Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease: the GOLD science committee report 2019

High Serum Level of IL-17 in Patients with Chronic Obstructive Pulmonary Disease and the Alpha-1 Antitrypsin PiZ Allele

Chronic obstructive pulmonary disease (COPD) is multifactorial disease, which is characterized by airflow limitation and can be provoked by genetic factors, including carriage of the PiZ allele of the protease inhibitor (Pi) gene, encoding alpha-1 antitrypsin (A1AT). Both homozygous and heterozygous PiZ allele carriers can develop COPD. It was found recently that normal A1AT regulates cytokine levels, including IL-17, which is involved in COPD progression. The aim of this study was to determine whether homozygous or heterozygous PiZ allele carriage leads to elevated level of IL-17 and other proinflammatory cytokines in COPD patients. Materials and Methods. Serum samples and clinical data were obtained from 44 COPD patients, who included 6 PiZZ, 8 PiMZ, and 30 PiMM A1AT phenotype carriers. Serum concentrations of IL-17, IL-6, IL-8, IFN-γ, and TNF-α were measured by the enzyme-linked immunosorbent assay (ELISA). All A1AT phenotypes were verified by narrow pH range isoelectrofocusing with selective A1AT staining. A turbidimetric method was used for quantitative A1AT measurements. Results. COPD patients with both PiZZ and PiMZ phenotypes demonstrated elevated IL-17 and decreased IFN-γ levels in comparison to patients with the PiMM phenotype of A1AT. Thereafter, the ratio IL-17/IFN-γ in PiZZ and PiMZ groups greatly exceeded the values of the PiMM group. Homozygous PiZ allele carriers also had significantly higher levels of IL-6 and lower levels of IL-8, and IL-6 values correlated negatively with A1AT concentrations. Conclusions. The presence of the PiZ allele in both homozygous and heterozygous states is associated with altered serum cytokine levels, including elevated IL-17, IL-17/IFN-γ ratio, and IL-6 (only PiZZ), but lower IFN-γ and IL-8.

Dual use of bronchodilators versus monotherapy, and its impact on pulmonary rehabilitation in COPD patients

INTRODUCTION

Long-acting bronchodilators are the therapy with the best evidence for treating stable chronic obstructive pulmonary disease (COPD). Long-acting combinations of β2 agonists and anticholinergics (LABA-LAMA) are recommended in advanced stages when monotherapy has not generated the desired effects. Pulmonary Rehabilitation (PR) is an effective non-pharmacological strategy. The aim of this study was to compare the results obtained in patients with COPD who received monotherapy versus dual bronchodilator therapy in terms of functional aerobic capacity, symptoms and quality of life.

MATERIALS AND METHODS

Prospective non randomized intervention study; the patients were divided into two groups: in one group patients were treated with LAMA (Tiotropium Bromide, 5 μg every 24 h) and in the other group patients were treated with LABA + LAMA (Indacaterol/Glycopyrronium, 110/50 μg once a day). After receiving the concept of pulmonology, patients were intervened with 8 weeks of PR. The study was approved by the committee of the Clinica Neumológica del Pacifico in Cali and the Institución Universitaria Escuela Nacional del Deporte, Colombia. To determine the differences, t pair test for intragroup, and t-test was performed for intergroup analysis. For all tests, a p-value <0.05 was considered as statistically significant.

RESULTS

53 patients participated in this study, of which 20 were assigned to the LAMA group and 33 to the LAMA + LABA group. Patients in both groups presented changes in the distance of the 6MWT, in the VO2e, dyspnea and in all the SGRQ domains. Regarding the comparison between groups, there were found no differences in the variables at the beginning of the PR and significant differences (p < 0.05) at the end of the 8 week-period in favor of the LABA + LAMA group, in symptoms with the mMRC scale, functional aerobic capacity with the 6 min walking test and in health related quality of life specifically in the symptoms domain, where the dual therapy group obtained better results.

CONCLUSION

The addition of LABA to the treatment with LAMA showed better response results compared with the monotherapy in patients with COPD who attended PR.

Chronic Cough in Individuals With COPD: A Population-Based Cohort Study

BACKGROUND

The role and impact of chronic cough in individuals with COPD have not been described in the general population. This study hypothesized that comorbid chronic cough is a marker of disease severity in individuals with COPD.

METHODS

This study identified individuals with COPD and chronic cough, and recorded respiratory symptoms, health-care utilizations, lung function, and inflammatory biomarkers in blood in a nested cohort of 43,271 adults from the Copenhagen General Population Study (CGPS).

RESULTS

Among 43,271 individuals from the general population, 8,181 (19%) experienced COPD, of whom 796 (10%) had chronic cough. Individuals with COPD and chronic cough had a Leicester Cough Questionnaire median (25th-75th percentiles) total score of 17.7 (16.0-18.9), corresponding to 5.9 (5.3-6.3) for the physical domain, 5.6 (4.9-6.3) for the psychological domain, and 6.3 (5.8-6.8) for the social domain. Among individuals with COPD, those with chronic cough vs those without chronic cough more often experienced sputum production (60% vs 8%), wheezing (46% vs 14%), dyspnea (66% vs 38%), chest pain/tightness (9% vs 4%), nighttime dyspnea (8% vs 3%), episodes of acute bronchitis/pneumonias in the last 10 years (45% vs 25%), and ≥ 3 general practitioner visits in the past 12 months (53% vs 37%). Furthermore, these individuals had lower FEV₁ % predicted (81% vs 89%) and FEV₁/FVC (0.64 vs 0.66), as well as higher levels of high-sensitivity C-reactive protein, fibrinogen, leukocytes, neutrophils, eosinophils, and IgE in blood.

CONCLUSIONS

Comorbid chronic cough in individuals with COPD is associated with a more severe disease in terms of more respiratory symptoms and health-care utilizations, lower lung function, and increased inflammation in blood.

Nasal High Flow Use in COPD Patients with Hypercapnic Respiratory Failure: Treatment Algorithm & Review of the Literature

Nasal high flow (NHF) therapy has recently gained attention as a new respiratory support system and is increasingly being utilized in every day clinical practice. Recent studies suggest that it may also be effective in patients with hypercapnia and suggest NHF as a possible alternative for patients who cannot tolerate standard noninvasive ventilation. The present review discusses the mechanisms of action that make NHF potentially suitable for chronic obstructive pulmonary disease (COPD) patients and evaluates the current evidence of NHF use for treatment of stable hypercapnic COPD patients as well as acute hypercapnic exacerbation of COPD. An algorithm is also proposed for the clinical application of NHF in patients with acute hypercapnic exacerbation of COPD, based on current literature.

Endobronchial Valve Treatment in Emphysema Patients with a Very Low DLCO

BACKGROUND

For selected patients with severe emphysema, bronchoscopic lung volume reduction with endobronchial valves (EBV) is recognized as an additional treatment option. In most trials investigating EBV treatment, patients with a very low diffusing capacity (DLCO) were excluded from participation.

OBJECTIVES

Our goal was to investigate whether EBV treatment in patients with emphysema with a very low DLCO is safe and effective.

METHODS

This was a single-center retrospective analysis including patients with emphysema and a DLCO ≤20%pred who underwent EBV treatment. Follow-up was performed 6 months post-treatment. Outcome parameters were compared to a historical matched control group (DLCO >20%pred, matched for sex, age, forced expiratory volume in 1 s [FEV1], and residual volume [RV]).

RESULTS

Twenty patients (80% female, 64 ± 6 years, FEV1 26 ± 6%pred, RV 233 ± 45%pred, DLCO 18 ± 1.6%pred) underwent EBV treatment. At 6 months follow-up, we found a statistically significant improvement in FEV1 (0.08 ± 0.12 L), RV (-0.45 ± 0.95 L), 6-min walking distance (38 ± 65 m), and St. George's Respiratory Questionnaire (-12 ± 13 points). With the exception of FEV1, all exceeded the minimal clinically important difference. The most common serious adverse event was a pneumothorax requiring intervention (15%). There were no significant differences in outcome compared to the DLCO >20%pred control group.

CONCLUSIONS

In this single-center retrospective analysis, we showed statistically significant and clinically relevant improvements in lung function, exercise capacity, and quality of life up to 6 months after EBV treatment in emphysema patients with a DLCO ≤20% (14-20%) of predicted with no increased risk of serious adverse events.

Is Metrnl an Adipokine İnvolved in the Anti-inflammatory Response to Acute Exacerbations of COPD?

PURPOSE

Chronic obstructive pulmonary disease (COPD) is a common lung disease characterized by airflow limitation and systemic inflammation. Recently, there has been growing interest in adipose tissue-mediated inflammation in the pathogenesis of COPD. The aim of our study was to determine the relationships between a new adipocytokine, meteorin-like protein (Metrnl), and acute exacerbations of COPD, smoking, and comorbidities.

MATERIALS AND METHODS

The study included 313 patients aged 40-65 years in four groups: Group 1: ex-smokers (≥ 20 pack-years) with COPD hospitalized for COPD exacerbation (n = 133), Group 2: current-smokers (≥ 20 pack-years) without COPD (n = 60), Group 3: ex-smokers (≥ 20 pack-years) without COPD (n = 60), and Group 4: never-smokers without COPD (n = 60). Peripheral venous blood samples (5 cc) were collected from all participants. Plasma Metrnl levels were measured using commercial enzyme-linked immunosorbent assay (ELISA) kit.

RESULTS

Mean Metrnl levels were 28.45 ± 11.27 ng/ml in Group 1, 24.34 ± 4.38 ng/ml in Group 2, 18.84 ± 3.8 ng/ml in Group 3, and 19.44 ± 3.92 ng/ml in Group 4. Group 1 had significantly higher mean Metrnl level compared to the other groups (p = 0.006, p = 0.001, p = 0.001). Metrnl level was also significantly higher in Group 2 when compared with Groups 3 and 4 (p = 0.001, p = 0.005). Group 1 patients with diabetes mellitus and coronary artery disease showed significantly lower Metrnl levels compared to other patients in the group (p = 0.001, p = 0.001).

CONCLUSION

The high Metrnl level in COPD exacerbations and active smoking may be important in balancing the inflammatory response. However, plasma Metrnl levels were found to be lower in COPD patients with comorbidities.

Analysis of the Mechanism of Zhichuanling Oral Liquid in Treating Bronchial Asthma Based on Network Pharmacology

Zhichuanling oral liquid (ZOL) as a preparation of traditional Chinese medicine is widely used for the treatment of asthma in China; therefore, it is necessary to systematically clarify bioactive chemical ingredients and the mechanism of action of ZOL. Information on ZOL ingredients and asthma-related targets was collected, and we used the latest systematic pharmacological methods to construct protein-protein interaction network and compound-target network and then visualized them. Finally, GO and KEGG pathway enrichment analysis was conducted through the clusterProfiler package in the R software. The results showed that 58 bioactive ingredients and 42 potential targets of ZOL related to asthma were identified, following six important components and nine hub genes screened. Further cluster and enrichment analysis suggested that NF-κB signaling pathway, PI3K/Akt signaling pathway, IL-17 signaling pathway, Toll-like receptor signaling pathway, and TNF signaling pathway might be core pathways of ZOL for asthma. Our work successfully predicted the active ingredients and potential targets of ZOL and provided the explanation for the mechanism of action of ZOL for asthma through the systematic analysis, which suggested that ZOL played a major role in many ways including reducing airway inflammation and inhibiting airway remodeling and mucus secretion. Moreover, ZOL combined with glucocorticoids may have some effects on severe asthma.

Lung epithelium damage in COPD - An unstoppable pathological event?

Chronic obstructive pulmonary disease (COPD) is a common term for alveolar septal wall destruction resulting in emphysema, and chronic bronchitis accompanied by conductive airway remodelling. In general, this disease is characterized by a disbalance of proteolytic/anti-proteolytic activity, augmented inflammatory response, increased oxidative/nitrosative stress, rise in number of apoptotic cells and decreased proliferation. As the first responder to the various environmental stimuli, epithelium occupies an important position in different lung pathologies, including COPD. Epithelium sequentially transitions from the upper airways in the direction of the gas exchange surface in the alveoli, and every cell type possesses a distinct role in the maintenance of the homeostasis. Basically, a thick ciliated structure of the airway epithelium has a major function in mucus secretion, whereas, alveolar epithelium which forms a thin barrier covered by surfactant has a function in gas exchange. Following this line, we will try to reveal whether or not the chronic bronchitis and emphysema, being two pathological phenotypes in COPD, could originate in two different types of epithelium. In addition, this review focuses on the role of lung epithelium in COPD pathology, and summarises underlying mechanisms and potential therapeutics.

[The concept of chronic obstructive pulmonary disease clinical control as a decision - making tool in real clinical practice for optimizing of basic pharmacotherapy]

The main goals of COPD therapy are to achieve clinical stability with minimal clinical manifestations and low risk of relapse. The proposed COPD control concept by analogy with asthma has not been quite well characterized yet. COPD control is defined as "the long - term maintenance of a clinical situation with a low impact of symptoms on the patient's life and absence of exacerbations." The situation of clinical control in COPD is considered desirable and potentially achievable for most patients with COPD. Pharmacotherapeutic options for COPD are constantly expanding. The control concept may be useful when the decision on treatment of COPD is made for dynamic adjustment of the therapy volume.

Glucocorticoid Receptor α Mediates Roflumilast's Ability to Restore Dexamethasone Sensitivity in COPD

Background

Glucocorticoids are commonly prescribed to treat inflammation of the respiratory system; however, they are mostly ineffective for controlling chronic obstructive pulmonary disease (COPD)-associated inflammation. This study aimed to elucidate the molecular mechanisms responsible for such glucocorticoid inefficacy in COPD, which may be instrumental to providing better patient outcomes. Roflumilast is a selective phosphodiesterase-4 (PDE4) inhibitor with anti-inflammatory properties in severe COPD patients who have a history of exacerbations. Roflumilast has a suggested ability to mitigate glucocorticoid resistance, but the mechanism is unknown.

Methods

To understand the mechanism that mediates roflumilast-induced restoration of glucocorticoid sensitivity in COPD, we tested the role of glucocorticoid receptor α (GRα). Roflumilast's effects on GRα expression and transcriptional activity were assessed in bronchial epithelial cells from COPD patients.

Results

We found that both GRα expression and activity are downregulated in bronchial epithelial cells from COPD patients and that roflumilast stimulates both GRα mRNA synthesis and GRα's transcriptional activity in COPD bronchial epithelial cells. We also demonstrate that roflumilast enhances dexamethasone's ability to suppress pro-inflammatory mediator production, in a GRα-dependent manner.

Discussion

Our findings highlight the significance of roflumilast-induced GRα upregulation for COPD therapeutic strategies by revealing that roflumilast restores glucocorticoid sensitivity by sustaining GRα expression.

Locomotor Muscles in COPD: The Rationale for Rehabilitative Exercise Training

Exercise training as part of pulmonary rehabilitation is arguably the most effective intervention to improve tolerance to physical exertion in patients with chronic obstructive pulmonary disease (COPD). Owing to the fact that exercise training has modest effects on exertional ventilation, operating lung volumes and respiratory muscle performance, improving locomotor muscle structure and function are key targets for pulmonary rehabilitation in COPD. In the current concise review, we initially discuss whether patients’ muscles are exposed to deleterious factors. After presenting corroboratory evidence on this regard (e.g., oxidative stress, inflammation, hypoxemia, inactivity, and medications), we outline their effects on muscle macro- and micro-structure and related functional properties. We then finalize by addressing the potential beneficial consequences of different training strategies on these muscle-centered outcomes. This review provides, therefore, an up-to-date outline of the rationale for rehabilitative exercise training approaches focusing on the locomotor muscles in this patient population.

Reduced airway levels of fatty-acid binding protein 4 in COPD: relationship with airway infection and disease severity

Background

For still unclear reasons, chronic airway infection often occurs in patients with Chronic Obstructive Pulmonary Disease (COPD), particularly in those with more severe airflow limitation. Fatty-acid binding protein 4 (FABP4) is an adipokine involved in the innate immune response against infection produced by alveolar macrophages (Mɸ). We hypothesized that airway levels of FABP4 may be altered in COPD patients with chronic airway infection.

Methods

In this prospective and controlled study we: (1) compared airway FABP4 levels (ELISA) in induced sputum, bronchoalveolar lavage fluid (BALF) and plasma samples in 52 clinically stable COPD patients (65.2 ± 7.9 years, FEV₁ 59 ± 16% predicted) and 29 healthy volunteers (55.0 ± 12.3 years, FEV₁ 97 ± 16% predicted); (2) explored their relationship with the presence of bacterial airway infection, defined by the presence of potentially pathogenic bacteria (PPB) at ≥10³ colony-forming units/ml in BALF; (3) investigated their relationship with the quantity and proportion of Mɸ in BALF (flow cytometry); and, (4) studied their relationship with the severity of airflow limitation (FEV₁), GOLD grade and level of symptoms (CAT questionnaire).

Results

We found that: (1) airway levels of FABP4 (but not plasma ones) were reduced in COPD patients vs. controls [219.2 (96.0–319.6) vs. 273.4 (203.1–426.7) (pg/ml)/protein, p = 0.03 in BALF]; (2) COPD patients with airway infection had lower sputum FABP4 levels [0.73 (0.35–15.3) vs. 15.6 (2.0–29.4) ng/ml, p = 0.02]; (3) in COPD patients, the number and proportion of Mɸ were positively related with FABP4 levels in BALF; (4) BALF and sputum FABP4 levels were positively related with FEV₁, negatively with the CAT score, and lowest in GOLD grade D patients.

Conclusions

Airway FABP4 levels are reduced in COPD patients, especially in those with airway infection and more severe disease. The relationship observed between Mɸ and airway FABP4 levels supports a role for FABP4 in the pathogenesis of airway infection and disease severity in COPD.

Alterations of grey matter volumes and network-level functions in patients with stable chronic obstructive pulmonary disease

OBJECTIVE

The purpose of this study was to investigate structural and functional alterations of the brain in the patients with stable chronic obstructive pulmonary disorder (COPD) and further investigate how these alterations correlated to parameters of pulmonary function test, cognitive function and disease duration in patients with COPD.

METHOD

Forty-five patients with stable COPD and forty age- and gender-matched healthy controls were enrolled into this study. Both resting-state fMRI and structural MRI were acquired for each participant. Voxel-based morphology was utilized to analyze alterations of the grey matter volume (GMV), and the seed-based resting-state functional connectivity (FC) was used to evaluate the network-level functional alterations.

RESULTS

Compared to healthy controls, patients with stable COPD showed decreased GMV in the left supramarginal gyrus/precentral gyrus (SMG/PreCG), bilateral posterior midcingulate cortex (pMCC), right middle occipital gyrus (MOG) and right SMG. Furthermore, COPD patients mainly showed decreased FC within the visual network, frontoparietal network and other brain regions. Subsequent correlational analyses revealed that the decreased FC within visual network, frontoparietal network were positively correlated with the Montreal Cognitive Assessment score, language-domain score, attention-domain score and disease duration in patients with COPD.

CONCLUSION

Our findings provided evidence that COPD patients showed decreased GMV and regional and network-level functional alterations within the visual network, frontoparietal network and other networks. We speculated that atrophic GMV and FC of visual network and frontoparietal network are involved in the neural mechanism of mild cognitive impairment in stable COPD patients.

The stability of blood Eosinophils in chronic obstructive pulmonary disease

Blood eosinophils are a predictive biomarker of inhaled corticosteroid response in chronic obstructive pulmonary disease (COPD). We investigated blood eosinophil stability over 1 year using the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2019 thresholds of < 100, 100- < 300 and ≥ 300 eosinophils/μL in 225 patients from the COPDMAP cohort. Blood eosinophils showed good stability (rho: 0.71, p < 0.001, ICC 0.84), and 69.3% of patients remained in the same eosinophil category at 1 year. 85.3% of patients with eosinophils < 100 cells/μL had stable counts. The majority of blood eosinophil counts remain stable over 1 year using the GOLD 2019 thresholds.

Ultrasound Evaluation of the Quadriceps Muscle Contractile Index in Patients with Stable Chronic Obstructive Pulmonary Disease: Relationships with Clinical Symptoms, Disease Severity and Diaphragm Contractility

Rationale

Chronic obstructive pulmonary disease (COPD) is associated with changes in the composition and function of peripheral and respiratory muscles, which can negatively impact quality of life. Ultrasonography can provide a non-invasive evaluation of the integrity of both peripheral muscles and diaphragm, but its use in patients with COPD is still being investigated. We aimed at evaluating the relationship between quadriceps size, using ultrasonography and symptoms, lung function and diaphragm contractility in a cohort of patients with COPD.

Methods

COPD patients were prospectively recruited and ultrasonography of the dominant quadriceps and of the diaphragm was performed. Quadriceps size was evaluated using three measurements: 1) cross-sectional area of the rectus femoris (Qcsa), 2) thickness (Qthick) and 3) contractile index (Qci), defined as the ratio of quadriceps thickness/total anterior thigh thickness. Diaphragm contractility was evaluated using thickening fraction (TFdi). Clinical characteristics and number of moderate-to-severe exacerbations in the previous year were retrieved from medical files. Dyspnea (mMRC scale) and disease impact on health status (COPD Assessment Test (CAT)) were measured at inclusion. Fat-free mass index (FFMI) was assessed using bioelectrical impedance.

Results

Forty patients were recruited (20 males, mean age and FEV₁ 66±6 years and 49±17%predicted, respectively). Mean Qcsa, Qthick and Qci were 336±145 mm², 1.55±0.53 cm and 64±16%, respectively, and mean TFdi was 91±36%. Qci was significantly correlated with FFMI (rho=0.59, p=0.001), TFdi (rho=0.41, p=0.008), FEV₁ (rho=0.43, p=0.001) but not with age (rho=0.18, p=0.28). Qci was significantly correlated to CAT score (rho=−0.47, p=0.002), even when controlled for FEV₁, and was lower in patients with an mMRC score ≥2 (55±15 vs 70±14%, p=0.002). Qcsa and Qci were significantly lower in patients with frequent exacerbations. In a multiple linear regression analysis that included age, gender, FFMI, FEV₁ and TFdi, only FFMI and TFdi were found to be significantly related to lower Qci values.

Conclusion

In patients with COPD, ultrasound evaluation of the quadriceps contractile index is feasible and related to disease severity, clinical symptoms, exacerbation history and diaphragm contractility. As such, it may provide a novel tool for the evaluation of the severity and burden of the disease in this population. Further studies are required to better delineate its potential role as a prognostic marker in this population.

Lung function and cardiovascular disease: A link

The relationship between lung and heart diseases has long been recognized, with necropsy studies demonstrating silent myocardial infarctions or coronary artery calcification in patients with advanced emphysema as the death cause. Improvements in non-invasive techniques and epidemiologic approaches established that lung and cardiovascular diseases frequently coexist in mid and late life. Even among those without diagnosed lung disease, lower than expected forced vital capacity, forced expiratory volume in 1 s, and their ratio each portend greater risk of developing cardiovascular risk factors including hypertension, obesity, and metabolic syndrome, and for incident cardiovascular diseases including left heart failure, atrial fibrillation and stroke. Greater longitudinal declines in these spirometric measures are further associated with cardiovascular morbidity and mortality. While obstructive ventilatory patterns are more common, restrictive ventilatory patterns seem to demonstrate an independent and more robust association with cardiovascular diseases such as heart failure. These subclinical alterations in pulmonary function also relate to subclinical abnormalities of cardiac structure and function. Although the biologic pathways linking pulmonary and cardiovascular dysfunction are not clear, chronic systemic inflammation appears to be one important underlying pathophysiologic link. Despite the growing evidence of lung dysfunction as a cardiovascular risk factor, spirometric evaluation is still underutilized in clinical practice, particularly among cardiac patients, and optimal therapeutic and preventive strategies are still unclear. In this review, we address the current knowledge and controversies regarding the links between lung function and cardiovascular disease.

ERS International Congress, Madrid, 2019: highlights from the General Pneumology Assembly

This article contains highlights and a selection of the scientific advances from the European Respiratory Society's General Pneumology Assembly that were presented at the 2019 European Respiratory Society International Congress in Madrid, Spain. The most relevant topics from the different groups will be discussed, covering a wide range of areas including rehabilitation and chronic care, general practice and primary care and M-health and E-health. In this review, the newest research and actual data as well as award-winning abstracts and highlight sessions will be discussed.

A Review of Current Tools Used for Evaluating the Severity of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common and heterogeneous disease characterized by episodic collapse within the upper airways, which leads to reduced ventilation and adverse consequences, including hypoxia, hypercapnia, sleep fragmentation, and long-term effects such as cardiovascular comorbidities. The clinical diagnosis of OSA and its severity classification are often determined based on the apnea-hypopnea index (AHI), defining the number of apneic and hypopnea events per hour of sleep. However, the limitations of the AHI to assess disease severity have necessitated the exploration of other metrics for additional information to reflect the complexity of OSA. Novel parameters such as the hypoxic burden have the potential to better capture the main features of OSA by maximizing the information available from the polysomnogram. These emerging measures have described multidimensional qualities of sleep-disordered breathing events and breathing irregularity and will ultimately result in better management of OSA.

Is it possible to reverse frailty in patients with chronic obstructive pulmonary disease?

In recent years, frailty has attracted increasing attention from clinicians and health care workers. The influence of frailty on the elderly, especially those with chronic diseases of the respiratory system, is highly significant. Frailty is particularly more common in patients with chronic obstructive pulmonary disease (COPD). Frailty and COPD share many risk factors and pathophysiological mechanisms. As a comprehensive interventional method for chronic respiratory diseases, pulmonary rehabilitation is an important basic measure for the management of patients with COPD. Frailty in these patients can be reversed using pulmonary rehabilitation by targeting five components of the frailty phenotype at the entry point. The present review discusses the benefits of pulmonary rehabilitation in patients with COPD complicated by frailty and provides a theoretical basis for pulmonary rehabilitation treatment in this population. In addition, the timing of pulmonary rehabilitation is also addressed, with the prefrail stage being the "golden" period. The implementation of pulmonary rehabilitation must vary among individuals, and individualized treatment strategies will help maximize benefits.

Airway epithelial cell differentiation relies on deficient Hedgehog signalling in COPD

BACKGROUND

Hedgehog (HH) pathway is constantly under scrutiny in the context of organ development. Lung morphogenesis requires HH signalling which participates thereafter to the pulmonary homeostasis by regulating epithelial cell quiescence and repair. Since epithelial remodelling is a hallmark of Chronic Obstructive Pulmonary Disease (COPD), we investigated whether the main molecular actors of HH pathway participate to airway epithelial cell differentiation and we analysed their alterations in COPD patients.

METHODS

Sonic HH (Shh) secretion was assessed by ELISA in airway epithelial cell (AEC) air-liquid interface culture supernatants. HH pathway activation was evaluated by RT-qPCR, western blot and immunostaining. Inhibition of HH signalling was achieved upon Shh chelation during epithelial cell differentiation. HH pathway core components localization was investigated in lung tissues from non-COPD and COPD patients.

FINDINGS

We demonstrate that progenitors of AEC produced Shh responsible for the activation of HH signalling during the process of differentiation. Preventing the ligand-induced HH activation led to the establishment of a remodelled epithelium with increased number of basal cells and reduced ciliogenesis. Gli2 activating transcription factor was demonstrated as a key-element in the regulation of AEC differentiation. More importantly, Gli2 and Smo were lost in AEC from COPD patients.

INTERPRETATION

Our data suggest that HH pathway is crucial for airway epithelial cell differentiation and highlight its role in COPD-associated epithelial remodelling.

Airway Inflammation Biomarker for Precise Management of Neutrophil-Predominant COPD

Chronic obstructive pulmonary disease (COPD) course can be divided into stable stage and acute exacerbation. Deepen the understanding to the function and role of airway inflammatory cells in stable COPD is important for developing new therapies to restore airway dysfunction and preventing stable stage COPD progress to acute exacerbation COPD. Neutrophil is a feature of lower airways and lung inflammation in majority COPD patients at stable stage and increased neutrophils usually means COPD patients are in a more serious stage. Neutrophil-predominant COPD always accompanied by increased numbers of macrophages, lymphocytes, and dendritic cells. The composition proportion of different inflammatory cells are changed with disease severity. Recently, neutrophilic inflammation has been proved to be correlated with the disturbance of airway resident microbiota, which promote neutrophil influx and exacerbates inflammation. Consequently, understanding the details of increased neutrophils and dysbacteriosis in COPD is necessary for making precise management strategy against neutrophil-associated COPD.

Novel versus Traditional Inspiratory Muscle Training Regimens as Home-Based, Stand-Alone Therapies in COPD: Protocol for a Randomized Controlled Trial

BACKGROUND

Subjects with COPD frequently develop considerable weakness and deconditioning of the inspiratory musculature, which can be corrected with inspiratory muscle training (IMT). While rehabilitation centers may be able to provide IMT as part of the rather complex management of COPD, there is currently a lack of rehabilitation services in the Czech Republic. Remote IMT may then benefit subjects with COPD who are unable to attend or do not have access to rehabilitation programs. We aim at evaluating the utility of the test of incremental respiratory endurance (TIRE) as an at-home IMT method in subjects with COPD, while comparing the effectiveness of this novel training approach to the outcomes of traditional, threshold loading IMT protocols.

METHODS/DESIGN

This prospective, randomized controlled trial will comprise 8 weeks of at-home IMT sessions with remote supervision followed by 4 months of unsupervised, independent IMT. Eligible subjects will be randomly assigned to one of the following three distinct home-based IMT protocols: (1) TIRE, (2) Threshold loading, and (3) Sham training. Subjects allocated to the TIRE group will train once daily using an advanced IMT electronic system (PrO2), while the other two groups will receive threshold devices. Study outcomes will include measures of inspiratory muscle strength and endurance, pulmonary function, COPD-specific symptomatology, functional exercise capacity, surrogate markers of mortality risk, mental health status and health-related quality of life.

DISCUSSION

While we acknowledge the value of threshold loading IMT protocols, we believe that the TIRE training method has the potential to provide additional clinical benefits in COPD given its sophisticated remote tracking system and ability to modulate all aspects of muscular performance, including not only strength but also endurance, power and work capacity, allowing users to achieve considerably higher inspiratory pressures throughout the full range of inspiration when compared to other more traditionally used IMT methods.

The Significance of iron deficiency and anemia in a real-life COPD cohort

Background: Current evidence suggests an increased prevalence of iron deficiency (ID) and anemia in chronic obstructive pulmonary disease (COPD). ID and subsequent anemia can be due to iron losses via bleeding resulting in absolute ID or inflammation-driven retention of iron within macrophages resulting in functional ID and anemia of inflammation. Methods: This is a retrospective analysis of 204 non-exacerbated COPD patients in outpatient care. Current definitions of absolute and functional ID were applied to determine the prevalence of ID and to analyze associations to disease severity in terms of lung function parameters and clinical symptoms. Results: The studied cohort of COPD patients demonstrated a high prevalence of ID, ranging from 30 to 40% during the observation time. At the initial presentation, absolute or functional ID was found in 9.3% to 12.3% of COPD individuals, whereas combined forms of absolute and functional ID were most prevalent (25.9% of all individuals). The prevalence of ID increased during longitudinal follow-up (37 ± 15 months), and especially combined forms of ID were significantly related to anemia. Anemia prevalence ranged between 14.2% and 20.8% during the observation period and anemia was associated with lower FEV1, DLCOc, and CRP elevation. Accordingly, ID was associated with decreased FEV1, DLCOc, and an elevation in CRP. Conclusion: ID is common in COPD patients, but a uniform definition for accurate diagnosis does not exist. Prevalence of functional ID and anemia increased during follow-up. The associations of ID and anemia with reduced functional lung capacity and elevated inflammation may reflect a more severe COPD phenotype.

Inhaled Corticosteroids Prescribed for COPD Patients with Mild or Moderate Airflow Limitation: Who Warrants a Trial of Withdrawal?

COPD patients prescribed inhaled corticosteroids (ICS) outside guidelines should be targeted for ICS withdrawal. Within a primary care population of 209,618 we used a combination of digital search algorithm, individual record review, and clinical review to identify COPD patients suitable for a trial of ICS withdrawal. At most, 39% of COPD patients with mild or moderate airflow limitation prescribed ICS were suitable for withdrawal according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Recurrent exacerbations and reversible airway obstruction were the main reasons for patients’ unsuitability for withdrawal. Identifying COPD patients in whom ICS withdrawal should be considered presents a challenge to primary care clinicians.

Lifetime Occupational History, Respiratory Symptoms and Chronic Obstructive Pulmonary Disease: Results from a Population-Based Study

Purpose

To ascertain the effect of lifelong occupational history, ambient air pollution, and biochemically verified smoking status on chronic obstructive pulmonary disease (COPD) in a general population of one the largest cities in Central Asia, Almaty.

Patients and methods

1500 adults (median age 49, interquartile range (IQR) 28 years), 50% females, were randomly selected from a registry of enlisted population of a primary care facility in Almaty, Kazakhstan and they filled in the questionnaire on demographics, respiratory symptoms (CAT and mMRC), smoking status, verified by exhaled carbon monoxide, and detailed lifetime occupational history. COPD was defined as postbronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) below lower limit of normal (LLN) using Belintelmed MAS-2 spirometer (Belarus).

Results

230 (15%) subjects had CAT≥10; 136 (9%) participants had mMRC score ≥2. Greater CAT score was associated with age, smaller income, and less exercise, but not with smoking or living closer to a major road. 26% of the population was ever exposed to vapors, gases, dusts, and fumes (VGDF). In age group 40 years and above (N=1024), COPD was found in 57 participants (prevalence 5.6%), more in men (8.7% vs 3.4%). In the multivariate model adjusted for age, sex, ever-smoking, income, and exercise, any exposure to VGDF increased the odds of COPD (odds ratio (OR) 1.71; 95% confidence interval (CI) 1.03; 2.84), more in the highest exposure category (OR 2.36 (95% CI 1.20; 4.66)).

Conclusion

Lifetime exposure to VGDF, found in ¼ of the general population, increased the odds of COPD independent of smoking by 71%.

Machine Learning Characterization of COPD Subtypes: Insights From the COPDGene Study

COPD is a heterogeneous syndrome. Many COPD subtypes have been proposed, but there is not yet consensus on how many COPD subtypes there are and how they should be defined. The COPD Genetic Epidemiology Study (COPDGene), which has generated 10-year longitudinal chest imaging, spirometry, and molecular data, is a rich resource for relating COPD phenotypes to underlying genetic and molecular mechanisms. In this article, we place COPDGene clustering studies in context with other highly cited COPD clustering studies, and summarize the main COPD subtype findings from COPDGene. First, most manifestations of COPD occur along a continuum, which explains why continuous aspects of COPD or disease axes may be more accurate and reproducible than subtypes identified through clustering methods. Second, continuous COPD-related measures can be used to create subgroups through the use of predictive models to define cut-points, and we review COPDGene research on blood eosinophil count thresholds as a specific example. Third, COPD phenotypes identified or prioritized through machine learning methods have led to novel biological discoveries, including novel emphysema genetic risk variants and systemic inflammatory subtypes of COPD. Fourth, trajectory-based COPD subtyping captures differences in the longitudinal evolution of COPD, addressing a major limitation of clustering analyses that are confounded by disease severity. Ongoing longitudinal characterization of subjects in COPDGene will provide useful insights about the relationship between lung imaging parameters, molecular markers, and COPD progression that will enable the identification of subtypes based on underlying disease processes and distinct patterns of disease progression, with the potential to improve the clinical relevance and reproducibility of COPD subtypes.

[The future of computer-aided diagnostics in chest computed tomography]

Recently, more and more attention has been paid to the utility of artificial intelligence in medicine. Radiology differs from other medical specialties with its high digitalization, so most software developers operationalize this area of medicine. The primary condition for machine learning is met because medical diagnostic images have high reproducibility. Today, the most common anatomic area for computed tomography is the thorax, particularly with the widespread lung cancer screening programs using low-dose computed tomography. In this regard, the amount of information that needs to be processed by a radiologist is snowballing. Thus, automatic image analysis will allow more studies to be interpreted. This review is aimed at highlighting the possibilities of machine learning in the chest computed tomography.

Clinical Significance of Bronchodilator Responsiveness Evaluated by Forced Vital Capacity in COPD: SPIROMICS Cohort Analysis

Objective

Bronchodilator responsiveness (BDR) is prevalent in COPD, but its clinical implications remain unclear. We explored the significance of BDR, defined by post-bronchodilator change in FEV₁ (BDR_FEV1) as a measure reflecting the change in flow and in FVC (BDR_FVC) reflecting the change in volume.

Methods

We analyzed 2974 participants from a multicenter observational study designed to identify varying COPD phenotypes (SPIROMICS). We evaluated the association of BDR with baseline clinical characteristics, rate of prospective exacerbations and mortality using negative binomial regression and Cox proportional hazards models.

Results

A majority of COPD participants exhibited BDR (52.7%). BDR_FEV1 occurred more often in earlier stages of COPD, while BDR_FVC occurred more frequently in more advanced disease. When defined by increases in either FEV₁ or FVC, BDR was associated with a self-reported history of asthma, but not with blood eosinophil counts. BDR_FVC was more prevalent in subjects with greater emphysema and small airway disease on CT. In a univariate analysis, BDR_FVC was associated with increased exacerbations and mortality, although no significance was found in a model adjusted for post-bronchodilator FEV₁.

Conclusion

With advanced airflow obstruction in COPD, BDR_FVC is more prevalent in comparison to BDR_FEV1 and correlates with the extent of emphysema and degree of small airway disease. Since these associations appear to be related to the impairment of FEV₁, BDR_FVC itself does not define a distinct phenotype nor can it be more predictive of outcomes, but it can offer additional insights into the pathophysiologic mechanism in advanced COPD.

Clinical trials registration

ClinicalTrials.gov: NCT01969344T4.

An Evaluation Of Single And Dual Long-Acting Bronchodilator Therapy As Effective Interventions In Maintenance Therapy-Naïve Patients With COPD

Background

Ideally, treatment recommendations for maintenance therapy-naïve patients with COPD should be based on studies conducted specifically in this population. We have reviewed evidence from previous studies of pharmacological treatments in maintenance therapy-naïve patients with COPD and performed a new post-hoc analysis of dual bronchodilator treatment in this population, aiming to assess the effectiveness of these interventions.

Materials and methods

A literature review identified clinical trials that included analyses of patients with COPD who were maintenance therapy-naïve with long-acting β2-agonists (LABA) or long-acting muscarinic antagonists (LAMA). Additionally, a post-hoc subgroup analysis was conducted for maintenance therapy-naïve patients with COPD in two large phase III, randomized, double-blind, 24-week trials investigating the efficacy of aclidinium bromide/formoterol fumarate (AB/FF) fixed-dose combination versus monotherapy or placebo (ACLIFORM [NCT01462942] and AUGMENT [NCT01437397]).

Results

Treatment-naïve patients with COPD often represent a population of patients at the earliest stage at which most patients seek treatment. Of nine relevant studies identified, all reported positive findings for efficacy of LABA, LAMA, or LABA/LAMA treatment in maintenance therapy-naïve populations. Improvements were observed in lung function, symptoms, and health status versus monotherapy or placebo. Post-hoc analysis of ACLIFORM and AUGMENT demonstrated that AB/FF was effective in improving lung function in patients who had received no prior maintenance therapy. AB/FF showed improvements in 1 hr post-dose FEV1, trough FEV1, and patient-reported outcomes versus placebo and monotherapies. Combined with reviews of previous studies in maintenance therapy-naïve patients, these findings suggest that earlier intervention with a dual bronchodilator maintenance therapy, such as AB/FF, may provide significantly greater benefits than LAMA or LABA mono-bronchodilator therapy as a first maintenance treatment for COPD.

Conclusion

These data show that therapeutic intervention is effective in treatment-naïve patients. Intervention with dual bronchodilator therapy as a first maintenance treatment for COPD may provide greater benefits than LAMA or LABA monotherapy.

Critical Inhaler Handling Error Is an Independent Risk Factor for Frequent Exacerbations of Chronic Obstructive Pulmonary Disease: Interim Results of a Single Center Prospective Study

Objective

Chronic obstructive pulmonary disease (COPD) acute exacerbations are significant causes of morbidity and mortality. “Frequent exacerbator” phenotypes are considered a distinct subgroup and this phenotype has a negative effect on lung function, quality of life, activity, hospital admission, and mortality. We assess inhaler handling technique and adherence, and evaluate risk factors associated with frequent exacerbations in COPD patients.

Methods

This study was a cross-sectional, case-control study. We prospectively enrolled 189 COPD patients from Yeungnam University Hospital from January 2018 to November 2018. Subjects were tested regarding their inhaler technique in face-to-face interviews with an advanced practice nurse of inhaler upon study entry. Frequency of moderate to severe COPD exacerbations were reviewed via electronic medical records during 12 months prior to study entry. Frequent exacerbations were defined as ≥2 moderate to severe exacerbations in the prior 12 months. Multivariate logistic regression was performed to identify risk factors for frequent exacerbations.

Results

Among 189 COPD patients, 50 (26.5%) were frequent exacerbators. Based on univariate analyses, body mass index (BMI) < 25 kg/m², lower forced expiratory volume in 1 s (FEV₁), higher mMRC, lower feeling of satisfaction with the inhaler, and any critical errors were potential risk factors for frequent exacerbations. Multivariate logistic regression analyses revealed that BMI < 25 kg/m² (OR, 2.855, 95% CI, 1.247–6.534; p=0.013), higher mMRC (OR, 1.625, 95% CI, 1.072–2.463; p=0.022), and any critical error (OR, 2.020, 95% CI, 1.021–3.999; p=0.044) were risk factors.

Conclusion

Any critical error, BMI < 25 kg/m² and high mMRC are independent risk factors for frequent exacerbations in COPD patients. Careful monitoring and education around inhaler devices, particularly in frequent exacerbators, are important components of COPD treatment.

A clinical trial to evaluate the effect of the Mediterranean diet on smokers lung function

Data on the association between lung function and some dietary patterns have been published. However, it is not yet well known if whether the Mediterranean Diet (MD) pattern can preserve or improve lung function. Our purpose is to evaluate the effect of increased MD adherence on lung function in smokers. A multicenter, parallel, cluster-randomized, controlled clinical trial is proposed. A total of 566 active smokers (>10 packs-year), aged 25–75 years will be included, without previous respiratory disease and who sign an informed consent to participate. Twenty Primary Care Centres in Tarragona (Spain) will be randomly assigned to a control or an intervention group (1:1). All participants will receive advice to quit smoking, and the intervention group, a nutritional intervention (2 years) designed to increase MD adherence by: (1) annual visit to deliver personalized nutritional education, (2) annual telephone contact to reinforce the intervention, and (3) access to an online dietary blog. We will evaluate (annually for 2 years): pulmonary function by forced spirometry and MD adherence by a 14-item questionnaire and medical tests (oxidation, inflammation and consumption biomarkers). In a statistical analysis by intention-to-treat basis, with the individual smoker as unit of analysis, pulmonary function and MD adherence in both groups will be compared; logistic regression models will be applied to analyze their associations. We hope to observe an increased MD adherence that may prevent the deterioration of lung function in smokers without previous respiratory disease. This population may benefit from a dietary intervention, together with the recommendation of smoking cessation.

Clinical And Economic Burden Of Eosinophilic COPD In A Large Retrospective US Cohort

Purpose

We sought to describe clinical and economic outcomes for COPD patients by blood eosinophil (EOS) count.

Methods

This retrospective cohort study of COPD patients used data from the Practice Fusion electronic medical records (EMR) database linked to Symphony Health Solutions transactional pharmacy, medical, outpatient, and inpatient claims data to evaluate COPD-related and all-cause health care resource utilization and cost in the 12-month period following the date of each patient’s greatest recorded blood eosinophil count during the 27-month period from January 2014 to March 2016. A post-index moderate exacerbation was defined as an outpatient or emergency care visit for COPD and a prescription for oral corticosteroid and/or antibiotics within 10 days of the visit. Severe exacerbation was defined as an inpatient hospitalization with COPD as primary diagnosis.

Results

Of 48,090 EMR patients, 39,939 (83.1%) had a charge in the claims data both pre- and post-index (mean age 67.2 years, 58.3% female), 17,397 (43.6%) had EOS ≥220 cells/µL. Moderate and severe exacerbations were more frequent for patients with EOS≥220 cells/µL compared with those with EOS <220 cells/µL (moderate: 6.8% vs 6.1%, p<0.05; severe: 3.1% vs 2.5%, p<0.001). After adjustment for baseline clinical characteristics, each 100-unit increase in EOS count was associated with a significant 2.24% increase in total all-cause costs and 4.54% increase in total COPD-related costs (p<0.001 for both). COPD-related costs were significantly greater for patients with an EOS count of ≥220 cells/µL compared with those with EOS <220 cells/µL (p<0.001). These costs appear to have been driven by a greater percentage of patients in the ≥220 cells/µL cohort with COPD-related resource use including hospitalization, office visits, ambulatory procedures and pharmacy prescriptions.

Conclusion

COPD patients with EOS counts ≥220 cells/µL were more likely to have had moderate or severe exacerbations and greater cost of care than those with EOS <220 cells/µL.

Impact Of Peak Oxygen Pulse On Patients With Chronic Obstructive Pulmonary Disease

Introduction

Patients with chronic obstructive pulmonary disease (COPD) are at an increased risk of cardiovascular comorbidities such as pulmonary hypertension or heart failure. Impaired cardiovascular function often has a significant impact on patients with COPD. Oxygen pulse (O₂P) is a surrogate for stroke volume. However, studies regarding O₂P, health-related quality of life (HRQL), and exercise capacity in patients with COPD are lacking. We aimed to confirm the association between O₂P, HRQL, exercise capacity, severe exacerbation of COPD, and other parameters in exercise testing.

Materials and methods

This study included 79 patients with COPD who underwent lung function testing, a cardiopulmonary exercise test (CPET), Borg Dyspnea Scale evaluation, completion of the St. George's Respiratory Questionnaire, and echocardiography. Cardiovascular comorbidities, COPD-related hospitalizations, and emergency room visits were recorded. We compared these parameters between two groups of patients: those with normal peak O₂P and those with impaired peak O₂P. The relationships of peak O₂P with CPET and lung function were analyzed using simple linear regression.

Results

Patients with normal peak O₂P had higher exercise capacity (peak oxygen uptake and work rate), better HRQL, lower dyspnea score, lower COPD-related hospitalizations, and higher circulatory and ventilator parameters than patients with impaired peak O₂P. According to a simple linear regression analysis, the anaerobic threshold (AT) and forced expiratory volume in one second (FEV1) showed a significant association with peak O₂P, and the Pearson correlation coefficients (Pearson's r) were 0.756 and 0.461, respectively.

Conclusion

Peak O₂P has a significant impact on exercise capacity, HRQL, dyspnea, COPD-related hospitalization, and circulatory and ventilatory functions in patients with COPD. The AT and FEV1 have strong and moderate associations with peak O₂P, respectively. Therefore, peak O₂P is an important indicator of disease severity for patients with COPD.

Prevalence, Awareness, and Associated Factors of Airflow Obstruction in Russia: The Ural Eye and Medical Study

Background: Although chronic obstructive pulmonary disease and asthma belong to the most important causes of disability and death in all world regions, data about the prevalence of airflow obstruction and asthma in Russia and the associated parameters have been scarce so far. We therefore assessed the prevalence of airflow obstruction and asthma in a Russian population. Methods: The population-based Ural Eye and Medical Study, conducted in a rural and urban region of Bashkortostan/Russia, included 5,392 participants (mean age: 58.6 ± 10.6 years; range: 40-94 years) out of 7,328 eligible individuals. Airflow obstruction was defined spirometrically and asthma by self-reported diagnosis. Results: Airflow obstruction was present in 369 individuals (6.8%; 95% confidence interval (CI): 6.2, 7.5) with an awareness rate of 63.4% (95%CI: 58.5, 68.4) and known duration of 19.5 ± 15.8 years (median: 16 years). Prevalence of undiagnosed airflow obstruction was 2.6% (95%CI: 2.2, 3.1). Higher prevalence of airflow obstruction was associated (multivariable analysis) with higher prevalence of current smoking [P < 0.001; odds ratio (OR): 2.91; 95%CI: 1.76, 4.83] and number of cigarette package years (P < 0.001; OR: 1.03; 95%CI: 1.02, 1.08), female gender (P = 0.03; OR: 1.42; 95%CI: 1.04, 1.93), urban region (P = 0.003; OR: 1.43; 95% CI: 1.12, 1.79), higher prevalence of cardiovascular diseases/stroke (P < 0.001; OR: 1.86; 95%CI: 1.45, 2.39), higher depression score (P = 0.002; OR: 1.05; 95%CI: 1.02, 1.08), and lower physical activity (P = 0.01; OR: 0.71; 95%CI: 0.54, 0.93). Asthma prevalence (2.6%; 95%CI: 2.0, 3.1; known duration: 17.2 ± 15.0 years) was associated with less alcohol consumption (OR: 0.53; 95%CI: 0.33, 0.87; P = 0.01), higher depression score (OR: 1.08; 95%CI: 1.03, 1.12; P < 0.001), and urban region (OR: 0.68; 95CI: 0.49, 0.95; P = 0.0.03). Conclusions: In this Russian population aged 40+ years, the prevalence of airflow obstruction was 6.8% with an awareness rate of 63.4% and smoking as main risk factor. Asthma prevalence was 2.6%.

Triple Therapy Versus Dual Bronchodilation and Inhaled Corticosteroids/Long-Acting β-Agonists in COPD: Accumulating Evidence from Network Meta-Analyses

Guidelines are mainly based on evidence of well-designed randomized controlled trials (RCTs), but there are limitations to the transferability of conclusions of RCTs to usual care mainly because the patients enrolled in RCTs are selected and not representative of the population encountered in daily practice; moreover, the research environment is substantially different from that of the real world. Because of the scarcity of data generated in large unselected populations in everyday clinical practice, the possibility of using meta-analyses can be considered. Recently, several meta-analyses have attempted to clarify the role of triple therapy containing a long-acting β-agonist (LABA), a long-acting muscarinic antagonist (LAMA) and an inhaled corticosteroid (ICS) delivered from a single inhaler in chronic obstructive pulmonary disease (COPD), also considering that there is a big difference in the use of triple therapy between what is recommended by COPD guidelines or strategies and the prescriptive behaviour of clinicians. Taking into account the results of the most recent meta-analyses, we believe that triple therapy provides modest clinical benefit in the general COPD population, but in patients on LABA/LAMA combination therapy, who still experience acute exacerbations of COPD (AECOPDs) and have blood eosinophil counts ≥ 300 cells·μl⁻¹, it is of clinical relevance. On the contrary, adding a LAMA to an ICS/LABA combination elicits relevant clinical benefit in the general COPD population, supporting the role of dual bronchodilation therapy for the treatment of COPD. The quantitative synthesis of the currently available clinical evidence seems to suggest that, in patients with COPD already on ICS/LABA combination, the therapy can be improved without an increase of cardiovascular severe adverse events (SAEs) when a LAMA is added to the combination.

Determinants of Smoking Status in a Sample of Outpatients Afferent to a Tertiary Referral Hospital

The identification of determinants of attempts to quit smoking and quitting smoking success is crucial for effective smoking prevention and/or cessation programs. Thus, here we have conducted a survey to determine the sociodemographic characteristics of tobacco use and the potential determinants of quitting smoking among a population of 140 subjects—101 smokers and 39 ex-smokers—referred to our clinic for respiratory diseases. Subject characteristics included demographic data, employment and education status, respiratory disease family history, smoking habits, life habits, diet, alcohol intake, and physical activity. In comparison with former smokers, active smokers were younger, lived with at least one smoking family member, and were more frequently exposed to passive smoke. They also displayed a higher coffee consumption, a higher frequency of in-between-meal snacks, and a lower chronic obstructive pulmonary disease (COPD) prevalence. In comparison with subjects who had never attempted to quit smoking, individuals who had attempted to quit smoking were younger, had a lower pack-year median, consumed a higher amount of coffee and alcohol, and conducted regular physical activity. Determinants of successful smoking cessation were older age, lower passive smoking exposure and daily coffee intake, and COPD diagnosis. Overall, our findings underscore the importance of health education in fostering successful smoking cessation in respiratory disease patients.

Acute effects of photobiomodulation therapy applied to respiratory muscles of chronic obstructive pulmonary disease patients: a double-blind, randomized, placebo-controlled crossover trial

To investigate the effects of photobiomodulation applied to respiratory muscles on lung function, thoracoabdominal mobility, respiratory muscle strength, and functional capacity in COPD patients. This is a randomized double-blind crossover clinical trial. Twelve male COPD patients participated in the study. Participants were randomly allocated to receive two photobiomodulation sessions, 1 week apart: (1) an effective photobiomodulation session applied at the main respiratory muscles by means of a cluster with 69 light-emitting diodes (LEDs), containing 35 red (630 ± 10 nm; 10 mW; 0.2 cm²) and 34 near-infrared (830 ± 20 nm; 10 mW; 0.2 cm²) LEDs and (2) a sham photobiomodulation session, following the same procedures without emitting light. The primary outcomes were pulmonary function (spirometric indexes); thoracoabdominal mobility (cirtometry); respiratory muscle strength (maximal respiratory pressures), assessed at three moments: (1) baseline, (2) 1 h after intervention, and (3) 24 h after intervention; and the functional capacity, assessed by the 6-min walk test (6MWT) at baseline and 24 h after intervention. No significant interactions were found for spirometric variables, maximal respiratory pressures, and cirtometry. However, there was a Time × Condition interaction (F = 18.63; p = 0.001; η²_p = 0.62) in the walked distance on the 6MWT, with a significant increase after photobiomodulation intervention (p < 0.01) compared with the baseline. Photobiomodulation applied to respiratory muscles was effective in improving acute functional capacity in COPD patients. To the best of our knowledge, this is the first study assessing the effects of photobiomodulation applied to respiratory muscles in patients with COPD.

Inhaled corticosteroids and risk of pneumonia in patients with chronic obstructive pulmonary disease: A meta-analysis of randomized controlled trials

OBJECTIVE

Inhaled corticosteroids (ICS) are generally used to treat patients with chronic obstructive pulmonary disease (COPD) who suffer from repeated exacerbations. Recently, it was reported that ICS treatment increased the risk of pneumonia in COPD patients. But it is controversial.The objective of this paper is to clarify the associations between ICS treatment and the risk of pneumonia in COPD patients.

METHODS

PubMed, Cochrane Library, Clinical Trials.gov, and Embase were searched from February 2019 to June 2019. Randomized clinical trials (RCTs) were incorporatedthat compared ICS with non-ICS treatment on the risk of pneumonia in COPD patients. Meta-analyses were conducted by the Peto and Mantel-Haenszel approaches with corresponding 95% CIs.

RESULTS

Twenty-five trials (N = 49,982 subjects) were included. Pooled results demonstrated a significantly increased risk of pneumonia with ICS use in COPD patients (RR, 1.59, 95% CI, 1.33-1.90; I² = 51%). ICS treatment also increased the risk of severe pneumonia (RR, 2.17, 95% CI, 1.47-3.22; I² = 29%). The results of subgroup analysis based on doses of ICS were consistent with the above. However, subgroup analyses based on types of ICS revealed that fluticasone therapy was associated with an increased risk of pneumonia but not budesonide. In addition, medium- and low-doses of budesonide treatment also did not increase the risk of pneumonia.

CONCLUSIONS

Use of ICS increases the risk of pneumonia in patients with COPD. The above is prominent for fluticasone-containing ICSs but not for budesonide-containing ICSs.

The potential of mesenchymal stem cell therapy for chronic lung disease

Introduction: Mesenchymal stem/stromal cells (MSCs) have been shown to improve lung function and survival in chronic inflammatory lung diseases, including asthma, chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), pulmonary arterial hypertension (PAH), and silicosis.Areas covered: This review covers rationale for the use of MSC therapy, along with preclinical studies and clinical trials with MSC therapy in chronic lung diseases.Expert opinion: MSC therapy holds promise for the treatment of chronic lung diseases, mainly when administered at early stages. In clinical trials, MSC administration was safe, but associated with limited effects on clinical outcomes. Further studies are required to elucidate unresolved issues, including optimal MSC source and dose, route of administration, and frequency (single vs. multiple-dose regimens). A better understanding of the mechanisms of MSC action, local microenvironment of each disease, and development of strategies to potentiate the beneficial effects of MSCs may improve outcomes.

Use High-Flow Nasal Cannula for Acute Respiratory Failure Patients in the Emergency Department: A Meta-Analysis Study

Objective

To evaluate the efficacy of high-flow nasal cannula (HFNC) therapy compared with conventional oxygen therapy (COT) or noninvasive ventilation (NIV) for the treatment of acute respiratory failure (ARF) in emergency departments (EDs).

Method

We comprehensively searched 3 databases (PubMed, EMBASE, and the Cochrane Library) for articles published from database inception to 12 July 2019. This study included only randomized controlled trials (RCTs) that were conducted in EDs and compared HFNC therapy with COT or NIV. The primary outcome was the intubation rate. The secondary outcomes were the mortality rate, intensive care unit (ICU) admission rate, ED discharge rate, need for escalation, length of ED stay, length of hospital stay, and patient dyspnea and comfort scores.

Result

Five RCTs (n = 775) were included. There was a decreasing trend regarding the application of HFNC therapy and the intubation rate, but the difference was not statistically significant (RR, 0.53; 95% CI, 0.26–1.09; p=0.08; I² = 0%). We found that compared with patients who underwent COT, those who underwent HFNC therapy had a reduced need for escalation (RR, 0.41; 95% CI, 0.22–0.78; p=0.006; I² = 0%), reduced dyspnea scores (MD −0.82, 95% CI −1.45 to −0.18), and improved comfort (SMD −0.76 SD, 95% CI −1.01 to −0.51). Compared with the COT group, the HFNC therapy group had a similar mortality rate (RR, 1.25; 95% CI, 0.79–1.99; p=0.34; I² = 0%), ICU admission rate (RR, 1.11; 95% CI, 0.58–2.12; p=0.76; I² = 0%), ED discharge rate (RR, 1.04; 95% CI, 0.63–1.72; p=0.87; I² = 0%), length of ED stay (MD 1.66, 95% CI −0.95 to 4.27), and hospital stay (MD 0.9, 95% CI −2.06 to 3.87).

Conclusion

Administering HFNC therapy in ARF patients in EDs might decrease the intubation rate compared with COT. In addition, it can decrease the need for escalation, decrease the patient's dyspnea level, and increase the patient's comfort level compared with COT.

Ten Research Questions for Improving COPD Care in the Next Decade

With the 60th anniversary of the CIBA symposium, it is worth evaluating research questions that should be prioritized in the future. Coming research initiatives can be summarized in 10 main areas. (1) From epidemiology the impact of new forms of electronic cigarettes on prevalence and mortality of COPD will be sought. (2) The study of the disease endotypes and its relationship phenotypes will have to be unraveled in the next decade. (3) Diagnosis of COPD faces several challenges opening the possibility of a change in the definition of the disease itself. (4) Patients' classification and risk stratification will need to be clarified and reassessed. (5) The asthma-COPD overlap dilemma will have to be clarified and define whether both conditions represent one only chronic airway disease again. (6) Integrating comorbidities in COPD care will be key in a progressively ageing population to improve clinical care in a chronic care model. (7) Nonpharmacological management have areas for research including pulmonary rehabilitation and vaccines. (8) Improving physical activity should focus research because of the clear prognostic impact. (9). Pharmacological therapies present several challenges including efficacy and safety issues with current medications and the development of biological therapy. (10) The definition, identification, categorization and specific therapy of exacerbations will also be an area of research development. During the next decade, we have a window of opportunity to address these research questions that will put us on the path for precision medicine.

Blood eosinophils as biomarkers of therapeutic response to chronic obstructive pulmonary disease: Still work in progress

Disease phenotyping is a key step towards an increasingly personalized approach to chronic obstructive pulmonary disease (COPD), leading to a more precise assessment, treatment and definition of disease outcomes. The search for biomarkers able to guide the identification of COPD phenotypes are of great importance for both researchers and clinicians. However, while several biomarkers of inflammation [e.g., peripheral blood eosinophils and fractional expired nitric oxide] have been identified and applied in asthma, none has been successfully linked to discrete clinical parameters of COPD such as exacerbations, natural progression, and treatment response or mortality risk. Recently, several studies have shown that blood eosinophils are a potential biomarker for patient subset stratification in COPD therapy. Here we reviewed the value of blood eosinophils in predicting the response of COPD patients to treatment.

Digital health for COPD care: the current state of play

Chronic obstructive pulmonary disease (COPD) imposes a huge burden to our healthcare systems and societies. To alleviate the burden, digital health-"the use of digital technologies for health"-has been recognized as a potential solution for improving COPD care at scale. The aim of this review is to provide an overview of digital health interventions in COPD care. We accordingly reviewed recent and emerging evidence on digital transformation approaches for COPD care focusing on (I) self-management, (II) in-hospital care, (III) post-discharge care, (IV) hospital-at-home, (V) ambient environment, and (VI) public health surveillance. The emerging approaches included digital-technology-enabled homecare programs, electronic records, big data analytics, and environment-monitoring applications. The digital health approaches of telemonitoring, telehealth and mHealth support the self-management, post-discharge care, and hospital-at-home strategy, with prospective effects on reducing acute COPD exacerbations and hospitalizations. Electronic records and classification tools have been implemented; and their effectiveness needs to be further evaluated in future studies. Air pollution concentrations in the ambient environment are associated with declined lung functions and increased risks for hospitalization and mortality. In all the digital transformation approaches, clinical evidence on reducing mortality, the ultimate goal of digital health intervention, is often inconsistent or insufficient. Digital health transformation provides great opportunities for clinical innovations and discovery of new intervention strategies. Further research remains needed for achieving reliable improvements in clinical outcomes and cost-benefits in future studies.