Measurement of Exhaled Nitric Oxide and Exhaled Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
Evaluation of exhaled nitric oxide and exhaled breath condensate are proposed as techniques to diagnose and monitor asthma and/or other respiratory conditions. Asthma is characterized by airway inflammation that leads to airway obstruction and hyperresponsiveness, which in turn lead to characteristic clinical symptoms including wheezing, shortness of breath, cough, and chest tightness.
Measurement of exhaled nitric oxide (ENO) (e.g., NIOX®, NIOX MINO®, NIOX VERO®) is being investigated as a noninvasive marker of airway inflammation. Exhaled nitric oxide is typically measured during single breath exhalations. First, the individual inspires nitric oxide-free air via a mouthpiece until total lung capacity is achieved. This is followed immediately by exhalation through the mouthpiece into the measuring device. Researchers have raised concerns regarding the lack of a standardized protocol for monitoring ENO, which creates difficulties for use of ENO levels for monitoring.
Measurement of exhaled breath condensate (EBC) is being investigated as a noninvasive method for studying the composition/inflammation of the fluid lining the airway. There are a variety of laboratory techniques (e.g., RTube™ Exhaled Breath Condensate collection system, ECoScreen™ EBC collection system) to measure EBC. These techniques include pH measurement, gas chromatography/mass spectrometry and high performance liquid chromatography. It is not known if EBC pH measurements provide accurate estimates of airway pH. Researchers have raised concerns regarding the standardization of EBC collection and measurement methods.
Measurement of exhaled nitric oxide for the diagnosis and management of respiratory disorders, including, but not limited to the following: asthma, chronic cough, cystic fibrosis, and primary ciliary dyskinesia is considered investigational.
Measurement of exhaled breath condensate for the diagnosis and management of respiratory disorders, including, but not limited to the following: asthma, chronic cough, cystic fibrosis, and primary ciliary dyskinesia is considered investigational.
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There is a lack of well-designed, long-term studies in peer-reviewed journals that evaluate whether the addition of exhaled nitric oxide and/or exhaled breath condensate measurements to clinical and lung function assessment results in improved control of respiratory disorders or improved health outcomes.
Agency for Healthcare Research and Quality. (2017, December). Comparative effectiveness review number 197: The clinical utility of fractional exhaled nitric oxide (FeNO) in asthma management. Retrieved May 1, 2018 from PubMed database.
Aldakheel, F., Thomas, P., Bourke, J., Matheson, M., Dharmage, S., & Lowe, A. (2016). Relationships between adult asthma and oxidative stress markers and pH in exhaled breath condensate: a systematic review. Allergy, 2016, DOI: 10.000/all.12865. (Level 1 evidence)
American Academy of Allergy Asthma & Immunology/American Academy of Allergy, Asthma and Immunology. (2012). AAAAI/ACAAI joint statement of support of the ATS clinical practice guideline: interpretation of exhaled nitric oxide for clinical applications. Retrieved May 6, 2016 from http://www.aaaai.org/my-membership/constituency-groups/joint-efforts-of-the-AAAAI-ACAAI.
BlueCross BlueShield Association. Evidence Positioning System. (6:2018). Measurement of exhaled nitric oxide and exhaled breath condensate in the diagnosis and management of respiratory disorders (2.01.61). Retrieved January 11, 2018 from https://www.evidencepositioningsystem.com/. (47 articles and/or guidelines reviewed)
CMS.gov. Centers for Medicare & Medicaid Services. Palmetto GBA. (2018, May). Local Coverage Determination (LCD): Noncovered services other than CPT category III non-covered services (L36954). Retrieved December 18, 2018 from https://www.cms.gov/.
Dinakar, C. & Chipps, B. (2017). Clinical tools to assess asthma control in children. Pediatrics, 139 (1), e20163438. (Level 2 evidence)
Essat, M., Harnan, S., Gomersall, T., Tappenden, P., Wong, R., Pavord, I., et al. (2016). Fractional exhaled nitric oxide for the management of asthma in adults: a systematic review. European Respiratory Journal, 47 (3), 751-768. (Level 1 evidence)
European Respiratory Society (ERS). American Thoracic Society (ATS). (2014; corrections made 2018). International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma. Retrieved December 18, 2018 from https://erj.ersjournals.com/content/43/2/343#sec-67.
Gomersal, T., Harnan, S., Essat, M., Tappenden, P., Wong, R., Lawson, R., et al. (2016). A systematic review of fractional exhaled nitric oxide in the routine management of childhood asthma. Pediatric Pulmonology, 51 (3), 316-328. Abstract retrieved May 5, 2016 from PubMed database.
Guo, Z., Wang, Y., Xing, G., & Wang, X. (2016). Diagnostic accuracy of fractional exhaled nitric oxide in asthma: a systematic review and meta-analysis of prospective studies. The Journal of Asthma, 53 (4), 404-412. Abstract retrieved May 5, 2016 from PubMed database.
Lehtimäki, L., Csonka, P., Mäkinen, E., Isojärvi, J., Hovi, S., Ahovuo-Saloranta, A. (2016). Predictive value of exhaled nitric oxide in the management of asthma: a systematic review. European Respiratory Journal, 48 (3), 706-714. Abstract retrieved February 3, 2017 from PubMed database.
National Institute for Health and Care Excellence. (2014, April). Measuring fractional exhaled nitric oxide concentration in asthma: NIOX MINO, NIOX VERO and NObreath. Retrieved December 18, 2018 from www.nice.org.uk.
Song, W., Kim, H., Shim, J., Won, H., Kang, S., Sohn, K., et al. (2017). Diagnostic accuracy of fractional exhaled nitric oxide in predicting cough variant asthma and eosinophilic bronchitis in adult patients with chronic cough: a systematic review and meta-analysis. The Journal of Allergy and Clinical Immunology, 2017 Jan 11. (Epub ahead of print). Abstract retrieved February 3, 2017 from PubMed database.
Tang, S., Xie, Y., Yuan, C., Sun, X., & Cui, Y. (2016). Fractional exhaled nitric oxide for the diagnosis of childhood asthma: a systematic review and meta-analysis. Clinical Reviews in Allergy and Immunology, 2016 Jul 21 (Epub ahead of print). Abstract retrieved February 3, 2017 from PubMed database.
Winifred S. Hayes, Inc., Medical Technology Directory. (2016, October; last update search October 2018). Nitric oxide breath analysis for the diagnosis of asthma. Retrieved December 18, 2018 from https://www.hayesinc.com/subscribers. (56 articles and/or guidelines reviewed)
Winifred S. Hayes, Inc., Medical Technology Directory. (2016,September; last update search October 2018). Nitric oxide breath analysis for the management of asthma. Retrieved December 18, 2018 from https://www.hayesinc.com/subscribers. (67 articles and/or guidelines reviewed)
ORIGINAL EFFECTIVE DATE: 11/11/2006
MOST RECENT REVIEW DATE: 1/10/2019
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