Open Access

Factors affecting exhaled nitric oxide measurements: the effect of sex

Respiratory Research20078:82

https://doi.org/10.1186/1465-9921-8-82

Received: 02 June 2007

Accepted: 15 November 2007

Published: 15 November 2007

Abstract

Background

Exhaled nitric oxide (FENO) measurements are used as a surrogate marker for eosinophilic airway inflammation. However, many constitutional and environmental factors affect FENO, making it difficult to devise reference values. Our aim was to evaluate the relative importance of factors affecting FENO in a well characterised adult population.

Methods

Data were obtained from 895 members of the Dunedin Multidisciplinary Health and Development Study at age 32. The effects of sex, height, weight, lung function indices, smoking, atopy, asthma and rhinitis on FENO were explored by unadjusted and adjusted linear regression analyses.

Results

The effect of sex on FENO was both statistically and clinically significant, with FENO levels approximately 25% less in females. Overall, current smoking reduced FENO up to 50%, but this effect occurred predominantly in those who smoked on the day of the FENO measurement. Atopy increased FENO by 60%. The sex-related differences in FENO remained significant (p < 0.001) after controlling for all other significant factors affecting FENO.

Conclusion

Even after adjustment, FENO values are significantly different in males and females. The derivation of reference values and the interpretation of FENO in the clinical setting should be stratified by sex. Other common factors such as current smoking and atopy also require to be taken into account.

Background

Measurement of exhaled nitric oxide (FENO) is increasingly recognised as an important addition to pulmonary function testing in clinical practice [1]. FENO may be used as a surrogate marker for airway eosinophilia [2], and as an alternative to other more invasive or time-consuming assessments of airway pathology such as induced sputum, [2, 3] bronchial lavage fluid, [4] or mucosal biopsy. [57] Against this background, FENO measurements are increasingly being used to clarify the aetiology of non-specific respiratory symptoms as well as monitor levels of inflammation in conditions characterised by airway eosinophilia [8].

There are a number of demographic and biological factors which cause variation in FENO levels. The commonest are cigarette smoking [9, 10] and atopy [1113] with or without allergic rhinitis. [13, 14] Others include age [15, 16], and IgE levels [17]. However, conflicting results concerning the importance of these factors has precluded a clear definition of so-called "normal" values. Buchvald et al. have reported reference values in a large population of children, but important biological confounders were evaluated only by questionnaire. [15] The same issues were addressed more recently in adults by Olin et al. [18] and Travers et al. [19], and Travers et al. provided reference ranges which sought to take account of commonly encountered variables which affect FENO. However, there are some significant inconsistencies between these reports, not least in respect of the effects of sex on FENO. Clearly further data are needed so that routine FENO measurements can be interpreted appropriately. In the present study, comprising a well characterised cohort of nearly 1000 32-year old individuals born in Dunedin, New Zealand, we obtained detailed clinical and laboratory information regarding factors affecting FENO, and their potential relevance to reference ranges for FENO was evaluated.

Methods

The Dunedin Multidisciplinary Health and Development Study is a cohort study of 1037 children (52% male) born between April 1972 and March 1973. [20, 21] Follow-up assessments have been conducted at ages 3, 5, 7, 9, 11, 13, 15, 18, 21, 26, and at 32 years, at which time 972 (96%) of 1015 living Study members participated.

At age 32, Study members were questioned about current and previous asthma, as well as symptoms of wheezing, cough, episodic shortness of breath, hay fever and rhinitis. Current asthma was defined as reported diagnosed asthma with symptoms in the last 12 months. Current wheezing was recorded as any wheeze in the last 12 months but excluding subjects with only one or two episodes each lasting less than 1 hour. Asthma treatment was any inhaled bronchodilator, corticosteroid or cromoglycate medication. Current smoking was defined as smoking tobacco cigarettes daily for at least one month during the previous 12 months, or smoking cannabis 6 or more times during the previous 12 months. Current smokers were further subdivided into two groups: those who did and did not smoke on the study day. Ex-smokers were defined as having discontinued for at least 12 months.

Height and weight in light clothing without shoes were measured to calculate body mass index (BMI) in kg/m2. FENO was then measured on-line using a Logan LR 2000 series chemiluminescence analyser (Logan Research Ltd., Rochester, England) in accordance with ATS/ERS guidelines at a flow rate of 50 mL/sec. [22] Exhaled nitric oxide in parts per billion (ppb) was recorded continuously throughout expiration. Individual results were read at the first nitric oxide plateau and the mean of two acceptable tests was recorded. A third was obtained only where one or both of the first two were considered to be technically unsatisfactory. The NO recording was determined for each test by two observers on a separate occasion. The first 44 Study members were tested using a flow rate of 250 mL/second and results were adjusted to 50 mL/second using a previously validated formula [23].

FENO measurements were obtained immediately prior to carrying out spirometry. Skin prick testing included house dust mite (D. pteronyssinus), grass, cat, dog, horse, cockroach, wool, Aspergillus fumigatus, alternaria, penicillium, and cladosporium. A weal diameter 3 mm or greater than the saline control was considered positive. Atopy was defined as a positive response to one or more allergens. A blood sample was obtained for eosinophil count and total serum immunoglobulin E (IgE).

Statistical analysis

Study members who were pregnant at the time of assessment (n = 31) were excluded from all analyses. FENO measurements were not normally distributed, and were log transformed prior to analysis. Both univariate and multivariate linear regression analyses were performed to identify those factors which significantly affected FENO levels and to derive regression equations, with stratification for those factors which were shown to significantly affect exhaled nitric oxide levels. The selection of appropriate linear regression models was based on maximum R-square and an examination of the residuals, to ensure an adequate model fit. Significant interaction terms (p < 0.05) were retained in the model. Results are presented as anti-log values with 95% confidence intervals following back-transformation.

Ethics

The Otago Ethics Committee approved the study and written informed consent was obtained.

Results

Eight hundred and ninety-five Study members completed the respiratory procedures in the Study. Of these, 471 (52.6%) were male, 486 (54.8%) were atopic, 349 (39.0%) had rhinitis/hay fever, 253 (28.3%) had current wheeze, 156 (17.4%) had current asthma, and 54 (6.6%) were using inhaled corticosteroid treatment. Three hundred and ninety five were current smokers (44.1%), of whom 235 (59.5%) smoked on the study assessment day prior to testing, and 107 were ex-smokers (12.0%). Two hundred and fifteen were cannabis smokers (24%), of whom 78 (8.7%) smoked cannabis alone.

The FENO values obtained from the Study population are shown in Table 1. Data relating to smoking status are shown in Table 2. FENO was on average 25% higher in males than females (males: 15.3 ppb [95% C.I.:14.3–16.3] versus females: 11.6 ppb [95% C.I.: 11.0–12.4]; p < 0.0001; Table 1). Unadjusted analyses revealed that, for all Study members, there were also significant differences in FENO in relation to height, FEV1, FEV1 % predicted and FVC (Table 3). However, none of these factors remained significant after stratifying by sex. In contrast, current smoking (on the day of testing), atopy, log IgE, history of rhinitis, and current asthma and the use of inhaled corticosteroids remained significant in both males and females.
Table 1

Mean values (with 95% confidence intervals) for FENO stratified by sex, smoking, atopy, rhinitis current wheeze and asthma. * not all Study members underwent skin testing

All

All subjects, n = 895

13.4 (12.9, 14.1)

Gender

Male, n = 471

15.3 (14.3,16.3)

Female, n = 424

11.6 (11.0, 12.4)

Smoking

Current smoker (smoked on the day of testing)

Current smoker (not smoked on the day of testing)

Ex-smoker or non-smoker

Current smoker (smoked on the day of testing)

Current smoker (not smoked on the day of testing)

Ex-smoker or non smoker

 

n = 133

8.8

(7.9, 9.7)

n = 102

16.6

(14.7, 18.9)

n = 236

20.2

(18.6, 21.9)

n = 102

7.4

(6.7, 8.2)

n = 58

12.3

(10.2, 14.7)

n = 264

13.7

(12.8, 14.7)

Atopy

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

 

n = 68

9.9

(8.6,11.5)

n = 62

7.6

(6.7, 8.7)

n = 61

19.8

(16.6, 23.6)

n = 41

12.9

(11.1, 14.9)

n = 141

24.8

(22.2, 27.7)

n = 92

14.9

(13.6, 16.3

n = 32

9.5

(7.8, 11.5)

n = 69

6.7

(5.9, 7.5)

n = 35

14.0

(10.6, 18.5)

n = 23

10.0

(8.2, 12.2)

n = 149

15.9

(14.4, 17.6)

n 114

11.2

(10.3, 12.2)

Rhinitis

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

 

n = 50

9.2

(8.0, 10.7)

n = 83

8.5

(7.4, 9.7)

n = 30

21.0

(16.0, 27.5)

n = 72

15.1

(13.2, 17.4)

n = 97

24.0

(21.2, 27.2)

n = 139

17.9

(16.1, 19.9)

n = 33

9.0

(7.5,10.9)

n = 69

6.8

(6.0, 7.7)

n = 23

13.4

(10.1, 17.8)

n = 35

11.6

(9.0, 14.9)

n = 116

16.1

(14.3, 18.0)

n = 148

12.1

(11.1, 13.1)

Current wheeze

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

All

n = 49

8.4

(6.9, 10.2)

n = 84

9.0

(8.0, 10.0)

n = 35

17.7

(13.4, 23.3)

n = 67

16.1

(14.1, 18.5)

n = 53

28.4

(23.0, 34.9)

n = 183

18.3

(16.9, 19.9)

n = 41

7.6

(6.4, 9.1)

n = 61

7.3

(6.4, 8.4)

n = 18

15.2

(9.4, 24.3)

n = 40

11.1

(9.3, 13.3)

n = 57

16.8

(14.2, 19.8)

n = 207

12.9

(12.0, 13.9)

Taking ICS

n = 8

8.0

(4.1, 15.6)

Nil

n = 5

24.0

(12.7, 45.5)

n = 1

72.9

n = 17

27.5

(19.6, 38.7)

n = 2

28.5

(NA)

n = 3

8.8

(2.0, 40.0)

n = 4

9.4

(1.9, 45.2)

n = 3

32.4

(9.3, 112.0)

Nil

n = 13

17.3

(13.1, 22.8)

n = 3

17.8

(3.3, 96.9)

Not taking ICS

n = 41

8.5

(6.9, 10.4)

n = 84

9.0

(8.0, 10.0)

n = 30

12.3

(16.8, 22.9)

n = 66

15.8

(13.8, 17.9)

n = 36

28.8

(21.9, 37.8)

n = 181

18.2

(16.8, 19.8)

n = 38

7.5

(6.2, 9.1)

n = 57

7.2

(6.4, 8.2)

n = 15

13.0

(7.7, 22.1)

n = 40

11.1

(9.3, 13.1)

n = 44

16.7

(13.6, 20.5)

n = 204

12.9

(11.9, 13.9)

Current asthma

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

All

n = 21

9.8

(6.9, 14.0)

n = 112

8.6

(7.7, 9.5)

n = 27

21.7

(16.5, 28.5)

n = 75

15.1

(13.2, 17.4)

n = 39

29.7

(23.7, 37.2)

n = 197

18.7

(17.2, 20.4)

n = 18

9.5

(6.5, 13.9)

n = 84

7.0

(6.4,7.8)

n = 10

28.0

(14.7, 53.3)

n = 48

10.3

(8.9, 12.0)

n = 41

15.7

(12.7, 19.5)

n = 223

13.3

(12.4, 14.3)

Taking ICS

n = 8

8.0

(4.1, 15.6)

Nil

n = 6

28.9

(14.7, 57.0)

Nil

n = 18

26.5

(19.1, 36.8)

n = 1

58.3

n = 5

11.0

(3.8, 32.2)

n = 2

5.7

(0.5, 72.1)

n = 3

32.4

(9.3, 112.0)

Nil

n = 14

18.3

(13.8, 24.3)

n = 2

12.0

(3.1, 47.4)

Not taking ICS

n = 13

11.2

(7.1, 17.8)

n = 112

8.6

(7.7, 9.5)

n = 21

20.0

(14.6, 27.4)

n = 75

15.1

(13.2, 17.4)

n = 21

32.7

(23.5, 45.6)

n = 196

18.6

(17.1, 20.2)

n = 13

9.0

(5.8, 14.2)

n = 82

7.1

(6.4, 7.8)

n = 7

26.4

(9.9, 69.9)

n = 48

10.3

(8.9, 12.0)

n = 27

14.6

(10.8, 19.5)

n = 221

13.3

(12.4, 14.4)

Table 2

Mean values (with 95% confidence intervals) for FENO, stratified by smoking status and sex

F E NO (ppb) Mean 95% C.I.

All subjects

Males

Females

All Study members

n = 895

13.4

(12.8, 14.1)

n = 471

15.3

(14.3, 16.3)

n = 424

11.6

(11.0, 12.4)

All current smokers (within last 12 months)

n = 395

10.4

(9.7, 11.1)

n = 235

11.6

(10.6, 12.6)

n = 160

8.9

(8.1, 9.8)

Current smokers who smoked on the day of F E NO testing

n = 235

8.2

(7.6, 8.8)

n = 133

8.8

(7.9, 9.7)

n = 102

7.4

(6.7, 8.2)

Current smokers who did not smoke on day of F E NO testing

n = 160

14.9

(13.4, 16.6)

n = 102

16.6

(14.7, 18.9)

n = 58

12.3

(10.2, 14.7)

Ex-smokers (greater than 12 months)

n = 107

16.0

(14.3, 17.8)

n = 36

21.1

(17.6, 25.3)

n = 71

13.8

(12.2, 15.7)

Never smokers

n = 393

16.6

(15.6, 17.7)

n = 200

20.0

(18.3, 22.0)

n = 193

13.6

(12.5, 14.8)

Table 3

Factors affecting FENO by linear regression analysis, without controlling for any other factors Magnitude of effect = change compared to reference group (females, non-smokers, non-atopics, non-rhinitics, non-wheezers, or non-asthmatics)

 

All

Males

Females

Factor

Magnitude of effect*

Significance

Magnitude of effect*

Significance

Magnitude of effect*

Significance

Female Gender

0.7605

<0.0001

---

---

BMI

1.0015

0.7571

1.0045

0.5600

0.9966

0.5503

Height

1.0013

<0.0001

1.0003

0.5859

1.0007

0.0969

FEV 1

1.1315

<0.0001

0.9956

0.9328

1.0229

0.7230

FEV 1 % predicted

0.9957

0.0166

0.9988

0.6422

0.9981

0.4432

FVC

1.1058

<0.0001

0.9832

0.6963

1.0443

0.4044

Current smoker (smoked on day of testing)

0.49600

<0.0001

0.43350

<0.0001

0.54337

<0.0001

Current smoker (within last 12 months, not smoked on day of testing)

0.90579

0.0825

0.82377

0.0091

0.89582

0.1945

Atopy (≥3 mm)

1.6028

<0.0001

1.60363

<0.0001

1.5472

<0.0001

Log IgE

1.3897

<0.0001

1.3971

<0.0001

1.3235

<0.0001

Current rhinitis

1.3126

<0.0001

1.2868

0.0002

1.3670

<0.0001

Current wheeze

1.1009

0.0617

1.0906

0.2349

1.1004

0.1658

Current asthma

1.4132

<0.0001

1.4434

<0.0001

1.3495

0.0003

Using ICS

1.3904

0.0004

1.3780

0.0134

1.3755

0.0130

In the adjusted regression analyses, significant predictors of FENO were sex, body mass index (BMI), current smoking (on the day of testing), atopy, current asthma, and the interaction between sex and smoking. Current wheeze was not a significant factor. This was perhaps because of the significant confounding relationship between current smoking (resulting in reduced FENO) and wheeze (p = 0003; model 4; see Additional File 1). Details of all the models examined are provided in Additional File 1.

After controlling for all of the significant factors affecting FENO, the sex-related differences in FENO remained significant (p < 0.001). The factors which significantly affected FENO were different for males and females. For males, current smoking (all), current asthma, and atopy (any positive SPT ≥ 3 mm over the negative control) were significant independent predictors of FENO. For females, while current smoking (all), current asthma, and atopy (any positive SPT ≥ 3 mm over the negative control) were significant independent predictors of FENO, those females who were current smokers and also had asthma had an additional increase in their FENO (FENO increased by 131%; p = 0.001; Table 4).
Table 4

Adjusted linear regression models with FENO as the dependent variable

Sample

Variables

Anti-log B-coefficient

p-value

R-square

All Study Members

Intercept

15.9

<0.0001

0.331

 

Sex

0.69

<0.0001

 
 

Current Smoking – smoked on the testing day

0.45

<0.0001

 
 

Current Smoking – not smoked on the testing day

0.80

0.0014

 
 

Current Asthma

1.26

<0.0001

 
 

Atopy

1.41

<0.0001

 
 

Sex*Current Smoking – smoked on the testing day

1.32

0.0025

 
 

Sex*Current Smoking – not smoked on the testing day

1.10

0.3970

 

Males

Intercept

15.60

<0.0001

0.343

 

Current Smoking – smoked on the testing day

0.45

<0.0001

 
 

Current Smoking – not smoked on the testing day

0.81

0.0021

 
 

Current Asthma

1.25

0.0025

 
 

Atopy

1.45

<0.0001

 

Females

Intercept

11.31

<0.0001

0.276

 

Current Smoking – smoked on the testing day

0.57

<0.0001

 
 

Current Smoking – not smoked on the testing day

0.77

0.0022

 
 

Current Asthma

1.09

0.3460

 
 

Atopy

1.37

<0.0001

 
 

Current Asthma*Current Smoking – smoked on the testing day

1.13

0.4722

 
 

Current Asthma*Current Smoking – not smoked on the testing day

2.31

<0.0001

 

Based on these results, the equations for predicting FENO in our study cohort were:

For males: log FENO = 1.1932 - 0.3496*current smoking (smoked day of testing) - 0.0940*current smoking (not smoked day of testing) + 0.16511*atopy + 0.0973*asthma

(R2 = 0.3434)

For females: log FENO = 1.0533 - 0.2407*current smoking (smoked day of testing) - 0.1160*current smoking (not smoked on day of testing) + 0.0388*asthma + 0.1355*atopy + 0.0531*current smoking (smoked day of testing)*asthma + 0.3630*current smoking (not smoked day of testing)*asthma

(R2 = 0.2760)

where, for the terms current smoking, atopy and asthma, yes = 1, and no = 0.

Using these equations, the predicted values and ranges (95% C.I.) for clinically important populations are presented in Table 5. For comparison, the actual values obtained from each subgroup of the study population are also presented.
Table 5

Mean values and reference ranges for FENO (with 95% confidence intervals), based on prediction equations for males and females. For comparison, the measured values (with 95% confidence intervals) obtained in the Study members are provided

  

Males

Females

Population

 

F E NO (ppb)

95% C.I.

F E NO(ppb)

95% C.I.

Non-smokers, non-atopic, non-asthmatic

Predicted

15.6

14.1, 17.2

11.3

10.3, 12.4

 

Actual

14.7

13.4, 16.1

11.2

10.3, 12.2

Non-smokers, atopic, non-asthmatic

Predicted

22.6

18.3, 28.0

15.4

12.6, 18.9

 

Actual

23.1

20.4, 26.2

15.6

13.9,, 17.4

Non-smokers, non-atopic, asthmatic

Predicted

19.5

15.3, 24.9

12.4

9.4, 16.3

 

Actual

22.5

8.0, 63.8

11.5

7.0, 18.9

Non-smokers, atopic, asthmatic

Predicted

28.3

19.8, 40.5

16.9

11.5, 24.9

 

Actual

30.4

23.9, 38.7

17.2

13.5, 22.1

Smokers (not smoked on the day of testing), non-atopic, non-asthmatic

Predicted

12.6

9.9, 18.2

8.7

6.7, 11.3

 

Actual

13.0

11.0, 15.2

9.6

7.8, 11.7

Smokers (not smoked on the day of testing), atopic, non-asthmatic

Predicted

18.2

12.8, 25.5

11.8

8.2, 17.2

 

Actual

17.6

14.1, 22.0

10.9

8.7, 13.8

Smokers (not smoked on the day of testing), non-atopic, asthmatic

Predicted

15.7

10.7, 22.8

21.8

9.2, 51.8

 

Actual

12.0

7.5, 19.5

16.0

0.3, 743.5

Smokers (not smoked on the day of testing), atopic, asthmatic

Predicted

22.8

13.6, 36.9

29.8

11.3, 79.0

 

Actual

24.0

17.8, 32.4

32.3

14.6, 71.2

Smokers (smoked on the day of testing), non-atopic, non-asthmatic

Predicted

7.0

5.6, 8.8

6.5

5.1, 8.2

 

Actual

7.3

6.4, 8.3

6.5

5.8, 7.3

Smokers (smoked on the day of testing), atopic, non-asthmatic

Predicted

10.1

7.2, 14.0

8.9

6.3, 12.5

 

Actual

10.2

8.8, 11.8

8.9

7.3, 10.9

Smokers (smoked on the day of testing), non-atopic, asthmatic

Predicted

8.7

6.0, 12.5

8.0

3.8, 17.0

 

Actual

8.9

7.3, 10.9

8.1

4.0, 16.4

Smokers (smoked on the day of testing), atopic, asthmatic

Predicted

12.6

7.6, 20.3

11.0

4.6, 26.0

 

Actual

9.3

6.2, 13.8

10.9

6.6, 18.0

Discussion

The results of the present study provide further evidence that sex is a major factor determining exhaled nitric oxide (FENO) measurements. Without adjusting for other factors such as atopy, current smoking, and diagnosed asthma, the mean FENO levels in males were significantly higher than in females (p = 0.0001). However, even after appropriate adjustments, this difference persisted. The magnitude of the difference was approximately 25%. This is clinically as well as statistically significant [24].

A review of the literature provides somewhat conflicting data regarding this issue. It is important to take account of the different methodologies used for FENO measurements when making comparisons between studies, particularly with regard to expiratory flow rates. However, within studies, significant differences between males and females will still be valid, and the balance of evidence suggests that sex-related differences in FENO are indeed important. In early investigations, both Jilma et al. [25] and Tsang et al. [26] reported sex-related differences in FENO whose magnitude (50% and 53% higher in males compared to females, respectively) was comparable to the present result. More recently, Olivieri et al. have reported higher levels in males, with an upper limit of normal of 28.8 ppb, compared to 21.5 ppb for females [27]. Travers et al. [19] reported that the mean FENO in males was 23% higher than in females (95% C.I. 7–43; p = 0.004, n = 191). In that study, the significance of the difference persisted even after controlling for height. In the study by Berry et al. a similar highly significant difference between males and females was recorded [28]. However, in the largest study to date to focus on factors affecting FENO, comprising 2,200 subjects, Olin et al. has presented contrasting results [18]. Although there was a male-female FENO difference in non-smokers amounting to 19%, this was not statistically significant in a multiple linear regression analysis in which adjustments for all other factors were included [18]. The reasons why the difference failed to reach statistical significance are unclear.

After adjusting for sex, we found that other anthropometric factors such as height and lung function were no longer significant factors affecting FENO. Previously it has been argued that sex-related differences in FENO result from differences in the surface area of airway epithelium, the major source of exhaled NO, and for which height is an important anthropometric correlate. Thus our results are perhaps surprising. However, given that plasma levels of nitrate, a product of NO metabolism, are similarly different between the sexes [25, 29], it seems unlikely that NO production in the airways is solely a reflection of differences in airway size, but rather reflects sex-related differences in endogenous NO production. This is consistent with the results of a twin study, which showed that genetic rather than environmental factors are more important in determining FENO [30].

Our findings raise the question as to whether guidelines for the interpretation of FENO should be stratified by sex, and that reference ranges for males and females should be different. In the paper by Olivieri et al. the authors propose that reference ranges should be stratified for sex [27]. Travers et al. [19] advocate reference ranges based on sex, smoking status and atopy, but not age or height. We concur with this view, and the reference ranges contained in Table 5 of the present paper are based on this approach. In the study by Olin et al. [18], similar to conventional pulmonary function tests, both age and height but not sex, were deemed to be significant, although reference values as such were not provided. All studies concur that smoking and atopy are important considerations, and both are included in the reference values given here and by Travers et al. [19].

In fact, interpreting FENO levels in clinical practice is even more complex. Reference values which take into account background characteristics such as sex, atopy and smoking may indeed be useful in guiding the diagnosis of airways-related symptoms. In asymptomatic individuals, it is still possible that increased FENO reflects subclinical airway inflammation [7, 28], but this interpretation is less likely if appropriate reference values which take factors such as sex into account have been used in the first place. The interpretation of FENO levels in the context of ongoing management of diagnosed asthma is far from clear. Despite optimal anti-inflammatory treatment, FENO levels may remain resolutely high [31], and it is generally agreed that normalizing FENO in relation to reference values for a healthy population is not a desirable therapeutic aim [8]. This point is perhaps reflected in the results obtained in the present study, which showed that in non-smoking, atopic, male asthmatics, who were all clinically stable, the upper limit of the 95% confidence interval was 38.8 ppb, considerably higher than the levels obtained in non-smoking, atopic, male, non-asthmatics (28.2 ppb).

One of the weaknesses of our study is that the FENO measurements were obtained in individuals who were all aged 32 years. Thus it was not possible to explore the influence of age as a factor in the regression analyses or to conclude whether reference values ought to include it as a factor. Previous studies have reported that FENO rises with increasing age in children [15, 16, 3234]. In adults, Olin et al. [18] have reported that an effect of age also occurs: FENO was shown to increase over the age range 35 to 65 years, with the magnitude of effect similar to that of atopy. In contrast, in the study by Travers et al. no significant relationship was noted over a similar age range, but numbers were much smaller [19]. In children, it is suggested that the changes with age are attributable to increasing airway NO flux, probably reflecting larger airway surface area with growth [34]. If at all, any increase in FENO with age in adults is likely to be due to non-anthropometric factors, and if the results from Olin et al. are repeatable, this may be an important consideration.

In summary, our data confirm that differences in FENO between males and females are of sufficient magnitude that the interpretation of FENO should be stratified by sex. This approach should be incorporated into clinical practice. Other common and easily identified factors such as current smoking and atopy also require to be taken into account when interpreting FENO values in adults. Contrasting results from a number of studies still leave open the question as to whether age and height ought to be included in future reference equations. These outstanding issues add to the current challenges which still remain in the application and interpretation of FENO levels in clinical practice, and require further study.

Abbreviations

C.I.: 

confidence interval

FENO: 

fraction of nitric oxide in expired air

FEV1

forced expiratory volume in one second

FVC: 

forced vital capacity

NO: 

nitric oxide

mL/sec: 

milliliters per second

ppb: 

parts per billion

SPT: 

skin prick test

Declarations

Acknowledgements

The authors wish to acknowledge the loyalty of each of the Study members of the Dunedin Multidisciplinary Health and Development Study, and the support of Michelle McCann and Professor Richie Poulton. Professor Temi Moffitt kindly permitted the use of data pertaining to cannabis smoking.

Authors’ Affiliations

(1)
Department of Respiratory Medicine, Dunedin School of Medicine, University of Otago
(2)
Firestone Institute for Respiratory Health, Department of Medicine, McMaster University
(3)
Dunedin Multidisciplinary Health and Development Research Unit, Dunedin School of Medicine, University of Otago

References

  1. Smith AD, Taylor DR: Is exhaled nitric oxide measurement a useful clinical test in asthma? Curr Opin Allergy Clin Immunol 2005, 5:49–56.View ArticlePubMedGoogle Scholar
  2. Jatakanon A, Lim S, Kharitonov SA, Chung KF, Barnes PJ: Correlation between exhaled nitric oxide, sputum eosinophils, and methacholine responsiveness in patients with mild asthma. Thorax 1998, 53:91–5.View ArticlePubMedPubMed CentralGoogle Scholar
  3. Berlyne GS, Parameswaran K, Kamada D, Efthimiadis A, Hargreave FE: A comparison of exhaled nitric oxide and induced sputum as markers of airway inflammation. J Allergy Clin Immunol 2000, 106:638–44.View ArticlePubMedGoogle Scholar
  4. Warke TJ, Fitch PS, Brown V, Taylor R, Lyons JD, Ennis M, Shields MD: Exhaled nitric oxide correlates with airway eosinophils in childhood asthma. Thorax 2002, 57:383–7.View ArticlePubMedPubMed CentralGoogle Scholar
  5. Brightling CE, Symon FA, Birring SS, Bradding P, Wardlaw AJ, Pavord ID: Comparison of airway immunopathology of eosinophilic bronchitis and asthma. Thorax 2003, 58:528–32.View ArticlePubMedPubMed CentralGoogle Scholar
  6. Payne DN, Adcock IM, Wilson NM, Oates T, Scallan M, Bush A: Relationship between exhaled nitric oxide and mucosal eosinophilic inflammation in children with difficult asthma, after treatment with oral prednisolone. Am J Respir Crit Care Med 2001, 164:1376–81.View ArticlePubMedGoogle Scholar
  7. van den Toorn LM, Overbeek SE, Overbeek SE, de Jongste JC, Leman K, Hoogsteden HC, Prins JB: Airway inflammation is present during clinical remission of atopic asthma. Am J Respir Crit Care Med 2001, 164:2107–13.View ArticlePubMedGoogle Scholar
  8. Taylor DR, Pijnenburg MW, Smith AD, De Jongste JC: Exhaled nitric oxide measurements: clinical application and interpretation. Thorax 2006, 61:817–27.View ArticlePubMedPubMed CentralGoogle Scholar
  9. Kharitonov SA, Robbins RA, Yates D, Keatings V, Barnes PJ: Acute and chronic effects of cigarette smoking on exhaled nitric oxide. Am J Respir Crit Care Med 1995, 152:609–12.View ArticlePubMedGoogle Scholar
  10. Persson MG, Zetterstrom O, Agrenius V, Ihre E, Gustafsson LE: Single-breath nitric oxide measurements in asthmatic patients and smokers. Lancet 1994, 343:146–7.View ArticlePubMedGoogle Scholar
  11. van Amsterdam JG, Janssen NA, de Meer G, Fischer PH, Nierkens S, van Loveren H, Opperhuizen A, Steerenberg PA, Brunekreef B: The relationship between exhaled nitric oxide and allergic sensitization in a random sample of school children. Clin Exp Allergy 2003, 33:187–91.View ArticlePubMedGoogle Scholar
  12. Jouaville LF, Annesi-Maesano I, Nguyen LT, Bocage AS, Bedu M, Caillaud D: Interrelationships among asthma, atopy, rhinitis and exhaled nitric oxide in a population-based sample of children. Clin Exp Allergy 2003, 33:1506–11.View ArticlePubMedGoogle Scholar
  13. Gratziou C, Lignos M, Dassiou M, Roussos C: Influence of atopy on exhaled nitric oxide in patients with stable asthma and rhinitis. Eur Respir J 1999, 14:897–901.View ArticlePubMedGoogle Scholar
  14. Henriksen AH, Sue-Chu M, Lingaas Holmen T, Langhammer A, Bjermer L: Exhaled and nasal NO levels in allergic rhinitis: relation to sensitization, pollen season and bronchial hyperresponsiveness. Eur Respir J 1999, 13:301–6.View ArticlePubMedGoogle Scholar
  15. Buchvald F, Baraldi E, Carraro S, Gaston B, De Jongste J, Pijnenburg MW, Silkoff PE, Bisgaard H: Measurements of exhaled nitric oxide in healthy subjects age 4 to 17 years. J Allergy Clin Immunol 2005, 115:1130–6.View ArticlePubMedGoogle Scholar
  16. Avital A, Uwyyed K, Berkman N, Bar-Yishay E, Godfrey S, Springer C: Exhaled nitric oxide is age-dependent in asthma. Pediatr Pulmonol 2003, 36:433–8.View ArticlePubMedGoogle Scholar
  17. Cardinale F, de Benedictis FM, Muggeo V, Giordano P, Loffredo MS, Iacoviello G, Armenio L: Exhaled nitric oxide, total serum IgE and allergic sensitization in childhood asthma and allergic rhinitis. Pediatr Allergy Immunol 2005, 16:236–42.View ArticlePubMedGoogle Scholar
  18. Olin AC, Rosengren A, Thelle DS, Lissner L, Bake B, Toren K: Height, age, and atopy are associated with fraction of exhaled nitric oxide in a large adult general population sample. Chest 2006, 130:1319–25.View ArticlePubMedGoogle Scholar
  19. MS Travers J, S Aldington, M Williams, P Shirtcliffe, A Pritchard, M Weatherall, R Beasley: Reference ranges for exhaled nitric oxide derived from a random community survey of adults. American Journal of Respiratory and Critical Care Medicine 2007.Google Scholar
  20. Sears MR, Greene JM, Willan AR, Wiecek EM, Taylor DR, Flannery EM, Cowan JO, Herbison GP, Silva PA, Poulton R: A longitudinal, population-based, cohort study of childhood asthma followed to adulthood. N Engl J Med 2003, 349:1414–22.View ArticlePubMedGoogle Scholar
  21. SW Silva PA: From child to adult: The Dunedin Multidisciplinary Health and Development Study. Auckland: Oxford University Press; 1996.Google Scholar
  22. ATS/ERS Recommendations for Standardized Procedures for the Online and Offline Measurement of Exhaled Lower Respiratory Nitric Oxide and Nasal Nitric Oxide 2005Am J Respir Crit Care Med 2005, 171:912–930.Google Scholar
  23. Smith AD, Cowan JO, Brassett KP, Herbison GP, Taylor DR: Use of exhaled nitric oxide measurements to guide treatment in chronic asthma. N Engl J Med 2005, 352:2163–73.View ArticlePubMedGoogle Scholar
  24. Kharitonov SA, Gonio F, Kelly C, Meah S, Barnes PJ: Reproducibility of exhaled nitric oxide measurements in healthy and asthmatic adults and children. Eur Respir J 2003, 21:433–8.View ArticlePubMedGoogle Scholar
  25. Jilma B, Kastner J, Mensik C, Vondrovec B, Hildebrandt J, Krejcy K, Wagner OF, Eichler HG: Sex differences in concentrations of exhaled nitric oxide and plasma nitrate. Life Sci 1996, 58:469–76.View ArticlePubMedGoogle Scholar
  26. Tsang KW, Ip SK, Leung R, Tipoe GL, Chan SL, Shum IH, Ip MS, Yan C, Fung PC, Chan-Yeung M, et al.: Exhaled nitric oxide: the effects of age, gender and body size. Lung 2001, 179:83–91.View ArticlePubMedGoogle Scholar
  27. Olivieri M, Talamini G, Corradi M, Perbellini L, Mutti A, Tantucci C, Malerba M: Reference values for exhaled nitric oxide (reveno) study. Respir Res 2006, 7:94.View ArticlePubMedPubMed CentralGoogle Scholar
  28. Berry MA, Shaw DE, Green RH, Brightling CE, Wardlaw AJ, Pavord ID: The use of exhaled nitric oxide concentration to identify eosinophilic airway inflammation: an observational study in adults with asthma. Clin Exp Allergy 2005, 35:1175–9.View ArticlePubMedGoogle Scholar
  29. Takahashi H, Nakanishi T, Nishimura M, Tanaka H, Yoshimura M: Measurements of serum levels of nitrate ions in men and women: implications of endothelium-derived relaxing factor in blood pressure regulation and atherosclerosis. J Cardiovasc Pharmacol 1992, 20:S214–6.View ArticlePubMedGoogle Scholar
  30. Lund MB, Kongerud J, Nystad W, Boe J, Harris JR: Genetic and environmental effects on exhaled nitric oxide and airway responsiveness in a population-based sample of twins. Eur Respir J 2006, 1:1.Google Scholar
  31. Pijnenburg MW, Bakker EM, Lever S, Hop WC, De Jongste JC: High fractional concentration of nitric oxide in exhaled air despite steroid treatment in asthmatic children. Clin Exp Allergy 2005, 35:920–5.View ArticlePubMedGoogle Scholar
  32. Kissoon N, Duckworth LJ, Blake KV, Murphy SP, Taylor CL, DeNicola LR, Silkoff PE: Exhaled nitric oxide concentrations: online versus offline values in healthy children. Pediatr Pulmonol 2002, 33:283–92.View ArticlePubMedGoogle Scholar
  33. Franklin PJ, Taplin R, Stick SM: A community study of exhaled nitric oxide in healthy children. Am J Respir Crit Care Med 1999, 159:69–73.View ArticlePubMedGoogle Scholar
  34. Latzin P, Beck J, Griese M: Exhaled nitric oxide in healthy children: variability and a lack of correlation with atopy. Pediatr Allergy Immunol 2002, 13:37–46.View ArticlePubMedGoogle Scholar

Copyright

© Taylor et al. 2007

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Advertisement