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Belikova M, Al-Ameri M, Orre AC, Säfholm J. Defining the contractile prostanoid component in hyperosmolar-induced bronchoconstriction in human small airways. Prostaglandins Other Lipid Mediat 2023; 168:106761. [PMID: 37336434 DOI: 10.1016/j.prostaglandins.2023.106761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/06/2023] [Accepted: 06/16/2023] [Indexed: 06/21/2023]
Abstract
Exercise-induced bronchoconstriction (EIB) is thought to be triggered by increased osmolarity at the airway epithelium. The aim of this study was to define the contractile prostanoid component of EIB, using an ex vivo model where intact segments of bronchi (inner diameter 0.5-2 mm) isolated from human lung tissue and subjected to mannitol. Exposure of bronchial segments to hyperosmolar mannitol evoked a contraction (64.3 ± 3.5 %) which could be prevented either by elimination of mast cells (15.8 ± 4.3 %) or a combination of cysteinyl leukotriene (cysLT1), histamine (H1) and thromboxane (TP) receptor antagonists (11.2 ± 2.3 %). Likewise, when antagonism of TP receptor was exchanged for inhibition of either cyclooxygenase-1 (8 ± 2.5 %), hematopoietic prostaglandin (PG)D synthase (20.7 ± 5.6 %), TXA synthase (14.8 ± 4.9 %), or the combination of the latter two (12.2 ± 4.6 %), the mannitol-induced contraction was prevented, suggesting that the TP-mediated component is induced by PGD2 and TXA2 generated by COX-1 and their respective synthases.
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Affiliation(s)
- Maria Belikova
- Institute of Environmental Medicine, Karolinska Institutet, Sweden; Centre for Allergy Research, Karolinska Institutet, Sweden
| | - Mamdoh Al-Ameri
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Sweden
| | | | - Jesper Säfholm
- Institute of Environmental Medicine, Karolinska Institutet, Sweden; Centre for Allergy Research, Karolinska Institutet, Sweden.
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2
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Price OJ, Walsted ES, Bonini M, Brannan JD, Bougault V, Carlsen K, Couto M, Kippelen P, Moreira A, Pite H, Rukhadze M, Hull JH. Diagnosis and management of allergy and respiratory disorders in sport: An EAACI task force position paper. Allergy 2022; 77:2909-2923. [PMID: 35809082 PMCID: PMC9796481 DOI: 10.1111/all.15431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/02/2022] [Accepted: 07/06/2022] [Indexed: 01/27/2023]
Abstract
Allergy and respiratory disorders are common in young athletic individuals. In the context of elite sport, it is essential to secure an accurate diagnosis in order to optimize health and performance. It is also important, however, to consider the potential impact or consequences of these disorders, in recreationally active individuals engaging in structured exercise and/or physical activity to maintain health and well-being across the lifespan. This EAACI Task Force was therefore established, to develop an up-to-date, research-informed position paper, detailing the optimal approach to the diagnosis and management of common exercise-related allergic and respiratory conditions. The recommendations are informed by a multidisciplinary panel of experts including allergists, pulmonologists, physiologists and sports physicians. The report is structured as a concise, practically focussed document, incorporating diagnostic and treatment algorithms, to provide a source of reference to aid clinical decision-making. Throughout, we signpost relevant learning resources to consolidate knowledge and understanding and conclude by highlighting future research priorities and unmet needs.
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Affiliation(s)
- Oliver J. Price
- School of Biomedical SciencesFaculty of Biological Sciences, University of LeedsLeedsUK,Leeds Institute of Medical Research at St James'sUniversity of LeedsLeedsUK
| | - Emil S. Walsted
- Department of Respiratory MedicineRoyal Brompton HospitalLondonUK,Department of Respiratory MedicineBispebjerg HospitalCopenhagenDenmark
| | - Matteo Bonini
- Fondazione Policlinico Universitario A. Gemelli – IRCCSUniversità Cattolica del Sacro CuoreRomeItaly,National Heart and Lung Institute (NHLI)Imperial College LondonLondonUK
| | | | | | - Kai‐Håkon Carlsen
- Division of Paediatric and Adolescent MedicineOslo University HospitalOsloNorway,Faculty of Medicine, University of OsloInstitute of Clinical MedicineOsloNorway
| | - Mariana Couto
- Allergy CenterCUF Descobertas HospitalLisbonPortugal
| | - Pascale Kippelen
- Division of Sport, Health and Exercise SciencesCollege of Health, Medicine and Life Sciences, Brunel University LondonUK
| | - André Moreira
- Centro Hospitalar Universitário de São JoãoPortoPortugal,Epidemiology Unit (EPIUnit)Laboratory for Integrative and Translational Research in Population Health (ITR)Basic and Clinical Immunology, Department of Pathology, Faculty of MedicineUniversity of PortoPortoPortugal
| | - Helena Pite
- Allergy Center, CUF Descobertas Hospital and CUF Tejo HospitalCEDOC, NOVA University, Universidade NOVA de LisboaLisbonPortugal
| | | | - James H. Hull
- Department of Respiratory MedicineRoyal Brompton HospitalLondonUK,Institute of Sport, Exercise and Health (ISEH)Division of Surgery and Interventional Science, University College London (UCL)LondonUK
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3
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Management of Exercise-Induced Bronchoconstriction in Athletes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2183-2192. [PMID: 32620432 DOI: 10.1016/j.jaip.2020.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/25/2020] [Accepted: 03/13/2020] [Indexed: 11/22/2022]
Abstract
Exercise-induced bronchoconstriction (EIB) is a phenomenon observed in asthma but is also seen in healthy individuals and frequently in athletes. High prevalence rates are observed in athletes engaged in endurance sports, winter sports, and swimming. The pathophysiology of EIB is thought to be related to hyperventilation, cold air, and epithelial damage caused by chlorine and fine particles in inspired air. Several diagnostic procedures can be used; however, the diagnosis of EIB based on self-reported symptoms is not reliable and requires an objective examination. The hyperosmolar inhalation test and eucapnic voluntary hyperpnea test, which involve indirect stimulation of the airway, are useful for the diagnosis of EIB. A short-acting β-agonist is the first choice for prevention of EIB, and an inhaled corticosteroid is essential for patients with asthma. Furthermore, treatment should accommodate antidoping requirements in elite athletes. Tailoring of the therapeutic strategy to the individual case and the prognosis after cessation of athletic activity are issues that should be clarified in the future.
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Brannan JD, Kippelen P. Bronchial Provocation Testing for the Identification of Exercise-Induced Bronchoconstriction. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:2156-2164. [PMID: 32620430 DOI: 10.1016/j.jaip.2020.03.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 03/10/2020] [Accepted: 03/14/2020] [Indexed: 01/26/2023]
Abstract
Exercise-induced bronchoconstriction (EIB) occurs in patients with asthma, children, and otherwise healthy athletes. Poor diagnostic accuracy of respiratory symptoms during exercise requires objective assessment of EIB. The standardized tests currently available are based on the assumption that the provoking stimulus to EIB is dehydration of the airway surface fluid due to conditioning large volumes of inhaled air. "Indirect" bronchial provocation tests that use stimuli to cause endogenous release of bronchoconstricting mediators from airway inflammatory cells include dry air hyperpnea (eg, exercise and eucapnic voluntary hyperpnea) and osmotic aerosols (eg, inhaled mannitol). The airway response to different indirect tests is generally similar in patients with asthma and healthy athletes with EIB. Furthermore, the airway sensitivity to these tests is modified by the same pharmacotherapy used to treat asthma. In contrast, pharmacological agents such as methacholine, given by inhalation, act directly on smooth muscle to cause contraction. These "direct" tests have been used traditionally to identify airway hyperresponsiveness in clinical asthma but are less useful to diagnose EIB. The mechanistic differences between indirect and direct tests have helped to elucidate the events leading to airway narrowing in patients with asthma and elite athletes, while improving the clinical utility of these tests to diagnose and manage EIB.
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Affiliation(s)
- John D Brannan
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton, NSW, Australia.
| | - Pascale Kippelen
- Centre for Human Performance, Exercise and Rehabilitation, Brunel University London, Uxbridge, United Kingdom; Division of Sport, Health and Exercise Sciences, College of Health and Life Sciences, Brunel University London, Uxbridge, United Kingdom
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5
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Abstract
This article will discuss in detail the pathophysiology of asthma from the point of view of lung mechanics. In particular, we will explain how asthma is more than just airflow limitation resulting from airway narrowing but in fact involves multiple consequences of airway narrowing, including ventilation heterogeneity, airway closure, and airway hyperresponsiveness. In addition, the relationship between the airway and surrounding lung parenchyma is thought to be critically important in asthma, especially as related to the response to deep inspiration. Furthermore, dynamic changes in lung mechanics over time may yield important information about asthma stability, as well as potentially provide a window into future disease control. All of these features of mechanical properties of the lung in asthma will be explained by providing evidence from multiple investigative methods, including not only traditional pulmonary function testing but also more sophisticated techniques such as forced oscillation, multiple breath nitrogen washout, and different imaging modalities. Throughout the article, we will link the lung mechanical features of asthma to clinical manifestations of asthma symptoms, severity, and control. © 2020 American Physiological Society. Compr Physiol 10:975-1007, 2020.
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Affiliation(s)
- David A Kaminsky
- University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - David G Chapman
- University of Technology Sydney, Sydney, New South Wales, Australia
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6
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Hvidtfeldt M, Sverrild A, Backer V, Porsbjerg C. Airway hyperresponsiveness to mannitol improves in both type 2 high and type 2 low asthma after specialist management. J Asthma 2020; 58:1221-1228. [PMID: 32519918 DOI: 10.1080/02770903.2020.1780255] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Type 2 low (T2-low) asthma is reported to respond less to anti-inflammatory treatment compared with Type 2 high (T2-high) asthma. Airway hyperresponsiveness (AHR) to mannitol, a marker of airway mast cell activation, may be indicative of response to treatment in patients with T2-low disease. We investigated whether AHR to mannitol improves in patients with T2-low asthma after specialist management. METHODS Patients with asthma or suspected asthma, referred to our specialist outpatient clinic, were enrolled consecutively and assessed with FeNO, asthma control, blood eosinophils, mannitol and methacholine tests and induced sputum. T2-low asthma was defined in patients with FeNO < 25ppb and sputum eosinophils < 3% and blood eosinophils < 300µl-1 at inclusion. Patients with asthma and AHR to mannitol (PD15 ≤ 635 mg) were followed and reassessed after 12 months of specialist management. RESULTS Thirty-two patients (Females: 56%, age: 22 years (15-59)) were followed. Fourteen (44%) with T2-high and 18 (56%) with T2-low asthma. Baseline AHR to mannitol was comparable: Gmean PD15: 150 mg (95% CI 61-368) and 214 mg (95% CI 106-432) for T2-high and T2-low asthma respectively (P = 0.51). Both groups improved equally: Gmean PD15: 488 mg (95% CI 311-767) and 507 mg (95% CI 345-746); corresponding to a doubling-dose of: 3.00 (95% CI 1.58-5.74, P = 0.003) and 2.28 (95% CI 1.47-3.53, P = 0.001) respectively. There were no concomitant improvements in AHR to methacholine. CONCLUSION Patients with asthma and AHR to mannitol improve similarly in responsiveness to mannitol after 12 months of specialist management regardless of Type 2 inflammatory biomarker levels. Mechanisms driving AHR in T2-low asthma need to be further elucidated.
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Affiliation(s)
| | - Asger Sverrild
- Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark.,Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
| | - Vibeke Backer
- Center for Physical Activity Research, Rigshospitalet, Copenhagen, Denmark
| | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg Hospital, Copenhagen, Denmark.,Department of Respiratory Medicine, Bispebjerg Hospital, Copenhagen, Denmark
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7
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Legere SA, Haidl ID, Légaré JF, Marshall JS. Mast Cells in Cardiac Fibrosis: New Insights Suggest Opportunities for Intervention. Front Immunol 2019; 10:580. [PMID: 31001246 PMCID: PMC6455071 DOI: 10.3389/fimmu.2019.00580] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 03/04/2019] [Indexed: 12/19/2022] Open
Abstract
Mast cells (MC) are innate immune cells present in virtually all body tissues with key roles in allergic disease and host defense. MCs recognize damage-associated molecular patterns (DAMPs) through expression of multiple receptors including Toll-like receptors and the IL-33 receptor ST2. MCs can be activated to degranulate and release pre-formed mediators, to synthesize and secrete cytokines and chemokines without degranulation, and/or to produce lipid mediators. MC numbers are generally increased at sites of fibrosis. They are potent, resident, effector cells producing mediators that regulate the fibrotic process. The nature of the secretory products produced by MCs depend on micro-environmental signals and can be both pro- and anti-fibrotic. MCs have been repeatedly implicated in the pathogenesis of cardiac fibrosis and in angiogenic responses in hypoxic tissues, but these findings are controversial. Several rodent studies have indicated a protective role for MCs. MC-deficient mice have been reported to have poorer outcomes after coronary artery ligation and increased cardiac function upon MC reconstitution. In contrast, MCs have also been implicated as key drivers of fibrosis. MC stabilization during a hypertensive rat model and an atrial fibrillation mouse model rescued associated fibrosis. Discrepancies in the literature could be related to problems with mouse models of MC deficiency. To further complicate the issue, mice generally have a much lower density of MCs in their cardiac tissue than humans, and as such comparing MC deficient and MC containing mouse models is not necessarily reflective of the role of MCs in human disease. In this review, we will evaluate the literature regarding the role of MCs in cardiac fibrosis with an emphasis on what is known about MC biology, in this context. MCs have been well-studied in allergic disease and multiple pharmacological tools are available to regulate their function. We will identify potential opportunities to manipulate human MC function and the impact of their mediators with a view to preventing or reducing harmful fibrosis. Important therapeutic opportunities could arise from increased understanding of the impact of such potent, resident immune cells, with the ability to profoundly alter long term fibrotic processes.
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Affiliation(s)
- Stephanie A. Legere
- Departments of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
| | - Ian D. Haidl
- Departments of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
| | - Jean-François Légaré
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
- Department of Surgery, Dalhousie Medicine New Brunswick, Saint John, NB, Canada
| | - Jean S. Marshall
- Departments of Microbiology and Immunology, Dalhousie University, Halifax, NS, Canada
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
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8
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Kippelen P, Anderson SD, Hallstrand TS. Mechanisms and Biomarkers of Exercise-Induced Bronchoconstriction. Immunol Allergy Clin North Am 2019; 38:165-182. [PMID: 29631728 DOI: 10.1016/j.iac.2018.01.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Exercise is a common trigger of bronchoconstriction. In recent years, there has been increased understanding of the pathophysiology of exercise-induced bronchoconstriction. Although evaporative water loss and thermal changes have been recognized stimuli for exercise-induced bronchoconstriction, accumulating evidence points toward a pivotal role for the airway epithelium in orchestrating the inflammatory response linked to exercise-induced bronchoconstriction. Overproduction of inflammatory mediators, underproduction of protective lipid mediators, and infiltration of the airways with eosinophils and mast cells are all established contributors to exercise-induced bronchoconstriction. Sensory nerve activation and release of neuropeptides maybe important in exercise-induced bronchoconstriction, but further research is warranted.
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Affiliation(s)
- Pascale Kippelen
- Department of Life Sciences, Division of Sport, Health and Exercise Sciences, Centre for Human Performance, Exercise and Rehabilitation, Brunel University London, Kingston Lane, Uxbridge UB8 3PH, UK
| | - Sandra D Anderson
- Central Clinical School, Sydney Medical School, University of Sydney, Parramatta Road, Sydney New South Wales 2006, Australia.
| | - Teal S Hallstrand
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Center for Lung Biology, University of Washington, Box 358052, 850 Republican Street, Seattle, WA 98109-4714, USA
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9
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Hallstrand TS, Leuppi JD, Joos G, Hall GL, Carlsen KH, Kaminsky DA, Coates AL, Cockcroft DW, Culver BH, Diamant Z, Gauvreau GM, Horvath I, de Jongh FHC, Laube BL, Sterk PJ, Wanger J. ERS technical standard on bronchial challenge testing: pathophysiology and methodology of indirect airway challenge testing. Eur Respir J 2018; 52:13993003.01033-2018. [PMID: 30361249 DOI: 10.1183/13993003.01033-2018] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/20/2018] [Indexed: 12/20/2022]
Abstract
Recently, this international task force reported the general considerations for bronchial challenge testing and the performance of the methacholine challenge test, a "direct" airway challenge test. Here, the task force provides an updated description of the pathophysiology and the methods to conduct indirect challenge tests. Because indirect challenge tests trigger airway narrowing through the activation of endogenous pathways that are involved in asthma, indirect challenge tests tend to be specific for asthma and reveal much about the biology of asthma, but may be less sensitive than direct tests for the detection of airway hyperresponsiveness. We provide recommendations for the conduct and interpretation of hyperpnoea challenge tests such as dry air exercise challenge and eucapnic voluntary hyperpnoea that provide a single strong stimulus for airway narrowing. This technical standard expands the recommendations to additional indirect tests such as hypertonic saline, mannitol and adenosine challenge that are incremental tests, but still retain characteristics of other indirect challenges. Assessment of airway hyperresponsiveness, with direct and indirect tests, are valuable tools to understand and to monitor airway function and to characterise the underlying asthma phenotype to guide therapy. The tests should be interpreted within the context of the clinical features of asthma.
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Affiliation(s)
- Teal S Hallstrand
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Joerg D Leuppi
- University Clinic of Medicine, Cantonal Hospital Baselland, Liestal, and Medical Faculty University of Basel, Basel, Switzerland
| | - Guy Joos
- Dept of Respiratory Medicine, University of Ghent, Ghent, Belgium
| | - Graham L Hall
- Children's Lung Health, Telethon Kids Institute, School of Physiotherapy and Exercise Science, Curtin University, and Centre for Child Health Research University of Western Australia, Perth, Australia
| | - Kai-Håkon Carlsen
- University of Oslo, Institute of Clinical Medicine, and Oslo University Hospital, Division of Child and Adolescent Medicine, Oslo, Norway
| | - David A Kaminsky
- Pulmonary and Critical Care, University of Vermont College of Medicine, Burlington, VT, USA
| | - Allan L Coates
- Division of Respiratory Medicine, Translational Medicine, Research Institute-Hospital for Sick Children, University of Toronto, ON, Canada
| | - Donald W Cockcroft
- Division of Respirology, Critical Care and Sleep Medicine, Royal University Hospital, Saskatoon, SK, Canada
| | - Bruce H Culver
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA
| | - Zuzana Diamant
- Dept of Clinical Pharmacy and Pharmacology and QPS-Netherlands, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.,Dept of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Gail M Gauvreau
- Division of Respirology, Dept of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ildiko Horvath
- Dept of Pulmonology, National Korányi Institute of Pulmonology, Budapest, Hungary
| | - Frans H C de Jongh
- Dept of Pulmonary Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Beth L Laube
- Division of Pediatric Pulmonology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter J Sterk
- Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Jack Wanger
- Pulmonary Function Testing and Clinical Trials Consultant, Rochester, MN, USA
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10
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Kim K, Cho HJ, Yoon JW, Choi SH, Sheen YH, Han MY, Baek H. Exhaled nitric oxide and mannitol test to predict exercise-induced bronchoconstriction. Pediatr Int 2018; 60:691-696. [PMID: 29786927 DOI: 10.1111/ped.13599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 04/03/2018] [Accepted: 05/15/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Exercise-induced bronchoconstriction (EIB) is diagnosed via exercise challenge on a treadmill, but such testing requires complex equipment and sufficient health-care resources. The fraction of exhaled nitric oxide (FeNO) test and mannitol bronchial provocation test (BPT) may serve as a surrogate for exercise testing. METHODS We compared the diagnostic utilities of the FeNO test and mannitol BPT in predicting EIB in asthmatic children. We retrospectively analyzed data from 60 asthmatic children aged 6-16 years. We compared the exercise BPT results, FeNO levels, and mannitol BPT data. RESULTS All subjects were divided into exercise-positive (n = 41) or -negative (n = 19) BPT groups. Of the 41 exercise-positive patients, 32 were mannitol BPT positive and nine were mannitol BPT negative. Of the 19 exercise-negative patients, nine and 10, respectively, were mannitol BPT positive and BPT negative. The maximum % forced expiratory volume in 1 s (FEV1 ) decrease after exercise was positively correlated with FeNO (r = 0.556, P < 0.001), and with mannitol response-dose ratio (RDR; r = 0.416, P = 0.001). The receiver operating characteristic (ROC) curve for FeNO to discriminate between asthmatic subjects with and without EIB had an area under the curve (AUC) of 0.771 (95%CI: 0.643-0.870). The discriminatory ROC curve for mannitol RDR had an AUC of 0.763 (95%CI: 0.633-0.864). The AUC of FeNO and mannitol RDR did not differ significantly. CONCLUSIONS EIB significantly correlated with both FeNO and mannitol BPT data. Given that both methods similarly predicted EIB in asthmatic children, the simpler and safer FeNO test alone may be a clinically useful diagnostic tool.
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Affiliation(s)
- Kyubo Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Seoul, Korea
| | - Hong Je Cho
- Department of Pediatrics, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jung Won Yoon
- Department of Pediatrics, Myongji Hospital, Goyang, Korea
| | - Sun Hee Choi
- Department of Pediatrics, Kyung Hee University School of Medicine, Seoul, Korea
| | - Youn Ho Sheen
- Department of Pediatrics, CHA Gangnam Medical Center, CHA University, Seoul, Korea
| | - Man Yong Han
- Department of Pediatrics, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Heysung Baek
- Department of Pediatrics, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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11
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Anderson SD. Repurposing drugs as inhaled therapies in asthma. Adv Drug Deliv Rev 2018; 133:19-33. [PMID: 29906501 DOI: 10.1016/j.addr.2018.06.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/26/2018] [Accepted: 06/06/2018] [Indexed: 01/06/2023]
Abstract
For the first 40 years of the 20th century treatment for asthma occurred in response to an asthma attack. The treatments were given by injection or orally and included the adrenergic agonists adrenalin/epinephrine and ephedrine and a phosphodiesterase inhibitor theophylline. Epinephrine became available as an aerosol in 1930. After 1945, isoprenaline, a non-selective beta agonist, became available for oral use but it was most widely used by inhalation. Isoprenaline was short-acting with unwanted cardiac effects. More selective beta agonists, with a longer duration of action and fewer side-effects became available, including orciprenaline in 1967, salbutamol in 1969 and terbutaline in 1970. The inhaled steroid beclomethasone was available by 1972 and budesonide by 1982. Spirometry alone and in response to exercise was used to assess efficacy and duration of action of these drugs for the acute benefits of beta2 agonists and the chronic benefits of corticosteroids. Early studies comparing oral and aerosol beta2 agonists found equivalence in bronchodilator effect but the aerosol treatment was superior in preventing exercise-induced bronchoconstriction. Inhaled drugs are now widely used including the long-acting beta2 agonists, salmeterol and formoterol, and the corticosteroids, fluticasone, ciclesonide, mometasone and triamcinolone, that act locally and have low systemic bio-availability. Repurposing drugs as inhaled therapies permitted direct delivery of low doses of drug to the site of action reducing the incidence of unwanted side-effects and permitting the prophylactic treatment of asthma.
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Affiliation(s)
- Sandra D Anderson
- Clinical Professor, Central Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW 2006, Australia.
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12
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Anderson SD, Daviskas E, Brannan JD, Chan HK. Repurposing excipients as active inhalation agents: The mannitol story. Adv Drug Deliv Rev 2018; 133:45-56. [PMID: 29626547 DOI: 10.1016/j.addr.2018.04.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 03/30/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
Abstract
The story of how we came to use inhaled mannitol to diagnose asthma and to treat cystic fibrosis began when we were looking for a surrogate for exercise as a stimulus to identify asthma. We had proposed that exercise-induced asthma was caused by an increase in osmolarity of the periciliary fluid. We found hypertonic saline to be a surrogate for exercise but an ultrasonic nebuliser was required. We produced a dry powder of sodium chloride but it proved unstable. We developed a spray dried preparation of mannitol and found that bronchial responsiveness to inhaling mannitol identified people with currently active asthma. We reasoned that mannitol had potential to replace the 'osmotic' benefits of exercise and could be used as a treatment to enhance mucociliary clearance in patients with cystic fibrosis. These discoveries were the start of a journey to develop several registered products that are in clinical use globally today.
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13
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Liu XC, Wang Q, She YS, Chen S, Luo X, Xu H, Zang DA, Zhang WJ, Qiu JY, Liu BB, Shen J, Peng YB, Zhao P, Xue L, Chen W, Ma LQ, Fu X, Chen J, Liu QH, Yu MF. Hypertonic saline inhibits airway smooth muscle contraction by inhibiting Ca 2+ sensitization. Clin Exp Pharmacol Physiol 2017; 44:1053-1059. [PMID: 28682475 DOI: 10.1111/1440-1681.12807] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 06/21/2017] [Accepted: 06/23/2017] [Indexed: 11/26/2022]
Abstract
The effects of hypertonic solution on airway smooth muscle (ASM) contraction and the underlying mechanisms are largely unknown. We found that hypertonic saline (HS) inhibited acetylcholine (ACh)-induced contraction of ASM from the mouse trachea and human bronchi. In single mouse ASM cells (ASMCs), ACh induced an increase in intracellular Ca2+ that was further enhanced by 5% NaCl, indicating that the HS-induced inhibition of ASM contraction was not mediated by a decrease in cytosolic Ca2+ . The Rho-associated kinase (ROCK) inhibitor Y-27632 relaxed ACh-induced precontraction of mouse tracheal rings. However, such inhibition was not observed after the relaxation induced by 5% NaCl. Moreover, the incubation of mouse tracheal rings with 5% NaCl decreased ACh-induced phosphorylation of myosin light chain 20 and myosin phosphatase target subunit 1. These data indicate that HS inhibits the contraction of ASM by inhibiting Ca2+ sensitization, not by decreasing intracellular Ca2+ .
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Affiliation(s)
- Xiao-Cao Liu
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Qian Wang
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Yu-Shan She
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Shu Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xi Luo
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Hao Xu
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Dun-An Zang
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Wen-Jing Zhang
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Jun-Ying Qiu
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Bei-Bei Liu
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Jinhua Shen
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Yong-Bo Peng
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Ping Zhao
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Lu Xue
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Weiwei Chen
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Li-Qun Ma
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Xiangning Fu
- Department of Thoracic, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jingyu Chen
- Jiangsu Key Laboratory of Organ Transplantation, Department of Cardiothoracic Surgery, Lung Transplant Group, Wuxi People's Hospital, Nanjing Medical University, Wuxi, Jiangsu, China
| | - Qing-Hua Liu
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
| | - Meng-Fei Yu
- Institute for Medical Biology and Hubei Provincial Key Laboratory for Protection and Application of Special Plant Germplasm in Wuling Area of China, College of Life Sciences, South-Central University for Nationalities, Wuhan, Hubei, China
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14
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Park YA, Park HB, Kim YH, Sul IS, Yoon SH, Kim HR, Kim KW, Kim KE, Sohn MH. Airway hyperresponsiveness to mannitol and methacholine and exhaled nitric oxide in children with asthma. J Asthma 2017; 54:644-651. [PMID: 28055271 DOI: 10.1080/02770903.2016.1255751] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Asthma is characterized by airway hyperresponsiveness (AHR), inflammation, and obstruction. AHR to stimuli that indirectly cause bronchial smooth muscle (BSM) contractions via release of endogenous mediators is thought to better reflect airway inflammation than AHR to stimuli that act directly on BSM. Fractional exhaled nitric oxide (FeNO) is a useful parameter for noninvasive clinical airway inflammation assessments. Accordingly, this study aimed to examine the relationships of mannitol and methacholine challenge test outcomes with FeNO and the influence of inhaled corticosteroid treatment in children with asthma. METHODS One hundred thirty-four asthmatic children (89 males; ages: 5-17 years, median: 9 years) underwent spirometry, FeNO measurement, serum total/specific IgE testing, and blood eosinophil count. All subjects were challenged with mannitol dry powder (MDP; AridolH, Pharmaxis, Australia) and methacholine at 7-day intervals. Data of steroid-treated and steroid-naïve children were compared. RESULTS Positive responses to MDP and methacholine challenge tests were observed in 74.6% and 67.2% of total subject group, respectively, and 72 children had positive response to both challenge tests. The median FeNO level, response-dose ratio (RDR) of PC20 methacholine, and RDR of PD15 MDP were significantly higher in the steroid-treated group than in the steroid-naïve group (p < 0.001, 0.226, and 0.004, respectively). FeNO levels associated significantly with PD15 MDP and RDR PD15 MDP in total subject populations (p = 0.016 and 0.003, respectively); however, a significant correlation between FeNO and RDR PD15 MDP was observed only in the steroid-naïve group. CONCLUSIONS Compared with AHR to methacholine, AHR to MDP more closely reflected the level of FeNO in steroid-naïve asthmatic children.
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Affiliation(s)
- Young A Park
- a Department of Pediatrics , Severance Children's Hospital , Seoul , Republic of Korea
| | - Hyun Bin Park
- a Department of Pediatrics , Severance Children's Hospital , Seoul , Republic of Korea
| | - Yoon Hee Kim
- b Gangnam Severance Hospital, Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine , Seoul , Republic of Korea
| | - In Sook Sul
- a Department of Pediatrics , Severance Children's Hospital , Seoul , Republic of Korea
| | - Seo Hee Yoon
- a Department of Pediatrics , Severance Children's Hospital , Seoul , Republic of Korea
| | - Hye Ran Kim
- a Department of Pediatrics , Severance Children's Hospital , Seoul , Republic of Korea
| | - Kyung Won Kim
- a Department of Pediatrics , Severance Children's Hospital , Seoul , Republic of Korea
| | - Kyu-Earn Kim
- b Gangnam Severance Hospital, Institute of Allergy, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine , Seoul , Republic of Korea
| | - Myung Hyun Sohn
- a Department of Pediatrics , Severance Children's Hospital , Seoul , Republic of Korea
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15
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Park TY, Yi MJ, Choi WH, Kim SY, Yu R, Ban JE, Yang S, Hwang IT, Baek HS. Relationship between atopy and bronchial hyperresponsiveness to indirect stimuli in asthmatic children. ALLERGY ASTHMA & RESPIRATORY DISEASE 2017. [DOI: 10.4168/aard.2017.5.2.83] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Tae-Young Park
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Min-Ju Yi
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Woo-Hyeok Choi
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Su-Yeong Kim
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Rita Yu
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Ji-Eun Ban
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Seong Yang
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Il-Tae Hwang
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Hey-Sung Baek
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
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16
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Vakali S, Vogiatzis I, Florou A, Giavi S, Zakynthinos S, Papadopoulos NG, Gratziou C. Exercice-induced bronchoconstriction among athletes: Assessment of bronchial provocation tests. Respir Physiol Neurobiol 2016; 235:34-39. [PMID: 27677405 DOI: 10.1016/j.resp.2016.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 09/16/2016] [Accepted: 09/22/2016] [Indexed: 11/30/2022]
Abstract
Diagnosis of exercise-induced bronchoconstriction (EIB) requires the use of bronchial provocation tests (BPTs). We assessed exercise-induced respiratory symptoms (EIRS), EIB and asthma in athletes and evaluated the validity of BPTs in the diagnosis of EIB. Rhinitis and atopy were also assessed. Athletes with (n=55) and without previous asthma diagnosis (n=145) were tested by skin prick tests, lung function and eNO measurements. EIRS were recorded and EIB was assessed by methacholine (Mch), eucapnic voluntary hyperpnoea (EVH), mannitol and exercise test. EIRS were highly reported and history of asthma was common among athletes. A high prevalence of atopy (48.7%) and allergic rhinitis (30.5%) was found. Athletes with asthma had a higher response rate to Mch and to EVH, as compared with athletes without a previous asthma diagnosis (P=0.012 and P=0.017 respectively). Report of EIRS, rhinitis and atopy were not associated with a positive BPT response. Screening athletes for EIB using BPTs is suggested, irrespective of reported EIRS or a previous asthma diagnosis.
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Affiliation(s)
- S Vakali
- Asthma and Allergy Centre, Medical School, University of Athens, Evgenidio Hospital, Athens, Greece.
| | - I Vogiatzis
- Faculty of Physical Education and Sports Sciences and 1st Department of Critical Care Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - A Florou
- Asthma and Allergy Centre, Medical School, University of Athens, Evgenidio Hospital, Athens, Greece
| | - S Giavi
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
| | - S Zakynthinos
- Faculty of Physical Education and Sports Sciences and 1st Department of Critical Care Medicine, National and Kapodistrian University of Athens, Evangelismos Hospital, Athens, Greece
| | - N G Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece; Centre for Pediatrics and Child Health, Institute of Human Development, University of Manchester, UK
| | - Ch Gratziou
- Asthma and Allergy Centre, Medical School, University of Athens, Evgenidio Hospital, Athens, Greece
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17
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Weiler JM, Brannan JD, Randolph CC, Hallstrand TS, Parsons J, Silvers W, Storms W, Zeiger J, Bernstein DI, Blessing-Moore J, Greenhawt M, Khan D, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Schuller DE, Tilles SA, Wallace D. Exercise-induced bronchoconstriction update-2016. J Allergy Clin Immunol 2016; 138:1292-1295.e36. [PMID: 27665489 DOI: 10.1016/j.jaci.2016.05.029] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/13/2016] [Accepted: 05/25/2016] [Indexed: 12/26/2022]
Abstract
The first practice parameter on exercise-induced bronchoconstriction (EIB) was published in 2010. This updated practice parameter was prepared 5 years later. In the ensuing years, there has been increased understanding of the pathogenesis of EIB and improved diagnosis of this disorder by using objective testing. At the time of this publication, observations included the following: dry powder mannitol for inhalation as a bronchial provocation test is FDA approved however not currently available in the United States; if baseline pulmonary function test results are normal to near normal (before and after bronchodilator) in a person with suspected EIB, then further testing should be performed by using standardized exercise challenge or eucapnic voluntary hyperpnea (EVH); and the efficacy of nonpharmaceutical interventions (omega-3 fatty acids) has been challenged. The workgroup preparing this practice parameter updated contemporary practice guidelines based on a current systematic literature review. The group obtained supplementary literature and consensus expert opinions when the published literature was insufficient. A search of the medical literature on PubMed was conducted, and search terms included pathogenesis, diagnosis, differential diagnosis, and therapy (both pharmaceutical and nonpharmaceutical) of exercise-induced bronchoconstriction or exercise-induced asthma (which is no longer a preferred term); asthma; and exercise and asthma. References assessed as relevant to the topic were evaluated to search for additional relevant references. Published clinical studies were appraised by category of evidence and used to document the strength of the recommendation. The parameter was then evaluated by Joint Task Force reviewers and then by reviewers assigned by the parent organizations, as well as the general membership. Based on this process, the parameter can be characterized as an evidence- and consensus-based document.
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18
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Anderson SD. 'Indirect' challenges from science to clinical practice. Eur Clin Respir J 2016; 3:31096. [PMID: 26908255 PMCID: PMC4764958 DOI: 10.3402/ecrj.v3.31096] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 01/25/2016] [Indexed: 12/17/2022] Open
Abstract
Indirect challenges act to provoke bronchoconstriction by causing the release of endogenous mediators and are used to identify airway hyper-responsiveness. This paper reviews the historical development of challenges, with exercise, eucapnic voluntary hyperpnoea (EVH) of dry air, wet hypertonic saline, and with dry powder mannitol, that preceded their use in clinical practice. The first challenge developed for clinical use was exercise. Physicians were keen for a standardized test to identify exercise-induced asthma (EIA) and to assess the effect of drugs such as disodium cromoglycate. EVH with dry air became a surrogate for exercise to increase ventilation to very high levels. A simple test was developed with EVH and used to identify EIA in defence force recruits and later in elite athletes. The research findings with different conditions of inspired air led to the conclusion that loss of water by evaporation from the airway surface was the stimulus to EIA. The proposal that water loss caused a transient increase in osmolarity led to the development of the hypertonic saline challenge. The wet aerosol challenge with 4.5% saline, provided a known osmotic stimulus, to which most asthmatics were sensitive. To simplify the osmotic challenge, a dry powder of mannitol was specially prepared and encapsulated. The test pack with different doses and an inhaler provided a common operating procedure that could be used at the point of care. All these challenge tests have a high specificity to identify currently active asthma. All have been used to assess the benefit of treatment with inhaled corticosteroids. Over the 50 years, the methods for testing became safer, less complex, and less expensive and all used forced expiratory volume in 1 sec to measure the response. Thus, they became practical to use routinely and were recommended in guidelines for use in clinical practice.
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Affiliation(s)
- Sandra D Anderson
- Sydney Medical School, Central Clinical School, University of Sydney, Sydney, NSW, Australia;
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19
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Simpson AJ, Bood JR, Anderson SD, Romer LM, Dahlén B, Dahlén SE, Kippelen P. A standard, single dose of inhaled terbutaline attenuates hyperpnea-induced bronchoconstriction and mast cell activation in athletes. J Appl Physiol (1985) 2016; 120:1011-7. [PMID: 26846550 PMCID: PMC4894945 DOI: 10.1152/japplphysiol.00700.2015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 01/28/2016] [Indexed: 12/30/2022] Open
Abstract
This study provides the first in vivo evidence for a mast cell stabilizing effect of the short-acting inhaled β2-adrenoceptor agonist terbutaline, when administered prophylactically at a clinically recommended dose (0.5 mg) before bronchial provocation with dry air. Our data therefore support the proposal that β2-adrenoceptor agonist-mediated mast cell stabilization is a major contributor to bronchoprotection in individuals with exercise-induced bronchoconstriction. Release of bronchoactive mediators from mast cells during exercise hyperpnea is a key factor in the pathophysiology of exercise-induced bronchoconstriction (EIB). Our aim was to investigate the effect of a standard, single dose of an inhaled β2-adrenoceptor agonist on mast cell activation in response to dry air hyperpnea in athletes with EIB. Twenty-seven athletes with EIB completed a randomized, double-blind, placebo-controlled, crossover study. Terbutaline (0.5 mg) or placebo was inhaled 15 min prior to 8 min of eucapnic voluntary hyperpnea (EVH) with dry air. Pre- and postbronchial challenge, urine samples were analyzed by enzyme immunoassay for 11β-prostaglandin F2α (11β-PGF2α). The maximum fall in forced expiratory volume in 1 s of 14 (12–20)% (median and interquartile range) following placebo was attenuated to 7 (5–9)% with the administration of terbutaline (P < 0.001). EVH caused a significant increase in 11β-PGF2α from 41 (27–57) ng/mmol creatinine at baseline to 58 (43–72) ng/mmol creatinine at its peak post-EVH following placebo (P = 0.002). The rise in 11β-PGF2α was inhibited with administration of terbutaline: 39 (28–44) ng/mmol creatinine at baseline vs. 40 (33–58) ng/mmol creatinine at its peak post-EVH (P = 0.118). These data provide novel in vivo evidence of mast cell stabilization following inhalation of a standard dose of terbutaline prior to bronchial provocation with EVH in athletes with EIB.
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Affiliation(s)
- A J Simpson
- Centre for Human Performance, Exercise and Rehabilitation, College of Health and Life Sciences, Brunel University London, United Kingdom
| | - J R Bood
- Unit for Experimental Asthma Research, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Unit for Clinical Asthma Research, Department of Internal Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden; Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden; and
| | - S D Anderson
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - L M Romer
- Centre for Human Performance, Exercise and Rehabilitation, College of Health and Life Sciences, Brunel University London, United Kingdom
| | - B Dahlén
- Unit for Clinical Asthma Research, Department of Internal Medicine, Karolinska University Hospital Huddinge, Stockholm, Sweden; Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden; and
| | - S-E Dahlén
- Unit for Experimental Asthma Research, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden; and
| | - P Kippelen
- Centre for Human Performance, Exercise and Rehabilitation, College of Health and Life Sciences, Brunel University London, United Kingdom;
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20
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Rundell KW, Anderson SD, Sue-Chu M, Bougault V, Boulet LP. Air quality and temperature effects on exercise-induced bronchoconstriction. Compr Physiol 2016; 5:579-610. [PMID: 25880506 DOI: 10.1002/cphy.c130013] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Exercise-induced bronchoconstriction (EIB) is exaggerated constriction of the airways usually soon after cessation of exercise. This is most often a response to airway dehydration in the presence of airway inflammation in a person with a responsive bronchial smooth muscle. Severity is related to water content of inspired air and level of ventilation achieved and sustained. Repetitive hyperpnea of dry air during training is associated with airway inflammatory changes and remodeling. A response during exercise that is related to pollution or allergen is considered EIB. Ozone and particulate matter are the most widespread pollutants of concern for the exercising population; chronic exposure can lead to new-onset asthma and EIB. Freshly generated emissions particulate matter less than 100 nm is most harmful. Evidence for acute and long-term effects from exercise while inhaling high levels of ozone and/or particulate matter exists. Much evidence supports a relationship between development of airway disorders and exercise in the chlorinated pool. Swimmers typically do not respond in the pool; however, a large percentage responds to a dry air exercise challenge. Studies support oxidative stress mediated pathology for pollutants and a more severe acute response occurs in the asthmatic. Winter sport athletes and swimmers have a higher prevalence of EIB, asthma and airway remodeling than other athletes and the general population. Because of fossil fuel powered ice resurfacers in ice rinks, ice rink athletes have shown high rates of EIB and asthma. For the athlete training in the urban environment, training during low traffic hours and in low traffic areas is suggested.
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Affiliation(s)
- Kenneth W Rundell
- Department of The Basic Sciences, The Commonwealth Medical College, Scranton, PA, USA
| | - Sandra D Anderson
- Clinical Professor Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Malcolm Sue-Chu
- Department of Thoracic Medicine, St Olavs Hospital, Trondheim University Hospital, Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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21
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Arismendi E, Rivas E, Vidal J, Barreiro E, Torralba Y, Burgos F, Rodriguez-Roisin R. Airway Hyperresponsiveness to Mannitol in Obesity Before and After Bariatric Surgery. Obes Surg 2015; 25:1666-71. [PMID: 25618781 PMCID: PMC4522033 DOI: 10.1007/s11695-014-1564-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The relationship between airway hyperresponsiveness (AHR) and obesity, a low-grade systemic inflammatory condition, remains largely unknown. It is established that AHR to indirect stimuli is associated with active airway inflammation. The objectives were to investigate the rate of AHR to mannitol in obese subjects and its changes 1 year after bariatric surgery (BS). METHODS We enrolled 58 candidates to BS severely obese (33 nonsmokers and 25 smokers) without history of asthma and 20 healthy, nonobese participants and related AHR to functional findings and serum and exhaled biomarkers. RESULTS Before surgery, AHR was observed in 16 (28 %) obese with the provocation doses of mannitol to induce a 15 % fall in FEV1 (PD15) of (geometric mean [95 % CI]) 83 (24-145) mg. Compared to control participants, obese participants had lower spirometric values and higher serum and exhaled biomarkers (p < 0.05 each). After surgery, AHR was abolished (p < 0.01) in all but four obese subjects. CONCLUSIONS Weight loss induced by BS was the key independent factor associated to AHR improvement. AHR to mannitol is highly prevalent in obesity, and it is largely abolished by BS.
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Affiliation(s)
- Ebymar Arismendi
- Servei de Pneumologia (Institut del Tòrax), and Fundació Clínic per la Recerca Biomèdica, Hospital Clínic, Barcelona, Spain
- Ciber Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Eva Rivas
- Servei de Anestesiologia and Fundació Clínic per la Recerca Biomèdica, Hospital Clínic, Barcelona, Spain
| | - Josep Vidal
- Institut d’Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Servei de Endocrinologia, and Fundació Clínic per la Recerca Biomèdica, Hospital Clínic, Barcelona, Spain
- Ciber Diabetes y Enfermedades Metabólicas (CIBERDEM), Barcelona, Spain
| | - Esther Barreiro
- Ciber Enfermedades Respiratorias (CIBERES), Barcelona, Spain
- Pulmonology Department, Hospital del Mar, Parc de Recerca Biomèdica de Barcelona (PRBB), Universitat Pompeu Fabra, Barcelona, Spain
| | - Yolanda Torralba
- Servei de Pneumologia (Institut del Tòrax), and Fundació Clínic per la Recerca Biomèdica, Ciber Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Felip Burgos
- Servei de Pneumologia (Institut del Tòrax), and Fundació Clínic per la Recerca Biomèdica, Hospital Clínic, Barcelona, Spain
- Institut d’Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Ciber Enfermedades Respiratorias (CIBERES), Barcelona, Spain
| | - Roberto Rodriguez-Roisin
- Servei de Pneumologia (Institut del Tòrax), and Fundació Clínic per la Recerca Biomèdica, Hospital Clínic, Barcelona, Spain
- Institut d’Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
- Ciber Enfermedades Respiratorias (CIBERES), Barcelona, Spain
- Institut Clínic del Tòrax, Servei de Pneumologia, Hospital Clínic, Villarroel, 170, Barcelona, 08036 Spain
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22
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Attanasi M, Rapino D, Marcovecchio ML, Consilvio NP, Scaparrotta A, Cingolani A, Di Pillo S, Chiarelli F. Airway hyper-responsiveness to mannitol provides a good evaluation of atopy in childhood asthma. Acta Paediatr 2015; 104:718-23. [PMID: 25661794 DOI: 10.1111/apa.12968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 12/11/2014] [Accepted: 02/02/2015] [Indexed: 01/27/2023]
Abstract
AIM The relationship between airway hyper-responsiveness (AHR) and atopy has been previously investigated, but there are still some issues to be clarified. The aim of this study was to assess the link between AHR and mannitol and atopy in asthmatic children. METHODS We evaluated 44 children with asthma, aged 6-16 years of age, using skin prick tests (SPTs), serum total and specific immunoglobulin E (IgE) levels and the mannitol challenge test (MCT). RESULTS We found a good correlation between AHR to mannitol and specific IgE against Dermatophagoides pteronissinus (r = -0.66, p < 0.001) and a weak correlation with specific IgE against dog dander (r = -0.33, p = 0.01) and Aspergillus fumigatus (r = -0.23, p = 0.02). Furthermore, we found a weak correlation between AHR to mannitol and serum total IgE (r = -0.30; p = 0.03), the sum of specific IgE to aeroallergens (r = -0.37, p = 0.01) and the number of positive SPTs (r = -0.31, p = 0.02). CONCLUSION Measuring AHR with MCT might provide an accurate evaluation of the degree of atopy in children. The patients with a higher degree of atopy were significantly more reactive to mannitol. In clinical practice, these results indicate that children with asthma who are more atopic may require more intensive treatment strategies to reduce AHR.
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Affiliation(s)
- M Attanasi
- Allergy and Respiratory Diseases Clinic; Department of Paediatrics; University of Chieti; Chieti Italy
| | - D Rapino
- Allergy and Respiratory Diseases Clinic; Department of Paediatrics; University of Chieti; Chieti Italy
| | | | - N P Consilvio
- Allergy and Respiratory Diseases Clinic; Department of Paediatrics; University of Chieti; Chieti Italy
| | - A Scaparrotta
- Allergy and Respiratory Diseases Clinic; Department of Paediatrics; University of Chieti; Chieti Italy
| | - A Cingolani
- Allergy and Respiratory Diseases Clinic; Department of Paediatrics; University of Chieti; Chieti Italy
| | - S Di Pillo
- Allergy and Respiratory Diseases Clinic; Department of Paediatrics; University of Chieti; Chieti Italy
| | - F Chiarelli
- Department of Paediatrics; University of Chieti; Chieti Italy
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23
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Brannan JD, Bood J, Alkhabaz A, Balgoma D, Otis J, Delin I, Dahlén B, Wheelock CE, Nair P, Dahlén SE, O'Byrne PM. The effect of omega-3 fatty acids on bronchial hyperresponsiveness, sputum eosinophilia, and mast cell mediators in asthma. Chest 2015; 147:397-405. [PMID: 25321659 DOI: 10.1378/chest.14-1214] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Omega-3 fatty acid supplements have been reported to inhibit exercise-induced bronchoconstriction (EIB). It has not been determined whether omega-3 supplements inhibit airway sensitivity to inhaled mannitol, a test for bronchial hyperresponsiveness (BHR) and model for EIB in people with mild to moderate asthma. METHODS In a double-blind, crossover trial, subjects with asthma who had BHR to inhaled mannitol (n = 23; 14 men; mean age, 28 years; one-half taking regular inhaled corticosteroids) were randomized to omega-3 supplements (4.0 g/d eicosapentaenoic acid and 2.0 g/d docosahexaenoic acid) or matching placebo for 3 weeks separated by a 3-week washout. The primary outcome was the provoking dose of mannitol (mg) to cause a 15% fall in FEV1 (PD15). Secondary outcomes were sputum eosinophil count, spirometry, Asthma Control Questionnaire (ACQ) score, serum triacylglyceride level, and lipid mediator profile in urine and serum. RESULTS PD15 (geometric mean, 95% CI) to mannitol following supplementation with omega-3s (78 mg, 51-119 mg) was not different from placebo (88 mg, 56-139 mg, P = .5). There were no changes in sputum eosinophils (mean ± SD) in a subgroup of 11 subjects (omega-3, 8.4% ± 8.2%; placebo, 7.8% ± 11.8%; P = .9). At the end of each treatment period, there were no differences in FEV1 % predicted (omega-3, 85% ± 13%; placebo, 84% ± 11%; P = .9) or ACQ score (omega-3, 1.1% ± 0.5%; placebo, 1.1% ± 0.5%; P = .9) (n = 23). Omega-3s caused significant lowering of blood triglyceride levels and expected shifts in serum fatty acids and eicosanoid metabolites, confirming adherence to the supplements; however, no changes were observed in urinary mast cell mediators. CONCLUSIONS Three weeks of omega-3 supplements does not improve BHR to mannitol, decrease sputum eosinophil counts, or inhibit urinary excretion of mast cell mediators in people with mild to moderate asthma, indicating that dietary omega-3 supplementation is not useful in the short-term treatment of asthma. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00526357; URL: www.clinicaltrials.gov.
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Affiliation(s)
- John D Brannan
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare and McMaster University, Hamilton, ON, Canada.
| | - Johan Bood
- National Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Medicine, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden; Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Ahmad Alkhabaz
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare and McMaster University, Hamilton, ON, Canada
| | - David Balgoma
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden; National Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Joceline Otis
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare and McMaster University, Hamilton, ON, Canada
| | - Ingrid Delin
- National Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Barbro Dahlén
- Department of Medicine, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden; Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Craig E Wheelock
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden; Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Parameswaran Nair
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare and McMaster University, Hamilton, ON, Canada
| | - Sven-Erik Dahlén
- National Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Paul M O'Byrne
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare and McMaster University, Hamilton, ON, Canada
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Porsbjerg C, Sverrild A, Backer V. Combining the Mannitol Test and FeNO in the Assessment of Poorly Controlled Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:553-9. [PMID: 25824441 DOI: 10.1016/j.jaip.2015.02.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/01/2015] [Accepted: 02/11/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND International guidelines recommend up-titration of anti-inflammatory treatment in asthmatic patients with poor symptom control, but patients without eosinophilic airway inflammation are less likely to benefit from this. The mannitol bronchoprovocation test and fractional exhaled nitric oxide (FeNO) are increasingly used in the diagnostic assessment of asthma, but the utility of combining these tests has not been evaluated. AIM The aim of this study was to determine the value of combining FeNO and the mannitol test to assess patients with asthma referred for specialist assessment because of poor symptom control. METHODS All patients referred consecutively over a 12-month period for the assessment of asthma at the Respiratory Outpatient Clinic at Bispebjerg Hospital in Copenhagen were examined with bronchial provocation to mannitol, FeNO, and induced sputum. RESULTS Among asthmatic patients with partly controlled or uncontrolled symptoms according to Global Initiative for Asthma criteria, only 23% had sputum eosinophilia (eosinophils >2.99%). A positive mannitol test did not increase the likelihood of airway eosinophilia significantly (positive test: 32% vs negative test: 18%, P = .12). However, a positive mannitol test combined with a FeNO > 25 ppb indicated a high likelihood of airway eosinophilia (73%), compared with FeNO > 25 ppb and a negative mannitol test (29%) (P < .05). In contrast, in patients with FeNO < 25 ppb, a positive mannitol test was not associated with airway eosinophilia (sputum eosinophils > 2.99%: positive mannitol test: 0%, negative test: 11%, ns). CONCLUSION Combining the mannitol test and FeNO may aid in the differentiation between eosinophilic and noneosinophilic asthma in patients referred for specialist management because of poorly controlled asthma symptoms.
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Affiliation(s)
- Celeste Porsbjerg
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark.
| | - Asger Sverrild
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Vibeke Backer
- Respiratory Research Unit, Department of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
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25
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Leuppi JD. Bronchoprovocation tests in asthma: direct versus indirect challenges. Curr Opin Pulm Med 2014; 20:31-6. [PMID: 24275928 DOI: 10.1097/mcp.0000000000000009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review describes different bronchoprovocation tests and their merits in diagnosing asthma. RECENT FINDINGS A new indirect challenge test using dry powder mannitol has been made available and has been systematically validated and tested in different populations. SUMMARY Airway hyperresponsiveness (AHR) is a characteristic feature of asthma, and its measurement using direct inhalation challenges, particularly with inhaled methacholine or histamine, or indirect challenges using stimuli such as exercise, dry air hyperpnea, distilled water, hypertonic saline and mannitol, and the pharmacological agent adenosine monophosphate is important in establishing a correct diagnosis. Direct challenge tests are sensitive and have a high negative predictive value to exclude asthma. This is particularly true in excluding asthma as a diagnosis in patients with symptoms that suggest asthma, but are caused by another condition. Indirect AHR correlates better with eosinophilic airway inflammation. Therefore, indirect challenge tests are seen as more specific. A newer indirect challenge test that uses a kit containing prepacked capsules of dry powder mannitol in different doses is safe and efficient to use. Indirect challenge tests are superior to direct challenge tests to confirm the presence of asthma.
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Affiliation(s)
- Jörg D Leuppi
- Medical University Clinic, Canton Hospital Baselland, Liestal, Switzerland
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26
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Kim CH, Woo H, Hyun IG, Song WJ, Kim C, Choi JH, Kim DG, Lee MG, Jung KS. Pulmonary function assessment in the early phase of patients with smoke inhalation injury from fire. J Thorac Dis 2014; 6:617-24. [PMID: 24976982 DOI: 10.3978/j.issn.2072-1439.2014.04.11] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 04/02/2014] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Fire smoke contains toxic gases and numerous chemical compounds produced by incomplete combustion, and may cause injury to the airways. Increased airway reactivity, as well as a decrease in lung function, has been reported as a sequela of smoke inhalation injury. This study was undertaken to assess lung functions in the early phase of patients with smoke inhalation damage from fires. METHODS A total of 15 patients with fire smoke inhalation (fire smoke group) and 15 subjects with chronic cough but no previous history of lung disease (chronic cough group) were enrolled. For diagnosis of inhalation injury, we performed bronchoscopy, high-resolution computed tomography (HRCT), as well as arterial carboxyhemoglobin (COHb) at admission. Clinical characteristics, pulmonary function tests (PFTs) and mannitol bronchial provocation tests (BPTs) were analyzed and compared between the two groups. RESULTS In fire smoke group, initial COHb levels and the PaO2/FiO2 ratio were (14.8±18.49)% and 425.7±123.68, respectively. Of seven patients performing HRCT, 4 (57.1%) showed the CT findings compatible with lung involvement of inhalation injury. Post bronchodilator value of the percent of forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were (76.0±24.27)% and (79.8±27.82)%, respectively. Pre-and post- bronchodilator forced expiratory flow between 25% and 75% of the FVC (FEF25-75) and the percent predicted FEF25-75 were 2.41±1.47 vs. 2.65±1.45 L (P=0.045), and (68.7±37.29)% vs. (76.4±36.70)% (P=0.031), respectively. Two patients (13.3%) had positive bronchodilator response (BDR). In fire smoke and chronic cough group, all the subjects showed mannitol BPTs within normal limits. CONCLUSIONS Fire smoke inhalation leads to mild obstructive small airway disease pattern of pulmonary function in the early phase of patients with fire smoke damage. Further studies, however, need to be followed to identify the relationship between airway narrowing to inhaled mannitol and smoke inhalation injury.
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Affiliation(s)
- Cheol-Hong Kim
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Heungjeong Woo
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - In Gyu Hyun
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Won Jun Song
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Changhwan Kim
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Jeong-Hee Choi
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Dong-Gyu Kim
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Myung Goo Lee
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
| | - Ki-Suck Jung
- 1 Department of Internal Medicine, 2 Lung Research Institute, Hallym University College of Medicine, Chuncheon, Korea
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Hantera M, Abdel-Hafiz H. Methacholine challenge test as indicator for add on inhaled corticosteroids in COPD patients. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2014. [DOI: 10.1016/j.ejcdt.2014.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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28
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Price OJ, Hull JH, Ansley L. Advances in the diagnosis of exercise-induced bronchoconstriction. Expert Rev Respir Med 2014; 8:209-20. [PMID: 24552653 DOI: 10.1586/17476348.2014.890517] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Exercise-induced bronchoconstriction (EIB) describes the post exercise phenomenon of acute airway narrowing in association with physical activity. A high prevalence of EIB is reported in both athletic and recreationally active populations. Without treatment, EIB has the potential to impact upon both health and performance. It is now acknowledged that clinical assessment alone is insufficient as a sole means of diagnosing airway dysfunction due to the poor predictive value of symptoms. Furthermore, a broad differential diagnosis has been established for EIB, prompting the requirement of objective evidence of airway narrowing to secure an accurate diagnosis. This article provides an appraisal of recent advances in available methodologies, with the principle aim of optimising diagnostic assessment, treatment and overall clinical care.
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Affiliation(s)
- Oliver J Price
- Faculty of Health and Life Sciences, Northumbria University, Newcastle, UK
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29
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Porsbjerg C, Sverrild A, Backer V. The usefulness of the mannitol challenge test for asthma. Expert Rev Respir Med 2014; 7:655-63. [DOI: 10.1586/17476348.2013.847370] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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30
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Yoo JK, Shin JY, You JS, Jeong SI, Song JS, Yang S, Hwang IT, Lee HB, Baek HS. Serum leptin levels correlate with bronchial hyper-responsiveness to mannitol in asthmatic children. ALLERGY ASTHMA & RESPIRATORY DISEASE 2014. [DOI: 10.4168/aard.2014.2.1.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jung-Kyung Yoo
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Jae Young Shin
- Department of Pediatrics, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Jueng-Sup You
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Soo-In Jeong
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Joon-Sup Song
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Seong Yang
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Il-Tae Hwang
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Ha-Baik Lee
- Department of Pediatrics, Hanyang University Medical Center, Seoul, Korea
| | - Hey-Sung Baek
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
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31
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Scherr A, Schafroth Török S, Jochmann A, Miedinger D, Maier S, Taegtmeyer AB, Chhajed PN, Tamm M, Leuppi JD. Response to add-on inhaled corticosteroids in COPD based on airway hyperresponsiveness to mannitol. Chest 2013; 142:919-926. [PMID: 22459771 DOI: 10.1378/chest.11-2535] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The use of inhaled corticosteroids in mild to moderate COPD is controversial. The aim of this study was to determine whether airway hyperresponsiveness to mannitol might identify patients who are likely to respond to add-on inhaled corticosteroids. METHODS Ninety subjects with mild to moderate COPD were recruited and 68 subsequently randomized in a double-blind manner to receive inhaled budesonide (1,600 μg/d, n = 31) or placebo (n = 37) for 3 months. Thirty-eight subjects had airway hyperresponsiveness to mannitol (17 received budesonide, 21 placebo). All subjects received tiotropium throughout the study, including 4 weeks before randomization. Spirometry, quality of life (St. George Respiratory Questionnaire), degree of dyspnea, airway responsiveness to mannitol, and exhaled nitric oxide were assessed at week 0 (recruitment), week 4 (baseline prior to randomization), and week 16 (posttreatment). RESULTS Compared with placebo, budesonide was associated with improved quality of life in subjects showing airway hyperresponsiveness to mannitol (difference of changes in quality of life score between randomization and study completion, −9.1; 95% CI, −15.8 to −2.3; P < .01). Treatment with inhaled budesonide also led to a reduction in airway responsiveness to mannitol compared with placebo (difference in log10 response-dose ratio, −0.3; 95% CI, −0.6 to −0.04; P < .01). However, postrandomization changes in FEV1 % predicted, quality of life, and exhaled nitric oxide showed no difference between budesonide and placebo. CONCLUSIONS In subjects with mild to moderate COPD and airway hyperresponsiveness to mannitol, quality of life and airway responsiveness improved after treatment with inhaled corticosteroids added to long-acting bronchodilator therapy.
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Affiliation(s)
- Andreas Scherr
- Clinic of Respiratory Medicine, University Hospital Basel, Basel, Switzerland; Clinic of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | | | - Anja Jochmann
- Clinic of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - David Miedinger
- Clinic of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Sabrina Maier
- Clinic of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Anne B Taegtmeyer
- Clinic of Clinical Pharmacology and Toxicology, University Hospital Basel, Basel, Switzerland
| | - Prashant N Chhajed
- Clinic of Internal Medicine, University Hospital Basel, Basel, Switzerland
| | - Michael Tamm
- Clinic of Respiratory Medicine, University Hospital Basel, Basel, Switzerland
| | - Joerg D Leuppi
- Clinic of Internal Medicine, University Hospital Basel, Basel, Switzerland.
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Anderson SD, Kippelen P. Assessment of EIB: What you need to know to optimize test results. Immunol Allergy Clin North Am 2013; 33:363-80, viii. [PMID: 23830130 DOI: 10.1016/j.iac.2013.02.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Respiratory symptoms and asthma control questionnaires are poor predictors of the presence or severity of exercise-induced bronchoconstriction (EIB), and objective measurement is recommended. To optimize the chance of a positive test result, there are several factors to consider when exercising patients for EIB, including the ventilation achieved and sustained during exercise, water content of the inspired air, and the natural variability of the response. The high rate of negative exercise test results has led to the development of surrogates to identify EIB in laboratory or office settings, including eucapnic voluntary hyperpnea of dry air and inhalation of hyperosmolar aerosols.
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Affiliation(s)
- Sandra D Anderson
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales 2050, Missenden road, Australia.
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33
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Kippelen P, Anderson SD. Pathogenesis of exercise-induced bronchoconstriction. Immunol Allergy Clin North Am 2013; 33:299-312, vii. [PMID: 23830126 DOI: 10.1016/j.iac.2013.02.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
This article presents the various potential mechanisms responsible for the development of exercise-induced bronchoconstriction (EIB). Although the etiology of EIB is multifactorial, and the physiologic processes involved may vary between individuals (especially between those with and without asthma), drying of the small airways with an associated inflammatory response seems prerequisite for EIB. Dysregulated repair processes following exercise-induced airway epithelial injury may also serve as basis for EIB development/progression.
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Affiliation(s)
- Pascale Kippelen
- Centre for Sports Medicine & Human Performance, Brunel University, Uxbridge, Middlesex UB8 3PH, UK.
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34
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Hallstrand TS, Kippelen P, Larsson J, Bougault V, van Leeuwen JC, Driessen JMM, Brannan JD. Where to from here for exercise-induced bronchoconstriction: the unanswered questions. Immunol Allergy Clin North Am 2013; 33:423-42, ix. [PMID: 23830134 DOI: 10.1016/j.iac.2013.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The role of epithelial injury is an unanswered question in those with established asthma and in elite athletes who develop features of asthma and exercise-induced bronchorestriction (EIB) after years of training. The movement of water in response to changes in osmolarity is likely to be an important signal to the epithelium that may be central to the onset of EIB. It is generally accepted that the mast cell and its mediators play a major role in EIB and the presence of eosinophils is likely to enhance EIB severity.
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Affiliation(s)
- Teal S Hallstrand
- Division of Pulmonary and Critical Care, University of Washington, Department of Medicine, 1959 NE Pacific Street, Box 356166, Seattle, WA 98195-6522, USA.
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Refractoriness to exercise challenge: a review of the mechanisms old and new. Immunol Allergy Clin North Am 2013; 33:329-45, viii. [PMID: 23830128 DOI: 10.1016/j.iac.2013.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This article discusses the available literature on refractoriness in exercise-induced bronchoconstriction, namely, a decrease in airway responsiveness with repeated exercise challenges. The mechanisms of this naturally occurring protective feature is unknown. Reviewing previous studies together with findings in more recent studies, the authors propose desensitization of the G protein-coupled cysteinyl leukotriene receptor1 as the mechanism of refractoriness and that this desensitization occurs as a result of interplay between leukotrienes and prostaglandins.
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36
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Dres M, Ferre A, Becquemin MH, Dessanges JF, Reychler G, Durand M, Escabasse V, Sauvaget E, Dubus JC. [Inhalation therapy: provocation tests, infectious risks, acute bronchiolitis and ENT diseases. GAT aerosolstorming, Paris 2011]. Rev Mal Respir 2012; 29:1186-97. [PMID: 23228677 DOI: 10.1016/j.rmr.2011.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2011] [Accepted: 11/29/2011] [Indexed: 11/29/2022]
Abstract
Communications from the 2011 meeting of the GAT are reported in this second article on the practical management of bronchial provocation tests and infectious risks associated with the use of nebulization. Recent advances on the role of nebulized hypertonic saline in the treatment of acute bronchiolitis in infants and of the nebulization in sinusal diseases are also reported.
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Affiliation(s)
- M Dres
- Service de Pneumologie et Réanimation, Hôtel-Dieu, Université Paris Descartes, 75004 Paris, France
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37
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Brannan JD, Lougheed MD. Airway hyperresponsiveness in asthma: mechanisms, clinical significance, and treatment. Front Physiol 2012; 3:460. [PMID: 23233839 PMCID: PMC3517969 DOI: 10.3389/fphys.2012.00460] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 11/19/2012] [Indexed: 01/25/2023] Open
Abstract
Airway hyperresponsiveness (AHR) and airway inflammation are key pathophysiological features of asthma. Bronchial provocation tests (BPTs) are objective tests for AHR that are clinically useful to aid in the diagnosis of asthma in both adults and children. BPTs can be either “direct” or “indirect,” referring to the mechanism by which a stimulus mediates bronchoconstriction. Direct BPTs refer to the administration of pharmacological agonist (e.g., methacholine or histamine) that act on specific receptors on the airway smooth muscle. Airway inflammation and/or airway remodeling may be key determinants of the response to direct stimuli. Indirect BPTs are those in which the stimulus causes the release of mediators of bronchoconstriction from inflammatory cells (e.g., exercise, allergen, mannitol). Airway sensitivity to indirect stimuli is dependent upon the presence of inflammation (e.g., mast cells, eosinophils), which responds to treatment with inhaled corticosteroids (ICS). Thus, there is a stronger relationship between indices of steroid-sensitive inflammation (e.g., sputum eosinophils, fraction of exhaled nitric oxide) and airway sensitivity to indirect compared to direct stimuli. Regular treatment with ICS does not result in the complete inhibition of responsiveness to direct stimuli. AHR to indirect stimuli identifies individuals that are highly likely to have a clinical improvement with ICS therapy in association with an inhibition of airway sensitivity following weeks to months of treatment with ICS. To comprehend the clinical utility of direct or indirect stimuli in either diagnosis of asthma or monitoring of therapeutic intervention requires an understanding of the underlying pathophysiology of AHR and mechanisms of action of both stimuli.
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Affiliation(s)
- John D Brannan
- Respiratory Function Laboratory, Department of Respiratory and Sleep Medicine, Westmead Hospital Sydney, NSW, Australia
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38
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Brannan JD, Porsbjerg C, Anderson SD. Inhaled mannitol as a test for bronchial hyper-responsiveness. Expert Rev Respir Med 2012; 3:457-68. [PMID: 20477336 DOI: 10.1586/ers.09.38] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Bronchial provocation tests (BPTs) are useful for identifying one of the key features of asthma: bronchial hyper-responsiveness (BHR). The symptoms of asthma are not always reflective of the underlying pathophysiology of asthma and there is a need for objective tests to identify the presence and severity of BHR. A new BPT, involving the inhalation of dry powder mannitol, has recently been approved to identify BHR and is now in use as a diagnostic tool for currently active asthma. Airway sensitivity to mannitol identifies BHR that is dependent upon the presence of airway inflammation and would probably benefit from treatment with inhaled corticosteroids. The mannitol BPT is available commercially as a (single-use) test kit (Aridol/Osmohale), with the only additional requirement to perform the test being a spirometer. Accordingly, the mannitol BPT provides a point-of-need tool to identify BHR to assist in the diagnosis of asthma.
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Affiliation(s)
- John D Brannan
- Department of Respiratory and Sleep Medicine, 11 West, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia.
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Yue L, Durand M, Lebeau Jacob MC, Hogan P, McManus S, Roux S, de Brum-Fernandes AJ. Prostaglandin D2 induces apoptosis of human osteoclasts by activating the CRTH2 receptor and the intrinsic apoptosis pathway. Bone 2012; 51:338-46. [PMID: 22705147 DOI: 10.1016/j.bone.2012.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Revised: 05/31/2012] [Accepted: 06/02/2012] [Indexed: 12/11/2022]
Abstract
Prostaglandin D(2) (PGD(2)) is a lipid mediator synthesized from arachidonic acid that directly activates two specific receptors, the D-type prostanoid (DP) receptor and chemoattractant receptor homologous molecule expressed on T-helper type 2 cells (CRTH2). PGD(2) can affect bone metabolism by influencing both osteoblast and osteoclast (OC) functions, both cells involved in bone remodeling and in in vivo fracture repair as well. The objective of the present study was to determine the effects of PGD(2), acting through its two specific receptors, on human OC apoptosis. Human OCs were differentiated in vitro from peripheral blood mononuclear cells in the presence of receptor activator for nuclear factor κB ligand (RANKL) and macrophage-colony stimulating factor (M-CSF), and treated with PGD(2), its specific agonists and antagonists. Treatment with PGD(2) for 24hours in the presence of naproxen (10μM) to inhibit endogenous prostaglandin production increased the percentage of apoptotic OCs in a dose-dependent manner, as did the specific CRTH2 agonist compound DK-PGD(2) but not the DP agonist compound BW 245C. In the absence of naproxen, the CRTH2 antagonist compound CAY 10471 reduced OC apoptosis rate but the DP antagonist BW A868C had no effect. The induction of PGD(2)-CRTH2 dependent apoptosis was associated with the activation of caspase-9, but not caspase-8, leading to caspase-3 cleavage. These data show that PGD(2) induces human OC apoptosis through activation of CRTH2 and the apoptosis intrinsic pathway.
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Affiliation(s)
- Li Yue
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada.
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Turton JA, Glasgow NJ, Brannan JD. Feasibility and acceptability of using bronchial hyperresponsiveness to manage asthma in primary care: a pilot study. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2012; 21:28-34. [PMID: 21938353 DOI: 10.4104/pcrj.2011.00079] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIMS To determine if indirect testing for bronchial hyperresponsiveness (BHR) to monitor inhaled corticosteroid (ICS) treatment in asthma is feasible and acceptable in primary care. METHODS Fourteen adult patients with asthma aged 22-70 years (4M:10F, forced expiratory volume in 1 s >70% predicted) taking ICS performed a test for BHR using mannitol on three visits 6 weeks apart. ICS dose adjustments were made based on the presence of BHR. The Asthma Quality of Life Questionnaire (AQLQ) and the Asthma Control Questionnaire were used at each visit. A semi structured interview at study exit assessed subject acceptability. RESULTS BHR did not return in those with no BHR at study entry (n=9) with decreasing ICS dose. Improvements in BHR with increasing ICS dose (n=5) were observed with clinically significant improvements in AQLQ (mean score increase >0.5, p=0.02). Feasibility and acceptability of BHR testing was demonstrated. CONCLUSIONS It is feasible and acceptable to perform BHR testing using mannitol to help identify patients with asthma who would benefit from ICS dose increases and those with no BHR who could have a dose reduction. TRIAL REGISTRATION Australia New Zealand Clinical Trial Registry ACTRN12610000807055.
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Affiliation(s)
- James A Turton
- Medical School, Australian National University, Canberra, ACT 2606, Australia.
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Tepper RS, Wise RS, Covar R, Irvin CG, Kercsmar CM, Kraft M, Liu MC, O'Connor GT, Peters SP, Sorkness R, Togias A. Asthma outcomes: pulmonary physiology. J Allergy Clin Immunol 2012; 129:S65-87. [PMID: 22386510 DOI: 10.1016/j.jaci.2011.12.986] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Accepted: 12/23/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND Outcomes of pulmonary physiology have a central place in asthma clinical research. OBJECTIVE At the request of National Institutes of Health (NIH) institutes and other federal agencies, an expert group was convened to provide recommendations on the use of pulmonary function measures as asthma outcomes that should be assessed in a standardized fashion in future asthma clinical trials and studies to allow for cross-study comparisons. METHODS Our subcommittee conducted a comprehensive search of PubMed to identify studies that focused on the validation of various airway response tests used in asthma clinical research. The subcommittee classified the instruments as core (to be required in future studies), supplemental (to be used according to study aims and in a standardized fashion), or emerging (requiring validation and standardization). This work was discussed at an NIH-organized workshop in March 2010 and finalized in September 2011. RESULTS A list of pulmonary physiology outcomes that applies to both adults and children older than 6 years was created. These outcomes were then categorized into core, supplemental, and emerging. Spirometric outcomes (FEV(1), forced vital capacity, and FEV(1)/forced vital capacity ratio) are proposed as core outcomes for study population characterization, for observational studies, and for prospective clinical trials. Bronchodilator reversibility and prebronchodilator and postbronchodilator FEV(1) also are core outcomes for study population characterization and observational studies. CONCLUSIONS The subcommittee considers pulmonary physiology outcomes of central importance in asthma and proposes spirometric outcomes as core outcomes for all future NIH-initiated asthma clinical research.
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Sverrild A, Porsbjerg C, Backer V. The use of inhaled mannitol in the diagnosis and management of asthma. Expert Opin Pharmacother 2011; 13:115-23. [PMID: 22118547 DOI: 10.1517/14656566.2012.638917] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Airway hyperresponsiveness (AHR) is a key feature of asthma and can be assessed by the use of bronchial provocation tests. A test using inhaled dry powder mannitol for diagnosing asthma is now regulatory approved in 20 countries. AREAS COVERED This paper reviews the literature on inhaled mannitol from the first publication in 1997 until present (October 2011). It discusses the current knowledge on the clinical usefulness as a tool for diagnosing and managing asthma. EXPERT OPINION Inhaled mannitol can be regarded as a safe, standardized, specific, but less sensitive, tool for the diagnosis of asthma in both children and adults. Discomfort, in terms of cough, during the test occurs in 85.3% of subjects, but rarely (1.3%) leads to discontinuation. Headache (6.1%), pharyngolaryngeal pain (2.6%) and cough (1.3%) are the most frequent adverse events that occur on the day of the test. The test holds several advantages compared with existing tests; there is no need for additional equipment (i.e., a nebulizer) besides a spirometer; it requires no cleaning and has only one standard operating protocol. In a new study using mannitol for monitoring mild and moderate persistent asthma in primary care, the number of mild exacerbations was reduced.
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Affiliation(s)
- Asger Sverrild
- University Hospital of Copenhagen, Department of Respiratory Medicine, Bispebjerg, 2400 Copenhagen NV, Denmark.
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Purokivi M, Koskela H, Brannan JD, Kontra K. Cough response to isocapnic hyperpnoea of dry air and hypertonic saline are interrelated. COUGH 2011; 7:8. [PMID: 21999754 PMCID: PMC3205007 DOI: 10.1186/1745-9974-7-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 10/14/2011] [Indexed: 01/13/2023]
Abstract
Background Mechanisms behind asthmatic cough are largely unknown. It is known that hyperosmolar challenges provoke cough in asthmatic but not in the healthy subjects. It has been postulated that isocapnic hyperpnea of dry air (IHDA) and hypertonic aerosols act via similar mechanisms in asthma to cause bronchoconstriction. We investigated whether there is an association between cough response induced by IHDA and hypertonic saline (HS) challenges. Methods Thirty-six asthmatic and 14 healthy subjects inhaled HS solutions with increasing osmolalities administered via ultrasonic nebuliser until 15 cumulative coughs were recorded. The IHDA consisted of three three-minute ventilation steps: 30%, 60% and 100% of maximal voluntary ventilation with an end-point of 30 cumulative coughs. The challenges were performed on separate days at least 48 hours between them and within one week. Inhaled salbutamol (400 mcg) was administered before the challenges to prevent bronchoconstriction. The cough response was expressed as the cough-to-dose ratio (CDR) which is the total number of coughs divided by the maximal osmolality inhaled or the maximal ventilation achieved. Results Cough response to IHDA correlated with the HS challenge (Rs = 0.59, p < 0.001). Cough response to IHDA was at its strongest during the first minute after the challenge. IHDA induced more cough among asthmatic than healthy subjects CDR being (mean ± SD) 0.464 ± 0.514 and 0.011 ± 0.024 coughs/MVV%, p < 0.001, respectively. Salbutamol effectively prevented bronchoconstriction to both challenges. Conclusions Asthmatic patients are hypersensitive to the cough-provoking effect of hyperpnoea, as they are to hypertonicity. Cough response induced by IHDA and HS correlated well suggesting similar mechanisms behind the responses.
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Affiliation(s)
- Minna Purokivi
- Department of Respiratory Medicine, Kuopio University Hospital, P,O, Box 1777, 70211 Kuopio, Finland.
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Suh DI, Lee JK, Kim JT, Koh YY. Airway refractoriness to inhaled mannitol after repeated challenge. Pediatr Pulmonol 2011; 46:1007-14. [PMID: 21520439 DOI: 10.1002/ppul.21468] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Revised: 02/28/2011] [Accepted: 02/28/2011] [Indexed: 11/10/2022]
Abstract
Exercise and inhaled mannitol are thought to cause bronchoconstriction through a similar mechanism in asthma. The response to exercise becomes refractory with repeated challenges. This study aimed to investigate whether repeated challenge with mannitol induces refractoriness, as with exercise. Forty-one children with asthma underwent two consecutive dose-response mannitol challenges (Phase 1); the second challenge proceeded after recovery (FEV(1) : 95% or more of baseline value) from the first. The response to mannitol was expressed as a provocative dose causing a 15% fall in FEV(1) (PD(15) ) and the response-dose ratio (RDR) (% fall in FEV(1) /cumulative dose). In 18 subjects who were deemed to have mannitol refractoriness in Phase 1, a mannitol challenge was performed before and after a methacholine challenge (Phase 2). In Phase 1, the time taken for the FEV(1) to recover after the first mannitol challenge ranged from 20 to 100 min with a median of 50 min. In the 23 subjects with a measurable mannitol PD(15) in both challenges, the geometric mean (95%CI) PD(15) in the second challenge (163 mg [114-232]) was significantly higher than that in the first challenge (66 mg [50-88], P < 0.001). The geometric mean (95%CI) RDR decreased from the value of 0.083%/mg (0.055-0.125) in the first challenge to 0.029%/mg (0.017-0.048) in the second challenge (P < 0.001). In Phase 2, prior challenge with methacholine or mannitol did not significantly alter subsequent bronchoconstriction to the opposite challenge. Repeated challenge with mannitol resulted in less bronchoconstriction when compared with the initial challenge. This refractoriness seems not to be attributable to functional loss of responsiveness or non-specific effect of prior bronchoconstriction.
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Affiliation(s)
- Dong In Suh
- Department of Pediatrics, Seoul National University Hospital, Seoul, Korea
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Stickland MK, Rowe BH, Spooner CH, Vandermeer B, Dryden DM. Accuracy of eucapnic hyperpnea or mannitol to diagnose exercise-induced bronchoconstriction: a systematic review. Ann Allergy Asthma Immunol 2011; 107:229-34.e8. [PMID: 21875541 DOI: 10.1016/j.anai.2011.06.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 06/10/2011] [Accepted: 06/18/2011] [Indexed: 10/17/2022]
Abstract
BACKGROUND Exercise challenge testing is the typical method for diagnosing exercise induced bronchoconstriction; however, alternate tests have been developed. OBJECTIVE The purpose of this paper was to summarize the current literature comparing eucapnic voluntary hyperpnea and mannitol with standard exercise challenge testing to determine whether either test is a suitable alternative to standard exercise testing for the diagnosis of exercise-induced bronchoconstriction. METHODS Using valid systematic review methods, a comprehensive search strategy to avoid publication bias, we identified 10 studies that compared exercise challenge testing with either eucapnic voluntary hyperpnea or mannitol. RESULTS For the 7 diagnostic cross-sectional studies that examined eucapnic voluntary hyperpnea, the sensitivity and specificity values were heterogeneous, ranging from 25 to 90% for sensitivity and 0 to 71% for specificity. In the 3 diagnostic cross-sectional studies that evaluated mannitol, the sensitivity and specificity ranged from 58 to 96% and 65 to 78%, respectively. For most studies, a representative spectrum of participants being tested was not used. CONCLUSION Given the heterogeneity in sensitivity and specificity of eucapnic voluntary hyperpnea studies and the relatively small number of studies that have examined mannitol, insufficient evidence is available to conclude that either of these tests are suitable alternatives to exercise challenge testing to detect exercise-induced bronchoconstriction. Additional research is required.
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Affiliation(s)
- Michael K Stickland
- Department of Medicine, University of Alberta & Centre for Lung Health, Edmonton, AB, Canada.
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Weiler JM, Anderson SD, Randolph C, Bonini S, Craig TJ, Pearlman DS, Rundell KW, Silvers WS, Storms WW, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang DM, Nicklas RA, Oppenheimer J, Portnoy JM, Schuller DE, Spector SL, Tilles SA, Wallace D, Henderson W, Schwartz L, Kaufman D, Nsouli T, Shieken L, Rosario N. Pathogenesis, prevalence, diagnosis, and management of exercise-induced bronchoconstriction: a practice parameter. Ann Allergy Asthma Immunol 2011; 105:S1-47. [PMID: 21167465 DOI: 10.1016/j.anai.2010.09.021] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Accepted: 09/26/2010] [Indexed: 02/06/2023]
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Keller M, Schierholz J. Have inadequate delivery systems hampered the clinical success of inhaled disodium cromoglycate? Time for reconsideration. Expert Opin Drug Deliv 2011; 8:1-17. [PMID: 21174604 DOI: 10.1517/17425247.2010.542141] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
IMPORTANCE OF THE FIELD Disodium cromoglycate (DSCG) fits with the perception of a safe drug, but conclusions from questionable meta-analyses reduced its use. In addition, drug delivery aspects, such as hygroscopicity and the poor performance of delivery systems, were not considered to be important determinants of therapeutic failures. AREAS COVERED IN THIS REVIEW Drug delivery aspects and parameters affecting lung deposition and distribution, important parameters for therapeutic efficacy, are addressed. In addition, the distribution and ratio of mast cell tryptase and chymase-positive phenotypes in the lungs and their role in the prostaglandin and leukotriene pathway are discussed. WHAT THE READER WILL GAIN Information on why in vitro data are an excellent tool to understand better therapeutic failures associated with the moisture sensitivity of DSCG and the difficulty in handling and operating DSCG delivery systems in a therapeutically reliable way. TAKE HOME MESSAGE Pharmacological efficacy of DSCG has been demonstrated in animals and humans. If the drug is delivered to the site of inflammation in an effective dose, a reliable therapeutic effect can be expected. DSCG has extra properties and potential unspecific antiviral properties and may offer new therapeutic treatment aspects for asthma and viral-induced bronchiolitis in early childhood.
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Affiliation(s)
- Manfred Keller
- PARI Pharma GmbH, Aerosol Research Institute, Lochhamer Schlag 21, D-82166 Graefelfing, Germany.
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Abstract
PURPOSE OF REVIEW Performing a bronchial provocation test (BPT) using a direct or indirect stimulus to identify bronchial hyper-responsiveness (BHR) reduces the possibility of over and under-diagnosis of asthma based on history and symptoms. This review discusses some long-held beliefs of BPTs to include or exclude a diagnosis of asthma or exercise-induced bronchoconstriction (EIB). RECENT FINDINGS A high frequency of negative methacholine tests has been reported in 240 patients given a diagnosis of asthma at the end of the study, many of whom had documented EIB. This suggests that a negative methacholine test should not be relied upon to rule out asthma. Further, a positive methacholine test alone should be interpreted with caution as it may reflect airway injury rather than asthma or EIB. Mannitol, an indirect stimulus, identified a similar prevalence of BHR to methacholine and identified more patients than a single exercise test in three studies. However, neither mannitol nor methacholine identified all patients with EIB. Mannitol has a higher specificity for a physician diagnosis of asthma than methacholine. SUMMARY It is likely that both a direct test and an indirect test result may be required in some patients in order to confirm or exclude a diagnosis of asthma with certainty.
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Larsson J, Perry CP, Anderson SD, Brannan JD, Dahlén SE, Dahlén B. The occurrence of refractoriness and mast cell mediator release following mannitol-induced bronchoconstriction. J Appl Physiol (1985) 2011; 110:1029-35. [PMID: 21252215 DOI: 10.1152/japplphysiol.00978.2010] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
For several hours after exercise-induced bronchoconstriction, there is diminished responsiveness to repeated challenge. The mechanism causing this refractoriness is unclear. Inhalation of dry powder mannitol is a new bronchial provocation test that has been suggested as a surrogate for an exercise challenge. Refractoriness to repeated mannitol challenge has however not been established. Our objective was to investigate if repeated challenge with mannitol is associated with refractoriness and diminished release of mast cell mediators of bronchoconstriction. Sixteen subjects with asthma underwent repeated inhalation of mannitol 90 min apart. Lung function was assessed by forced expiratory volume in 1 s (FEV₁). The urinary excretion (ng/mmol creatinine) of the mediators 9α,11β-prostaglandin (PG) F₂ and leukotriene (LT) E₄ were measured. The group mean fall in FEV₁ after the second challenge was 48.5 ± 5.8% of the first (P < 0.001). The protection afforded by the initial challenge, however, varied considerably between subjects (range 88-0%). Furthermore, the urinary excretion of the two mediators was increased after both challenges. The average excretion of mediators after the challenges was significantly higher for the six most refractory subjects. This was observed both for LTE₄ (95.6 ± 5.2 vs. 58.0 ± 2.4 for the 6 least refractory) (P < 0.001) and for 9α,11β-PGF₂ (137.6 ± 6.7 vs. 50.1 ± 1.1 for the 6 least refractory) (P = 0.002). As occurs with exercise-induced bronchoconstriction, repeated inhalation of mannitol induced refractoriness. We propose that refractoriness is due to tachyphylaxis at the level of the airway smooth muscle responsiveness to mediators of bronchoconstriction rather than due to fatigue of their release from mast cells.
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Affiliation(s)
- Johan Larsson
- The Unit for Experimental Asthma and Allergy Research, Division of Physiology, The National Institute of EnvironmentalMedicine, Sweden.
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de Nijs SB, Fens N, Lutter R, Dijkers E, Krouwels FH, Smids-Dierdorp BS, van Steenwijk RP, Sterk PJ. Airway inflammation and mannitol challenge test in COPD. Respir Res 2011; 12:11. [PMID: 21241520 PMCID: PMC3036630 DOI: 10.1186/1465-9921-12-11] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Accepted: 01/18/2011] [Indexed: 11/10/2022] Open
Abstract
Background Eosinophilic airway inflammation has successfully been used to tailor anti-inflammatory therapy in chronic obstructive pulmonary disease (COPD). Airway hyperresponsiveness (AHR) by indirect challenges is associated with airway inflammation. We hypothesized that AHR to inhaled mannitol captures eosinophilia in induced sputum in COPD. Methods Twenty-eight patients (age 58 ± 7.8 yr, packyears 40 ± 15.5, post-bronchodilator FEV1 77 ± 14.0%predicted, no inhaled steroids ≥4 wks) with mild-moderate COPD (GOLD I-II) completed two randomized visits with hypertonic saline-induced sputum and mannitol challenge (including sputum collection). AHR to mannitol was expressed as response-dose-ratio (RDR) and related to cell counts, ECP, MPO and IL-8 levels in sputum. Results There was a positive correlation between RDR to mannitol and eosinophil numbers (r = 0.47, p = 0.03) and level of IL-8 (r = 0.46, p = 0.04) in hypertonic saline-induced sputum. Furthermore, significant correlations were found between RDR and eosinophil numbers (r = 0.71, p = 0.001), level of ECP (r = 0.72, p = 0.001), IL-8 (r = 0.57, p = 0.015) and MPO (r = 0.64, p = 0.007) in sputum collected after mannitol challenge. ROC-curves showed 60% sensitivity and 100% specificity of RDR for >2.5% eosinophils in mannitol-induced sputum. Conclusions In mild-moderate COPD mannitol hyperresponsiveness is associated with biomarkers of airway inflammation. The high specificity of mannitol challenge suggests that the test is particularly suitable to exclude eosinophilic airways inflammation, which may facilitate individualized treatment in COPD. Trial registration Netherlands Trial Register (NTR): NTR1283
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Affiliation(s)
- Selma B de Nijs
- Department of Respiratory Medicine, Academic Medical Centre and University of Amsterdam, Amsterdam, The Netherlands.
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