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Sputum Tests and Exhaled NO in the Diagnosis and Monitoring of Asthma

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Allergy Frontiers: Diagnosis and Health Economics

Part of the book series: Allergy Frontiers ((ALLERGY,volume 4))

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Optimal control of asthma has yet to be achieved globally, as costs of care continue to mount, patient quality of life remains inadequate and mortality rates are unacceptably high. While prevalence rates are rising, asthma continues to be under-diagnosed and under-treated. Because of disease heterogeneity, it is difficult to determine the type and dose of medication that will afford patients the best risk/benefit ratio and to determine which patients will or will not develop irreversible airflow limitation. Poor patient compliance/adherence can negatively impact outcomes and must also be assessed.

While inflammation is an essential component of asthma, current practice parameters do not include its measurement in the diagnosis or management of disease. Studies employing surrogate markers of inflammation to orchestrate therapy, including induced sputum for eosinophils and methacholine sensitivity, a measure of airways hyper-reactivity, have revealed improved asthma outcomes. While these studies are less invasive than the direct assessment of inflammation with bronchial biopsy and/or evaluation of BAL washings, they are still time consuming and labor intensive and impractical for routine asthma management.

Inducible nitric oxide synthase (iNOS) is produced predominantly by airway epithelial cells and is up-regulated as part of the inflammatory process resulting in elevated levels of fractional exhaled nitric oxide (FENO) in patients with asthma. As there is a positive correlation between airway hyper-reactivity, sputum eosinophilia and FENO, this surrogate marker of eosinophilic inflammation, which is non-invasive and is quickly and easily measured, has significant potential as an “inflammometer” in the management of asthma. Despite some controversy, studies indicate that the evaluation of FENO, which is more sensitive, but correlates poorly with pulmonary function, should prove to be a valuable adjunct to current guideline recommendations.

Although further studies are needed to understand the scope and potential impact of measuring FENO, it appears to fulfill an unmet need by providing a simple, non-invasive well-tolerated, standardized and reproducible test that is a surrogate measure of eosinophilic airway inflammation in patients with asthma. When used to complement standard monitoring tools, improved asthma outcomes appear likely.

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Authors and Affiliations

  1. Medicine, State University of New York, Stony Brook Medical Center, 9 Cypress Drive, Woodbury, NY, 11797, USA

    Myron Zitt

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  1. Myron Zitt
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  1. Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, Japan

    Ruby Pawankar

  2. Southampton General Hospital, University of Southampton, Tremona Road, Southampton, UK

    Stephen T. Holgate

  3. UMKC School of Medicine, Children's Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO, 64108, USA

    Lanny J. Rosenwasser

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Zitt, M. (2009). Sputum Tests and Exhaled NO in the Diagnosis and Monitoring of Asthma. In: Pawankar, R., Holgate, S.T., Rosenwasser, L.J. (eds) Allergy Frontiers: Diagnosis and Health Economics. Allergy Frontiers, vol 4. Springer, Tokyo. https://doi.org/10.1007/978-4-431-98349-1_5

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