“You can’t cheat FeNO!” - an interview with Dr Priya Ilangovan

We were fortunate to catch up with consultant paediatrician Dr Priya Ilangovan to ask about her experience of testing fractional exhaled nitric oxide (FeNO) in children.¹ Dr Ilangovan has been a paediatric consultant for 27 years, setting up the respiratory service in Basingstoke and North Hampshire Hospitals’ secondary care in the UK, as well as a dedicated asthma clinic. Here, Dr Ilangovan shares her experience of FeNO, as well as some thought-provoking asthma case-studies.¹

How do you use FeNO testing for asthma diagnosis?

“FeNO is part of the diagnostic jigsaw,” Dr Ilangovan explains. “We take symptoms and a full clinical history, carry out an examination, review x-rays, test FeNO and perform spirometry for those who are able to.” For Dr Ilangovan, it all comes back to the right diagnosis. “Get the diagnosis right and then you can decide the treatment. Don’t send everybody home on inhaled steroids just because they come in with a wheezy episode. I undo the diagnosis of asthma in a third of the children who come to the four-week discharge clinic. FeNO can help tell you whether asthma is there or not.”¹

FeNO is particularly helpful for patients requiring a straightforward test. “For instance, I tried spirometry on a four-year-old,” Dr Ilangovan says. “From the evidence, I was absolutely convinced he had asthma but he couldn’t manage spirometry. I asked him to take a FeNO test. Up came the number and my diagnosis was confirmed: he had Type 2 asthma. FeNO is really helpful in the pre-school age when they can’t manage the lung function tests.”¹

What about FeNO for the management of asthma?

Dr Ilangovan sees FeNO as standard for monitoring asthma now. “We have our NIOX VERO® there and we measure FeNO then we perform spirometry. We use FeNO for all our follow-up appointments. I tend to follow up frequently in the asthma clinic, at around every four to six weeks, to keep patients out of hospital. A constant reminder about the importance of taking their inhaled steroids regularly seems to work, instead of saying “come back in four months”.¹

“Apart from history, we also have access to GP prescription uptake records. If the patient is not collecting their medication, I can show them. It’s a bit like Big Brother but it means I can talk to them about the importance of using their prescription. I tell them children die of asthma – I don’t beat around the bush.”¹

Dr Ilangovan has found that asthma is such a common condition that people don’t realise how serious it is. “If patients haven’t collected their prescription then it’s obvious their asthma won’t be well controlled. Then I test FeNO. And FeNO will tell me. If they are able to, I then test lung function but I always test FeNO first. Ideally, nurses should be trained so they are able to include it: measure height, weight, FeNO and lung function – then the patient takes those results to the doctor.¹

“I check inhaler technique and also use FeNO to assess compliance. Patients tell you “of course I’m taking my medication!” but they’re not. The FeNO number is there – and you can’t cheat FeNO!”¹

Can you share some cases where FeNO testing has been useful in your practice?

“I had a patient who was 11 years old. She lived with her grandparents who both suffered from asthma and COPD. The patient would come in with severe, life-threatening asthma. I had referred her and requested that she be started on biologics. For the first month, we could see she was taking her medication. However, she lost weight, which doesn’t add up on a high dose of steroids. We screened for diabetes and other conditions but there was nothing. I asked her grandmother to supervise the patient when she took her medication and to ensure all her prescriptions were collected.”¹

“FeNO was the eye-opener and the turning point.”

The value of FeNO testing for patient and family education was an important factor for Dr Ilangovan in this case. “I tested her FeNO. It was 255 ppb! This sky-high score helped me explain to the patient and her family that she could die at any time if she had an asthma attack! They understood straight away the importance of taking asthma medication as prescribed. With monthly follow-up, we managed to reduce the patient’s treatment and now, four years later, her FeNO is normal, her lung function is normal and she is on minimal treatment. FeNO was the eye-opener and the turning point.”¹

Looking at another case, Dr Ilangovan says: “I had a teenaged patient who said: “I have asthma but I only use my inhaler occasionally.” I decided we should test his FeNO – I always test FeNO first – and the result was 5 ppb, which is in the normal range. I asked whether he had been taking any inhaled steroids recently and he said no. By the time I had taken the history as well, I could see he didn’t have asthma. He actually had disordered breathing. I taught him diaphragmatic breathing to fully utilise the lungs and removed the asthma diagnosis.¹

“I also used FeNO to confirm an asthma diagnosis in a young man of 16, who was sure he didn’t have the condition and wanted to stop his treatment. He wanted to join the army and had been training. The patient reported that he did not experience symptoms while training. I suggested that we measure his FeNO level and his score was 38. His lung function was also sub-optimal. He was very disappointed but unfortunately, the asthma diagnosis was maintained.”¹

What do you do once you have the FeNO result?

“I talk to the patient about what it means and why we are measuring it,” says Dr Ilangovan. “Management of any chronic illness is about education. Empower patients to manage their condition. We use FeNO to track progress and teach patients that lower FeNO means they are in more control of their asthma and they can wind down their steroid dosage slightly. We work in partnership with these children. Once you educate patients and they feel in control, they feel so much better about it. Fully engaged families embrace it straight away.”¹ “FeNO brings us one step closer to the precision medicine that we all talk about.”

Do you have any pointers for clinicians who might be new to FeNO testing?

“Please test FeNO. Don’t ignore it. If you want to provide a quality service that improves the quality of life of your patients, you will do it. FeNO brings us one step closer to the precision medicine that we all talk about. You are identifying people who have Type 2 inflammation, some of whom have now got biologics. And that’s precision medicine.”¹

You said previously that you perform FeNO testing with NIOX VERO®. What made you choose this device in particular?

“NIOX VERO® is easy to use and it’s easy to train people on. For patients, I ask parents: “What do you understand about asthma?” to ascertain the level of knowledge. Then I explain that asthma has two main components: one is that the patient experiences a bronchospasm and two, that it’s caused by airway inflammation in the lungs – and that’s what NIOX VERO® measures. It’s easy to put that into context for patients.¹

“I also like the animations for children. It’s visual and you get the results in a minute. Kids love the countdown! Especially the little ones. It’s very easy to get the kids engaged and easier to explain than spirometry.¹

“After his diagnosis, one pre-school boy was transferred from the asthma clinic to a consultant and he immediately asked: “Can I do it again?! The machine where the cloud goes across the screen?” I spend more time trying to teach children how to take a lung function test than I do for FeNO – once you’ve shown them how to take a FeNO test, they just do it. They are so competitive and so motivated – they WANT to do it! Children find it fascinating – especially with the NIOX VERO®’s animations. They get a reward, perhaps a smiley face on the screen at the end, and they tell me it’s like a video game.¹

“Children who can’t manage spirometry will do FeNO easily and that’s the difference – with FeNO, you will get at least one successful measurement at the appointment. Everybody should educate teams about it.”¹