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Original Research: Asthma |

Guideline-Recommended Fractional Exhaled Nitric Oxide Is a Poor Predictor of Health-care Use Among Inner-city Children and Adolescents Receiving Usual Asthma CareBiomarker is a Poor Predictor of Health-care Use

Meredith C. McCormack, MD, MHS; Charles Aloe, MPH; Jean Curtin-Brosnan, MA; Gregory B. Diette, MD, MHS; Patrick N. Breysse, PhD; Elizabeth C. Matsui, MD, MHS
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine (Drs McCormack and Diette), Johns Hopkins University School of Medicine; and the Division of Pediatric Allergy and Immunology (Mr Aloe, Ms Curtin-Brosnan, and Dr Matsui) and Bloomberg School of Public Health, Department of Environmental Health Sciences (Dr Breysse), Johns Hopkins University, Baltimore, MD.

Correspondence to: Meredith C. McCormack, MD, MHS, Pulmonary and Critical Care Medicine, Johns Hopkins University, 1830 E Monument St, 5th Floor, Baltimore, MD 21205; e-mail: mmccor16@jhmi.edu


Funding/Support: This work was supported by the National Institute of Environmental Health Sciences of the National Institutes of Health (NIH) [Grants P50ES015903, P01ES018176, and K23ES016819]; the Environmental Protection Agency [Grant R832139]; the NIH’s National Institute of Allergy and Infectious Diseases [Grants R01AI070630 and U01AI083238]; and the Johns Hopkins University School of Medicine General Clinical Research Center [Grant M01-RR00052], from the National Center for Research Resources/NIH.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(3):923-929. doi:10.1378/chest.12-3098
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Background:  American Thoracic Society guidelines support using fractional exhaled nitric oxide (Feno) measurements in patients with asthma and highlight gaps in the evidence base. Little is known about the use of Feno levels to predict asthma exacerbations among high-risk, urban, minority populations receiving usual care.

Methods:  Children with persistent asthma (n = 138) were enrolled in a prospective, observational cohort study and skin tested at baseline (a wheal ≥ 3 mm indicated a positive skin-prick test). Feno levels, lung function, and asthma-related health-care use were assessed at baseline and every 3 months thereafter for 1 year. Relationships between Feno levels and health-care use in the subsequent 3 months were examined. Final models accounted for repeated outcome measures and were adjusted for age, sex, and lung function.

Results:  The mean age of the children was 11 years (range, 5-17 years), and most were male (57%), black (91%), and atopic (90%). At baseline, the median Feno level was 31.5 parts per billion (interquartile range, 16-61 ppb) and mean FEV1/FVC was 80.7% (SD, ± 9.6%). There were 237 acute asthma-related health-care visits, 105 unscheduled doctor visits, 125 ED visits, and seven hospitalizations during the follow-up period. Feno level was not a significant predictor of acute visits, ED visits, unscheduled doctor visits, or hospitalization in either unadjusted or adjusted analyses. Use of recommended cut points did not improve the predictive value of the Feno level (positive predictive value, 0.6%-32.8%) nor did application of the guideline-based algorithm to assess change over time.

Conclusions:  Feno level may not be a clinically useful predictor of health-care use for asthma exacerbations in urban minority children with asthma.

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