Evaluation of exhaled nitric oxide's ability to predict methacholine challenge in adults with nonobstructive...

Compared with methacholine challenge, exhaled nitric oxide is less expensive, is performed as a simpler point-of-care maneuver, and may provide treatment guiding information.

To determine whether exhaled nitric oxide levels can predict the outcome of methacholine challenge in patients without obvious baseline obstruction.

This retrospective database and medical record review included adults presenting to a tertiary care center from November 1, 2009, through August 31, 2013, who underwent methacholine challenge and exhaled nitric oxide measurement within 2 weeks of each other. Database extraction identified age, sex, body mass index, baseline corticosteroid use, testing indication, forced expiratory volume in 1 second (FEV₁), and testing results. Individuals taking corticosteroid-containing medication or who had an FEV₁ less than the lower limit of normal at baseline were excluded.

A total of 1,322 individuals were identified, with 774 meeting the eligibility criteria. A total of 123 methacholine challenges (16%) had positive results. Fractional exhaled nitric oxide was statistically higher in those with positive methacholine challenge results (mean [SD], 41.9 [54.5] ppb vs 25.2 [19.7] ppb; P < .01). Receiver operating characteristic curve revealed an area under the curve of 0.572 (P < .01), suggesting a poor correlation between exhaled nitric oxide level and methacholine challenge outcome. Fractional exhaled nitric oxide of greater than 50 ppb has a sensitivity, specificity, positive predictive value, and negative predictive value of 12%, 89%, 17%, and 84%, respectively, for a positive methacholine challenge result.

In this large, retrospective cohort of corticosteroid-naive pulmonary patients with normal FEV₁ on baseline spirometry, exhaled nitric oxide poorly predicts the outcome of a methacholine challenge.