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Ruhl AP, Jackson JM, Carhuas CJ, Niño de Rivera JG, Fay MP, Weinberg JB, Que LG, Ackerman HC. Association of alpha globin gene copy number with exhaled nitric oxide in a cross-sectional study of healthy Black adults. BMJ Open Respir Res 2023; 10:e001714. [PMID: 38123476 DOI: 10.1136/bmjresp-2023-001714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 11/14/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION The genetic determinants of fractional exhalation of nitric oxide (FeNO), a marker of lung inflammation, are understudied in Black individuals. Alpha globin (HBA) restricts nitric oxide signalling in arterial endothelial cells via interactions with nitric oxide synthase; however, its role in regulating the release of NO from respiratory epithelium is less well understood. We hypothesised that an HBA gene deletion, common among Black individuals, would be associated with higher FeNO. METHODS Healthy Black adults were enrolled at four study sites in North Carolina from 2005 to 2008. FeNO was measured in triplicate using a nitric oxide analyzer. The -3.7 kb HBA gene deletion was genotyped using droplet digital PCR on genomic DNA. The association of FeNO with HBA copy number was evaluated using multivariable linear regression employing a linear effect of HBA copy number and adjusting for age, sex and serum immunoglobulin-E levels. Post-hoc analysis employing a recessive mode of inheritance was performed. RESULTS 895 individuals were in enrolled in the study and 720 consented for future genetic research; 643 had complete data and were included in this analysis. Median (25th, 75th) FeNO was 20 (13, 31) ppb. HBA genotypes were: 30 (4.7%) -a/-a, 197 (30.6%) -a/aa, 405 (63%) aa/aa and 8 (1.2%) aa/aaa. Subjects were 35% male with median age 20 (19, 22) years. Multivariable linear regression analysis revealed no association between FeNO and HBA copy number (β=-0.005 (95% CI -0.042 to 0.033), p=0.81). In the post-hoc sensitivity analysis, homozygosity for the HBA gene deletion was associated with higher FeNO (β=0.107 (95% CI 0.003 to 0.212); p=0.045). CONCLUSION We found no association between HBA copy number and FeNO using a prespecified additive genetic model. However, a post hoc recessive genetic model found FeNO to be higher among subjects homozygous for the HBA deletion.
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Affiliation(s)
- A Parker Ruhl
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Pulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Jarrett M Jackson
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Carlos J Carhuas
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jessica G Niño de Rivera
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Michael P Fay
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - J Brice Weinberg
- Department of Medicine and Division of Hematology, Duke University School of Medicine and Durham VA Medical Centers, Durham, North Carolina, USA
| | - Loretta G Que
- Department of Medicine and Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine and Durham VA Medical Centers, Durham, North Carolina, USA
| | - Hans C Ackerman
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Sunde RB, Thorsen J, Skov F, Hesselberg L, Kyvsgaard J, Følsgaard NV, Schoos AMM, Stokholm J, Bønnelykke K, Chawes B. Exhaled nitric oxide is only an asthma-relevant biomarker among children with allergic sensitization. Pediatr Allergy Immunol 2023; 34:e14044. [PMID: 38010005 DOI: 10.1111/pai.14044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Fraction of exhaled nitric oxide (FeNO) is used for diagnosing and monitoring asthma in children, but the influence of allergic sensitization is still poorly understood. Here, we investigate how asthma and allergic sensitization influence FeNO levels during childhood. METHODS We investigated the associations between asthma, aeroallergen sensitization, and FeNO measured from age 5-18 years in the COPSAC2000 birth cohort of 411 children using repeated measurement mixed models adjusted for gestational age, sex, concurrent airway infection, inhaled corticosteroids, and tobacco exposure. Replication was sought in the similarly designed COPSAC2010 cohort of 700 children. RESULTS In the COPSAC2000 cohort, 133 had asthma between age 5 and 18 years, and in the COPSAC2010 cohort, 112 had asthma between age 5 and 10 years. In the COPSAC2000 cohort, asthma and aeroallergen sensitization were both associated with higher FeNO from age 5 to 18 years: adjusted geometric mean ratio (aGMR), 1.22 (1.08-1.35), p < .01, and 1.41 (1.21-1.65), p < 0.001, respectively. However, asthma was associated with increased FeNO among children with aeroallergen sensitization: 1.44 (1.23-1.69), p < .0001, whereas asthma was associated with decreased FeNO among nonsensitized children: 0.80 (0.65-0.99), p = .05 (p-interaction<.0001 for asthma x sensitization). Replication in the COPSAC2010 cohort showed similar results (p-interaction <.01). Further, blood eosinophil count, total-IgE, bronchodilator response, and bronchial hyperreactivity were all associated with increased FeNO among children sensitized to aeroallergens, but not among nonsensitized children. CONCLUSION Fraction of exhaled nitric oxide is elevated through childhood in children with asthma and is correlated with asthma-associated traits depending on the presence of aeroallergen sensitization. These findings indicate that FeNO is only a valid asthma biomarker in children with concurrent aeroallergen sensitization, which is important for guideline recommendations on the clinical use of FeNO.
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Affiliation(s)
- Rikke Bjersand Sunde
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | - Jonathan Thorsen
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Frederikke Skov
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | - Laura Hesselberg
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Julie Kyvsgaard
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | - Nilofar V Følsgaard
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ann-Marie Malby Schoos
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | - Jakob Stokholm
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
- Department of Food Science, Section of Microbiology and Fermentation, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Bønnelykke
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Bo Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
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Habib SS, Alzoghaibi MA, Habib SH, Al-Regaiey KA. Reference Ranges and Determinant Factors for Fractional Exhaled Nitric Oxide in a Healthy Saudi Adult Population. Med Sci Monit Basic Res 2020; 26:e926382. [PMID: 32830193 PMCID: PMC7466833 DOI: 10.12659/msmbr.926382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Fractional exhaled nitric oxide (FENO) has emerged as a promising marker in respiratory research. The aim of this study was to determine the reference range values of FENO for healthy Saudi adults and the factors associated with FENO levels. MATERIAL AND METHODS This cross-sectional study was conducted at the Department of Physiology, King Saud University, Riyadh, Saudi Arabia, from January 2016 to August 2017. A total of 429 healthy Saudi adults were initially recruited. The final selection included 412 participants, consisting of 307 men and 105 women. FENO measurements were performed according to the current recommendations of the American Thoracic Society. RESULTS We observed that the FENO levels of women were significantly lower than those of men (18.6 vs. 21.3, P=0.009). In women, the measured FENO ranged from 5.7 ppb to 42 ppb, and in men from 5.0 ppb to 55.0 ppb. The mean FENO level in the entire study population was 20.6, with a range of 5.0 ppb to 55.0 ppb. The difference became non-significant when we calculated the FENO after adjusting for body surface area by different percentile distributions. Multiple linear regression analysis showed that body surface area and weight were significant predictors of FENO levels. CONCLUSIONS In this study, FENO levels were significantly affected by demographic variables. Therefore, it is important to consider the factors influencing FENO values to make a valid clinical interpretation.
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Affiliation(s)
- Syed Shahid Habib
- Department of Physiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mohammad A Alzoghaibi
- Department of Physiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Syed Hamid Habib
- Department of Physiology, Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, Pakistan
| | - Khalid A Al-Regaiey
- Department of Physiology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Blake TL, Chang AB, Chatfield MD, Marchant JM, Petsky HL, McElrea MS. Fractional Exhaled Nitric Oxide Values in Indigenous Australians 3 to 16 Years of Age. Chest 2019; 156:239-246. [PMID: 30910638 DOI: 10.1016/j.chest.2019.02.401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/12/2019] [Accepted: 02/22/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Fractional exhaled nitric oxide (Feno) levels can identify eosinophilic asthma phenotypes. We aimed to determine Feno values of healthy Aboriginal and/or Torres Strait Islander (Indigenous) Australians, differences between these Indigenous ethnic groups, and appropriateness of published cutoff values. METHODS We measured Feno levels in 1,036 Indigenous Australians (3-16 years of age). Participants were classified into healthy (ie, no asthma or atopy history) or asthmatic and/or atopic groups. RESULTS Median Feno values and distribution did not differ between Indigenous ethnicities. For healthy participants < 12 years of age (n = 390), 7.2% of our cohort fell into the inflammatory zone of the American Thoracic Society (ATS), National Institute for Health and Care Excellence (NICE), and British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) guidelines (cutoff 35 parts per billion [ppb]), but only 3.8% fell into this category when using the Global Initiative for Asthma (GINA) guidelines (50 ppb). Similarly, when using the NICE and BTS/SIGN guidelines (40 ppb) for participants 12 to 16 years of age (n = 213), more healthy participants fell into the inflammatory zone compared with the ATS and GINA guidelines (50 ppb) (9.9% vs 4.7%, respectively). CONCLUSIONS Feno values for healthy Indigenous Australians children (3-16 years of age) are likely higher than published white-based values. The GINA recommended cutoff value (> 50 ppb) appears the most appropriate for identifying healthy Indigenous children but requires confirmation from a larger study.
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Affiliation(s)
- Tamara L Blake
- Centre for Children's Health Research, Queensland University of Technology, Brisbane, QLD; Indigenous Respiratory Outreach Care Program, The Prince Charles Hospital, Brisbane, QLD.
| | - Anne B Chang
- Centre for Children's Health Research, Queensland University of Technology, Brisbane, QLD; Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, QLD; Child Health Division, Menzies School of Health Research, Darwin, NT
| | - Mark D Chatfield
- Child Health Division, Menzies School of Health Research, Darwin, NT; The University of Queensland, Brisbane, QLD
| | - Julie M Marchant
- Centre for Children's Health Research, Queensland University of Technology, Brisbane, QLD; Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, QLD
| | - Helen L Petsky
- School of Nursing and Midwifery, Griffith University, Nathan, QLD, Australia
| | - Margaret S McElrea
- Centre for Children's Health Research, Queensland University of Technology, Brisbane, QLD; Indigenous Respiratory Outreach Care Program, The Prince Charles Hospital, Brisbane, QLD; Department of Respiratory and Sleep Medicine, Queensland Children's Hospital, Brisbane, QLD
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Jacinto T, Amaral R, Malinovschi A, Janson C, Fonseca J, Alving K. Exhaled NO reference limits in a large population-based sample using the Lambda-Mu-Sigma method. J Appl Physiol (1985) 2018; 125:1620-1626. [PMID: 30161011 DOI: 10.1152/japplphysiol.00093.2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Absolute values are used in the interpretation of the fraction of exhaled nitric oxide (FeNO), but it has been suggested that equations to calculate reference values may be a practical and clinically useful approach. We hypothesize that the application of the Lambda-Mu-Sigma (LMS) method may improve FeNO reference equations and their interpretation. Our aims were to develop FeNO reference equations with the LMS method and to describe the difference between this method and the absolute fixed cut-offs of the current recommendations. We utilized the United States National Health and Nutrition Examination Surveys 2007-2012 and included healthy individuals with no respiratory diseases and blood eosinophils <300/mm3 ( n = 8,340). Natural log-transformed FeNO was modeled using the LMS method, imbedded in the generalized additive models for location, scale, and shape models. A set of FeNO reference equations was developed. The explanatory variables were sex, age, height, smoking habits, and race/ethnicity. A significant proportion of individuals with normal FeNO given by the equations were classified as having intermediate levels by the current recommendations. Further lower predicted FeNO compared with previous linear models was seen. In conclusion, we suggest a novel model for the prediction of reference FeNO values that can contribute to the interpretation of FeNO in clinical practice. This approach should be further validated in large samples with an objective measurement of atopy and a medical diagnosis of asthma and rhinitis. NEW & NOTEWORTHY Novel reference equations and fraction of exhaled nitric oxide (FeNO)-predicted values to improve interpretation of FeNO in clinical practice are presented. These may increase the accuracy of ruling out airway inflammation in patients with asthma or suspected asthma.
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Affiliation(s)
- Tiago Jacinto
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto , Porto , Portugal.,Department of Cardiovascular and Respiratory Sciences, Porto Health School , Porto , Portugal
| | - Rita Amaral
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto , Porto , Portugal
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University , Uppsala , Sweden
| | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy, and Sleep Research, Uppsala University , Uppsala , Sweden
| | - João Fonseca
- Center for Health Technology and Services Research, Faculty of Medicine, University of Porto , Porto , Portugal.,Department of Community Medicine, Information, and Health Sciences: Faculty of Medicine, University of Porto , Porto , Portugal
| | - Kjell Alving
- Department of Women's and Children's Health, Paediatric Research, Uppsala University , Uppsala , Sweden
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Jiang M, Liu M, Wang Y, Xu L, Bu X, An L, Zhang H, Huang K. Association between fractional exhaled nitric oxide and clinical characteristics and outcomes in patients with subacute cough. CLINICAL RESPIRATORY JOURNAL 2017; 12:1068-1075. [PMID: 28296234 DOI: 10.1111/crj.12629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 03/01/2017] [Accepted: 03/07/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate the relationships between fractional exhaled nitric oxide (FENO) and clinical characteristics and outcomes in patients with subacute cough. METHODS Patients with subacute cough (n = 189) after upper respiratory tract infection were enrolled in this single-center prospective study, and were divided into low-FENO (<25 ppb) and high-FENO groups (≥25 ppb). Empirical therapies (without inhaled or systemic corticosteroids) were prescribed based on clinical experience and follow-up until the disease course reached 8 weeks. FENO values, cough symptom scores (CSS), and Leicester Cough Questionnaire (LCQ) scores were obtained, analyzed, and compared between two groups of patients. RESULTS The low-FENO and high-FENO groups comprised 136 and 53 patients, respectively. The multiple regression analysis showed that blood eosinophil count and gender were independent factors for elevated FENO (β = 1.38, 0.25, respectively). LCQ scores, total CSS, and daytime CSS were comparable between the low-FENO and high-FENO groups. The nighttime CSS of the high-FENO group were significantly higher than that of the low-FENO group (P = .03). The CSS and LCQ score were improved in both groups but were comparable between groups after 10 days treatment. CONCLUSIONS Patients with subacute cough and high-FENO levels have more severe nocturnal cough than those of patients with low-FENO levels. However, FENO levels do not appear to correlate with the clinical outcomes or treatment response. The significance of FENO in the management of subacute cough needs to be further evaluated, at least in the current empirical treatment without corticosteroids.
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Affiliation(s)
- Mingming Jiang
- Department of Pulmonary and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Min Liu
- Department of Pulmonary and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Ying Wang
- Department of Pulmonary and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Lili Xu
- Department of Pulmonary and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Xiaoning Bu
- Department of Pulmonary and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Li An
- Department of Pulmonary and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Hong Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Kewu Huang
- Department of Pulmonary and Critical Care Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
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Blake TL, Chang AB, Chatfield MD, Petsky HL, Rodwell LT, Brown MG, Hill DC, McElrea MS. Does Ethnicity Influence Fractional Exhaled Nitric Oxide in Healthy Individuals?: A Systematic Review. Chest 2017; 152:40-50. [PMID: 28215791 DOI: 10.1016/j.chest.2017.02.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/21/2016] [Accepted: 02/01/2017] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Fractional exhaled nitric oxide (Feno) is used clinically as a biomarker of eosinophilic airway inflammation. Awareness of the factors influencing Feno values is important for valid clinical interpretation. METHODS We undertook a systematic review of PubMed, Cochrane Library, Scopus, and Web of Science databases and reference lists of included articles to evaluate whether ethnicity influences Feno values, and to determine if this influence affects clinical interpretation according to current guidelines. We included all studies that performed online Feno measurements on at least 25 healthy, non-Caucasian individuals, and examined the effect of ethnicity on Feno. RESULTS From 62 potential studies, 12 studies were included. One study recruited only children (< 12 years of age), six studies recruited children and/or adolescents, four studies recruited adults only, and a single study involved children, adolescents, and adults. In total, 16 different ethnic populations representing 11 ethnicities were studied. Ethnicity was considered a significant influencing factor in 10 of the included studies. We found the geometric mean Feno to be above the normal healthy range in two studies. We also identified five studies in which at least 5% of participants had Feno results above the age-specific inflammatory ranges. CONCLUSIONS Ethnicity influences Feno values, and for some ethnic groups this influence likely affects clinical interpretation according to current guidelines. There is a need to establish healthy Feno reference ranges for specific ethnic groups to improve clinical application.
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Affiliation(s)
- Tamara L Blake
- Queensland University of Technology, Centre for Children's Health Research, South Brisbane, QLD, Australia; Indigenous Respiratory Outreach Care Program, The Prince Charles Hospital, Chermside, QLD, Australia; Department of Respiratory and Sleep Medicine, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia.
| | - Anne B Chang
- Indigenous Respiratory Outreach Care Program, The Prince Charles Hospital, Chermside, QLD, Australia; Department of Respiratory and Sleep Medicine, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia; Child Health Division, Menzies School of Health Research, Darwin, NT, Australia
| | - Mark D Chatfield
- Child Health Division, Menzies School of Health Research, Darwin, NT, Australia
| | - Helen L Petsky
- Queensland University of Technology, Centre for Children's Health Research, South Brisbane, QLD, Australia
| | - Leanne T Rodwell
- Department of Respiratory and Sleep Medicine, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia
| | - Michael G Brown
- Department of Thoracic Medicine, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Deb C Hill
- Indigenous Respiratory Outreach Care Program, The Prince Charles Hospital, Chermside, QLD, Australia
| | - Margaret S McElrea
- Queensland University of Technology, Centre for Children's Health Research, South Brisbane, QLD, Australia; Indigenous Respiratory Outreach Care Program, The Prince Charles Hospital, Chermside, QLD, Australia; Department of Respiratory and Sleep Medicine, Lady Cilento Children's Hospital, South Brisbane, QLD, Australia
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Jacinto T, Alving K, Correia R, Costa-Pereira A, Fonseca J. Setting reference values for exhaled nitric oxide: a systematic review. CLINICAL RESPIRATORY JOURNAL 2016; 7:113-20. [PMID: 22789005 DOI: 10.1111/j.1752-699x.2012.00309.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The values obtained when the fraction of exhaled nitric oxide (FeNO) is measured are affected by several factors that are specific to the individual patient, making interpretation difficult, especially in the initial assessment of patients with respiratory symptoms. METHODS Systematic review of studies on FeNO reference values and individual-specific factors that influence them. RESULTS From 3739 references, 15 studies were included. Four studies included children and adolescents. In nine studies, samples were selected from the general population. Most studies reported objective measures for atopy (nine studies), but not for smoking status (one). Significant determinants of FeNO values reported were age and height (seven studies), atopy (six), smoking (four), weight (four), sex (three) and race (three). Additional factors were included in eight studies. R2 was reported in only five studies. The logarithmic transformation of FeNO was inadequately described in seven studies. CONCLUSION There are several equations for FeNO reference values that may be used in clinical practice, although the factors they include and the statistical methods they use vary considerably. We recommend the development of standard methods for the evaluation of normal FeNO data and that reference equations should be formulated based on a predetermined physiological model.
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Affiliation(s)
- Tiago Jacinto
- CINTESIS – Center for Research in Health Technologies and Information Systems, Faculty of Medicine, University of Porto, Porto, Portugal.
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Sfaxi I, Ben Saad H, Rouatbi S. Fraction of exhaled nitric oxide in healthy elderly Tunisian subjects. Nitric Oxide 2015; 50:88-97. [PMID: 26344327 DOI: 10.1016/j.niox.2015.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/29/2015] [Accepted: 08/31/2015] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Exhaled-fraction-of-nitric-oxide (FeNO) norms are absent in healthy elderly North-African subjects. OBJECTIVES i) to identify FeNO influencing factors of elderly Tunisians older 50 years and more; ii) to assess the applicability of some published FeNO norms for elderly in local population; iii) to set-up FeNO norms and to prospectively evaluate their validity in two elderly validation-groups (healthy and asthmatic subjects). METHODS A convenience sample of healthy and asthmatic elderly Tunisians was recruited. Subjects responded to a medical questionnaire and then FeNO levels were measured by an online method (Medisoft, Sorinnes (Dinant), Belgium). Clinical, anthropometric and spirometric data were collected. Three groups of subjects were identified: group I (healthy-elderly; n = 100, 57 females); group II (healthy-validation; n = 17, 4 females) and group III (asthmatic-validation; n = 10, 9 females). ANOVA was performed to compare the three groups' data. RESULTS No significant factor, among those evaluated, influenced Tunisian elderly FeNO values. The available published FeNO norms did not reliably predict FeNO in Tunisian elderly population. The mean ± SD (minimum-maximum) of FeNO (ppb) for group I was 14 ± 6 (3-34). For Tunisian people, each elderly FeNO value higher than 34 ppb will be considered as abnormal. There was no statistical significant difference between FeNO (ppb) mean values of group I and groups II (15 ± 8) or III (18 ± 13). No subject of group II had a FeNO value higher than 34 ppb. Thirty percent of group III subjects had a FeNO value higher than 34 ppb. CONCLUSION In practice, FeNO value of more than 34 ppb is considered abnormal in elderly Tunisian population.
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Affiliation(s)
- Ines Sfaxi
- Laboratory of Physiology, Faculty of Medicine of Sousse, University of Sousse, 4000 Sousse, Tunisia; Department of Physiology and Functional Explorations, Farhat HACHED Hospital, Sousse, Tunisia.
| | - Helmi Ben Saad
- Laboratory of Physiology, Faculty of Medicine of Sousse, University of Sousse, 4000 Sousse, Tunisia; Department of Physiology and Functional Explorations, Farhat HACHED Hospital, Sousse, Tunisia; Research Laboratory N° LR14ES05: Interactions of the Cardiopulmonary System, Faculty of Medicine of Sousse, University of Sousse, Tunisia
| | - Sonia Rouatbi
- Laboratory of Physiology, Faculty of Medicine of Sousse, University of Sousse, 4000 Sousse, Tunisia; Department of Physiology and Functional Explorations, Farhat HACHED Hospital, Sousse, Tunisia
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Zhang Y, Berhane K, Eckel SP, Salam MT, Linn WS, Rappaport EB, Bastain TM, Gilliland FD. Determinants of Children's Exhaled Nitric Oxide: New Insights from Quantile Regression. PLoS One 2015. [PMID: 26214692 PMCID: PMC4516246 DOI: 10.1371/journal.pone.0130505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
While the fractional concentration of exhaled nitric oxide (FeNO) has proven useful in asthma research, its exact role in clinical care remains unclear, in part due to unexplained inter-subject heterogeneity. In this study, we assessed the hypothesis that the effects of determinants of the fractional concentration of exhaled nitric oxide (FeNO) vary with differing levels of FeNO. In a population-based cohort of 1542 school children aged 12–15 from the Southern California Children's Health Study, we used quantile regression to investigate if the relationships of asthma, socio-demographic and clinical covariates with FeNO vary across its distribution. Differences in FeNO between children with and without asthma increased steeply as FeNO increased (Estimated asthma effects (in ppb) at selected 20th, 50th and 80th percentiles of FeNO are 2.4, 6.3 and 22.2, respectively) but the difference was steeper with increasing FeNO in boys and in children with active rhinitis (p-values<0.01). Active rhinitis also showed significantly larger effects on FeNO at higher concentrations of FeNO (Estimated active rhinitis effects (in ppb) at selected 20th, 50th and 80th percentiles of FeNO are 2.1, 5.7 and 14.3, respectively). Boys and children of Asian descent had higher FeNO than girls and non-Hispanic whites; these differences were significantly larger in those with higher FeNO (p-values<0.01). In summary, application of quantile regression techniques provides new insights into the determinants of FeNO showing substantially varying effects in those with high versus low concentrations.
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Affiliation(s)
- Yue Zhang
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, United States of America
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah, United States of America
- Veteran Affairs Salt Lake City Health Care System, Salt Lake City, Utah, United States of America
- * E-mail:
| | - Kiros Berhane
- Department of Preventive Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Sandrah P. Eckel
- Department of Preventive Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Muhammad T. Salam
- Department of Preventive Medicine, University of Southern California, Los Angeles, California, United States of America
- Department of Psychiatry, Kern Medical Center, Bakersfield, California, United States of America
| | - William S. Linn
- Department of Preventive Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Edward B. Rappaport
- Department of Preventive Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Theresa M. Bastain
- Department of Preventive Medicine, University of Southern California, Los Angeles, California, United States of America
| | - Frank D. Gilliland
- Department of Preventive Medicine, University of Southern California, Los Angeles, California, United States of America
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The importance of atopy on exhaled nitric oxide levels in African American children. Ann Allergy Asthma Immunol 2015; 114:399-403. [PMID: 25752733 DOI: 10.1016/j.anai.2015.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/05/2015] [Accepted: 02/09/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND For physicians to be maximally effective in managing asthma in minority populations, a better understanding of the factors that affect fractional exhaled nitric oxide (FeNO) measurements in African Americans is needed. OBJECTIVE To examine demographic, environmental, and physiologic factors that influence FeNO measurements in African American children with and without asthma. METHODS A cross-sectional study of 128 African American children aged 7 to 18 years (44% with asthma) was conducted. FeNO measurements, skin prick tests (as a measure of atopy), spirometry, and questionnaire data were obtained from all participants. Regression models were constructed after identifying factors significantly associated on univariate analysis. RESULTS Among all study participants, the mean FeNO measurement at baseline was 24.4 ppb. Children with asthma had a higher level than those without (30.9 vs 19.3 ppb, P = .002). When examining all children through logistic regression analysis, an elevated FeNO level was significantly associated with atopy, lower spirometric values, and current asthma (P < .05 for all). Among asthmatic children, univariate analysis revealed that an elevated FeNO level was associated with inhaled corticosteroid use, recent respiratory infection, and atopy (P < .05 for all). However, only atopy remained significant after regression analysis. For asthmatic and nonasthmatic children, FeNO levels were directly correlated with the number of positive skin test results. CONCLUSION In African American children with and without asthma, FeNO levels are strongly influenced by atopy. Guidelines for FeNO measurements that incorporate atopic status are needed.
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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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Calhoun KH. The role of fractional exhaled nitric oxide in asthma management. Otolaryngol Clin North Am 2014; 47:87-96. [PMID: 24286682 DOI: 10.1016/j.otc.2013.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Measuring fractional exhaled nitric oxide (FeNO) is a relatively new option for assessing allergic inflammation in the lungs. Clinical management of asthma is challenging, and measuring exhaled nitric oxide can provide another type of data to assist in meeting this challenge. FeNO is easy to perform, and the equipment is not forbiddingly expensive. FeNO provides a complement to traditional measures of asthma control and can help guide diagnostic and treatment choices. This article explains what it is, how the measurements are performed, what the norms are, and its use and limitations in the management of asthma.
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Affiliation(s)
- Karen H Calhoun
- Department of Otolaryngology - Head & Neck Surgery, Wexner Medical Center, The Ohio State University College of Medicine, Columbus, OH, USA.
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Fraction of exhaled nitric oxide (FeNO ) norms in healthy Tunisian adults. BIOMED RESEARCH INTERNATIONAL 2014; 2014:269670. [PMID: 24991544 PMCID: PMC4065671 DOI: 10.1155/2014/269670] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 04/23/2014] [Accepted: 04/23/2014] [Indexed: 11/30/2022]
Abstract
Aims. To establish FeNO norms for healthy Tunisian adults aged 18–60 years and to prospectively assess their reliability. Methods. This was a cross-sectional analytical study. A convenience sample of healthy Tunisian adults was recruited. Subjects responded to a medical questionnaire, and then FeNO levels were measured by an online method (Medisoft, Sorinnes (Dinant), Belgium). Clinical, anthropometric, and plethysmographic data were collected. All analyses were performed on natural logarithm values of FeNO. Results. 257 adults (145 males) were retained. The proposed reference equation to predict FeNO value is lnFeNO (ppb) = 3.47−0.56× height (m). After the predicted FeNO value for a given adult was computed, the upper limit of normal could be obtained by adding 0.60 ppb. The mean ± SD (minimum-maximum) of FeNO (ppb) for the total sample was 13.54 ± 4.87 (5.00–26.00). For Tunisian and Arab adults of any age and height, any FeNO value greater than 26.00 ppb may be considered abnormal. Finally, in an additional group of adults prospectively assessed, we found no adult with a FeNO higher than 26.00 ppb. Conclusion. The present FeNO norms enrich the global repository of FeNO norms that the clinician can use to choose the most appropriate norms.
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Ogino K, Wang DH, Kubo M, Obase Y, Setiawan H, Yan F, Takahashi H, Zhang R, Tsukiyama Y, Yoshida J, Zou Y. Association of serum arginase I with L-arginine, 3-nitrotyrosine, and exhaled nitric oxide in healthy Japanese workers. Free Radic Res 2013; 48:137-45. [PMID: 24060156 DOI: 10.3109/10715762.2013.842979] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The associations of serum arginase I with serum L-arginine, serum 3-nitrotyrosine, and fractional exhaled nitric oxide (FENO) were evaluated cross-sectionally in healthy Japanese workers. The serum median (minimum-maximum) levels of arginase I, 3-nitrotyrosine, and FENO in healthy people (n = 130) were 14.6 (0.94-108.1) ng/mL, 81.0 (0.27-298.6) pmol/mg protein, and 14.0 (5.0-110.0) parts per billion, respectively. Significant correlations of arginase I with FENO, L-arginine, 3-nitrotyrosine, and percent predicted forced expiratory volume in 1 s (FEV1 (% predicted)) were observed, and correlations of FENO with immunoglobulin E (IgE), NOx, arginase I, and sex and allergy were also observed. By multiple regression analysis, arginase I showed positive associations with FENO and 3-nitrotyrosine, and a negative association with L-arginine; and FENO showed positive associations with IgE and NO2(-) + NO3(-) (NOx), and a negative association with L-arginine, as well as an association with sex. Moreover, logistic regression analysis showed linear inverse associations of arginase I and 3-nitrotyrosine with L-arginine, and showed linear positive associations of FENO with IgE and NOx. It was concluded that serum arginase I might regulate serum L-arginine and 3-nitrotyrosine via L-arginine, and that IgE or NOx might regulate FENO in a healthy Japanese population.
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Affiliation(s)
- K Ogino
- Department of Public Health, Okayama University, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences , Okayama , Japan
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Reference values and factors associated with exhaled nitric oxide: U.S. youth and adults. Respir Med 2013; 107:1682-91. [PMID: 24041745 DOI: 10.1016/j.rmed.2013.07.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Revised: 06/28/2013] [Accepted: 07/04/2013] [Indexed: 01/13/2023]
Abstract
BACKGROUND Normative values for fractional exhaled nitric oxide (FeNO) and the associated co-factors are important in understanding the role of FeNO as a biomarker in airway disease. The objective of this study is to establish reference FeNO values for youth and adult asymptomatic, lifetime nonsmokers in the United States, and to describe the factors affecting these levels. METHODS Cross-sectional analyses of the National Health and Nutrition Examination Survey from 2007 to 2010. The analytic sample consisted of 4718 youth and adults, ages 6-79 years, who were lifelong nonsmokers, and free of asthma, and other respiratory conditions and symptoms. Loge FeNO values were used as dependent variables to test associations of demographic and health related-covariates. Multivariable regression models were used to assess the independent effect and covariate-adjusted contribution of the factors. RESULTS The geometric mean FeNO level was 8.3, 12.1, and 16.2 ppb for males 6-11, 12-19, and 20-79 years, and 8.4, 10.9, and 12.6 ppb for females in the corresponding age groups. Overall, FeNO levels increased with increasing age (p < 0.001), and height (p < 0.001). In all age groups, FeNO levels were positively associated with eosinophil counts, and with testing in the morning. Among youths 6-11 and 12-19 years, non-Hispanics whites had lower FeNO values than non-Hispanic blacks and Hispanic youths. No race-ethnic difference in FeNO levels was evident for adults 20-79 years. Among adolescents and adults, FeNO levels were higher for males than for females, controlling for all other factors. CONCLUSIONS These reference values and associated attributes in youths and adults are useful in evaluating the role of FeNO in airway diseases.
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Wang Z, Sundy JS, Foss CM, Barnhart HX, Palmer SM, Allgood SD, Trudeau E, Alexander KM, Levesque MC. Racial differences in the association of CD14 polymorphisms with serum total IgE levels and allergen skin test reactivity. J Asthma Allergy 2013; 6:81-92. [PMID: 23836995 PMCID: PMC3699133 DOI: 10.2147/jaa.s42695] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background The CD14 C-159T single nucleotide polymorphism (SNP) has been investigated widely as a candidate genetic locus in patients with allergic disease. There are conflicting results for the association of the CD14 C-159T SNP with total serum immunoglobulin E (IgE) levels and atopy. There are limited data regarding the association of the CD14 C-159T SNP in subjects of African ancestry. The aim of the study was to determine whether the C-159T SNP and other CD14 SNPs (C1188G, C1341T) were associated with total serum IgE levels and with allergy skin test results in nonatopic and atopic subjects; as well as in Caucasian and African American subjects. Methods A total of 291 participants, 18–40 years old, were screened to determine whether they were atopic and/or asthmatic. Analyses were performed to determine the association between CD14 C-159T, C1188G, or C1341T genotypes with serum IgE levels and with the number of positive skin tests among Caucasian or African American subjects. Results We found no significant association of serum total IgE level with CD14 C-159T, C1188G, or C1341T genotypes within nonatopic or atopic subjects. Subjects with CD14-159 T alleles had significantly more positive allergen skin tests than subjects without CD14-159 T alleles (P = 0.0388). There was a significant association between the CD14 1188 G allele, but not the CD14 1341 T allele, with the number of positive skin-test results in Caucasians, but not in African Americans. Conclusion These results support a possible association between CD14 polymorphisms and atopy. CD14-159 T or CD14 1188 G alleles were associated with atopic disease. For subjects with CD14 1188 G alleles, the association with atopic disease was stronger in Caucasians compared to African Americans.
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Affiliation(s)
- Zongyao Wang
- Division of Pulmonary, Allergy and Critical Care Medicine
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18
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See KC, Christiani DC. Normal values and thresholds for the clinical interpretation of exhaled nitric oxide levels in the US general population: results from the National Health and Nutrition Examination Survey 2007-2010. Chest 2013; 143:107-116. [PMID: 22628492 DOI: 10.1378/chest.12-0416] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Elevated fractional excretion of exhaled nitric oxide (FENO) reflects airway inflammation, but few studies have established its normal values. This study aims to establish the normal values and thresholds for the clinical interpretation of FENO in the US general population. METHODS Thirteen thousand two hundred seventy-five subjects aged 6 to 80 years sampled for the National Health and Nutrition Examination Survey (NHANES) 2007-2010 underwent interviews, physical examination, and FENO analysis at 50 mL/s using an online chemiluminescence device according to American Thoracic Society/European Respiratory Society guidelines. After excluding subjects with self-reported asthma and subjects with wheeze in the prior 12 months, prediction equations for the natural logarithm (ln) of FENO were constructed using age, sex, ethnicity, height, BMI, active/passive smoke exposure, and hay fever episodes as covariates. RESULTS The fifth to 95th percentile values of FENO were 3.5 to 36.5 parts per billion (ppb) for children < 12 years of age and 3.5 to 39 ppb for subjects 12 to 80 years of age. Using multiple linear regression, prediction equations explained only 10.3% to 15.7% of the variation in the general population. In the general population, 39% to 45% had ln(FENO) levels > 2 SD of the predicted means. When applied to the general population inclusive of subjects who reported asthma but who did not have attacks within the past year, nearly identical results were obtained. CONCLUSIONS Assuming 95% of the healthy US general population had no clinically significant airway inflammation as assessed by FENO, values exceeding the 95th percentiles indicated abnormality and a high risk of airway inflammation. A large variation of normal FENO values existed in the general population, which was poorly predicted by multiple linear regression models.
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Affiliation(s)
- Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore; Harvard School of Public Health, Boston, MA.
| | - David C Christiani
- Harvard School of Public Health, Boston, MA; Department of Medicine, Harvard Medical School, Boston, MA; Department of Medicine, Massachusetts General Hospital, Boston, MA
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Grob NM, Dweik RA. Exhaled nitric oxide in asthma: progress since the introduction of standardized methodology. J Breath Res 2012; 2:37002. [PMID: 20664809 DOI: 10.1088/1752-7155/2/3/037002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The measurement of nitric oxide (NO) in exhaled breath has given us the ability to learn about and monitor the inflammatory status of the airway through a non-invasive method that is easy to perform and repeat. This has been most useful in the diagnosis and management of asthma and has promised a seemingly unlimited potential for evaluating the airways and how clinical decisions are made (Grob N M and Dweik R A 2008 Chest133 837-9). The exhaled NO field was initially limited, however, due to the absence of standardized methodology. The ATS and ERS jointly released recommendations for standardized methods of measuring and reporting exhaled NO in 1999 that were revised in 2005 (1999 Am. J. Respir. Crit. Care. Med. 160 2104-17; 2005 Am. J. Respir. Crit. Care. Med. 171 912-30). In this paper, we summarize the literature that followed this standardization. We searched the literature for all papers that included the term 'exhaled nitric oxide' and selected those that followed ATS guidelines for online measurement for further review. We also reviewed cut-off values suggested by groups studying exhaled nitric oxide. We found a wide range of NO values reported for normal and asthma populations. The geometric mean for FE(NO) ranged from 10 ppb to 33 ppb in healthy adult control populations. For asthma, the FE(NO) geometric mean ranged from 6 ppb to 98 ppb. This considerable variation likely reflects the different clinical settings and purposes of measurement. Exhaled NO has been used for a multitude of reasons that range from screening, to diagnosis, to monitoring the effect of therapy. The field of exhaled NO has made undeniable progress since the standardization of the measurement methods. Our challenge now is to have guidelines to interpret exhaled NO levels in the appropriate context. As the utility of exhaled NO continues to evolve, it can serve as a good example of the crucial role of the standardization of collection and measurement methods to propel any new test in the right direction as it makes its way from a research tool to a clinically useful test.
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Affiliation(s)
- Natalia M Grob
- Department of Pulmonary, Allergy and Critical Care Medicine/Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Ingram JL, Kraft M. IL-13 in asthma and allergic disease: asthma phenotypes and targeted therapies. J Allergy Clin Immunol 2012; 130:829-42; quiz 843-4. [PMID: 22951057 DOI: 10.1016/j.jaci.2012.06.034] [Citation(s) in RCA: 195] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2012] [Revised: 06/25/2012] [Accepted: 06/29/2012] [Indexed: 02/07/2023]
Abstract
Decades of research in animal models have provided abundant evidence to show that IL-13 is a key T(H)2 cytokine that directs many of the important features of airway inflammation and remodeling in patients with allergic asthma. Several promising focused therapies for asthma that target the IL-13/IL-4/signal transducer and activator of transcription 6 pathway are in development, including anti-IL-13 mAbs and IL-4 receptor antagonists. The efficacy of these new potential asthma therapies depends on the responsiveness of patients. However, an understanding of how IL-13-directed therapies might benefit asthmatic patients is confounded by the complex heterogeneity of the disease. Recent efforts to classify subphenotypes of asthma have focused on sputum cellular inflammation profiles, as well as cluster analyses of clinical variables and molecular and genetic signatures. Researchers and clinicians can now evaluate biomarkers of T(H)2-driven airway inflammation in asthmatic patients, such as serum IgE levels, sputum eosinophil counts, fraction of exhaled nitric oxide levels, and serum periostin levels, to aid decision making in clinical trials and drug development and to identify subsets of patients who might benefit from therapies. Although it is unlikely that these therapies will benefit all asthmatic patients with this heterogeneous disease, advances in understanding asthma subphenotypes in relation to clinical variables and T(H)2 cytokine responses offer the opportunity to improve the efficacy and safety of proposed therapies for asthma.
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Affiliation(s)
- Jennifer L Ingram
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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Szefler SJ, Wenzel S, Brown R, Erzurum SC, Fahy JV, Hamilton RG, Hunt JF, Kita H, Liu AH, Panettieri RA, Schleimer RP, Minnicozzi M. Asthma outcomes: biomarkers. J Allergy Clin Immunol 2012; 129:S9-23. [PMID: 22386512 DOI: 10.1016/j.jaci.2011.12.979] [Citation(s) in RCA: 276] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Accepted: 12/23/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Measurement of biomarkers has been incorporated within clinical research studies of asthma to characterize the population and associate the disease with environmental and therapeutic effects. OBJECTIVE National Institutes of Health institutes and federal agencies convened an expert group to propose which biomarkers should be assessed as standardized asthma outcomes in future clinical research studies. METHODS We conducted a comprehensive search of the literature to identify studies that developed and/or tested asthma biomarkers. We identified biomarkers relevant to the underlying disease process progression and response to treatment. We classified the biomarkers as either core (required in future studies), supplemental (used according to study aims and standardized), or emerging (requiring validation and standardization). This work was discussed at an National Institutes of Health-organized workshop convened in March 2010 and finalized in September 2011. RESULTS Ten measures were identified; only 1, multiallergen screening to define atopy, is recommended as a core asthma outcome. Complete blood counts to measure total eosinophils, fractional exhaled nitric oxide (Feno), sputum eosinophils, urinary leukotrienes, and total and allergen-specific IgE are recommended as supplemental measures. Measurement of sputum polymorphonuclear leukocytes and other analytes, cortisol measures, airway imaging, breath markers, and system-wide studies (eg, genomics, proteomics) are considered as emerging outcome measures. CONCLUSION The working group participants propose the use of multiallergen screening in all asthma clinical trials to characterize study populations with respect to atopic status. Blood, sputum, and urine specimens should be stored in biobanks, and standard procedures should be developed to harmonize sample collection for clinical trial biorepositories.
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Corradi M, Gergelova P, Di Pilato E, Folesani G, Goldoni M, Andreoli R, Selis L, Mutti A. Effect of exposure to detergents and other chemicals on biomarkers of pulmonary response in exhaled breath from hospital cleaners: a pilot study. Int Arch Occup Environ Health 2011; 85:389-96. [PMID: 21785865 DOI: 10.1007/s00420-011-0686-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 07/11/2011] [Indexed: 11/29/2022]
Abstract
PURPOSE The main aim of the study was to provide evidence whether professional cleaning was associated with biomarkers of lung damage in non-invasively collected biological fluids (exhaled air and exhaled breath condensate--EBC). MATERIALS AND METHODS This cross-sectional study involved 40 cleaners regularly exposed to cleaning detergents and 40 controls. The subjects completed a standard questionnaire from European Community Respiratory Health Survey (ECRHS II) and underwent a spirometry. Fractional exhaled nitric oxide (F(E)NO) was measured online, and pH, ammonium (NH(4) (+)), H(2)O(2) and 4-hydroxynonenal (4-HNE) were assayed in EBC. RESULTS Among the cleaners, the frequency of asthma and rhinitis was, respectively, 2.5 and 20%. The most frequently reported symptoms were sneezing (27.5%), nasal and/or pharyngeal pruritus (25%), ocular pruritus (22.5%) and cough (22.5%). There were no significant differences in comparison with the control group. Median F(E)NO levels were higher in African than in Caucasian cleaners (21.5 [16.5-30.0] ppb and 18.0 [13.5-20.5] ppb; p < 0.05). H(2)O(2)-EBC (0.26 [0.09-0.53] μM vs. 0.07 [0.04-0.15] μM; p < 0.01), NH(4) (+)-EBC (857 [493-1,305] μM vs. 541 [306-907] μM; p < 0.01) and pH-EBC (8.17 [8.09-8.24] vs. 8.06 [7.81-8.10]; p < 0.01) were higher in the cleaners than in the controls. Finally, the cleaners showed significant correlations between pH-EBC and NH(4) (+)-EBC (r = 0.33, p < 0.05) and a weak correlation between 4-HNE-EBC and H(2)O(2)-EBC (r = 0.37, p < 0.05). CONCLUSION The promising role of EBC analysis in biomonitoring of exposed workers was confirmed. It was also possible to identify the potential biomarkers of exposure to alkaline products (increased ammonium-EBC and pH-EBC levels) and potential biomarkers of oxidative stress (increased H(2)O(2)-EBC levels correlated with 4-HNE-EBC levels) in workers with no signs of airway diseases.
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Affiliation(s)
- Massimo Corradi
- Laboratory of Industrial Toxicology, Department of Clinical Medicine, Nephrology and Health Sciences, University of Parma, Via Gramsci 14, 431 00, Parma, Italy.
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Exhaled nitric oxide and influencing factors in a random population sample. Respir Med 2010; 105:713-8. [PMID: 21146387 DOI: 10.1016/j.rmed.2010.11.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Revised: 10/31/2010] [Accepted: 11/05/2010] [Indexed: 12/17/2022]
Abstract
The aim of the current study was to determine the impact and interaction of important influencing factors on the fraction of exhaled nitric oxide (FeNO). FeNO was measured in a population-based sample of 1250 middle-aged subjects from the KORA F4 cohort (Augsburg, Germany). Analysis of covariance models was performed including the factors age, height, FVC, FEV(1), sex, current smoking status, recent respiratory tract infection, and respiratory allergy. Geometric mean (SD as factor; 95% confidence interval as factor) FeNO was 13.9 (1.9; 1.033) ppb. FeNO significantly depended on age, height, smoking, infection and allergy. Smoking reduced FeNO by 21%, while infection and allergy led to increases by 9 and 11%, respectively. Increases in age by 10 years and in height by 10 cm were associated with increases of FeNO by 15 and 10%, respectively. Non-smokers demonstrated independent multiplicative superposition of factors affecting FeNO while the effect of allergy was virtually eliminated in smokers without infection. We conclude that in middle-aged non-smokers the effects of infection, age and height can be easily taken into account and do not significantly disturb the effect of respiratory tract allergies on FeNO. In current smokers, however, effects were heterogeneous and information on smoking intensity seems to be useful for better adjustment.
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Banovcin P, Jesenak M, Michnova Z, Babusikova E, Nosal S, Mikler J, Fabry J, Barreto M. Factors attributable to the level of exhaled nitric oxide in asthmatic children. Eur J Med Res 2010; 14 Suppl 4:9-13. [PMID: 20156716 PMCID: PMC3521341 DOI: 10.1186/2047-783x-14-s4-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Asthma is a heterogeneous disease with variable symptoms especially in children. Exhaled nitric oxide (FeNO) has proved to be a marker of inflammation in the airways and has become a substantial part of clinical management of asthmatic children due to its potential to predict possible exacerbation and adjust the dose of inhalant corticosteroids. Objectives We analyzed potential factors that contribute to the variability of nitric oxide in various clinical and laboratory conditions. Materials and methods Study population consisted of 222 asthmatic children and 27 healthy control subjects. All children underwent a panel of tests: fractioned exhaled nitric oxide, exhaled carbon monoxide, asthma control test scoring, blood sampling, skin prick tests, and basic spirometry. Results FeNO and other investigated parameters widely changed according to clinical or laboratory characteristics of the tested children. Asthmatics showed increased levels of FeNO, exhaled carbon monoxide, total serum IgE, and higher eosinophilia. Boys had higher FeNO levels than girls. We found a significant positive correlation between FeNO levels and the percentage of blood eosinophils, %predicted of forced vital capacity, total serum IgE levels, and increasing age. Conclusions Various phenotypes of children's asthma are characterized by specific pattern of the results of clinical and laboratory tests. FeNO correlates with total serum IgE, blood eosinophilia, age, and some spirometric parameters with different strength. Therefore, the coexistence of atopy, concomitant allergic rhinitis/rhinoconjunctivitis, and some other parameters should be considered in critical evaluation of FeNO in the management of asthmatic children.
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Affiliation(s)
- P Banovcin
- Department of Pediatrics, Comenuis University in Bratislava, Jessenius School of Medicine, Kollarova 2 St., 036 59 Martin, Slovakia
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Kim SH, Kim TH, Sohn JW, Yoon HJ, Shin DH, Park SS. Reference values and determinants of exhaled nitric oxide in healthy Korean adults. J Asthma 2010; 47:563-7. [PMID: 20536283 DOI: 10.3109/02770901003702840] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Measuring fractional exhaled nitric oxide (FeNO) provides an indication of airway inflammation and is used as an inflammatory marker for asthma management. However, reference values and determinants of FeNO levels are not well defined in healthy Asian adults. This study aimed to establish FeNO reference values in nonsmoking, healthy Asian adults and to determine the factors related to FeNO levels. METHODS The authors measured FeNO in 166 nonsmoking, healthy Korean adults and collected data regarding factors possibly associated with FeNO, including age, height, weight, and respiratory symptoms. Lung function was measured using spirometry, and atopic status was determined based on the skin-prick test. RESULTS In a multivariate linear regression analysis, FeNO levels were positively associated with male gender (p = .008) and atopy (p = .044) after adjusting for age, height, weight, forced expiratory volume in one second (FEV(1)), and chronic rhinitis. Reference values were presented according to gender and atopic status, and the mean FeNO value was highest in male atopic subjects (37.3 +/- 12.1 ppb), followed by nonatopic males (33.9 +/- 14.3 ppb), atopic females (28.6 +/- 17.7 ppb), and nonatopic females (24.1 +/- 10.6 ppb). In healthy Korean adults, FeNO levels showed a significant and independent association with male gender and atopy. CONCLUSIONS We believe that the presented FeNO reference values and the determining factors could be useful for research and clinical practice in the adult Asian population.
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Affiliation(s)
- Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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26
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Nadif R, Matran R, Maccario J, Bechet M, Le Moual N, Scheinmann P, Bousquet J, Kauffmann F, Pin I. Passive and active smoking and exhaled nitric oxide levels according to asthma and atopy in adults. Ann Allergy Asthma Immunol 2010; 104:385-93. [PMID: 20486328 DOI: 10.1016/j.anai.2010.03.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND No data are available regarding the utility of fractional exhaled nitric oxide (FeNO) level in guiding therapy in smoking asthmatic patients. Identification of the effect of smoking in a large sample is needed. OBJECTIVE To study the association between smoking and FeNO level according to current asthma and atopy status in adults from the French EGEA (Epidemiological study on the Genetics and Environment of Asthma, bronchial hyperresponsiveness and atopy). METHODS Levels of FeNO were measured at 50 mL/s in 654 adults (268 asthmatic participants). Active smoking and environmental tobacco smoke (ETS) exposure at home, at work, and during leisure activities were recorded. Participants were categorized as having no exposure to ETS, mild exposure (ETS <2 h/d), and noticeable exposure (ETS > or = 2 h/d). Multivariate analyses were performed, with adjustment for age, sex, height, and center. RESULTS Mean adjusted FeNO values increased with asthma (15.1 vs 19.5 ppb), atopy (14.2 vs 18.9 ppb), and eosinophilia (15.8 vs 24.8 ppb) (P < .001 for all). Mean FeNO levels decreased with smoking (18.4, 17.5, and 14.5 ppb in nonsmokers, ex-smokers, and current smokers, respectively; P for trend = .001). The association with smoking was observed in nonasthmatic and asthmatic participants, especially in atopic asthmatic participants. Multivariate analyses showed that ETS exposure of at least 2 h/d and active smoking were negatively and significantly associated with FeNO levels independent of age, sex, height, and center in nonasthmatic participants (mean [SE], -0.13 [0.06], P = .03 and -0.10 [0.03], P < .001) and in asthmatic participants (mean [SE], -0.18 [0.07], P = .01 and -0.14 [0.04], P = .02). CONCLUSIONS Active and passive smoking decreased FeNO levels in adults. Careful consideration of asthma, atopy, and active and passive smoking are needed to interpret FeNO values.
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Affiliation(s)
- Rachel Nadif
- Inserm, CESP Centre for Research in Epidemiology and Population Health, Respiratory and Environmental Epidemiology Team U1018, Villejuif, France.
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27
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Mahut B, Peiffer C, Thibaudon M, Chevalier-Bidaud B, Defrance-Hutinet MF, Trinquart L, Delclaux C. What Does a Single Exhaled Nitric Oxide Measurement Tell us in Asthmatic Children? J Asthma 2009. [DOI: 10.1080/02770900903114580] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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28
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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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29
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Apter AJ. Advances in adult asthma diagnosis and treatment and health outcomes, education, delivery, and quality in 2008. J Allergy Clin Immunol 2009; 123:35-40. [PMID: 19130925 DOI: 10.1016/j.jaci.2008.11.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Accepted: 11/19/2008] [Indexed: 01/05/2023]
Abstract
In 2008 the Journal reported new findings in management of asthma. Dosing schedules of inhaled steroids have been modified and individualized. New, more costly propellants are replacing ozone-depleting chlorofluorocarbons. An association of asthma with pneumococcal disease has been observed. Smoking bans in public places are eliminating second-hand smoke and reducing asthma-related emergency department visits among adults. In contrast with these advances, however, disparity in asthma morbidity persists: black persons compared with white persons have a 4-fold greater risk of an asthma-related emergency department visit.
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Affiliation(s)
- Andrea J Apter
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Hauswirth DW, Sundy JS, Mervin-Blake S, Fernandez CA, Patch KB, Alexander KM, Allgood S, McNair PD, Levesque MC. Normative values for exhaled breath condensate pH and its relationship to exhaled nitric oxide in healthy African Americans. J Allergy Clin Immunol 2008; 122:101-6. [PMID: 18472151 DOI: 10.1016/j.jaci.2008.03.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2007] [Revised: 03/24/2008] [Accepted: 03/26/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Exhaled breath condensate (EBC) pH and exhaled nitric oxide (FeNO) have been proposed as markers of asthma severity. EBC pH values below 6.5 have been associated with asthma exacerbations. Protonation of airway nitrite occurs at low pH and may contribute to FeNO. OBJECTIVE To establish normative EBC pH values and to determine the contribution of EBC pH to FeNO in healthy African Americans. METHODS Two hundred seventy healthy African American subjects without asthma between 18 and 40 years old were evaluated. Subjects had simultaneous measurement of EBC pH, EBC nitrite, nitrate, and FeNO. RESULTS The median EBC pH was 8.14 (interquartile range, 7.83-8.28). Of subjects, 11.9% had an EBC pH < or = 6.5. In subjects with EBC pH values below 6.5, there was an inverse correlation between EBC pH and FeNO (r(2) = 0.158; P = .0245; n = 32). In the entire cohort, there was a direct correlation between EBC pH and EBC nitrite (r(2) = 0.163; P < .0001), but there was no correlation between EBC nitrite and FeNO. In multivariate analyses, EBC pH and nitrite did not contribute significantly to FeNO variation while controlling for other confounders of FeNO. CONCLUSION There was an increased prevalence (11.9%) of low EBC pH (less than 6.5) in healthy African American subjects compared with white subjects (<5%). EBC pH and nitrite were directly correlated, but there was no correlation between EBC nitrite and FeNO. FeNO correlated with EBC pH at pH values less than 6.5 in univariate but not multivariate analyses. This suggests that EBC pH and nitrite are not significant determinants of FeNO in healthy subjects.
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Affiliation(s)
- David W Hauswirth
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Ohio State University Medical Center, Columbus, Ohio 43221, USA.
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