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Singh D, Han MK, Hawkins NM, Hurst JR, Kocks JWH, Skolnik N, Stolz D, El Khoury J, Gale CP. Implications of Cardiopulmonary Risk for the Management of COPD: A Narrative Review. Adv Ther 2024; 41:2151-2167. [PMID: 38664329 PMCID: PMC11133105 DOI: 10.1007/s12325-024-02855-4] [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: 02/23/2024] [Accepted: 03/22/2024] [Indexed: 05/29/2024]
Abstract
Chronic obstructive pulmonary disease (COPD) constitutes a major global health burden and is the third leading cause of death worldwide. A high proportion of patients with COPD have cardiovascular disease, but there is also evidence that COPD is a risk factor for adverse outcomes in cardiovascular disease. Patients with COPD frequently die of respiratory and cardiovascular causes, yet the identification and management of cardiopulmonary risk remain suboptimal owing to limited awareness and clinical intervention. Acute exacerbations punctuate the progression of COPD in many patients, reducing lung function and increasing the risk of subsequent exacerbations and cardiovascular events that may lead to early death. This narrative review defines and summarises the principles of COPD-associated cardiopulmonary risk, and examines respiratory interventions currently available to modify this risk, as well as providing expert opinion on future approaches to addressing cardiopulmonary risk.
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Affiliation(s)
- Dave Singh
- Medicines Evaluation Unit, Manchester University NHS Foundation Trust, University of Manchester, Manchester, M23 9QZ, UK.
| | - MeiLan K Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Janwillem W H Kocks
- General Practitioners Research Institute, Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Pulmonology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Daiana Stolz
- Clinic of Respiratory Medicine, Medical Center and Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | | | - Chris P Gale
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
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Phillips DB, James MD, Vincent SG, Elbehairy AF, Neder JA, Kirby M, Ora J, Day AG, Tan WC, Bourbeau J, O'Donnell DE. Physiological Characterization of Preserved Ratio Impaired Spirometry in the CanCOLD Study: Implications for Exertional Dyspnea and Exercise Intolerance. Am J Respir Crit Care Med 2024; 209:1314-1327. [PMID: 38170674 DOI: 10.1164/rccm.202307-1184oc] [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: 07/11/2023] [Accepted: 01/03/2024] [Indexed: 01/05/2024] Open
Abstract
Rationale: It is increasingly recognized that adults with preserved ratio impaired spirometry (PRISm) are prone to increased morbidity. However, the underlying pathophysiological mechanisms are unknown. Objectives: Evaluate the mechanisms of increased dyspnea and reduced exercise capacity in PRISm. Methods: We completed a cross-sectional analysis of the CanCOLD (Canadian Cohort Obstructive Lung Disease) population-based study. We compared physiological responses in 59 participants meeting PRISm spirometric criteria (post-bronchodilator FEV1 < 80% predicted and FEV1/FVC ⩾ 0.7), 264 control participants, and 170 ever-smokers with chronic obstructive pulmonary disease (COPD), at rest and during cardiopulmonary exercise testing. Measurements and Main Results: Individuals with PRISm had lower total lung, vital, and inspiratory capacities than healthy controls (all P < 0.05) and minimal small airway, pulmonary gas exchange, and radiographic parenchymal lung abnormalities. Compared with healthy controls, individuals with PRISm had higher dyspnea/[Formula: see text]o2 ratio at peak exercise (4.0 ± 2.2 vs. 2.9 ± 1.9 Borg units/L/min; P < 0.001) and lower [Formula: see text]o2peak (74 ± 22% predicted vs. 96 ± 25% predicted; P < 0.001). At standardized submaximal work rates, individuals with PRISm had greater Vt/inspiratory capacity (Vt%IC; P < 0.001), reflecting inspiratory mechanical constraint. In contrast to participants with PRISm, those with COPD had characteristic small airways dysfunction, dynamic hyperinflation, and pulmonary gas exchange abnormalities. Despite these physiological differences among the three groups, the relationship between increasing dyspnea and Vt%IC during cardiopulmonary exercise testing was similar. Resting IC significantly correlated with [Formula: see text]o2peak (r = 0.65; P < 0.001) in the entire sample, even after adjusting for airflow limitation, gas trapping, and diffusing capacity. Conclusions: In individuals with PRISm, lower exercise capacity and higher exertional dyspnea than healthy controls were mainly explained by lower resting lung volumes and earlier onset of dynamic inspiratory mechanical constraints at relatively low work rates. Clinical trial registered with www.clinicaltrials.gov (NCT00920348).
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Affiliation(s)
- Devin B Phillips
- School of Kinesiology and Health Science, Faculty of Health, and
- Muscle Health Research Center, York University, Toronto, Ontario, Canada
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Site, Kingston, Ontario, Canada
| | - Matthew D James
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Site, Kingston, Ontario, Canada
| | - Sandra G Vincent
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Site, Kingston, Ontario, Canada
| | - Amany F Elbehairy
- Department of Chest Diseases, Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Division of Infection, Immunity, and Respiratory Medicine, The University of Manchester, and Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - J Alberto Neder
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Site, Kingston, Ontario, Canada
| | - Miranda Kirby
- Department of Physics, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Josuel Ora
- Division of Respiratory Medicine, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Andrew G Day
- Kingston General Hospital Research Institute, Kingston, Ontario, Canada
| | - Wan C Tan
- Centre for Heart Lung Innovation, Providence Health Care Research Institute, University of British Columbia, St. Paul's Hospital, Vancouver, British Columbia, Canada; and
| | - Jean Bourbeau
- Research Institute of the McGill University Health Centre, Translational Research in Respiratory Diseases Program and Respiratory Epidemiology and Clinical Research Unit, and
- Division of Respiratory Medicine, Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Site, Kingston, Ontario, Canada
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Müllerová H, Chan JSK, Heatley H, Carter V, Townend J, Skinner D, Franzén S, Marshall J, Price D. Budesonide/Glycopyrrolate/Formoterol for the Management of COPD in a UK Primary Care Population: Real-World Use and Early Medication Success. Int J Chron Obstruct Pulmon Dis 2024; 19:1153-1166. [PMID: 38813078 PMCID: PMC11134059 DOI: 10.2147/copd.s452624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 05/14/2024] [Indexed: 05/31/2024] Open
Abstract
Purpose Real-life research is needed to evaluate the effectiveness of budesonide/glycopyrrolate/formoterol (BGF) in routine COPD primary care management. We assessed the frequency of medication success among patients with COPD who initiated BGF using real-world data. Patients and Methods Patients with a recorded diagnostic COPD code who started BGF with ≥2 prescriptions within 90-days were identified in the UK Optimum Patient Care Research Database and followed from first prescription until censoring at the end of follow-up (180-days), death, leaving database or end of data at 24/10/2022. The primary outcome was medication success at 90-days post-BGF initiation, defined as no major cardiac or respiratory event (ie no complicated COPD exacerbation, hospitalization for any respiratory event, myocardial infarction, new/hospitalized heart failure, and death) and no incidence of pneumonia. Medication success was also assessed at 180-days post-BGF initiation. Overall real-life medication success was claimed if the lower 95% confidence interval (CI) for the proportion of patients meeting the primary outcome was ≥70% (defined a priori). Results Two hundred eighty-five patients were included. Prior to BGF initiation, these patients often had severe airflow obstruction (mean ppFEV1: 54.5%), were highly symptomatic (mMRC ≥2: 77.9% (n = 205/263); mean CAT score: 21.7 (SD 7.8)), with evidence of short-acting β2-agonist (SABA) over-use (≥3 inhalers/year: 62.1%, n=179/285), repeat OCS prescriptions (≥2 courses/year: 33.0%, n = 95/285) and multiple primary care consultations (≥2 visits/year: 61.1%, n = 174/285). Overall, 39.6% of patients (n = 113/285) switched from previous triple therapies. Real-life medication success was achieved by 96.5% of patients (n = 275/285 [95% CI: 93.6, 98.3]) during 90-days treatment with BGF and by 91.8% (n = 169/184 [95% CI: 86.9, 95.4]) of patients at 180-days. The prescribed daily dose of SABA remained stable over the study period. Conclusion The majority of patients initiating BGF experienced real-life medication success reflecting the absence of severe cardiopulmonary events. These benefits were apparent after 90-days of treatment and sustained over 180-days.
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Affiliation(s)
- Hana Müllerová
- Medical Evidence Strategy, Biopharmaceuticals R&I Medical, AstraZeneca, Cambridge, UK
| | | | - Heath Heatley
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - John Townend
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Derek Skinner
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Stefan Franzén
- BPM Evidence Statistics, Biopharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Jonathan Marshall
- Global Medical Affairs, Biopharmaceuticals R&I Medical, AstraZeneca, Cambridge, UK
| | - David Price
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Hurst JR, Gale CP. MACE in COPD: addressing cardiopulmonary risk. THE LANCET. RESPIRATORY MEDICINE 2024; 12:345-348. [PMID: 38437859 DOI: 10.1016/s2213-2600(24)00038-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 01/23/2024] [Accepted: 02/13/2024] [Indexed: 03/06/2024]
Affiliation(s)
- John R Hurst
- UCL Respiratory, University College London, London, UK
| | - Chris P Gale
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Leeds Institute for Cardiovascular and Metabolic Medicine, University of Leeds, Leeds LS2 9JT, UK; Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.
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Montiel AM, Ruiz-Esteban P, Del Río AD, Valdivielso P, Chaparro MÁS, Olveira C. Differences in cardiovascular risk and health-related quality of life in COPD patients according to clinical phenotype. Sci Rep 2024; 14:9687. [PMID: 38678074 PMCID: PMC11055945 DOI: 10.1038/s41598-024-60406-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/23/2024] [Indexed: 04/29/2024] Open
Abstract
Chronic obstructive pulmonary disease (COPD) has a high prevalence and a major impact on health-related quality of life (HRQL). COPD exacerbations are an important cause of morbidity and mortality, affecting cardiovascular risk, and are associated with poorer health status. The aim of this study was to assess the association between cardiovascular risk (CVR) and HRQL, according to exacerbator or non-exacerbator phenotype. We undertook a cross-sectional, observational, descriptive study of 107 patients with COPD. Patients with two or more moderate exacerbations or one severe exacerbation in the previous year were considered as exacerbators. The CVR was calculated with the Framingham scale and SCORE (Systematic Coronary Risk Evaluation) and the HRQL was assessed with the generic questionnaire Short Form-36 Health Survey (SF-36), the St George Respiratory Questionnaire (SGRQ) and the COPD Assessment Test (CAT). Statistical analysis was done with SPSS version 26.0 for Windows. The SF-36 and the SGRQ showed lower values for the exacerbator phenotype, indicating a poorer quality of life. The CAT questionnaire showed values above 10 for the exacerbator phenotype, and lower values in the non-exacerbator group. After categorizing the sample according to their median age (65 years), we found a greater deterioration in HRQL in patients under 65 years of age according to the SF-36, the SGRQ and the CAT. We also detected differences in HRQL between non-exacerbator patients with a high CVR according to the Framingham (≥ 20%) and SCORE (≥ 5%) scales compared to those without this risk. A tendency towards worse HRQL was observed in non-exacerbator patients with a high CVR, which was statistically significant for the SGRQ impact domain on the SCORE scale. The CAT also showed a worse quality of life in non-exacerbator patients with a high CVR, which was significant in the Framingham model (Framingham high risk 8.41 vs non-high risk 6.05, p < 0.01). These differences were not observed in exacerbator patients. Our findings confirm that a high CVR influences HRQL in patients with COPD, especially in non-exacerbator patients with a high CVR, measured according to the SGRQ and the CAT.
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Affiliation(s)
- Ana Muñoz Montiel
- Pulmonology Service. Monographic COPD Office, Regional University Hospital of Malaga, University of Malaga, Malaga, Spain
| | - Pedro Ruiz-Esteban
- Nephrology Department, The Biomedical Research Institute of Malaga (IBIMA-Plataforma BIONAND), Regional University Hospital of Malaga, University of Malaga, RICORS2040 (RD21/0005/0012), Malaga, Spain.
| | - Adolfo Doménech Del Río
- Pulmonology Service. Monographic COPD Office, Regional University Hospital of Malaga, University of Malaga, Malaga, Spain
| | - Pedro Valdivielso
- Laboratory of Lipids and Atherosclerosis, Medico-Sanitarias Research Center (IBIMA), University of Malaga, Malaga, Spain
- Internal Medicine, University Hospital Virgen de La Victoria, Department of Medicine and Dermatology and Biomedical Research Institute of Malaga (IBIMA), Platform Bionand, University of Malaga, Malaga, Spain
| | - Miguel Ángel Sánchez Chaparro
- Internal Medicine, University Hospital Virgen de La Victoria, Department of Medicine and Dermatology and Biomedical Research Institute of Malaga (IBIMA), Platform Bionand, University of Malaga, Malaga, Spain
| | - Casilda Olveira
- Pulmonology Service, Regional University Hospital of Malaga, Department of Medicine and Dermatology and Biomedical Research Institute of Malaga (IBIMA), Platform Bionand, University of Malaga, Malaga, Spain
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Im Y, Park HY, Lee JY, Kim H, Yoo H, Kang M, Cho SJ, Hwang JH, Park YB, Cho J, Kang D, Shin SH. Impact of preserved ratio impaired spirometry on coronary artery calcium score progression: a longitudinal cohort study. ERJ Open Res 2024; 10:00819-2023. [PMID: 38259813 PMCID: PMC10801717 DOI: 10.1183/23120541.00819-2023] [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: 10/27/2023] [Accepted: 12/07/2023] [Indexed: 01/24/2024] Open
Abstract
Background Preserved ratio impaired spirometry (PRISm) is associated with increased cardiovascular disease (CVD) risk and mortality. However, a causal relationship between PRISm and CVD remains unclear. We investigated the progression of coronary artery calcium (CAC) scores based on the presence of PRISm and reduced forced vital capacity (FVC). Methods This retrospective cohort study included 11 420 participants aged ≥40 years with forced expiratory volume in 1 s (FEV1)/FVC ≥0.7 who underwent at least two health screening examinations with coronary computed tomography scan between 2003 and 2020, and were without a history of CVD or interstitial lung disease. Participants with PRISm, defined as FEV1/FVC ≥0.7 and FEV1 <80% predicted, were further divided by low FVC (FVC <80% predicted). We estimated the 5-year progression rates of CAC by comparing participants with and without PRISm at baseline using mixed linear models. Results Of the 11 420 participants, 8536 (75%), 811 (7%) and 2073 (18%) had normal spirometry, PRISm with normal FVC and PRISm with low FVC, respectively. During the mean (range) follow-up of 6.0 (0.5-17.2) years, the multivariable adjusted ratio of 5-year CAC progression rates comparing participants with PRISm to those with normal spirometry was 1.08 (95% CI 1.04-1.13). This rate was higher in participants with PRISm with low FVC (1.21 (95% CI 1.12-1.30)) than in those with normal FVC. Conclusion In this longitudinal cohort study of subjects without a history of CVD, PRISm was significantly associated with CAC progression, which was more evident in the group with PRISm and low FVC.
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Affiliation(s)
- Yunjoo Im
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- These authors contributed equally to this work as first authors
| | - Hye Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- These authors contributed equally to this work as first authors
| | - Jin-Young Lee
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- These authors contributed equally to this work as first authors
| | - Hyunsoo Kim
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea
| | - Hongseok Yoo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Mira Kang
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Soo Jin Cho
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jung Hye Hwang
- Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yong Bum Park
- Department of Pulmonary and Critical Care Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Juhee Cho
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea
- Department of Epidemiology and Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Danbee Kang
- Center for Clinical Epidemiology, Samsung Medical Center, Seoul, South Korea
- Department of Clinical Research Design and Evaluation, SAIHST, Sungkyunkwan University, Seoul, South Korea
- These authors contributed equally to this work as senior authors
| | - Sun Hye Shin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- These authors contributed equally to this work as senior authors
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Yang S, Liao G, Tse LA. Association of preserved ratio impaired spirometry with mortality: a systematic review and meta-analysis. Eur Respir Rev 2023; 32:230135. [PMID: 37914194 PMCID: PMC10618908 DOI: 10.1183/16000617.0135-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/04/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Preserved ratio impaired spirometry (PRISm) is prevalent within the general population. Increased mortality has been reported among subjects with PRISm, but the evidence has never been summarised. This systematic review aims to synthesise evidence on the association between PRISm and the risk of all-cause, cardiovascular and respiratory-related mortality. METHODS We systematically searched MEDLINE, Embase and Web of Science for population-based cohort studies from inception to April 2023 using the terms related to impaired spirometry and mortality. Titles and abstracts were screened to identify eligible studies that reported mortality estimates for individuals with PRISm. We excluded studies that adopted other definitions of impaired spirometry, had a specific study setting (e.g. HIV patients), had an insufficient follow-up period (<1 year) or reported duplicated data. Random-effects meta-analysis was used to produce pooled hazard ratio (HR) with 95% confidence intervals. Between-study heterogeneity was assessed with I2. RESULTS Eight studies met the inclusion criteria involving 40 699 individuals with PRISm. All included studies reported increased risk of all-cause mortality among adults with PRISm. Meta-analysis showed that PRISm was associated with an increased risk of all-cause mortality (pooled HR 1.71, 95% CI 1.51-1.93; I2=64%), cardiovascular mortality (pooled HR 1.57, 95% CI 1.44-1.72; I2=35%) and respiratory-related mortality (pooled HR 1.97, 95% CI 1.55-2.49; I2=0%). CONCLUSIONS Individuals with PRISm have a significantly increased risk of mortality compared with those with normal spirometry.
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Affiliation(s)
- Shuyuan Yang
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Gengze Liao
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Lap Ah Tse
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
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Wan ES. Sharing More Than Space: The Heart and Lungs. Chest 2023; 164:566-567. [PMID: 37689465 DOI: 10.1016/j.chest.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 09/11/2023] Open
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Amegadzie JE, Sadatsafavi M. A long overdue recognition: COPD as a distinct predictor of cardiovascular disease risk. Eur Respir J 2023; 62:2301167. [PMID: 37652564 DOI: 10.1183/13993003.01167-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/30/2023] [Indexed: 09/02/2023]
Affiliation(s)
- Joseph Emil Amegadzie
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
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