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Published ahead of print on May 18, 2005, doi:10.1164/rccm.200411-1498OC

Am. J. Respir. Crit. Care Med., Volume 172, Number 4, August 2005, 453-459

A more recent version of this article appeared on August 15, 2005
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Submitted on November 10, 2004
Accepted on May 14, 2005

Exhaled Nitric Oxide: A Predictor of Steroid Response

Andrew D Smith1, Jan O Cowan1, Karen P Brassett1, Sue Filsell1, Chris McLachlan1, Gabrielle Monti-Sheehan1, G. Peter Herbison1, and D. Robin Taylor1*

1 Otago Respiratory Research Unit, Dunedin School of Medicine, University of Otago Medical School, Dunedin, New Zealand

* To whom correspondence should be addressed. E-mail: robin.taylor{at}stonebow.otago.ac.nz.

Rationale: The initial management of patients who present with persistent respiratory symptoms includes recognizing those with the potential to benefit from inhaled steroid therapy. To date, this has required undertaking a "trial of steroid" in order to identify responders. There is increasing evidence that steroid response is more likely in patients with eosinophilic airway inflammation, and this can be assessed indirectly using exhaled nitric oxide (FENO) measurements. Objectives: We aimed to assess the predictive accuracy of FENO to identify steroid response in 52 patients presenting with undiagnosed respiratory symptoms in a single-blind, fixed-sequence, placebo-controlled trial of inhaled fluticasone for 4 weeks. Methods: Comparisons of predictive accuracy were made between FENO and other conventional predictors: peak flows, spirometry, bronchodilator response, and airway hyper-responsiveness (AHR) measured at baseline. "Steroid response" was defined as change in symptoms, peak flows, spirometry, or AHR to adenosine based on established guidelines and recommendations. Results: Steroid response was significantly greater in the highest FENO tertile (>47ppb) for each end-point. This outcome was independent of the diagnostic label. The predictive values for FENO were significantly greater than for almost all other baseline predictors with an optimum cut-point of 47ppb. Conclusions: We conclude that FENO measurements greater than 47ppb provide a means of predicting steroid response in patients with undiagnosed respiratory symptoms. Assessing airway inflammation is of more practical value than diagnostic labelling when considering the potential usefulness of inhaled anti-inflammatory therapy.
Key words: Exhaled nitric oxide, inhaled corticosteroid, asthma, symptoms, treatment response




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