Nitric oxide production in PCD: possible evidence for differential nitric oxide synthase function

Primary cilliary dyskinesia (PCD) is characterized by decreased levels of fractional exhaled nitric oxide (FeNO), thought to reflect low activity of airway inducible nitric oxide synthase (iNOS) levels. Alveolar NO (Calv) concentration and bronchial NO (JNO) flux can be calculated from FeNO measured at multiple exhalation flow rates. We hypothesised that whereas bronchial NO would be reduced in PCD due to reduced iNOS function, alveolar NO would reflect endothelial NOS (eNOS) function and be normal. We recorded the medical history; measured FeNO at multiple flow rates (50, 100, 200, 260 ml/sec); and performed spirometry in 24 children (aged 8-16 years). FeNO50 of the PCD children was significantly lower than normal mean (+/-SD) 8.1 +/- 1.3 ppb versus 12.5 +/- 1.6 ppb, P = 0.033. The mean +/- SD values of PCD (n = 24) and normal (n = 20) subjects were respectively: JNO: 383.5 +/- 307.9 versus 650.1 +/- 489 pl/s, P = 0.033, Calv: 1.60 +/- 0.78 versus 1.60 +/- 0.75 ppb, P = NS. We show that Calv is normal in PCD, demonstrating that there is no generalized disorder of NO handling in this condition. This differs from a previous report. Furthermore, we speculate that these data may provide supportive evidence that variable flow NO measurements can assess the relative activity of iNOS and eNOS.     

Enhanced production of oxygen radicals in nocturnal asthma.

Although the mechanisms of nocturnal worsening of pulmonary function in asthmatics have not been entirely established, airway inflammation is felt to be a major factor in disease severity. Consequently, to determine whether changes in bronchoalveolar lavage (BAL) fluid cellular components and their functions are related to nocturnal airway obstruction, we performed BAL at 4:00 A.M. and at 4:00 P.M. in asthma subjects with (n = 5) and without (n = 10) nocturnal asthma. No significant changes were observed from 4:00 P.M. to 4:00 A.M. in the concentration of total cells or the percentage or concentration of eosinophils or neutrophils in BAL fluid from subjects with or without nocturnal asthma. However, superoxide anion generation by air-space cells from subjects with nocturnal asthma was significantly greater at 4:00 A.M. than at 4:00 P.M. (6.9 +/- 1.7 versus 1.8 +/- 0.5 nmol/500K cells/h, p less than 0.05). Moreover, superoxide production at 4:00 A.M. was greater in subjects with than in those without nocturnal asthma (6.9 +/- 1.7 versus 2.2 +/- 0.6, p less than 0.02). Furthermore, in our group of asthmatics, the change in generation of superoxide anion from 4:00 P.M. to 4:00 A.M. was significantly correlated with the change in FEV1 (r = -0.71, p less than 0.01). We conclude that the development of nocturnal airway obstruction in asthma is associated with enhanced production of oxygen radicals by air-space cells. Because oxygen radicals can cause airway injury and thus enhance bronchial obstruction, it is possible that the release of these reactive compounds is causally associated with nocturnal asthma.     

Neuronal nitric oxide synthase is associated with airway obstruction in BALB/c mice exposed to ozone

BACKGROUND: The functional role of nitric oxide (NO) and the various nitric oxide synthase (NOS) isoforms in asthma is controversial. OBJECTIVE: To investigate the role of NO in mice exposed to ozone, three known isoforms of NOS [inducible NOS (iNOS), neuronal NOS (nNOS), and endothelial NOS (eNOS)] were studied. METHODS: The expression of iNOS, nNOS, and eNOS was determined in lung by Western blot analysis after exposure to filtered air and ozone (0.12, 0.5, 1 or 2 ppm) for 3 h. Using barometric whole-body plethysmography and increase in enhanced pause (P(enh)) as an index of airway obstruction, we measured airway responses to ozone exposure. Bronchoalveolar lavage (BAL) was performed. Nitrate and nitrite were measured using a modified Griess reaction. RESULTS: The nitrate concentration in BAL fluid, which indicates the in vivo generation of NO in airways, from the ozone-exposed group was significantly greater than that from the group exposed to filtered air (631.0 +/- 86.4 vs. 152.1 +/- 16.9 micromol/l, p < 0.05). The nitrate concentration in BAL fluid was increased more in mice exposed to 2-ppm ozone than that in mice exposed to filtered air or 0.12-, 0.5-, or 1-ppm ozone. Increases in P(enh) after exposure to ozone or filtered air were significantly higher in the ozone-exposed groups than in the group exposed to filtered air (p < 0.01). Increases in P(enh) were dependent on the ozone concentration. Although the protein levels of eNOS and iNOS determined were within normal levels, the amount of nNOS protein was markedly elevated in airway tissue homogenates of the group exposed to 2-ppm ozone. CONCLUSION: These findings demonstrate that the nNOS isoform may be involved in airway obstruction in mice exposed to ozone.     

Expression of nitric oxide synthase isoforms in the human placenta is not altered by labor

Nitric oxide has various biological activities including smooth muscle relaxation, anti-inflammatory activity, anti-coagulatory activity. As the human placenta is known to express nitric oxide synthases, this study investigated the possible effect of labor on the expression of endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS) in human placental tissues at term. Both eNOS and iNOS mRNA expression in placental tissues in labor were significantly higher than those in the amnion, chorion laeve, decidua vera and myometrium. The eNOS mRNA and protein expressions in placental tissues in labor (n = 12) were 1.6023 +/- 0.1652 (eNOS/GAPDH, mean +/- SEM) and 12.8 +/- 1.3 arbitrary units (AU), respectively, which were similar to those not in labor (n = 10), 1.5806 +/- 0.2042 (eNOS/GAPDH) and 11.4 +/- 1.8 AU. The iNOS mRNA and protein expressions in the placental tissues in labor were 1.2831 +/- 0.2436 (iNOS/GAPDH) and 10.7 +/- 2.1 AU respectively, similar to those not in labor, 1.9254 +/- 0.8004 (iNOS/GAPDH) and 13.3 +/- 1.8 AU. The guanosine 3',5'-cyclic monophosphate (cGMP) concentration in the placental tissues in labor was 23.6 +/- 1.4 fmol/g wet tissue, similar to that not in labor, 26.1 +/- 2.0 fmol/g wet tissue. These findings suggest that nitric oxide production in the human placenta is maintained during labor.     

Effect of tumor necrosis factor-alpha on endothelial and inducible nitric oxide synthase messenger ribonucleic acid expression and nitric oxide synthesis in ischemic and nonischemic isolated rat heart

OBJECTIVES: The present study aimed to investigate the influence of endogenous tumor necrosis factor-alpha (TNF-alpha) that was synthesized during ischemia and exogenous TNF-alpha on endothelial and inducible nitric oxide synthase (eNOS and iNOS) messenger ribonucleic acid (mRNA) expression and nitric oxide (NO) production in the isolated rat heart. BACKGROUND: Tumor necrosis factor-alpha is recognized as being a proinflammatory cytokine with a significant cardiodepressant effect. One of the proposed mechanisms for TNF-alpha-induced cardiac contractile dysfunction is increased NO production via iNOS mRNA upregulation, but the role of NO in TNF-alpha-induced myocardial dysfunction is highly controversial. METHODS: Isolated rat hearts studied by a modified Langendorff model were randomly divided into subgroups to investigate the effect of 1-h global cardioplegic ischemia or the effect of 1-h perfusion with exogenous TNF-alpha on the expression of eNOS mRNA and iNOS mRNA and on NO production. RESULTS: After 1 h of ischemia, there were significant increases in TNF levels in the effluent (from hearts), and eNOS mRNA expression had declined (from 0.91 +/- 0.08 to 0.68 +/- 0.19, p < 0.001); but there were no changes in iNOS mRNA expression, and NO was below detectable levels. Perfusion of isolated hearts with TNF-alpha had a cardiodepressant effect and decreased eNOS mRNA expression to 0.67 +/- 0.04 (p < 0.002). Inducible nitric oxide synthase mRNA was unchanged, and NO was below detectable levels. CONCLUSIONS: We believe this is the first study to directly show that TNF-alpha does not increase NO synthesis and release but does downregulate eNOS mRNA in the ischemic and nonischemic isolated rat heart.     

Nitric oxide levels in exhaled air and inducible nitric oxide synthase immunolocalization in pulmonary sarcoidosis.

Cytokines such as tumour necrosis factor-alpha and interferon gamma are associated with active pulmonary inflammation in sarcoidosis and they upregulate inducible nitric oxide synthase (iNOS). The objectives of this study were to examine iNOS upregulation in sarcoidosis by showing raised exhaled nitric oxide and increased iNOS activity in lung biopsy specimens of these patients utilizing immunohistochemistry. Exhaled NO was measured by a chemiluminescence analyser in 12 patients with newly diagnosed biopsy-proven sarcoidosis before and after 6 weeks of corticosteroid therapy. Lung biopsy specimens from these patients were subjected to immunohistochemical staining with a specific iNOS antibody. Exhaled NO was raised in newly diagnosed sarcoidosis (mean+/-SEM): 9.8+/-0.4 versus 4.1+/-0.2 parts per billion (ppb) in 21 healthy controls, p<0.001; and fell significantly after 6 weeks treatment with corticosteroids to 5.9+/-1.4 ppb; p<0.01. There was no correlation between exhaled NO and other markers of disease activity. Immunohistochemical staining demonstrated iNOS activity in respiratory epithelium and granulomas in patients with sarcoidosis. Exhaled nitric oxide is raised in patients with active pulmonary sarcoidosis and may be a result of inducible nitric oxide synthase upregulation. The fall in exhaled nitric oxide following corticosteroid therapy may reflect inhibition of inducible nitric oxide synthase in the respiratory epithelium and granulomas.     

Glucocorticoid treatment reduces exhaled nitric oxide in cystic fibrosis patients.

In cystic fibrosis (CF), low concentrations of exhaled nitric oxide (NO) and reduced expression of inducible nitric oxide synthase (iNOS) in airway epithelium have been reported. However, abundant iNOS expression has been found in the subepithelial tissues and elevated concentrations of NO metabolites in breath condensate and sputum. These conflicting results may be explained by increased scavenging of NO by superoxide radicals, resulting in rapid conversion to peroxynitrite, so that only a small proportion of the NO produced in the lung tissue reaches the airway lumen. If iNOS were active in the CF lung, exhaled NO would be further reduced by glucocorticoid treatment. CF patients (n = 13) were recruited to a double-blind, placebo-controlled study with crossover. Treatment comprised prednisolone or placebo for 5 days with a 9 day washout. After each treatment, exhaled NO was measured, spirometry performed and blood collected for measurement of serum nitrogen dioxide/nitrous oxide (NO2/NO3). Ten patients (8 male) completed the study. Following prednisolone treatment (mean +/- SD) exhaled NO concentration (3.1 +/- 1.6 parts per billion (ppb)) was significantly reduced versus placebo treatment (4.9 +/- 4.2 ppb; p<0.05, Wilcoxon signed-rank test). Spirometric indices and serum NO2/NO3 concentration were unchanged. These findings support the hypothesis that glucocorticoids suppress nitric oxide production in cystic fibrosis airways by reducing inducible nitric oxide synthase expression or by inhibiting recruitment of neutrophils, cells which express inducible nitric oxide synthase.     

Effect of intravenous hydrocortisone on nocturnal airflow limitation in childhood asthma.

Low endogenous cortisol levels appear to contribute to the pathophysiology of nocturnal asthma. Lower cortisol levels are associated with lower forced expiratory volume in one second (FEV1) levels in children with asthma. The aim of the present study was to identify whether substitution of low serum cortisol with intravenous hydrocortisone decreases 24-h FEV1 variation and/or indirect measures of airway inflammation. Hydrocortisone was given over 24 h in a double-blind randomised crossover design to 26 subjects. FEV1 was measured every 4 h during 24 h; blood eosinophils and airway responsiveness to methacholine and adenosine 5'-monophosphate (AMP) were measured at 04:00 h and 16:00 h. Cortisol levels increased during the night and morning hours. FEV1 values were higher at all time points in children with nocturnal asthma (n=10; 24-h FEV1 variation > or = 15%) which was significant at 08:00 h, unlike in the non-nocturnal asthma (NA-) group (n=16). Numbers of eosinophils (10(9) x L(-1)) at 04:00 h decreased in the asthma group (median 0.61 (range 0.05-1.42) versus 0.52 (0.05-1.79)). Provocative dose causing a 20% fall in FEV1 (PD20) methacholine did not change, whereas PD20 AMP improved only at 16:00 h in the NA- group (72.0 (0.13-144.0) versus 144.0 (2.25-144.0) mg x mL(-1)). These results show that substitution of lower endogenous 24-h values of cortisol contribute to higher forced expiratory volume in one second values and a decrease of blood eosinophils as an inflammatory marker in more severe airway obstruction.     

Increased alveolar nitric oxide concentration in asthmatic patients with nocturnal symptoms.

Nocturnal asthma symptoms and impaired lung function at night are related to inflammatory activity in the peripheral lung compartment. Exhaled nitric oxide (NO) measurement at multiple exhalation flow rates can be used to separately assess alveolar and bronchial NO production and inflammation. The authors hypothesised that asthmatic patients with nocturnal symptoms have a higher alveolar NO concentration than those with only daytime symptoms. The authors asked 40 patients with newly-diagnosed steroid-na?ve asthma about their nocturnal asthma symptoms through the use of a written questionnaire. Alveolar NO concentration and bronchial NO flux were assessed in the 40 asthmatics and 40 healthy controls. Nineteen of the 40 patients reported nocturnal symptoms. Patients with nocturnal symptoms had a higher alveolar NO concentration (1.7+/-0.3 (mean+/-SEM) parts per billion (ppb)) than patients without nocturnal symptoms (0.8+/-0.3 ppb, p=0.012) or healthy controls (1.0+/-0.1 ppb, p=0.032). Bronchial NO flux was higher both in patients with (2.4+/-0.4 nL x s(-1), p<0.001) and without (2.6+/-0.4 nL x s(-1), p<0.001) nocturnal symptoms, compared to controls (0.7+/-0.1 nL x s(-1)). Nocturnal symptoms in asthmatic patients are related to a higher alveolar nitric oxide concentration. The results suggest that assessment of alveolar nitric oxide concentration can be used to detect the parenchymal inflammation in asthmatic patients with nocturnal symptoms.     

Changes in the expression and distribution of the inducible and endothelial nitric oxide synthase in mucosal biopsy specimens of inflammatory bowel disease

OBJECTIVE: The role of nitric oxide (NO) in the pathophysiology of inflammatory bowel disease (IBD) is controversial. The aim of this study was to investigate the expression and localization of nitric oxide synthase isoforms (iNOS, eNOS) in IBD colonic mucosa. MATERIAL AND METHODS: Forty-four patients with IBD (24 ulcerative colitis (UC), 20 Crohn's disease (CD) and 16 controls) were investigated by colonoscopy. iNOS and eNOS in tissue sections was demonstrated by histochemistry (NADPH-diaphorase reaction) and immunohistochemistry. Cell type analysis and quantitative assessment of the iNOS immunoreactive (IR) cells and densitometry of iNOS in immunoblots were also performed. RESULTS: iNOS-IR cells were significantly numerous in inflamed mucosa of UC (64+/-4 cells/mm2) than in CD (4+/-2 cells/mm2). iNOS-IR/CD15-IR cells showed significant elevation in inflamed (i) versus uninflamed (u) UC mucosa (UCu 8+/-3%, UCi 85+/-10%) In CD, the percentage of iNOS-IR/CD68-IR cells was lower in inflamed sites (CDu 23+/-8%, CDi 4+/-3%). Immunoblot of biopsies revealed significant elevation of iNOS in active UC compared with uninflamed sites, whereas in CD no significant changes were detected. Differences were observed in eNOS and endothelial marker CD31 immunoreactivity. In patients with UC and in controls the ratios of eNOS/CD31-IR vessels were 82.3% and 92.0% respectively, whereas in CD the ratio was 8.3% with a concomitantly significant increase of CD31-IR vessels. The distribution and morphological characteristics of the NOS-IR inflammatory cells and endothelia were similar to those showing NADPH-diaphorase reactivity. CONCLUSIONS: Differences observed in the expression and distribution of NOS isoforms in immune and endothelial cells may contribute to better understanding of the structural and physiological changes in UC and CD.     

In stable lung transplant recipients, exhaled nitric oxide levels positively correlate with airway neutrophilia and bronchial epithelial iNOS

In conditions characterized by airway inflammation, exhaled nitric oxide (eNO) levels are increased. Variable degrees of airway inflammation are present in stable lung transplant recipients (LTR), and may lead to airway remodeling and chronic graft dysfunction. The hypothesis tested is that in stable LTR, eNO concentrations would reflect the expression of inducible (iNOS) (but not constitutive [cNOS] nitric oxide synthase) in the bronchial epithelium as well as the degree of airway inflammation. We determined eNO concentrations in 20 stable LTR, free of infection, rejection, or obliterative bronchiolitis (OB). At routine bronchoscopy, we measured the differential cell count on bronchoalveolar lavage (BAL) and a quantitative assessment of iNOS and cNOS expression in endobronchial biopsies by immunohistochemistry. Mean +/- SEM eNO concentrations in stable LTR were not significantly different from control subjects (13 +/- 0.7 ppb versus 14.2 +/- 0.49; p = 0.42). Percent BAL neutrophils was 11.5 +/- 3.2 which was significantly higher than in a group of local control subjects (1.7 +/- 0.6; p < 0.001). The bronchial epithelium and lamina propria contained abundant iNOS but cNOS was present only in the lamina propria. Using regression analysis, percent BAL neutrophils (r(2) = 0.82; p < 0.0001) and iNOS expression in the bronchial epithelium (r(2) = 0.75; p < 0.0001), but not in the lamina propria (r(2) = 0.16; p = 0.08), were positively predictive of eNO. There was an inverse relationship between cNOS and eNO. We conclude that eNO concentrations although normal for the group, still reflect the degree of airway inflammation in stable LTR. Epithelial iNOS appears to be the major source of eNO and expression of cNOS may be downregulated with increasing iNOS expression.     

Abstracts

Increase in Alveolar Nitric Oxide in the Presence of Symptoms in Childhood Asthma; Mahut, B., Delacourt, C., Zerah-Lancner, F., et al. Chest 2004; 125:1012-1018.

Background. Asthma is defined as an inflammation encompassing both the proximal and distal pulmonary airways. Exhaled nitric oxide is regarded as a non-invasive surrogate of airway inflammation. There is evidence of cellular inflammation in the very small airways and alveoli that result in an increase in nitric oxide (Q_no) output. There is documentation using bronchial alveolar lavage of cytokine expression, eosinophil presence, and nitric oxide synthetase expression in the distal airways. The authors hypothesized that increased nitric oxide output could result from distal airways and/or alveoli in asthmatic individuals.

Objective. The objective was to assess the contributions of alveolar and proximal airway compartments in exhaled nitric oxide (NO) output (Q_no) in children with asthma and to determine their correlation with mild symptoms of bronchial obstruction.

Methods. The subjects in this study included 15 children with asthma with recent onset of mild symptoms, 30 asymptomatic asthmatic children and 15 healthy children. The investigators measured exhaled nitric oxide concentration at multiple expiratory flow rates (V) allowing the determination of alveolar and proximal airway contributions in Q_no. Spirometric measurements and flow volume curves were obtained, as well.

Results. The asymptomatic and recently symptomatic individuals were not significantly different with regard to spirometry measurements. The maximal airway nitric oxide output was more elevated in recently symptomatic versus asymptomatic asthmatics, and in asymptomatic asthmatics versus healthy children. Variables that impacted airway nitric oxide output were symptoms and distal airway obstruction as assessed by MEF (25-75). The nitric oxide determination from the distal airways was significantly higher in individuals with MEF (25-75) less than 50% of predicted as compared with children whose MEF (25-75) was greater than 50% of predicted. Alveolar nitric oxide was significantly elevated in recently symptomatic children as compared with children who were asymptomatic, whereas it was not significantly different between asymptomatic and healthy children.

Conclusions. An increase in alveolar nitric oxide concentration was observed in correlation with increased symptoms of asthma and proximal airway nitric oxide was correlated with distal obstruction during asthma.

Reviewer's Comment. This is a useful prospective study, having healthy children as control subjects, which indicates the increased sensitivity and specificity of nitric oxide determination in the assessment of airway inflammation and correlating with the results of pulmonary function tests. It further extends our knowledge of airway inflammation to include the smallest airways and alveoli and indicates that even with mild or no symptoms, airway inflammation can be present distally as detected by nitric oxide, although it is not detected by conventional pulmonary function testing. It would be of interest to determine the correlation of nitric oxide with increasing levels of symptoms to provide parameters that might parallel the NHLBI Guidelines for mild, moderate, and severe asthma. Nitric oxide determination, particularly of the distal airway, may be useful as a marker of recent symptoms and of increasing loss of asthma control.

Christopher Randolph, M.D.

Waterbury, CT     

Effect of IBD sera on expression of inducible and endothelial nitric oxide synthase in human umbilical vein endothelial cells

AIM: To study the expression of endothelial and inducible nitric oxide synthases (eNOS and iNOS) and their role in inflammatory bowel disease (IBD). METHODS: We examined the effect of sera obtained from patients with active Crohn's disease (CD) and ulcerative colitis (UC) on the function and viability of human umbilical vein endothelial cells (HUVEC). HUVECs were cultured for 0-48 h in the presence of a medium containing pooled serum of healthy controls, or serum from patients with active CD or UC. Expression of eNOS and iNOS was visualized by immunofluorescence, and quantified by the densitometry of Western blots. Proliferation activity was assessed by computerized image analyses of Ki-67 immunoreactive cells, and also tested in the presence of the NOS inhibitor, 10-4 mol/ L L-NAME. Apoptosis and necrosis was examined by the annexin-V-biotin method and by propidium iodide staining, respectively. RESULTS: In HUVEC immediately after exposure to UC, serum eNOS was markedly induced, reaching a peak at 12 h. In contrast, a decrease in eNOS was observed after incubation with CD sera and the eNOS level was minimal at 20 h compared to control (18%±16% vs 23%±15% P<0.01). UC or CD serum caused a significant increase in iNOS compared to control (UC: 300%±1%; CD: 275%±7% vs 108%±4%, P<0.01). Apoptosis/ne-crosis characteristics did not differ significantly in either experiment. Increased proliferation activity was detected in the presence of CD serum or after treatment with L-NAME. Cultures showed tube-like formations after 24 h treatment with CD serum. CONCLUSION: IBD sera evoked changes in the ratio of eNOS/iNOS, whereas did not influence the viability of HUVEC. These involved down-regulation of eNOS and up-regulation of iNOS simultaneously, leading to increased proliferation activity and possibly a reduced anti-inflammatory protection of endothelial cells.     

Peripheral muscle alterations in non-COPD smokers

BACKGROUND: Although tobacco smoke is the main cause of COPD, relatively little attention has been paid to its potential damage to skeletal muscle. This article addresses the effect of smoking on skeletal muscle. METHODS: The vastus lateralis muscle was studied in 14 non-COPD smokers (FEV(1)/FVC, 78 +/- 5%) and 20 healthy control subjects (FEV(1)/FVC, 80 +/- 3%). Muscular structure, enzyme activity, constitutive and inducible nitric oxide (NO) synthases (endothelial NO oxide synthase [eNOS], neuronal NO synthase [nNOS] and inducible NO synthase [iNOS]), nitrites, nitrates, nitrotyrosine, and the presence of macrophages were analyzed. RESULTS: In smokers, type I muscle fibers cross-sectional area was decreased, and a similar trend was found in type IIa fibers. Lactate dehydrogenase levels and the percentage of fibers with low oxidative and high glycolytic capacity were increased in smokers. nNOS (96.9 +/- 11.7 vs 125.4 +/- 31.9 ng/mg protein; p < 0.01) and eNOS (38.9 +/- 11.0 vs 45.2 +/- 7.7 ng/mg protein [+/- SD]; p < 0.05) were lower in smokers, while fiber type distribution, capillarity measures, beta-hydroxy-acyl-CoA-dehydrogenase levels, iNOS, nitrite, nitrate, and nitrotyrosine levels, and macrophage number in the muscle tissue were similar to the nonsmoker subjects. CONCLUSIONS: Smokers presented some alterations of skeletal muscle such as oxidative fiber atrophy, increased glycolytic capacity, and reduced expression of the constitutive NO synthases (eNOS and nNOS). The findings support some muscular structural and metabolic damage but not the presence of local inflammation in the smokers. In addition, they suggest a possible effect of tobacco smoke impairing the normal process of NO generation.     

Post-lung transplant bronchiolitis obliterans syndrome (BOS) is characterized by increased exhaled nitric oxide levels and epithelial inducible nitric oxide synthase

In conditions characterized by airway inflammation, exhaled nitric oxide (eNO) levels are increased. Post-lung transplant bronchiolitis obliterans syndrome (BOS) is characterized by airway inflammation and development of progressive airway narrowing and fibrosis. We have previously shown that in stable lung transplant recipients (LTR), mean eNO levels were not elevated but were still related to the degree of airway neutrophilia within the group. The hypothesis now tested is that in BOS, eNO levels are increased in association with even greater airway neutrophilia and enhanced expression of inducible (iNOS) nitric oxide synthase in the bronchial epithelium. We determined eNO levels in 40 LTR in four groups: well and "stable": LTR (n = 20), BOS (n = 8), bacterial airway infection (BI, n = 6), and acute rejection (AR, n = 6). Following bronchoscopic sampling, we performed a quantitative assessment of iNOS and constitutive nitric oxide synthase (cNOS) expression in endobronchial biopsies by immunohistochemistry. Mean +/- SEM eNO levels in BOS and BI were significantly higher than in stable LTR (20 +/- 1.2 parts per billion [ppb] and 24.7 +/- 1.7 ppb versus 12.5 +/- 0.9 ppb; p < 0.01 for both). In AR, eNO levels (13.4 ppb +/- 0.5) were not different in stable LTR (p = 0.34). When compared with stable LTR, there was increased expression of iNOS in the bronchial epithelium and generally in the lamina propria (LP) in patients with BOS and BI. In AR, iNOS expression was increased but only in the LP in a perivascular distribution. Expression of cNOS was reduced in BOS but not in BI and AR compared with the stable group. Using regression analysis, only iNOS expression in the bronchial epithelium (r(2) = 0.77; p < 0.0001) and %BAL neutrophils (r(2) = 0. 79; p < 0.0001) were positively related to eNO in stable LTR and BOS. We conclude that epithelial iNOS appears to be the major source of eNO. Exhaled NO levels also appear to reflect the degree of airway neutrophilia in both stable LTR and BOS groups. This suggests that serial eNO measurements may be able to predict the early development of BOS.     

Effects of sex and of gene variants in constitutive nitric oxide synthases on exhaled nitric oxide

Genetic factors may contribute to the variability of exhaled nitric oxide in healthy individuals. We studied exhaled nitric oxide and genetic variants in both neuronal and endothelial nitric oxide synthases in 105 healthy nonsmoking and smoking subjects. Genomic DNA was screened for a repeat polymorphism in intron 20 of the neuronal nitric oxide synthase gene and for the 894G/T mutation of the endothelial nitric oxide synthase gene. Exhaled nitric oxide was significantly higher in males than females among both nonsmokers (p < 0.0001) and smokers (p = 0.003). No association was found between exhaled nitric oxide and the endothelial nitric oxide synthase gene variant. However, healthy nonsmoking females with greater numbers of repeats (i.e., both alleles with 12 or more repeats) in neuronal nitric oxide synthase had significantly lower nitric oxide levels than did females with fewer numbers of repeats (i.e., at least one allele with fewer than 12 repeats) (13.6 +/- 1.6 versus 19.4 +/- 1.6 ppb, p = 0.02). No association was found between exhaled nitric oxide and neuronal nitric oxide synthase genotype in males. These data suggest that variants in the neuronal nitric oxide synthase gene contribute to the variability of airway nitric oxide concentrations in healthy females.     

Expression of endothelial nitric oxide synthase and inducible nitric oxide synthase in synovium of rheumatoid arthritis]

OBJECTIVES: To examine the localization and distribution of endothelial nitric oxide synthase (eNOS) and inducible nitric oxide synthase (iNOS), which participate in nitric oxide (NO) production, in synovium of rheumatoid arthritis (RA). MATERIALS AND METHODS: Immunohistochemical analysis for eNOS and iNOS in synovial tissues obtained from 10 patients with RA who were underwent total knee replacement. Synovial tissues of osteoarthritis (OA) were used as control. The percentage of cells that were positive for eNOS and iNOS was estimated in five hundred endothelial cells, synovial lining cells and interstitial cells, respectively. And mRNA expression of NOS was confirmed by in situ hybridization. In addition, to test NO production, nitration of tyrosines was assessed by immunohistochemistry. RESULTS: Not only endothelial cells but also synovial lining cells and interstitial cells exhibited immune-reactive both eNOS and iNOS. Cells which were seemed immune-reactive eNOS and iNOS expressed nitrotyrosin. By in situ hybridization, we detected mRNA expression for eNOS and iNOS. CONCLUSIONS: Endothelial cells, synovial lining cells and interstitial cells expressed both eNOS and iNOS with high frequency in RA synovium compared with OA synovium. It seemed to correlate with NO production. These results suggest that expression of iNOS may be involved in the induction of arthritis and eNOS may be participated in augmentation of inflammation in RA.     

Increased inflammatory activity parallels increased basal nitric oxide production and blunted response to nitric oxide in vivo in rheumatoid arthritis

BACKGROUND: Endothelial dysfunction, defined as loss of bioactivity of NO in the vessel wall, is thought to precede atherosclerosis. OBJECTIVE: To determine whether endothelial dysfunction characterises patients with RA and whether these patients have increased inducible nitric oxide synthase (iNOS) dependent NO production in vivo. METHODS: and results: Twenty patients with RA and 33 normal subjects received intrabrachial artery infusions of endothelium dependent (acetylcholine (ACh)) and independent (sodium nitroprusside (SNP)) vasodilators to determine arterial responsiveness to NO. Basal flow and its percentage decrease by NG-monomethyl-L-arginine (L-NMMA), an inhibitor of both iNOS and endothelium dependent NOS (eNOS), was used to determine the contribution of iNOS and eNOS dependent NO to basal flow. Both SNP (p<0.01) and ACh (p<0.05) increased blood flow significantly less in patients with RA than normal subjects. Serum concentrations of TNFalpha were, within the RA group, inversely correlated with blood flow responses to both SNP (r=-0.67, p=0.002) and ACh (r=-0.64, p<0.005). Basal flow was significantly increased in RA and correlated within this group with serum CRP (r=0.48, p<0.05), TNFalpha (r=0.61, p<0.01) concentrations, and ESR (r=0.68, p<0.002). L-NMMA decreased basal flow significantly more (-34+/-2%) in the patients with RA than the normal subjects (-24+/-3%, p<0.02), suggesting in view of the blunted response to ACh, increased iNOS activity. CONCLUSIONS: Patients with RA have a dual abnormality in NO dependent vascular function. Basal blood flow is increased in proportion to inflammatory activity and more inhibited by L-NMMA, suggesting increased iNOS activity, and responsiveness to NO is reduced.     

Intestinal endotoxemia plays a central role in development of hepatopulmonary syndrome in a cirrhotic rat model induced by multiple pathogenic factors

AIM： To characterize the correlation between severity of hepatopulmonary syndrome （HPS） and degree of hepatic dysfunction, and to explore how intestinal endotoxemia （IETM） affects the development of HPS in cirrhotic rats.
METHODS： Male Wister rats were fed with a diet containing maize flour, lard, cholesterol, and alcohol and injected subcutaneously with CCl4 oil solution every two days for 8 wk to induce typical cirrhosis and development of HPS. The animals were also given a nitric oxide （NO） production inhibitor, N^ω-nitro-L-arginine methyl ester （L-NAME） intraperitoneally, and an iNOS inhibitor, aminoguanidine hydrochloride （AG） via gavage daily from the end of the 4th wk to the end of the 6th or 8th wk, or a HO-1 inhibitor, zinc protoporphyrin （ZnPP） intraperitoneally 12 h prior to killing. Blood, liver and lung tissues were sampled.
RESULTS： Histological deterioration of the lung paralleled to that of the liver in the cirrhotic rats. The number of pulmonary capillaries was progressively increased from 6.1 ± 1.1 （count/filed） at the 4th wk to 14.5 ± 2.4 （count/filed） at the 8th wk in the cirrhotic rats. Increased pulmonary capillaries were associated with increased blood levels of lipopolysaccharide （LPS） （0.31 ± 0.08 EU/mL vs control 0.09 ± 0.03 EU/mL）, alanine transferase （ALT, 219.1 ± 17.4 U/L vs control 5.9 ± 2.2 U/L） and portal vein pressure. Compared with normal control animals, the number of total cells in bronchoalveolar lavage fluid （BALF） of the cirrhotic rats at the 8th wk was not changed, but the number of macrophages and the ratio of macrophages to total cells were increased by nearly 2-fold, protein expression of inducible nitric oxide synthase （iNOS） and endothelial nitric oxide synthase （eNOS） started to increase significantly at the 4th wk, and reached its peak at the 8th wk in the lung of cirrhotic rats. The increase of iNOS expression appeared to be quicker than that of eNOS. NO2^-/NO3^- was also increased, which was cor     

Abstracts

Increase in Alveolar Nitric Oxide in the Presence of Symptoms in Childhood Asthma; Mahut, B., Delacourt, C., Zerah-Lancner, F., et al. Chest 2004; 125:1012–1018.

Background. Asthma is defined as an inflammation encompassing both the proximal and distal pulmonary airways. Exhaled nitric oxide is regarded as a non-invasive surrogate of airway inflammation. There is evidence of cellular inflammation in the very small airways and alveoli that result in an increase in nitric oxide (Q_no) output. There is documentation using bronchial alveolar lavage of cytokine expression, eosinophil presence, and nitric oxide synthetase expression in the distal airways. The authors hypothesized that increased nitric oxide output could result from distal airways and/or alveoli in asthmatic individuals.

Objective. The objective was to assess the contributions of alveolar and proximal airway compartments in exhaled nitric oxide (NO) output (Q_no) in children with asthma and to determine their correlation with mild symptoms of bronchial obstruction.

Methods. The subjects in this study included 15 children with asthma with recent onset of mild symptoms, 30 asymptomatic asthmatic children and 15 healthy children. The investigators measured exhaled nitric oxide concentration at multiple expiratory flow rates (V) allowing the determination of alveolar and proximal airway contributions in Q_no. Spirometric measurements and flow volume curves were obtained, as well.

Results. The asymptomatic and recently symptomatic individuals were not significantly different with regard to spirometry measurements. The maximal airway nitric oxide output was more elevated in recently symptomatic versus asymptomatic asthmatics, and in asymptomatic asthmatics versus healthy children. Variables that impacted airway nitric oxide output were symptoms and distal airway obstruction as assessed by MEF (25-75). The nitric oxide determination from the distal airways was significantly higher in individuals with MEF (25-75) less than 50% of predicted as compared with children whose MEF (25-75) was greater than 50% of predicted. Alveolar nitric oxide was significantly elevated in recently symptomatic children as compared with children who were asymptomatic, whereas it was not significantly different between asymptomatic and healthy children.

Conclusions. An increase in alveolar nitric oxide concentration was observed in correlation with increased symptoms of asthma and proximal airway nitric oxide was correlated with distal obstruction during asthma.

Reviewer's Comment. This is a useful prospective study, having healthy children as control subjects, which indicates the increased sensitivity and specificity of nitric oxide determination in the assessment of airway inflammation and correlating with the results of pulmonary function tests. It further extends our knowledge of airway inflammation to include the smallest airways and alveoli and indicates that even with mild or no symptoms, airway inflammation can be present distally as detected by nitric oxide, although it is not detected by conventional pulmonary function testing. It would be of interest to determine the correlation of nitric oxide with increasing levels of symptoms to provide parameters that might parallel the NHLBI Guidelines for mild, moderate, and severe asthma. Nitric oxide determination, particularly of the distal airway, may be useful as a marker of recent symptoms and of increasing loss of asthma control.

Christopher Randolph, M.D.

Waterbury, CT