Novel Outcome Measures for Clinical Trials in Cystic Fibrosis

Cystic fibrosis (CF) is a common inherited condition caused by mutations in the gene encoding the CF transmembrane regulator protein. With increased understanding of the molecular mechanisms underlying CF and the development of new therapies there comes the need to develop new outcome measures to assess the disease, its progression and response to treatment. As there are limitations to the current endpoints accepted for regulatory purposes, a workshop to discuss novel endpoints for clinical trials in CF was held in Anaheim, California in November 2011. The pros and cons of novel outcome measures with potential utility for evaluation of novel treatments in CF were critically evaluated. The highlights of the 2011 workshop and subsequent advances in technologies and techniques that could be used to inform the development of clinical trial endpoints are summarized in this review. Pediatr Pulmonol. © 2014 The Authors. Pediatric Pulmonology published by Wiley Periodicals, Inc.

[1]  Aditi Sinha,et al.  The authors reply. , 2015, Kidney international.

[2]  A. Bankier,et al.  Quantitative and O 2 EnhancedMRI of the Pathologic Lung : Findings in Emphysema , Fibrosis , and Cystic Fibrosis , 2015 .

[3]  G. Borsboom,et al.  The authors reply , 2014, Pediatric pulmonology.

[4]  Paul Kinahan,et al.  Multimodality molecular imaging of the lung , 2014, Clinical and Translational Imaging.

[5]  C. Leone,et al.  Sweat conductivity: an accurate diagnostic test for cystic fibrosis? , 2014, Journal of cystic fibrosis : official journal of the European Cystic Fibrosis Society.

[6]  Umer Khan,et al.  Clinical mechanism of the cystic fibrosis transmembrane conductance regulator potentiator ivacaftor in G551D-mediated cystic fibrosis. , 2014, American journal of respiratory and critical care medicine.

[7]  M. van Straten,et al.  Monitoring cystic fibrosis lung disease by computed tomography. Radiation risk in perspective. , 2014, American journal of respiratory and critical care medicine.

[8]  R. P. Guillerman,et al.  Don't let radiation scare trump patient care: 10 ways you can harm your patients by fear of radiation-induced cancer from diagnostic imaging , 2014, Thorax.

[9]  H. Kauczor,et al.  Magnetic resonance imaging detects changes in structure and perfusion, and response to therapy in early cystic fibrosis lung disease. , 2014, American journal of respiratory and critical care medicine.

[10]  P. Reix,et al.  Lung clearance index: evidence for use in clinical trials in cystic fibrosis. , 2014, Journal of cystic fibrosis : official journal of the European Cystic Fibrosis Society.

[11]  G. Musch,et al.  Lung [18F]fluorodeoxyglucose Uptake and Ventilation–Perfusion Mismatch in the Early Stage of Experimental Acute Smoke Inhalation , 2014, Anesthesiology.

[12]  P. Sly,et al.  Airway, but not serum or urinary, levels of YKL-40 reflect inflammation in early cystic fibrosis lung disease , 2014, BMC Pulmonary Medicine.

[13]  D. Sin,et al.  Plasma sCD14 as a Biomarker to Predict Pulmonary Exacerbations in Cystic Fibrosis , 2014, PloS one.

[14]  Larry C. Lands,et al.  Candidate Markers Associated with the Probability of Future Pulmonary Exacerbations in Cystic Fibrosis Patients , 2014, PloS one.

[15]  B. Tümmler,et al.  Nasal potential difference measurements in diagnosis of cystic fibrosis: an international survey. , 2014, Journal of cystic fibrosis : official journal of the European Cystic Fibrosis Society.

[16]  M. Rosenfeld,et al.  Small airway involvement in cystic fibrosis lung disease: Routine spirometry as an early and sensitive marker , 2013, Pediatric pulmonology.

[17]  D. Sin,et al.  Systematic review of blood biomarkers in cystic fibrosis pulmonary exacerbations. , 2013, Chest.

[18]  Ewart A. C. Thomas,et al.  In Vivo Readout of CFTR Function: Ratiometric Measurement of CFTR-Dependent Secretion by Individual, Identifiable Human Sweat Glands , 2013, PloS one.

[19]  P. Lee,et al.  Assessment of clinical response to ivacaftor with lung clearance index in cystic fibrosis patients with a G551D-CFTR mutation and preserved spirometry: a randomised controlled trial. , 2013, The Lancet. Respiratory medicine.

[20]  R. Szczesniak,et al.  Multicenter Intestinal Current Measurements in Rectal Biopsies from CF and Non-CF Subjects to Monitor CFTR Function , 2013, PloS one.

[21]  M. Boon,et al.  Lung clearance index predicts pulmonary exacerbations in young patients with cystic fibrosis , 2013, Thorax.

[22]  P. D. de Jong,et al.  Pediatric chest computed tomography at a radiation dose approaching a chest radiograph. , 2013, American journal of respiratory and critical care medicine.

[23]  S. Stanojevic,et al.  Lung clearance index as an outcome measure for clinical trials in young children with cystic fibrosis. A pilot study using inhaled hypertonic saline. , 2013, American journal of respiratory and critical care medicine.

[24]  A. Gaggar,et al.  Acquired cystic fibrosis transmembrane conductance regulator dysfunction in the lower airways in COPD. , 2013, Chest.

[25]  J. Clancy,et al.  Optimizing Nasal Potential Difference Analysis for CFTR Modulator Development: Assessment of Ivacaftor in CF Subjects with the G551D-CFTR Mutation , 2013, PloS one.

[26]  Synho Do,et al.  Sinogram-affirmed iterative reconstruction of low-dose chest CT: effect on image quality and radiation dose. , 2013, AJR. American journal of roentgenology.

[27]  J. Mainz,et al.  Efficacy and safety of ivacaftor in patients aged 6 to 11 years with cystic fibrosis with a G551D mutation. , 2013, American journal of respiratory and critical care medicine.

[28]  T. Corcoran,et al.  Multisite comparison of mucociliary and cough clearance measures using standardized methods. , 2013, Journal of aerosol medicine and pulmonary drug delivery.

[29]  D. Bang,et al.  Lateral topography for reducing effective dose in low-dose chest CT. , 2013, AJR. American journal of roentgenology.

[30]  Peter D Sly,et al.  Risk factors for bronchiectasis in children with cystic fibrosis. , 2013, The New England journal of medicine.

[31]  J. Stocks,et al.  An official American Thoracic Society workshop report: optimal lung function tests for monitoring cystic fibrosis, bronchopulmonary dysplasia, and recurrent wheezing in children less than 6 years of age. , 2013, Annals of the American Thoracic Society.

[32]  E. Picard,et al.  Evaluation of the intestinal current measurement method as a diagnostic test for cystic fibrosis , 2013, Pediatric pulmonology.

[33]  S. Stanojevic,et al.  Multiple Breath Nitrogen Washout: A Feasible Alternative to Mass Spectrometry , 2013, PloS one.

[34]  H. Duivenvoorden,et al.  Impact of bronchiectasis and trapped air on quality of life and exacerbations in cystic fibrosis , 2013, European Respiratory Journal.

[35]  B. Chowdhury,et al.  Change in sweat chloride as a clinical end point in cystic fibrosis clinical trials: the ivacaftor experience. , 2013, Chest.

[36]  S. Sagel,et al.  Sputum biomarkers of inflammation and lung function decline in children with cystic fibrosis. , 2012, American journal of respiratory and critical care medicine.

[37]  Marleen de Bruijne,et al.  Chest computed tomography scores are predictive of survival in patients with cystic fibrosis awaiting lung transplantation. , 2012, American journal of respiratory and critical care medicine.

[38]  P. Quinton,et al.  β-adrenergic sweat secretion as a diagnostic test for cystic fibrosis. , 2012, American journal of respiratory and critical care medicine.

[39]  L. Saiman,et al.  Effect of azithromycin on systemic markers of inflammation in patients with cystic fibrosis uninfected with Pseudomonas aeruginosa. , 2012, Chest.

[40]  T. Liou,et al.  Ivacaftor in subjects with cystic fibrosis who are homozygous for the F508del-CFTR mutation. , 2012, Chest.

[41]  M. Charron,et al.  Cystic fibrosis: detecting changes in airway inflammation with FDG PET/CT. , 2012, Radiology.

[42]  R. Keogh,et al.  Sputum Biomarkers and the Prediction of Clinical Outcomes in Patients with Cystic Fibrosis , 2012, PloS one.

[43]  A. Wade,et al.  Lung function is abnormal in 3-month-old infants with cystic fibrosis diagnosed by newborn screening , 2012, Thorax.

[44]  R. Kronmal,et al.  Inhaled hypertonic saline in infants and children younger than 6 years with cystic fibrosis: the ISIS randomized controlled trial. , 2012, JAMA.

[45]  D. Sanders,et al.  The Sensitivity of Lung Disease Surrogates in Detecting Chest CT Abnormalities in Children With Cystic Fibrosis , 2012, Pediatric pulmonology.

[46]  Annette Kopp-Schneider,et al.  Morphologic and functional scoring of cystic fibrosis lung disease using MRI. , 2012, European journal of radiology.

[47]  S. Davis,et al.  Improvement in pulmonary function following antibiotics in infants with cystic fibrosis , 2012, Pediatric pulmonology.

[48]  M. Henry,et al.  A novel neutrophil derived inflammatory biomarker of pulmonary exacerbation in cystic fibrosis. , 2012, Journal of cystic fibrosis : official journal of the European Cystic Fibrosis Society.

[49]  J. Stockman Effect of VX-770 in Persons with Cystic Fibrosis and the G551D-CFTR Mutation , 2012 .

[50]  P. Sly,et al.  Progression of early structural lung disease in young children with cystic fibrosis assessed using CT , 2011, Thorax.

[51]  M. Gappa,et al.  Lung clearance index: clinical and research applications in children. , 2011, Paediatric respiratory reviews.

[52]  Matthias Griese,et al.  A CFTR potentiator in patients with cystic fibrosis and the G551D mutation. , 2011, The New England journal of medicine.

[53]  Austin Reno,et al.  Using hyperpolarized 3He MRI to evaluate treatment efficacy in cystic fibrosis patients , 2011, Journal of magnetic resonance imaging : JMRI.

[54]  S. Matsumoto,et al.  Pulmonary Magnetic Resonance Imaging for Airway Diseases , 2011, Journal of thoracic imaging.

[55]  B. Medoff,et al.  18F-FDG Uptake Rate Is a Biomarker of Eosinophilic Inflammation and Airway Response in Asthma , 2011, The Journal of Nuclear Medicine.

[56]  W. Morgan,et al.  The importance of imaging in cystic fibrosis. , 2011, American journal of respiratory and critical care medicine.

[57]  O. Eickelberg,et al.  The Chitinase-Like Protein YKL-40 Modulates Cystic Fibrosis Lung Disease , 2011, PloS one.

[58]  K. Carson,et al.  Acute inhalation of hypertonic saline does not improve mucociliary clearance in all children with cystic fibrosis , 2011, BMC pulmonary medicine.

[59]  P. Sly,et al.  Air Trapping on Chest CT Is Associated with Worse Ventilation Distribution in Infants with Cystic Fibrosis Diagnosed following Newborn Screening , 2011, PloS one.

[60]  J. Clancy,et al.  Results of a phase IIa study of VX-809, an investigational CFTR corrector compound, in subjects with cystic fibrosis homozygous for the F508del-CFTR mutation , 2011, Thorax.

[61]  W. Hop,et al.  Improved treatment response to dornase alfa in cystic fibrosis patients using controlled inhalation , 2011, European Respiratory Journal.

[62]  M. Rosenfeld,et al.  Bronchiectasis and pulmonary exacerbations in children and young adults with cystic fibrosis. , 2011, Chest.

[63]  O. Yılmaz,et al.  A new model for cystic fibrosis management: control concept. , 2011, Pneumologia.

[64]  Marleen de Bruijne,et al.  201* Reversibility of trapped air on CT scans of cystic fibrosis patients, an automated approach , 2011 .

[65]  N. Derichs,et al.  New clinical diagnostic procedures for cystic fibrosis in Europe. , 2011, Journal of cystic fibrosis : official journal of the European Cystic Fibrosis Society.

[66]  R. Ware,et al.  Randomised controlled trials in cystic fibrosis: what, when and how? , 2011, European Respiratory Journal.

[67]  P. Gustafsson,et al.  The effect of dornase alfa on ventilation inhomogeneity in patients with cystic fibrosis , 2011, European Respiratory Journal.

[68]  R. Prato,et al.  Analysis of Inflammatory and Immune Response Biomarkers in Sputum and Exhaled Breath Condensate by a Multi-Parametric Biochip Array in Cystic Fibrosis , 2011, International journal of immunopathology and pharmacology.

[69]  S. Stanojevic,et al.  Lung Clearance Index and HRCT are complementary markers of lung abnormalities in young children with CF , 2011, Thorax.

[70]  S. Stanojevic,et al.  Lung clearance index at 4 years predicts subsequent lung function in children with cystic fibrosis. , 2011, American journal of respiratory and critical care medicine.

[71]  L. Hoffman,et al.  Using bacterial biomarkers to identify early indicators of cystic fibrosis pulmonary exacerbation onset , 2011, Expert review of molecular diagnostics.

[72]  J. Clancy,et al.  Nasal potential difference measurements to assess CFTR ion channel activity. , 2011, Methods in molecular biology.

[73]  Y. Yau,et al.  Sputum induction in routine clinical care of children with cystic fibrosis. , 2010, The Journal of pediatrics.

[74]  M. Gappa,et al.  Sensitivity of Lung Clearance Index and chest computed tomography in early CF lung disease. , 2010, Respiratory medicine.

[75]  H. Kauczor,et al.  Computed tomography and magnetic resonance imaging in cystic fibrosis lung disease , 2010, Journal of magnetic resonance imaging : JMRI.

[76]  M. Rosenfeld,et al.  Multicenter evaluation of infant lung function tests as cystic fibrosis clinical trial endpoints. , 2010, American journal of respiratory and critical care medicine.

[77]  J. Clancy,et al.  An international randomized multicenter comparison of nasal potential difference techniques. , 2010, Chest.

[78]  Antonia Zapf,et al.  Intestinal current measurement for diagnostic classification of patients with questionable cystic fibrosis: validation and reference data , 2010, Thorax.

[79]  C. Porro,et al.  ResearchIsolation and characterization of microparticles in sputum from cystic fibrosis patients , 2010 .

[80]  M. Puderbach,et al.  The role of advanced imaging techniques in cystic fibrosis follow-up: is there a place for MRI? , 2010, Pediatric Radiology.

[81]  F. Ratjen,et al.  Hypertonic saline improves the LCI in paediatric patients with CF with normal lung function , 2010, Thorax.

[82]  M. Gappa,et al.  Lung clearance index: Normal values, repeatability, and reproducibility in healthy children and adolescents , 2009, Pediatric pulmonology.

[83]  F. Accurso,et al.  Sputum desmosine during hospital admission for pulmonary exacerbation in cystic fibrosis. , 2009, Chest.

[84]  N. Freedman,et al.  18F-fluorodeoxyglucose-PET/CT imaging of lungs in patients with cystic fibrosis. , 2009, Chest.

[85]  P. Sly,et al.  Bronchiectasis in infants and preschool children diagnosed with cystic fibrosis after newborn screening. , 2009, The Journal of pediatrics.

[86]  Michael Deimling,et al.  Non‐contrast‐enhanced perfusion and ventilation assessment of the human lung by means of fourier decomposition in proton MRI , 2009, Magnetic resonance in medicine.

[87]  A. Horsley Lung clearance index in the assessment of airways disease. , 2009, Respiratory medicine.

[88]  W. Hop,et al.  Lung morphology assessment using MRI: A robust ultra‐short TR/TE 2D steady state free precession sequence used in cystic fibrosis patients , 2009, Magnetic resonance in medicine.

[89]  A Munck,et al.  A European consensus for the evaluation and management of infants with an equivocal diagnosis following newborn screening for cystic fibrosis. , 2009, Journal of cystic fibrosis : official journal of the European Cystic Fibrosis Society.

[90]  P. Sly,et al.  Lung function in infants with cystic fibrosis diagnosed by newborn screening. , 2008, American journal of respiratory and critical care medicine.

[91]  R. Dweik,et al.  Biomarkers in exhaled breath condensate: a review of collection, processing and analysis , 2008, Journal of breath research.

[92]  Eitan Kerem,et al.  Effectiveness of PTC124 treatment of cystic fibrosis caused by nonsense mutations: a prospective phase II trial , 2008, The Lancet.

[93]  Shreyas S Vasanawala,et al.  Advances in pediatric MR imaging. , 2008, Magnetic resonance imaging clinics of North America.

[94]  Vicky A Legrys,et al.  Guidelines for diagnosis of cystic fibrosis in newborns through older adults: Cystic Fibrosis Foundation consensus report. , 2008, The Journal of pediatrics.

[95]  T J Williams,et al.  The spectrum of structural abnormalities on CT scans from patients with CF with severe advanced lung disease , 2008, Thorax.

[96]  S. Patz,et al.  Functional MR imaging of the lung. , 2008, Magnetic resonance imaging clinics of North America.

[97]  H. Kauczor,et al.  Radiation dose reduction in chest CT: a review. , 2008, AJR. American journal of roentgenology.

[98]  D. Brenner,et al.  Computed tomography--an increasing source of radiation exposure. , 2007, The New England journal of medicine.

[99]  H. Kauczor,et al.  Assessment of Morphological MRI for Pulmonary Changes in Cystic Fibrosis (CF) Patients: Comparison to Thin-Section CT and Chest X-ray , 2007, Investigative radiology.

[100]  H. Tiddens,et al.  Multiple-breath inert gas washout and spirometry versus structural lung disease in cystic fibrosis , 2007, Thorax.

[101]  B. Ramsey Use of lung imaging studies as outcome measures for development of new therapies in cystic fibrosis. , 2007, Proceedings of the American Thoracic Society.

[102]  M. Konstan,et al.  Sputum biomarkers of inflammation in cystic fibrosis lung disease. , 2007, Proceedings of the American Thoracic Society.

[103]  M. Dolovich,et al.  Positron emission tomography and computed tomography versus positron emission tomography computed tomography: tools for imaging the lung. , 2007, Proceedings of the American Thoracic Society.

[104]  T. Corcoran,et al.  Mucociliary clearance as an outcome measure for cystic fibrosis clinical research. , 2007, Proceedings of the American Thoracic Society.

[105]  J. Clancy,et al.  Detection of cystic fibrosis transmembrane conductance regulator activity in early-phase clinical trials. , 2007, Proceedings of the American Thoracic Society.

[106]  R. Gibson,et al.  No detectable improvements in cystic fibrosis transmembrane conductance regulator by nasal aminoglycosides in patients with cystic fibrosis with stop mutations. , 2007, American journal of respiratory cell and molecular biology.

[107]  F. Korosec,et al.  Functional lung imaging using hyperpolarized gas MRI , 2007, Journal of magnetic resonance imaging : JMRI.

[108]  Peter M. Jakob,et al.  Quantitative and O2 Enhanced MRI of the Pathologic Lung: Findings in Emphysema, Fibrosis, and Cystic Fibrosis , 2007, Int. J. Biomed. Imaging.

[109]  R. Kronmal,et al.  Association between pulmonary function and sputum biomarkers in cystic fibrosis. , 2007, American journal of respiratory and critical care medicine.

[110]  A. Wade,et al.  Early detection of cystic fibrosis lung disease: multiple-breath washout versus raised volume tests , 2007, Thorax.

[111]  Tilo Winkler,et al.  PET imaging of regional 18F-FDG uptake and lung function after cigarette smoke inhalation. , 2007, Journal of nuclear medicine : official publication, Society of Nuclear Medicine.

[112]  H. Kauczor,et al.  Proton MRI appearance of cystic fibrosis: Comparison to CT , 2007, European Radiology.

[113]  J. Stocks,et al.  Multiple breath washout with a sidestream ultrasonic flow sensor and mass spectrometry: A comparative study , 2006, Pediatric pulmonology.

[114]  M. Corey,et al.  Mutations in the cystic fibrosis transmembrane regulator gene and in vivo transepithelial potentials. , 2006, American journal of respiratory and critical care medicine.

[115]  G. Musch,et al.  Positron emission tomography imaging of regional lung function. , 2006, Minerva anestesiologica.

[116]  Hans-Ulrich Kauczor,et al.  Contrast-enhanced 3D MRI of lung perfusion in children with cystic fibrosis—initial results , 2006, European Radiology.

[117]  M. Knowles,et al.  Mucus clearance and lung function in cystic fibrosis with hypertonic saline. , 2006, The New England journal of medicine.

[118]  W. Hop,et al.  Progression of lung disease on computed tomography and pulmonary function tests in children and adults with cystic fibrosis , 2005, Thorax.

[119]  Jonathan D. Campbell,et al.  Computed tomography correlates with pulmonary exacerbations in children with cystic fibrosis. , 2005, American journal of respiratory and critical care medicine.

[120]  J. Pepper,et al.  Potential difference measurements in the lower airway of children with and without cystic fibrosis. , 2005, American journal of respiratory and critical care medicine.

[121]  M. Svartengren,et al.  Long-term clearance from small airways in patients with cystic fibrosis , 2005, European Respiratory Journal.

[122]  Janet Stocks,et al.  Multiple-breath washout as a marker of lung disease in preschool children with cystic fibrosis. , 2005, American journal of respiratory and critical care medicine.

[123]  S. Lum ATS/ERS statement: raised volume forced expirations in infants: guidelines for current practice. , 2005, American journal of respiratory and critical care medicine.

[124]  M. E. Wohl,et al.  Variability of markers of inflammation and infection in induced sputum in children with cystic fibrosis. , 2004, The Journal of pediatrics.

[125]  L. Lands,et al.  Induced sputum in cystic fibrosis: within-week reproducibility of inflammatory markers. , 2004, Clinical biochemistry.

[126]  M. Amaral,et al.  CFTR Cl- channel function in native human colon correlates with the genotype and phenotype in cystic fibrosis. , 2004, Gastroenterology.

[127]  B. Tümmler,et al.  Intestinal current measurements to diagnose cystic fibrosis. , 2004, Journal of cystic fibrosis : official journal of the European Cystic Fibrosis Society.

[128]  K. Kunzelmann,et al.  Assessment of CFTR function in rectal biopsies for the diagnosis of cystic fibrosis. , 2004, Journal of cystic fibrosis : official journal of the European Cystic Fibrosis Society.

[129]  W. Hop,et al.  Pulmonary disease assessment in cystic fibrosis: comparison of CT scoring systems and value of bronchial and arterial dimension measurements. , 2004, Radiology.

[130]  D. Schuster,et al.  Positron emission tomography with [18F]fluorodeoxyglucose to evaluate neutrophil kinetics during acute lung injury. , 2004, American journal of physiology. Lung cellular and molecular physiology.

[131]  J. Riordan,et al.  The DeltaF508 mutation results in loss of CFTR function and mature protein in native human colon. , 2004, Gastroenterology.

[132]  D. Schuster,et al.  Positron emission tomography with [ 18 F ] fluorodeoxyglucose to evaluate neutrophil kinetics during acute lung injury , 2004 .

[133]  R. Gibson,et al.  Inflammatory and microbiologic markers in induced sputum after intravenous antibiotics in cystic fibrosis. , 2003, American journal of respiratory and critical care medicine.

[134]  P. Gustafsson,et al.  Evaluation of ventilation maldistribution as an early indicator of lung disease in children with cystic fibrosis , 2003, European Respiratory Journal.

[135]  B. Kerem,et al.  Gentamicin-induced correction of CFTR function in patients with cystic fibrosis and CFTR stop mutations. , 2003, The New England journal of medicine.

[136]  L. Saiman,et al.  Azithromycin in patients with cystic fibrosis chronically infected with Pseudomonas aeruginosa: a randomized controlled trial. , 2003, JAMA.

[137]  H. Magnussen,et al.  Cellular profiles of induced sputum in children with stable cystic fibrosis: comparison with BAL , 2003, European Respiratory Journal.

[138]  M. Dolovich,et al.  Uptake of 18fluorodeoxyglucose in the cystic fibrosis lung: a measure of lung inflammation? , 2003, European Respiratory Journal.

[139]  Ramin Shahidi,et al.  Validation of medical image processing in image-guided therapy , 2002, IEEE Transactions on Medical Imaging.

[140]  A. Wade,et al.  Airway function in infants newly diagnosed with cystic fibrosis , 2001, The Lancet.

[141]  S. Eberl,et al.  Effect of a short course of rhDNase on cough and mucociliary clearance in patients with cystic fibrosis , 2000, Pediatric pulmonology.

[142]  J. Stocks,et al.  The raised volume rapid thoracoabdominal compression technique , 2000 .

[143]  E. Daviskas,et al.  Regional mucociliary clearance in patients with cystic fibrosis. , 2000, Journal of aerosol medicine : the official journal of the International Society for Aerosols in Medicine.

[144]  The raised volume rapid thoracoabdominal compression technique. The Joint American Thoracic Society/European Respiratory Society Working Group on Infant Lung Function. , 2000, American journal of respiratory and critical care medicine.

[145]  R. Kubin,et al.  Oral Ciprofloxacin in the Treatment of Pseudomonas Exacerbations of Paediatric Cystic Fibrosis: Clinical Efficacy and Safety Evaluation Using Magnetic Resonance Image Scanning , 1998, The Journal of international medical research.

[146]  G. Cutting,et al.  The diagnosis of cystic fibrosis: a consensus statement. Cystic Fibrosis Foundation Consensus Panel. , 1998, The Journal of pediatrics.

[147]  H. Fuchs,et al.  Effect of rhDNase on airflow obstruction and mucociliary clearance in cystic fibrosis. , 1996, American journal of respiratory and critical care medicine.

[148]  J. Gustafson,et al.  Cystic Fibrosis , 2009, Journal of the Iowa Medical Society.