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eNO Should Not be the Basis of Monitoring Asthma

eNO Should Not be the Basis of Monitoring Asthma. S.Godfrey. Jerusalem ,. The Saba Support Group. eNO Should Not be the Basis of Monitoring Asthma. Is clinical monitoring any good?. eNO Should Not be the Basis of Monitoring Asthma. History taking - no Asthma Diaries - no

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eNO Should Not be the Basis of Monitoring Asthma

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  1. eNO Should Not be the Basis of Monitoring Asthma S.Godfrey Jerusalem, The Saba Support Group

  2. eNO Should Not be the Basis of Monitoring Asthma • Is clinical monitoring any good?

  3. eNO Should Not be the Basis of Monitoring Asthma • History taking - no • Asthma Diaries - no • Physical examination and lung function - no • Home monitoring of PEF - no • Bronchial Challenges – probably no

  4. eNO Should Not be the Basis of Monitoring Asthma We need something better than clinical monitoring – what have we got? Is this really the answer ?

  5. eNO Should Not be the Basis of Monitoring Asthma • Is clinical monitoring any good? • Is there anything good to say about eNO?

  6. (1) (2) Godfrey, AJRCCM 2002

  7. eNO Should Not be the Basis of Monitoring Asthma • Is clinical monitoring any good? • Is there anything good to say about eNO? • Can eNO be used to guide treatment?

  8. Smith et al. NEJM 2005 Looks impressive – less steroids, less exacerbations - but – - • Patients all adults • Results could be explained by threshold for dose reduction in clinical arm being too high or dose reduction in eNO arm being too low. • The 45.6% reduction in rate of exacerbations in eNO group sounds very impressive but it was not significant • No difference in oral steroids, clinical control, lung function, or sputum eosinophils.

  9. Really? (Amer J Respir Crit Cre Med 172: 831-836, 2005)

  10. Pijnenburg et al. AJRCCM 2005 Reduced bronchial hyperreactivity – that’s great - but – - • Improvement in bronchial hyperresponsiveness was 2.5 doubling doses but control group also improved by 1.1 doubling doses! • Difference in improvement in hyperresponsiveness was 1.3 doubling doses –very close to the limits of error of measurement and clinically meaningless. • Measurements of eNO and bronchial reactivity every 3 months over a year resulted in – • no difference in symptoms or steroid consumption • and a trivial change in hyperresponsiveness

  11. eNO Should Not be the Basis of Monitoring Asthma • Is clinical monitoring any good? • Is there anything good to say about eNO? • Can eNO be used to guide treatment? • Can eNO control steroid reduction?

  12. (Amer J Respir Crit Cre Med 171: 1077-1082, 2005)

  13. Zacharasiewicz et al. AJRCCM 2005 eNO can predict failure of steroid reduction – but how reliably ? – - • ROC curves used to calculate sensitivity and specificity but no data given for area under ROC curve which really defines the value of the test. • ROC curves show the best sensitivity eNO was about 75%. • Even worse is the specificity indicates that some 25% of children with either eNO or sputum eosinophils elevated could have had their steroid dose reduced without failure.

  14. eNO Should Not be the Basis of Monitoring Asthma • Is clinical monitoring any good? • Is there anything good to say about eNO? • Can eNO be used to guide treatment? • Can eNO control steroid reduction? • Is daily measurement of eNO the answer?

  15. eNO Should Not be the Basis of Monitoring Asthma - - and now for the Coup de Grace !

  16. Oh dear, Oy vey, poor Dr. de Jongste (ופרופ' סיוון המסכן!) AJRCCM Articles in Press. Published on October 17, 2008 as doi:10.1164/rccm.200807-1010OC

  17. eNO Should Not be the Basis of Monitoring Asthma • Is clinical monitoring any good? • Is there anything good to say about eNO? • Can eNO be used to guide treatment? • Can eNO control steroid reduction? • Is daily measurement of eNO the answer? The answer to all questions is – NO – and eNO Should Not be the Basis of Monitoring Asthma

  18. eNO Should Not be the Basis of Monitoring Asthma תודה!

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