The Correlation Between Asthma Severity and Neutrophil to Lymphocyte Ratio


  •   Meena Abdul-Sattar Darwesh

  •   Ibtihal Shukri Abd Alhaleem

  •   Muhammed Waheeb Salman Al-Obaidy


Background—The prognosis is essential in management and follows up of asthmatic patients. Neutrophil to lymphocyte ratio is considered as the common prognostic marker for many diseases especially the asthma.

Aim of study—To assess the relationship between asthma severity and neutrophil to lymphocyte ratio in comparison to healthy controls.

Patients and methods—This study is a cross sectional study conducted in Respiratory Consultancy Clinic in Baghdad Teaching Hospital in Medical City during the period from 1st of October, 2018 to 31st of March, 2019 on sample of 50 asthmatic patients and 50 healthy controls. The diagnosis of asthma was confirmed by the supervisor through clinical symptoms, signs, spirometery with reversibility test (according to GINA guideline.).

Results—A highly significant difference was observed between asthmatic cases and controls regarding age (p<0.001). A significant association was observed between obesity and asthmatic cases (p=0.001). There was a highly significant association between high neutrophil/lymphocyte ratio and asthmatic cases (p<0.001). The neutrophil/lymphocyte ratio was significantly increased with advanced age, females, severe and uncontrolled asthma.

Conclusions—The neutrophil to lymphocyte ratio is useful biomarker in assessment of asthma severity.

Keywords: Asthma, Neutrophil to Lymphocyte Ratio.


Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. 2014. Available at:

Uwaezuoke SN, Ayuk AC, Eze JN. Severe bronchial asthma in children: a review of novel biomarkers used as predictors of the disease. J Asthma Allergy 2018; 11:11-18.

Moore WC, Hastie AT, Li X. Sputum neutrophils are associated with more severe asthma phenotypes using cluster analysis. Journal of Allergy and Clinical Immunology 2014; 133: 1557–1563.

Bloemen K, Van Den Heuvel R, Govarts E. A new approach to study exhaled proteins as potential biomarkers for asthma. Clinical and Experimental Allergy 2011; 41: 346–356.

Imtiaz F, Shafique K, Mirza SS. Neutrophil lymphocyte ratio as a measure of systemic inflammation in prevalent chronic diseases in Asian population. International Archives of Medicine 2012; 5: 2.

Zhang XY, Simpson JL, Powell H. Full blood count parameters for the detection of asthma inflammatory phenotypes. Clinical and Experimental Allergy 2014; 44: 1137–1145.

Uthamalingam S, Patvardhan EA, Subramanian S. Utility of the neutrophil to lymphocyte ratio in predicting long-term outcomes in acute decompensated heart failure. Am J Cardiol 2011; 107(3):433-438.

Azab B, Bhatt VR, Phookan J. Usefulness of the neutrophil-to lymphocyte ratio in predicting short- and long term mortality in breast cancer patients. Ann Surg Oncol 2012; 19(1):217-224.

de Jager CP, van Wijk PT, Mathoera RB, de Jongh-Leuvenink J,van der Poll T, Wever PC. Lymphocytopenia and neutrophillymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit. Crit Care 2010; 14(5): R192.

Alkhouri N, Morris-Stiff G, Campbell C. Neutrophil to lymphocyte ratio: a new marker for predicting steatohepatitis and fibrosis in patients with nonalcoholic fatty liver disease. Liver Int 2012; 32(2):297-302.

Spark JI, Sarveswaran J, Blest N, Charalabidis P, Asthana S. An elevated neutrophil-lymphocyte ratio independently predicts mortality in chronic critical limb ischemia. J Vasc Surg 2010; 52(3):632-636.

Ouellet G, Malhotra R, Penne EL, Usvya L, Levin NW, Kotanko P.Neutrophil-lymphocyte ratio as a novel predictor of survival in chronic hemodialysis patients. Clin Nephrol 2016; 85(4):191-198.

Chung KF. Targeting the interleukin pathway in the treatment of asthma. Lancet 2015; 386 (9998): 1086–1096.

Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA: A Cancer Journal for Clinicians 2011; 61 (2): 69–90.

Gohy ST, Hupin C, Pilette C, Ladjemi MZ. Chronic inflammatory airway diseases: The central role of the epithelium revisited. Clinical and Experimental Allergy 2016; 46 (4): 529–542.

Ekström M, Bornefalk-Hermansson A. Cardiovascular and antacid treatment and mortality in oxygen-dependent pulmonary fibrosis: A population-based longitudinal study. Respirology 2016; 21(4):705-711.

Xu XF, Dai HP, Li YM, Xiao F, Wang C. Mass Spectrometry based Proteomics in Acute Respiratory Distress Syndrome: A Powerful Modality for Pulmonary Precision Medicine. Chin Med J (Engl) 2016; 129(19):2357-2364.

Cardamone C, Parente R, Feo GD, Triggiani M. Mast cells as effector cells of innate immunity and regulators of adaptive immunity. Immunology Letters 2016; 178: 10–14.

Li H, Yang T, Li FY, Ning Q, Sun ZM. TLR4 Overexpression inhibits endothelial PAS domain-containing protein 1 expression in the lower respiratory tract of patients with chronic COPD. Cellular Physiology and Biochemistry 2016; 39 (2): 685–692.

Gheita TA, Gheita HA, Kenawy SA. Rituximab restored the muscle power and rescued from a refractory fatal respiratory failure in a patient with elderly-onset polymyositis. Joint Bone Spine 2012; 79 (1): 101-102.

Konrad FM, Braun S, Ngamsri KC, Vollmer I, Reutershan J. Heme oxygenase-1 attenuates acute pulmonary inflammation by decreasing the release of segmented neutrophils from the bone marrow. American Journal of Physiology. Lung Cellular andMolecular Physiology 2014; 307 (9): L707–L717.

Rosales C, Demaurex N, Lowell CA, Uribe-Querol E. Neutrophils: Their role in innate and adaptive immunity. Journal of Immunology Research 2016, Article ID 1469780, 2 pages.

Gordon CJ, Phillips PM, Ledbetter A, Snow SJ, Schladweiler MC, Johnstone AF, et al. Active vs. sedentary lifestyle from weaning to adulthood and susceptibility to ozone in rats. Am J Physiol Lung Cell Mol Physiol 2017; 312(1):L100-L109.

Vargas A, Roux-Dalvai F, Droit A, Lavoie JP. Neutrophil-Derived Exosomes: A New Mechanism Contributing to Airway Smooth Muscle Remodeling. Am J Respir Cell Mol Biol 2016; 55(3):450-461.

Global Initiative for Asthma, Global Strategy for Asthma Management and Prevention, GINA, Fontana, WI, USA, 2017.Available at:

Wang F, He XY, Baines KJ. Different inflammatory phenotypes in adults and children with acute asthma,” The European Respiratory Journal 2011; 38 (3): 567–574.

Khatry DB, Gossage DL, Geba GP, Parker JM, Jarjour NN, Busse WW, et al. Discriminating sputum-eosinophilic asthma: Accuracy of cutoffs in blood eosinophil measurements versus a composite index, ELEN. J Allergy Clin Immunol 2015; 136(3):812-814.e2.

Simpson JL, Scott R, Boyle MJ, Gibson PG. Inflammatory subtypes in asthma: assessment and identification using induced sputum. Respirology 2006; 11(1):54-61.

Kupczyk M, Dahlen B, Sterk PJ. Stability of phenotypes defined by physiological variables and biomarkers in adults with asthma. Allergy 2014; 69 (9): 1198–1204.

Wang M, Gao P, Wu X. Impaired anti-inflammatory action of glucocorticoid in neutrophil from patients with steroid-resistantasthma. Respir Res 2016; 17(1):153.

Uribe Echevarría EM, Maldonado CA, Uribe Echevarría AM, Aoki A. Neutrophil predominance in induced sputum from asthmatic patients. Therapeutic implications and role of clara cell 16-KD protein. Medicina (B Aires) 2011; 71(4):343-349.

Green BL, Wiriyachaiporn S, Grainge C. Potentially pathogenic airway bacteria and neutrophilic inflammation in treatment resistant severe asthma. PloS One 2014; 9 (6): article e100645.

Alam R, Good J, Rollins D. Airway and serum biochemical correlates of refractory neutrophilic asthma. J Allergy Clin Immunol 2017; 140(4):1004-1014.e13.10

Ito T, Hirose K, Norimoto A. Dectin-1 plays an important role in house dust mite-induced allergic airway inflammation through the activation of CD11b+ dendritic cells. Journal of Immunology 2017; 198 (1): 61–70.

Mosca T, Menezes MC, Silva AV, Stirbulov R, Forte WC. Chemotactic and phagocytic activity of blood neutrophils inallergic asthma. Immunological Investigations 2015; 44 (5): 509–520.

Siew LQC, Wu SY, Ying S, Corrigan CJ. Cigarette smoking increases bronchial mucosal IL-17A expression in asthmatics, which acts in concert with environmental aeroallergens to engender neutrophilic inflammation. Clin Exp Allergy 2017; 47(6):740-750.

Doukas J, Eide L, Stebbins K. Aerosolized phosphoinositide 3-kinase gamma/delta inhibitor TG100-115 [3-[2,4-diamino-6-(3-hydroxyphenyl)pteridin-7-yl]phenol] as a therapeutic candidate forasthma and chronic obstructive pulmonary disease. The Journal of Pharmacology and Experimental Therapeutics 2009; 328 (3): 758–765.

Fung-Leung WP. Phosphoinositide 3-kinase delta (PI3Kdelta) in leukocyte signaling and function. Cellular Signalling 2011; 23 (4):603–608.

Gupta V, Khan A, Higham A. The effect of phosphatidylinositol-3 kinase inhibition on matrix metalloproteinase-9 and reactiveoxygen species release from chronic obstructive pulmonary disease neutrophils. International Immunopharmacology 2016; 35: 155–162.

Hsia BJ, Whitehead GS, Thomas SY. Trif-dependent induction of Th17 immunity by lung dendritic cells. Mucosal Immunology 2015; 8 (1): 186–197.

Tang FS, Van Ly D, Spann K. Differential neutrophil activation in viral infections: Enhanced TLR-7/8-mediated CXCL8 release in asthma. Respirology 2015; 21(1):172-9.

Tang FS, Foxley GJ, Gibson PG, Burgess JK, Baines KJ, Oliver BG. Altered Innate Immune Responses in Neutrophils from Patients with Well- and Suboptimally Controlled Asthma. Mediators Inflamm 2015; 2015:219374.

Page K, Lierl KM, Hughes VS, Zhou P, Ledford JR, Wills-Karp M. TLR2-mediated activation of neutrophils in response to German cockroach frass. J Immunol 2008; 180(9):6317-6324.

McAlees JW, Whitehead GS, Harley IT. Distinct Tlr4-expressing cell compartments control neutrophilic and eosinophilic airway inflammation. Mucosal Immunology 2015; 8 (4): 863–873.

Uller L, Persson CG, Erjefält JS. Resolution of airway disease:removal of inflammatory cells through apoptosis, egression or both? Trends Pharmacol Sci 2006; 27(9):461-466.

Baines KJ, Simpson JL, Bowden NA, Scott RJ, Gibson PG. Differential gene expression and cytokine production from neutrophils in asthma phenotypes. The European Respiratory Journal 2010; 35 (3): 522–531.

Simpson JL, Powell H, Boyle MJ, Scott RJ, Gibson PG.Clarithromycin targets neutrophilic airway inflammation in refractory asthma. American Journal of Respiratory and Critical Care Medicine 2008; 177 (2): 148–155.

Côté O, Clark ME, Viel L. Secretoglobin 1A1 and 1A1A differentially regulate neutrophil reactive oxygen species production, phagocytosis and extracellular trap formation. PLoS One 2014; 9(4):e96217.

Tian BP, Xia LX, Bao ZQ,, Zhang H, Xu ZW, Mao YY, et al. Bcl- 2 inhibitors reduce steroid-insensitive airway inflammation. J Allergy Clin Immunol 2017; 140(2):418-430.

Uddin M, Nong G, Ward J. Prosurvival activity for airway neutrophils in severe asthma. Thorax 2010; 65 (8): 684–689.

Sikkeland LI, Johnsen HL, Riste TB, Alexis NE, Halvorsen B, Søyseth V, et al. Sputum neutrophils are elevated in smelter workers and systemic neutrophils are associated with rapid decline in FEV1. Occup Environ Med 2016; 73(7):459-466.

Murad HA, Habib HS, Rafeeq MM, Sulaiman MI, Abdulrahman AS, Khabaz MN. Co-inhalation of roflumilast, rather than formoterol, with fluticasone more effectively improves asthma in asthmatic mice. Exp Biol Med (Maywood) 2017; 242(5):516-526.

Yu JH, Long L, Luo ZX, You JR. Effect of PPARgamma agonist (rosiglitazone) on the secretion of Th2 cytokine in asthmamice. Asian Pacific Journal of Tropical Medicine 2017; 10 (1): 64–68.

Liu J, Pang Z, Wang G. Advanced Role of Neutrophils in Common Respiratory Diseases. Journal of Immunology Research 2017,Article ID 6710278, 21 pages.

Forget P, Khalifa C, Defour JP, Latinne D, Van Pel MC, De Kock M. What is the normal value of the neutrophil-to-lymphocyte ratio? BMC Res Notes 2017; 10(1):12.

Gao H, Ying S, Dai Y. Pathological Roles of Neutrophil-Mediated Inflammation in Asthma and Its Potential for Therapy as a Target. J Immunol Res 2017; 2017:3743048.

Gungen AC, Aydemir Y. The correlation between asthma disease and neutrophil to lymphocyte ratio. Res J Allergy Immunol 2017; 1(1):1-4.

Duffy BK, Gurm HS, Rajagopal V, Gupta R, Ellis SG, Bhatt DL.Usefulness of an elevated neutrophil to lymphocyte ratio in predicting long-term mortality after percutaneous coronary intervention. Am J Cardiol 2006; 97: 993-996.

Arbel Y, Finkelstein A, Halkin A, Birati EY, Revivo M, Zuzut M, et al. Neutrophil/lymphocyte ratio is related to the severity of coronary artery disease and clinical outcome in patients undergoing angiography. Atherosclerosis 2012; 225: 456-460.

Gunay E, Ulasli SS, Akar O, Ahsen A, Gunay S, Koyuncu T, et al. Neutrophil-tolymphocyte ratio in chronic obstructive pulmonary disease: a retrospective study. Inflammation 2014; 37: 374-380.

Nacaroglu HT, İsgüder R, Bent S, Erdem Bahceci S, Ceylan G, Korkmaz HA, et al. Can neutrophil/lymphocyte ratio be a novel biomarker of inflammation in children with asthma? European Journal of Inflammation 2016; 109–112. Available at:

Shi G, Zhao JW, Ming L. Clinical significance of peripheral blood neutrophil-lymphocyte ratio and platelet- lymphocyte ratio inpatients with asthma. Nan Fang Yi Ke Da Xue Xue Bao 2017; 37(1):84-88.

Fu JJ, McDonald VM, Gibson PG, Simpson JL. Systemic inflammation in older adults with asthma-COPD overlap syndrome. Allergy Asthma Immunol Res 2014; 6:316-324.

Brüünsgaard H, Pedersen BK. Age-related inflammatory cytokines and disease. Immunol Allergy Clin North Am 2003; 23: 15-39.

Mochimaru T, Fukunaga K, Kuwae M, Watanabe R, Okuzumi S, B aba R, et al. Neutrophil to Lymphocyte Ratio Is a Novel Predictor of Severe Exacerbation in Asthma Patients. American Journal of Respiratory and Critical Care Medicine 2018; 197:A1406.

Campo P, Rodr يguez F, Sánchez-García S. Phenotypes and endotypes of uncontrolled severe asthma: new treatments. J Investig Allergol Clin Immunol 2013; 23:76–88.

Acarturk G, Acay A, Demir K, Ulu MS, Ahsen A, Yuksel S. Neutrophil-to-lymphocyte ratio in inflammatory bowel disease – as a new predictor of disease severity. Bratisl Lek Listy 2015; 116(4):213-217.

Rice J, Dodge JL, Bambha KM, Bajaj JS, Reddy KR, Gralla J, et al. Neutrophil-to-Lymphocyte Ratio Associates Independently With Mortality in Hospitalized Patients With Cirrhosis. Clin Gastroenterol Hepatol 2018; 16(11):1786-1791.e1.

Erdem E. Neutrophil lymphocyte ratio in aute renal failure. Indian J Nephrol 2015; 25(2):126-127.

Hendy RM, Elawady MA, Mansour AI. Assessment of neutrophil/lymphocyte percentage in bronchial asthma. The Egyptian Journal of Chest Diseases and Tuberculosis 2019; 68:74–79.

Bruijnzeel PL, Uddin M, Koenderman L. Targeting neutrophilic inflammation in severe neutrophilic asthma: can we target the disease-relevant neutrophil phenotype? J Leukoc Biol 2015; 98(4):549-556.

Tarraf H, Aydin O, Mungan D. Prevalence of asthma among the adult general population of five Middle Eastern countries: results of the SNAPSHOT program. BMC Pulm Med 2018; 18(1):68.

Battaglia S, Benfante A, Spatafora M, Scichilone N. Asthma in the elderly: a different disease? Breathe (Sheff) 2016; 12(1):18-28.

Imtiaz F, Shafique K, Mirza SS, Ayoob Z, Vart P, Rao S. Neutrophil lymphocyte ratio as a measure of systemic inflammation in prevalent chronic diseases in Asian population. Int Arch Med 2012; 5(1):2.

Zein JG, Dweik RA, Comhair SA. Asthma Is More Severe in Older Adults. PLoS One 2015; 10(7):e0133490.

Lin BD, Hottenga JJ, Abdellaoui A. Causes of variation in the neutrophil-lymphocyte and platelet-lymphocyte ratios: a twinfamily study. Biomark Med 2016; 10(10):1061-1072.

Mohanan S, Tapp H, McWilliams A, Dulin M. Obesity and asthma: pathophysiology and implications for diagnosis and management in primary care. Exp Biol Med (Maywood) 2014;239(11):1531-1540.

Hasan HA. Evaluation of the Relation between Asthma, Obesity and Leptin Level in Iraqi Asthmatic Patients and the Main Risk Factors that are Associated with Leptin Level. Iraqi J Pharm Sci 2011; 20(2): 96-101.

Chhabra SK. Clinical application of spirometry in asthma: Why, when and how often?. Lung India 2015; 32(6):635-637.

Lambert A, Drummond MB, Wei C. Diagnostic accuracy of FEV1/forced vital capacity ratio z scores in asthmatic patients. J Allergy Clin Immunol 2015; 136(3):649-653.e4.

Melam GR, Buragadda S, Alhusaini A, Alghamdi MA, Alghamdi MS, Kaushal P. Effect of Different Positions on FVC and FEV1 Measurements of Asthmatic Patients. J Phys Ther Sci 2014; 26(4):591-593.


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How to Cite
Darwesh, M., Abd Alhaleem, I., & Al-Obaidy, M. W. (2020). The Correlation Between Asthma Severity and Neutrophil to Lymphocyte Ratio. European Journal of Medical and Health Sciences, 2(2).