Reducing and managing chronic obstructive pulmonary disease exacerbations with tiotropium + olodaterol

OBJECTIVE

The aim of this study was to review clinical evidence supporting the use of fixed-dose combination of tiotropium and olodaterol, a long-acting muscarinic antagonist (LAMA) and a long-acting β₂-agonist (LABA), respectively, as the initial and follow-up treatment choice in patients with chronic obstructive pulmonary disease (COPD) as per Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2020 recommendations-the impact of this treatment strategy on the reduction in the risk of exacerbations-and the importance of early therapeutic interventions.

METHODS

For this narrative review, the available literature was searched to identify studies including patients with COPD receiving tiotropium and olodaterol as either monotherapy or combination therapy and studies including patients with COPD receiving inhaled corticosteroids (ICS) in addition to long-acting bronchodilators. Relevant studies were included in the review.

RESULTS

Patients with COPD are often prescribed ICS therapy, which, when used over a long term, can be associated with local and systemic adverse effects. The GOLD 2020 report recommends dual bronchodilator therapy as both an initial and follow-up treatment option. A LABA + LAMA combination is mechanistically synergistic, and cumulative evidence surrounding the efficacy and safety of fixed-dose combination of tiotropium and olodaterol supports therapeutic advantages over monotherapy in most patients with COPD.

CONCLUSIONS

The early stages of COPD may represent a "window of therapeutic opportunity" during which initiation of tiotropium and olodaterol dual bronchodilator therapy may improve lung function and quality of life and reduce exacerbations in patients with COPD.

Distinguishing Smoking-Related Lung Disease Phenotypes Via Imaging and Molecular Features

BACKGROUND

Chronic tobacco smoke exposure results in a broad range of lung pathologies including emphysema, airway disease and parenchymal fibrosis as well as a multitude of extra-pulmonary comorbidities. Prior work using CT imaging has identified several clinically relevant subgroups of smoking related lung disease, but these investigations have generally lacked organ specific molecular correlates.

RESEARCH QUESTION

Can CT imaging be used to identify clinical phenotypes of smoking related lung disease that have specific bronchial epithelial gene expression patterns to better understand disease pathogenesis?

STUDY DESIGN AND METHODS

Using K-means clustering, we clustered participants from the COPDGene study (n = 5,273) based on CT imaging characteristics and then evaluated their clinical phenotypes. These clusters were replicated in the Detection of Early Lung Cancer Among Military Personnel (DECAMP) cohort (n = 360), and were further characterized using bronchial epithelial gene expression.

RESULTS

Three clusters (preserved, interstitial predominant and emphysema predominant) were identified. Compared to the preserved cluster, the interstitial and emphysema clusters had worse lung function, exercise capacity and quality of life. In longitudinal follow-up, individuals from the emphysema group had greater declines in exercise capacity and lung function, more emphysema, more exacerbations, and higher mortality. Similarly, genes involved in inflammatory pathways (tumor necrosis factor-α, interferon-β) are more highly expressed in bronchial epithelial cells from individuals in the emphysema cluster, while genes associated with T-cell related biology are decreased in these samples. Samples from individuals in the interstitial cluster generally had intermediate levels of expression of these genes.

INTERPRETATION

Using quantitative CT imaging, we identified three groups of individuals in older ever-smokers that replicate in two cohorts. Airway gene expression differences between the three groups suggests increased levels of inflammation in the most severe clinical phenotype, possibly mediated by the tumor necrosis factor-α and interferon-β pathways.

CLINICAL TRIAL REGISTRATION

COPDGene (NCT00608764), DECAMP-1 (NCT01785342), DECAMP-2 (NCT02504697).

Socheongryongtang suppresses COPD-related changes in the pulmonary system through both cytokines and chemokines in a LPS COPD model

Context: Socheongryongtang is a traditional Korean medical prescription used to treat pulmonary diseases.Objective: This study investigated the therapeutic mechanism of socheongryongtang for pulmonary diseases.Materials and methods: Seventy BALB/c mice were used: control, 0.8 mg/kg/study LPS intranasal instillation, 1 mg/kg/day Spiriva oral administration for five days, two socheongryongtang groups (150 or 1500 mg/kg/day orally treatment for five days). To illuminate the anti-COPD mechanism, several factors were evaluated such as WBC and differential counts in BALF and IgE in serum, morphological changes, and changes of COPD-related cytokines (TNF-α, IFN-γ, TGF-β) and chemokines (CXCL1, CCL-2, CCR2) in the lung. In order to confirm the statistical significance, all results were compared under p < 0.01 and p < 0.05.Results: LPS induced a high level of WBC, neutrophils and eosinophils in our in vivo study. Additionally, COPD related cytokines and chemokines such as TNF-α, IFN-γ, TGF-β, CXCL1, CCL-2 and CCR2 were induced by LPS. Compared to the LPS treatment group, socheongryongtang significantly controlled the level of WBC, neutrophils and eosinophils as well as the level of IgE. It effectively down-regulated the morphological changes, such as fibrosis near bronchoalveolar spaces, small airway destruction (emphysema), etc. It also inhibited the levels of COPD-related cytokines (TNF-α, IFN-γ, TGF-β) and chemokines (CXCL1, CCL-2, CCR2) compared to the LPS treatment group. In particular, socheongryongtang significantly down-regulated the levels of TNF-α, IFN-γ, and CCR2.Conclusions: Socheongryongtang controlled COPD, but as it has been used as a prescription for respiratory disease, we should additionally evaluate the therapeutic effects against various pulmonary diseases.

Heat-Not-Burn cigarette induces oxidative stress response in primary rat alveolar epithelial cells

There has been an increase in the usage of heat-not-burn (HNB) cigarette products. However, their effects on alveolar epithelial cells (AECs) remain unknown. AECs are the target cells of conventional cigarette smoking-related respiratory diseases such as chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis and lung cancer whose pathogenesis involves oxidative stress. In this study, primary rat AECs were isolated, cultured and stimulated by HNB cigarette smoke extract (CSE). Our data indicate that rat AECs exposed to HNB CSE induced oxidative stress response genes (e.g. Hmox-1, Gsta1, Gsta3 and Nqo1). We also compared the oxidative stress response between two different types of AECs, alveolar type I-like (ATI-like) cells and type II (ATII) cells, and between two different types of cigarette, HNB cigarettes and conventional cigarettes. The expressions of Gsta1, Gsta3 and Nqo1 were higher in ATII cells than ATI-like cells in response to HNB and conventional cigarettes, but there was no significant difference in their expression levels between HNB cigarette and conventional cigarette. Taken together, our results suggest that HNB cigarettes have the similar potential as conventional cigarette products to induce oxidative stress response in AECs.

Mitotic Spindle Apparatus Abnormalities in Chronic Obstructive Pulmonary Disease Cells: A Potential Pathway to Lung Cancer

Chronic obstructive pulmonary disease (COPD) is a long-term lung disease characterized by irreversible lung damage resulting in airflow limitation, abnormal permanent air-space enlargement, and emphysema. Cigarette smoking is the major cause of COPD with 15% to 30% of smokers developing either disease. About 50% to 80% of patients with lung cancer have preexisting COPD and smokers who have COPD are at an increased risk for developing lung cancer. Therefore, COPD is considered an independent risk for lung cancer, even after adjusting for smoking. A crucial early event in carcinogenesis is the induction of the genomic instability through alterations in the mitotic spindle apparatus. To date, the underlying mechanism by which COPD contributes to lung cancer risk is unclear. We hypothesized that tobacco smoke carcinogens induce mitotic spindle apparatus abnormalities and alter expression of crucial genes leading to increased genomic instability and ultimately tumorigenesis. To test our hypothesis, we assessed the genotoxic effects of a potent tobacco-smoke carcinogen [4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone, (NNK)] on bronchial epithelial cells from patients with COPD and normal bronchial epithelial cells and identified genes associated with mitotic spindle defects and chromosome missegregation that also overlap with lung cancer. Our results indicate that exposure to NNK leads to a significantly altered spindle orientation, centrosome amplification, and chromosome misalignment in COPD cells as compared with normal epithelial cells. In addition, we identified several genes (such as AURKA, AURKB, and MAD2L2) that were upregulated and overlap with lung cancer suggesting a potential common pathway in the transition from COPD to lung cancer.

Time-weighted average of fine particulate matter exposure and cause-specific mortality in China: a nationwide analysis

BACKGROUND

Most previous assessments of the hazardous effects attributable to fine particulate matter (PM_2·5) exposure have used ambient PM_2·5 as an exposure metric, resulting in substantial bias in effect estimates. We did a study to examine the association between cause-specific mortality and the time-weighted average of PM_2·5 exposure after accounting for indoor exposure in 267 cities in China.

METHODS

We did a nationwide study, using Laser Egg air quality monitors in 36 cities to obtain data for indoor PM_2·5 concentrations from 18 484 anonymised households between Nov 1, 2015 and July 2, 2018. We developed and validated a nationwide indoor PM_2·5 prediction model for a further 302 cities by retrieving raw records of hourly concentrations from residents' air sensors; the model was used to predict indoor PM_2·5 during 2013 to 2018. Daily ambient PM_2·5 concentration data were estimated by averaging hourly ambient PM_2·5 concentrations obtained from China's National Urban Air Quality Real-time Publishing Platform. Daily numbers of deaths from all non-accidental causes were obtained from 324 cities from the Disease Surveillance Point System of China between Jan 1, 2013, to Dec 31, 2017, and calculated for 267 cities that had an average daily mortality above three, and data for PM_2·5 concentrations and meteorological information for at least 1 year between 2013 and 2017. We used distributed lag non-linear models to estimate city-specific associations between cause-specific mortality and reconstructed PM_2·5 exposure by considering indoor PM_2·5 exposure. We combined the city-specific effect estimates at the national level using a random effects meta-analysis.

FINDINGS

13 972 records of daily indoor PM_2·5 concentrations for 36 cities, extracted from 47 459 183 raw records from the sensors were included for modelling indoor PM_2·5 levels. The nationwide indoor PM_2·5 concentration was 40 μg/m³ (SD 21) between 2013 and 2017, which was approximately 20% lower than the ambient PM_2·5 concentration of 50 μg/m³ (42). An increase of 10 μg/m³ in time-averaged PM_2·5 exposure concentrations was associated with increased daily mortality estimates of 0·44% (95% CI 0·33-0·54) for total non-accidental causes, 0·50% (0·37-0·63) for cardiovascular diseases, 0·46% (0·28-0·63) for coronary heart disease, 0·49% (0·32-0·66) for stroke, 0·59% (0·39-0·79) for respiratory diseases, and 0·69% (0·45-0·92) for chronic obstructive pulmonary disease, respectively. Compared with previous estimations based on ambient PM_2·5, our estimates approximately doubled the size of the effects related to PM_2·5.

INTERPRETATION

This nationwide study revealed a higher mortality risk attributed to time-averaged indoor and ambient PM_2·5 exposure compared with the risk associated with ambient PM_2·5 exposure alone, which indicates that caution should be exercised when using ambient PM_2·5 as a surrogate for PM_2·5 exposure.

FUNDING

National Natural Science Foundation of China (Youth Program) and the Fundamental Research Project of Beihang University.

The protective effects of thymoquinone on lung damage caused by cigarette smoke

Chronic obstructive pulmonary disease (COPD) is characterized by systemic inflammation that usually is caused by exposure to noxious particles or gases. Thymoquinone (TQ) prevents the production of inflammatory mediators, such as thromboxane B2 and leukotriene, by altering arachidonic acid metabolism. We investigated the preventive and curative effects of TQ on lung damage in rats caused by cigarette smoke (CS). We used 50 adult male rats, 30 of which were exposed to CS every day for 3 months. TQ in dimethylsulfoxide (DMSO) was administered intraperitoneally (i.p.) every day to ten animals to investigate the protective effects of TQ, and to ten other animals during the last 21 days to investigate the curative effect. Ten rats received saline for the last 21 days. Ten subjects were untreated controls. Ten controls that were not exposed to CS received TQ for the last ten days. Serum IL-8, IL-6, IL-1β and MMP-9 levels were measured using ELISA. IL-1β and IL-8 levels were elevated in the group exposed to CS compared to controls. IL-8 levels were decreased in the group that received only TQ compared to controls, which indicated the anti-inflammatory effect of TQ. The apoptotic index (AI) was increased in all groups that were exposed to CS compared to controls. The AI index was decreased in the group that received TQ for the last 21 days compared to the other CS groups. AI was increased in the group that received TQ daily compared to the other CS groups. Our findings indicate that TQ exerts curative effects for the inflammation caused by CS and may prevent apoptosis if administered in appropriate doses; however, long term TQ or DMSO exposure may produce cumulative toxic effects.

Preventive effect of ursolic acid derivative on particulate matter 2.5-induced chronic obstructive pulmonary disease involves suppression of lung inflammation

Respiratory diseases like chronic obstructive pulmonary disease (COPD) are associated with the presence of particulate matter 2.5 (PM2.5) in the air. In the present study, the effect of synthesized ursolic acid derivatives on mice model of PM2.5-induced COPD was investigated in vivo. The mice model of COPD was established by the administration of 25 μL of PM2.5 suspension through intranasal route daily for 1 week. The levels of oxidative stress markers and inflammatory cytokines like tumor necrosis factors-α and interleukin-6 in the mice bronchoalveolar fluids increased markedly on administration with PM2.5. However, treatment with ursolic acid derivative caused a significant suppression in PM2.5-induced increase in oxidative stress markers and inflammatory cytokines in dose-dependent manner. Hematoxylin and eosin staining showed excessive inflammatory cell infiltration in pulmonary tissues in mice with COPD. The inflammatory cell infiltration was inhibited on treatment of the mice with ursolic acid derivative. The ursolic acid derivative treatment increased level of superoxide dismutase in mice with COPD. The lung injury induced by PM2.5 in mice was also prevented on treatment with ursolic acid derivative. Thus, ursolic acid derivative inhibits pulmonary tissues damage in mice through suppression of inflammatory cytokine and oxidative enzymes. Therefore, ursolic acid derivative can be of therapeutic importance for treatment of PM2.5-induced COPD.

Prevalence of spirometry-defined airflow obstruction in never-smoking working US coal miners by pneumoconiosis status

INTRODUCTION

This study estimated the prevalence of spirometry-defined airflow obstruction and coal workers' pneumoconiosis (CWP) among never-smoking coal miners participating in the National Institute for Occupational Safety and Health (NIOSH) Coal Workers' Health Surveillance Program (CWHSP).

METHODS

Data were from working miners screened by a CWHSP mobile unit who had valid spirometry and chest radiography results. Spirometry-defined airflow obstruction was determined when the ratio of forced expiratory volume in the first second to forced vital capacity is less than the lower limit of normal. Chest radiographs were classified according to the International Labour Office system to identify pneumoconiosis, including the most severe form of pneumoconiosis, progressive massive fibrosis (PMF).

RESULTS

Prevalence of airflow obstruction among never-smoking coal miners in this sample was 7.7% overall, 16.4% among miners with CWP and 32.3% among miners with PMF. Airflow obstruction was significantly associated with CWP and PMF.

CONCLUSIONS

There was a higher prevalence of airflow obstruction among never-smoking coal miners with pneumoconiosis compared with those without pneumoconiosis. These findings support prior research on airflow obstruction and smoking and show pneumoconiosis might present with an obstructive pattern regardless of smoking status.

Au W, Zhao W, Xia ZL. A Systematic Review and Meta-Analysis of Short-Term Ambient Ozone Exposure and COPD Hospitalizations

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death globally and ozone exposure is a main cause of its disease burden. However, studies on COPD hospitalizations from short-term ambient level ozone exposure have not generated consensus results. To address the knowledge gap, comprehensive and systematic searches in several databases were conducted using specific keywords for publications up to February 14, 2020. Random-effect models were used to derive overall excess risk estimates between short-term ambient-level ozone exposure and COPD hospitalizations. The influence analyses were used to test the robustness of the results. Both meta-regression and subgroup analyses were used to explore the sources of heterogeneity and potential modifying factors. Based on the results from 26 eligible studies, the random-effect model analyses show that a 10 µg/m³ increase in maximum 8-h ozone concentration was associated with 0.84% (95% CI: 0.09%, 1.59%) higher COPD hospitalizations. The estimates were higher for warm season and multiple-day lag but lower for old populations. Results from subgroup analyses also indicate a multiple-day lag trend and bigger significant health effects during longer day intervals. Although characteristics of individual studies added modest heterogeneity to the overall estimates, the results remained robust during further analyses and exhibited no evidence of publication bias. Our systematic review and meta-analysis indicate that short-term ambient level ozone exposure was associated with increased risk of COPD hospitalizations. The significant association with multiple-day lag trend indicates that a multiple-day exposure metric should be considered for establishing ambient ozone quality and exposure standards for improvement of population health. Future investigations and meta-analysis studies should include clinical studies as well as more careful lag selection protocol.

[Comparative study on serum transitional components of Huatan Jiangqi Capsules in rats under pathological and physiological status]

The differences of transitional components and metabolic processes of Huatan Jiangqi Capsules(HTJQ) in rats under normal physiological and pathological conditions of COPD were analyzed by UPLC-Q-TOF-MS. The rat COPD model was established by passive smoking and intratracheal instillation of lipopolysaccharide. After the normal and COPD model rats were douched with HTJQ, the blood was collected from hepatic portal vein and the drug-containing serum samples were prepared by methanol precipitation of protein. Then, 10 batches of drug-containing serum samples of HTJQ were prepared and analyzed by UPLC serum fingerprint to evaluate the quality and stability of drug-containing serum samples. UPLC-Q-TOF-MS was used to collect the mass spectrometric information of the transitional components. Twenty-eight transitional components of HTJQ in normal rats and 25 transitional components of HTJQ in COPD model rats were identified by UPLC-Q-TOF-MS. Under pathological and physiological conditions, there were not only the same transitional components in rat serum, but also corresponding differences. Further studies showed that there were also differences in the metabolic process of transitional components between the two conditions. In normal rats, most of the metabolic types of transitional components were phase I reactions. In COPD model rats, phase Ⅰ reactions decreased and phase Ⅱ reactions increased correspondingly. With UPLC-Q-TOF-MS technology, the differences of transitional components and the metabolism process of HTJQ in rats under normal physiological and pathological conditions were analyzed. The results showed that types of transitional components and the activity of some metabolic enzymes would be changed in COPD pathological state, which would affect the metabolic process of bioactive components in vivo. It laid a foundation for further elucidating the metabolic process and pharmacodynamic substance basis of HTJQ.

Risk of COPD due to indoor air pollution from biomass cooking fuel: a systematic review and meta-analysis

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality in developing nations. In this meta-analysis, we aimed to determine the association between indoor air pollution and risk of COPD. Database searches were conducted using indoor air pollution, biomass and COPD related terms to identify relevant articles. The eligible studies were case-control, retrospective cohort, cross-sectional studies and conducted in adults that assessed COPD using any diagnostic criteria. A total of 35 studies with 73,122 participants were included. The pooled analysis showed that exposure to indoor air pollution due to solid biomass fuels increased risk of COPD by 2.65 (95% confidence interval [CI] 2.13-3.31; n = 73,122) and chronic bronchitis by 2.89 (95% CI 2.18-3.82) times more compared to non-biomass fuels. The risk of COPD was higher in Africa region (odds ratio [OR] 3.19), Asia (OR 2.88), South America (OR 2.15), Europe (OR 2.30) and North America (OR 2.14). The results of our meta-analysis indicated that exposure to indoor air pollution due to biomass smoke is strongly associated with COPD.Abbreviations: CS: cross-sectional; CC: case-control; NR: not reported; ATS: American Thoracic Society; BMRC: British Medical Research Council; GOLD: Global Initiative for Obstructive Lung Disease; IAP: indoor air pollution; BMF: biomass fuel; CB: chronic bronchitis; OR: odds ratio; UCI; upper confidence interval; LCI: lower confidence interval; COPD: chronic obstructive pulmonary disease.

National and sub-national exposure to ambient fine particulate matter (PM2.5) and its attributable burden of disease in Iran from 1990 to 2016

Ambient particulate matter is a public health concern. We aimed (1) to estimate national and provincial long-term exposure of Iranians to ambient particulate matter (PM) < 2.5 μm (PM_2.5) from 1990 to 2016, and (2) to estimate the national and provincial burden of disease attributable to PM_2.5 in Iran. We used all available ground measurements of PM < 10 μm (PM₁₀) (used to estimate PM_2.5) from 91 monitoring stations. We estimated the annual mean exposure to PM_2.5 for all Iranian population from 1990 to 2016 through a multi-stage modeling process. By applying comparative risk assessment methodology and using life table for years of life lost (YLL), we estimated the mortality and YLL attributable to PM_2.5 for five outcomes. The predicted provincial annual mean PM_2.5 concentrations range was between 21.7 μg/m³ (UI: 19.03-24.9) and 35.4 μg/m³ (UI: 31.4-39.4) from 1990 to 2016. We estimated in 2016, about 41,000 deaths (95% uncertainty interval [UI] 35634, 47014) and about 3,000,000 YLL (95% UI: 2632101, 3389342) attributable to the long-term exposure to PM_2.5 in Iran. Ischemic heart disease was the leading cause of mortality by 31,363 deaths (95% UI: 27520, 35258), followed by stroke (7012 (5999, 8062) deaths), lower respiratory infection (1210 (912, 1519) deaths), chronic obstructive pulmonary disease (1019 (715, 1328) deaths), and lung cancer (668 (489, 848) deaths). In 2016, about 43% of all PM_2.5 related mortality in Iran was, respectively, in the following provinces: Tehran (12.6%), Isfahan (9.3%), Khorasan Razavi (8.0%), Fars (6.5%), and Khozestan (6.4%). In summary, we found that the majority of Iranians were exposed to the levels of ambient particulate matter exceeding the WHO guidelines from 1990 to 2016. Further, we found that there was an increasing trend of total mortality attributed to PM_2.5 in Iran from 1990 to 2016 where the slope was higher in western provinces.

Environmental correlates of chronic obstructive pulmonary disease in 96 779 participants from the UK Biobank: a cross-sectional, observational study

BACKGROUND

The role of environmental exposures in chronic obstructive pulmonary disease (COPD) remains inconclusive. We examined the association between environmental exposures (PM_2·5, greenness, and urbanicity) and COPD prevalence using the UK Biobank cohort data to identify key built environment correlates of COPD.

METHODS

In this cross-sectional, observational study we used baseline data for UK Biobank participants. Included participants were aged 39 years and older, white, had available spirometry data, and had complete data for phenotypes and exposures. COPD was defined by spirometry with the 2017 Global Initiative for Chronic Obstructive Lung Disease criteria. Environmental exposures were PM_2·5 derived from monitoring data and interpolated using land-use regression at the participants' geocoded residential addresses. Built environment metrics of residential greenness were modelled in terms of normalised difference vegetation index from remotely sensed colour infrared data within a 500 m residential catchment, and an urbanicity index derived from spatial analyses and measured with a 1 km buffer around each participant's residential address. Logistic regression models examined the associations between environmental exposures and COPD prevalence adjusting for a range of confounders. Subgroup analyses by urbanicity and effect modification by white blood cell count as an inflammatory marker were also done.

FINDINGS

We assessed 96 779 participants recruited between April 4, 2006, and Oct 1, 2010, of which 5391 participants had COPD with a prevalence of 5·6%. Each 10 μg/m³ increment in ambient PM_2·5 exposure at a participant's residential location was associated with higher odds of COPD (odds ratio 1·55, 95% CI 1·14-2·10). Among the built environment metrics, urbanicity was associated with higher odds of COPD (1·05, 1·01-1·08 per interquartile increment), whereas residential greenness was protective, being associated with lower odds of COPD (0·89, 0·84-0·93 for each interquartile increment in greenness). The results remained consistent in models of COPD defined as per lower limit of normal criteria. The highest quartile of white blood cell count was associated with lower lung function and higher COPD risk with a significant interaction between PM_2·5 and white blood cell count only in the model of lung function (p=0·0003).

INTERPRETATION

In this study of the built environment and COPD, to our knowledge the largest done in the UK, we found that exposure to ambient PM_2·5 and urbanicity were associated with a higher risk of COPD. Residing in greener areas, as measured by normalised difference vegetation index, was associated with lower odds of COPD, suggesting the potential value of urban planning and design in minimising or offsetting environmental risks for the prevention and management of COPD.

FUNDING

University of Hong Kong, UK Biobank, and UK Economic & Social Research Council.

Cigarette smoke affects the onco-suppressor DAB2IP expression in bronchial epithelial cells of COPD patients

Cigarette smoke is a risk factor for COPD and lung cancer. In cancer, epigenetic modifications affect the expression of Enhancer of Zester Homolog 2 (EZH2), and silenced disabled homolog 2 interacting protein gene (DAB2IP) (onco-suppressor gene) by Histone H3 tri-methylation in lysine 27 (H3K27me3). In"ex vivo"studies, we assessed EZH2, H3K27me3 and DAB2IP immunoreactivity in bronchial epithelial cells from COPD patients (smokers, ex-smokers), Smoker and control subjects. In"in vitro" experiments we studied the effect of cigarette smoke extract (CSE) on EZH2/H3K27me3/DAB2IP expression, apoptosis, invasiveness, and vimentin expression in 16HBE, primary cells, and lung cancer cell lines (A549) long-term exposed to CSE. Finally, in "in vitro"studies, we tested the effect of GSK343 (selective inhibitor of EZH2). EZH2 and H3K27me3 expression was higher, while DAB2IP was lower levels, in bronchial epithelium from COPD and Smokers than in Controls. CSE increased EZH2, H3K27me3 expression and decreased DAB2IP, cell apoptosis and invasiveness in epithelial cells. GSK343 restored the effects of CSE. Cigarette smoke affects EZH2 expression, and reduced DAB2IP via H3K27me3 in COPD patients. The molecular mechanisms associated with EZH2 expression, generate a dysregulation of cell apoptosis, mesenchymal transition, and cell invasiveness in bronchial epithelial cells, encouraging the progression of airway inflammation toward lung cancer in COPD patients.

Reactive Oxygen Species-Dependent Calpain Activation Contributes to Airway and Pulmonary Vascular Remodeling in Chronic Obstructive Pulmonary Disease

Aims: Airway and pulmonary vascular remodeling is an important pathological feature in the pathogenesis of chronic obstructive pulmonary disease (COPD). Tobacco smoke (TS) induces the production of large amounts of reactive oxygen species (ROS) in COPD lungs. We investigated how ROS lead to airway and pulmonary vascular remodeling in COPD. Results: We used in vitro bronchial and pulmonary artery smooth muscle cells (BSMCs and PASMCs), in vivo TS-induced COPD rodent models, and lung tissues of COPD patients. We found that H2O2 and TS extract (TSE) induced calpain activation in BSMCs and PASMCs. Calpain activation was elevated in smooth muscle of bronchi and pulmonary arterioles in COPD patients and TS-induced COPD rodent models. Calpain inhibition attenuated H2O2- and TSE-induced collagen synthesis and proliferation of BSMCs and PASMCs. Exposure to TS causes increases in airway resistance, right ventricular systolic pressure (RVSP), and thickening of bronchi and pulmonary arteries. Calpain inhibition by smooth muscle-specific knockout of calpain and the calpain inhibitor MDL28170 attenuated increases in airway resistance, RVSP, and thickening of bronchi and pulmonary arteries. Moreover, smooth muscle-specific knockout of calpain did not reduce TS-induced emphysema in the mouse model, but MDL28170 did reduce TS-induced emphysema in the rat model. Innovation: This study provides the first evidence that ROS-induced calpain activation contributes to airway and pulmonary vascular remodeling in TS-induced COPD. Calpain might be a novel therapeutic target for the treatment of COPD. Conclusion: These results indicate that ROS-induced calpain activation contributes to airway and pulmonary vascular remodeling and pulmonary hypertension in COPD.

Silencing FUNDC1 alleviates chronic obstructive pulmonary disease by inhibiting mitochondrial autophagy and bronchial epithelium cell apoptosis under hypoxic environment

Chronic obstructive pulmonary disease (COPD) is a major global epidemic with increasing incidence worldwide. The pathogenesis of COPD is involved with mitochondrial autophagy. Recently, it has been reported that FUN14 domain containing 1 (FUNDC1) is a mediator of mitochondrial autophagy. Therefore, we hypothesized that FUNDC1 was involved in cigarette smoke (CS)-induced COPD progression by regulating mitochondrial autophagy. In vitro cigarette smoke extract (CSE)-treated human bronchial epithelial cell (hBEC) Beas-2B cell line and in vivo CS-induced COPD mouse models were developed, in which FUNDC1 expression was measured. Next, whether FUNDC1 interacted with dynamin-related protein 1 (DRP1) in COPD was investigated. The functional mechanism of FUNDC1 in COPD was evaluated through gain- or loss-of-function studies. Then, pulmonary function, mitochondrial transmembrane potential (MTP) and mucociliary clearance (MCC) were examined. Levels of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) and expression of autophagy-specific markers (light chain 3 [LC3] II, LC3 I, and Tom20) were measured. Finally, apoptosis and mitochondrial autophagy were assessed. FUNDC1 was highly expressed in CSE-treated hBECs and COPD mice. Meanwhile, FUNDC1 was proved to interact with DRP1 in CSE-treated cells. Moreover, in CSE-treated hBECs, silencing FUNDC1 was observed to reduce levels of IL-6 and TNF-α, and MTP but increase MCC, and inhibit CSE-induced mitochondrial autophagy and Beas-2B cell apoptosis, which was consistent with the trend in COPD mouse models. In addition, pulmonary function of COPD mouse models was increased in response to FUNDC1 silencing. Finally, silencing of DRP1 also inhibited mitochondrial autophagy and Beas-2B cell apoptosis. Collectively, FUNDC1 silencing could suppress the progression of COPD by inhibiting mitochondrial autophagy and hBEC apoptosis through interaction with DRP1, highlighting a potential therapeutic target for COPD treatment.

Cigarette Smoke Exposure Induces Retrograde Trafficking of CFTR to the Endoplasmic Reticulum

Chronic obstructive pulmonary disease (COPD), which is most commonly caused by cigarette smoke (CS) exposure, is the third leading cause of death worldwide. The cystic fibrosis transmembrane conductance regulator (CFTR) is an apical membrane anion channel that is widely expressed in epithelia throughout the body. In the airways, CFTR plays an important role in fluid homeostasis and helps flush mucus and inhaled pathogens/toxicants out of the lung. Inhibition of CFTR leads to mucus stasis and severe airway disease. CS exposure also inhibits CFTR, leading to the decreased anion secretion/hydration seen in COPD patients. However, the underlying mechanism is poorly understood. Here, we report that CS causes CFTR to be internalized in a clathrin/dynamin-dependent fashion. This internalization is followed by retrograde trafficking of CFTR to the endoplasmic reticulum. Although this internalization pathway has been described for bacterial toxins and cargo machinery, it has never been reported for mammalian ion channels. Furthermore, the rapid internalization of CFTR is dependent on CFTR dephosphorylation by calcineurin, a protein phosphatase that is upregulated by CS. These results provide new insights into the mechanism of CFTR internalization, and may help in the development of new therapies for CFTR correction and lung rehydration in patients with debilitating airway diseases such as COPD.

Changes in the acute response of respiratory diseases to PM2.5 in New York State from 2005 to 2016

Prior studies reported that exposure to increased concentrations of fine particulate matter (PM_2.5) were associated with increased rates of hospitalization and emergency department (ED) visits for asthma and chronic obstructive pulmonary disease (COPD). In this study, rates were examined from 2005 to 2016 using a case-crossover design to ascertain if there have been changes in the rates per unit mass exposure given substantial reductions in PM_2.5 concentration and changes in its composition. PM_2.5 concentrations were reduced through a combination of policies designed to improve air quality and economic drivers, including the 2008 economic recession and shifts in the relative costs of coal and natural gas. The study period was split into three periods reflecting that much of the emissions changes occurred between 2008 and 2013. Thus, the three periods were defined as: BEFORE (2005 to 2007), DURING (2008-2013), and AFTER (2014-2016). In general, the number of hospitalizations and ED visits declined with the decreased concentration of PM_2.5. However, the rate of COPD hospitalizations and asthma ED visits associated with each interquartile range increase in ambient PM_2.5 concentration was larger in the AFTER period than the DURING and BEFORE periods. For example, each 6.8 μg/m³ increase in PM_2.5 on the same day was associated with 0.4% (0.0%, 0.8%), 0.3% (-0.2%, 0.7%), and 2.7% (1.9%, 3.5) increases in the rate of asthma emergency department visits in the BEFORE, DURING, and AFTER periods, respectively, suggesting the same mass concentration of PM_2.5 was more toxic in the AFTER period.

Nix/BNIP3L-dependent mitophagy accounts for airway epithelial cell injury induced by cigarette smoke

Cigarette smoke-induced airway epithelial cell mitophagy is an important mechanism in the pathogenesis of chronic obstructive pulmonary disease (COPD). Mitochondrial protein Nix (also known as BNIP3L) is a selective autophagy receptor and participates in several human diseases. However, little is known about the role of Nix in airway epithelial cell injury during the development of COPD. The aim of the present study is to investigate the effects of Nix on mitophagy and mitochondrial function in airway epithelial cells exposed to cigarette smoke extract (CSE). Our present study has found that CSE could increase Nix protein expression and induce mitophagy in airway epithelial cells. And Nix siRNA significantly inhibited mitophagy and attenuated mitochondrial dysfunction and cell injury when airway epithelial cells were stimulated with 7.5% CSE. In contrast, Nix overexpression enhanced mitophagy and aggravated mitochondrial dysfunction and cell injury when airway epithelial cells were incubated with 7.5% CSE. These data suggest that Nix-dependent mitophagy promotes airway epithelial cell and mitochondria injury induced by cigarette smoke, and may be involved in the pathogenesis of COPD and other cigarette smoke-associated diseases.

Therapeutic effects of soluble guanylate cyclase stimulation on pulmonary hemodynamics and emphysema development in guinea pigs chronically exposed to cigarette smoke

We have analyzed the effect of the soluble guanylate cyclase (sGC) stimulator BAY 41-2272 in a therapeutic intervention in guinea pigs chronically exposed to cigarette smoke (CS). The effects of sGC stimulation on respiratory function, pulmonary hemodynamics, airspace size, vessel remodeling, and inflammatory cell recruitment to the lungs were evaluated in animals that had been exposed to CS for 3 mo. CS exposure was continued for an additional 3 mo in half of the animals and withdrawn in the other half. Animals that stopped CS exposure had slightly lower pulmonary artery pressure (PAP) and right ventricle (RV) hypertrophy than those who continued CS exposure, but they did not recover from the emphysema and the inflammatory cell infiltrate. Conversely, oral BAY 41-2272 administration stopped progression or even reversed the CS-induced emphysema in both current and former smokers, respectively. Furthermore, BAY 41-2272 produced a reduction in the RV hypertrophy, which correlated with a decrease in the PAP values. By contrast, the degree of vessel remodeling induced by CS remained unchanged in the treated animals. Functional network analysis suggested perforin/granzyme pathway downregulation as an action mechanism capable of stopping the progression of emphysema after sGC stimulation. The pathway analysis also showed normalization of the expression of cGMP-dependent serine/kinases. In conclusion, in guinea pigs chronically exposed to CS, sGC stimulation exerts beneficial effects on the lung parenchyma and the pulmonary vasculature, suggesting that sGC stimulators might be a potential alternative for chronic obstructive pulmonary disease treatment that deserves further evaluation.

IL-22 and its receptors are increased in human and experimental COPD and contribute to pathogenesis

Chronic obstructive pulmonary disease (COPD) is the third leading cause of morbidity and death globally. The lack of effective treatments results from an incomplete understanding of the underlying mechanisms driving COPD pathogenesis.Interleukin (IL)-22 has been implicated in airway inflammation and is increased in COPD patients. However, its roles in the pathogenesis of COPD is poorly understood. Here, we investigated the role of IL-22 in human COPD and in cigarette smoke (CS)-induced experimental COPD.IL-22 and IL-22 receptor mRNA expression and protein levels were increased in COPD patients compared to healthy smoking or non-smoking controls. IL-22 and IL-22 receptor levels were increased in the lungs of mice with experimental COPD compared to controls and the cellular source of IL-22 included CD4+ T-helper cells, γδ T-cells, natural killer T-cells and group 3 innate lymphoid cells. CS-induced pulmonary neutrophils were reduced in IL-22-deficient (Il22 -/-) mice. CS-induced airway remodelling and emphysema-like alveolar enlargement did not occur in Il22 -/- mice. Il22 -/- mice had improved lung function in terms of airway resistance, total lung capacity, inspiratory capacity, forced vital capacity and compliance.These data highlight important roles for IL-22 and its receptors in human COPD and CS-induced experimental COPD.

Associations between daily air quality and hospitalisations for acute exacerbation of chronic obstructive pulmonary disease in Beijing, 2013-17: an ecological analysis

BACKGROUND

Air pollution in Beijing has been improving through implementation of the Air Pollution Prevention and Control Action Plan (2013-17), but its implications for respiratory morbidity have not been directly investigated. We aimed to assess the potential effects of air-quality improvements on respiratory health by investigating the number of cases of acute exacerbations of chronic obstructive pulmonary disease (COPD) advanced by air pollution each year.

METHODS

Daily city-wide concentrations of PM10, PM2·5, PMcoarse (particulate matter >2·5-10 μm diameter), nitrogen dioxide (NO2), sulphur dioxide (SO2), carbon monoxide (CO), and ozone (O3) in 2013-17 were averaged from 35 monitoring stations across Beijing. A generalised additive Poisson time-series model was applied to estimate the relative risks (RRs) and 95% CIs for hospitalisation for acute exacerbation of COPD associated with pollutant concentrations.

FINDINGS

From Jan 18, 2013, to Dec 31, 2017, 161 613 hospitalisations for acute exacerbation of COPD were recorded. Mean ambient concentrations of SO2 decreased by 68% and PM2·5 decreased by 33% over this 5-year period. For each IQR increase in pollutant concentration, RRs for same-day hospitalisation for acute exacerbation of COPD were 1·029 (95% CI 1·023-1·035) for PM10, 1·028 (1·021-1·034) for PM2·5, 1·018 (1·013-1·022) for PMcoarse, 1·036 (1·028-1·044) for NO2, 1·019 (1·013-1·024) for SO2, 1·024 (1·018-1·029) for CO, and 1·027 (1·010-1·044) for O3 in the warm season (May to October). Women and patients aged 65 years or older were more susceptible to the effects of these pollutants on hospitalisation risk than were men and patients younger than 65 years. In 2013, there were 12 679 acute exacerbations of COPD cases that were advanced by PM2·5 pollution above the expected number of cases if daily PM2·5 concentrations had not exceeded the WHO target (25 μg/m3), whereas the respective figure in 2017 was 7377 cases.

INTERPRETATION

Despite improvement in overall air quality, increased acute air pollution episodes were significantly associated with increased hospitalisations for acute exacerbations of COPD in Beijing. Stringent air pollution control policies are important and effective for reducing COPD morbidity, and long-term multidimensional policies to safeguard public health are indicated.

FUNDING

UK Medical Research Council.

Animal production, insecticide use and self-reported symptoms and diagnoses of COPD, including chronic bronchitis, in the Agricultural Health Study

BACKGROUND

Occupational exposure to animal production is associated with chronic bronchitis symptoms; however, few studies consider associations with chronic obstructive pulmonary disease (COPD). We estimated associations between animal production activities and prevalence of self-reported COPD among farmers in the Agricultural Health Study.

METHODS

During a 2005-2010 interview, farmers self-reported information about: their operations (i.e., size, type, number of animals, insecticide use), respiratory symptoms, and COPD diagnoses (i.e., COPD, chronic bronchitis, emphysema). Operations were classified as small or medium/large based on regulatory definitions. Farmers were classified as having a COPD diagnosis, chronic bronchitis symptoms (cough and phlegm for ≥3 months during 2 consecutive years), or both. Polytomous logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

Of 22,491 participating farmers (median age: 59 years), 922 (4%) reported a COPD diagnosis only, 254 (1%) reported a diagnosis and symptoms, and 962 (4%) reported symptoms only. Compared to raising no commercial animals, raising animals on a medium/large operation was positively associated with chronic bronchitis symptoms with (OR: 1.59; 95% CI: 1.16, 2.18) and without a diagnosis (OR: 1.69; 95% CI: 1.42, 2.01). Ever use of multiple organophosphates, carbaryl, lindane, and permethrin were positively associated with chronic bronchitis symptoms.

CONCLUSION

Animal production work, including insecticide use, was positively associated with chronic bronchitis symptoms; but not consistently with COPD diagnosis alone. Our results support the need for further investigation into the role of animal production-related exposures in the etiology of COPD and better respiratory protection for agricultural workers.