Allergy Asthma Immunol Res.  2018 Sep;10(5):478-489. 10.4168/aair.2018.10.5.478.

Measurement of Exhaled Nitric Oxide in Children: A Comparison Between NObreath® and NIOX VERO® Analyzers

• Inoue Y
• Sato S
• Manabe T
• Makita E
• Chiyotanda M
• Takahashi
• Yamamoto H
• Yanagida N
• Ebisawa M

• KMID: 2418046
• DOI: http://doi.org/10.4168/aair.2018.10.5.478

Abstract

PURPOSE
Few studies have compared fractional exhaled nitric oxide (FeNO) measurement by NIOX VERO® (NOV) and other devices in children. Moreover, there is no agreement between differences in FeNO values obtained using different devices in adults. Here, we compared FeNO values obtained using NOV and NObreath® (NOB) systems to derive a correction equation for children.
METHODS
Eighty-eight participants (age 7-15 years) who were diagnosed with atopic bronchial asthma and visited Sagamihara National Hospital as outpatients between January and April of 2017 were included. We measured FeNO values obtained using NOB and NOV, and analyzed them using Wilcoxon tests and Altman-Bland plots.
RESULTS
The median age of the participants was 11.5 years, and the scored Asthma Control Test (ACT) or Childhood ACT (C-ACT) was 25 (interquartile range, 24-25) or 26 (24-27). NOB and NOV values were significantly different (31 [14-52] versus 36 [20-59] ppb; P = 0.020) and strongly correlated (r = 0.92). An equation to convert NOB values into NOV values was derived using linear regression as follows: log NOV = 0.7329 × log NOB + 0.4704; NOB for 20, 40, 58, 80 and 100 ppb corresponded to NOV for 27, 44, 59, 73 and 86 ppb. Thus, NOB < 58 ppb suggested NOB < NOV, whereas NOB > 58 ppb suggested NOB > NOV.
CONCLUSIONS
NOB and NOV values were strongly correlated. Participants whose FeNO values were relatively low represented NOB < NOV, whereas those whose FeNO values were relatively high represented NOB > NOV.

Keyword

Bronchial asthma; exhalation; nitric oxide

MeSH Terms

Adult
Asthma
Child*
Exhalation
Humans
Linear Models
Nitric Oxide*
Outpatients
Nitric Oxide

Figure

• 

  Fig. 1 Study flow chart. Eighty-eight participants (outpatients; ages 7–15 years) who were diagnosed with atopic bronchial asthma were subjected to FeNO measurement using NObreath® and NIOX VERO®.

• 

  Fig. 2 FeNO values obtained using NObreath® and NIOX VERO® devices. FeNO, fractional exhaled nitric oxide. *Wilcoxon test.

• 

  Fig. 3 Correlation between log NOB and log NOV. The x-axis represents log NOB (ppb), and the y-axis represents log NOV (ppb). r = 0.92, the continuous and dotted lines represent linear regression and the range of the 95% confidence interval, respectively. NOB, NObreath®; NOV, NIOX VERO®.

• 

  Fig. 4 Altman-Bland plots showing differences between log NOB and log NOV. Agreement between NOB and NOV values was determined using Altman-Bland plots comparing the interdevice mean with the interdevice difference. NOB, NObreath®; NOV, NIOX VERO®; SD, standard deviation.

• 

  Fig. 5 Comparison of the ages of participants who were able to undergo acceptable NIOX VERO® measurements on the first attempt or after many attempts. *Mann-Whitney test.

• 

  Fig. 6 Comparison of VASs obtained using NObreath® and NIOX VERO® devices. The difficulty in using each device was assessed using VAS. VAS, visual analog scales.

Reference

1. Pohunek P, Warner JO, Turzíková J, Kudrmann J, Roche WR. Markers of eosinophilic inflammation and tissue re-modelling in children before clinically diagnosed bronchial asthma. Pediatr Allergy Immunol. 2005; 16:43–51.

2. Smith AD, Cowan JO, Filsell S, McLachlan C, Monti-Sheehan G, Jackson P, et al. Diagnosing asthma: comparisons between exhaled nitric oxide measurements and conventional tests. Am J Respir Crit Care Med. 2004; 169:473–478.

3. Smith AD, Cowan JO, Brassett KP, Filsell S, McLachlan C, Monti-Sheehan G, et al. Exhaled nitric oxide: a predictor of steroid response. Am J Respir Crit Care Med. 2005; 172:453–459.

4. Knuffman JE, Sorkness CA, Lemanske RF Jr, Mauger DT, Boehmer SJ, Martinez FD, et al. Phenotypic predictors of long-term response to inhaled corticosteroid and leukotriene modifier therapies in pediatric asthma. J Allergy Clin Immunol. 2009; 123:411–416.

5. Pijnenburg MW, Hofhuis W, Hop WC, De Jongste JC. Exhaled nitric oxide predicts asthma relapse in children with clinical asthma remission. Thorax. 2005; 60:215–218.

6. American Thoracic Society, European Respiratory 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; 171:912–930.

7. Kim HB, Eckel SP, Kim JH, Gilliland FD. Exhaled NO: determinants and clinical application in children with allergic airway disease. Allergy Asthma Immunol Res. 2016; 8:12–21.

8. Yoon J, Choi YJ, Lee E, Cho HJ, Yang SI, Kim YH, et al. Allergic rhinitis in preschool children and the clinical utility of FeNO. Allergy Asthma Immunol Res. 2017; 9:314–321.

9. Pisi R, Aiello M, Tzani P, Marangio E, Olivieri D, Chetta A. Measurement of fractional exhaled nitric oxide by a new portable device: comparison with the standard technique. J Asthma. 2010; 47:805–809.

10. Kapande KM, McConaghy LA, Douglas I, McKenna S, Hughes JL, McCance DR, et al. Comparative repeatability of two handheld fractional exhaled nitric oxide monitors. Pediatr Pulmonol. 2012; 47:546–550.

11. Fukuhara A, Saito J, Sato S, Sato Y, Nikaido T, Saito K, et al. Validation study of asthma screening criteria based on subjective symptoms and fractional exhaled nitric oxide. Ann Allergy Asthma Immunol. 2011; 107:480–486.

12. Tsuburai T, Kamide Y, Nakamura Y, Tomita Y, Hamada Y, Watai K, et al. Differences in fraction of exhaled nitric oxide values measured by two hand-held analyzers (NO breath^® and NIOX Vero^®). Arerugi. 2017; 66:204–208.

13. National Institute for Health and Care Excellence. NICE Guidance [Internet]. London: National Institute for Health and Care Excellence;2017. cited 2017 Aug 16. Available from: https://www.nice.org.uk/Guidance.

14. Buchvald F, Baraldi E, Carraro S, Gaston B, De Jongste J, Pijnenburg MW, et al. Measurements of exhaled nitric oxide in healthy subjects age 4 to 17 years. J Allergy Clin Immunol. 2005; 115:1130–1136.

15. Hamasaki Y, Kohno Y, Ebisawa M, Kondo N, Nishima S, Nishimuta T, et al. Japanese pediatric guideline for the treatment and management of bronchial asthma 2012. Pediatr Int. 2014; 56:441–450.

16. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: NHLBI_WHO workshop report. National Heart, Lung, and Blood Institute, National Institutes of Health [Internet]. place unknown: Global Initiative for Asthma;2009. cited 2009. Available from: http://www.ginasthma.org.

17. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma. National Heart, Lung and Blood Institute, National Institutes of Health;2007. NIH Publication Number 08-5846.

18. Nathan RA, Sorkness CA, Kosinski M, Schatz M, Li JT, Marcus P, et al. Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol. 2004; 113:59–65.

19. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986; 1:307–310.

20. Dweik RA, Boggs PB, Erzurum SC, Irvin CG, Leigh MW, Lundberg JO, American Thoracic Society Committee on Interpretation of Exhaled Nitric Oxide Levels (FENO) for Clinical Applications, et al. An official ATS clinical practice guideline: interpretation of exhaled nitric oxide levels (FENO) for clinical applications. Am J Respir Crit Care Med. 2011; 184:602–615.