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1.  Abrupt withdrawal of inhaled corticosteroids does not result in spirometric deterioration in chronic obstructive pulmonary disease: Effect of phenotyping? 
Annals of Thoracic Medicine  2012;7(4):238-242.
BACKGROUND AND OBJECTIVE:
Some studies show a decline of FEV1 only one month after withdrawal of inhaled corticosteroids (ICS), while others show no decline. We speculate that the presence of an asthma phenotype in the Chronic Obstructive Pulmonary Disease (COPD) population, and that its exclusion may result in no spirometric deterioration.
METHODS:
We performed a prospective clinical observation study on 32 patients who fulfilled the Global Initiative for Chronic Obstructive lung disease definition of COPD (Grade II-IV). They were divided into two phenotypic groups. 1. Irreversible asthma (A and B) (n = 13): A. Asthma: Bronchial biopsy shows diffuse thickening of basement membrane (≥ 6.6 μm). B. Airflow limitation (AFL) likely to be asthma: KCO > 80% predicted if the patient refused biopsy. 2. COPD (A and B) (n = 19): A. COPD: hypercapneic respiratory failure with raised bicarbonate, panlobular emphysema with multiple bullas, or bronchial biopsy showing squamous metaplasia and epithelial/subepithelial inflammation without thickening of the basement membrane. B. AFL likely to be COPD: KCO < 80% predicted.
RESULTS:
The asthma phenotype was significantly younger, had a strong association with hypertrophy of nasal turbinates, and registered a significant improvement of FEV1 (350 ml) vs a decline of - 26.5 ml in the COPD phenotype following therapy with budesonide/formoterol for one year. Withdrawal of budesonide for 4 weeks in the COPD phenotype resulted in FEV1 + 1.33% (SD ± 5.71) and FVC + 1.24% (SD ± 5.32); a change of <12% in all patients.
CONCLUSIONS:
We recorded no spirometric deterioration after exclusion of the asthma phenotype from a COPD group.
doi:10.4103/1817-1737.102185
PMCID: PMC3506105  PMID: 23189102
Asthma; COPD; radiology and other imaging; respiratory function tests
2.  Exhaled nitric oxide in diagnosis and management of respiratory diseases 
Annals of Thoracic Medicine  2009;4(4):173-181.
The analysis of biomarkers in exhaled breath constituents has recently become of great interest in the diagnosis, treatment and monitoring of many respiratory conditions. Of particular interest is the measurement of fractional exhaled nitric oxide (FENO) in breath. Its measurement is noninvasive, easy and reproducible. The technique has recently been standardized by both American Thoracic Society and European Respiratory Society. The availability of cheap, portable and reliable equipment has made the assay possible in clinics by general physicians and, in the near future, at home by patients. The concentration of exhaled nitric oxide is markedly elevated in bronchial asthma and is positively related to the degree of esinophilic inflammation. Its measurement can be used in the diagnosis of bronchial asthma and titration of dose of steroids as well as to identify steroid responsive patients in chronic obstructive pulmonary disease. In primary ciliary dyskinesia, nasal NO is diagnostically low and of considerable value in diagnosis. Among lung transplant recipients, FENO can be of great value in the early detection of infection, bronchioloitis obliterans syndrome and rejection. This review discusses the biology, factors affecting measurement, and clinical application of FENO in the diagnosis and management of respiratory diseases.
doi:10.4103/1817-1737.56009
PMCID: PMC2801041  PMID: 19881162
Diseases; exhaled nitric oxide; measurement; respiratory
3.  Exhaled nitric oxide in stable chronic obstructive pulmonary disease 
Annals of Thoracic Medicine  2009;4(2):65-70.
STUDY OBJECTIVE:
The objective of the study was to test the hypothesis that fraction of exhaled nitric oxide (FENO) is elevated in nonsmoking subjects with stable chronic obstructive pulmonary disease (COPD) and compare it with the results in patients with asthma and a control population.
DESIGN:
Cross-sectional study.
MATERIALS AND METHODS:
Pulmonology Clinic at a University Hospital. Twenty five control subjects, 25 steroid naïve asthmatics and 14 COPD patients were studied. All the patients were nonsmokers and stable at the time of the study. All subjects completed a questionnaire and underwent spirometry. Exhaled nitric oxide was measured online by chemiluminescence, using single-breath technique.
RESULTS:
All the study subjects were males. Subjects with stable COPD had significantly higher values of FENO than controls (56.54±28.01 vs 22.00±6.69; P=0.0001) but lower than the subjects with asthma (56.54±28.01 vs 84.78±39.32 P=0.0285).The FENO values in COPD subjects were inversely related to the FEV1/FVC ratio. There was a significant overlap between the FENO values in COPD and the control subjects.
CONCLUSION:
There is a significant elevation in FENO in patients with stable COPD, but the elevation is less than in asthmatic subjects. Its value in clinical practice may be limited by the significant overlap with control subjects.
doi:10.4103/1817-1737.44649
PMCID: PMC2700486  PMID: 19561927
Asthma; chronic obstructive pulmonary disease; exhaled nitric oxide; stable

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