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МЕДИЧН1 ПЕРСПЕКТИВЕ / MEDICNIPERSPEKTIVI
UDC 616.2-021.5-07-053.5:612.2:546.172.6(439.22)
https://doi.Org/10.26641/2307-0404.2020.2.206355
M. Czubaj-Kowal2,
MEASUREMENT OF NITRIC OXIDE
T. Friediger 1, Z. Hudáková 1, M. Sokolowski2,
IN EXHALED AIR IN PRIMARY SCHOOL
CHILDREN IN RUZOMBEROK
E. Walczak-Kapolka 2,
I. Astaryová 1, A. Lesñáková1
Catholic University in Ruzomberok1 Faculty of Health,
Nam. Andreja Hlinku, 48, Ruzomberok, 034 01, Slovakia Stefan Zeromski Specialist Hospital in Krakow2 Pediatric Department Na Skarpie, 66, Krakow, 31-913, Poland
Католицъкий Умверситет у Ружомберощ1 Факультет охорони здоров'я Ружомберок, Словаччина
Спец1ал1зована лтарня iM. Стефана Жеромского в KpaKoei2
nediampu4He eiddrnenm
KpaKie, Полъща
e-mail: martacz58@gmail.com
Цитування: Медичт перспективы. 2020. Т. 25, № 2. С. 55-59 Cited: Medicni perspektivi 2020;25(2):55-59
Key words: nitric oxide, FeNO, air pollution, eosinophilic inflammation, children, asthma
Ключов! слова: оксид азоту, FeNO, забруднення пов1тря, еозинофшьне запалення, dimu, астма Ключевые слова: оксид азота, FeNO, загрязнение воздуха, эозинофилъное воспаление, дети, астма
Abstract. Measurement of nitric oxide in exhaled air in primary school children in Ruzomberok. Czubaj-Kowal M., Friediger Т., Hudakova Z., Sokolowski M., Walczak-Kapolka E., Astaryova I., Lesnakova A.
Nowadays, there are a number of respiratory illnesses that directly affect children. Exhaled nitric oxide measurement (FeNO) is one of the modern methods of investigation used for diagnosing and controlling allergic eosinophilic airway inflammation. It is a simple, painless and time-saving method for the patient. Because of its non-invasiveness and simplicity, it is a valuable diagnostic method, especially in younger children. Measurement of FeNO is a recognized biomarker and an accurate quantitative indicator in the detection, assessment and monitoring of airway inflammation, including asthma. However, only a few studies assess the relationship between FeNO and level of air pollution. The aim of our study is to determine the relationship between FeNO in third-grade students of primary schools and the level of air pollution in Ruzomberok. 146 children aged 8-10 years were included in the research. This is the first stage of a wider research project involving FeNO measurements in children at different times of the year. The goal of the research is to determine the concentration of FeNO in the studied group of children in the autumn when air pollution is lower than in second stage which is observed in winter. The study showed elevated values of FeNO>20 ppb in 11% of the tested children and correct values <20 ppb in 89% of them. Level of average air pollution in survey days for PM10 ranged from 23 to 40 fig/m3 and for NO2 - from 28 to 44 ^g/m3 The study shows that the significant majority of children have normal levels of nitric oxide in the exhaled air when air pollution is low. Analysis of the second phase of FeNO measurements in winter, when air pollution was higher, will allow to compare the results and assess the correlation between the FeNO value and air pollution.
Реферат. Вим1рювання оксиду азоту в noiiiipi, mo видихаеться, у д!тей початковоТ школи в Ружомберощ. Чубай-Коваль М., Фрдагер Т., Худакова 3., Соколовський М., Вальчак-Каполька Е., Астарьова I., Лещакова А. У наш час icnye низка рестраторних захворювань, яю безпосереднъо уражаютъ dimeu. Вим1рю-вання оксиду азоту (FeNO) - один i3 сучасних Memodie досл1дження, який застосовуетъся для diaznocmuKU та контролю алерг1чного запалення еозинофшъних дихальних шлях1в. Це простий, безбол1снии i економний для часу пац1ента метод. Через свою не1нвазивтсть та простоту eiH е цтним методом diaznocmuKU, особливо в dimeu молодшого eiKy. Вим1рювання FeNO е визнаним бюмаркером i точним ктъюсним показником при еияелент, оцтц1 та мотторингу запалення дихальних шлях1в, включаючи астму. Однак лише деят досл1дження оц1нюють взаемозв'язок м1ж FeNO та pieneM забруднення повтря. Метою нашого досл1дження е визначення взаемозв'язку м1ж FeNO у dimeu третьего класу початкових шкт та pieneM забруднення пов1тря в
Ружомбероку. У досл1джент взяли участь 146 дтеи ежом 8-10 роте. Це перший етап бшъш широкого дослгдницького проекту, що передбачае вимгрювання ЕеЫО у дтеи у ргзнии час року. Метою дослгдження е визначення концентраци ЕеЫО у дослгджуванш групг дтеи восени, коли забруднення повгтря нижче, нгж на другт стадИ, що забезпечуетъся взимку. Дослгдження показало пгдвищен/ значения ГеЫО>20ррЬ в 11% тестованих дгтеи та правильт значения <20 ррЬ у 89% з них. Ргвень середнъого забруднення повгтря за спостережуван! дт для РМ10 коливався вгд 23 до 40 мкг/м3, а для ЫО2 - вгд 28 до 44 мкг/м3. Дослгдження показуе, що значна частина дтеи мае нормальний ргвень оксиду азоту в повгтрг, що еидихаетъся, коли забруднення повтря низьке. Анализ другой фази вимгрювань ЕеЫО взимку, коли забруднення повтря було вищим, дозволить поргвняти результати та оцтити спгввгдношення мгж значениям ЕеЫО та забрудненням повтря.
Exhaled nitric oxide measurement (FeNO) is one of the modern, simple and noninvasive method of investigation used for diagnosing and controlling eosinophilic inflammation. Measurement of bronchial FeNO is a recognized biomarker and an accurate quantitative indicator in the detection, assessment and monitoring of airway inflammation, including bronchial asthma [9, 10, 11, 12, 13]. In connection with asthma, FeNO is currently the most sensitive method for the determination of eosinophilic airway inflammation [1]. Nitric oxide is a molecule with high biological activity and plays an important role in physiology and human pathology as well. Its effect on the body depends on its concentration. Low concentration regulates homeostasis of the circulatory, respiratory, immune and nervous systems. High concentration is pro-inflammatory and cytotoxic directly or via active metabolites. The first presence of NO in the exhaled air was confirmed by Gustafsson in 1991 and the first guidelines principles for the measurement of nitric oxide in exhaled air were published by the American Thoracic Society in 1999. FeNO is able to determine the presence and amount of nitric oxide in an exhaled air stream, which the lungs of a healthy person excrete only in a minimal amount [4, 5]. In recent years, the measurement of FeNO has been increasingly used in the diagnosis of respiratory diseases in children. A lot of scientific publications show a good correlation between FeNO and the results of other diagnostic tests. In children, FeNO is a specific indicator of asthma exacerbation and treatment response. It can be repeated for each cooperating child. In patients with eosinophilic inflammation, the amount of FeNO increases, which is caused by activated airway epithelial cells in inflammation of the airways. It is used for evaluation of the activity of the airway inflammatory process. FeNO values respond quickly to the treatment or worsening of the disease. The result is immediately visible and treatment is adjusted accordingly [2]. FeNO measurement can help us with diagnosis of bronchial asthma, along with other diagnostic methods such as spirometry, bronchoprovocation tests, and monitoring the effectiveness of the treatment. FeNO allows to determine the lowest effective
dose of inhaled corticosteroids that sufficiently controls inflammation in the airways. This method is possible since the age of 4 years [3]. Other functional diagnostic tests also help diagnose bronchial asthma early, in addition to a thorough medical history and physical examination. FeNO is preferred to other methods such as bronchial mucosal biopsy or bronchial lavage that are invasive, time-consuming, and uncomfortable [6]. Many studies confirm the usefulness of this method in the diagnosis of respiratory diseases in children. However, only a few studies assess the relationship between FeNO and level of air pollution, which is the aim of our study.
The aim of the study is to determine the relationship between the concentration of nitric oxide in exhaled air in children of the third grade of primary school and the level of air pollution in Ruzomberok. The whole project includes two stages: Stage 1 September 19th, October 8th and Stage 2 February 4th and 5th. The study presents the results of the first stage of the measurement performed on September 19th, 2018 and October 8th, 2018. There is a large company producing paper and cellulose pulp in Ruzomberok, but at the same time, there are variables that have a large impact on the level of air pollution in Ruzomberok, which are not related to the paper and pulp production. In addition, there is long-distance international transport near the city, which also causes air pollution. According to modelling and analysis results, it contributes to average annual PM10 and N02 concentrations in ambient air [7].
MATERIALS AND METHODS OF RESEARCH
Our study examined all third-grade children who were in school on the days of the research. The aim of the research is to determine the concentration of nitric oxide in the exhaled air in the studied group of children in autumn, when the air pollution is lower than in winter. This is the first stage of a wider research project involving FeNO measurements in children at different times of the year. The research of the first phase of the project included children of the third grade of elementary schools at the age of 89 years, several children were at the age of 10 years, whose parents gave their written consent prior to this measurement. Including the invitation to the
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research parents received information regarding the type, purpose and methodology of the test. Our study examined all third-grade primary school children who were at school on the days when the measurements were taken on September 19th and October 8th, 2018.
Pre-Examination Preparation: Children should be rested 15 minutes prior to examination and should not eat, drink or exercise for 2 hours prior to examination.
Measurement method: The study was carried out by measuring the concentration of nitric oxide in the exhaled air using Nitric oxide analyser MediSoft Belgium. The examination consisted of slow inhalation and exhalation through a mouthpiece with an antibacterial filter. The safety of the examination was ensured by non-invasiveness, simplicity of the test and absence of side effects. The examination was painless and lasted 1-2 minutes. The child holds the device with his/her hands and exhales as much as possible outside the device. Through a special mouthpiece with filter, the child breathes outside the device as much as possible, holds its breath briefly and exhales into the device for 6 seconds with moderate effort. The correct exhalation intensity is seen on the computer screen or is audibly controlled. The result of the examination is available within 2 minutes. The measurement of nitric oxide in exhaled air was performed twice in each child. Before the test, children were instructed by the doctor who performed the test and the way in which the test was performed was shown.
According to the generally accepted methodology for this type of research, the determination of
nitric oxide concentration in exhaled air is given in dimensionless quantities ppb (parts per billion, 10"9). The limit value of FeNO measurement result in children was 20 ppb, as assumed in most studies.
In our study we divided the increased FeNO values into three groups:
Group I - NO concentration range 21-50 ppb Group II - NO concentration range 51-99 ppb Group III - NO concentration range > 99 ppb
RESULTS AND DISCUSSION 146 children aged 8-10 years from elementary schools in Ruzomberok participated in the first phase of the research. The measurement of nitric oxide concentration in the exhaled air was performed in each child according to the planned research methodology. The range of FeNO values in the whole studied population ranged from 2 to 55 ppb. The increased values ranged from 22 to 55 ppb (Table). Measurement values of exhaled nitric oxide concentration in 130 examined children (89.0%) were normal FeNO<20 ppb and inl6 examined children (11.0%) FeNO were increased >20 ppb (Fig. 1). Among 16 children (11%) with increased FeNO >20ppb, 15 of them were in group I (FeNO 21-50ppb) and 1 child was in group II (FeNO 5199 ppb), which was 6.25% of the group of children with increased results. There was no child in Group III (Fig. 2). Average values of air pollution (smog) in Ruzomberok during the FeNO measure in children for PM10 ranged from 23 to 40 ^g/m3 and for N02 from 28 to 44 ^g/m3 and were below the WHO and EU standard 50 ^g/m3.
Elevated FeNO values
Elevated FeNO values
21 - 50 ppb
51 - 99 ppb
>99 ppb
22, 22, 22, 24, 24, 26, 27, 27, 28, 29, 29, 31, 36, 46, 48
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no results
The 1-hour and 3-hour maximum values for N02 levels in Ruzomberok during the FeNO measure in children were:
September 19th, 2018 mlh- maximum 1-hour average ofN02: 44 [^g/m3]
m3h - maximum 3-hour average ofN02: 39 [^g/m3] October 8th, 2018 mlh - maximum 1-hour average ofN02: 29 [^g/m3]
m3h - maximum 3-hour average ofN02: 28 [^g/m3].
N02 in 2018 did not exceed the hourly limit value at any monitoring station. Exceeding the limit value for the protection of human health for hourly concentrations did not occur at any monitoring station. In 2018, no case of exceeding the alert threshold was discovered. The critical level for vegetation protection (30 ^g/m3 per calendar year expressed as N02) was not exceeded at any of the EMEOP stations in 2018. The values were way below the lower limit for ASHM vegetation protection [8].
□ < 20 ppb □> 20 ррЪ
Fig. 1. Range of FeNO values in all examined children
□ 21-50 □ 51-99 B>99
Fig. 2. Range of FeNO in children with increased values
CONCLUSIONS
1. The first stage of FeNO measurements in children in the autumn of 2018, when air pollution was low, showed that most children (89%) had normal FeNO values.
2. Analysis of the second phase of FeNO measurements in the winter of 2019, when air pollution was higher, will allow to compare the results and assess the correlation between the FeNO value and air pollution.
3. Children with elevated FeNO values are recommended for control tests and diagnostics for respiratory diseases, including asthma.
4. The second phase of the measurements and their comparative analysis will be presented in the next study.
Conflict of interests. The authors declare no conflict of interest.
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Crana Haimmna ao pe^aKuii 03.11.2019
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