Nitric oxide and asthmatic inflammation

Fractional exhaled nitric oxide measurements in rhinitis and asthma in children

Exaled nitric oxide (FeNO) is considered a good noninvasive marker to assess airway inflammation in asthma and allergic rhinitis. In asthma, exhaled NO is very useful to verify adherence to therapy, and to predict upcoming asthma exacerbations. It has been also proposed that adjusting anti-inflammatory drugs guided by the monitoring of exhaled NO, could improve overall asthma control. Other studies showed increased FeNO levels in subjects with allergic rhinitis.

Smoking, COPD, and 3-nitrotyrosine levels of plasma proteins

BACKGROUND

Nitric oxide is a physiological regulator of endothelial function and hemodynamics. Oxidized products of nitric oxide can form nitrotyrosine, which is a marker of nitrative stress. Cigarette smoking decreases exhaled nitric oxide, and the underlying mechanism may be important in the cardiovascular toxicity of smoking. Even so, it is unclear if this effect results from decreased nitric oxide production or increased oxidative degradation of nitric oxide to reactive nitrating species. These two processes would be expected to have opposite effects on nitrotyrosine levels, a marker of nitrative stress.

OBJECTIVE

In this study, we evaluated associations of cigarette smoking and chronic obstructive pulmonary disease (COPD) with nitrotyrosine modifications of specific plasma proteins to gain insight into the processes regulating nitrotyrosine formation.

METHODS

A custom antibody microarray platform was developed to analyze the levels of 3-nitrotyrosine modifications on 24 proteins in plasma. In a cross-sectional study, plasma samples from 458 individuals were analyzed.

RESULTS

Average nitrotyrosine levels in plasma proteins were consistently lower in smokers and former smokers than in never smokers but increased in smokers with COPD compared with smokers who had normal lung-function tests.

CONCLUSIONS

Smoking is associated with a broad decrease in 3-nitrotyrosine levels of plasma proteins, consistent with an inhibitory effect of cigarette smoke on endothelial nitric oxide production. In contrast, we observed higher nitrotyrosine levels in smokers with COPD than in smokers without COPD. This finding is consistent with increased nitration associated with inflammatory processes. This study provides insight into a mechanism through which smoking could induce endothelial dysfunction and increase the risk of cardiovascular disease.

Role of inducible nitric oxide synthase pathway on methotrexate-induced intestinal mucositis in rodents

BACKGROUND

Methotrexate treatment has been associated to intestinal epithelial damage. Studies have suggested an important role of nitric oxide in such injury. The aim of this study was to investigate the role of nitric oxide (NO), specifically iNOS on the pathogenesis of methotrexate (MTX)-induced intestinal mucositis.

METHODS

Intestinal mucositis was carried out by three subcutaneous MTX injections (2.5 mg/kg) in Wistar rats and in inducible nitric oxide synthase knock-out (iNOS-/-) and wild-type (iNOS+/+) mice. Rats were treated intraperitoneally with the NOS inhibitors aminoguanidine (AG; 10 mg/Kg) or L-NAME (20 mg/Kg), one hour before MTX injection and daily until sacrifice, on the fifth day. The jejunum was harvested to investigate the expression of Ki67, iNOS and nitrotyrosine by immunohistochemistry and cell death by TUNEL. The neutrophil activity by myeloperoxidase (MPO) assay was performed in the three small intestine segments.

RESULTS

AG and L-NAME significantly reduced villus and crypt damages, inflammatory alterations, cell death, MPO activity, and nitrotyrosine immunostaining due to MTX challenge. The treatment with AG, but not L-NAME, prevented the inhibitory effect of MTX on cell proliferation. MTX induced increased expression of iNOS detected by immunohistochemistry. MTX did not cause significant inflammation in the iNOS-/- mice.

CONCLUSION

These results suggest an important role of NO, via activation of iNOS, in the pathogenesis of intestinal mucositis.

Anti-allergic Activity of Stem Bark of Myrica esculenta Buch.-Ham. (Myricaceae)

Allergic diseases, such as allergic asthma, are hypersensitivity reactions initiated by immunological mechanisms. Myrica esculenta (M. esculenta) is known traditionally in Ayurveda to possess anti-asthmatic activity. The present investigation was undertaken to evaluate the effect of crude extract of stem bark of M. esculenta (Family Myricaceae, commonly known as Kaiphal) on experimental allergic reactions. Experimental models studied were allergic pleurisy and vascular permeability induced by acetic acid in mice. Pretreatment with M. esculenta (75 mg/kg and 150 mg/kg, p.o.) significantly inhibited the eosinophil accumulation (P < 0.01) respectively in the pleural cavity. M. esculenta (75 and 150 mg/kg, p.o.) significantly inhibited the rise in plasma exudation (57.12% and 59.77%, P < 0.01) induced by acetic acid in mice. These findings demonstrate that the crude extract from the stem bark of M. esculenta possesses antiallergic activity. This activity may be mediated by reducing the release of mediators such as histamine, inhibition of mast cell degranulation, and inhibition of eosinophil accumulation thereby preventing the release of cytokines and chemokines.

Exhaled nitric oxide levels in childhood asthma: a more reliable indicator of asthma severity than lung function measurement?

The level of exhaled nitric oxide (NO) has been demonstrated to reflect the degree of airway inflammation in patients with asthma and to be related to the severity of asthma, as well as to the efficacy of treatment. In contrast, lung function tests provide information about airway volumes and flows reflecting the level of airway obstruction, but do not allow any direct information about the degree of airway inflammation. Several studies have evaluated the relationships between the level of airway inflammation assessed by exhaled NO and the levels of airway obstruction and/or bronchial hyperresponsiveness in asthmatic adults and children. These studies highlight the complex pathophysiology of asthma and suggest that exhaled NO may have a promising role in addition to lung function measurement in the evaluation of asthma severity in children.

Increased parasympathetic tone as the underlying cause of asthma: a hypothesis

Asthma is a chronic inflammatory disease of airways that is characterized by increased responsiveness of the tracheo-bronchial tree to multiple number of stimuli. Immunological theory does not explain all features in asthma, for example hyper-reactivity of the airways. Neurogenic theory also fails to explain the pathogenesis of asthma comprehensively. Higher parasympathetic tone has been reported in asthmatics but has never been suggested as a major underlying cause of asthma. This article attempts to explain the occurrence of hyper-responsiveness, inflammatory/allergic reactions and broncho-constriction in asthma on a common basis of inherent higher parasympathetic tone in asthmatics. The higher background parasympathetic firing leads to increased nitric oxide (NO) production owing to its co-localization with acetylcholine (ACh) in inhibitory non-adrenergic and non-cholinergic (i-NANC) nerves. NO is a neurotransmitter of i-NANC system and it mediates bronchodilation. Increased NO release has been found to be responsible for hyper-responsiveness and increased inflammation in the airways. The authors suggest that an inherently higher background parasympathetic tone in concert with inflammation or a specific genetic background could modify the effects of NO on lung homeostasis in humans leading to increased susceptibility to an asthmatic state.

Correlation between peripheral blood T-cell profiles and clinical and inflammatory parameters in stable COPD

BACKGROUND

Recent studies suggest that Tc1/Tc2 imbalances are implicated in the pathogenesis of chronic obstructive pulmonary disease (COPD). The purpose of this study was to clarify the relationship between peripheral blood T-cell profiles and pulmonary function or inflammatory parameters.

METHODS

Thirty-one patients with stable COPD (median age 70 years, 30 males, 15 current smokers and 16 ex-smokers) and 30 healthy control subjects were enrolled in this study. The subjects underwent blood tests, exhaled nitric oxide (eNO) measurement, pulmonary function tests, and sputum induction. Tc1/Tc2 and Th1/Th2 were determined by analyzing intracellular cytokine staining for IFN-gamma and IL-4 in peripheral blood CD8+ and CD4+ T cells using flow cytometry after stimulation with phorbol 12-myristate 13-acetate and ionomycin.

RESULTS

There was a significantly increased proportion of IFN-gamma-producing and IL-4-producing CD8+ T cells in patients with COPD compared with control subjects (median [IQR] 73.6% [63.9%-80.7%] vs 62.0% [45.6%-73.8%], p=0.004; and 2.6% [1.1%-6.9%] vs 1.1% [0.6%-2.2%], p=0.002, respectively). In addition, the proportion of IFN-gamma-producing CD4+ T cells was significantly higher in patients with COPD compared with control subjects (25.7% [21.2%-38.0%] vs 22.8% [15.6%-29.2%], p=0.027). The proportion of IFN-gamma-producing CD8+ T cells was correlated negatively with single-breath carbon monoxide transfer coefficient (Kco)(rho=-0.45, p=0.033) and positively with eNO (rho=0.50, p=0.012). The proportion of IL-4-producing CD8+ T cells was positively correlated with body mass index (rho=0.42, p=0.023) and Kco (rho=0.47, p=0.026).

CONCLUSIONS

It is suggested that Tc1 cells have a detrimental role and that Tc2 cells have a protective role in disease progression.

The Clinical Application of Ozonetherapy

The reader may be eager to examine in which diseases ozonetherapy can be proficiently used and she/he will be amazed by the versatility of this complementary approach (Table 9 1). The fact that the medical applications are numerous exposes the ozonetherapist to medical derision because superficial observers or sarcastic sceptics consider ozonetherapy as the modern panacea. This seems so because ozone, like oxygen, is a molecule able to act simultaneously on several blood components with different functions but, as we shall discuss, ozonetherapy is not a panacea. The ozone messengers ROS and LOPs can act either locally or systemically in practically all cells of an organism. In contrast to the dogma that “ozone is always toxic”, three decades of clinical experience, although mostly acquired in private clinics in millions of patients, have shown that ozone can act as a disinfectant, an oxygen donor, an immunomodulator, a paradoxical inducer of antioxidant enzymes, a metabolic enhancer, an inducer of endothelial nitric oxide synthase and possibly an activator of stem cells with consequent neovascularization and tissue reconstruction.

Exhaled nitric oxide levels are elevated in persons with tetraplegia and comparable to that in mild asthmatics

The role of airway inflammation in mediating airflow obstruction in persons with chronic traumatic tetraplegia is unknown. Measurement of the fraction of exhaled nitric oxide (FeNO) affords a validated noninvasive technique for gauging the airway inflammatory response in asthma, although it has never been assessed in persons with tetraplegia. This study was designed to determine the FeNO in individuals with chronic tetraplegia compared with that in patients with mild asthma and healthy able-bodied individuals. Nine subjects with chronic tetraplegia, seven subjects with mild asthma, and seven matched healthy able-bodied controls were included in this prospective, observational, pilot study. All subjects were nonsmokers and clinically stable at the time of study. Spirometry was performed on all participants at baseline. FENO was determined online by a commercially available closed circuit, chemiluminescence method, using a single-breath technique. Subjects with tetraplegia had significantly higher values of FeNO than controls (17.72 +/- 3.9 ppb vs. 10.37 +/- 4.9 ppb; P < or = 0.01), as did subjects with asthma (20.23 +/- 4.64 ppb vs. 10.37 +/- 4.9 ppb, P < or = 0.001). There was no significant difference in FeNO between subjects with tetraplegia and those with asthma (17.72 +/- 3.9 ppb vs. 20.23 +/- 4.64 ppb, P < or = 0.27). Individuals with chronic tetraplegia have FeNO levels that are comparable to that seen in mild asthmatics and higher than that in healthy able-bodied controls. The clinical relevance of this observation has yet to be determined.

Effect of natural seasonal pollen exposure and repeated nasal allergen provocations on elevation of exhaled nitric oxide

BACKGROUND

Exhaled nitric oxide (FENO) is a marker for allergic airway inflammation. We wondered whether in patients with intermittent allergic rhinitis only (i) natural pollen exposure and (ii) artificial pollen exposure by repeated nasal allergen provocations may lead to an elevation of FENO.

METHODS

In two prospective studies, we compared the FENO of nonatopic controls with the FENO of nonasthmatic individuals with mild intermittent rhinitis to tree and/or grass pollen. Study I: 13 atopic individuals and seven controls had measurements of FENO, blood eosinophils and eosinophilic cationic protein (ECP) before, during and after pollen season. Study II: 16 atopic individuals and 12 controls had nasal allergen provocations on four following days out of pollen season, with daily measurements of FENO before, 2 and 6 h after provocation, and determination of blood eosinophils, ECP and FEV1 at baseline, on days 5 and 10-12.

RESULTS

Natural pollen exposure (study I) caused a significant elevation of FENO in allergic individuals. Nasal allergen provocations (study II) did not elicit a statistically significant rise neither of FENO nor of blood eosinophils between baseline and day 5. However, a subgroup of four individuals with a rise of blood eosinophils during nasal allergen provocations showed also a rise of FENO.

CONCLUSIONS

We suppose that in allergic rhinitis a concomitant reaction of the bronchial system is dependent on a strong local inflammation leading to a generalized immune stimulation.

Protector mechanisms of the association between gastroesophageal reflux disease and asthma: experimental study in rats

BACKGROUND

It is well known the association between gastroesophageal reflux disease and asthma. The hyperreactivity of the airways is a characteristic of an asthmatic. Many studies associate the increase of the airways reactivity with gastroesophageal reflux disease.

AIM

In this study we have evaluated the effect of the intraluminal exposition to gastric juice of trachea on the reactivity to methacholine from rats submitted to a pulmonary allergic inflammation.

METHODS

Group of rats were sensitized and challenged with ovalbumin. After 24 hours the animals were sacrificed, and their tracheae were removed to be cultured with gastric juice. The gastric juice was obtained from a donor rat. Subsequently the segments were placed into plastic plates with RPMI-1640 for incubation, under suitable atmosphere and time. After the period of incubation the segments were put into chambers for the analysis of the contractile response to methacholine.

RESULTS

We observed reduction in the contractile response of trachea cultured with gastric juice from allergic rats. This result was confirmed by the pharmacological treatments with compound 48/80 and dissodium cromoglicate (mast cells blockade), L-NAME (nitric oxide inhibitor, NO), capsaicin (neuropeptides depletion) and indomethacin (ciclooxigenase inhibitor).

CONCLUSIONS

Our results highlight to the existence of a complex interaction between pulmonary allergy and gastric juice in the airways. The involvement of the non-adrenergic non-cholinergic system, NO, prostanoids and mast cells are directly related to this interaction. We suggest that the reduced contractile response observed in vitro may represent a protector mechanism of the airways. Despite its presence in the human body it can not be observed due to the predominant effects of excitatory the non-adrenergic non-cholinergic system.

Exhaled nitric oxide in the diagnosis and management of asthma: clinical implications

Exhaled nitric oxide (eNO) used as an aid to the diagnosis and management of lung disease is receiving attention from pulmonary researchers and clinicians alike because it offers a noninvasive means to directly monitor airway inflammation. Research evidence suggests that eNO levels significantly increase in individuals with asthma before diagnosis, decrease with inhaled corticosteroid administration, and correlate with the number of eosinophils in induced sputum. These observations have been used to support an association between eNO levels and airway inflammation. This review presents an update on current opportunities regarding use of eNO in patient care, and more specifically on its potential usage for asthma diagnosis and monitoring. The review will also discuss factors that may complicate use of eNO as a diagnostic tool, including changes in disease severity, symptom response, and technical measurement issues. Regardless of the rapid, convenient, and noninvasive nature of this test, additional well-designed, long-term longitudinal studies are necessary to fully evaluate the clinical utility of eNO in asthma management.

CHIP facilitates ubiquitination of inducible nitric oxide synthase and promotes its proteasomal degradation

Inducible nitric oxide synthase (iNOS) is responsible for nitric oxide (NO) synthesis from l-arginine in response to inflammatory mediators. It is reported that iNOS is degraded mainly by the ubiquitin-proteasome pathway in RAW264.7 cells and human embryonic kidney (HEK) 293 cells. In this study, we showed that iNOS was ubiquitinated and degraded dependent on CHIP (COOH terminus of heat shock protein 70-interacting protein), a chaperone-dependent ubiquitin ligase. The results from overexpression and RNAi experiments demonstrated that CHIP decreased the protein level of iNOS, shortened the half-life of iNOS and attenuated the production of NO. Furthermore, CHIP promoted ubiquitination and proteasomal degradation of iNOS by associating with iNOS. These results suggest that CHIP plays an important role in regulation iNOS activity.

Nitric oxide in exhaled and aspirated nasal air as an objective measure of human response to indoor air pollution

The concentration of nitric oxide (NO) in exhaled and aspirated nasal air was used to objectively assess human response to indoor air pollutants in a climate chamber exposure experiment. The concentration of NO was measured before exposure, after 2, and 4.5 h of exposure, using a chemiluminescence NO analyzer. Sixteen healthy female subjects were exposed to two indoor air pollutants and to a clean reference condition for 4.5 h. Subjective assessments of the environment were obtained by questionnaires. After exposure (4.5 h) to the two polluted conditions a small increase in NO concentration in exhaled air was observed. After exposure to the reference condition the mean NO concentration was significantly reduced compared to pre-exposure. Together these changes resulted in significant differences in exhaled NO between exposure to reference and polluted conditions. NO in nasal air was not affected by the exposures. The results may indicate an association between polluted indoor air and subclinical inflammation.

PRACTICAL IMPLICATIONS

Measurement of nitric oxide in exhaled air is a possible objective marker of subclinical inflammation in healthy adults.

Effect of Nippostrongylus brasiliensis L3 ES on inflammatory mediator gene transcription in lipopolysaccharide lung inflammation

The anti-inflammatory properties of parasitic helminths have been largely linked to their excretory-secretory (ES) products. Some studies have noted a lack of TNF-alpha production and limited recruitment of neutrophils into the lungs after Nippostrongylus brasiliensis infection. We previously reported that instillation of ES from L3 larvae of N. brasiliensis to the lungs could inhibit the recruitment of neutrophils on a background of LPS-induced inflammation. A similar reduction in neutrophil recruitment was observed in this study. This reduction was associated with the significant inhibition in gene transcription of the adhesion molecule, ICAM-1, and the chemokine, MIP-2 in bronchoalveolar lavage (BAL) cells. The LPS-stimulated gene transcription of the pro-inflammatory cytokines TNF-alpha and IL-1beta was also significantly reduced by L3 ES. Inducible nitric oxide synthase (iNOS) is normally elevated in classically activated macrophages, however, in this case gene transcription of iNOS was inhibited by L3 ES and may suggest a phenotype change to anti-inflammatory. The general inhibition of pro-inflammatory mediators observed in this study suggests that infective stage L3 larvae excrete and/or secrete inhibitory products capable of modifying the normally potent LPS inflammatory response.

Interaction of ambient air pollution with asthma medication on exhaled nitric oxide among asthmatics

The interaction between ambient air pollution and asthma medication remains unclear. The authors compared airway inflammation response to air pollution among asthmatics. Increases of 10 ppb of nitrogen dioxide (NO2) and of 10 microg/m3 of particulate matter < 10 micron in diameter (PM10) daily concentrations were associated with an increase in exhaled nitric oxide (eNO) of 0.13 ppb (95% confidence interval = 0.06, 0.19) and of 0.07 ppb (95% confidence interval = 0.02, 0.12), respectively, in models adjusted for important covariates. The results show that the medication could not counteract airway inflammation effects of air pollution. Specifically, the patients on triamcinolone decreased the sensitivity to PM10 but increased the sensitivity to NO2. The patients on salmeterol were more vulnerable to both NO2 and PM10. This study indicates that the current pollution levels may still enhance airway inflammation among patients with persistent asthma even when they are on asthma medications.

Induced nitric oxide synthase as a major player in the oncogenic transformation of inflamed tissue

Nitric oxide (NO) is a free radical that is involved in the inflammatory process and carcinogenesis. There are four nitric oxide synthase enzymes involved in NO production: induced nitric oxide synthase (iNOS), endothelial NO synthase (eNOS), neural NO synthase (nNOS), and mitochondrial NOS. iNOS is an inducible and key enzyme in the inflamed tissue. Recent literatures indicate that NO as well as iNOS and eNOS can modulate cancer-related events including nitro-oxidative stress, apoptosis, cell cycle, angio-genesis, invasion, and metastasis. This chapter focuses on linking NO/iNOS/eNOS to inflammation and carcinogenesis from experimental evidence to potential targets on cancer prevention and treatment.

Adjuvant Activity of Ambient Particulate Matter in Macrophage Activity-Suppressed,N-Acetylcysteine-Treated, iNOS- and IL-4-Deficient Mice

In previous studies, we have shown strong adjuvant activity for Ottawa dust (EHC-93) after coexposure of the BALB/c mouse to EHC-93 and ovalbumin. Mice were intranasally sensitized at days 0 and 14 with 200 microg ovalbumin and 150 microg EHC-93, and challenged with ovalbumin at days 35, 38, and 41 with 200 microg ovalbumin. Mice were autopsied at day 42. This adjuvant activity was shown for the antibody response to ovalbumin (immunoglobulins E, G1, and G2a), histopathological lesions in the lung, cytokines, and the numbers of eosinophils in lung lavages. To study the mechanisms of this adjuvant activity, mice (BALB/cC.D2-Vil6) with natural-resistance-associated macrophage protein (Nramp1s), BALB/c mice pretreated with the antioxidant N-acetylcysteine (NAC), mice (B6.129P2-Nos2tmLau) deficient in inducible nitric oxide synthase (iNOS), and mice with interleukin-4 (IL-4) deficiency (BALB/cIl4< tm2Nnt) were coexposed to ovalbumin and EHC-93. Our studies have shown that the adjuvant activity induced after such coexposure does not change if the macrophage activation of the mice is disturbed or if the mice have been pretreated with N-acetylcysteine. In addition, the adjuvant activity does not develop through the pathway in which inducible nitric oxide synthase is involved. Because the histopathological lesions are statistically significant less in the IL-4 knockout strain in comparison with the wild type, we conclude that interleukin-4 might play an important role in the adjuvant activity caused by EHC-93.

Curcumin attenuates ovalbumin-induced airway inflammation by regulating nitric oxide

Curcumin has been strongly implicated as an anti-inflammatory agent, but the precise mechanisms of its action are largely unknown. In this study, we show that curcumin contributes to anti-inflammatory activity in the murine asthma model and lung epithelial cell A549 through suppression of nitric oxide (NO). To address this problem, curcumin was injected into the peritoneum of ovalbumin (OVA)-sensitized mice before the last allergen challenge. OVA challenge resulted in activation of the production of inducible nitric oxide (iNOS) in lung tissue, inflammatory cytokines, recruitment of eosinophils to lung airways, and airway hyper-responsiveness to inhaled methacholine. These effects of ovalbumin challenge were all inhibited by pretreatment of mice with curcumin. Furthermore, supplementation with curcumin in the A549 human airway epithelial cells decreased iNOS and NO production induced by IFN-gamma. These findings show that curcumin may be useful as an adjuvant therapy for airway inflammation through suppression of iNOS and NO.

The role of nitric oxide in inflammatory reactions

Nitric oxide (NO) was initially described as a physiological mediator of endothelial cell relaxation, an important role in hypotension. NO is an intercellular messenger that has been recognized as one of the most versatile players in the immune system. Cells of the innate immune system--macrophages, neutrophils and natural killer cells--use pattern recognition receptors to recognize the molecular patterns associated with pathogens. Activated macrophages then inhibit pathogen replication by releasing a variety of effector molecules, including NO. In addition to macrophages, a large number of other immune-system cells produce and respond to NO. Thus, NO is important as a toxic defense molecule against infectious organisms. It also regulates the functional activity, growth and death of many immune and inflammatory cell types including macrophages, T lymphocytes, antigen-presenting cells, mast cells, neutrophils and natural killer cells. However, the role of NO in nonspecific and specific immunity in vivo and in immunologically mediated diseases and inflammation is poorly understood. This Minireview will discuss the role of NO in immune response and inflammation, and its mechanisms of action in these processes.

Nitric oxide: a new concept in chronic sinusitis pathogenesis

PURPOSE

Exhaled NO is produced mainly in paranasal sinuses and nasal mucosa. Nasal NO has been suggested to have a variety of effects in nasal cavity. Decreased exhaled NO is found in chronic sinusitis, and NO metabolite levels are increased in animal models of chronic sinusitis, suggesting a role for them in sinusitis pathogenesis. There was no data available on human NO metabolite level.

MATERIALS AND METHODS

We lavaged maxillary sinuses in a control and 2 patient groups. The control group was patients who underwent functional endoscopic sinus surgery (FESS) due to any other reason than chronic sinusitis. The patient groups had chronic rhinosinusitis with and without polyposis who underwent FESS. Maxillary sinuses were lavaged during FESS, and NO metabolites (nitrate and nitrite) were lavaged in the lavage fluid.

RESULTS

Nitric oxide metabolite levels (mean +/- SEM) were 8.085 +/- 1.43 mumol/L in healthy maxillary sinus lavage fluid and 18.04 +/- 3.51 and 16.78 +/- 2.91 mumol/L in chronic rhinosinusitis with and without polyposis, respectively. Lavage fluid of sinuses with chronic sinusitis had elevated levels of NO metabolites, which were significantly higher than the control group. The difference between the chronic sinusitis with and without polyposis groups was not significant.

CONCLUSIONS

Nitric oxide metabolites were significantly higher in maxillary sinuses of patients with chronic sinusitis. Elevated levels of NO and NO metabolites in sinusitis might damage healthy sinus epithelium. NO metabolites may have an important role in sinusitis pathogenesis.

High serum levels of tumour necrosis factor-alpha and interleukin-8 in severe asthma: markers of systemic inflammation?

BACKGROUND

Severe asthma is characterized by elevated levels of pro-inflammatory cytokines and neutrophilic inflammation in the airways. Blood cytokines, markers of 'systemic' inflammation, may be a feature of amplified inflammation in severe asthma.

OBJECTIVE

To detect differences in IL-8, TNF-alpha, IL-16 and IL-13 levels in the serum(s) of stable severe and mild-moderate asthmatics related to blood leucocytes proportion, airway calibre and exhaled nitric oxide (NO) levels.

METHODS

We assessed cytokine serum levels by ELISA and blood leucocyte counts by an alkaline peroxidase method in 20 healthy controls, 22 mild-moderate [forced expiratory volume in 1 s (FEV1)(%pred): 89+/-3] and 14 severe asthmatics [FEV1(%pred): 49+/-2].

RESULTS

IL-8 and TNF-alpha levels were higher in severe asthmatics than in mild-moderate asthmatics or in controls (P<0.05). No differences in IL-16 and IL-13 levels were detected. Severe asthmatics showed higher circulating neutrophil and eosinophil number than controls (P<0.05). In severe asthmatics, exhaled NO levels were superior than in controls (P<0.05), but inferior than in mild-moderate asthmatics (P<0.05). We found positive correlation between TNF-alpha levels and exhaled NO (r=0.67; P=0.01) or circulating neutrophil counts (r=0.57; P=0.03) in severe asthmatics.

CONCLUSION

sTNF-alpha and sIL-8 are markers of 'systemic' inflammation in severe asthmatics, in conjunction with augmented circulating neutrophils, suggesting the involvement of neutrophil-derived cytokine pattern in severe asthma.

Nitric oxide induces MUC5AC mucin in respiratory epithelial cells through PKC and ERK dependent pathways

Background

Nitric oxide (NO) is generally increased during inflammatory airway diseases. This increased NO stimulates the secretion of mucin from the goblet cell and submucosal glands but the mechanism is still unknown precisely. In this study, we investigated potential signaling pathways involving protein kinase C (PKC) and mitogen-activated protein kinase (MAPK) in the NO-induced MUC5AC mucin gene and protein expression in A549 cells.

Methods

Nitric oxide was donated to the A549 cells by NOR-1. MUC5AC mucin levels were assayed by enzyme-linked immunosorbent assay (ELISA). MUC5AC promoter activity was determined by measuring luciferase activity after the lysing the transfected cells. Activation of PKC isoforms were measured by assessing the distribution of the enzyme between cytosolic and membrane fractions using immunoblotting. Immunoblotting experiments using a monoclonal antibody specific to PKC isoforms were performed in the cytosol and membrane fractions from A549 cells. Western blot analysis for pERK and p38 were performed using the corresponding antibodies from the cell lysates after donating NO to the A549 cells by NOR-1.

Results

The transcriptional activity of MUC5AC promoter was maximal at the concentration of 0.1 mM NOR-1 for 1 hour incubation in transfected A549 cells. (±)-(E)-methyl-2-((E)-hydroxyimino)-5-nitro-6-methoxy-3-hexenamide (NOR-1) markedly displaced the protein kinase C (PKC)α and PKCδ from the cytosol to the membrane. Furthermore, the PKC-α,βinhibitors, GÖ6976 (10 nM) and PKCδ inhibitors, rottlerin (4 μM) inhibited the NOR-1 induced migration of PKCα and PKCδ respectively. NOR-1 also markedly increased the MUC5AC promoter activity and mRNA expression, mucin synthesis and ERK1/2 phosphorylation. The PKC inhibitors also inhibited the NOR-1 induced MUC5AC mRNA and MUC5AC protein synthesis by inhibiting the activation of PKCα and PKCδ with ERK1/2 pathways.

Conclusion

Exogenous NO induced the MUC5AC mucin gene and protein through the PKCα and PKCδ – ERK pathways in A549 cells. Inhibition of PKC attenuated NO-mediated MUC5AC mucin synthesis. In view of this findings, PKC inhibitors might be useful in the treatment of bronchial asthma and chronic bronchitis patients where NO and mucus are increased in the bronchial airways.

Lung function and exhaled nitric oxide levels in infants developing chronic lung disease

Chronic lung disease (CLD) is a common outcome of neonatal intensive care. To determine whether the results of serial exhaled nitric oxide (eNO) measurements during the perinatal period differed between infants who did and did not develop CLD. In addition, we wished to assess whether eNO results were more predictive of CLD development than lung function test results or readily available clinical data (gestational age and birthweight). The patients were 24 infants with a median gestational age of 27 (range 25-31) weeks. Measurements of eNO levels, functional residual capacity (FRC), and compliance of the respiratory system (CRS) were attempted on postnatal days 1, 3, 5, 7, 14, and 28 days. The 12 infants who developed CLD were of significantly lower birthweight and gestational age than the rest of the cohort; in addition, they had lower median FRC (P < 0.02) and CRS (P < 0.02) results, but not higher eNO levels, in the first week after birth. Construction of receiver operator characteristic (ROC) curves demonstrated that the CRS and FRC results on Day 3 were the best predictors of CLD development; the areas under the ROC curves were 0.94 and 0.91, respectively. Early lung function test results, but not eNO levels, are useful in predicting CLD development, but are not significantly better than birthweight.

Effect of montelukast on symptoms and exhaled nitric oxide levels in 7- to 14-year-old children with seasonal allergic rhinitis

BACKGROUND

Cysteinyl leukotrienes have been found to exert potent inflammatory effects in the upper airways and play a fundamental role in the pathogenesis of allergic rhinitis. Previous studies have reported increased levels of exhaled nitric oxide (eNO) in patients with allergic rhinitis without asthma symptoms.

OBJECTIVE

To investigate the role of treatment with montelukast on symptoms, eNO levels, and peripheral eosinophil counts of children with seasonal allergic rhinitis during pollen season.

METHODS

A randomized, double-blind, parallel-group study performed between April and June 2005 in 57 children aged 7 to 14 years with seasonal allergic rhinitis was performed. The study comprised a 1-week screening period, a 1-week run-in period, and a 2-week treatment period with once daily montelukast, 5 mg, or matching placebo.

RESULTS

No significant difference at baseline was found in symptom scores, eNO levels, and blood eosinophil counts between the treatment and placebo groups. After 2 weeks of montelukast treatment, improvements from the baseline in the daytime nasal, composite, and daytime eye symptoms scores were significantly greater in the montelukast group compared with the placebo group (P < .001, P < .001, and P < .01, respectively). A significant decrease was also found in eosinophil counts (P < .001) in the montelukast group compared with the placebo group after treatment. Montelukast treatment did not produce a significant effect on eNO levels compared with placebo (P = .96).

CONCLUSION

Montelukast treatment provided significant improvement in symptoms and peripheral eosinophil counts of school-age children with seasonal allergic rhinitis; however, it did not show a significant effect on eNO levels.

Production of nitric oxide by airways neutrophils in the initial phase of murine asthma

In experimental models of asthma, nitric oxide (NO) is produced and contributes to the physiopathology of the disease. Neutrophil is the first cell to infiltrate the lung in response to antigen stimulation, it has the capacity to produce NO but a clear demonstration that neutrophils contribute to NO production in asthma is lacking. This was the aim of the present study. At weekly intervals C57Bl/6 mice were sensitized twice with ovalbumin-alumen and challenged twice with ovalbumin aerosol. The peak of neutrophil infiltration in the bronchoalveolar lavage fluid (BALF) was 12 h after challenge, when neutrophils constituted 70% of the cell population and eosinophils only 1.5%. BALF cell preparations were stained with a NO-sensitive fluorescent dye (DAF-2) and with a nucleus marker (DAPI). Most DAF-2 stained cells could be identified as polymorphonuclear leukocytes, by the co-localization of both DAF-2 and DAPI staining. Cells from animals treated with l-NAME, were not stained for DAF-2 confirming the specificity of DAF-2 staining for NO. Moreover, the peak expression of inducible nitric oxide synthase (NOS2), in BALF cells and lung homogenates, was coincident with the peak of BALF neutrophil influx. NOS2 protein expression (arbitrary units) was detected 6 h after challenge (17.8+/-9.1 in BALF cells; 47.5+/-7.7 in lung homogenates), peak expression was at 12 h (54.5+/-8.7 and 133.7+/-10), decreasing thereafter, being no longer detected after 24 h. Thus, the neutrophils infiltrating the lung in the initial phase of murine asthma are producing NO via NOS2.

Anti-TNF-alpha and Th1 cytokine-directed therapies for the treatment of asthma

PURPOSE OF REVIEW

This article examines recent work about the role of TNF-alpha and of selected Th1-related cytokines in asthma with particular emphasis on the therapeutic potential of blocking the biological activity of these mediators.

RECENT FINDINGS

Current research endeavours suggest that asthma pathogenesis is driven by a mixed Th1/Th2 immune response. The contribution of individual Th1-associated and Th2-associated effector mechanisms to this mixed response profile is highly heterogeneous and variations in response patterns seem to be associated with heterogeneity in clinical phenotypes. In particular, it is now acknowledged that allergen-specific Th1 responses appear to be responsible for the pathogenetic effects seen in patients suffering from the more severe chronic forms of the disease. This is important because usual treatments for asthma appear to have limited effects on the more chronic severe forms of the disease and there is a pressing need for the development of new treatment strategies. The failure of topical corticosteroids to reduce TNF-alpha and Th1-derived cytokines to a significant level in asthmatic airways may explain to a certain extent why these drugs appear to have limited effects in the more severe forms of asthma.

SUMMARY

It is likely that therapies blocking TNF-alpha and interfering with Th1-derived cytokines may be a considerable advance in the management of those asthma patients who are particularly resistant to typical treatment modalities.

Association study of promoter polymorphisms within the NOS3 gene and allergic diseases

BACKGROUND

Nitric oxide (NO) is an important mediator of physiologic and pathologic processes in the airways. On this basis, we hypothesized that polymorphisms in the NOS3 gene could be associated with the disease process.

METHODS

Two promoter variants (-786C/T and -691C/T) were examined in a Caucasian Czech population of allergic patients [n = 671, with a subgroup of asthmatics (n = 305)] and healthy controls (n = 334) using PCR-RFLP analyses.

RESULTS

NOS3 -786C/T and -691C/T were not associated with allergic diseases or asthma. However, the -786 variant was significantly associated with asthma in men (p < 0.01, p(corr) < 0.05) but not in women. NOS3 -691C/T was found to be in strong linkage disequilibrium with -786C/T, and the distribution of combined genotypes was marginally different between the asthmatic and control men.

CONCLUSION

Our results suggest that NOS3 gene variants may be one of the factors that participate in the pathogenesis of asthma in men.

Exhaled nitric oxide in asthma: variability, relation to asthma severity, and peripheral blood lymphocyte cytokine expression

Exhaled nitric oxide has been used as a means of indirectly measuring the underlying inflammation in asthma. The objectives of the study were to measure exhaled nitric oxide levels in asthma patients and healthy volunteers, to study peripheral blood lymphocyte cytokine expression, and to study the relationship between exhaled nitric oxide and intracellular cytokine expression. Exhaled nitric oxide was elevated in patients with moderate to severe asthma and with treatment decreased in the first week reaching to a near normal level by 4 weeks. Elevated exhaled nitric oxide was associated with decreased IL-4 and IL-13 cytokine expression by CD8 lymphocytes.

Scientific and medical aspects of ozone therapy. State of the art

The aim of this review is to dispel misconceptions and skepticism regarding ozone therapy and to clarify the biochemical and pharmacological mechanisms of action of ozone dissolved in biological fluids. The work performed in the last decade in our laboratory allows drawing a comprehensive framework for understanding and recommending ozone therapy in some diseases. It is hoped that this report will open a dialogue among clinical scientists and will inform physicians about the beneficial effects of ozone therapy.

Overexpression of endothelial nitric oxide synthase suppresses features of allergic asthma in mice

Background

Asthma is associated with airway hyperresponsiveness and enhanced T-cell number/activity on one hand and increased levels of exhaled nitric oxide (NO) with expression of inducible NO synthase (iNOS) on the other hand. These findings are in paradox, as NO also relaxes airway smooth muscle and has immunosuppressive properties. The exact role of the endothelial NOS (eNOS) isoform in asthma is still unknown. We hypothezised that a delicate regulation in the production of NO and its bioactive forms by eNOS might be the key to the pathogenesis of asthma.

Methods

The contribution of eNOS on the development of asthmatic features was examined. We used transgenic mice that overexpress eNOS and measured characteristic features of allergic asthma after sensitisation and challenge of these mice with the allergen ovalbumin.

Results

eNOS overexpression resulted in both increased eNOS activity and NO production in the lungs. Isolated thoracic lymph nodes cells from eNOS overexpressing mice that have been sensitized and challenged with ovalbumin produced significantly less of the cytokines IFN-γ, IL-5 and IL-10. No difference in serum IgE levels could be found. Further, there was a 50% reduction in the number of lymphocytes and eosinophils in the lung lavage fluid of these animals. Finally, airway hyperresponsiveness to methacholine was abolished in eNOS overexpressing mice.

Conclusion

These findings demonstrate that eNOS overexpression attenuates both airway inflammation and airway hyperresponsiveness in a model of allergic asthma. We suggest that a delicate balance in the production of bioactive forms of NO derived from eNOS might be essential in the pathophysiology of asthma.

Role of local pulmonary IFN-gamma expression in murine allergic airway inflammation

Generalized underrepresentation of IFN-gamma has been implicated in the development of allergic asthma. However, the role of local IFN-gamma in the lung during the development of this disease has not been completely elucidated. We studied the influence of local pulmonary IFN-gamma expression on the development of allergen-induced lung inflammation. To restrict our analysis to IFN-gamma expression in the lung and to exclude influences of systemic IFN-gamma production, we generated a transgenic mouse line with a targeted deletion of the IFN-gamma gene and constitutive, lung-specific IFN-gamma expression (Clara cell 10 [CC10]-IFN-gamma-tg-IFN-gamma-KO mice), and compared allergen-induced airway inflammation in these mice with that of wild-type and IFN-gamma- KO mice on the C57BL/6 background. Cytokine quantification in lungs of mice with allergic airway inflammation revealed that pulmonary IFN-gamma expression increased expression of IL-5 and IL-13. Consistent with this observation, eosinophilia in bronchoalveolar lavage of CC10-IFN-gamma-tg-IFN-gamma-KO mice was profoundly increased, indicating that this critical component of asthma is enhanced by local IFN-gamma expression. In contrast, airway hyperresponsiveness and anti-ovalbumin-IgE serum levels were reduced by local IFN-gamma expression. Together, our results demonstrate pleiotropic action of constitutive IFN-gamma expression in the lung, and question the therapeutic value of IFN-gamma in allergic asthma. Local expression of IFN-gamma in the lung increases markers of allergic airway inflammation, but decreases airway hyperresponsiveness in a murine model of allergic-asthma.

Correlation of exhaled nitric oxide, spirometry and asthma symptoms

Asthma is the most common chronic disease of childhood. Asthma severity is monitored by spirometry. However, this does not directly measure airway inflammation. Exhaled nitric oxide (FeNO) is a proposed method to measure airway inflammation non-invasively. Previous studies have shown that FeNO correlates with endobronchial biopsies and symptoms in patients with asthma. We monitored daily asthma symptoms compared to monthly spirometry and FeNO. Total monthly symptom scores correlated with both forced expiratory volume at 1 sec (FEV1) and FeNO. FeNO had a strong correlation than FEV1. FeNO and FEV1 were not correlated. We propose that FeNO should be used as an additional monitoring tool for asthma.

Modulation of nitric oxide pathways: therapeutic potential in asthma and chronic obstructive pulmonary disease

Nitric oxide (NO) is present in the exhaled breath of humans and other mammalian species. It is generated in the lower airways by enzymes of the nitric oxide synthase (NOS) family, although nonenzymatic synthesis and consumptive processes may also influence levels of NO in exhaled breath. The biological properties of NO in the airways are multiple, complex, and bidirectional. Under physiological conditions, NO appears to play a homeostatic bronchoprotective role. However, its proinflammatory properties could also potentially cause tissue injury and contribute to airway dysfunction in disease states such as asthma and chronic obstructive pulmonary disease (COPD). This article will review the physiological and pathophysiological roles of NO in the airways, discuss the rationale for the use of drugs that modulate NO pathways--nitric oxide synthase inhibitors and NO donors--to treat inflammatory airway diseases, and attempt to predict the likely therapeutic benefit of such agents.

Hemoglobin is expressed by alveolar epithelial cells

Hemoglobin gene expression in non-erythroid cells has been previously reported in activated macrophages from adult mice and lens cells, and recent studies indicate that alveolar epithelial cells can be derived from hematopoietic stem cells. Our laboratory has now produced strong evidence that hemoglobin is expressed by alveolar type II (ATII) cells and Clara cells, the primary producers of pulmonary surfactant. ATII cells are also closely involved in innate immunity within the lung and are stem cells that differentiate into alveolar type I cells. Reverse transcriptase-PCR was used to measure the expression of transcripts from the alpha- and beta-globin gene clusters in several human and rodent pulmonary epithelial cells. Surprisingly, the two major globin mRNAs characteristic of adult erythroid precursor cells were clearly expressed in human A549 and H441 cell lines, mouse MLE-15 cells, and primary ATII cells isolated from normal rat and mouse lungs. DNA sequencing verified that these PCR products were indeed the result of specific amplification of globin gene cDNAs. These alveolar epithelial cells also expressed the corresponding hemoglobin protein subunits as determined by Western blotting, and tandem mass spectrometry sequencing was used to verify the presence of both alpha- and beta-globin polypeptides in rat primary ATII cells. The function of hemoglobin expression by cells of the pulmonary epithelium will be determined by future studies, but this novel finding could potentially have important implications for the physiology and pathology of the lung.

Susceptibility to pulmonary blastomycosis in young compared to adult mice: immune deficiencies in young mice

The immunological basis for differences in resistance to pulmonary blastomycosis between young (3 to 4-week-old) and adult (7 to 8-week-old) CD-1 mice is unknown. We assessed whether there were differences in fungicidal activity of phagocytes and Th-1 lymphocyte cytokine production. The fungicidal activity of young bronchoalveolar macrophages (BAM) (20%) against Blastomyces dermatitidis (Bd) was comparable to killing by adult BAM (25%). However, IFN-gamma enhanced the killing by adult BAM (from 30 to 69%) to a greater extent than BAM from young animals (from 20 to 30%). Killing of Bd by young peritoneal macrophages (PM) (46%) and adult PM (42%) was similar, and the enhancement of cells of both by IFN-gamma was similar. TNFalpha production by young macrophages (BAM or PM), when cocultured with Bd for 18 h, was half of TNFalpha secreted by adult macrophages. We found that polymorphonuclear neutrophils (PMN) from young mice had deficient fungicidal activity against Bd (37%) compared with adult PMN (80%). Interferon-gamma (IFN-gamma) treatment increased PMN killing of Bd by PMN of young animals from 37 to 80%. In an assessment of innate responses, we found spleen cells from young mice produced three-fold less IFN-gamma and three-fold less IL-2 than adult spleen cells in response to 1 microg/ml concanavalin A (Con A). The young spleen cells also produced more NO, which we demonstrated reduced Con A-induced proliferation. These in vitro results demonstrate several immunological deficiencies in cells from young mice and these deficiencies correlate with susceptibility. In a pilot reconstitution experiment in pulmonary blastomycosis, treatment of infected young mice with IFN-gamma (18.5 x 10(3) U, s.c.) on days 0, 1, and 2 significantly increased survival.

Human bronchial epithelium controls TH2 responses by TH1-induced, nitric oxide-mediated STAT5 dephosphorylation: implications for the pathogenesis of asthma

Increased levels of NO in exhaled air in association with increased NO synthetase (NOS)2 expression in bronchial epithelial are hallmark features of asthma. It has been suggested that NO contributes to asthma pathogenesis by selective down-regulation of TH1 responses. We demonstrate, however, that NO can reversibly limit in vitro expansion of both human TH1 and TH2 CD4+ T cells. Mechanistically, NO induces cGMP-mediated reversible STAT5 dephosphorylation and therefore interferes with the IL-2R activation cascade. Human bronchial epithelial cells (HBEC) up-regulate NOS2 after stimulation with IFN-gamma secreted by TH1 CD4+ T cells and release NO, which inhibits both TH1 and TH2 cell proliferation. This reversible T cell growth arrest depends on NO because T cell proliferation is completely restored after in vitro blocking of NOS2 on HBEC. HBEC thus drive the effector end of a TH1-controlled feedback loop, which protects airway mucosal tissues at the potential lesional site in asthma from overwhelming CD4+ TH2 (and potentially TH1) responses following allergen exposure. Variations in the efficiency of this feedback loop provides a plausible mechanism to explain why only a subset of atopics sensitized to ubiquitous aeroallergens progress to expression of clinically relevant levels of airways inflammation.

Acute inhibition of inducible nitric oxide synthase but not its absence suppresses asthma-like responses

In the present study we investigated the lymphocytes infiltration and other parameters of allergic lung inflammation comparing mice submitted to acute suppression of nitric oxide synthesis with mice deficient in inducible nitric oxide synthase (NOS2-/-) gene. At weekly intervals C57Bl/6 mice, wild type and NOS2-/- were sensitized twice with ovalbumin-alumen and challenged twice with ovalbumin aerosol and lungs examined 24 h later. In wild type mice, treatment with nitric oxide synthase inhibitor, N(omega)-nitro-L-arginine-methyl-ester (L-NAME) or aminoguanidine (i.p., 30 min before each ovalbumin challenge) caused a significant decrease in bronchoalveolar lavage cell number: eosinophils (90%), lymphocytes NK1.1+ (70%), Tgammadelta+ (50%), CD4+ (55%), CD8+ (60%) and B220+ (65%). Both inhibitors abolished airway hyperreactivity and significantly reduced mucus secretion (L-NAME 64%; aminoguanidine 58%). Surprisingly, in NOS2-/- mice these parameters of allergic lung inflammation were not significantly different when compared with wild type mice. In addition, treatment of NOS2-/- mice with L-NAME or aminoguanidine did not affect these parameters. Thus, acute inhibition of NOS2 activity inhibits asthma-like responses but absence of NOS2 has no affect.

Complement components (C3, C4) in childhood asthma

OBJECTIVE

To assess the involvement of complements (C3, C4) in the pathophysiology of bronchial asthma.

METHODS

Selection of patients (n = 64) were made according to the recommended international criteria for diagnosis and classification of asthma. Serum levels of complement components (C3, C4) were measured by radial immunodiffusion technique in 64 Libyan children (age: 1-12 years, sex: 39 males, 25 females) with mild to moderately severe asthma (Group A). Among these patients, 35 had active disease (AA) and 29 had inactive disease (NA). According to age range, 20, 21 and 23 patients were between 1-3 years (A1), > 3-5 years (A2) and > 5-12 years (A3) respectively. A1 had 9 and 11 patients with active (AA1) and inactive (NA1) disease; A2 had 10 and 11 patients with active (AA2) and inactive (NA2) disease; A3 had 16 and 7 patients with active (AA3) and inactive (NA3) disease respectively. Age matched comparisons were made with 57 healthy children (age: 1-12 years; sex: 30 males, 27 females) (Group B). Among the controls, 15, 19 and 23 children were between 1-3 years (B1), > 3-5 years (B2) and > 5-12 years (B3) respectively.

RESULTS

Mean C3 level was significantly elevated in patients, while C4 level was normal (A vs B --> C3: P < 0.2, C4: P > 0.2). Serum C3 level was significantly higher in patients with active disease only, while it was normal in patients with inactive disease (AA, NA, B --> P = 0.045); AA vs NA --> P < 0.05, AA vs B --> P < 0.02, NA vs B --> P > 0.05) and C4 levels were normal in both the groups (AA, NA, B --> P = 0.354). Further, C3 levels were significantly elevated in all the age groups, but in patients with active disease only (AA1, NA1, B1 --> P = 0.0024; AA2, NA2, B2 --> P = 0.0411; AA3, NA3, B3 --> P = 0.0102).

CONCLUSION

The elevated C3 level was possibly due to induction by pro-inflammatory cytokines such as tumour necrosis factor-alpha (TNF-alpha) and interleukin-1 (IL-1). The probable mechanisms of C3 involvement in the pathophysiology of bronchial asthma were discussed.