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Exhaled nitric oxide in the diagnosis of asthma: comparison with bronchial provocation tests

Institute of Pulmonology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel

Correspondence to:
Correspondence to:
Dr N Berkman
Institute of Pulmonology, Hadassah University Hospital, POB 12000, Jerusalem, Israel il-91120; neville{at}hadassah.org.il

Background: Bronchial provocation tests such as exercise, methacholine (MCH), and adenosine-5'-monophosphate (AMP) challenges are used extensively in the diagnosis of asthma. A study was undertaken to determine whether exhaled nitric oxide (eNO) can be used to diagnose asthma in patients with non-specific respiratory symptoms and to compare this test with conventional provocation tests.

Methods: Patients with non-specific respiratory symptoms and normal spirometric parameters were included in the study. eNO was measured and exercise, MCH and AMP challenges performed in all subjects. Patients were defined as asthmatic based on clinical follow up 24 months after testing.

Results: Forty patients were considered asthmatic and 45 were not. The area under receiver operating characteristic curves gave values of 0.896 for eNO, 0.781 for exercise, 0.924 for MCH, and 0.939 for AMP (p = 0.033, 0.575 and 0.085 for eNO v exercise, MCH and AMP respectively). From our data, a cut off value of NO >7 ppb at a flow rate of 250 ml/s best differentiates between asthmatics and non-asthmatics (sensitivity 82.5%, specificity 88.9%). Optimal cut off values for other tests were exercise: FEV₁ 10% (sensitivity 57.9%, specificity 100%); PC₂₀-MCH: 3 mg/ml (sensitivity 87.5%, specificity 86.7%); and PC₂₀-AMP: 150 mg/ml (sensitivity 89.5%, specificity 95.6%).

Conclusions: Measurement of eNO can be used as a safe, simple and rapid test for the diagnosis of asthma and is as good as bronchial provocation tests.

Abbreviations: AMP, adenosine 5'-monophosphate; eNO, exhaled nitric oxide; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; MCH, methacholine; NO, nitric oxide

Keywords: asthma; exhaled nitric oxide; exercise; methacholine; adenosine 5'-monophosphate (AMP); diagnosis

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