Fractional Exhaled Nitric Oxide Values Research Articles

Patient-Selected Treatment Goals in Severe Asthma

Goal-orientated health care accounts for patient preferences and values, not just physician treatment aims. The Global Initiative for Asthma (GINA) management strategy states that clinicians should elicit patients' own treatment goals as a central part of care. Despite this recommendation, data on patients' treatment goals are sparse among patients with severe asthma. The objective of this study is to investigate the relationship between rates of treatment adherence and goal achievement, and patient-selected goals. Thematic analysis was used to characterize patient-selected goals. Previously undescribed goal categories in asthma were identified, quantified, and related to clinical characteristics. Goal achievement was aligned with objectively measured treatment adherence. Three categories of patients-selected goals were identified from 2 randomized control trials: disease-specific (n= 98 [51%] and n= 92 [54%], respectively), function-related (n= 90 [48%] and n= 61 [36%]), and knowledge (n= 1 [1%] and n= 17 [10%]). Only 53% of goals aligned with clinician treatment goals. Patients who chose disease-specific goals were more likely to achieve both control and their specified goal (n= 98 [45%], odds ratio: 1.789, confidence interval: 1.066-3.001). Male participants are more likely to focus on disease-specific goals. Patients who achieved their goals were more likely to be T2-high, have an elevated fractional exhaled nitric oxide (FeNO) at their first visit, and have a lower FeNO value at their final visit. Interestingly, adherence rates decline significantly for those who achieve their goals. Almost half of patient-selected goals do not align with GINA clinical asthma management goals. Participants who chose goals that do align with clinicians were more likely to achieve them.

The comparison of two exhaled nitric oxide analyzers: NIOX VERO and SUNVOU-CA2122

As a marker of eosinophilic airway inflammation, fractional exhaled nitric oxide (FeNO) was widely used in clinical practice. NIOX VERO (VERO) and SUNVOU-CA2122 (CA2122) are two commonly used eNO analyzers in China. However, what’s the difference and agreement between the two devices and whether the two types of devices can be replaced by each other in the application of common respiratory diseases have not been reported. The purpose of this study was to compare the two types of devices and to evaluate the difference between them in clinical use and whether they could be replaced. FeNO levels in 244 respiratory patients (including asthma, chronic obstructive pulmonary disease, chronic cough) were measured by CA2122 analyzer and VERO analyzer, respectively. The FeNO values obtained by the two devices were compared and the differences were analyzed. The success rate, the number of attempts and the total time required for a successful measurement by CA2122 and VERO were compared. The FeNO values measured by CA2122 online and offline were also compared. FeNO values obtained by CA2122 were slightly higher than those of VERO [median(range): 29.0(9–271) parts per billion (ppb) vs 25.5 (5–263) ppb, P = 0.000]. There was a high correlation between FeNO values measured by the two types of devices (r = 0.964, P = 0.000). By comparison, there was a high degree of agreement between the FeNO values measured by two devices, in all patients with different respiratory diseases. FeNO values measured online and offline by CA2122 were highly correlated and there was a high degree of agreement between online and offline methods. The success rate of CA2122 was higher than VERO, and the number of attempts (2.1 vs 2.4) and the total time (110.5 ± 35.7 vs 117.5 ± 48.1 s) required for a successful measurement by CA2122 were lower than those of VERO. CA2122 and VERO can be replaced by each other, and FeNO values can be converted if necessary. CA2122 has some advantages in success rate, the mean attempts and time required for successful measurement of FeNO.

The FeNO Normal Value Analysis of Healthy Children Aged 6-15Years Old in Chengdu.

To investigate the fractional exhaled nitric oxide (FeNO) normal value of healthy children, and provide a reliable theoretical basis for clinical diagnosis. 481 healthy children aged 6-15-y-old in three primary schools in Chengdu were subjected for FeNO detection. Through the statistical analysis, the upper limit normal value of FeNO among the healthy children was obtained, and the related influencing factors of FeNO value were analyzed. Among the 481 heathy children, the geometric mean value of FeNO was 14.59ppb (minimum value was 5ppb, maximum value was 69ppb), and the upper limit of normal value was 28ppb. The age, height, and weight all have significant correlations with FeNO. The upper limit of FeNO in healthy children aged 6-15-y-old was 28.0ppb. Inflammation in the airway was suggested when the value of FeNO exceeds 28.0ppb. Furthermore, the influencing factors such as age, weight, height must be considered.

Effects of the salbutamol bronchodilator response on measurements of fractional exhaled nitric oxide in children with asthma: a prospective, observational study.

Salbutamol bronchodilator response (BDR) test and fractional exhaled nitric oxide (FeNO) have been recommended for the diagnosis of asthma in children, but FeNO levels is affected by many factors. Nonetheless, data of the effect on the FeNO values throughout the bronchodilator test and the differences in FeNO values between BDR positive (BDR+) and negative (BDR-) children with asthma are still limited. We aimed to evaluate the effect of the BDR test on FeNO and the differences in FeNO levels between BDR+ and BDR- children with asthma. This was a prospective, observational study performed over a 5-month period (December 2018 to April 2019) and involved 57 children with asthma. The FeNO levels at pre-spirometry, post-spirometry, and post-salbutamol BDR testing were estimated. Finally, the children were divided into two groups i.e., BDR+ and BDR-, and differences in the FeNO levels were compared between the two groups. The spirometry results were normal in 2 patients (3.5%). There were 53 (93%) patients with obstructive lung disease, including 40 (70.2%), 11 (19.3%), and 2 (3.5%) patients with mild, moderate, and severe obstruction, respectively. The remaining two patients had mixed lesions (3.5%), none of which were restrictive. The baseline median FeNO levels were significantly higher in the BDR+ group than in the BDR- group [33.00 (23.78, 46.73) vs. 23.00 (9.80, 37.80), (P=0.048)]. Following spirometry, there was a statistically significant decrease in median FeNO levels from baseline to post-spirometry (P=0.002). However, there was no significant difference between the median FeNO levels at baseline and following the BDR test (P=0.976). The impact of spirometry on FeNO was not statistically different in BDR+ versus BDR- children (Z=-0.186, P=0.853); however, the impact of bronchodilators on FeNO exhibited a statistically significant difference between the two groups (Z=3.160, P=0.002). This study revealed dynamic changes in the FeNO levels during the BDR test. The use of a bronchodilator results in a statistically significant difference in FeNO levels between BDR+ and BDR- children with asthma. Moreover, spirometry leads to a marked decrease in the FeNO levels. Our results will allow clinicians to better interpret FeNO, BDR and pulmonary function outcomes and better develop clinical protocols.

The study of fractional exhaled nitric oxide in newly diagnosed cases of bronchial asthma and chronic obstructive pulmonary disease

INTRODUCTION: Fractional exhaled nitric oxide (FENO) is a measurement of fractional nitric oxide (NO) concentration in exhaled breath. It is a quantitative, noninvasive, simple, and safe method to measure airway inflammation for the assessment of airways diseases. OBJECTIVE: The study was conducted at the tertiary care hospital to study the FENO levels in newly diagnosed patients of bronchial asthma and chronic obstructive pulmonary disease (COPD). MATERIALS AND METHODS: A total number of 105 patients were included in the study, diagnosed based on pulmonary function test and symptomatology. FENO levels were measured using Medisoft FENO machine, and the results were analyzed. RESULTS AND CONCLUSIONS: We found that both COPD and bronchial asthma are more prevalent among males. FENO levels were higher in bronchial asthma patients as compared to COPD patients. In bronchial asthma, FENO levels were higher in patients with very severe obstruction, and in COPD, patients with mild obstruction had slightly higher FENO values.

The Value of Inflammatory Biomarkers in Differentiating Asthma-COPD Overlap from COPD.

PurposeTo evaluate the accuracy of inflammatory biomarkers in differentiating patients with asthma–COPD overlap (ACO) from those with COPD alone.MethodsClinical data of 134 patients with COPD and 48 patients with ACO admitted to the First Affiliated Hospital of Xi’an Jiaotong University from January 2016 to June 2019 were retrospectively analyzed. Receiver operating characteristic (ROC) curve analysis was performed to determine the best cut-off values of fractional exhaled nitric oxide (FeNO), blood eosinophil counts (EOS), and neutrophil to lymphocyte ratio (NLR) for differentiating between ACO and COPD alone. Spearman correlation analysis was conducted to evaluate the relationships between these inflammatory biomarkers and the forced expiratory volume in one second/prediction (FEV1%pred).ResultsFeNO and EOS in the ACO patients were significantly higher than those in the COPD patients (FeNO: median 37.50 vs 24.50 ppb, P < 0.001; EOS: median 0.20 vs 0.10 ×109/L, P = 0.004). FeNO was positively correlated with FEV1%pred (r = 0.314, P = 0.030), while NLR was negatively correlated with FEV1%pred (r = −0.372, P = 0.009) in patients with ACO. In addition, a positive correlation between FeNO and EOS was also found in ACO, especially in patients without history of inhaled corticosteroids (ICS) use (r = 0.682, P < 0.001). The optimal cut-off value of FeNO was 31.5 ppb (AUC = 0.758, 95% CI = 0.631–0.886) in patients with smoking history, with 70.0% sensitivity and 89.9% specificity for differentiating ACO from COPD. In patients without history of ICS use, the best cut-off value of FeNO was 39.5 ppb (AUC = 0.740, 95% CI = 0.610–0.870), with 58.3% sensitivity and 84.9% specificity. Among patients without history of ICS use and smoking, 27.5 ppb was optimal cut-off level for FeNO (AUC = 0.744, 95% CI = 0.579–0.908) to diagnose ACO, with 81.8% sensitivity and 60.7% specificity, and the sensitivity was improved to 91.7% when FeNO was combined with EOS.ConclusionThe inflammatory biomarkers FeNO and EOS can be used as indicators for differentiating between ACO and COPD alone.

EVALUATION OF FRACTIONAL EXHALED NITRIC OXIDE IN INTERSTITIAL LUNG DISEASE

SESSION TITLE: Diffuse Lung Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: No established biomarkers are available to guide the treatment of chronic interstitial lung diseases (ILDs). Nitric oxide reflects the inflammation in the airway, and fractional exhaled nitric oxide (FeNO) is a non-invasive and reproducible biomarker in lung-disease diagnosis and treatment. Whether FeNO can help manage ILDs remains uncertain. This study aimed to determine the role of FeNO in ILDs and the association between FeNO and ILD subtype. METHODS: Fifty-three patients with ILDs were retrospectively recruited. Patient characteristics, FeNO values, pulmonary function test (PFT) data, and inflammatory markers values were obtained. RESULTS: This group of patients with ILDs had decreased vital capacity(VC)and total lung capacity(TLC) of 71.75 ± 17.58% and 75.27 ± 14.07%, respectively. The diffusion capacity of the lung for carbon monoxide (DLCO) also declined, with an average level of 38.15 ± 11.10%. The average FeNO value was 20.34 ± 9.97 ppb. According to the characteristics of chest computed tomography, patients were divided into usual interstitial pneumonia (UIP)-ILD (n = 24) and non-UIP-ILD (n = 29). The FeNO value in the UIP-ILD group was 12.58 ± 3.63 ppb. This value was significantly lower than that of the non-UIP-ILD group (26.62 ± 8.61 ppb, P<0.0001). However, no significant differences were observed in the PFT values, blood eosinophils, IgE, and systemic inflammatory markers between the two groups. According to the etiology, all patients with ILDs were divided into connective tissue diseases associated with interstitial lung disease (CTD-ILD) (n = 30) and non-CTD-ILD (n = 23). There were more female patients in CTD-ILD group compared to non-CTD ILD group and patients in CTD-ILD group were younger. With regard to the FeNO, PFT values, and systemic inflammatory markers, no significant differences were observed between groups. In the overall ILD population, FeNO level correlated with blood eosinophil (r = 0.3066, P=0.0333), but no statistically significant correlations were observed between the FeNO and blood eosinophil percentage, IgE or systemic inflammatory markers. Among the 29 patients with non-UIP-ILDs, 20 received systemic treatment like corticosteroid and they all responded well. The response rate was higher than that of UIP-ILD group (P<0.01). The FeNO cut-off value of 18.5 ppb showed a sensibility of 83.3% and a specificity of 95.8% in discriminating non-UIP-ILDs from UIP ILDs. CONCLUSIONS: Our study suggested the importance of FeNO test in patients with ILDs. High FeNO levels may indicate the need of systemic treatment, and FeNO can be a helpful biomarker for ILD management. CLINICAL IMPLICATIONS: FeNO can be a helpful biomarker for ILD management. High FeNO levels may indicate the need of systemic treatment in ILDs. DISCLOSURES: No relevant relationships by Xuefei Li, source=Web Response No relevant relationships by Gengpeng Lin, source=Web Response No relevant relationships by Zhaohui Zhang, source=Web Response

BLOOD EOSINOPHIL COUNT AND FRACTIONAL EXHALED NITRIC OXIDE AS A COMBINED PREDICTOR OF TREATMENT RESPONSE TO BENRALIZUMAB FOR PATIENTS WITH SEVERE, EOSINOPHILIC ASTHMA

SESSION TITLE: Allergy and Airway Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: In a Phase IIb RCT in severe, eosinophilic asthma, benralizumab (20 mg or 100 mg every 8 weeks [with the first three doses every 4 weeks] for 1 year) reduced asthma exacerbation rate (AER) for adults with blood eosinophil counts (BEC) ≥300 cells/μL (Lancet Respir Med. 2014;2:878–90). Data suggest that fractional exhaled nitric oxide (FeNO) correlates with eosinophilic inflammation. In addition, along with BEC, FeNO may provide prognostic information for a more complete assessment of treatment response to biological medication in patients with severe asthma (Am J Respir Crit Care Med. 2019;200:1308–12). To further understand the possible additive prognostic value of FeNO, we compared treatment for subgroups of severe eosinophilic asthma patients with high and low baseline FeNO measurements. METHODS: We conducted post-hoc analyses of a treatment effect for subgroups of asthma patients with BEC ≥300 cells/μL (eosinophilic patients) receiving benralizumab (combined 20 mg and 100 mg groups) or placebo with high- (≥25 ppb) or low-FeNO (<25 ppb) measurements. Treatment effects were assessed through modelled AER and change from baseline in lung function (FEV1) for the high- and low-FeNO groups. RESULTS: Eosinophilic patients with high FeNO (n=136) had a greater median baseline BEC (536 cells/μL) compared with eosinophilic patients with low FeNO (n=114 [400 cells/μL]). Benralizumab reduced AER by 58% compared with placebo (0.30 for benralizumab vs. 0.72 for placebo, nominal p<0.0424) for eosinophilic patients with high FeNO and by 41% compared with placebo (0.36 for benralizumab vs. 0.61 for placebo, nominal p=0.1074) for eosinophilic patients with low FeNO. Eosinophilic patients with either high or low FeNO treated with benralizumab improved pre-bronchodilator FEV1 at Week 52 compared with placebo (210 mL, nominal p=0.0349; 150 mL, nominal p=0.065; respectively). CONCLUSIONS: Eosinophilic patients with high-FeNO measurements had greater baseline BEC than patients with low-FeNO measurements. Although the response in AER and FEV1 was numerically greater for eosinophilic patients with high FeNO, benralizumab reduced AER and improved lung function regardless of FeNO at baseline. CLINICAL IMPLICATIONS: Benralizumab reduced AER and improved lung function in eosinophilic patients regardless of high- or low-FeNO measurement. These post-hoc analyses suggest that FeNO may provide limited additional prognostic information for patients with severe, eosinophilic asthma. DISCLOSURES: Employee relationship with AstraZeneca Please note: >$100000 Added 03/31/2020 by Esther Garcia Gil, source=Web Response, value=Salary Employee relationship with AstraZeneca Please note: >$100000 Added 04/03/2020 by Ian Hirsch, source=Web Response, value=Salary Employee relationship with AstraZeneca Please note: $20001 - $100000 Added 04/01/2020 by Rohit Katial, source=Web Response, value=Salary Removed 04/01/2020 by Rohit Katial, source=Web Response Employee relationship with AstraZeneca Please note: >$100000 Added 04/01/2020 by Rohit Katial, source=Web Response, value=Salary Employee relationship with AsraZeneca Please note: >$100000 Added 04/08/2020 by James Kreindler, source=Web Response, value=Salary Stockholder relationship with AsraZeneca Please note: >$100000 Added 04/08/2020 by James Kreindler, source=Web Response, value=Ownership interest Employee relationship with Astrazeneca Please note: >$100000 Added 04/02/2020 by Paul Newbold, source=Web Response, value=Salary

Evaluation of olfactory dysfunction to estimate the presence of eosinophilic chronic rhinosinusitis in patients with asthma.

Eosinophilic chronic rhinosinusitis (ECRS) is often complicated by asthma and can be difficult to diagnose. This study aimed to clarify the usefulness of the self-administered odor questionnaire (SAOQ) and visual analog scale (VAS) to identify olfactory disorders in patients with asthma. This retrospective study was conducted on patients with asthma who were referred to the Otolaryngology clinic between May and September 2018. The treatment step of asthma, asthma control test (ACT), pulmonary function test, peripheral blood eosinophils, and fractional exhaled nitric oxide (FeNO) were analyzed. ECRS was diagnosed based on the Japanese Epidemiological Survey of Refractory Eosinophilic Chronic Rhinosinusitis Study score. Olfactory dysfunction was evaluated using the SAOQ and VAS for olfactory disorders. The study included 56 patients (18 males and 38 females), who were divided into two groups; those with ECRS (n=18) and those without ECRS (n=38). Age, sex, treatment step, ACT score, and pulmonary function were not significantly different between the groups. The ECRS group had a significantly higher FeNO value (89.1ppb vs. 39.1ppb) and a significantly lower SAOQ score (40.1% vs. 96.1%). The area under the receiver operating characteristic curve for the efficacy of ECRS diagnosis was 0.88, 0.889, 0.799, and 0.757 for SAOQ, VAS, blood eosinophil count, and FeNO, respectively. The SAOQ and VAS scores were useful tools that presented similar results to the blood eosinophil count and FeNO, and may help to improve the diagnosis of ECRS in patients with asthma.

Comparison of effects of air pollution on children between urban and rural area in west Bengal, India

Abstract Background Air pollution is a serious problem in India. According to World Bank's data in 2015, about 660 million people were categorized as poor (US$3.20 per day per capita) in India and the proportion to total the population was 50.4 %. Even though the number and proportion are large, the effects on the poor people have not been studied very well. We measured the effects of air pollution on children of the poor and compared between urban and rural area in West Bengal, India. Methods 24 male students (12.5 ± 0.8 years) in urban area (Kolkata) and 20 male students (12.5 ± 0.5 years) in rural area (Jata) were recruited. We measured fractional exhaled nitric oxide (FeNO), which was index of airway inflammation and checked allergic symptoms. The survey was conducted in January (dry season) and August (rainy season) 2019 to confirm a seasonal difference. Air quality index (AQI) in each area was used for index of air pollution. Results Average AQI was 335 (Kolkata) and 155 (Haldia: near Jata) for 2 months from December 2018 to January 2019, while average AQI was 51 (Kolkata) and 38 (Haldia) for 2 months from July to August 2019. As for FeNO in dry season, the value in Kolkata was 24.9 ± 16.1 and the value in Jata was 11.7 ± 3.5. As for FeNO in rainy season, the value in Kolkata was 22.3 ± 17.5 and the value in Jata was 16.8 ± 6.7. The value of FeNO in Kolkata was higher than Jata in either season. Although a seasonal difference was not detected in Kolkata, the value in dry season was lower than in rainy season in Jata. The prevalence of allergic symptoms in dry season was higher than in rainy season in Kolkata. On the other hand, there was no difference in the prevalence between dry and rainy season in Jata. Conclusions Even though AQI and the prevalence of allergic symptoms decreased, the value of FeNO did not decrease in Kolkata. Because AQI decreased, indoor air pollution might have influenced on airway. It is supposed that prevention of indoor air pollution is important. Key messages Airway of children in urban area may be influenced on by air pollution more than in rural area. Indoor air pollution may influence on children of the poor more than outdoor air pollution.

Reference Ranges and Determinant Factors for Fractional Exhaled Nitric Oxide in a Healthy Saudi Adult Population.

BackgroundFractional exhaled nitric oxide (FENO) has emerged as a promising marker in respiratory research. The aim of this study was to determine the reference range values of FENO for healthy Saudi adults and the factors associated with FENO levels.Material/MethodsThis cross-sectional study was conducted at the Department of Physiology, King Saud University, Riyadh, Saudi Arabia, from January 2016 to August 2017. A total of 429 healthy Saudi adults were initially recruited. The final selection included 412 participants, consisting of 307 men and 105 women. FENO measurements were performed according to the current recommendations of the American Thoracic Society.ResultsWe observed that the FENO levels of women were significantly lower than those of men (18.6 vs. 21.3, P=0.009). In women, the measured FENO ranged from 5.7 ppb to 42 ppb, and in men from 5.0 ppb to 55.0 ppb. The mean FENO level in the entire study population was 20.6, with a range of 5.0 ppb to 55.0 ppb. The difference became non-significant when we calculated the FENO after adjusting for body surface area by different percentile distributions. Multiple linear regression analysis showed that body surface area and weight were significant predictors of FENO levels.ConclusionsIn this study, FENO levels were significantly affected by demographic variables. Therefore, it is important to consider the factors influencing FENO values to make a valid clinical interpretation.

An Emerging Role for Exhaled Nitric Oxide in Guiding Biological Treatment in Severe Asthma

Asthma is a heterogeneous disease with regard to the inflammatory pathways activated. In recent years, biologic drugs (monoclonal antibodies) directed towards specific components of type 2 inflammation have been approved for the treatment of severe asthma. Phenotyping of patients with severe asthma and evaluation of biomarkers have been recommended to help identify patients who are candidates for treatment with biologics and to monitor treatment responses. Fractional exhaled Nitric Oxide (FeNO) is a biomarker of type 2 inflammation in asthma, signaling activation of Interleukin (IL)-4/IL-13 pathway. FeNO could be useful to assess treatment response or identify candidates for a specific drug that acts on type 2 inflammation mechanisms linked to Nitric Oxide (NO) production, such as the IL-4/IL-13 pathway or upstream processes. The value of FeNO as a biomarker predictive of responses to the biologics available for treating severe asthma is discussed based on the published studies at the moment of the review.

Clinical Features of Chronic Obstructive Pulmonary Disease with High Fractional Exhaled Nitric Oxide.

Background The fractional exhaled nitric oxide (FENO) test is useful in asthma patients. However, a few studies on its usefulness in chronic obstructive pulmonary disease (COPD) patients have been reported. We analyzed the FENO level distribution and clinical characteristics according to the FENO level in COPD patients.Methods From December 2014 to June 2019, COPD patients who underwent pulmonary function and FENO tests at Chonnam National University Hospital were retrospectively evaluated for FENO, comorbidities, asthma history, blood eosinophil, and pulmonary function test. The high FENO group was defined as those with FENO level>25 parts per billion (ppb).Results A total of 849 COPD patients (mean age, 70.3±9.4 years) were included. The mean forced expiratory volume at 1 second was 66.5±21.7% and the mean FENO level was 24.3±20.5 ppb. Patients with FENO ≤25 ppb were 572 (67.4%) and those with FENO >25 ppb were 277 (32.6%). Blood eosinophil percentage was significantly higher (4.2±4.8 vs. 2.7±2.5, p<0.001) in patients with the high FENO group than the low FENO group. The high FENO group revealed a significantly higher frequency of patients with blood eosinophil percentage >3% (46.9% vs. 34.8%, p=0.001) and asthma history (25.6% vs. 8.6%, p<0.001) than the lower FENO group. Asthma history, blood eosinophil percentage >3%, and positive bronchodilator response (BDR) were independent risk factors for the high FENO level (adjusted odds ratio [aOR], 3.85; p<0.001; aOR, 1.46; p=0.017; and aOR, 1.57, p=0.034, respectively) in the multivariable analysis.Conclusion The FENO level distribution varied in COPD patients and the mean FENO value was slightly elevated. Asthma history, eosinophil percent, and positive BDR were independent risk factors for the high FENO level.

Role of pulmonary function and FeNO detection in early screening of patients with ACO.

Measurement of fractional exhaled nitric oxide (FeNO) is a quantitative and non-invasive approach to examine airway inflammation, which is a powerful aid in diagnosing chronic disorders of airways like asthma. Diagnostic value of FeNO and relevant indices on pulmonary function in the patients with asthma and chronic obstructive pulmonary disease (COPD) was evaluated. A total of 164 patients [58 asthma, 49 COPD and 57 asthma-COPD overlap (ACO)] were randomly recruited. FeNO, pulmonary ventilation function, and bronchial diastolic function were performed. Eight indicators including FeNO, vital capacity percentage (VC%), forced vital capacity percentage (FVC%), forced expiratory volume in one second percentage (FEV1%), forced expiratory volume in one second to forced vital capacity percentage (FEV1/FVC%), maximum independent ventilation volume percentage (MVV%), the increased percentage of FEV1 after bronchial diastolic test, the increased absolute value of FEV1 after bronchial diastolic test were examined. Significant difference in VC%, FVC%, FEV1%, FEV1/FVC%, MVV%, the increased absolute value of FEV1 after bronchial diastolic test and FeNO were significantly different between patients with asthma and patients with COPD (P<0.05). There were significant differences of VC%, FVC%, FEV1%, FEV1/FVC%, MVV% and the increased percentage of FEV1 after bronchial diastolic test in cases of patients with asthma compared to ACO patients (P<0.05). There was no statistical significance on VC%, FVC%, FEV1%, FEV1/FVC%, MVV% between COPD patients and ACO patients (P>0.05). However, more importantly, the increased percentage of FEV1 after bronchial diastolic test, the increased absolute value of FEV1 after bronchial diastolic test and the alterations on FeNO were found significantly different in ACO group compared with COPD alone (P<0.05). We compared the results from pulmonary ventilation function, bronchial diastolic function examination as well as FeNO detection among 3 groups of asthma, COPD and ACO. The examination of pulmonary ventilation function and bronchial diastolic function combined with FeNO detection is helpful in the early screening of ACO.

Fractional exhaled nitric oxide in adult congenital heart disease

BackgroundFractional exhaled nitric oxide levels are related to various clinical diseases. This study investigated the associations between the clinical characteristics and the level of fractional exhaled nitric oxide in patients with adult congenital heart disease. Methods and resultsFractional exhaled nitric oxide values were measured in 30 adult patients with stable congenital heart disease who had undergone right heart catheterization and 17 healthy individuals (controls). There was no significant difference in fractional exhaled nitric oxide values between patients with congenital heart disease and healthy controls. Depending on whether their fractional exhaled nitric oxide values were above or below the median value, patients with congenital heart disease were divided into two groups (low vs. high fractional exhaled nitric oxide groups). The relationship between fractional exhaled nitric oxide values and clinical characteristics was investigated. There was a higher percentage of patients with cyanosis in the low fractional exhaled nitric oxide group (50%) than in the high fractional exhaled nitric oxide group (7.1%). There was no significant difference in right heart catheterization data between the low and high fractional exhaled nitric oxide groups. The fractional exhaled nitric oxide value was correlated to the number of neutrophils in patients with cyanosis (r = 0.84 (N = 8), p = 0.005). ConclusionsIn this cohort of patients with adult congenital heart disease, lower levels of fractional exhaled nitric oxide corresponded to the presence of cyanosis.

Correlation between fractional exhaled nitric oxide and Asthma Control Test score and spirometry parameters in on-treatment-asthmatics in Ho Chi Minh City.

BackgroundAlthough fractional exhaled nitric oxide (FeNO) is a reliable and easily applied marker of airway inflammation in asthma, the relationship between FeNO and indicators of asthma control [Asthma Control Test (ACT) score] and/or severity (spirometry parameters) remains unclear. This study aims to determine possible correlations between FeNO and ACT score; and between FeNO and spirometry parameters.MethodsA cross-sectional study with convenience sampling was conducted among ambulatory patients in the Asthma & COPD clinic at the University Medical Center, Ho Chi Minh City from March 2016 to March 2017. Using measurement of FeNO, the ACT questionnaire and a spirometry test, correlations were determined between FeNO and the ACT score and spirometry parameters.ResultsFour hundred and ten asthmatic patients (mean age 42 years; 65% female) were included and analyzed; their mean time since onset of asthma was 9.5 years. All patients were treated following step 2 to 4 of GINA guidelines. Mean (SD) FeNO was 29.5 (24.4) parts per billion (ppb) and mean (SD) ACT score was 20.5 (40). A significant difference in FeNO values was found among the three groups with different asthma control levels categorized according to the ACT score (P=0.001) but was not found among the three groups with different asthma treatment levels (P=0.425). FeNO was significantly inversely correlated with the ACT score (Spearman’s r =−0.224, P<0.001) and with spirometry parameters indicate airway obstruction such as predicted FEV1, FEV1/FVC, predicted PEF and predicted FEF25–75% with Spearman’s r were −0.187; −0.143; −0.091 and −0.195, respectively (all P<0.05), whereas no correlation between FeNO and FVC—an indicator of airway restriction—was found.ConclusionsIn these asthmatic patients in Vietnam, an inverse correlation was found between FeNO and the ACT score and between FeNO and spirometry indicators of airway obstruction. Therefore, FeNO may be a useful tool in asthma management.

Role of the Bronchodilator Test Defined by the Forced Vital Capacity in Chronic Obstructive Pulmonary Disease Phenotyping.

PurposeIn clinical practice, some chronic obstructive pulmonary disease (COPD) patients experienced a remarkable increase in forced vital capacity (FVC) after bronchodilator administration, whereas forced expiratory volume in the first second (FEV1) remains substantially unchanged. We assume this may relate to airway inflammatory type. We aim to analyze the clinical characteristics and explore the usefulness of the bronchodilator test, especially FVC, in this new COPD phenotype.Patients and MethodsA total of 346 COPD patients with exacerbation who underwent bronchodilator tests, fractional exhaled nitric oxide (FeNO) measurements and blood eosinophil counts were analyzed. The characteristics, FeNO levels, and blood eosinophil counts were compared between patients with and without significant bronchodilator responsiveness in terms of FVC.ResultsPatients with significant FVC responsiveness displayed poorer lung function and higher FeNO levels compared with those without considerable FVC responsiveness (Z= −5.042 to −0.375, p=0.000–0.022). There is a discernible linear relationship between FeNO levels and FVC responsiveness to bronchodilator use (r=0.251, P=0.001). The application of bronchodilator responsiveness of FVC for detecting high FeNO levels in COPD patients exhibited relatively high sensitivity (61.8%) and specificity (86.7%).ConclusionWe demonstrated that COPD patients with significant FVC responsiveness had higher FeNO levels than non-responders and established a simple method for detecting high FeNO values. FVC responders may be identified as a separate group of COPD patients.

Patients with psoriatic arthritis have higher levels of FeNO than those with only psoriasis, which may reflect a higher prevalence of a subclinical respiratory involvement.

Psoriatic arthritis (PsA) patients are often affected by numerous comorbidities. However, contrasting results have been reported with regard to the respiratory involvement in PsA patients. The aim of this study was to evaluate the presence of subclinical airway inflammation in non-smoking PsA patients compared to patients with only psoriasis using the fraction of exhaled nitric oxide (FeNO) as an indirect marker of airway inflammation. The study included 164 non-smoking psoriatic patients (Psoriasis Area of Severity Index or PASI score > 10): 82 with and 82 without PsA, who underwent FeNO tests at different flow rates (30, 50, 100, 200mL/s). PsA patients were evaluated with Disease Activity in PSoriatic Arthritis Score (DAPSA). Both study groups were compared in terms of FeNO values and its association with the PASI score. The correlations between the variables were evaluated by means of Pearson's coefficient. Patient with PsA had higher levels of FeNO than those with psoriasis but without arthritis (at 30mL/s, 71.09 ± 18.40ppb vs 66.88 ± 19.12ppb (NS); at 50mL/s, 36.61 ± 9.30ppb vs 30.88 ± 9.73ppb (p < 0.001); at 100mL/s, 19.09 ± 4.66ppb vs 16.63 ± 4.90ppb (p < 0.001); and at 200mL/s, 10.88 ± 2.53ppb vs 9.43 ± 2.55ppb (p < 0.001), respectively). PASI score correlated to FeNO only in psoriatic patients without arthritis. However, CASPAR index correlated with FeNO (FeNO30: r = 0.81, p < 0.001; FeNO50: r = 0.84, p < 0.001; FeNO100: r = 0.71, p < 0.001; FeNO200: r = 0.58, p < 0.001). DAPSA was also correlated with FeNO to all flows (FeNO30: r = 0.43, p < 0.001; FeNO50: r = 0.33, p < 0.001; FeNO100: r = 0.34, p < 0.001; FeNO200: r = 0.25, p < 0.001). PsA patients seem to have more commonly subclinical airway inflammation than those with only psoriasis. Further studies are needed to replicate these findings. Key Points • Fraction of exhaled nitric oxide (FeNO) is a useful device to detect and monitor airway inflammation not only in asthma but also in systemic inflammatory diseases such as psoriatic arthritis and psoriasis. • Clinicians should be aware to check respiratory diseases in patients with psoriatic arthritis.

Fraction of exhaled nitric oxide measured by NO breath® correlate with airway hyperreactivity

Measurement of fraction of exhaled nitric oxide (FeNO) concentration in the breath of patients with asthma is non-invasive and useful method to assess eosinophilic or type 2 airway inflammation. However, results vary with the type of device used. The association between airway hyperreactivity (AHR) and FeNO measured using NO breath® (Bedfont Scientific, Maidstone, UK) is unknown. We included 62 consecutive patients with asthma who underwent FeNO quantification (NO breath®) and AHR examination at our hospital. The exclusion criteria were administration of systemic corticosteroids, pregnancy and current smoking habit. AHR was detected using histamine. The FeNO value was negatively correlated with AHR (r= -0.3915, p=0.037). This outcome was confirmed both ICS-positive and -negative patients. Additionally, FeNO was positively correlated with the eosinophil count in the blood. FeNO measured using NO breath® is associated with AHR using histamine.

Triple Therapy with Budesonide/Glycopyrrolate/Formoterol Fumarate Improves Inspiratory Capacity in Patients with Asthma-Chronic Obstructive Pulmonary Disease Overlap.

PurposeAsthma-chronic obstructive pulmonary disease overlap (ACO), characterized by airway limitation, is an important condition with high incidence and mortality. Although some guidelines recommend triple therapy with inhaled corticosteroids/long-acting muscarinic antagonists/long-acting β2 agonists, this treatment approach is based on the extrapolation of data from studies of asthma or chronic obstructive pulmonary disease (COPD) alone.MethodsA 12-week, randomized, open-label cross-over pilot study was conducted in 19 patients with ACO to investigate the effect of triple therapy with glycopyrrolate (GLY) 50 µg/day on budesonide/formoterol fumarate (BUD/FORM) 640/18 µg/day. The study period included a 4-week wash-out, 4-week run-in, and 4-week treatment period. Respiratory function tests, fractional exhaled nitric oxide (FeNO), a COPD assessment test (CAT) and an asthma control questionnaire (ACQ) were carried out 0, 4, and 8 weeks after randomization.ResultsA total of 19 patients with stable ACO (19 males and no females) with a mean age of 70.7 ± 7.6 years (± standard deviation, SD; range 55–83 years) participated in this study. All patients were ex-smokers with a smoking history of 63.1 ± 41.1 pack-years (± SD). Mean values for inspiratory capacity (IC), an index of hyperinflation of the lung that causes exertional dyspnea and reduced exercise, were 1.93 L (± 0.47 L) after the run-in, 1.85 L (± 0.51 L) after the BUD/FORM dual therapy period and 2.11 L (± 0.58 L) after the BUD/GLY/FORM triple therapy period. IC values after the BUD/GLY/FORM triple therapy were significantly higher than those after the run-in (p < 0.02). FeNO values, ACQ, and CAT scores were not significantly different among the run-in, wash-out, and triple-therapy periods.ConclusionThe present pilot study showed that triple therapy with BUD/GLY/FORM results in an improvement in lung function parameters including IC, indicating the potential value of triple therapy as standard treatment for ACO.