Exhaled nitric oxide monitoring does not reduce exacerbation frequency or inhaled corticosteroid dose in paediatric asthma: a randomised controlled trial

Clin Respir J. 2013 Apr;7(2):204-13. doi: 10.1111/j.1752-699X.2012.00306.x.


Introduction: Inhaled corticosteroid therapy (ICS) for asthma is currently modified according to symptoms and lung function. Fractional exhaled nitric oxide (FENO) has been demonstrated to be a non-invasive marker of eosinophilic inflammation. Studies of FENO-driven asthma management show variable success. Objectives: This study aimed to evaluate whether monitoring FENO can improve outpatient management of children with moderate to severe asthma using a pragmatic design.

Methods: Children aged 6–17 years with moderate to severe asthma were recruited. Their asthma was stabilised before randomisation to FENO-driven therapy or to a standard management group where therapy was driven by conventional markers of asthma control. ICS or long-acting bronchodilator therapies were altered according to FENO levels in combination with reported symptoms in the FENO group. Participants were assessed 2 monthly for 12 months. ICS dose and exacerbation frequency change were compared between groups in an intention to treat analysis.

Results: Ninety children were randomised. No difference was found between the two groups in either change in corticosteroid dose or exacerbation frequency. Results were similar in a planned secondary analysis of atopic asthmatics.

Conclusion: FENO-guided ICS titration does not appear to reduce corticosteroid usage or exacerbation frequency in paediatric outpatients with moderate to severe asthma. This may reflect limitations in FENO-driven management algorithms, as there are now concerns that FENO levels relate to atopy as much as they relate to asthma control.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Administration, Inhalation
  • Adolescent
  • Adrenal Cortex Hormones / administration & dosage*
  • Adrenal Cortex Hormones / therapeutic use*
  • Anti-Asthmatic Agents / administration & dosage*
  • Asthma / diagnosis*
  • Asthma / drug therapy*
  • Asthma / metabolism
  • Biomarkers / analysis
  • Biomarkers / metabolism
  • Child
  • Exhalation
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Monitoring, Physiologic / methods
  • Nitric Oxide / analysis*
  • Nitric Oxide / metabolism
  • Quality of Life
  • Surveys and Questionnaires


  • Adrenal Cortex Hormones
  • Anti-Asthmatic Agents
  • Biomarkers
  • Nitric Oxide

Associated data

  • ISRCTN/ISRCTN50872816