Exhaled nitric oxide in acute exacerbation of pediatric asthma
Keywords:
exhaled nitric oxide, asthma exacerbations, eosinophils, FEV1
Abstract
Background Measurement of exhaled nitric oxide (eNO) is a non-invasive and easy method to monitor airway inflammation.
Objectives To compare the levels of eNO during and after an
exacerbation of asthma, to evaluate the effect of glucocor-
ticosteroids (GCS) on the levels of eNO and to correlate eNO
with other markers of inflammation such as symptom scores, FEV 1
and sputum eosinophils.
Methods The observational study was performed over 24 months
at a tertiary paediatric hospital. Subjects underwent eNO
measurement, spirometry and sputum induction during an asthma
exacerbation and then two weeks later. A symptom score was
recorded everyday for two weeks. All subjects were treated with
ß 2 -adrenergic agonists and an oral glucocorticosteroid (GCS).
Results Fifteen subjects with acute asthma exacerbation aged 5
and 16 years old participated in the study. The mean level of
eNO during the acute exacerbation was significantly higher than
eNO levels at the follow-up visit, 11.2 (95%CI 9.2;13.2) vs. 8.0
(95%CI 5.0;11.1) ppb, P=0.03. In the acute exacerbation, eNO
correlated with sputum eosinophils (P=0.04), but no correlation
could be found between eNO and the other markers of
inflammation during exacerbation or follow up.
Conclusions eNO level increased during asthma exacerbation and
decreased after two weeks of glucocorticosteroid therapy.
Measurement of eNO is a practical monitoring method in
emergency management of asthmatic children.
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Chavis C, Bousquet J, et al. Eosinophilic inflammation in
sputum of poorly controlled asthmatics. Eur Respir J
2002:1370-7.
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Mahony J, Dolovich J, et al. Sputum in severe exacerbations
of asthma: kinetics of inflammatory indices after prednisone
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36. Jatakanon A, Lim S, Barnes PJ. Changes in sputum
eosinophils predict loss of asthma control. Am J Respir Crit
Care Med 2000;161:64-72.
37. Sont JK, Han J, van Krieken JHJM, Evertse CE, Hooijer R,
Willems LNA, et al. Relationship between the inflammatory
infiltrate in bronchial biopsy specimens and clinical severity
of asthma in patients treated with inhaled steroids. Thorax
1996;51:496-502.
38. Nguyen V, Morton J, Henry RL, Thomas PS. Exhaled nitric
oxide in acute paediatric asthma. Respirology 2004;9S:A29.
N Eng J Med 2001;344:350-62.
2. Nelson BV, Sears S, Woods J, Ling CY, Hunt J, Clapper LM,
et al. Expired nitric oxide as a marker for childhood asthma.
J Pediatr 1997;130:423-7.
3. Thomas PS, Gibson PG, Wang H, Shah S, Henry RL. The
relationship of exhaled nitric oxide to airway inflammation
and responsiveness in children. J Asthma 2005;42:291-9.
4. Alving K, Weitzberg E, Lundberg JM. Increased amount of
nitric oxide in exhaled air of asthmatics. Eur Respir J
1993;6:1368-70.
5. Frank TL, Adisesh A, Pickering AC, Morrison JFJ, Wright
T, Francis H, et al. Relationship between exhaled nitric oxide
and childhood asthma. Am J Respir Crit Care Med
1998;158:1032-6.
6. Massaro AF, Gaston B, Kita D, Fanta C, Stamler JS, Drazen
JM. Expired nitric oxide levels during treatment of acute
asthma. Am J Respir Crit Care Med 1995;152:800-3.
7. Kharitonov SA, Yates DH, Barnes PJ. Inhaled glucocorticoids
decrease nitric oxide in exhaled air of asthmatic patients.
Am J Respir Crit Care Med 1996;153:454-7.
8. Lanz MJ, Leung DY, White CW. Comparison of exhaled nitric
oxide to spirometry during emergency treatment of asthma
exacerbations with glucocorticoids in children. Ann Allergy
Asthma Immunol 1999;82:161-4.
9. Baraldi E, Azzolin N, Nicoletta M, Zanconato S, Dario C,
Zaccello F. Corticosteroids decrease exhaled nitric oxide in
children with acute asthma. J Pediatr 1997;13:381-5.
10. Hamid Q, Springall DR, Riveros-Moreno V, Chanez P,
Howarth P, Redington A, et al. Induction of nitric oxide
synthase in asthma. Lancet 1993;342:1510-3.
11. Yates DH, Kharitonov SA, Robbins RA, Thomas PS, Barnes
PJ. Effect of a nitric oxide synthase inhibitor and
glucocorticosteroid on exhaled nitric oxide. Am J Respir Crit
Care Med 1995;152:892-6.
12. Crater SE, Peters EJ, Martin ML, Murphy AW, Platts-Mills
TAE. Expired nitric oxide and airway obstruction in asthma
patients with an acute exacerbation. Am J Respir Crit Care
Med 1999;159:806-11.
13. Warke TJ, Fitch PS, Brown V, Taylor R, Lyons JDM, Ennis
M, et al. Exhaled nitric oxide correlates with airway
eosinophils in childhood asthma. Thorax 2002;57:383-7.
14. Jatakanon A, Lim S, Kharitonov SA, Chung KF, Barnes PJ.
Correlation between exhaled nitric oxide, sputum eosi-
nophils, and methacholine responsiveness in patients with
mild asthma. Thorax 1998;53:91-5.
15. Mattes J, Van’s Gravesande S, Reining U, Alving K, Ihorst
G, Henschen M, et al. NO in exhaled air is correlated with
markers of eosinophilic airway inflammation in corti-
costeroid-dependent childhood asthma. Eur Respir J
1999;13:1391-5.
16. Piacentini G, Bodini A, Costella S, Vicentini L, Mazzi P,
Sperandio S, et al. Exhaled nitric oxide and sputum eosinophil
markers of inflammation in asthmatic children. Eur Respir J
1999;13:1386-90.
17. Khan MSR, O’Meara M, Henry RL. Background severity of
asthma in children discharged from the emergency
department. J Paediatr Child Health 2003;39:432-5.
18. Reddel H, Jenkins C, Woolcock A. Diurnal variability-time
to change asthma guidelines? BMJ 1999;319:45-7.
19. American Thoracic Society. ATS/ERS Recommendations for
standardized procedures for the online and offline
measurement of exhaled lower respiratory nitric oxide and
nasal nitric oxide, 2005. Am J Respir Crit Care Med
2005;171:912-30.
20. Pin I, Gibson PG, Kolendowicz R, Girgis-Gabardo, Denburg
JA, Hargreave FE, et al. Use of induced sputum cell counts
to investigate airway inflammation in asthma. Thorax
1992;47:25-9.
21. Gibson PG, Simpson JL, Hankin R, Powell H, Henry RL.
Relationship between induced sputum eosinophils and the
clinical pattern of childhood asthma. Thorax 2003;58:116-
21.
22. Gibson PG, Wlodarczyk JW, Hensley MJ, Gleeson M, Henry
RL, Cripps AL, et al. Epidemiological association of airway
inflammation with asthma symptoms and airway hyper-
responsiveness in childhood. Am J Respir Crit Care Med
1998;158:36-41.
23. Corradi M, Pelizzoni A, Majori M, Cuomo A, de’ Munari E,
Pescia A. Influence of atmospheric nitric oxide concentration
on the measurement of nitric oxide in exhaled air. Thorax
1998;53:673-6.
24. Global strategies for asthma management and prevention.
Available from: url: http://www.ginasthma.org.
25. National Asthma Council. Asthma Management Handbook.
Melbourne: National Asthma Council of Australia; 2002. p.
1-84.
26. Littenberg B, Gluck EH. A controlled trial of methyl-
prednisolone in the emergency treatment of acute asthma.
N Eng J Med 1986;314:150-2.
27. Chapman KR, Verbeek PR, White JG, Rebuck AS. Effect of
a short course of prednisolone in the prevention of early
relapse after emergency room treatment of acute asthma. N
Eng J Med 1991;324:788-94.
28. Beck-Ripp J, Griese M, Arenz S, Koring C, Pasqualoni B,
Bufler P. Changes of exhaled nitric oxide during steroid
treatment of childhood asthma. Eur Respir J 2002;19:1015-
9.
29. Gill M, Walker S, Khan A, Green SM, Kim L, Gray S, et al.
Exhaled nitric oxide levels during acute asthma exacerbation.
Acad Emerg Med 2005;12:579-86.
30. Stirling RG, Kharitonov SA, Campbell D, Robinson DS,
Durham SR, Chung KF, et al. Increase in exhaled nitric oxide
levels in patients with difficult asthma and correlation with
symptoms and disease severity despite treatment with oral
and inhaled corticosteroids. Thorax 1998;53:1030-4.
31. Deykin A, Lazarus S, Fahy J, Wechsler M, Boushey H,
Chinchilli V, et al. Sputum eosinophil counts predict asthma
control after discontinuation of inhaled corticosteroids.
Journal of Allergy and Clinical Immunology 2005;115:720-
7.
32. Jatakanon A, Kharitonov S, Lim S, Barnes PJ. Effect of
differing doses of inhaled budesonide on markers of airway
inflammation in patients with mild asthma. Thorax
1999;54:108-14.
33. James AL, Maxwell PS, Elliot JG. Comparison of sputum
induction using inhaled methacholine or hypertonic saline.
Respirology 2005;10:57-62.
34. Romagnoli M, Vachier I, Tarodo de la Fuente P, Meziane H,
Chavis C, Bousquet J, et al. Eosinophilic inflammation in
sputum of poorly controlled asthmatics. Eur Respir J
2002:1370-7.
35. Pizzichini MM, Pizzichini E, Clelland L, Efthimiadis A,
Mahony J, Dolovich J, et al. Sputum in severe exacerbations
of asthma: kinetics of inflammatory indices after prednisone
treatment. Am J Respir Crit Care Med 1997;155:1501-8.
36. Jatakanon A, Lim S, Barnes PJ. Changes in sputum
eosinophils predict loss of asthma control. Am J Respir Crit
Care Med 2000;161:64-72.
37. Sont JK, Han J, van Krieken JHJM, Evertse CE, Hooijer R,
Willems LNA, et al. Relationship between the inflammatory
infiltrate in bronchial biopsy specimens and clinical severity
of asthma in patients treated with inhaled steroids. Thorax
1996;51:496-502.
38. Nguyen V, Morton J, Henry RL, Thomas PS. Exhaled nitric
oxide in acute paediatric asthma. Respirology 2004;9S:A29.
Published
2008-05-01
How to Cite
1.
Ratnawati R, Nguyen V, Morton J, Henry R, Thomas P. Exhaled nitric oxide in acute exacerbation of pediatric asthma. PI [Internet]. 1May2008 [cited 22Dec.2024];48(2):64-0. Available from: https://paediatricaindonesiana.org/index.php/paediatrica-indonesiana/article/view/480
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Received 2016-09-07
Accepted 2016-09-07
Published 2008-05-01
Accepted 2016-09-07
Published 2008-05-01
