Features of severe asthma in school-age children: Atopy and increased exhaled nitric oxide
Open accessAbstract
Background Children with severe asthma have persistent symptoms despite treatment with inhaled corticosteroids (ICSs). The differentiating features of severe asthma in children are poorly defined.Objective To identify features of severe versus mild-to-moderate asthma in school-age children using noninvasive assessments of lung function, atopy, and airway inflammation.Methods A total of 75 children (median age, 10 years) with asthma underwent baseline characterization including spirometry and lung volume testing, methacholine bronchoprovocation, allergy evaluation, and offline measurement of exhaled nitric oxide (F(ENO)). Twenty-eight were followed longitudinally over 6 months. Participants were assigned to the severe asthma subgroup if they required high-dose ICS plus 2 or more minor criteria.Results Children with severe versus mild-to-moderate asthma had more symptoms, greater airway obstruction, more gas trapping, and increased bronchial responsiveness to methacholine. Subjects with severe asthma also had higher concentrations of F(ENO) and significantly greater sensitization to aeroallergens. With long-term study, both the reduction in FEV(1) and increase in F(ENO) persisted in the severe versus mild-to-moderate group. Furthermore, despite adjustments in ICS doses, the frequency of exacerbations was significantly higher in subjects with severe (83%) versus mild-to-moderate asthma (43%).Conclusion Severe asthma in childhood is characterized by poor symptom control despite high-dose ICS treatment and can be differentiated from mild-to-moderate asthma by measurement of lung function and F(ENO).Clinical implications Clinicians should suspect severe asthma in children with poor response to ICS, airway obstruction, and high F(ENO).
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One factor strongly associated with severe asthma in children and adolescents is allergic sensitization.
“One factor strongly associated with severe asthma in children and adolescents is allergic sensitization (82–87).”
From Epidemiology of Asthma in Children and Adults (2019) · cites this paper as [82]
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Craig, T., King, T. S., Lemanske, R. F., Wechsler, M. E., Icitovic, N., Zimmerman, R. R., & Wasserman, S. I. (2008) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2007.12.1153 · Cited by 91 · see citing works
Nordlund, B., Konradsen, J. R., Kull, I., Borres, M. P., Önell, A., Hedlin, G., & Grönlund, H. (2012) · Allergy · doi:10.1111/j.1398-9995.2012.02797.x · Cited by 91 · see citing works
“Ongoing exposure to aeroallergens has been suggested to increase bronchial inflammation and the risk of exacerbations in severe asthmatics (6).”
BackgroundTH17 cells in asthma and inflammation
Aujla, S. J., & Alcorn, J. F. (2011) · Biochimica et Biophysica Acta (BBA) - General Subjects · doi:10.1016/j.bbagen.2011.02.002 · Cited by 89 · see citing works
Urinary Bromotyrosine Measures Asthma Control and Predicts Asthma Exacerbations in Children
Wedes, S. H., Wu, W., COMHAIR, S. A. A., McDowell, K. M., DiDonato, J. A., ERZURUM, S. C., & Hazen, S. L. (2011) · The Journal of Pediatrics · doi:10.1016/j.jpeds.2011.01.029 · Cited by 89 · see citing works
“Exhaled NO was measured during the initial study encounter by an online method at a constant flow rate of 50 mL/s, consistent with American Thoracic Society standards.(19,20) Spot clean-catch urine samples were collected at the initial study encounter, from which levels of free BrTyr were determined by stable isotope…”
Fitzpatrick, A. M., Teague, W. G., Burwell, L., Brown, M. S., & Brown, L. A. S. (2010) · Pediatric Research · doi:10.1203/pdr.0b013e3182026370 · Cited by 83 · see citing works
“Severe asthma was diagnosed in children treated with high-dose ICS or daily oral corticosteroids who also had two minor criteria (1).”
MethodInfluentialAssessment of problematic severe asthma in children: Figure 1–
Carlsen, K. C. L., Hedlin, G., Bush, A., Wennergren, G., de Benedictis, F. M., de Jongste, J. C., Baraldi, E., Pedroletti, C., Barbato, A., Malmström, K., et al. (2010) · European Respiratory Journal · doi:10.1183/09031936.00091410 · Cited by 83 · see citing works
Asthma across the ages: Knowledge gaps in childhood asthma
Szefler, S. J., Chmiel, J. F., Fitzpatrick, A. M., Giacoia, G. P., Green, T. P., Jackson, D. J., Nielsen, H. C., Phipatanakul, W., & Raissy, H. (2013) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2013.10.018 · Cited by 80 · see citing works
Antó, J. M., Pinart, M., Akdiş, M., Auffray, C., Bachert, C., Basagaña, X., Carlsen, K., Guerra, S., von Hertzen, L., Illi, S., et al. (2012) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2012.01.047 · Cited by 79 · see citing works
Severe Asthma in Children: Lessons Learned and Future Directions
Fitzpatrick, A. M. (2016) · The Journal of Allergy and Clinical Immunology In Practice · doi:10.1016/j.jaip.2015.10.008 · Cited by 78 · see citing works
Mold, Mycotoxins and a Dysregulated Immune System: A Combination of Concern?
Kraft, S., Buchenauer, L., & Polte, T. (2021) · International Journal of Molecular Sciences · doi:10.3390/ijms222212269 · Cited by 82 · see citing works
“According to Fitzpatrick et al., 2006 [52] severe asthma in children had a more profound IgE sensitization and more positive skin prick tests for different allergens (weed mix, D. farinae, and D. pteryn) than those of mild-to-moderate asthma phenotype children [52].”
MethodTeague, W. G., Lawrence, M. G., Shirley, D.-A. T., Garrod, A. S., Early, S. V., Payne, J. B., Wiśniewski, J., Heymann, P. W., Daniero, J. J., Steinke, J. W., et al. (2019) · The Journal of Allergy and Clinical Immunology In Practice · doi:10.1016/j.jaip.2018.12.027 · Cited by 76 · see citing works
Distinct epithelial gene expression phenotypes in childhood respiratory allergy
Giovannini‐Chami, L., Marcet, B., Moreilhon, C., Chevalier, B., Illie, M. I., Lebrigand, K., Robbe-Sermesant, K., Bourrier, T., Michiels, J., Mari, B. P., et al. (2011) · European Respiratory Journal · doi:10.1183/09031936.00070511 · Cited by 76 · see citing works
“already been associated with atopy in epidemiological studies (30).”
BackgroundAirway TGF-β1 and oxidant stress in children with severe asthma: Association with airflow limitation
Brown, S. D., Baxter, K. M., Stephenson, S. T., Esper, A. M., Brown, L. A. S., & Fitzpatrick, A. M. (2012) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2011.11.037 · Cited by 75 · see citing works
Severe asthma during childhood and adolescence: A longitudinal study
Ross, K. R., Gupta, R., DeBoer, M. D., Zein, J., Phillips, B. R., Mauger, D. T., Li, C., Myers, R., Phipatanakul, W., Fitzpatrick, A. M., et al. (2019) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2019.09.030 · Cited by 72 · see citing works
Fitzpatrick, A. M., Brown, L. A. S., Holguín, F., & Teague, W. G. (2009) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2009.08.039 · Cited by 71 · see citing works
Higher mortality of adults with asthma: A 15‐year follow‐up of a population‐based cohort
Lemmetyinen, R., Karjalainen, J., But, A., Renkonen, R., Pekkanen, J., Toppila-Salmi, S. K., & Haukka, J. K. (2018) · Allergy · doi:10.1111/all.13431 · Cited by 70 · see citing works
“In pediatric populations, polysensitization is associated with excess morbidity of asthma and related conditions such as allergic diseases.(11,37,38) We demonstrated previously that in adult asthmatic population, AR/ AC associates with a polysensitization pattern.”
BackgroundUS and European severe asthma cohorts: what can they teach us about severe asthma?
Kupczyk, M., & Wenzel, S. E. (2012) · Journal of Internal Medicine · doi:10.1111/j.1365-2796.2012.02558.x · Cited by 68 · see citing works
Noninvasive Markers of Airway Inflammation in Asthma
Wedes, S. H., Khatri, S. B., Zhang, R., Wu, W., COMHAIR, S. A. A., Wenzel, S. E., Teague, W. G., Israel, E., ERZURUM, S. C., & Hazen, S. L. (2009) · Clinical and Translational Science · doi:10.1111/j.1752-8062.2009.00095.x · Cited by 68 · see citing works
Allergic rhinitis: the “Ghost Diagnosis” in patients with asthma
Egan, M., & Bunyavanich, S. (2015) · Asthma Research and Practice · doi:10.1186/s40733-015-0008-0 · Cited by 64 · see citing works
Phenotypes and endotypes of uncontrolled severe asthma: new treatments.
Campo, P., Rodríguez, F., Sánchez-García, S., Barranco, P., Quirce, S., Pérez‐Francés, C., Torrijos, E. G., Cárdenas, R., Olaguibel, J. M., & Delgado, J. (2013) · PubMed · Cited by 63 · see citing works
Fitzpatrick, A. M., Stephenson, S. T., Hadley, G. R., Burwell, L., Penugonda, M., Simon, D. M., Hansen, J. M., Jones, D. P., & Brown, L. A. S. (2011) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2011.03.031 · Cited by 62 · see citing works
“Procedures Participants underwent phenotypic characterization consisting of questionnaires and allergy evaluation as previously described.(2) Exhaled nitric oxide was determined online (NIOX Mino; Aerocrine, Solna, Sweden) according to published recommendations.”
BackgroundMethodInfluentialThe Role and Immunobiology of Eosinophils in the Respiratory System: a Comprehensive Review
Eng, S., & DeFelice, M. L. (2016) · Clinical Reviews in Allergy & Immunology · doi:10.1007/s12016-015-8526-3 · Cited by 61 · see citing works
Residential Proximity to a Major Roadway Is Associated with Features of Asthma Control in Children
Brown, M. S., Sarnat, S. E., DeMuth, K. A., Brown, L. A. S., Whitlock, D. R., Wakefield, S., Tolbert, P. E., & Fitzpatrick, A. M. (2012) · PLoS ONE · doi:10.1371/journal.pone.0037044 · Cited by 59 · see citing works
“These children with severe, ICS-refractory asthma consume a large proportion of healthcare resources and suffer extreme morbidity [3,4].”
BackgroundRelation between inflammation and symptoms in asthma
Tillie‐Leblond, I., Montani, D., Crestani, B., Jacques de, B. L. I. C., Humbert, M. J. C., de Lara, M. T., Magnan, A., Roche, N., Ostinelli, J., & Chanez, P. (2009) · Allergy · doi:10.1111/j.1398-9995.2009.01971.x · Cited by 57 · see citing works
“(18) followed up 75 children with persistent asthma for 6 months.”
BackgroundInfluentialSheehan, W. J., & Phipatanakul, W. (2015) · Current Opinion in Allergy and Clinical Immunology · doi:10.1097/aci.0000000000000195 · Cited by 56 · see citing works
“Children with severe and uncontrolled asthma are more likely to have allergic sensitization [7,11,14,15].”
BackgroundThe Role of Allergy in Severe Asthma
Kennedy, J. L., Heymann, P. W., & Platts‐Mills, T. A. E. (2012) · Clinical & Experimental Allergy · doi:10.1111/j.1365-2222.2011.03944.x · Cited by 55 · see citing works
Konradsen, J. R., Nordlund, B., Lidegran, M. K., Pedroletti, C., Grönlund, H., van Hage, M., Dahlén, B., Hedlin, G., & In Cooperation with the Swedish network of Pediatric Allergists, S. A. N. (2010) · Pediatric Allergy and Immunology · doi:10.1111/j.1399-3038.2010.01098.x · Cited by 53 · see citing works
“(7) who studied an inner-city, predominantly AfricanAmerican, population and found that atopy and increased exhaled nitric oxide are features of severe childhood asthma.”
BackgroundResultInfluentialPark, Y. H., Fitzpatrick, A. M., Medriano, C. A., & Jones, D. P. (2016) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2016.08.018 · Cited by 50 · see citing works
Transcriptomic Profiles in Nasal Epithelium and Asthma Endotypes in Youth
Yue, M., Gaietto, K. M., Han, Y. Y., Rosser, F. J., Xu, Z., Qoyawayma, C., Acosta‐Pérez, E., CANINO, G. J., Forno, E., Chen, W., et al. (2025) · JAMA · doi:10.1001/jama.2024.22684 · Cited by 49 · see citing works
Severe Asthma: An Expanding and Mounting Clinical Challenge
Bell, M. C., & Busse, W. W. (2013) · The Journal of Allergy and Clinical Immunology In Practice · doi:10.1016/j.jaip.2013.01.005 · Cited by 46 · see citing works
Fitzpatrick, A. M., & Teague, W. G. (2010) · Pediatric Allergy Immunology and Pulmonology · doi:10.1089/ped.2010.0021 · Cited by 46 · see citing works
“Children also submit blood samples for genetic studies and quantification of immunoglobulin E (IgE) and peripheral eosinophils as described previously.(3,12) Data are reviewed for accuracy by a centralized Data Coordinating Center.”
BackgroundMethodInfluentialBreath Formate Is a Marker of Airway S-Nitrosothiol Depletion in Severe Asthma
Greenwald, R., Fitzpatrick, A. M., Gaston, B. M., Marozkina, N. V., ERZURUM, S. C., & Teague, W. G. (2010) · PLoS ONE · doi:10.1371/journal.pone.0011919 · Cited by 45 · see citing works
“This characterization procedure has been previously described in detail [1] and has been validated by our group for use with pediatric subjects [2].”
Cowan, K., & Guilbert, T. W. (2012) · Current Opinion in Pediatrics · doi:10.1097/mop.0b013e32835357ab · Cited by 43 · see citing works
Mummy, D. G., Carey, K. J., Evans, M. D., Denlinger, L. C., Schiebler, M. L., Sorkness, R. L., Jarjour, N. N., & Fain, S. B. (2020) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2020.02.029 · Cited by 44 · see citing works
Sex dependence of airflow limitation and air trapping in children with severe asthma
Sorkness, R. L., Teague, W. G., Penugonda, M., & Fitzpatrick, A. M. (2011) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2010.12.1079 · Cited by 41 · see citing works
Is allergic sensitization relevant in severe asthma? Which allergens may be culprits?
Lombardi, C., Savi, E., Ridolo, E., Passalacqua, G., & Canonica, G. W. (2017) · World Allergy Organization Journal · doi:10.1186/s40413-016-0138-8 · Cited by 41 · see citing works
Allergic Asthma in the Era of Personalized Medicine
Papapostolou, N., & Makris, M. P. (2022) · Journal of Personalized Medicine · doi:10.3390/jpm12071162 · Cited by 39 · see citing works
“found that allergic sensitization in school children with asthma was more prevalent in severe than in mild to moderate asthmatics [18].”
BackgroundProgressive airflow limitation is a feature of children with severe asthma
Fitzpatrick, A. M., & Teague, W. G. (2011) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2010.10.036 · Cited by 37 · see citing works
“Similar to adults with severe asthma (2), children with severe asthma were characterized by baseline airflow limitation that was not completely reversed with bronchodilation (1).”
BackgroundMethodResultInfluentialAsthma severity in childhood, untangling clinical phenotypes*
Lang, A. M., Mowinckel, P., Sachs‐Olsen, C., Riiser, A., Lunde, J., Carlsen, K., & Carlsen, K. C. L. (2010) · Pediatric Allergy and Immunology · doi:10.1111/j.1399-3038.2010.01072.x · Cited by 36 · see citing works
“Acknowledging the heterogeneity of asthma presentations, multiple symptom criteria are often used within one definition, and patients included for eliciting any combination of these (5, 8).”
BackgroundBusse, W. W. (2010) · Journal of Allergy and Clinical Immunology · doi:10.1016/j.jaci.2010.01.036 · Cited by 34 · see citing works
Inflammatory and Comorbid Features of Children Admitted to a PICU for Status Asthmaticus*
Grunwell, J. R., Travers, C. D., & Fitzpatrick, A. M. (2018) · Pediatric Critical Care Medicine · doi:10.1097/pcc.0000000000001695 · Cited by 33 · see citing works
Identifying problematic severe asthma in the individual child – does lung function matter?*
Lang, A., Konradsen, J. R., Carlsen, K.-H., Sachs‐Olsen, C., Mowinckel, P., Hedlin, G., & Carlsen, K. L. (2010) · Acta Paediatrica · doi:10.1111/j.1651-2227.2009.01625.x · Cited by 32 · see citing works
“Inclusion criteria to the present study were an adaptation of the ERS task force definition of ‘difficult ⁄ therapy-resistant asthma’ (28), similar to criteria used in previous paediatric studies using the terms ‘difficult’ or ‘severe asthma’ (4,29).”
BackgroundResultInfluentialde Planell‐Saguer, M., Lovinsky‐Desir, S., & Miller, R. L. (2014) · Environmental and Molecular Mutagenesis · doi:10.1002/em.21836 · Cited by 32 · see citing works
“Several studies have related elevated fractional exhaled nitric oxide (FeNO), a biomarker of airway inflammation, to early environmental exposures, and allergic airway inflammation, respiratory symptoms, and asthma (Cornell et al., 2012; Dweik et al., 2010; Fitzpatrick et al., 2006; Kalliola et al., 2013; Strunk et al…”
BackgroundFitzpatrick, A. M., Baena‐Cagnani, C. E., & Bacharier, L. B. (2012) · Current Opinion in Allergy and Clinical Immunology · doi:10.1097/aci.0b013e32835090ac · Cited by 31 · see citing works
“Exhaled nitric oxide Not distinguishing overall but associated with exacerbations in a selected phenotype [3,45&] Sustained elevations [2]”
BackgroundInfluentialPathophysiology of asthma: lessons from genetic research with particular focus on severe asthma
Melén, E., & Pershagen, G. (2012) · Journal of Internal Medicine · doi:10.1111/j.1365-2796.2012.02555.x · Cited by 29 · see citing works
Factors Associated with Asthma Severity in Children: Data from the French COBRAPed Cohort
Lezmi, G., Lejeune, S., Pin, I., Blanchon, S., Bouazza, N., Jolaine, V., Marguet, C., Houdoin, V., Berger, P., Fayon, M. J., et al. (2020) · The Journal of Allergy and Clinical Immunology In Practice · doi:10.1016/j.jaip.2020.12.027 · Cited by 29 · see citing works
Pediatric biomarkers in asthma: exhaled nitric oxide, sputum eosinophils and leukotriene E4
Gogate, S. U., & Katial, R. K. (2008) · Current Opinion in Allergy and Clinical Immunology · doi:10.1097/aci.0b013e3282f60f61 · Cited by 29 · see citing works
Cabral, A., Vollmer, W. M., Barbirotto, R. M., & Martins, M. A. (2009) · Annals of Allergy Asthma & Immunology · doi:10.1016/s1081-1206(10)60183-4 · Cited by 29 · see citing works
“4 [20–115] vs 11.”
Papadopoulos, N. G., Čustović, A., Deschildre, A., Gern, J. E., Garcia, A. N., Miligkos, M., Phipatanakul, W., Wong, G., Xepapadaki, P. V., Agache, I. O., et al. (2024) · Pediatric Allergy and Immunology · doi:10.1111/pai.14129 · Cited by 28 · see citing works
The chitinase-like protein YKL-40 is not a useful biomarker for severe persistent asthma in children
Santos, C. B., Davidson, J., Covar, R. A., & Spahn, J. D. (2014) · Annals of Allergy Asthma & Immunology · doi:10.1016/j.anai.2014.05.024 · Cited by 28 · see citing works
An update on paediatric asthma
Hedlin, G., Konradsen, J. R., & Bush, A. (2012) · European Respiratory Review · doi:10.1183/09059180.00003212 · Cited by 27 · see citing works
Diagnosis of chronic rhinosinusitis
Leo, G., Triulzi, F. M., & Incorvaia, C. (2012) · Pediatric Allergy and Immunology · doi:10.1111/j.1399-3038.2012.01320.x · Cited by 27 · see citing works
“Asthma in children is defined as ‘difficult-to-treat’ when is not controlled despite treatment with high doses of inhaled corticosteroids (38).”
BackgroundÓxido nítrico exhalado en niños: un indicador no invasivo de la inflamación de las vías aéreas
Barroso, N. C., Pérez‐Yarza, E. G., Sardón‐Prado, O., Bover, C. R., Gärtner, S., & Murúa, J. K. (2008) · Archivos de Bronconeumología · doi:10.1157/13114655 · Cited by 26 · see citing works
“Sin embargo, quedaría sin responder la pregunta de si es posible la evolución hacia distintos fenotipos de asma en un mis-mo individuo a lo largo de la vida 57,58 .”
Treatment Benefit with Omalizumab in Children by Indicators of Asthma Severity
Szefler, S. J., Casale, T. B., Haselkorn, T., Yoo, B., Ortiz, B. D., Kattan, M., & Busse, W. W. (2020) · The Journal of Allergy and Clinical Immunology In Practice · doi:10.1016/j.jaip.2020.03.033 · Cited by 26 · see citing works
Asthma Phenotypes and Biomarkers
Grunwell, J. R., & Fitzpatrick, A. M. (2025) · Respiratory Care · doi:10.1089/respcare.12352 · Cited by 28 · see citing works
High basophil allergen sensitivity (CD‐sens) is associated with severe allergic asthma in children
Konradsen, J. R., Nordlund, B., Nilsson, O. B., van Hage, M., Nopp, A., Hedlin, G., & Grönlund, H. (2012) · Pediatric Allergy and Immunology · doi:10.1111/j.1399-3038.2011.01260.x · Cited by 22 · see citing works
“asthma (1), whereas other studies have reported that atopy is associated with severe asthma (7).”
BackgroundRelationships Between Exhaled Nitric Oxide and Atopy Profiles in Children With Asthma
Jang, W.-N., Park, I.-S., Choi, C.-H., Bauer, S., Harmin, S., Seo, S., Choi, I. S., Choung, J. T., & Yoo, Y. (2013) · Allergy Asthma and Immunology Research · doi:10.4168/aair.2013.5.3.155 · Cited by 21 · see citing works
- Authors
- Fitzpatrick, A. M., Gaston, B. M., Erzurum, S. C., & Teague, W. G.
- Affiliations
- Emory University (US)
- University of Virginia (US)
- Cleveland Clinic (US)
- Corresponding author
- Fitzpatrick, Anne M.
- Venue
- Journal of Allergy and Clinical Immunology
- Publisher
- Elsevier BV
- Published
- 2006-12
- Volume
- 118
- Issue
- 6
- Pages
- 1218-1225
- ISSN
- 0091-6749 (ISSN-L)
- PMC
- PMC2878140
- OpenAlex
- W2086746792
- Cited by
- 197
- References
- 39
- Citations by year
- 2025: 5 · 2024: 4 · 2022: 7 · 2021: 5 · 2020: 9 · 2019: 16 · 2018: 11 · 2017: 13 · 2016: 9 · 2015: 10 · 2014: 9 · 2013: 16 · 2012: 23
- FWCI
- 6.19
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Allergy and Clinical Immunology (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Heart, Lung, and Blood Institute (U10HL109250, R01HL069170, R01 HL 69170)
- Topics
- Health Sciences › Medicine › Physiology › Asthma and respiratory diseases
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Occupational exposure and asthma
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Chronic Obstructive Pulmonary Disease (COPD) Research
- Keywords
- severe asthma, childhood asthma, atopy, exhaled nitric oxide, airway inflammation, inhaled corticosteroids, airway obstruction, asthma exacerbations, aeroallergen sensitization, lung function, FEV1 decline
- MeSH terms
- Adolescent, Allergens, Asthma, Bronchial Provocation Tests, Child, Diagnosis, Differential, Female, Humans, Hypersensitivity, Immediate, Immunization, Male, Nitric Oxide, Spirometry, Cohort Studies, Biomarkers, Methacholine Chloride, Exhalation
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