Fractional Exhaled Nitric Oxide Monitoring Research Articles

Analysis of the Budget Impact of Fractional Exhaled Nitric Oxide Monitoring in the Management of Childhood Asthma: The Colombian National Health System Perspective.

Fractional exhaled nitric oxide (FeNO) testing is a simple, noninvasive approach to assessing airway inflammation with minimal discomfort that provides results within a few minutes. For policy makers, the economic impact of this technology is the main concern, especially in developing countries. We evaluated the budget impact of asthma management using FeNO monitoring in patients aged between 4 and 18 years in Colombia. A budget impact analysis was performed to evaluate the potential cost of FeNO monitoring. The analysis was based on a 5-year time horizon and performed from the perspective of the Colombian National Health System. The incremental budget impact was calculated by subtracting the cost of the new treatment, in which FeNO is reimbursed, from the cost of conventional treatment without FeNO (management based on clinical symptoms [with or without spirometry/peak flow] or asthma guidelines [or both] for asthma-related cases). Univariate 1-way sensitivity analyses were performed. In the base case analysis the 5-year costs associated with FeNO and non-FeNO were estimated to be €469 904 130 and €480 485 149, respectively, indicating savings for the Colombian National Health System of €10 581 019 if FeNO is adopted for the routine management of patients with persistent asthma. This result proved to be robust in the univariate 1-way sensitivity analysis. FeNO monitoring generated cost savings in emergency settings for infants with persistent asthma. This evidence can be used by decision makers in Colombia to improve clinical practice guidelines and should be replicated to validate the results in other middle-income countries.

Cost utility of fractional exhaled nitric oxide monitoring for the management of children asthma

IntroductionFractional exhaled nitric oxide is a simple, non-invasive measurement of airway inflammation with minimal discomfort to the patient and with results available within a few minutes. This study aimed to evaluate the cost-effectiveness of asthma management using fractional exhaled nitric oxide monitoring in patients between 4 and 18 years of age.MethodsA Markov model was used to estimate the cost-utility of asthma management using fractional exhaled nitric oxide monitoring versus asthma management without using fractional exhaled nitric oxide monitoring (standard therapy) in patients between 4 and 18 years of age. Cost data were obtained from a retrospective study on asthma from a tertiary center, in Medellin, Colombia, while probabilities of the Markov model and utilities were obtained from the systematic review of published randomized clinical trials. The analysis was carried out from a societal perspective.ResultsThe model showed that fractional exhaled nitric oxide monitoring was associated with a lower total cost than standard therapy (US $1333 vs. US $1452 average cost per patient) and higher QALYs (0.93 vs. 0.92 average per patient). The probability that fractional exhaled nitric oxide monitoring provides a more cost-effective use of resources compared with standard therapy exceeds 99% for all willingness-to-pay thresholds.ConclusionAsthma management using fractional exhaled nitric oxide monitoring was cost-effective for treating patients between 4 and 18 years of age with mild to moderate allergic asthma. Our study suggests evidence that could be used by decision-makers to improve clinical practice guidelines, but this should be replicated in different clinical settings.

Fractional exhaled nitric oxide and forced expiratory volume in 1 second/forced vital capacity have predictive value of asthma exacerbation in Korean school children.

BackgroundThe incidence of asthma exacerbation (AE) and the predictive value of spirometry and fractional exhaled nitric oxide (FeNO) in school children have not been evaluated.ObjectiveWe sought to evaluate the efficacy of spirometry measurement and FeNO monitoring for predicting AE in school children in the Cheongju area in Korea.MethodsWith parental agreement, we studied 170 students aged 7–12 years. Children were evaluated by an asthma specialist using baseline spirometry, skin prick test, seasonal FeNO measurement, and asthma control test. The study participants underwent a physical examination and their medical history was also evaluated by the specialist. They were assessed for asthma control status during regular doctor visits for 1 year.ResultsIn total, 160 children (94.1%) completed follow-up and FeNO monitoring. Of which, 26 children (16.3%) had AE. AE was associated with male children and children with allergic rhinitis (p < 0.05). While, children with AE tended to have higher FeNO than those without AE, no significant difference was found. The maximum value of FeNO ≥35 ppb was associated with AE (p < 0.05). Children with AE had a significantly decreased baseline forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC), %predicted, forced expiratory flow at 25%–75% of FVC (FEF25%–75%). FEV1/FVC < 80% was associated with AE in children regardless of inhalant allergen sensitization (all p < 0.05).ConclusionBaseline spirometry had a predictive value of AE in school children. Sensitive spirometric parameters such as FEV1/FVC and FEF25%–75% can be used as prognostic factors to predict future childhood AE. FeNO value ≥ 35 ppb during monitoring was associated with AE in school children.

Cost impact of monitoring exhaled nitric oxide in asthma management.

Asthma guidelines recommend periodic assessment of impairment and risk factors to prevent exacerbations, which can lead to hospitalization and increased health care utilization and cost. According to recent meta-analysis data, fractional exhaled nitric oxide (FeNO) monitoring is associated with a 40-50% reduction in the risk of exacerbations. Cost modeling of these data indicates the potential for significant cost savings with FeNO use. Therefore, we attempted to verify this potential for cost savings within a real-world data base of Medicare beneficiaries. This retrospective observational study investigated asthma-related claims from a Medicare data base. Beneficiaries were included who had 2 years of records after an asthma-related inpatient hospitalization (IP) or emergency department (ED) claim. A case-crossover analysis was completed of asthma-related IP or ED events before and after FeNO use during the 2-year study period. Of the 5911 asthma beneficiaries who met the inclusion criteria within the data base, 101 had an FeNO test during the 2-year study period. During the period before FeNO use, 98 of 101 (97%) beneficiaries had an asthma-related IP or ED event compared with 46 of 101 (46%) during the FeNO period. Asthma-related IP or ED claims and charges per beneficiary per day during the period before FeNO were 0.004 and $16.21 compared with 0.002 and $6.46 during the FeNO period (p = 0.0433 and p = 0.0133, respectively). FeNO monitoring in beneficiaries with a history of exacerbations was associated with a substantial reduction in asthma-related IP and ED claims and charges. These data supported cost modeling estimates and demonstrated that FeNO use in asthma management was associated with significant cost savings.

Advance in application of exhaled nitric oxide in patients with chronic obstructive pulmonary disease and lung protection in general anesthesia

Background Measurement of fractional exhaled nitric oxide(FeNO) plays an important role in the diagnosis and treatment guidelines for asthma has been confirmed, however, the relationship between FeNO and chronic obstructive pulmonary disease(COPD) is not clear. Objective To explore the correlation between FeNO and COPD and its related complications. Contents Giving a summary of the mechanism of FeNO production and its role in COPD and related complications; describing the application of FeNO monitoring in general anesthesia. Trends To get a method or a potential biomarker for early diagnosis of COPD; Obtaining early warning of pulmonary complications after general anesthesia. Key words: Exhaled; Nitric Oxide; Chronic obstructive pulmonary disease

Fractional exhaled nitric oxide monitoring in paediatric asthma management

An annual review is recommended for children with asthma but objective measures of control are lacking.1 Monitoring exacerbations and a symptom score are both suggested, but the widely used Children’s Asthma Control Test (C-ACT) has a positive predictive value of only 46.7% for asthma exacerbations at the recommended score of <24/27.2 Additional tests such as peak expiratory flow or spirometry have not been shown to improve quality of life or symptom scores compared with symptom-based management.3 Fractional exhaled nitric oxide (FeNO) may provide additional information, such as quantifying eosinophilic airway inflammation to identify patients more likely to benefit from an adjustment in their inhaled corticosteroid (ICS) regimen over other treatment options. The National Institute for Health and Care Excellence (NICE) has evaluated three portable, hand-held devices that measure exhaled nitric oxide, produced in proportion to inflammation in the lungs: NObreath, NIOX VERO, and NIOX MINO.1 The devices cost between £1794–£2540, plus £4.93–£9.35 per test for the sensor and filter. Each is accurate to +/−5 ppb (parts per billion) and tend to be precise to <10% of the measured value. Child-friendly versions are available and FeNO monitoring has been shown to be reproducible and feasible in children aged ≥4 years. FeNO levels may help targeted optimisation of ICS dosing in children. In particular, FeNO could help decide whether children aged ≥5 years with suboptimal asthma control, despite treatment with …

A systematic review of fractional exhaled nitric oxide in the routine management of childhood asthma.

Fractional exhaled nitric oxide (FeNO) is a non-invasive biomarker of eosinophilic inflammation which may be used to guide the management of asthma in childhood. To synthesise the available evidence on the efficacy of FeNO-guided management of childhood asthma. Databases including MEDLINE and the Cochrane Library were searched, and randomised controlled trials (RCTs) comparing FeNO-guided management with any other monitoring strategy were included. Study quality was assessed using the Cochrane risk of bias tool for RCTs, and a number of outcomes were examined, including: exacerbations, medication use, quality of life, adverse events, and other markers of asthma control. Meta-analyses were planned if multiple studies with suitable heterogeneity were available. However, due to wide variations in study characteristics, meta-analysis was not possible. Seven RCTs were identified. There was some evidence that FeNO-guided monitoring results in improved asthma control during the first year of management, although few results attained statistical significance. The impact on severe exacerbations was unclear. Similarly, the impact on use of anti-asthmatic drugs was unclear, and appears to depend on the step up/down protocols, and the clinical characteristics of patients. The potential benefit of FeNO monitoring is equivocal. Trends toward reduced exacerbation and increased medication use were seen, but typically failed to reach statistical significance. There are a number of issues that complicate data interpretation, including differences in the likely severity of included cohorts and variations in treatment algorithms. Further work is needed to systematically explore the impact of these parameters.

Exhaled Nitric Oxide Decreases during Academic Examination Stress in Asthma.

Fractional exhaled nitric oxide (FeNO) is known to vary with multiple endogenous and exogenous factors. Laboratory stress and depressive mood have been associated with altered FeNO levels, but little is known about the susceptibility of FeNO to longer-lasting states of psychological stress in asthma. We sought to study changes in FeNO, lung function, and endogenous cortisol levels in students in a low-stress period during the academic term and in high-stress periods of up to 5 days during final exams. One hundred nine participants (35 with asthma) enrolled in a final examination stress study were assessed during the academic term (low stress) and during final exams (high stress). FeNO, spirometric lung function (FEV1, peak flow), salivary cortisol, and negative affect were measured at three time points. Control variables were medication use, cold symptoms, sex, and age. FeNO decreased substantially from low-stress baseline to the high-stress examination periods, with more pronounced decreases occurring in subjects with asthma (-11.5 ppb) than control subjects (-1.2 ppb). FEV1 decreased in both groups. Negative affect and cortisol increased during final exams, but these increases were smaller in asthma. Greater initial depression and greater cortisol increases were related to larger FeNO decreases during the final exam period, the latter only in asthma. Inhaled corticosteroid use did not affect these changes. Psychological stress and depressive mood are accompanied by decreases in both FeNO and lung function in asthma. Fluctuations related to life stress and mood levels should be considered in FeNO monitoring for asthma.

Exhaled nitric oxide as a biomarker in COPD and related comorbidities.

Chronic Obstructive Pulmonary Disease (COPD) is defined as a disease characterized by persistent, progressive airflow limitation. Recent studies have underlined that COPD is correlated to many systemic manifestations, probably due to an underlying pattern of systemic inflammation. In COPD fractional exhaled Nitric Oxide (FeNO) levels are related to smoking habits and disease severity, showing a positive relationship with respiratory functional parameters. Moreover FeNO is increased in patients with COPD exacerbation, compared with stable ones. In alpha-1 antitrypsin deficiency, a possible cause of COPD, FeNO levels may be monitored to early detect a disease progression. FeNO measurements may be useful in clinical setting to identify the level of airway inflammation, per se and in relation to comorbidities, such as pulmonary arterial hypertension and cardiovascular diseases, either in basal conditions or during treatment. Finally, some systemic inflammatory diseases, such as psoriasis, have been associated with higher FeNO levels and potentially with an increased risk of developing COPD. In these systemic inflammatory diseases, FeNO monitoring may be a useful biomarker for early diagnosis of COPD development.

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

BackgroundFractional exhaled nitric oxide (FeNO) is a surrogate marker of eosinophilic airway inflammation and good predictor of corticosteroid response.AimTo evaluate how FeNO is being used to guide primary care asthma management in the United Kingdom (UK) with a view to devising practical algorithms for the use of FeNO in the diagnosis of steroid-responsive disease and to guide on-going asthma management.MethodsEligible patients (n = 678) were those in the Optimum Patient Care Research Database (OPCRD) aged 4–80 years who, at an index date, had their first FeNO assessment via NIOX MINO® or Flex®. Eligible practices were those using FeNO measurement in at least ten patients during the study period. Patients were characterized over a one-year baseline period immediately before the index date. Outcomes were evaluated in the year immediately following index date for two patient cohorts: (i) those in whom FeNO measurement was being used to identify steroid-responsive disease and (ii) those in whom FeNO monitoring was being used to guide on-going asthma management. Outcomes for cohort (i) were incidence of new ICS initiation at, or within the one-month following, their first FeNO measurement, and ICS dose during the outcome year. Outcomes for cohort (ii) were adherence, change in adherence (from baseline) and ICS dose.OutcomesIn cohort (i) (n = 304) the higher the FeNO category, the higher the percentage of patients that initiated ICS at, or in the one month immediately following, their first FeNO measurement: 82%, 46% and 26% of patients with high, intermediate and low FeNO, respectively. In cohort (ii) (n = 374) high FeNO levels were associated with poorer baseline adherence (p = 0.005) but greater improvement in adherence in the outcome year (p = 0.017). Across both cohorts, patients with high FeNO levels were associated with significantly higher ICS dosing (p < 0.001).ConclusionsIn the UK, FeNO is being used in primary practice to guide ICS initiation and dosing decisions and to identify poor ICS adherence. Simple algorithms to guide clinicians in the practical use of FeNO could improved diagnostic accuracy and better tailored asthma regimens.

Role of Fractional Exhaled Nitric Oxide in Predicting Development of Allergic Rhinits in Children with Bronchial Asthma

Purpose Fractional exhaled nitric oxide (FeNO) has been widely reported as a marker for airway inflammationin, and FeNO have shown increased levels in the non-asthmatic patients with other atopy related diseases, such as rhinitis. Bronchial hyperresponsiveness is a characteristic feature of asthma, which is often associated with airway inflammationin allergic rhinitis. It has been suggested that asthma is associated with rhinitis, which is a link between the upper and the lower airways, beyond allergy associated inflammation in the respiratory tract. To evaluate the usefulness of FeNO measurement, as a risk factor of allergic and nonallergic rhinitis in children with asthma. Methods Fifty-three children included in this study were diagnosed as asthma from April through August 2005 in the Department of Pediatrics, Kyung Hee University School of Medicine. They conducted FeNO monitoring, total eosinophil count and serum immunoglobulin E at that time. We put a question to the participants' parents about the doctor diagnosed participants' manifestations (sneezing, nasal congestion, nasal itching, rhinorrhea), via a telephone interview survey or at the outpatient department in July 2011. Statistical analyses were performed using IBM SPSS ver. 18.0. Results The overall prevalence of rhinitis, among the 53 children, was 67.9%. The means of FeNO differed significantly between the two groups, being higher in children who have rhinitis symptoms and lower in asymptomatic children. (mean±SD, 29.4±24.6 to 13.6±11.8 parts per billion; P=0.003; T-test) Conclusion To take the measurement of FeNO value in asthmatics may be a tool in the predictor of the causes of rhinitis.