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American Journal of Respiratory and Critical Care Medicine Vol 172. pp. 931, (2005)
© 2005 American Thoracic Society

Correspondence

Clips, Spirometry, and Submaximal Inhalation for Exhaled Nitric Oxide

To the Editor:

In the timely update on recommendations for standardized procedures for the offline and online measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide (1), we note a change in the recommended online technique for adults. The inhalation phase now makes allowance for near TLC (total lung capacity) if TLC is difficult for the patient, in contrast to the 1999 ATS statement, which strictly recommended TLC (2). No evidence was given to support this rationale. We have recently shown that submaximal inspiration effort did not affect online exhaled nitric oxide levels in adults (3). In the same study, we also showed that the application of a nasal clip during online measurement or the performance of prior spirometric maneuver did not significantly affect exhaled nitric oxide levels. However, the omission of nasal clip and avoidance of spirometry prior to exhaled nitric oxide measurement continue to be recommended, despite few studies with adequate subject numbers. To our knowledge, there have been no other published studies on the effect of nasal clips or submaximal inhalation on exhaled nitric oxide. The studies by Deykin and coworkers (4, 5) and Silkoff and coworkers (6) support the concept of lowering of exhaled nitric oxide level after a forced vital capacity maneuver. However, these were done in 10 and 18 patients, respectively, hardly sufficient to be conclusive. The use of exhaled nitric oxide in research and possibly clinical practice warrants regular reviews to fine tune standardization of measurement technique, but we do not support inhalation to TLC, avoidance of nasal clips and prior spirometry as necessary prerequisites until further evidence from adequately powered studies is available.

K. H. Augustine Tee and K. P. Hui

Changi General Hospital, Singapore

FOOTNOTES

Conflict of Interest Statement: None of the authors have a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

REFERENCES

  1. American Thoracic Society. ATS/ERS recommendations for standardized procedures for the online and offline measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide, 2005. Am J Respir Crit Care Med 2005;171:912–930.[Free Full Text]
  2. American Thoracic Society. Recommendations for standardized procedures for the online and offline measurement of exhaled lower respiratory nitric oxide and nasal nitric oxide in adults and children — 1999. Am J Respir Crit Care Med 1999;160:2104–2117.[Free Full Text]
  3. Tee AKH, Hui KP. Effect of spirometric maneuver, nasal clip, and submaximal inspiratory effort on measurement of exhaled nitric oxide levels in asthmatic patients. Chest 2005;127:131–134.[Abstract/Free Full Text]
  4. Deykin A, Halpern O, Massaro AF, Drazen JM, Israel E. Expired nitric oxide after bronchoprovocation and repeated spirometry in patients with asthma. Am J Respir Crit Care Med 1998;157:769–775.[Abstract/Free Full Text]
  5. Deykin A, Massaro AF, Coulston E, Drazen JM, Israel E. Exhaled nitric oxide following repeated spirometry or repeated plethysmography in healthy individuals. Am J Respir Crit Care Med 2000;161:1237–1240.[Abstract/Free Full Text]
  6. Silkoff PE, Wakita S, Chatkin J, Ansarin K, Gutierrez C, Caramori M, McClean P, Slutsky AS, Zamel N, Chapman KR. Exhaled nitric oxide after beta2-agonist inhalation and spirometry in asthma. Am J Respir Crit Care Med 1999;159:940–944.[Abstract/Free Full Text]




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