Exacerbations of chronic obstructive pulmonary disease and chronic mucus hypersecretion

The efficacy of N-acetylcysteine in chronic obstructive pulmonary disease patients: a meta-analysis

BACKGROUND

N-acetylcysteine (NAC) may reduce acute exacerbations of chronic obstructive pulmonary disease through an antioxidant effect. Due to the heterogeneity in studies, the currently available data do not confirm the efficacy of oral NAC therapy in chronic obstructive pulmonary disease patients. We hypothesize that chronic obstructive pulmonary disease patients receiving regular oral NAC therapy do not achieve improved clinical outcomes.

OBJECTIVES

The purpose of this meta-analysis was to determine the efficacy of long-term oral NAC therapy in chronic obstructive pulmonary disease patients.

DATA SOURCES AND METHODS

The literature search was performed using the PubMed, Web of Science, and Cochrane Library databases to identify all included clinical studies. Studies were eligible for inclusion only if they directly compared the outcomes of NAC versus placebo in adults with chronic obstructive pulmonary disease between 1 January 2000 and 30 May 2022. All studies were included if they reported one or more of the following outcomes: number of patients with no acute exacerbations, forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), St George's Respiratory Questionnaire score, glutathione level, and adverse events.

RESULTS

Nine randomized controlled trials were included in the meta-analysis. There were 1061 patients in the NAC group and 1076 patients in the placebo group. The current meta-analysis provides evidence that the number of patients with no acute exacerbations (965 patients receiving NAC therapy, 979 control group patients), change in FEV1 (433 patients receiving NAC therapy, 447 control group patients), change in FVC (177 patients receiving NAC therapy, 180 control group patients), change in St George's Respiratory Questionnaire score (128 patients receiving NAC therapy, 131 control group patients), change in glutathione levels (38 patients receiving NAC therapy, 40 control group patients), and adverse events (832 patients receiving NAC therapy, 846 control group patients) were not significantly different between the two groups.

CONCLUSION

NAC did not reduce the risk of acute exacerbation or ameliorate the decline in lung volume in chronic obstructive pulmonary disease patients.

Characteristics, Management and In-Hospital Clinical Outcomes Among Inpatients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease in China: Results from the Phase I Data of ACURE Study

PURPOSE

The study aimed to give a comprehensive overview of characteristics and evaluate in-hospital clinical outcomes among hospitalized acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients in China using data from the AECOPD inpatient registry (ACURE).

PATIENTS AND METHODS

The ACURE is an ongoing, national, multicenter, observational registry. Participants enrolled during phase I stage (1st September 2017 to 25th February 2020) of ACURE with confirmed AECOPD diagnoses were studied. Descriptive analyses were conducted to describe features and occurrences of in-hospital clinical outcomes of AECOPD inpatients in real-world China.

RESULTS

A total of 5334 AECOPD inpatients from 163 sites in 28 provinces or province-level municipalities were included. Among all participants, 78.8% were males and the median age was 69.0 [interquartile range (IQR): 63.0-76.0] years. The proportions of current and former smokers were 23.6% and 44.2%, respectively. The median age at COPD diagnosis was 64.0 (IQR: 57.0-71.0) years and 88.7% participants demonstrated at least one comorbidity. During stable period, only 56.9% subjects received pharmacological therapies and the influenza vaccination rate was 2.9%. During hospitalization, 99.5% subjects received pharmacological treatments and antibiotics were prescribed to 90.9% participants. The all-cause in-hospital mortality was 0.1% and no significant difference was found across hospital categories.

CONCLUSION

Clinical features of Chinese AECOPD inpatients were different from those of other populations. In real-world China, the clinical management during stable period was unsatisfied, whereas therapy during hospitalization was effective regarding in-hospital clinical outcomes regardless of hospital category.

Antitussive, expectorant and anti-inflammatory activities of different extracts from Exocarpium Citri grandis

ETHNOPHARMACOLOGICAL RELEVANCE

Exocarpium Citri grandis (C. grandis, Huajuhong in Chinese), the epicarp of C. grandis 'Tomentosa', is used as an antitussive, expectorant and anti-inflammatory drug for hundreds of years in China. The study was aimed at evaluating the antitussive, expectorant and anti-inflammatory effects of different extracts of C. grandis, providing experimental evidence for its traditional use, and laying a foundation for its further researches.

MATERIALS AND METHODS

Crude drugs of C. grandis were extracted with four kinds of solvents (water, 50% ethanol, 70% ethanol and 90% ethanol) in reflux conditions, respectively. Solutions were concentrated in reduced pressure and lyophilized in vacuum to yield the aqueous extract, 50% ethanolic extract, 70% ethanolic extract, and 90% ethanolic extract of C. grandis. Antitussive evaluations were carried out with ammonia liquor induced mice cough; expectorant effects were tested with phenol red secretion experiments in mice; anti-inflammatory effects were assessed by murine model of xylene induced ear edema in mice.

RESULTS

Only aqueous and 70% ethanolic extracts of C. grandis displayed significant antitussive, expectorant and anti-inflammatory activities. Aqueous extract of C. grandis significantly decreased cough frequency caused by ammonia liquor, increased phenol red secretion and inhibited the development of ear edema in anti-inflammatory assay at the dose of 1005 mg/kg (P<0.05). However, aqueous extract of C. grandis did not lengthened the cough period. It was worth noting that, 70% ethanolic extract of C. grandis showed strong effect of decreasing cough frequency, prolonging cough period, increasing phenol red secretion and decreasing the extent of ear edema at the dose of 493 mg/kg (P<0.001). The low, middle, and high dose (247, 493, and 986 mg/kg) of 70% ethanolic extract of C. grandis showed significant antitussive, expectorant and anti-inflammatory effects in good dose dependant manner.

CONCLUSION

The results supported the folk use of C. grandis (decoction of C. grandis) with scientific evidence, and indicated that the 70% ethanolic extract of C. grandis might have better effects of antitussive, expectorant and anti-inflammatory than those of aqueous extract. Further investigation needs to be conducted to study the bioactive constituents of 70% ethanolic extract of C. grandis and the mechanism of observed antitussive, expectorant and anti-inflammatory activities.

Expectorant and antioxidant activities of purified fumarprotocetraric acid from Cladonia verticillaris lichen in mice

The lichen Cladonia verticillaris produces bioactive secondary metabolites, such as fumarprotocetraric (FUM) and protocetraric acids. Species of the genus Cladonia demonstrate anti-tumor, anti-inflammatory and antipyretic activities and have been used in folk medicine to treat respiratory diseases (throat irritation, cough, asthma and tuberculosis). The aim of the present study was to evaluate the expectorant and mucolytic activities of fumarprotocetraric acid in albino Swiss mice. FUM was extracted and purified from an acetone extract of C. verticillaris. The phenol red quantification method was used on the bronchoalveolar lavage fluid following the administration of FUM (25, 50 or 100 mg/kg orally or intraduodenally and 12.5, 25 or 50 mg/kg, intraperitoneally) for the evaluation of expectorant activity. Control groups received either saline solution (7.5 mL/kg) or ambroxol (1 mg/kg) through the same administration routes. Antioxidant activity was evaluated using the thiobarbituric acid reactive species assay in mouse lung tissue treated with the FUM at 25, 50 or 100 mg/kg orally, followed by a lipopolysaccharide solution at 1 mg/kg intrapleurally. The same protocol was used for the control groups using either saline solution (7.5 mL/kg, orally) or N-acetylcysteine (20 mg/kg, orally).

RESULTS

Orally administered FUM at doses of 25 and 50 mg/kg promoted significantly greater dose-dependent phenol red activity in the bronchoalveolar lavage and expectorant activity in comparison to the controls (p < 0.05). Lipid peroxidation (malondialdehyde equivalent) was reduced by 50% in the lung tissue.

CONCLUSION

The results confirm the expectorant and antioxidant properties of fumarprotocetraric acid produced by the lichen C. verticillaris.

Cigarette smoke suppresses Bik to cause epithelial cell hyperplasia and mucous cell metaplasia

RATIONALE

Aberrant regulation of airway epithelial cell numbers in airways leads to increased mucous secretions in chronic lung diseases such as chronic bronchitis. Because the Bcl-2 family of proteins is crucial for airway epithelial homeostasis, identifying the players that reduce cigarette smoke (CS)-induced mucous cell metaplasia can help to develop effective therapies.

OBJECTIVES

To identify the Bcl-2 family of proteins that play a role in reducing CS-induced mucous cell metaplasia.

METHODS

We screened for dysregulated expression of the Bcl-2 family members.

MEASUREMENTS AND MAIN RESULTS

We identified Bik to be significantly reduced in bronchial brushings of patients with chronic epithelial cell hyperplasia compared with nondiseased control subjects. Reduced Bik but increased MUC5AC mRNA levels were also detected when normal human airway epithelial cells (HAECs) were exposed to CS or when autopsy tissues from former smokers with and without chronic bronchitis were compared. Similarly, exposure of C57Bl/6 mice to CS resulted in increased numbers of epithelial and mucous cells per millimeter of basal lamina, along with reduced Bik but increased Muc5ac expression, and this change was sustained even when mice were allowed to recover in filtered air for 8 weeks. Restoring Bik expression significantly suppressed CS-induced mucous cell metaplasia in differentiated primary HAEC cultures and in airways of mice in vivo. Bik blocked nuclear translocation of phospho-ERK1/2 to induce apoptosis of HAECs. The conserved Leu61 within Bik and ERK1/2 activation were essential to induce cell death in hyperplastic mucous cells.

CONCLUSIONS

These studies show that CS suppresses Bik expression to block airway epithelia cell death and thereby increases epithelial cell hyperplasia in chronic bronchitis.