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FeNO (fractional exhaled nitric oxide) was discovered in the 1980s as a biomarker for airway inflammation. Over the past decades, authorities such as the European Respiratory Society and the American Thoracic Society (ATS) have created guidelines for optimal FeNO measurement.3,4 Today, FeNO testing is an important complement to traditional testing methods for better asthma control.
For many years, inhaled corticosteroids (ICS) have been a common treatment for asthma. However, research has shown that up to 45% of asthma patients don’t get any benefit from ICS therapy.4,5 As it can be difficult to diagnose asthma and assess steroid responsiveness, patients sometimes get unnecessary ICS treatment.6
FeNO measurement is a useful method for assessing type 2 airway inflammation that responds to ICS treatment.4,6 It is a quick and non-invasive test that can be done at the point of care. The NIOX VERO® has been proven to give accurate and reproduceable results and is recognised as a very reliable device.7,8
High levels of FeNO (> 50 parts per billion) mean a higher risk of potentially life-threatening asthma exacerbations.9 It can signal that the treatment with ICS should be increased or that patients are not taking their medicine consistently. Low FeNO values (< 25 parts per billion) could indicate good inflammation control, or even a lack of inflammation at all.4
According to a study, doctors who did not test FeNO levels were unable to diagnose significant airway inflammation in 66% of the patients. Once high FeNO levels were identified, anti-inflammatory treatment was then stepped up in two thirds of patients.6
Other studies show that FeNO monitoring better predicts if patients will respond to ICS treatment compared to spirometry, bronchodilator response, peak flow variation, and bronchial hyper-responsiveness.10,11 Regular testing can also show if a patient is taking their medication as prescribed or if a patient is at risk of future exacerbations.12
Patient - Pre NIOX VERO Test - NIOX®
Asthma is a common illness, impacting 1 in 12 adults in the UK.1 It is the second most common reason for hospitalisation of children and the fourth most common reason of adults.13 It is estimated that about 20% of asthma patients have attacks that result in hospitalisation, but they account for about 80% of the total cost related to asthma.14
This is where FeNO monitoring can make a difference. One study concluded that the number of exacerbations went down by approximately 50%, when the treatment was based on a diagnosis that included FeNO monitoring.15
Another study looked at asthma in pregnancy.16 Here, FeNO measurements also proved to be beneficial for treatment decisions. There was a drop in exacerbations and the life quality of the patients improved, compared to the control group where FeNO monitoring was not included in the diagnosis. Babies born to mothers who were in the FeNO group were hospitalised less often.
Regular FeNO testing not only shows benefits in terms of asthma control, but the drop in acute attacks can also free up time and resources in hospitals. This was shown by a study in the US.17 Over a 12-month period, the costs per patient decreased significantly, from $2,637 to $2,228, when FeNO levels were included in the treatment decisions. The treatment was also more effective, as reflected in an increase in quality-adjusted life years from 0.767 to 0.844.
Learn more about the gold standard FeNO device.
1. Asthma UK. https://www.asthma.org.uk/about/media/facts-and-statistics/. Last accessed 1st July 2020.
2. Mukherjee M et al. The epidemiology, healthcare and societal burden and costs of asthma in the UK and its member nations: analyses of standalone and linked national databases. BMC Med. 2016;14(1):113.
3. Holguin F et al. Management of severe asthma: a European Respiratory Society/American Thoracic Society guideline. Eur Respir J. 2020;55(1):1900588.
4. Dweik RA 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(5):602-15.
5. Schleich F et al. Heterogeneity of phenotypes in severe asthmatics. The Belgian Severe Asthma Registry (BSAR). Respir Med. 2014;108(12):1723-1732.
6. Hanania N et al. Measurement of fractional exhaled nitric oxide in real-world clinical practice alters asthma treatment decisions. Ann Allergy Asthma Immunol. 2018; 120: 414-418.
7. Alving K et al. Validation of a new portable exhaled nitric oxide analyzer, NIOX VERO®: randomized studies in asthma. Pulm Ther. 2017;3(1):207-218.
8. Labeling Summary/Package Insert NIOX VERO® (EU). 000247-07, Nov 2017.
9. Petsky HL et al. Exhaled nitric oxide levels to guide treatment for adults with asthma. Cochrane Database of Systematic Reviews. 2016;9(9):CD011440.
10. Smith AD et al. Exhaled nitric oxide: a predictor of steroid response. Am J Respir Crit Care Med. 2005;172:453-459.
11. Smith AD et al. Diagnosing asthma: comparisons between exhaled nitric oxide measurements and conventional tests. Am J Respir Crit Care Med. 2004;169:473-478.
12. Heaney LG et al. Remotely monitored therapy and nitric oxide suppression identifies nonadherence in severe asthma. Am J Respir Crit Care Med. 2019;199(4):454-464.
13. Meltzer EO et al. Asthma burden in the United States: results of the 2009 Asthma Insight and Management survey. Allergy Asthma Proc. 2012;33(1): 36-46.
14. Rodrigo GJ et al. Acute asthma in adults a review. Chest. 2004;125: 1081-1102.
15. Syk J et al. Anti-inflammatory treatment of atopic asthma guided by exhaled nitric oxide: a randomized, controlled trial. J Allergy Clin Immunol Pract. 2013;1(6):639-48.
16. Powell H et al. Management of asthma in pregnancy guided by measurement of fraction of exhaled nitric oxide: a double-blind, randomized controlled trial. Lancet. 2011;378: 983-990.
17. Brooks E, Massanari M. Cost-effectiveness analysis of monitoring fractional exhaled nitric oxide (FeNO) in the management of asthma. Manag Care. 2018;27(7): 42-48.