Use of Fractional Exhaled Nitric Oxide to Guide the Treatment of Asthma: An Official American Thoracic Society Clinical Practice Guideline

Abstract

Background: The fractional exhaled nitric oxide (FE NO ) test is a point-of-care test that is used in the assessment of asthma.Objective: To provide evidence-based clinical guidance on whether FE NO testing is indicated to optimize asthma treatment in patients with asthma in whom treatment is being considered.Methods: An international, multidisciplinary panel of experts was convened to form a consensus document regarding a single question relevant to the use of FE NO . The question was selected from three potential questions based on the greatest perceived impact on clinical practice and the unmet need for evidencebased answers related to this question. The panel performed systematic reviews of published randomized controlled trials between 2004 and 2019 and followed the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) evidence-to-decision framework to develop recommendations. All panel members evaluated and approved the recommendations.Main Results: After considering the overall low quality of the evidence, the panel made a conditional recommendation for FE NO -based care. In patients with asthma in whom treatment is being considered, we suggest that FE NO is beneficial and should be used in addition to usual care. This judgment is based on a balance of effects that probably favors the intervention; the moderate costs and availability of resources, which probably favors the intervention; and the perceived acceptability and feasibility of the intervention in daily practice.Conclusions: Clinicians should consider this recommendation to measure FE NO in patients with asthma in whom treatment is being considered based on current best available evidence.

Pulmonary Procedures During the COVID-19 Pandemic: A Work Group Report of the AAAAI Asthma Diagnosis and Treatment (ADT) Interest Section

“…8 Evidence has supported the greater risk of COVID-19 spread with aerosolized particles especially indoors and with greater expiratory activity. Bazant and Bush 8 calculated the relative infectious quanta of COVID-19/m 3 across a range of physiologic activities from nasal tidal breathing (1.1) to quiet speech (29) to loud speech (104) to singing (970). These relative quanta corresponded in trend and magnitude to a greater fraction of aerosolized particles from 0.2 to 5 mm.…”

“…FeNO is a quantitative biomarker of type 2 airway inflammation that is useful for evaluating patients with chronic cough and for determining corticosteroid responsiveness in patients with underlying eosinophilic asthma. 29 The testing characteristics of FeNO are favorable because it is noninvasive, can easily be repeated, and requires a simpler technique than other pulmonary tests. Furthermore, FeNO has not been identified as an AGP by the CDC, ATS, OSHA, and other national and international organizations including the latest NHLBI asthma guidelines.…”

Adolescent Athletes at Risk of Exercise-Induced Bronchoconstriction: A Result of Training or Pre-Existing Asthma?

“…The fractional exhaled nitric oxide (FeNO) measurements were performed according to the ATS/ERS recommendations, with a chemiluminescence analyzer (model 280i fractional exhaled nitric oxide analyzer: Sievers, Boulder, CO, USA) and defined in parts per billion (ppb) [ 13 ]. The analyzer provides online, continuous measurements of FeNO per a single exhalation, with a detection range of 0.1–500 ppb.…”

Targeting Downstream Type 2 Cytokines or Upstream Epithelial Alarmins for Severe Asthma

“…46 Similarly, thresholds of <25, !25, and !50 ppb were used to represent low, medium, and high levels of FeNO according to current American Thoracic Society guidelines. 47 The recommendations stratified by high, medium, and low levels of PBE and FeNO are based on the following considerations. First, in patients with moderate PBE together with moderate or high FeNO, either anti-IL-5(ra) or anti-IL-4ra could potentially be used as first line as both have been shown to be effective in T2 high disease.…”