Inhaled corticosteroids and the treatment of lymphocytic bronchiolitis following lung transplantation

Airway rejection after lung transplantation is recognized histologically as lymphocytic bronchiolitis (LB). We hypothesized that inhaled steroids coul d control LB and that changes in exhaled nitric oxide (eNO) would correlate with the development of LB and also have a role in monitoring response to treatment. A cohort of 120 lung transplant (LT) recipients attending for re view and biopsy had eNO measurements, FEV1, lavage microbiology, and biopsy histology performed prospectively. Wilcoxon signed-rank test was used to a ssess the significance of changes in eNO and FEV1. The coefficient of repro ducibility of eNO measurement in stable recipients was 2.36 ppb. Fourteen d eveloped graft dysfunction owing to isolated LB and were treated with inhal ed budesonide 800 mug twice daily. They showed significant increases in eNO at diagnosis, median (range) 10.9 ppb (4.6 to 48) ppb compared with baseli ne, 4.33 (1.0 to 10.76), p = 0.008, and a decrease in FEV1. After inhaled t reatment, both eNO and FEV1 returned to baseline values. Seven developed ac ute vascular rejection (with or without LB) and were treated with oral cort icosteroids, no changes in eNO occurred at diagnosis or after treatment. Se rial eNO measurements provide a useful noninvasive method of identifying ai rway inflammation in LT recipients. Inhaled budesonide may be a useful addi tion to Systemic immunosuppressants in controlling airway inflammation post transplant.