Sample collection for laboratory-based study of the nasal airway and sinuses: a research compendium.

BACKGROUND: Collection of biologic samples from the nasal cavity and paranasal sinuses is of critical importance to the study of infectious or inflammatory conditions that affect both upper and lower airways. Numerous techniques for the study of ex-vivo samples exist, with specific applications, strengths, and weaknesses associated with each of them. In this compendium we summarize the available methods for collection of primary human samples and incorporate expert discussion of the pros, cons, and applications associated with each technique. METHODS: An expert panel containing members of the American Rhinologic Society's Research and Grants Committee compiled this educational reference. Rationale for use and the potential advantages and disadvantages are discussed. Research protocols and key references are enumerated. RESULTS: Sampling of the nasal cavity and paranasal sinuses can be achieved through a number of methods. Nonspecific sinonasal secretions may be collected via forced exhalation, nasal lavage, and nasal spray aspiration. Targeted collection of sinonasal secretions may be achieved via endoscopic placement of absorbent matrices. Nasal cytology or collection of superficial epithelium may be completed via brushing or scraping of endonasal structures. Collection of mucosal biopsies may be completed via sinonasal explant or full-thickness biopsy. CONCLUSION: Multiple sampling techniques are available to collect biologic samples from the sinonasal cavity. These techniques differ in their ease of application, reproducibility, sample yield, and utility for different sinonasal pathologies or research goals. An appreciation of the benefits and drawbacks of each approach will allow investigators to select the techniques most appropriate for achieving research objectives.

Nasal lavage, blood or sputum: Which is best for phenotyping asthma?

BACKGROUND AND OBJECTIVE: Determination of asthma phenotypes, particularly inflammatory phenotypes, helps guide treatment and management of this heterogeneous disease. Induced sputum cytology has been the gold standard for determination of inflammatory phenotypes, but sputum induction is fairly invasive and technically challenging. Blood and nasal lavage cytology have been suggested as substitutes, but have not been fully verified. The aim of this study is to determine the accuracy of blood and nasal lavage cytometry as indicators of inflammatory phenotypes in asthma. METHODS: Clinical evaluation, Asthma Control Questionnaire (ACQ) and spirometry were performed for 121 adult asthma patients, and blood, nasal lavage and induced sputum samples were taken. Eosinophils and neutrophils were counted in three samples from each subject. Inflammatory phenotypes (eosinophilic, neutrophilic, mixed and paucicellular) and cells counts were analysed using Venn diagram and receiver operating characteristic (ROC) curve, respectively. RESULTS: ACQ score, spirometry and bronchodilator response did not differ among subjects with different inflammatory phenotypes. Inflammatory phenotypes defined by nasal lavage cytometry were in better concordance than those defined by blood cell counts with phenotypes determined by sputum cytology, and were significantly correlated with sputum phenotypes. For eosinophilia, nasal lavage cytology showed better accuracy than blood cytology (area under the curve (AUC): 0.89 vs 0.65). For all phenotypes, sensitivity and positive and negative predictive power were higher for nasal lavage cytometry than for blood. Blood cell counts gave a high level of false positives for all inflammatory phenotypes. CONCLUSION: We recommend nasal lavage cytology over blood cell count as a substitute for sputum cytology to identify inflammatory phenotypes in asthma.

Oxygen With Cold Bubble Humidification Is No Better Than Dry Oxygen in Preventing Mucus Dehydration, Decreased Mucociliary Clearance, and Decline in Pulmonary Function.

BACKGROUND: Little is known about the effects of long-term nasal low-flow oxygen (NLFO) on mucus and symptoms and how this variable is affected by dry or cold humidified gas. The aim of this study was to investigate the effects of dry-NLFO and cold bubble humidified-NLFO on nasal mucociliary clearance (MCC), mucus properties, inflammation, and symptoms in subjects with chronic hypoxemia requiring long-term domiciliary oxygen therapy. METHODS: Eighteen subjects (mean age, 68 years; 7 male; 66% with COPD) initiating NLFO were randomized to receive dry-NLFO (n = 10) or humidified-NLFO (n = 8). Subjects were assessed at baseline, 12 h, 7 days, 30 days, 12 months, and 24 months by measuring nasal MCC using the saccharin transit test, mucus contact angle (surface tension), inflammation (cells and cytokine concentration in nasal lavage), and symptoms according to the Sino-Nasal Outcome Test-20. RESULTS: Nasal MCC decreased significantly (40% longer saccharin transit times) and similarly in both groups over the study period. There was a significant association between impaired nasal MCC and decline in lung function. Nasal lavage revealed an increased proportion of macrophages, interleukin-8, and epidermal growth factor concentrations with decreased interleukin-10 during the study. No changes in the proportion of ciliated cells or contact angle were observed. Coughing and sleep symptoms decreased similarly in both groups. There were no outcome differences comparing dry vs cold bubble humidified NLFO. CONCLUSIONS: In subjects receiving chronic NLFO, cold bubble humidification does not adequately humidify inspired oxygen to prevent deterioration of MCC, mucus hydration, and pulmonary function. The unheated bubble humidification performed no better than no humidification. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT02515786; URL: www.clinicaltrials.gov.

Evaluation of atopy in patients with COPD.

OBJECTIVE: To determine the prevalence of atopy and to evaluate clinical, laboratory, and radiological profiles in patients with COPD. METHODS: This was a cross-sectional study involving outpatients with stable COPD (defined by the clinical history and a post-bronchodilator FEV1/FVC < 70% of the predicted value). The patients completed a questionnaire regarding clinical characteristics and atopy, after which they underwent nasal lavage cytology, skin prick testing, chest X-rays, arterial blood gas analyses, and determination of total serum IgE. RESULTS: Of the 149 subjects studied, 53 (35.6%), 49 (32.8%), and 88 (59.1%) presented with nasal eosinophilia, a positive skin prick test result, and symptoms of allergic rhinitis, respectively. Correspondence analysis confirmed these findings, showing two distinct patterns of disease expression: atopy in patients with COPD that was less severe; and no evidence of atopy in those with COPD that was more severe (reduced FEV1 and hyperinflation). There was a statistically significant association between nasal eosinophilia and a positive bronchodilator response. CONCLUSIONS: Using simple and reproducible methods, we were able to show that there is a high frequency of atopy in patients with COPD. Monitoring inflammation in the upper airways can be a useful tool for evaluating respiratory diseases in the elderly and in those with concomitant asthma and COPD, a clinical entity not yet fully understood.

Evaluation of atopy in patients with COPD / Avaliação de atopia em portadores de DPOC

OBJECTIVE: To determine the prevalence of atopy and to evaluate clinical, laboratory, and radiological profiles in patients with COPD. METHODS: This was a cross-sectional study involving outpatients with stable COPD (defined by the clinical history and a post-bronchodilator FEV1/FVC < 70% of the predicted value). The patients completed a questionnaire regarding clinical characteristics and atopy, after which they underwent nasal lavage cytology, skin prick testing, chest X-rays, arterial blood gas analyses, and determination of total serum IgE. RESULTS: Of the 149 subjects studied, 53 (35.6%), 49 (32.8%), and 88 (59.1%) presented with nasal eosinophilia, a positive skin prick test result, and symptoms of allergic rhinitis, respectively. Correspondence analysis confirmed these findings, showing two distinct patterns of disease expression: atopy in patients with COPD that was less severe; and no evidence of atopy in those with COPD that was more severe (reduced FEV1 and hyperinflation). There was a statistically significant association between nasal eosinophilia and a positive bronchodilator response. CONCLUSIONS: Using simple and reproducible methods, we were able to show that there is a high frequency of atopy in patients with COPD. Monitoring inflammation in the upper airways can be a useful tool for evaluating respiratory diseases in the elderly and in those with concomitant asthma and COPD, a clinical entity not yet fully understood. .

OBJETIVO: Determinar a prevalência de atopia e avaliar o perfil clínico, laboratorial e radiológico de pacientes com DPOC. MÉTODOS: Estudo de corte transversal com pacientes ambulatoriais portadores de DPOC estável (definida pela história clínica e relação VEF1/CVF < 70% do previsto após broncodilatador). Os pacientes responderam um questionário clínico e de atopia e foram submetidos a citologia de lavado nasal, teste cutâneo de alergia, radiografia de tórax, hemogasometria arterial e dosagem de IgE total. RESULTADOS: Dos 149 indivíduos avaliados, 53 (35,6%), 49 (32,8%) e 88 (59,1%), respectivamente, apresentavam eosinofilia no lavado nasal, teste cutâneo positivo e sintomas de rinite alérgica. A análise de correspondência confirmou esses achados, evidenciando dois perfis distintos de doença: a presença de atopia em pacientes com estágios mais leves de DPOC, e a ausência de características de atopia em pacientes com aspectos de doença mais grave (VEF1 reduzido e hiperinsuflação). Houve uma associação estatisticamente significante entre eosinofilia no lavado nasal e prova farmacodinâmica positiva. CONCLUSÕES: Este estudo identificou uma alta frequência de atopia em pacientes com DPOC, utilizando ferramentas simples e reprodutíveis. A monitorização inflamatória de vias aéreas parece ser uma ferramenta útil para avaliar as doenças respiratórias em idosos, assim como em pacientes com sobreposição de asma e DPOC, entidade clínica ainda pouco compreendida. .

[Supranuclear stria of ciliated cells in allergic rhinitis]. / La estría supranuclear de las células ciliadas en la rinitis alérgica.

Nasal secretions were studied in 80 allergic adults patients: 16 with intermittent rhinitis and 64 with persistent rhinitis. The percentage of supranuclear stria of ciliated cells with regard to leucocytes was studied by nasal scraping. Four groups of patients were classified according to nasal leucocytic predominance: patients with eosinophilic predominance with eosinophils > 10% in Group A (N=23), patients with abundant neutrophils and eosinophils >10% in Group B (N=15), patients with scant leucocytes in Group C (N=29), patients with neutrophilic predominance without eosinophils in Group D (N=13). An increase of supranuclear stria percentage was correlated to eosinophils > 10% and also correlated to scant leucocytes. Nevertheless, a significant decrease of supranuclear stria percentage was observed in neutrophilic leukocytosis of bacterial etiology.

La estria supranuclear de las células ciliadas en la rinitis alérgica / Supranuclear stria of ciliated cells in allergic rhinitis

Se estudiaron 80 pacientes adultos alérgicos, que cursaron con los siguientes cuadros clínicos: 16 casos de rinitis intermitente y 64 de rinitis persistente. Se realizó el recuento porcentual de la estría supranuclear de las células ciliadas, respecto de los leucocitos presentes en los extendidos obtenidos por toma endonasal. Con los datos obtenidos se clasificaron los extendidos en 4 grupos; Grupo A (N=23): predominio leucocitario eosinófilo con eosinofilia nasal >10%, Grupo B (N=15): abundantes leucocitos neutrófilos y eosinofilia nasal >10%, Grupo C (N=29): con escasos leucocitos, Grupo D (N=13): con abundantes leucocitos de predominio neutrófilo sin eosinofilia. Se observó que el incremento porcentual de estría supranuclear se correlacionó con eosinofilia nasal >10% y con las muestras que presentaron escasos leucocitos. Sin embargo se evidenció una marcada disminución del porcentaje de estría supranuclear en la leucocitosis neutrófila de etiología bacteriana.

Nasal secretions were studied in 80 allergic adults patients: 16 with intermittent rhinitis and 64 with persistent rhinitis. The percentage of supranuclear stria of ciliated cells with regard to leucocytes was studied by nasal scraping. Four groups of patients were classified according to nasal leucocytic predominance: patients with eosinophilic predominance with eosinophils > 10% in Group A (N=23), patients with abundant neutrophils and eosinophils >10% in Group B (N=15), patients with scant leucocytes in Group C (N=29), patients with neutrophilic predominance without eosinophils in Group D (N=13). An increase of supranuclear stria percentage was correlated to eosinophils > 10% and also correlated to scant leucocytes. Nevertheless, a significant decrease of supranuclear stria percentage was observed in neutrophilic leukocytosis of bacterial etiology.

La estria supranuclear de las células ciliadas en la rinitis alérgica / Supranuclear stria of ciliated cells in allergic rhinitis

Se estudiaron 80 pacientes adultos alérgicos, que cursaron con los siguientes cuadros clínicos: 16 casos de rinitis intermitente y 64 de rinitis persistente. Se realizó el recuento porcentual de la estría supranuclear de las células ciliadas, respecto de los leucocitos presentes en los extendidos obtenidos por toma endonasal. Con los datos obtenidos se clasificaron los extendidos en 4 grupos; Grupo A (N=23): predominio leucocitario eosinófilo con eosinofilia nasal >10%, Grupo B (N=15): abundantes leucocitos neutrófilos y eosinofilia nasal >10%, Grupo C (N=29): con escasos leucocitos, Grupo D (N=13): con abundantes leucocitos de predominio neutrófilo sin eosinofilia. Se observó que el incremento porcentual de estría supranuclear se correlacionó con eosinofilia nasal >10% y con las muestras que presentaron escasos leucocitos. Sin embargo se evidenció una marcada disminución del porcentaje de estría supranuclear en la leucocitosis neutrófila de etiología bacteriana.(AU)

Nasal secretions were studied in 80 allergic adults patients: 16 with intermittent rhinitis and 64 with persistent rhinitis. The percentage of supranuclear stria of ciliated cells with regard to leucocytes was studied by nasal scraping. Four groups of patients were classified according to nasal leucocytic predominance: patients with eosinophilic predominance with eosinophils > 10% in Group A (N=23), patients with abundant neutrophils and eosinophils >10% in Group B (N=15), patients with scant leucocytes in Group C (N=29), patients with neutrophilic predominance without eosinophils in Group D (N=13). An increase of supranuclear stria percentage was correlated to eosinophils > 10% and also correlated to scant leucocytes. Nevertheless, a significant decrease of supranuclear stria percentage was observed in neutrophilic leukocytosis of bacterial etiology.(AU)

[Upper airway cellular pattern in infants with acute bronchiolitis: neutrophils or eosinophils?]. / Padrão de celularidade nas vias aéreas superiores de lactentes com bronquiolite aguda: neutrófilos ou eosinófilos?

OBJECTIVE: To analyze the cellular pattern of nasopharyngeal secretions in infants with acute bronchiolitis (AB), focusing on the presence or absence of neutrophils and eosinophils. METHOD: Hospitalized children with AB admitted to Hospital São Lucas, Porto Alegre, Brazil, between May and July 2002 were recruited. Nasopharyngeal aspirates were collected during the first 48 hours after admission. Slides were stained with May Grunwald and Giemsa. Total cell count and cellular viability were obtained in all samples. RESULTS: Thirty-eight infants with AB were enrolled. The mean age was 2.2 months (interquartile range: 1.2-3.5), and 21 subjects were male. Neutrophils were the predominant cells in the nasopharyngeal aspirates (median 95%, interquartile: 94-97). No eosinophils were found in the samples studied. CONCLUSION: Our results suggest that eosinophils do not play a significant role in the pathophysiogenesis of AB. Infants with AB present a specific inflammatory response to viral infections, which is distinct from the immune response observed in asthma.

Pesquisa de eosinófilos em secreçäo nasal no Hospital Universitário de Florianópolis / A research on eosinophils in nasal secretion at the Florianópolis University Hospital

A caracterizaçäo de uma rinite depende de vários exames que incluem desde a anamnese até outros exames complementares, para a definiçäo da etiologia da rinite. é definido como rinite, um hiperfuncionamento nasal e inflamaçäo tecidual, que leva a congestäo nasal, rinorréia, obstruçäo nasal, prurido e espirros. As rinites podem ser classificadas quanto ao tipo como: näo-alérgica e näo-infecciosa, alérgica, alérgica aguda, alérgica sazonal, alérgica perene, infecciosa. Nesta pesquisa, analisamos 97 casos de exames, quanto à sua parte citológica, onde encontramos apenas 7 casos de eosinofilia. Na maior parte (46 exames), verificamos ausência de eosinófilos, seguido de 37 exames com menos de 10 porcento de presença de eosinófilos. Quanto ao sexo, outro item observado, observamos a equivalência de casos, ou seja, 50 exames para o sexo masculino e 47 para o sexo feminino

Nasal inflammatory responses in children exposed to a polluted urban atmosphere.

Southwest Metropolitan Mexico City (SWMMC) preadolescent children have been exposed to a highly polluted urban atmosphere most of their lives. The main objective of this study was to determine by nasal lavage (NAL) the acute inflammatory nasal influx elicited in these children upon exposure to three different polluted days. Ozone, the main criteria pollutant for SWMMC, varied both in the number of hours above the National Ambient Air Quality Standard (NAAQS), which is 0.12 ppm as a 1-h maximum concentration not to be exceeded more than once per year, and in the maximal concentrations in the preceding three NAL sampling dates. Nasal neutrophilic influx, the surface expression of the B2 integrin CD11b on the nasal polymorphonuclear leukocytes (PMNs), rhinoscopic findings, respiratory symptoms, and nasal cytologies were evaluated in the 38 exposed children and in the 28 control children living in a nonpolluted Pacific coast port. SWMMC children had an average daily outdoor exposure of 7.7 h and complained of nasal mucus secretion, epistaxis, intermittent nasal obstruction, diurnal cough episodes, and chest discomfort. Nasal mucosal atrophy by rhinoscopy was present in 37/38, and all children had an abnormal nasal cytology. Exposed children had significantly higher nasal PMNs and nasal PMN-CD11b expression than controls. PMN median values in exposed children were higher than controls on all sampling dates (November 12, p < .001; November 17, p < .001; and November 24, p < .00001). Interestingly, a lower nasal neutrophilic response (p < .0004) was recorded in the SWMMC children 18 h after exposure to the highest O3 concentrations (up to 0.307 ppm) and the largest number of hours with O3 > 0.12 ppm (7 h). The question of a competing inflammatory response at the bronchioalveolar level with structural damage is raised. These NAL findings underscore the need to restrict outdoor activity in SWMMC children during the months of greater potential exposure to ozone.

Human nasal mucosal changes after exposure to urban pollution.

Millions of people worldwide are living in areas where ozone (O3) concentrations exceed health standards (an hourly average of 235 micrograms/m3/0.12 ppm, not to be exceeded more than once per year). Ozone induces acute nasal inflammatory responses and significant epithelial lesions in experimental animals and humans. To determine the nasal effects of a 15-day exposure to an urban polluted atmosphere with O3 as the main pollutant, we studied a population of healthy, young males newly arrived to southwest metropolitan Mexico City (SWMMC). The study included 49 non-smoking residents in an unpolluted port, Veracruz City; 14 subjects stayed in the port and served as controls, while 35 subjects traveled to SWMMC and had serial nasal lavages at different times after arriving in SWMMC. Subjects had exposures to ambient O3 an average of 10.2 hr/day, with a total cumulative O3 exposure of 10.644 ppm.hr. Nasal inflammatory responses, polymorphonuclear leukocyte PMN-CD11b surface expression, rhinoscopic changes, and respiratory symptoms were evaluated. Exposed subjects had massive nasal epithelial shedding and significant responses in PMN nasal influx (p < 0.00001) and in PMN-CD11b expression (p < 0.05). Cumulative O3 exposure correlated with respiratory symptoms, PMNs (rs = 0.2374, p < 0.01), and CD11b (rs = 0.3094, p < 0.01); 94% of exposed subjects experienced respiratory symptoms, and 97% left the city with an abnormal nasal mucosa by rhinoscopy. Nasal epithelial changes persisted 2 weeks after the exposed subjects returned to their nonpolluted environment. Exposure to an urban polluted atmosphere induces significant and persistent nasal epithelial alterations in healthy subjects.(ABSTRACT TRUNCATED AT 250 WORDS)