers compared with atopic smokers and non-atopic subjects (P < 0.05). Smoking, a history of allergies, FEV(1)/FVC % observed and respiratory symptoms were the main determinants of FE(NO). CONCLUSIONS FE(NO) and spirometry were not overlapping dimensions in ABs and hairdressers, each test contributing unique information on the physiological status of the respiratory system. FE(NO) may provide added information on airway inflammation not provided by spirometry.
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Affiliation(s)
- A B Bohadana
- Department of Environmental Health and Work Health, University of Montreal, Montreal, Quebec H3T 1A8, Canada.
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Exhaled NO and exhaled breath condensate pH in the evaluation of asthma control. Respir Med 2010; 105:526-32. [PMID: 21051211 DOI: 10.1016/j.rmed.2010.10.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 10/04/2010] [Accepted: 10/13/2010] [Indexed: 11/23/2022]
Abstract
BACKGROUND Asthma is a chronic inflammatory airways disorder. However, no biomarker of airways inflammation has been included in the assessment of asthma control. OBJECTIVE To evaluate exhaled NO (FeNO) and exhaled breath condensate (EBC) pH in patients with asthma according to the level of control, and their performance in the identification of not well-controlled patients. METHODS FeNO and EBC pH after Argon deaeration were measured in 274 consecutive patients. Asthma control was evaluated by two asthma specialists blinded to FeNO and pH measurements according to GINA guidelines, as well as by asthma control test (ACT) and asthma control questionnaire (ACQ). RESULTS FeNO was higher and EBC pH was lower in patients with not well-controlled compared to controlled asthma. In ROC analysis, FeNO presented an AUC of 0.790 for the identification of not well-controlled asthma performing better in non-smokers; EBC pH presented an AUC of 0.791 for the identification of not well-controlled asthma, performing better in smokers. The performance of both biomarkers was inferior to that of ACT and ACQ. FeNO values >30 ppb presented positive predictive values (PPV) > 0.85 with the exception of smokers treated with inhaled corticosteroids. EBC pH values ≤7.20 presented PPV >0.80 in all groups. The presence of FeNO >30 ppb and/or EBC pH ≤7.20 was indicative of not well-uncontrolled asthma in 88.3% of the patients. CONCLUSION FeNO and EBC pH levels may identify patients with not well-controlled asthma. However, their performance was inferior to clinical judgment and may be limited to selected subgroups of asthmatic patients.
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Abstract
PURPOSE OF REVIEW The fraction of nitric oxide in exhaled air (FeNO) is elevated in the presence of airway inflammation, and it may be a useful biomarker in asthma. The purpose of the present review is to highlight the current literature investigating the use of exhaled nitric oxide in the diagnosis and management of asthma. RECENT FINDINGS The measurement of exhaled nitric oxide has been studied in normal populations and in asthmatics. FeNO appears to be a useful screening tool for asthma, although nondisease factors may confound the interpretation of an elevated FeNO level. Clinical trials investigating the use of FeNO measurements in predicting asthma exacerbation and tailoring maintenance therapy have had varying success. Further studies incorporating individualized FeNO profiles into treatment algorithms are needed. SUMMARY FeNO shows promise as a tool in the diagnosis and treatment of asthma. However, further studies are needed to address outstanding questions about its exact role in guiding asthma management.
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32
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Current world literature. Curr Opin Pulm Med 2010; 16:77-82. [PMID: 19996898 DOI: 10.1097/mcp.0b013e328334fe23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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33
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Goldsobel AB, Chipps BE. Cough in the pediatric population. J Pediatr 2010; 156:352-8. [PMID: 20176183 DOI: 10.1016/j.jpeds.2009.12.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Revised: 08/23/2009] [Accepted: 12/02/2009] [Indexed: 12/26/2022]
Affiliation(s)
- Alan B Goldsobel
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
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Papaioannou AI, Koutsokera A, Tanou K, Kiropoulos TS, Tsilioni I, Oikonomidi S, Liadaki K, Pournaras S, Gourgoulianis KI, Kostikas K. The acute effect of smoking in healthy and asthmatic smokers. Eur J Clin Invest 2010; 40:103-9. [PMID: 19912318 DOI: 10.1111/j.1365-2362.2009.02221.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acute exposure to cigarette smoke is related to airway and systemic inflammation and oxidative stress. Little is known about the acute effect of cigarette smoking in smoking asthmatics. The aim of this study was to evaluate the acute effect of smoking in airway and systemic inflammation and oxidative stress in normal smokers and patients with properly treated well-controlled persistent asthma. MATERIALS AND METHODS Ten normal smokers and 10 smokers with moderate persistent asthma controlled with LABA and ICS were recruited. Subjects refrained from smoking for at least 12 h prior to their inclusion. We compared the effects of smoking of two cigarettes on airway obstruction, airway inflammation and oxidative stress [by measuring fraction of exhaled nitric oxide (FeNO), plus pH and 8-isoprostane in exhaled breath condensate (EBC)] before and 30, 90 and 180 min after smoking. Furthermore, we evaluated systemic oxidative stress, C-reactive protein (CRP) and serum amyloid A (SAA) and urine leukotriene E(4) (LTE(4)) before and 180 min after smoking. RESULTS No differences were observed in EBC pH and 8-isoprostane, FeNO and systemic oxidative stress between the groups at baseline. In asthmatics, EBC pH decreased 30 min and EBC 8-isoprostane increased 90 min after smoking (P = 0.039 and P = 0.029 respectively), which was not evident in smoking controls. Serum oxidative stress increased only in asthmatic smokers at 180 min (P = 0.001). No differences were observed in SAA, CRP and urine LTE(4) levels before and after smoking. CONCLUSION Acute smoking has more deleterious effects in well-controlled properly treated asthmatic smokers compared with matched normal smokers.
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Demange V, Bohadana A, Massin N, Wild P. Exhaled nitric oxide and airway hyperresponsiveness in workers: a preliminary study in lifeguards. BMC Pulm Med 2009; 9:53. [PMID: 20043846 PMCID: PMC2805603 DOI: 10.1186/1471-2466-9-53] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 12/31/2009] [Indexed: 01/16/2023] Open
Abstract
Background Airway inflammation and airway hyperresponsiveness (AHR) are two characteristic features of asthma. Fractional exhaled nitric oxide (FENO) has shown good correlation with AHR in asthmatics. Less information is available about FENO as a marker of inflammation from work exposures. We thus examined the relation between FENO and AHR in lifeguards undergoing exposure to chloramines in indoor pools. Methods 39 lifeguards at six indoor pools were given a respiratory health questionnaire, FENO measurements, spirometry, and a methacholine bronchial challenge (MBC) test. Subjects were labeled MBC+ if the forced expiratory volume (FEV1) fell by 20% or more. The normalized linear dose-response slope (NDRS) was calculated as the percentage fall in FEV1 at the last dose divided by the total dose given. The relation between MBC and FENO was assessed using logistic regression adjusting on confounding factors. The association between NDRS and log-transformed values of FENO was tested in a multiple linear regression model. Results The prevalence of lifeguards MBC+ was 37.5%. In reactors, the median FENO was 18.9 ppb (90% of the predicted value) vs. 12.5 ppb (73% predicted) in non-reactors. FENO values ≥ 60% of predicted values were 80% sensitive and 42% specific to identify subjects MBC+. In the logistic regression model no other factor had an effect on MBC after adjusting for FENO. In the linear regression model, NDRS was significantly predicted by log FENO. Conclusions In lifeguards working in indoor swimming pools, elevated FENO levels are associated with increased airway responsiveness.
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Affiliation(s)
- Valérie Demange
- INRS, Département Epidémiologie en Entreprise, Rue du Morvan, CS 60027, 54519 Vandoeuvre-lès-Nancy Cedex, France.
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Villa Asensi JR. The monitoring of bronchial inflammation by bioimpedance. Allergol Immunopathol (Madr) 2009; 37:1-2. [PMID: 19268052 DOI: 10.1016/s0301-0546(09)70242-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Exhaled nitric oxide can now be measured in a clinical setting as a noninvasive, reproducible, facile, point-of-service test to measure airway inflammation, a central component of asthma that had not been assessed previously. An excellent surrogate marker of steroid-responsive eosinophilic airway inflammation, it serves to identify steroid-sensitive asthmatic patients and enables clinical monitoring of the response to steroid therapy and titration of the dose. Standardization of methodology and technological advances, such as the recent availability of handheld analyzers, individualized patient cards to store serial test measurements, and the assignment of coding procedural terminology, make this a necessary adjunct to clinical and functional assessment of airway obstruction and hyperresponsiveness in ambulatory pediatric and adult asthma practices.
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Affiliation(s)
- Chitra Dinakar
- Section of Allergy, Asthma, and Immunology, Children's Mercy Hospital and Clinics, Kansas City, MO 64108, USA.
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38
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Abstract
BACKGROUND Exhaled nitric oxide (FeNO) has been introduced in the diagnosis and control of asthma. Atopy related diseases are a common comorbidity in asthma, but in these cases the FeNO values and their relevance have not been clearly defined. In this study we compared the differences in FeNO levels in various atopic conditions. METHODS A prospective study was performed comparing online FeNO in six groups of patients (non-atopic control, asymptomatic atopic, non-active rhinitis, active rhinitis, asthma, asthma with rhinitis). RESULTS 90 children (15 per group) assisted in an outpatient hospital clinic were enrolled. FeNO levels (ppb) were: 7.9 (non-atopic control), 19 (asymptomatic atopic), 16.6 (non-active rhinitis), 26.3 (active rhinitis), 31 (asthma), and 35 (asthma and rhinitis). All groups presented higher levels of FeNO than the non-atopic control group (P < 0.001). Both asthma groups had higher levels than the rest of the groups (P < 0.05), except for the active rhinitis group. Dispersion of FeNO levels was wide in the study sample. No correlation was found between FeNO and FEV(1). A weak correlation was seen with age (r = 0.28) CONCLUSIONS Atopy, rhinitis and its exacerbations can be confounders in the interpretation of FeNO levels in asthmatic children.
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Tanou K, Koutsokera A, Kiropoulos TS, Maniati M, Papaioannou AI, Georga K, Zarogiannis S, Gourgoulianis KI, Kostikas K. Inflammatory and oxidative stress biomarkers in allergic rhinitis: the effect of smoking. Clin Exp Allergy 2009; 39:345-53. [PMID: 19187324 DOI: 10.1111/j.1365-2222.2008.03149.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Accumulating evidence confirms the presence of pan-airway inflammation in allergic rhinitis patients. Smoking is known to affect the asthmatic airway inflammation. However, no study has evaluated the impact of smoking on airway inflammation of allergic rhinitis patients. OBJECTIVE The aim of the present study was to evaluate the impact of smoking on inflammatory and oxidative stress biomarkers in patients with seasonal allergic rhinitis, using non-invasive methods for sample collection. METHODS Forty patients with seasonal allergic rhinitis (20 smokers and 20 non-smokers) and 30 healthy subjects (15 smokers and 15 non-smokers) were recruited for the study during pollen season. All subjects were submitted to measurement of the fraction of exhaled NO (FeNO), exhaled breath condensate (EBC) collection, nasal lavage collection, pre- and post- bronchodilation spirometry and metacholine bronchial challenge testing. pH, leukotriene B(4) (LTB(4)) and 8-isoprostane were determined in EBC and nasal lavage samples. RESULTS Patients with allergic rhinitis presented higher LTB(4) and 8-isoprostane levels in nasal lavage (P<0.0001 for both comparisons), with no significant differences between smokers and non-smokers. Patients with allergic rhinitis also presented higher LTB(4) levels and lower pH in EBC (P<0.001 and P=0.004, respectively), with prominent differences between smokers and non-smokers (P<0.0001 and P=0.003, for LTB(4) and pH, respectively). A significant correlation between nasal lavage and EBC LTB(4) values was observed (r(s)=0.313, P=0.048). CONCLUSIONS Patients with allergic rhinitis present increased LTB(4) and 8-isoprostane in their nasal cavity, however, with no significant differences between smokers and non-smokers. In contrast, smokers with allergic rhinitis present higher LTB(4) levels and lower pH in EBC, suggesting that these patients may be more susceptible to the deleterious effects of smoking, compared with non-smokers.
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Affiliation(s)
- K Tanou
- Respiratory Medicine Department, University of Thessaly Medical School, University Hospital of Larissa, Larissa, Greece.
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Schneider A, Tilemann L, Schermer T, Gindner L, Laux G, Szecsenyi J, Meyer FJ. Diagnosing asthma in general practice with portable exhaled nitric oxide measurement--results of a prospective diagnostic study: FENO < or = 16 ppb better than FENO < or =12 ppb to rule out mild and moderate to severe asthma [added]. Respir Res 2009; 10:15. [PMID: 19254389 PMCID: PMC2660901 DOI: 10.1186/1465-9921-10-15] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2008] [Accepted: 03/03/2009] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND To evaluate the sensitivity, specificity and predictive values of fractional exhaled nitric oxide (FENO) for the diagnosis of asthma in general practice. METHODS Prospective diagnostic study with 160 patients attending 10 general practices for the first time with complaints suspicious of obstructive airway disease (OAD). Patients were referred to a lung function laboratory for diagnostic investigation. The index test was FENO measured with a portable FENO analyser based on electrochemical sensor. The reference standard was the Tiffeneau ratio (FEV1/VC) as received by spirometric manoeuvre and/or results of bronchial provocation. Bronchial provocation with methacholine was performed to determine bronchial hyper-responsiveness (BHR) in the event of inconclusive spirometric results. RESULTS 88 (55%) were female; their average age was 43.9 years. 75 (46.9%) patients had asthma, 25 (15.6%) had COPD, 8 (5.0%) had an overlap of COPD and asthma, and 52 (32.5%) had no OAD. At a cut-off level of 46 parts per billion (ppb) (n = 30; 18.8%), sensitivity was 32% (95%CI 23-43%), specificity 93% (95%CI 85-97%), positive predictive value (PPV) 80% (95%CI 63-91%), negative predictive value (NPV) 61% (95%CI 52-69%) when compared with a 20% fall in FEV1 from the baseline value (PC20) after inhaling methacholine concentration CONCLUSION Asthma could be ruled in with FENO > 46 ppb. Mild and moderate to severe asthma could be ruled out with FENO
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Affiliation(s)
- Antonius Schneider
- Department of General Practice and Health Services Research, University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Lisa Tilemann
- Department of General Practice and Health Services Research, University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Tjard Schermer
- Department of Primary Care Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Lena Gindner
- Department of General Practice and Health Services Research, University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Gunter Laux
- Department of General Practice and Health Services Research, University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Joachim Szecsenyi
- Department of General Practice and Health Services Research, University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Franz Joachim Meyer
- Department of Cardiology, Pulmonology and Angiology, Medical Centre, University of Heidelberg, Heidelberg, Germany
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Abstract
PURPOSE OF REVIEW The purpose of this review is to highlight seminal and current literature that informs our understanding of the clinical and investigative utility of biomarkers in asthma. Biomarkers derive from a variety of sources [bronchiolar lavage (BAL), sputum, exhaled breath, and blood], and have widely variant performance characteristics, and applicability. RECENT FINDINGS Increasing attention is given to biomarkers in exhaled breath, both gaseous (exhaled nitric oxide) and higher molecular weight moieties [in exhaled breath condensate (EBC)]. Current research in EBC analysis has focused on validation, standardization, and technical considerations, whereas research on exhaled nitric oxide (ENO) has moved to testing its predictive value in clinical situations. The use of advanced biostatistical techniques, and combinatorial analyses has led to additional advances in the utility of biomarkers. SUMMARY To date, the best validated, and best performing biomarkers for clinical asthma appear to be measures of inflammation in induced sputum, and measures of ENO. Some trials using ENO appear particularly promising for early clinical use. EBC metrics are at present too inchoate for clinical purposes. However, not all important clinical and research questions can be addressed with sputum, EBC, or ENO metrics, leaving an important place for BAL, bronchial biopsy, and perhaps EBC measurements in the research arena.
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Grob NM, Dweik RA. Exhaled nitric oxide in asthma. From diagnosis, to monitoring, to screening: are we there yet? Chest 2008; 133:837-9. [PMID: 18398112 DOI: 10.1378/chest.07-2743] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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