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Published ahead of print on May 11, 2007, doi:10.1164/rccm.200610-1427OC

Am. J. Respir. Crit. Care Med., Volume 176, Number 3, August 2007, 231-237

A more recent version of this article appeared on August 1, 2007
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Submitted on October 5, 2006
Accepted on May 10, 2007

The Use of Exhaled Nitric Oxide to Guide Asthma Management: A Randomised Controlled Trial

Dominick E Shaw1, Mike A Berry1, Mike Thomas2, Ruth H Green1, Chris E Brightling1, Andrew J Wardlaw1, and Ian D Pavord1*

1 Department of Respiratory Medicine and Thoracic Surgery, Institute for Lung Health, Glenfield Hospital, Leicester, Leicestershire, United Kingdom, 2 Department of General Practice, University of Aberdeen, Aberdeen, Aberdeenshire, United Kingdom

* To whom correspondence should be addressed. E-mail: ian.pavord{at}uhl-tr.nhs.uk.

Rationale: Current asthma guidelines recommend adjusting anti-inflammatory treatment on the basis of the results of lung function tests and symptom assessment, neither of which are closely associated with airway inflammation. Objectives: We tested the hypothesis that titrating corticosteroid dose using the concentration of exhaled nitric oxide in exhaled breath (FENO) results in fewer asthma exacerbations and more efficient use of corticosteroids, when compared to traditional management. Methods: 118 participants with a primary care diagnosis of asthma were randomised to a single blind trial of corticosteroid therapy based on either FENO measurements (n = 58) or British Thoracic Society guidelines (n = 60). Participants were assessed monthly for 4 months and then two monthly for a further 8 months. The primary outcome was the number of severe asthma exacerbations. Analyses were by intention to treat. Measurements and Main Results: The estimated mean (SD) exacerbation frequency was 0.33/patient/year (0.69) in the FENO group and 0.42 (0.79) in the control group (mean difference -21% [95% CI -57% to 43%] p=0.43). Overall the FENO group used 11% more inhaled corticosteroid ([95% CI -17% to 42%] p=0.40), although the final daily dose of inhaled corticosteroid was lower in the FENO group (557µg vs. 895µg, mean difference 338µg [95% CI -640 to -37] p=0.028). Conclusion: An asthma treatment strategy based on the measurement of exhaled nitric oxide did not result in a large reduction in asthma exacerbations or in the total amount of inhaled corticosteroid therapy used over 12 months, when compared with current asthma guidelines. www.controlled-trials.com i.d. = ISRCTN08067387
Key words: asthma, asthma exacerbations, exhaled nitric oxide, airway inflammation




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