title: Symptoms, spirometry, exhaled nitric oxide, and asthma exacerbations in clinical practice.
abstract: BACKGROUND
  Patient symptoms, spirometry measurements, exacerbation rates, and exhaled nitric oxide (FE(NO)) levels have all been used to quantify asthma severity.
  
  
  OBJECTIVE
  To determine the relationships among these disease surrogates in clinical practice.
  
  
  METHODS
  Data were collected from 5 primary care asthma clinics on patient symptoms, reliever use, spirometry measurements, maintenance pharmacotherapy, disease severity (British Thoracic Society treatment step), and FE(NO) level. Exacerbation data (asthma-related unscheduled health care contact or rescue oral corticosteroid therapy) for the 12 months before and 3 months after the clinic visit were then obtained.
  
  
  RESULTS
  A total of 267 adult asthmatic patients (mean [SEM] age, 51.6 [1.1] years; forced expiratory volume in 1 second, 86.3% [1.2%] of predicted) participated, and 157 exacerbations were captured. For the 12 months before the clinic visit, exacerbation rate was positively correlated with dose of inhaled corticosteroid (P < .001), treatment step (P < .001), reliever use (P = .002), and symptom score (P < .001) but was negatively correlated with FE(NO) level (P = .04); only symptom scores correlated with exacerbation rate in the 3 months after the visit. Levels of FE(NO) were significantly lower in frequently exacerbating patients receiving higher doses of maintenance inhaled corticosteroids compared with patients with mild disease who were corticosteroid naive (19.7 vs 40.4 ppb, P < .001). Measurement of FE(NO) was an insensitive method (sensitivity, 66.7%; specificity, 51.9% at a cutoff value of 20 ppb) for identifying patients who subsequently exacerbated.
  
  
  CONCLUSIONS
  Levels of FE(NO) are paradoxically decreased in patients with more severe asthma and frequent exacerbations and may, therefore, be of limited utility in primary care.
authors.affiliation: Asthma and Allergy Research Group, Department of Medicine and Therapeutics, Ninewells Hospital and Medical School, Dundee, Scotland.
authors.forename: Daniel
authors.initials: D
authors.lastname: Menzies
authors.forename: Cathy
authors.initials: C
authors.lastname: Jackson
authors.forename: Catrina
authors.initials: C
authors.lastname: Mistry
authors.forename: Ruth
authors.initials: R
authors.lastname: Houston
authors.forename: Brian J
authors.initials: BJ
authors.lastname: Lipworth
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000627:therapeutic use; D001249:Asthma / Q000175:diagnosis* / Q000188:drug therapy / Q000378:metabolism; D001944:Breath Tests; D001980:Bronchi / Q000187:drug effects / Q000378:metabolism / Q000503:physiopathology; D004638:Emergency Treatment / Q000706:statistics & numerical data*; D005260:Female; D005541:Forced Expiratory Volume; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009569:Nitric Oxide / Q000378:metabolism*; D012372:ROC Curve; D012680:Sensitivity and Specificity; D013147:Spirometry; D014797:Vital Capacity
chemical_list: D000305:Adrenal Cortex Hormones; D009569:Nitric Oxide