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Chang AB, Yerkovich ST, Baines KJ, Burr L, Champion A, Chatfield MD, Eg KP, Goyal V, Marsh RL, McCallum GB, McElrea M, McPhail S, Morgan LC, Morris PS, Nathan AM, O'Farrell H, Sanchez MO, Parsons M, Schultz A, Torzillo PJ, West NP, Versteegh L, Marchant JM, Grimwood K. Erdosteine in children and adults with bronchiectasis (BETTER trial): study protocol for a multicentre, double-blind, randomised controlled trial. BMJ Open Respir Res 2024; 11:e002216. [PMID: 38719503 PMCID: PMC11086403 DOI: 10.1136/bmjresp-2023-002216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/19/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Bronchiectasis is a worldwide chronic lung disorder where exacerbations are common. It affects people of all ages, but especially Indigenous populations in high-income nations. Despite being a major contributor to chronic lung disease, there are no licensed therapies for bronchiectasis and there remain relatively few randomised controlled trials (RCTs) conducted in children and adults. Our RCT will address some of these unmet needs by evaluating whether the novel mucoactive agent, erdosteine, has a therapeutic role in children and adults with bronchiectasis.Our primary aim is to determine in children and adults aged 2-49 years with bronchiectasis whether regular erdosteine over a 12-month period reduces acute respiratory exacerbations compared with placebo. Our primary hypothesis is that people with bronchiectasis who regularly use erdosteine will have fewer exacerbations than those receiving placebo.Our secondary aims are to determine the effect of the trial medications on quality of life (QoL) and other clinical outcomes (exacerbation duration, time-to-next exacerbation, hospitalisations, lung function, adverse events). We will also assess the cost-effectiveness of the intervention. METHODS AND ANALYSIS We are undertaking an international multicentre, double-blind, placebo-RCT to evaluate whether 12 months of erdosteine is beneficial for children and adults with bronchiectasis. We will recruit 194 children and adults with bronchiectasis to a parallel, superiority RCT at eight sites across Australia, Malaysia and Philippines. Our primary endpoint is the rate of exacerbations over 12 months. Our main secondary outcomes are QoL, exacerbation duration, time-to-next exacerbation, hospitalisations and lung function. ETHICS AND DISSEMINATION The Human Research Ethics Committees (HREC) of Children's Health Queensland (for all Australian sites), University of Malaya Medical Centre (Malaysia) and St. Luke's Medical Centre (Philippines) approved the study. We will publish the results and share the outcomes with the academic and medical community, funding and relevant patient organisations. TRIAL REGISTRATION NUMBER ACTRN12621000315819.
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Affiliation(s)
- Anne B Chang
- Department of Respiratory Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- The Australian Centre for Health Services Innovation (AusHSI), Queensland University of Technology, Brisbane, Queensland, Australia
- Child and Maternal Health Division and andand NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Stephanie T Yerkovich
- The Australian Centre for Health Services Innovation (AusHSI), Queensland University of Technology, Brisbane, Queensland, Australia
- Child and Maternal Health Division and andand NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Katherine J Baines
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
- Immune Health Research Program, Hunter Medical Research Institute, Newcastle, New South Wales, Australia
| | - Lucy Burr
- Mater Health Services, South Brisbane, Queensland, Australia
| | - Anita Champion
- Department of Pharmacy, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | | | - Kah P Eg
- Department of Paediatrics, Universiti Malaya Faculty of Medicine, Kuala Lumpur, Malaysia
| | - Vikas Goyal
- The Australian Centre for Health Services Innovation (AusHSI), Queensland University of Technology, Brisbane, Queensland, Australia
- Department of Paediatrics, Gold Coast Health, Gold Coast, Queensland, Australia
| | - Robyn L Marsh
- Child and Maternal Health Division and andand NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Darwin, Northern Territory, Australia
- School of Health Sciences, University of Tasmania, Launceston, Tasmania, Australia
| | - Gabrielle B McCallum
- Child and Maternal Health Division and andand NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Margaret McElrea
- The Australian Centre for Health Services Innovation (AusHSI), Queensland University of Technology, Brisbane, Queensland, Australia
| | - Steven McPhail
- The Australian Centre for Health Services Innovation (AusHSI), Queensland University of Technology, Brisbane, Queensland, Australia
- School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Brisbane, Queensland, Australia
- Metro South Health, Clinical Informatics Directorate, Woollongabba, Queensland, Australia
| | - Lucy C Morgan
- Department of Respiratory Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Peter S Morris
- Child and Maternal Health Division and andand NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Anne M Nathan
- Department of Paediatrics, Universiti Malaya Faculty of Medicine, Kuala Lumpur, Malaysia
| | - Hannah O'Farrell
- The Australian Centre for Health Services Innovation (AusHSI), Queensland University of Technology, Brisbane, Queensland, Australia
- Child and Maternal Health Division and andand NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Marion O Sanchez
- Section of Pediatric Pulmonology, Institute of Pulmonary Medicine, St. Luke's Medical Center, Quezon City, Philippines
| | - Marianne Parsons
- Parent Advisory Group, Cough, Asthma and Airways Group, Queensland University of Technology Faculty of Health, Kelvin Grove, Queensland, Australia
| | - André Schultz
- Department of Respiratory Medicine, Princess Margaret Hospital for Children, Perth, Western Australia, Australia
- Wal-yan Respiratory Research Centre, Telethon Kids Institute & Division of Paediatrics, Faculty of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Paul J Torzillo
- Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Sydney Medical School, The University of Sydney Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Nicholas P West
- School of Medicine and Dentistry, Griffith University Griffith Health, Gold Coast, Queensland, Australia
| | - Lesley Versteegh
- Child and Maternal Health Division and andand NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE), Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Julie M Marchant
- Department of Respiratory Medicine, Queensland Children's Hospital, South Brisbane, Queensland, Australia
- The Australian Centre for Health Services Innovation (AusHSI), Queensland University of Technology, Brisbane, Queensland, Australia
| | - Keith Grimwood
- School of Medicine and Dentistry, Griffith University Griffith Health, Gold Coast, Queensland, Australia
- Departments of Infectious Disease and Paediatrics, Gold Coast Health, Gold Coast, Queensland, Australia
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Hirons B, Rhatigan K, Kesavan H, Turner RD, Birring SS, Cho PSP. Cough in chronic lung disease: a state of the art review. J Thorac Dis 2023; 15:5823-5843. [PMID: 37969279 PMCID: PMC10636467 DOI: 10.21037/jtd-22-1776] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 09/01/2023] [Indexed: 11/17/2023]
Abstract
Chronic cough (CC; ≥8 weeks in duration) is a common and burdensome feature of respiratory diseases. The understanding of cough has progressed significantly in recent years, albeit largely in refractory (unexplained) chronic cough (RCC) in the absence of other respiratory conditions. The prevalence of CC in respiratory diseases is poorly described, but estimates have been reported: asthma (8-58%), chronic obstructive pulmonary disease (COPD; 10-74%), bronchiectasis (82-98%), interstitial lung disease (ILD; 50-89%) and sarcoidosis (3-64%). CC in respiratory conditions generally predicts impaired health status and more severe disease. It is associated with increased symptom burden and disease severity in asthma, COPD, bronchiectasis and ILD, higher exacerbation frequency in asthma and bronchiectasis, and increased mortality and lung transplantation in idiopathic pulmonary fibrosis (IPF). Physiologically, heightened cough reflex sensitivity (CRS) has been reported and postulated to be mechanistic in isolated RCC. Cough reflex hypersensitivity (CRH) has also been reported in asthma, COPD, bronchiectasis, ILD and sarcoidosis. Unlike recent advances in isolated RCC, there are limited studies and understanding of central cough neuropathways in other respiratory conditions. Of note, dysfunctional central voluntary cough suppression neuropathways and physiology were observed in isolation in RCC; cough suppression is preserved in COPD. Understanding in the mechanism of RCC cannot be simply extrapolated to other respiratory conditions. The restricted understanding of cough mechanisms in these conditions has limited cough-specific therapeutic options in this context. There is currently an unmet need to expand our understanding of cough in chronic respiratory conditions, both in order to improve the quality of life of patients, and to improve knowledge of cough in general. This review aims to describe the prevalence, impact, pathophysiology and management of CC in asthma, COPD, bronchiectasis, ILD and sarcoidosis.
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Affiliation(s)
- Barnaby Hirons
- Department of Respiratory Medicine, King’s College Hospital, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Katherine Rhatigan
- Department of Respiratory Medicine, King’s College Hospital, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Harini Kesavan
- Department of Respiratory Medicine, King’s College Hospital, London, UK
| | - Richard D. Turner
- Department of Respiratory Medicine, Gold Coast University Hospital, Queensland, Australia
- School of Medicine and Dentistry, Griffith University, Queensland, Australia
| | - Surinder S. Birring
- Department of Respiratory Medicine, King’s College Hospital, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Peter S. P. Cho
- Department of Respiratory Medicine, King’s College Hospital, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
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Cazzola M, Page CP, Wedzicha JA, Celli BR, Anzueto A, Matera MG. Use of thiols and implications for the use of inhaled corticosteroids in the presence of oxidative stress in COPD. Respir Res 2023; 24:194. [PMID: 37517999 PMCID: PMC10388561 DOI: 10.1186/s12931-023-02500-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/25/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Oxidative stress and persistent airway inflammation are thought to be important contributors to the development of chronic obstructive pulmonary disease (COPD). This review summarizes the evidence for targeting oxidative stress and inflammation in patients with COPD with mucolytic/antioxidant thiols and inhaled corticosteroids (ICS), either alone or in combination. MAIN BODY Oxidative stress is increased in COPD, particularly during acute exacerbations. It can be triggered by oxidant air pollutants and cigarette smoke and/or by endogenous reactive oxygen species (ROS) released from mitochondria and activated inflammatory, immune and epithelial cells in the airways, together with a reduction in endogenous antioxidants such as glutathione (GSH). Oxidative stress also drives chronic inflammation and disease progression in the airways by activating intracellular signalling pathways and the release of further inflammatory mediators. ICS are anti-inflammatory agents currently recommended for use with long-acting bronchodilators to prevent exacerbations in patients with moderate-to-severe COPD, especially those with eosinophilic airway inflammation. However, corticosteroids can also increase oxidative stress, which may in turn reduce corticosteroid sensitivity in patients by several mechanisms. Thiol-based agents such as erdosteine, N-acetyl L-cysteine (NAC) and S-carboxymethylcysteine (S-CMC) are mucolytic agents that also act as antioxidants. These agents may reduce oxidative stress directly through the free sulfhydryl groups, serving as a source of reducing equivalents and indirectly though intracellular GSH replenishment. Few studies have compared the effects of corticosteroids and thiol agents on oxidative stress, but there is some evidence for greater antioxidant effects when they are administered together. The current Global Initiative for Chronic Obstructive Lung Disease (GOLD) report supports treatment with antioxidants (erdosteine, NAC, S-CMC) in addition to standard-of-care therapy as they have been demonstrated to reduce COPD exacerbations. However, such studies have demonstrated that NAC and S-CMC reduced the exacerbation risk only in patients not treated with ICS, whereas erdosteine reduced COPD exacerbations irrespective of concomitant ICS use suggesting that erdosteine has additional pharmacological actions to ICS. CONCLUSIONS Further clinical trials of antioxidant agents with and without ICS are needed to better understand the place of thiol-based drugs in the treatment of patients with COPD.
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Affiliation(s)
- Mario Cazzola
- Chair of Respiratory Medicine, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy.
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, UK
| | - Jadwiga A Wedzicha
- Respiratory Medicine Division, National Heart and Lung Institute, Imperial College London, London, UK
| | - Bartolome R Celli
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Antonio Anzueto
- Department of Pulmonary Medicine and Critical Care, University of Texas Health and South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Maria Gabriella Matera
- Unit of Pharmacology, Department of Experimental Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
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Shah BK, Singh B, Wang Y, Xie S, Wang C. Mucus Hypersecretion in Chronic Obstructive Pulmonary Disease and Its Treatment. Mediators Inflamm 2023; 2023:8840594. [PMID: 37457746 PMCID: PMC10344637 DOI: 10.1155/2023/8840594] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/29/2023] [Accepted: 06/23/2023] [Indexed: 07/18/2023] Open
Abstract
Most patients diagnosed with chronic obstructive pulmonary disease (COPD) present with hallmark features of airway mucus hypersecretion, including cough and expectoration. Airway mucus function as a native immune system of the lung that severs to trap particulate matter and pathogens and allows them to clear from the lung via cough and ciliary transport. Chronic mucus hypersecretion (CMH) is the main factor contributing to the increased risk of morbidity and mortality in specific subsets of COPD patients. It is, therefore, primarily important to develop medications that suppress mucus hypersecretions in these patients. Although there have been some advances in COPD treatment, more work remains to be done to better understand the mechanism underlying airway mucus hypersecretion and seek more effective treatments. This review article discusses the structure and significance of mucus in the lungs focusing on gel-forming mucins and the impacts of CMH in the lungs. Furthermore, we summarize the article with pharmacological and nonpharmacological treatments as well as novel and interventional procedures to control CMH in COPD patients.
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Affiliation(s)
- Binay Kumar Shah
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
- Tongji University School of Medicine, Shanghai 200092, China
| | - Bivek Singh
- Tongji University School of Medicine, Shanghai 200092, China
| | - Yukun Wang
- Tongji University School of Medicine, Shanghai 200092, China
| | - Shuanshuan Xie
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
| | - Changhui Wang
- Department of Respiratory Medicine, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai 200072, China
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5
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Paraskevas T, Kantanis A, Karalis I, Michailides C, Karamouzos V, Koniari I, Pierrakos C, Velissaris D. N-acetylcysteine efficacy in patients hospitalized with COVID-19 pneumonia: a systematic review and meta-analysis. ROMANIAN JOURNAL OF INTERNAL MEDICINE = REVUE ROUMAINE DE MEDECINE INTERNE 2023; 61:41-52. [PMID: 36627753 DOI: 10.2478/rjim-2023-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND N-acetylcysteine (NAC) is a mucolytic agents with anti-inflammatory properties that has been suggested as an adjunctive therapy in patients with COVID-19 pneumonia. OBJECTIVES We conducted a systematic review and meta-analysis to evaluate available evidence on the possible beneficial effects of NAC on SARS-CoV-2 infection. METHODS In September 2022, we conducted a comprehensive search on Pubmed/Medline and Embase on randomized controlled trials (RCTs) and observational studies on NAC in patients with COVID-19 pneumonia. Study selection, data extraction and risk of bias assessment was performed by two independent authors. RCTs and observational studies were analyzed separately. RESULTS We included 3 RCTs and 5 non-randomized studies on the efficacy of NAC in patients with COVID-19, enrolling 315 and 20826 patients respectively. Regarding in-hospital mortality, the summary effect of all RCTs was OR: 0.85 (95% CI: 0.43 to 1.67, I2=0%) and for non-randomized studies OR: 1.02 (95% CI: 0.47 to 2.23, I2=91%). Need for ICU admission was only reported by 1 RCT (OR: 0.86, 95% CI:0.44-1.69, p=0.66), while all included RCTs reported need for invasive ventilation (OR:0.91, 95% CI:0.54 to 1.53, I2=0). Risk of bias was low for all included RCTs, but certainty of evidence was very low for all outcomes due to serious imprecision and indirectness. CONCLUSION The certainty of evidence in the included studies was very low, thus recommendations for clinical practice cannot be yet made. For all hard clinical outcomes point estimates in RCTs are close to the line of no effect, while observational studies have a high degree of heterogeneity with some of them suggesting favorable results in patients receiving NAC. More research is warranted to insure that NAC is both effective and safe in patients with COVID-19 pneumonia.
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Affiliation(s)
| | - Anastasios Kantanis
- Department of General Practice and Family Medicine, General University Hospital of Patras, Patras, Greece
| | - Iosif Karalis
- Department of Internal Medicine, General University Hospital of Patras, Patras, Greece
| | - Christos Michailides
- Department of Internal Medicine, General University Hospital of Patras, Patras, Greece
| | | | - Ioanna Koniari
- Cardiology Department, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Charalampos Pierrakos
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Dimitrios Velissaris
- Department of Internal Medicine, General University Hospital of Patras, Patras, Greece
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Lewis A, Osadnik CR. Changing practice by changing pressures: a role for oscillating positive expiratory pressure in chronic obstructive pulmonary disease. Thorax 2023; 78:113-115. [PMID: 36167723 DOI: 10.1136/thorax-2022-219451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2022] [Indexed: 01/17/2023]
Affiliation(s)
- Adam Lewis
- Department of Health Sciences, Brunel University London, Uxbridge, UK
| | - Christian Robert Osadnik
- Department of Physiotherapy, Monash University Faculty of Medicine Nursing and Health Sciences, Clayton, Victoria, Australia
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Papadopoulou E, Hansel J, Lazar Z, Kostikas K, Tryfon S, Vestbo J, Mathioudakis AG. Mucolytics for acute exacerbations of chronic obstructive pulmonary disease: a meta-analysis. Eur Respir Rev 2023; 32:32/167/220141. [PMID: 36697209 PMCID: PMC9879332 DOI: 10.1183/16000617.0141-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/27/2022] [Indexed: 01/27/2023] Open
Abstract
This meta-analysis explored the safety and effectiveness of mucolytics as an add-on treatment for chronic obstructive pulmonary disease (COPD) exacerbations. Based on a pre-registered protocol and following Cochrane methods, we systematically searched for relevant randomised or quasi-randomised controlled trials (RCTs). We used the Risk of Bias v2 tool for appraising the studies and performed random-effect meta-analyses when appropriate. We assessed certainty of evidence using GRADE. This meta-analysis included 24 RCTs involving 2192 patients with COPD exacerbations, entailing at least some concerns of methodological bias. We demonstrated with moderate certainty that mucolytics increase the rate of treatment success (relative risk 1.37, 95% CI 1.08-1.73, n=383), while they also exert benefits on overall symptom scores (standardised mean difference 0.86, 95% CI 0.63-1.09, n=316), presence of cough at follow-up (relative risk 1.93, 95% CI 1.15-3.23) and ease of expectoration (relative risk 2.94, 95% CI 1.68-5.12). Furthermore, low or very low certainty evidence suggests mucolytics may also reduce future risk of exacerbations and improve health-related quality of life, but do not impact on breathlessness, length of hospital stay, indication for higher level of care or serious adverse events. Overall, mucolytics could be considered for COPD exacerbation management. These findings should be validated in further, rigorous RCTs.
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Affiliation(s)
- Efthymia Papadopoulou
- Pulmonology Department, General Hospital of Thessaloniki ‘G. Papanikolaou’, Thessaloniki, Greece
| | - Jan Hansel
- North West School of Intensive Care Medicine, Health Education England – North West, Manchester, UK
| | - Zsofia Lazar
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Konstantinos Kostikas
- Respiratory Medicine Department, University of Ioannina School of Medicine, Ioannina, Greece
| | - Stavros Tryfon
- Pulmonology Department, General Hospital of Thessaloniki ‘G. Papanikolaou’, Thessaloniki, Greece
| | - Jørgen Vestbo
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK,North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Alexander G. Mathioudakis
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester, UK,North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK,Corresponding author: Alexander G. Mathioudakis ()
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McElrea E, Chang AB, Yerkovich S, O'Farrell HE, Marchant JM. Mucolytics for children with chronic suppurative lung disease. Hippokratia 2022. [DOI: 10.1002/14651858.cd015313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Esther McElrea
- NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE) and Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation; Queensland University of Technology; Brisbane Australia
| | - Anne B Chang
- NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE) and Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation; Queensland University of Technology; Brisbane Australia
- Department of Respiratory and Sleep Medicine; Queensland Children's Hospital; Brisbane Australia
- Menzies School of Health Research; Charles Darwin University; Darwin Australia
| | - Stephanie Yerkovich
- NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE) and Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation; Queensland University of Technology; Brisbane Australia
- Menzies School of Health Research; Charles Darwin University; Darwin Australia
| | - Hannah E O'Farrell
- NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE) and Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation, Queensland University of Technology; Brisbane Australia
- Menzies School of Health Research, Charles Darwin University; Darwin Australia
| | - Julie M Marchant
- NHMRC Centre for Research Excellence in Paediatric Bronchiectasis (AusBREATHE) and Australian Centre for Health Services Innovation @ Centre for Healthcare Transformation; Queensland University of Technology; Brisbane Australia
- Department of Respiratory and Sleep Medicine, Queensland Children's Hospital; Brisbane Australia
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Pace E, Cerveri I, Lacedonia D, Paone G, Sanduzzi Zamparelli A, Sorbo R, Allegretti M, Lanata L, Scaglione F. Clinical Efficacy of Carbocysteine in COPD: Beyond the Mucolytic Action. Pharmaceutics 2022; 14:pharmaceutics14061261. [PMID: 35745833 PMCID: PMC9227620 DOI: 10.3390/pharmaceutics14061261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 12/14/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease with a versatile and complicated profile, being the fourth most common single cause of death worldwide. Several research groups have been trying to identify possible therapeutic approaches to treat COPD, such as the use of mucoactive drugs, which include carbocysteine. However, their role in the treatment of patients suffering from COPD remains controversial due to COPD's multifaceted profile. In the present review, 72 articles, published in peer-reviewed journals with high impact factors, are analyzed in order to provide significant insight and increase the knowledge about COPD considering the important contribution of carbocysteine in reducing exacerbations via multiple mechanisms. Carbocysteine is in fact able to modulate mucins and ciliary functions, and to counteract viral and bacterial infections as well as oxidative stress, offering cytoprotective effects. Furthermore, carbocysteine improves steroid responsiveness and exerts anti-inflammatory activity. This analysis demonstrates that the use of carbocysteine in COPD patients represents a well-tolerated treatment with a favorable safety profile, and might contribute to a better quality of life for patients suffering from this serious illness.
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Affiliation(s)
- Elisabetta Pace
- Institute of Translational Pharmacology (IFT), National Research Council, Via Ugo la Malfa, 153, 90146 Palermo, Italy;
| | - Isa Cerveri
- Department of Internal Medicine and Medical Therapy, University of Pavia, 27100 Pavia, Italy;
| | - Donato Lacedonia
- Institute of Respiratory Diseases, Department of Medical and Surgical Sciences, University of Foggia, 71122 Foggia, Italy;
| | - Gregorino Paone
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, 00185 Rome, Italy;
| | - Alessandro Sanduzzi Zamparelli
- UOC Pneumotisiologia, Scuola di Specializzazione in Malattie Respiratorie, Università degli Studi di Napoli Federico II A.O.R.N. Monaldi-Cotugno-CTO Piazzale Ettore Ruggieri, 80138 Napoli, Italy;
| | - Rossella Sorbo
- Dompé Farmaceutici SpA, 20122 Milan, Italy; (R.S.); (M.A.); (L.L.)
| | | | - Luigi Lanata
- Dompé Farmaceutici SpA, 20122 Milan, Italy; (R.S.); (M.A.); (L.L.)
| | - Francesco Scaglione
- Department of Oncology and Onco-Hematology, University of Milan, 20122 Milan, Italy
- Correspondence:
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Barnes PJ. Oxidative Stress in Chronic Obstructive Pulmonary Disease. Antioxidants (Basel) 2022; 11:antiox11050965. [PMID: 35624831 PMCID: PMC9138026 DOI: 10.3390/antiox11050965] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/06/2022] [Accepted: 05/11/2022] [Indexed: 12/16/2022] Open
Abstract
There is a marked increase in oxidative stress in the lungs of patients with COPD, as measured by increased exhaled 8-isoprostane, ethane, and hydrogen peroxide in the breath. The lung may be exposed to exogenous oxidative stress from cigarette smoking and indoor or outdoor air pollution and to endogenous oxidative stress from reactive oxygen species released from activated inflammatory cells, particularly neutrophils and macrophages, in the lungs. Oxidative stress in COPD may be amplified by a reduction in endogenous antioxidants and poor intake of dietary antioxidants. Oxidative stress is a major driving mechanism of COPD through the induction of chronic inflammation, induction of cellular senescence and impaired autophagy, reduced DNA repair, increased autoimmunity, increased mucus secretion, and impaired anti-inflammatory response to corticosteroids. Oxidative stress, therefore, drives the pathology of COPD and may increase disease progression, amplify exacerbations, and increase comorbidities through systemic oxidative stress. This suggests that antioxidants may be effective as disease-modifying treatments. Unfortunately, thiol-based antioxidants, such as N-acetylcysteine, have been poorly effective, as they are inactivated by oxidative stress in the lungs, so there is a search for more effective and safer antioxidants. New antioxidants in development include mitochondria-targeted antioxidants, NOX inhibitors, and activators of the transcription factor Nrf2, which regulates several antioxidant genes.
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Affiliation(s)
- Peter J Barnes
- National Heart and Lung Institute, Imperial College London, London SW5 9LH, UK
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11
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Chen J, Zhang H, Wang S, Du Y, Wei B, Wu Q, Wang H. Inhibitors of Bacterial Extracellular Vesicles. Front Microbiol 2022; 13:835058. [PMID: 35283837 PMCID: PMC8905621 DOI: 10.3389/fmicb.2022.835058] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/25/2022] [Indexed: 01/22/2023] Open
Abstract
Both Gram-positive and Gram-negative bacteria can secrete extracellular vesicles (EVs), which contain numerous active substances. EVs mediate bacterial interactions with their hosts or other microbes. Bacterial EVs play a double-edged role in infections through various mechanisms, including the delivery of virulence factors, modulating immune responses, mediating antibiotic resistance, and inhibiting competitive microbes. The spread of antibiotic resistance continues to represent a difficult clinical challenge. Therefore, the investigation of novel therapeutics is a valuable research endeavor for targeting antibiotic-resistant bacterial infections. As a pathogenic substance of bacteria, bacterial EVs have gained increased attention. Thus, EV inhibitors are expected to function as novel antimicrobial agents. The inhibition of EV production, EV activity, and EV-stimulated inflammation are considered potential pathways. This review primarily introduces compounds that effectively inhibit bacterial EVs and evaluates the prospects of their application.
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Affiliation(s)
- Jianwei Chen
- College of Pharmaceutical Science and Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, Hangzhou, China.,State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Taipa, Macau SAR, China
| | - Hongfang Zhang
- College of Pharmaceutical Science and Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, Hangzhou, China
| | - Siqi Wang
- College of Pharmaceutical Science and Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, Hangzhou, China
| | - Yujie Du
- College of Pharmaceutical Science and Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, Hangzhou, China
| | - Bin Wei
- College of Pharmaceutical Science and Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, Hangzhou, China
| | - Qiang Wu
- State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Taipa, Macau SAR, China
| | - Hong Wang
- College of Pharmaceutical Science and Collaborative Innovation Center of Yangtze River Delta Region Green Pharmaceuticals, Zhejiang University of Technology, Hangzhou, China.,Key Laboratory of Marine Fishery Resources Exploitment and Utilization of Zhejiang Province, Zhejiang University of Technology, Hangzhou, China
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12
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Uwagboe I, Adcock IM, Lo Bello F, Caramori G, Mumby S. New drugs under development for COPD. Minerva Med 2022; 113:471-496. [PMID: 35142480 DOI: 10.23736/s0026-4806.22.08024-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The characteristic features of chronic obstructive pulmonary disease (COPD) include inflammation and remodelling of the lower airways and lung parenchyma together with activation of inflammatory and immune processes. Due to the increasing habit of cigarette smoking worldwide COPD prevalence is increasing globally. Current therapies are unable to prevent COPD progression in many patients or target many of its hallmark characteristics which may reflect the lack of adequate biomarkers to detect the heterogeneous clinical and molecular nature of COPD. In this chapter we review recent molecular data that may indicate novel pathways that underpin COPD subphenotypes and indicate potential improvements in the classes of drugs currently used to treat COPD. We also highlight the evidence for new drugs or approaches to treat COPD identified using molecular and other approaches including kinase inhibitors, cytokine- and chemokine-directed biologicals and small molecules, antioxidants and redox signalling pathway inhibitors, inhaled anti-infectious agents and senolytics. It is important to consider the phenotypes/molecular endotypes of COPD patients together with specific outcome measures to target new therapies to particular COPD subtypes. This will require greater understanding of COPD molecular pathologies and a focus on biomarkers of predicting disease subsets and responder/non-responder populations.
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Affiliation(s)
- Isabel Uwagboe
- Airways Disease Section, National Heart and Lung Institute, Imperial College, London, UK
| | - Ian M Adcock
- Airways Disease Section, National Heart and Lung Institute, Imperial College, London, UK -
| | - Federica Lo Bello
- Pneumologia, Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali (BIOMORF), Università di Messina, Messina, Italy
| | - Gaetano Caramori
- Pneumologia, Dipartimento di Scienze Biomediche, Odontoiatriche e delle Immagini Morfologiche e Funzionali (BIOMORF), Università di Messina, Messina, Italy
| | - Sharon Mumby
- Airways Disease Section, National Heart and Lung Institute, Imperial College, London, UK
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13
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Jelić D, Papović S, Vraneš M, Gadžurić S, Berto S, Alladio E, Gajić D, Janković B. Thermo-Analytical and Compatibility Study with Mechanistic Explanation of Degradation Kinetics of Ambroxol Hydrochloride Tablets under Non-Isothermal Conditions. Pharmaceutics 2021; 13:pharmaceutics13111910. [PMID: 34834325 PMCID: PMC8621728 DOI: 10.3390/pharmaceutics13111910] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 10/22/2021] [Accepted: 11/08/2021] [Indexed: 11/16/2022] Open
Abstract
Ambroxol hydrochloride (AMB), used as a broncho secretolytic and an expectorant drug, is a semi-synthetic derivative of vasicine obtained from the Indian shrub Adhatoda vasica. It is a metabolic product of bromhexine. The paper provides comprehensive and detailed research on ambroxol hydrochloride, gives information on thermal stability, the mechanism of AMB degradation, and data of practical interest for optimization of formulation that contains AMB as an active compound. Investigation on pure AMB and in commercial formulation Flavamed® tablet (FT), which contains AMB as an active compound, was performed systematically using thermal and spectroscopic methods, along with a sophisticated and practical statistical approach. AMB proved to be a heat-stable and humidity-sensitive drug. For its successful formulation, special attention should be addressed to excipients since it was found that polyvinyl pyrrolidone and Mg stearate affect the thermal stability of AMB. At the same time, lactose monohydrate contributes to faster degradation of AMB and change in decomposition mechanism. It was found that the n-th order kinetic model mechanistically best describes the decomposition process of pure AMB and in Flavamed® tablets.
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Affiliation(s)
- Dijana Jelić
- Chemistry Department, Faculty of Sciences and Mathematics, University of Banja Luka, 78 000 Banja Luka, Bosnia and Herzegovina;
- Correspondence:
| | - Snežana Papović
- Department of Chemistry, Biochemistry and Environmental Protection, Faculty of Sciences, University of Novi Sad, 21 000 Novi Sad, Serbia; (S.P.); (M.V.); (S.G.)
| | - Milan Vraneš
- Department of Chemistry, Biochemistry and Environmental Protection, Faculty of Sciences, University of Novi Sad, 21 000 Novi Sad, Serbia; (S.P.); (M.V.); (S.G.)
| | - Slobodan Gadžurić
- Department of Chemistry, Biochemistry and Environmental Protection, Faculty of Sciences, University of Novi Sad, 21 000 Novi Sad, Serbia; (S.P.); (M.V.); (S.G.)
| | - Silvia Berto
- Department of Chemistry, University of Turin, 10125 Turin, Italy; (S.B.); (E.A.)
| | - Eugenio Alladio
- Department of Chemistry, University of Turin, 10125 Turin, Italy; (S.B.); (E.A.)
| | - Dragana Gajić
- Chemistry Department, Faculty of Sciences and Mathematics, University of Banja Luka, 78 000 Banja Luka, Bosnia and Herzegovina;
| | - Bojan Janković
- Department of Physical Chemistry, “Vinča” Institute of Nuclear Sciences—National Institute of the Republic of Serbia, University of Belgrade, 11 000 Belgrade, Serbia;
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14
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Kurukulaaratchy RJ, Rupani H, Fong WCG, Kyyaly A. A Role for Mucolytics and Expectorants in Aiding Inhaled Therapies in Asthma? [Response To Letter]. J Inflamm Res 2021; 14:5183-5185. [PMID: 34675596 PMCID: PMC8517631 DOI: 10.2147/jir.s341547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 12/20/2022] Open
Affiliation(s)
- Ramesh J Kurukulaaratchy
- Department of Respiratory Medicine, University Hospitals Southampton NHS Foundation Trust, Southampton, UK.,Clinical and Experimental Sciences, University of Southampton, Southampton, UK.,David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight, UK.,NIHR Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Hitasha Rupani
- Department of Respiratory Medicine, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Wei Chern Gavin Fong
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK.,David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight, UK
| | - Aref Kyyaly
- Clinical and Experimental Sciences, University of Southampton, Southampton, UK.,David Hide Asthma and Allergy Research Centre, Isle of Wight NHS Trust, Isle of Wight, UK
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15
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Janjua S, Pike KC, Carr R, Coles A, Fortescue R, Batavia M. Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD). Cochrane Database Syst Rev 2021; 9:CD013381. [PMID: 34496032 PMCID: PMC8425588 DOI: 10.1002/14651858.cd013381.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a chronic lung condition characterised by persistent respiratory symptoms and limited lung airflow, dyspnoea and recurrent exacerbations. Suboptimal therapy or non-adherence may result in limited effectiveness of pharmacological treatments and subsequently poor health outcomes. OBJECTIVES To determine the efficacy and safety of interventions intended to improve adherence to single or combined pharmacological treatments compared with usual care or interventions that are not intended to improve adherence in people with COPD. SEARCH METHODS We identified randomised controlled trials (RCTs) from the Cochrane Airways Trials Register, CENTRAL, MEDLINE and Embase (search date 1 May 2020). We also searched web-based clinical trial registers. SELECTION CRITERIA RCTs included adults with COPD diagnosed by established criteria (e.g. Global Initiative for Obstructive Lung Disease). Interventions included change to pharmacological treatment regimens, adherence aids, education, behavioural or psychological interventions (e.g. cognitive behavioural therapy), communication or follow-up by a health professional (e.g. telephone, text message or face-to-face), multi-component interventions, and interventions to improve inhaler technique. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. Working in pairs, four review authors independently selected trials for inclusion, extracted data and assessed risk of bias. We assessed confidence in the evidence for each primary outcome using GRADE. Primary outcomes were adherence, quality of life and hospital service utilisation. Adherence measures included the Adherence among Patients with Chronic Disease questionnaire (APCD). Quality of life measures included the St George's Respiratory Questionnaire (SGRQ), COPD Assessment Test (CAT) and Clinical COPD Questionnaire (CCQ). MAIN RESULTS We included 14 trials (2191 participants) in the analysis with follow-up ranging from six to 52 weeks. Age ranged from 54 to 75 years, and COPD severity ranged from mild to very severe. Trials were conducted in the USA, Spain, Germany, Japan, Jordan, Northern Ireland, Iran, South Korea, China and Belgium. Risk of bias was high due to lack of blinding. Evidence certainty was downgraded due to imprecision and small participant numbers. Single component interventions Six studies (55 to 212 participants) reported single component interventions including changes to pharmacological treatment (different roflumilast doses or different inhaler types), adherence aids (Bluetooth inhaler reminder device), educational (comprehensive verbal instruction), behavioural or psychological (motivational interview). Change in dose of roflumilast may result in little to no difference in adherence (odds ratio (OR) 0.67, 95% confidence interval (CI) 0.22 to 1.99; studies = 1, participants = 55; low certainty). A Bluetooth inhaler reminder device did not improve adherence, but comprehensive verbal instruction from a health professional did improve mean adherence (prescription refills) (mean difference (MD) 1.00, 95% CI 0.46 to 1.54). Motivational interview improved mean adherence scores on the APCD scale (MD 22.22, 95% CI 8.42 to 36.02). Use of a single inhaler compared to two separate inhalers may have little to no impact on quality of life (SGRQ; MD 0.80, 95% CI -3.12 to 4.72; very low certainty). A Bluetooth inhaler monitoring device may provide a small improvement in quality of life on the CCQ (MD 0.40, 95% CI 0.07 to 0.73; very low certainty). Single inhaler use may have little to no impact on the number of people admitted to hospital compared to two separate inhalers (OR 1.47, 95% CI 0.75 to 2.90; very low certainty). Single component interventions may have little to no impact on the number of people expereincing adverse events (very low certainty evidence from studies of a change in pharmacotherapy or use of adherence aids). A change in pharmacotherapy may have little to no impact on exacerbations or deaths (very low certainty). Multi-component interventions Eight studies (30 to 734 participants) reported multi-component interventions including tailored care package that included adherence support as a key component or included inhaler technique as a component. A multi-component intervention may result in more people adhering to pharmacotherapy compared to control at 40.5 weeks (risk ratio (RR) 1.37, 95% CI 1.18 to 1.59; studies = 4, participants = 446; I2 = 0%; low certainty). There may be little to no impact on quality of life (SGRQ, Chronic Respiratory Disease Questionnaire, CAT) (studies = 3; low to very low certainty). Multi-component interventions may help to reduce the number of people admitted to hospital for any cause (OR 0.37, 95% CI 0.22 to 0.63; studies = 2, participants = 877; low certainty), or COPD-related hospitalisations (OR 0.15, 95% CI 0.07 to 0.34; studies = 2, participants = 220; moderate certainty). There may be a small benefit on people experiencing severe exacerbations. There may be little to no effect on adverse events, serious adverse events or deaths, but events were infrequently reported and were rare (low to very certainty). AUTHORS' CONCLUSIONS Single component interventions (e.g. education or motivational interviewing provided by a health professional) can help to improve adherence to pharmacotherapy (low to very low certainty). There were slight improvements in quality of life with a Bluetooth inhaler device, but evidence is from one study and very low certainty. Change to pharmacotherapy (e.g. single inhaler instead of two, or different doses of roflumilast) has little impact on hospitalisations or exacerbations (very low certainty). There is no difference in people experiencing adverse events (all-cause or COPD-related), or deaths (very low certainty). Multi-component interventions may improve adherence with education, motivational or behavioural components delivered by health professionals (low certainty). There is little to no impact on quality of life (low to very low certainty). They may help reduce the number of people admitted to hospital overall (specifically pharmacist-led approaches) (low certainty), and fewer people may have COPD-related hospital admissions (moderately certainty). There may be a small reduction in people experiencing severe exacerbations, but evidence is from one study (low certainty). Limited evidence found no difference in people experiencing adverse events, serious adverse events or deaths (low to very low certainty). The evidence presented should be interpreted with caution. Larger studies with more intervention types, especially single interventions, are needed. It is unclear which specific COPD subgroups would benefit, therefore discussions between health professionals and patients may help to determine whether they will help to improve health outcomes.
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Affiliation(s)
- Sadia Janjua
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | | | - Robin Carr
- 28 Beaumont Street Medical Practice, Oxford, UK
| | - Andy Coles
- COPD Patient Advisory Group, St George's, University of London, London, UK
| | - Rebecca Fortescue
- Cochrane Airways, Population Health Research Institute, St George's, University of London, London, UK
| | - Mitchell Batavia
- Steinhardt School of Culture, Education and Human Development, Department of Physical Therapy, New York University, New York, NY, USA
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16
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Zhu L, Xu F, Kang X, Zhou J, Yao Q, Lin Y, Zhang W. The antioxidant N-acetylcysteine promotes immune response and inhibits epithelial-mesenchymal transition to alleviate pulmonary fibrosis in chronic obstructive pulmonary disease by suppressing the VWF/p38 MAPK axis. Mol Med 2021; 27:97. [PMID: 34479474 PMCID: PMC8414683 DOI: 10.1186/s10020-021-00342-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background/aim N-Acetylcysteine (NAC) demonstrates applications in the prevention of exacerbation of chronic obstructive pulmonary disease (COPD). COPD is often characterized by fibrosis of the small airways. This study aims at investigating the physiological mechanisms by which NAC might mediate the pulmonary fibrosis in COPD. Methods A total of 10 non-smokers without COPD and 10 smokers with COPD were recruited in this study, and COPD rat models were established. Cigarette smoke extract (CSE) cell models were constructed. The gain- or loss-of-function experiments were adopted to determine the expression of VWF and the extent of p38 MAPK phosphorylation, levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and immunoglobulins (IgG, IgM and IgA) in the serum of COPD rats and supernatant of alveolar epithelial cells and to detect cell invasion and migration and the ratio of CD3+, CD4+, CD8+ and CD4+/CD8+T lymphocytes. Results Expression of VWF and the extent of p38 MAPK phosphorylation were increased in COPD. NAC inhibited p38 MAPK phosphorylation by reducing the VWF expression. NAC could inhibit cell migration and invasion, elevate E-cadherin expression, the ratio of CD3+, CD4+, CD8+ and CD4+/CD8+T lymphocytes, and levels of IgG, IgA, and IgM, and reduce N-cadherin expression and levels of IL-6 and TNF-α in CSE cells and serum of COPD rats. NAC promoted immune response and suppressed epithelial-mesenchymal transformation (EMT) to relieve COPD-induced pulmonary fibrosis in vitro and in vivo by inhibiting the VWF/p38 MAPK axis. Conclusions Collectively, NAC could ameliorate COPD-induced pulmonary fibrosis by promoting immune response and inhibiting EMT process via the VWF/p38 MAPK axis, therefore providing us with a potential therapeutic target for treating COPD. Supplementary Information The online version contains supplementary material available at 10.1186/s10020-021-00342-y.
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Affiliation(s)
- Lanlan Zhu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Street, Nanchang, 330000, Jiangxi, People's Republic of China
| | - Fei Xu
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Street, Nanchang, 330000, Jiangxi, People's Republic of China
| | - Xiuhua Kang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Street, Nanchang, 330000, Jiangxi, People's Republic of China
| | - Jing Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Street, Nanchang, 330000, Jiangxi, People's Republic of China
| | - Qinqin Yao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Street, Nanchang, 330000, Jiangxi, People's Republic of China
| | - Yang Lin
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Street, Nanchang, 330000, Jiangxi, People's Republic of China
| | - Wei Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanchang University, No. 17, Yongwaizheng Street, Nanchang, 330000, Jiangxi, People's Republic of China.
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17
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Mucus, Microbiomes and Pulmonary Disease. Biomedicines 2021; 9:biomedicines9060675. [PMID: 34199312 PMCID: PMC8232003 DOI: 10.3390/biomedicines9060675] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/31/2021] [Accepted: 06/09/2021] [Indexed: 12/20/2022] Open
Abstract
The respiratory tract harbors a stable and diverse microbial population within an extracellular mucus layer. Mucus provides a formidable defense against infection and maintaining healthy mucus is essential to normal pulmonary physiology, promoting immune tolerance and facilitating a healthy, commensal lung microbiome that can be altered in association with chronic respiratory disease. How one maintains a specialized (healthy) microbiome that resists significant fluctuation remains unknown, although smoking, diet, antimicrobial therapy, and infection have all been observed to influence microbial lung homeostasis. In this review, we outline the specific role of polymerizing mucin, a key functional component of the mucus layer that changes during pulmonary disease. We discuss strategies by which mucin feed and spatial orientation directly influence microbial behavior and highlight how a compromised mucus layer gives rise to inflammation and microbial dysbiosis. This emerging field of respiratory research provides fresh opportunities to examine mucus, and its function as predictors of infection risk or disease progression and severity across a range of chronic pulmonary disease states and consider new perspectives in the development of mucolytic treatments.
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18
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Sarwar MR, McDonald VM, Abramson MJ, Paul E, George J. Treatable traits in an English cohort: prevalence and predictors of future decline in lung function and quality of life in COPD. ERJ Open Res 2021; 7:00934-2020. [PMID: 34084787 PMCID: PMC8165376 DOI: 10.1183/23120541.00934-2020] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/29/2021] [Indexed: 12/04/2022] Open
Abstract
Background “Treatable traits (TTs)” is a precision medicine approach for facilitating multidimensional assessment of every patient with chronic airway disease, in order to determine the core traits associated with disease outcomes where targeted treatments may be applied. Objectives To determine the prevalence of TTs in chronic obstructive pulmonary disease (COPD) and which traits predict future decline in lung function and quality of life (QoL). Methods A 4-year longitudinal evaluation was conducted using data from 3726 participants in the English Longitudinal Study of Ageing (ELSA). TTs were identified based on published recommendations. Traits that predicted decline in lung function and QoL were analysed using generalised estimating equations. Results Overall, 21 TTs, including pulmonary (n=5), extra-pulmonary (n=13) and behavioural/lifestyle risk-factors (n=3) were identified. In multivariate analyses, the traits of chronic bronchitis (β −0.186, 95% CI −0.290 to −0.082), breathlessness (β −0.093, 95% CI −0.164 to −0.022), underweight (β −0.216, 95% CI −0.373 to −0.058), sarcopenia (β −0.162, 95% CI −0.262 to −0.061) and current smoking (β −0.228, 95% CI −0.304 to −0.153) predicted decline in forced expiratory volume in 1 s (FEV1). Of the seven traits that predicted decline in QoL, depression (β −7.19, 95% CI −8.81 to −5.57) and poor family and social support (β −5.12, 95% CI −6.65 to −3.59) were the strongest. Conclusion The core TTs of COPD associated with a decline in lung function and QoL were identified. Targeting these impactful traits with individualised treatment using a precision medicine approach may improve outcomes in people with COPD. Targeting the traits of chronic bronchitis, breathlessness, underweight, sarcopenia, depression, smoking, and poor family and social support may significantly improve health outcomes in people with COPDhttps://bit.ly/3cLHIPV
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Affiliation(s)
- Muhammad Rehan Sarwar
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | - Vanessa Marie McDonald
- National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and Centre of Excellence in Treatable Traits, The University of Newcastle, Callaghan, Australia.,The Priority Research Centre for Healthy Lungs, School of Nursing and Midwifery, Callaghan, Australia.,Dept of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, Australia
| | - Michael John Abramson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Eldho Paul
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Johnson George
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
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19
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Mandru R, Zhou CY, Pauley R, Burkes RM. Considerations for and Mechanisms of Adjunct Therapy in COPD. J Clin Med 2021; 10:jcm10061225. [PMID: 33809583 PMCID: PMC7999347 DOI: 10.3390/jcm10061225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 12/26/2022] Open
Abstract
Inhaled bronchodilators and corticosteroids, when indicated, form the backbone of COPD therapy. However, over the last decade there has been an emergence of adjunct therapies in oral or inhaled form that are now part of the therapeutic approach to COPD. While these therapies have shown to be beneficial when used in the appropriate instances, there are particular considerations that need to be minded when using these therapies. This review article discussed the mechanism of roflumilast, macrolide antibiotics, other chronic antibiotic regimens, vitamin D supplementation, oral corticosteroids, n-acetylcysteine, and nebulized hypertonic saline, the clinical data behind each of these therapies, adverse events associated with therapy, and the expert recommendations for their utilization. Our goal is to provide a brief but informative and clinically useful review of commonly encountered therapies used in advanced COPD.
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Affiliation(s)
- Rachana Mandru
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH 45221, USA;
| | - Christine Y. Zhou
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (C.Y.Z.); (R.P.)
| | - Rachel Pauley
- Department of Internal Medicine, University of Cincinnati, Cincinnati, OH 45221, USA; (C.Y.Z.); (R.P.)
| | - Robert M. Burkes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, OH 45221, USA;
- Correspondence:
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20
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Dilly AK, Honick BD, Frederick R, Elapavaluru A, Velankar S, Makala H, Hitchens TK, Foley LM, Guo J, Beumer JH, Rigatti LH, Lee YJ, Bartlett DL, Choudry HA. Improved chemosensitivity following mucolytic therapy in patient-derived models of mucinous appendix cancer. Transl Res 2021; 229:100-114. [PMID: 33164812 PMCID: PMC7867596 DOI: 10.1016/j.trsl.2020.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 10/10/2020] [Accepted: 10/19/2020] [Indexed: 12/14/2022]
Abstract
Abundant intraperitoneal (IP) accumulation of extracellular mucus in patients with appendiceal mucinous carcinoma peritonei (MCP) causes compressive organ dysfunction and prevents delivery of chemotherapeutic drugs to cancer cells. We hypothesized that reducing extracellular mucus would decrease tumor-related symptoms and improve chemotherapeutic effect in patient-derived models of MCP. Mucolysis was achieved using a combination of bromelain (BRO) and N-acetylcysteine (NAC). Ex vivo experiments of mucolysis and chemotherapeutic drug delivery/effect were conducted with MCP and non-MCP tissue explants. In vivo experiments were performed in mouse and rat patient-derived xenograft (PDX) models of early and late (advanced) MCP. MCP tumor explants were less chemosensitive than non-MCP explants. Chronic IP administration of BRO + NAC in a mouse PDX model of early MCP and a rat PDX model of late (advanced) MCP converted solid mucinous tumors into mucinous ascites (mucolysis) that could be drained via a percutaneous catheter (rat model only), significantly reduced solid mucinous tumor growth and improved the efficacy of chemotherapeutic drugs. Combination of BRO + NAC efficiently lyses extracellular mucus in clinically relevant models of MCP. Conversion of solid mucinous tumors into mucinous ascites decreases tumor bulk and allows for minimally invasive drainage of liquified tumors. Lysis of extracellular mucus removes the protective mucinous coating surrounding cancer cells and improves chemotherapeutic drug delivery/efficacy in cancer cells. Our data provide a preclinical rationale for the clinical evaluation of BRO + NAC as a therapeutic strategy for MCP.
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Affiliation(s)
- Ashok K Dilly
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Brendon D Honick
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robin Frederick
- Division of Laboratory Animal Resources, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anuleka Elapavaluru
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sachin Velankar
- Department of Chemical and Petroleum Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hima Makala
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - T Kevin Hitchens
- Animal Imaging Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Neurobiology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lesley M Foley
- Animal Imaging Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jianxia Guo
- Cancer Therapeutics Program, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania
| | - Jan H Beumer
- Cancer Therapeutics Program, UPMC Hillman Cancer Center, Pittsburgh, Pennsylvania; Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania; Division of Hematology-Oncology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Lora Heather Rigatti
- Division of Laboratory Animal Resources, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yong J Lee
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David L Bartlett
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Haroon A Choudry
- Department of Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, Pennsylvania.
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21
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Di Stefano A, Maniscalco M, Balbi B, Ricciardolo FLM. Oxidative and Nitrosative Stress in the Pathogenesis of Obstructive Lung Diseases of Increasing Severity. Curr Med Chem 2021; 27:7149-7158. [PMID: 32496983 DOI: 10.2174/0929867327666200604165451] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 03/14/2020] [Accepted: 03/16/2020] [Indexed: 11/22/2022]
Abstract
The imbalance between increased oxidative agents and antioxidant defence mechanisms is central in the pathogenesis of obstructive lung diseases such as asthma and COPD. In these patients, there are increased levels of reactive oxygen species. Superoxide anions (O2 -), Hydrogen Peroxide (H2O2) and hydroxyl radicals (•OH) are critical for the formation of further cytotoxic radicals in the bronchi and lung parenchyma. Chronic inflammation, partly induced by oxidative stress, can further increase the oxidant burden through activated phagocytic cells (neutrophils, eosinophils, macrophages), particularly in severer disease states. Antioxidants and anti-inflammatory genes are, in fact, frequently downregulated in diseased patients. Nrf2, which activates the Antioxidant Response Element (ARE) leading to upregulation of GPx, thiol metabolism-associated detoxifying enzymes (GSTs) and stressresponse genes (HO-1) are all downregulated in animal models and patients with asthma and COPD. An exaggerated production of Nitric Oxide (NO) in the presence of oxidative stress can promote the formation of oxidizing reactive nitrogen species, such as peroxynitrite (ONO2 -), leading to nitration and DNA damage, inhibition of mitochondrial respiration, protein dysfunction, and cell damage in the biological systems. Protein nitration also occurs by activation of myeloperoxidase and H2O2, promoting oxidation of nitrite (NO2 -). There is increased nitrotyrosine and myeloperoxidase in the bronchi of COPD patients, particularly in severe disease. The decreased peroxynitrite inhibitory activity found in induced sputum of COPD patients correlates with pulmonary function. Markers of protein nitration - 3- nitrotyrosine, 3-bromotyrosine, and 3-chlorotyrosine - are increased in the bronchoalveolar lavage of severe asthmatics. Targeting the oxidative, nitrosative stress and associated lung inflammation through the use of either denitration mechanisms or new drug delivery strategies for antioxidant administration could improve the treatment of these chronic disabling obstructive lung diseases.
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Affiliation(s)
- Antonino Di Stefano
- Divisione di Pneumologia e Laboratorio di Immunopatologia dell'Apparato Cardio Respiratorio, Istituti Clinici Scientifici Maugeri SpA, Societa Benefit, IRCCS, Veruno, Italy
| | - Mauro Maniscalco
- Divisione di Pneumologia, Istituti Clinici Scientifici Maugeri SpA, Societa Benefit, IRCCS, Telese, Italy
| | - Bruno Balbi
- Divisione di Pneumologia e Laboratorio di Immunopatologia dell'Apparato Cardio Respiratorio, Istituti Clinici Scientifici Maugeri SpA, Societa Benefit, IRCCS, Veruno, Italy
| | - Fabio L M Ricciardolo
- Dipartimento di Scienze Cliniche e Biologiche, AOU, San Luigi, Orbassano, Universita di Torino, Torino, Italy
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22
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Liu S, Lai J, Wu L, Guo X. Chinese Medicine for Chronic Obstructive Pulmonary Disease: A Pilot Study on Patient Preferences. Patient Prefer Adherence 2021; 15:1529-1535. [PMID: 34267508 PMCID: PMC8275201 DOI: 10.2147/ppa.s316872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/05/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE The patient's preference plays an important role in clinical practice. There currently is no available evidence regarding the perception and attitudes of patients with chronic obstructive pulmonary disease (COPD) towards the use of Chinese medicine (CM) approaches. This study was designed to explore preferences and factors associated with CM among COPD patients. PATIENTS AND METHODS A pilot survey was conducted among COPD patients using a structured, pre-tested questionnaire. The perceptions of CM therapies (including herbal medicine, non-pharmacotherapies), and expected clinical outcomes were investigated based on patient preference. Factors associated with preference of treatment scenarios were estimated in order of importance. RESULTS Thirty patients were enrolled in the survey, including 27 males and 3 females. Two-thirds of the patients preferred integrative Chinese and Western medicine for the treatment of COPD. Chinese patent medicines and CM decoction therapy were more popular than CM injections. The preferred non-drug therapy was point application, followed by acupuncture, Tai chi, or Qigong. More than 70% of patients reported that important clinical outcomes were improvements in lung function (77%) and dyspnea, cough, and sputum symptoms (73%), followed by exercise endurance (50%). Besides clinical efficacy, costs and side effects were also important factors for treatment selection. CONCLUSION This pilot study showed that Chinese patent medicine and CM decoctions were preferred options for complementary medicines to combine with routine pharmacotherapy for COPD treatment according to the patients' preferences. The improvement of dyspnea, cough symptoms, and lung function was the most desired clinical outcomes for patients. Quicker symptom relief, lower costs, and fewer side effects were key attributes for the treatment selection. Further research with a larger sample size is needed to definitively address the comprehensive conclusion.
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Affiliation(s)
- Shaonan Liu
- Evidence-based Medicine & Clinical Research Service Group, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, Guangdong Province, People’s Republic of China
| | - Jiaqi Lai
- Evidence-based Medicine & Clinical Research Service Group, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, Guangdong Province, People’s Republic of China
| | - Lei Wu
- Respiratory Department, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, Guangdong Province, People’s Republic of China
| | - Xinfeng Guo
- Evidence-based Medicine & Clinical Research Service Group, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), Guangzhou, Guangdong Province, People’s Republic of China
- Correspondence: Xinfeng Guo Evidence-based Medicine & Clinical Research Service Group, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine (Guangdong Provincial Hospital of Chinese Medicine), No. 111, Dade Road, Guangzhou, People’s Republic of China, 510120Tel +8613678906862 Email
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23
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Zhang Y, Wang Z, Zhang Y, Tong H, Zhang Y, Lu T. Potential Mechanisms for Traditional Chinese Medicine in Treating Airway Mucus Hypersecretion Associated With Coronavirus Disease 2019. Front Mol Biosci 2020; 7:577285. [PMID: 33381519 PMCID: PMC7768030 DOI: 10.3389/fmolb.2020.577285] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/27/2020] [Indexed: 01/08/2023] Open
Abstract
Background The rapid development of coronavirus disease 2019 (COVID-19) pandemic has become a great threat to global health. Its mortality is associated with inflammation-related airway mucus hypersecretion and dysfunction of expectoration, and the subsequent mucus blockage of the bronchioles at critical stage is attributed to hypoxemia, complications, and even death. Traditional Chinese medicine (TCM) has rich experience in expectorant, including treatment of COVID-19 patients with airway mucus dysfunction, yet little is known about the mechanisms. This study is aiming to explore the potential biological basis of TCM herbal expectorant for treating COVID-19. Objective To get core herbs with high used frequency applications in the actions of expectoration by using association rule algorithm and to investigate the multitarget mechanisms of core herbs in expectorant formulae for COVID-19 therapies. Methods Forty prescriptions for expectorant were retrieved from TCM Formulae. The ingredient compounds and targets of core herbs were collected from the TCMSP database, Gene-Cards, and NCBI. The protein interaction network (PPI) was constructed by SRING, and the network analysis was done by Cytoscape software. Bioconductor was applied for functional enrichment analysis of targets. Results The core herbs of expectorant could regulate core pathways (MAP kinase activity, cytokine receptor binding, G-protein-coupled receptor binding, etc.) via interactions of ingredients (glycyrol, citromitin, etc.) on mucin family to eliminate phlegm. Conclusion TCM herbal expectorant could regulate MAPK and cytokine-related pathways, thereby modulating Mucin-family to affect mucus generation and clearance and eventually retarding the deterioration of COVID-19 disease.
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Affiliation(s)
- Yuanfeng Zhang
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Zheyi Wang
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China.,Department of Encephalopathy, Dongzhimen Hospital, Affiliated to BUCM, Beijing, China
| | - Yue Zhang
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Hongxuan Tong
- Institute of Basic Theory for Chinese Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Yiling Zhang
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Tao Lu
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
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24
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High-dose N-acetylcysteine for long-term, regular treatment of early-stage chronic obstructive pulmonary disease (GOLD I-II): study protocol for a multicenter, double-blinded, parallel-group, randomized controlled trial in China. Trials 2020; 21:780. [PMID: 32917271 PMCID: PMC7488567 DOI: 10.1186/s13063-020-04701-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 08/27/2020] [Indexed: 11/21/2022] Open
Abstract
Introduction The presence of increased oxidative stress and airway inflammation has been proven in subjects with chronic obstructive pulmonary disease (COPD). Several studies have demonstrated that drugs with antioxidant and anti-inflammatory properties such as N-acetylcysteine (NAC) can reduce the rate of exacerbations in patients with COPD. However, the beneficial effects of NAC in early-stage COPD are minimally discussed. We are investigating whether high-dose NAC has therapeutic effects in Chinese patients with early-stage COPD. Method and analysis A randomized, double-blinded, placebo-controlled, parallel-group, multicenter clinical trial is evaluating the efficacy and safety of NAC for the long-term treatment of patients with early-stage COPD at 24 centers in China. Subjects aged 40–80 years and recruited by physicians or researchers with special training will be randomized to either NAC 600 mg twice daily group or matching placebo group for 2 years. Measurements will include forced expiratory volume in 1 s (FEV1), the number of COPD exacerbations, health-related quality, and pharmacoeconomic analysis. Discussion Currently, there are no randomized controlled trials with high-dose N-acetylcysteine (600 mg twice daily) for patients with mild-to-moderate COPD (GOLD I–II). We designed this multicenter randomized controlled trial (RCT) to assess the effectiveness, safety, and cost-effectiveness of long-term treatment with high-dose N-acetylcysteine. The results of this trial may guide clinical practice and change the standard of early COPD management. Trial registration Chinese Clinical Trial Registry ChiCTR-IIR-17012604. Registered on 07 September 2017.
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25
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Updated evidence for oral mucolytics in COPD. Drug Ther Bull 2020; 58:102. [PMID: 32188685 DOI: 10.1136/dtb.2020.000015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Review of: Poole P, Sathananthan K, Fortescue R. Mucolytic agents versus placebo for chronic bronchitis or chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2019;5: 10.1002/14651858.CD001287.pub6.
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26
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Barnes PJ. Oxidative stress-based therapeutics in COPD. Redox Biol 2020; 33:101544. [PMID: 32336666 PMCID: PMC7251237 DOI: 10.1016/j.redox.2020.101544] [Citation(s) in RCA: 190] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 01/01/2023] Open
Abstract
Oxidative stress is a major driving mechanism in the pathogenesis of COPD. There is increased oxidative stress in the lungs of COPD patients due to exogenous oxidants in cigarette smoke and air pollution and due to endogenous generation of reactive oxygen species by inflammatory and structural cells in the lung. Mitochondrial oxidative stress may be particularly important in COPD. There is also a reduction in antioxidant defences, with inactivation of several antioxidant enzymes and the transcription factors Nrf2 and FOXO that regulate multiple antioxidant genes. Increased systemic oxidative stress may exacerbate comorbidities and contribute to skeletal muscle weakness. Oxidative stress amplifies chronic inflammation, stimulates fibrosis and emphysema, causes corticosteroid resistance, accelerates lung aging, causes DNA damage and stimulates formation of autoantibodies. This suggests that treating oxidative stress by antioxidants or enhancing endogenous antioxidants should be an effective strategy to treat the underlying pathogenetic mechanisms of COPD. Most clinical studies in COPD have been conducted using glutathione-generating antioxidants such as N-acetylcysteine, carbocysteine and erdosteine, which reduce exacerbations in COPD patients, but it is not certain whether this is due to their antioxidant or mucolytic properties. Dietary antioxidants have so far not shown to be clinically effective in COPD. There is a search for more effective antioxidants, which include superoxide dismutase mimetics, NADPH oxidase inhibitors, mitochondria-targeted antioxidants and Nrf2 activators.
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Affiliation(s)
- Peter J Barnes
- Airway Disease Section, National Heart & Lung Institute, Imperial College London, Dovehouse Street, SW3 6LY, London, UK.
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27
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Joskova M, Mokry J, Franova S. Respiratory Cilia as a Therapeutic Target of Phosphodiesterase Inhibitors. Front Pharmacol 2020; 11:609. [PMID: 32435198 PMCID: PMC7218135 DOI: 10.3389/fphar.2020.00609] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 04/20/2020] [Indexed: 11/30/2022] Open
Abstract
Mucociliary clearance is an essential airway defense mechanism dependent predominantly on the proper ciliary function and mucus rheology. The crucial role of cilia is evident in `a variety of respiratory diseases, as the ciliary dysfunction is associated with a progressive decline in lung function over time. The activity of cilia is under supervision of multiple physiological regulators, including second messengers. Their role is to enable a movement in coordinated metachronal waves at certain beat frequency. Ciliary function can be modulated by various stimuli, including agents from the group of beta2 agonists, cholinergic drugs, and adenosine triphosphate (ATP). They trigger cilia to move faster in response to elevated cytoplasmic Ca2+ originated from intracellular sources or replenished from extracellular space. Well-known cilia-stimulatory effect of Ca2+ ions can be abolished or even reversed by modulating the phosphodiesterase (PDE)-mediated breakdown of cyclic adenosine monophosphate (cAMP) since the overall change in ciliary beating has been dependent on the balance between Ca2+ ions and cAMP. Moreover, in chronic respiratory diseases, high ATP levels may contribute to cAMP hydrolysis and thus to a decrease in the ciliary beat frequency (CBF). The role of PDE inhibitors in airway cilia-driven transport may help in prevention of progressive loss of pulmonary function often observed despite current therapy. Furthermore, administration of selective PDE inhibitors by inhalation lowers the risk of their systemic effects. Based on this review we may conclude that selective (PDE1, PDE4) or dual PDE inhibitors (PDE3/4) increase the intracellular level of cyclic nucleotides in airway epithelial cells and thus may be an important target in the development of new inhaled mucokinetic agents. Further research is required to provide evidence of their effectiveness and feasibility regarding their cilia-modulating properties.
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Affiliation(s)
- Marta Joskova
- Department of Pharmacology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Juraj Mokry
- Department of Pharmacology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Sona Franova
- Department of Pharmacology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
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28
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Ellingsen J, Johansson G, Larsson K, Lisspers K, Malinovschi A, Ställberg B, Thuresson M, Janson C. Impact of Comorbidities and Commonly Used Drugs on Mortality in COPD - Real-World Data from a Primary Care Setting. Int J Chron Obstruct Pulmon Dis 2020; 15:235-245. [PMID: 32099348 PMCID: PMC7006848 DOI: 10.2147/copd.s231296] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 01/09/2020] [Indexed: 01/21/2023] Open
Abstract
Background Life expectancy is significantly shorter for patients with chronic obstructive pulmonary disease (COPD) than the general population. Concurrent diseases are known to infer an increased mortality risk in those with COPD, but the effects of pharmacological treatments on survival are less established. This study aimed to examine any associations between commonly used drugs, comorbidities and mortality in Swedish real-world primary care COPD patients. Methods Patients with physician-diagnosed COPD from a large primary care population were observed retrospectively, utilizing primary care records and mandatory Swedish national registers. The time to all-cause death was assessed in a stepwise multiple Cox proportional hazards regression model including demography, socioeconomic factors, exacerbations, comorbidities and medication. Results During the observation period (1999-2009) 5776 (32.5%) of 17,745 included COPD patients died. Heart failure (hazard ratio [HR]: 1.88, 95% confidence interval [CI]: 1.74-2.04), stroke (HR: 1.52, 95% CI: 1.40-1.64) and myocardial infarction (HR: 1.40, 95% CI: 1.24-1.58) were associated with an increased risk of death. Use of inhaled corticosteroids (ICS; HR: 0.79, 95% CI: 0.66-0.94), beta-blockers (HR: 0.86, 95% CI: 0.76-0.97) and acetylsalicylic acid (ASA; HR: 0.87, 95% CI: 0.77-0.98) was dose-dependently associated with a decreased risk of death, whereas use of long-acting muscarinic antagonists (LAMA; HR: 1.33, 95% CI: 1.14-1.55) and N-acetylcysteine (NAC; HR: 1.26, 95% CI: 1.08-1.48) were dose-dependently associated with an increased risk of death in COPD patients. Conclusion This large, retrospective, observational study of Swedish real-world primary care COPD patients indicates that coexisting heart failure, stroke and myocardial infarction were the strongest predictors of death, underscoring the importance of timely recognition and treatment of comorbidities. A decreased risk of death associated with the use of ICS, beta-blockers and ASA, and an increased risk associated with the use of LAMA and NAC, was also found.
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Affiliation(s)
- Jens Ellingsen
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Gunnar Johansson
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Kjell Larsson
- Integrative Toxicology, National Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Andrei Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Björn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | | | - Christer Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
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29
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Milan S, Bondalapati P, Megally M, Patel E, Vaghasia P, Gross L, Bachman EM, Chadha P, Weingarten JA. Positive Expiratory Pressure Therapy With And Without Oscillation And Hospital Length Of Stay For Acute Exacerbation Of Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2019; 14:2553-2561. [PMID: 31819393 PMCID: PMC6875493 DOI: 10.2147/copd.s213546] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 10/31/2019] [Indexed: 01/08/2023] Open
Abstract
Introduction Pharmacologic management of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is well-established. Our aim in the current study is to determine if therapy with a positive expiratory pressure (PEP) device with or without an oscillatory mechanism (OM) in addition to standard care results in a reduction in hospital length of stay (LOS) among patients hospitalized for AECOPD. Methods Two studies were performed and are reported here. Study 1: Patients admitted with AECOPD and sputum production were enrolled in a prospective trial comparing PEP therapy versus Oscillatory PEP (OPEP) therapy. Study 2: A retrospective historical cohort, matched in a 2 to 1 manner by age, gender, and season of admission, was compared with the prospectively collected data to determine the effect of PEP ± OM versus standard care on hospital LOS. Results In the prospective trial (Study 1; 91 subjects), median hospital LOS was 3.2 (95% CI 3.0–4.3) days in the OPEP group and 4.8 (95% CI 3.9–6.1) days in the PEP group (p=0.16). In fully adjusted models comparing the prospective trial data with the retrospective cohort (Study 2; 182 subjects), cases had a median hospital LOS of 4.2 days (95% CI 3.8–5.1) versus 5.2 days (95% CI 4.4–6.0) in controls, consistent with a shorter hospital LOS with adjunctive PEP±OM therapy versus standard care (p=0.04). Conclusion Adjunctive therapy with a PEP device versus standard care may reduce hospital LOS in patients admitted for AECOPD. Although the addition of an OM component to PEP therapy suggests a further reduction in hospital LOS, comprehensive multicenter randomized controlled trials are needed to confirm these findings. Clinical trial registration number NCT03094806.
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Affiliation(s)
- Stephen Milan
- Weill Cornell Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Praveen Bondalapati
- Weill Cornell Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Michael Megally
- Weill Cornell Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Eshan Patel
- Weill Cornell Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Pramil Vaghasia
- Weill Cornell Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Liam Gross
- Weill Cornell Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Elizabeth M Bachman
- Weill Cornell Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Puja Chadha
- Weill Cornell Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
| | - Jeremy A Weingarten
- Weill Cornell Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY, USA
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30
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Janjua S, Pike KC, Carr R, Coles A, Fortescue R. Interventions to improve adherence to pharmacological therapy for chronic obstructive pulmonary disease (COPD). Hippokratia 2019. [DOI: 10.1002/14651858.cd013381] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Sadia Janjua
- St George's, University of London; Cochrane Airways, Population Health Research Institute; London UK SW17 0RE
| | - Katharine C Pike
- UCL Great Ormond Street Institute of Child Health; Respiratory, Critical Care & Anaesthesia; London UK
| | - Robin Carr
- 28 Beaumont Street Medical Practice; Oxford UK
| | - Andy Coles
- St George's, University of London; COPD Patient Advisory Group; London UK
| | - Rebecca Fortescue
- St George's, University of London; Cochrane Airways, Population Health Research Institute; London UK SW17 0RE
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