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Ho TN, Wald J, Borhan S, Lauks S, Campbell A, Chaput C, Pierce M, Perkins J, Camera J, MacPherson A, Cox G, Raghavan N, Amer R, Nair P. Comprehensive Care Management in Conjunction with Sputum Cytometry-Guided Pharmacotherapy in a Post-Discharge Clinic for Patients with COPD. COPD 2021; 18:411-416. [PMID: 34223776 DOI: 10.1080/15412555.2021.1945022] [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: 10/20/2022]
Abstract
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are amongst the most common reasons for hospital admission, and recurrent episodes occur frequently. Comprehensive care management (CCM) strategies have modest effect in preventing re-admissions. The objectives of this study were to examine the utility of optimizing anti-inflammatory therapy guided by sputum cytometry in the post-hospitalization setting, and to assess the feasibility and effectiveness of a clinic combining CCM and sputum-guided therapy. This is an observational study examining patients who received open-label CCM and sputum cytometry-guided pharmacotherapy in a COPD post-discharge clinic. Referral was based on high risk for readmission after hospitalization for AECOPD. The primary outcome was the change in COPD-related healthcare utilization before and after Visit 1, and this was analyzed with a mixed-effects negative binomial model controlling for age, number of follow-up clinic visits, pack years, current smoking and FEV1. Of 138 patients referred to the clinic, 73% attended at least one visit. Mean FEV1 was 42.8 (19.3) % predicted. Of the patients attending clinic, 42.6% produced an adequate sputum sample, and 32.7% had an abnormal sputum. By individual, infectious bronchitis was the most common (25.7%), followed by eosinophilic bronchitis (13.9%). Comparing the 6-months prior to and after the first clinic visit, there was a lower incidence rate ratio after visit 1 for COPD-related healthcare utilization (0.26 (95%CI 0.22,0.33; p < 0.001)). A COPD post-discharge clinic combining sputum-guided treatment and CCM was feasible and associated with a nearly 75% reduction in the incidence of COPD-related healthcare utilization.
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Affiliation(s)
- Terence N Ho
- St. Joseph's Healthcare Hamilton, Hamilton, Canada.,Firestone Institute for Respiratory Health, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Joshua Wald
- St. Joseph's Healthcare Hamilton, Hamilton, Canada.,Firestone Institute for Respiratory Health, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Sayem Borhan
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Sylvia Lauks
- Firestone Institute for Respiratory Health, Hamilton, Canada
| | - Alec Campbell
- Department of Medicine, McMaster University, Hamilton, Canada
| | | | - Mary Pierce
- St. Joseph's Healthcare Hamilton, Hamilton, Canada.,Firestone Institute for Respiratory Health, Hamilton, Canada
| | - Janice Perkins
- St. Joseph's Healthcare Hamilton, Hamilton, Canada.,Firestone Institute for Respiratory Health, Hamilton, Canada
| | - Julianne Camera
- St. Joseph's Healthcare Hamilton, Hamilton, Canada.,Firestone Institute for Respiratory Health, Hamilton, Canada
| | | | - Gerard Cox
- St. Joseph's Healthcare Hamilton, Hamilton, Canada.,Firestone Institute for Respiratory Health, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Natya Raghavan
- St. Joseph's Healthcare Hamilton, Hamilton, Canada.,Firestone Institute for Respiratory Health, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Rebecca Amer
- St. Joseph's Healthcare Hamilton, Hamilton, Canada.,Firestone Institute for Respiratory Health, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
| | - Parameswaran Nair
- St. Joseph's Healthcare Hamilton, Hamilton, Canada.,Firestone Institute for Respiratory Health, Hamilton, Canada.,Department of Medicine, McMaster University, Hamilton, Canada
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2
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Ho T, Al‐Selahi E, Mukherjee M, Huang C, Radford K, Kjarsgaard M, Lavigne N, Halabecki J, Waserman S, Nair P. Sputum and serum immunoglobulins in adult asthmatics with recurrent respiratory tract infections. Allergy 2020; 75:2105-2108. [PMID: 32187682 DOI: 10.1111/all.14283] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 02/19/2020] [Accepted: 03/11/2020] [Indexed: 01/06/2023]
Affiliation(s)
- Terence Ho
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare Hamilton Ontario Canada
- Division of Respirology St. Joseph's Healthcare and Department of Medicine McMaster University Hamilton Ontario Canada
| | - Eiman Al‐Selahi
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare Hamilton Ontario Canada
- Division of Allergy and Immunology St. Joseph's Healthcare and Department of Medicine McMaster University Hamilton Ontario Canada
| | - Manali Mukherjee
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare Hamilton Ontario Canada
| | - Chynna Huang
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare Hamilton Ontario Canada
| | - Katherine Radford
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare Hamilton Ontario Canada
| | - Melanie Kjarsgaard
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare Hamilton Ontario Canada
| | - Nicola Lavigne
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare Hamilton Ontario Canada
| | - Janice Halabecki
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare Hamilton Ontario Canada
| | - Susan Waserman
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare Hamilton Ontario Canada
- Division of Allergy and Immunology St. Joseph's Healthcare and Department of Medicine McMaster University Hamilton Ontario Canada
| | - Parameswaran Nair
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare Hamilton Ontario Canada
- Division of Respirology St. Joseph's Healthcare and Department of Medicine McMaster University Hamilton Ontario Canada
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3
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Patelis A, Alving K, Middelveld R, James A, Ono J, Ohta S, Izuhara K, Borres MP, Forsberg B, Janson C, Malinovschi A. IgE sensitization to food allergens and airborne allergens in relation to biomarkers of type 2 inflammation in asthma. Clin Exp Allergy 2018; 48:1147-1154. [PMID: 29746003 DOI: 10.1111/cea.13165] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 03/18/2018] [Accepted: 03/28/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND We have recently reported that sensitization to food allergens and sensitization to airborne allergens had independent associations with increased fraction of exhaled nitric oxide (FeNO) and blood eosinophils in middle-aged adults and in young subjects with asthma. OBJECTIVE To investigate the relation between IgE sensitization and several type 2 inflammation biomarkers in adult asthmatics. METHODS FeNO, urinary eosinophil-derived neurotoxin (U-EDN), serum eosinophil cationic protein (S-ECP) and periostin were measured in 396 asthmatics, aged 17-76 years, from the Swedish GA2LEN study. Sensitization to airborne allergens was examined with skin prick tests (≥3 mm wheal) and sensitization to food allergens with measurement of specific IgE (≥0.35 kU/L). RESULTS Asthmatics sensitized to food allergens had higher FeNO, 22.3 ppb (18.6, 26.7) vs 16.1 ppb (14.2, 18.2) (P = .005), S-ECP, 17.7 mg/L (14.8, 21.1) vs 12.8 mg/L (10.9, 14.9) (P = .01), and periostin, 73.7 (67.5, 80.3) ng/mL vs 59.9 (55.8, 64.2) ng/mL (P = .003), than non-sensitized subjects. Periostin levels in this group were also significantly higher than in the group sensitized only to airborne allergens (P = .01). Sensitization to food allergens related independently to FeNO (P = .02), S-ECP (P = .006) and periostin (P = .004), whereas sensitization only to airborne allergens related only to FeNO (P = .02) after adjustments for age, sex, height, weight and smoking history. FeNO correlated weakly with S-ECP (r = .17, P < .001), periostin (r = .19, P < .001) and U-EDN (0.16, P < .001). S-ECP also correlated weakly with U-EDN (r = .12, P = .02). None of the correlations between the remaining pairs of markers of type 2 inflammation were significant. CONCLUSIONS & CLINICAL RELEVANCE Sensitization to food allergens related to several local and systemic type 2 inflammation markers, such as FeNO, S-ECP and periostin. Assessing the profile of allergic sensitization, including to food allergens, might improve the understanding and interpretation of inflammatory markers and potentially improve asthma management.
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Affiliation(s)
- A Patelis
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden.,Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden.,Division of Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - K Alving
- Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - R Middelveld
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - A James
- Experimental Asthma and Allergy Research, National Institute of Enviromental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - J Ono
- Shino-Test Corporation, Kanagawa, Japan
| | - S Ohta
- Department of Laboratory Medicine, Saga Medical School, Saga, Japan
| | - K Izuhara
- Division of Medical Biochemistry, Department of Biomolecular Sciences, Saga Medical School, Saga, Japan
| | - M P Borres
- Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - B Forsberg
- Division of Occupational and Environmental Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - C Janson
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - A Malinovschi
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
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4
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Abstract
PURPOSE OF REVIEW The inflammatory makeup of severe asthma is heterogeneous. Identification of the predominant cellular endotype via biomarkers can aid in the selection of more advanced therapies. This review is clinically focused on how to use these biomarkers to help select between biologic agents and/or bronchial thermoplasty. RECENT FINDINGS Several Th2 biomarkers exist for the detection of eosinophilic disease; however, the best biomarker for clinical practice is debatable depending upon local resources. Currently, there are three federal drug agency-approved biologic agents (omalizumab, mepolizumab and reslizumab) to treat severe asthma with frequent exacerbations despite standard medical therapy. Several others are either in clinical trials or in the development phase for the treatment of eosinophilic asthma. To date, agents targeting neutrophilic inflammation have been largely unsuccessful. Bronchial thermoplasty has emerged as an option for the treatment of severe asthma. SUMMARY The appropriate selection of patients through the use of eosinophilic biomarkers has led to significant reductions in exacerbations with the use of mAb therapy. Bronchial thermoplasty has also shown reductions in asthma exacerbations and improved quality of life; however, it is unclear which patients may respond best to this intervention.
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Abstract
Asthma is a heterogeneous disease that can be classified into different clinical endotypes, depending on the type of airway inflammation, clinical severity, and response to treatment. This article focuses on the eosinophilic endotype of asthma, which is defined by the central role that eosinophils play in the pathophysiology of the condition. It is characterized by elevated sputum and/or blood eosinophils on at least 2 occasions and by a significant response to treatments that suppress eosinophilia. Histopathologic demonstration of eosinophils in the airways provides the most direct diagnosis of eosinophilic asthma; but it is invasive, thus, impractical in clinical practice.
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Affiliation(s)
- Fernando Aleman
- Division of Respirology, St Joseph's Healthcare Hamilton, McMaster University, Hamilton, Ontario, Canada
| | - Hui Fang Lim
- Department of Respiratory Medicine, National University of Singapore, Singapore, Singapore
| | - Parameswaran Nair
- Division of Respirology, St Joseph's Healthcare Hamilton, McMaster University, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.
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A new approach to the classification and management of airways diseases: identification of treatable traits. Clin Sci (Lond) 2017; 131:1027-1043. [PMID: 28487412 DOI: 10.1042/cs20160028] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Revised: 12/14/2016] [Accepted: 01/26/2017] [Indexed: 12/16/2022]
Abstract
This review outlines a new, personalized approach for the classification and management of airway diseases. The current approach to airways disease is, we believe, no longer fit for purpose. It is impractical, overgeneralizes complex and heterogeneous conditions and results in management that is imprecise and outcomes that are worse than they could be. Importantly, the assumptions we make when applying a diagnostic label have impeded new drug discovery and will continue to do so unless we change our approach. This review suggests a new mechanism-based approach where the emphasis is on identification of key causal mechanisms and targeted intervention with treatment based on possession of the relevant mechanism rather than an arbitrary label. We highlight several treatable traits and suggest how they can be identified and managed in different healthcare settings.
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7
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Ho T, Dasgupta A, Hargreave FE, Nair P. The use of cellular and molecular biomarkers to manage COPD exacerbations. Expert Rev Respir Med 2017; 11:403-411. [PMID: 28347199 DOI: 10.1080/17476348.2017.1307738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Chronic obstructive pulmonary disease (COPD) exacerbations are a common cause of respiratory morbidity and mortality, and have various etiologies. Multiple cellular and molecular biomarkers have been associated with exacerbations. Quantitative sputum cell counts are able to identify the presence and type of bronchitis, which is an important contributor to exacerbations. Their utility to monitor bronchitis and to help treat exacerbations has been evaluated, yet they are not used in routine clinical practice. Areas covered: This review will provide a brief summary of biomarkers utilized in COPD, with a focus on the application of cellular markers for the management of exacerbations. A case study will demonstrate the application of these methods. With quantitative sputum cell counts, the presence of eosinophilic bronchitis predicts corticosteroid-responsiveness, while neutrophilic bronchitis identifies infection and suggests the need for antibiotics. Gastroesophageal reflux-related aspiration and heart failure can also be identified by examining sputum. Expert commentary: Quantitative sputum cytometry is an essential tool in the management of exacerbations of COPD, particularly those prone to frequent exacerbations. Treatment based on sputum cell counts is superior to current guideline-based recommendations to prevent future exacerbations and hospitalizations in observational and single-centre controlled trials. Large multicentre clinical trials are necessary to confirm this.
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Affiliation(s)
- Terence Ho
- a Firestone Institute for Respiratory Health, St Joseph's Healthcare Hamilton, and Department of Medicine , McMaster University , Hamilton , ON , Canada
| | - Angira Dasgupta
- a Firestone Institute for Respiratory Health, St Joseph's Healthcare Hamilton, and Department of Medicine , McMaster University , Hamilton , ON , Canada
| | - Frederick E Hargreave
- a Firestone Institute for Respiratory Health, St Joseph's Healthcare Hamilton, and Department of Medicine , McMaster University , Hamilton , ON , Canada
| | - Parameswaran Nair
- a Firestone Institute for Respiratory Health, St Joseph's Healthcare Hamilton, and Department of Medicine , McMaster University , Hamilton , ON , Canada
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8
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Uribe Echevarría L, Leimgruber C, García González J, Nevado A, Álvarez R, García LN, Quintar AA, Maldonado CA. Evidence of eosinophil extracellular trap cell death in COPD: does it represent the trigger that switches on the disease? Int J Chron Obstruct Pulmon Dis 2017; 12:885-896. [PMID: 28352169 PMCID: PMC5359000 DOI: 10.2147/copd.s115969] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In spite of the numerous studies on chronic obstructive pulmonary disease (COPD), the cellular and molecular basis of the disease’s development remain unclear. Neutrophils and eosinophils are known to be key players in COPD. Recently, neutrophil extracellular trap cell death (NETosis), a mechanism due to decondensation and extrusion of chromatin to form extracellular traps, has been demonstrated in COPD. However, there is limited knowledge about eosinophil extracellular trap cell death (EETosis) and its role in the pathogenesis of COPD. The aim of this study was to evaluate EETosis in stable COPD. Induced sputum obtained from healthy smokers and low exacerbation risk COPD A or B group patients or high exacerbation risk COPD C or D group patients were included. Samples were examined using electron microscopy and immunofluorescence. Healthy smokers (n=10) and COPD A (n=19) group exhibited neutrophilic or paucigranulocytic phenotypes, with NETosis being absent in these patients. In contrast, COPD B (n=29), with eosinophilic or mixed phenotypes, showed EETosis and incipient NETosis. COPD C (n=18) and COPD D groups (n=13) were differentiated from low exacerbation rate-COPD group by the abundant cellular debris, with COPD C group having an eosinophilic pattern and numerous cells undergoing EETosis. A hallmark of this group was the abundant released membranes that often appeared phagocytosed by neutrophils, which coincidentally exhibited early NETosis changes. The COPD D group included patients with a neutrophilic or mixed pattern, with abundant neutrophil extracellular trap-derived material. This study is the first to demonstrate EETosis at different stages of stable COPD. The results suggest a role for eosinophils in COPD pathophysiology, especially at the beginning and during the persistence of the disease, regardless of whether the patient quit smoking, with EETosis debris probably triggering uncontrolled NETosis. The main target of these findings should be young smokers with the potential to develop COPD.
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Affiliation(s)
| | - Carolina Leimgruber
- Electronic Microscopy Center, Instituto de Investigaciones en Ciencias de la Salud (INICSA-CONICET), Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Córdoba, Argentina
| | | | - Alberto Nevado
- Pneumonology Service, Sanatorio Allende (Nueva Córdoba), Córdoba, Argentina
| | - Ruth Álvarez
- Smoking Cessation Cente, Nuevo Hospital San Roque of Córdoba, Córdoba, Argentina
| | - Luciana N García
- Electronic Microscopy Center, Instituto de Investigaciones en Ciencias de la Salud (INICSA-CONICET), Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Córdoba, Argentina
| | - Amado A Quintar
- Electronic Microscopy Center, Instituto de Investigaciones en Ciencias de la Salud (INICSA-CONICET), Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Córdoba, Argentina
| | - Cristina A Maldonado
- Electronic Microscopy Center, Instituto de Investigaciones en Ciencias de la Salud (INICSA-CONICET), Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Córdoba, Argentina
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9
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Lim CS, Rani FA, Tan LE. Response of exhaled nitric oxide to inhaled corticosteroids in patients with stable COPD: A systematic review and meta-analysis. CLINICAL RESPIRATORY JOURNAL 2016; 12:218-226. [PMID: 27328740 DOI: 10.1111/crj.12518] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 06/13/2016] [Accepted: 06/18/2016] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To our knowledge, no meta-analysis has investigated the response of FeNO levels to corticosteroid treatment in ex-smokers with chronic obstructive pulmonary disease (COPD). OBJECTIVES This meta-analysis assessed the potential role of fraction of exhaled nitric oxide (FeNO) as a biomarker for corticosteroid response in ex-smokers with stable COPD. METHODS Medline, Cochrane, EMBASE, Google Scholar databases were searched until November 5, 2014 using the following terms: corticosteroid, chronic obstructive pulmonary disease, COPD, nitric oxide, NO, exhaled nitric oxide. Only randomized controlled trials (RCT) or two-arm prospective studies were included. The primary outcome measure was FeNO before and after treatment with inhaled corticosteroids (ICS) in ex-smokers with COPD. Sensitivity analysis was also performed. RESULTS Five studies were included in the analysis with a total of 171 COPD patients. All five studies included 125 ex-smokers and two of these also included 46 current smokers. There was a significant decrease of FeNO in ex-smoking COPD patients following inhaled corticosteroid treatment (-7.51, 95% CI: -11.51 to -3.51; P =0.003); and in a population of subjects that included both smokers and ex-smokers (-1.99, 95% CI: -3.41 to -0.56; P =0.006). CONCLUSION Our findings indicate that FeNO levels significantly decreased with corticosteroid treatment in ex-smokers with COPD. Additional studies are required to evaluate whether concurrent smoking has significant effect on FeNO response to ICS.
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Affiliation(s)
- Chor-Shen Lim
- Respiratory Unit, Department of Medicine, Tropicana Medical Centre, Petaling Jaya, Selangor, 47810, Malaysia
| | - Fauzi Abdul Rani
- Respiratory Unit, Department of Medicine, Tropicana Medical Centre, Petaling Jaya, Selangor, 47810, Malaysia.,Respiratory Unit, Faculty of Medicine, Universiti Teknologi MARA, Selayang, Selangor, 68100, Malaysia
| | - Lan-Eng Tan
- Respiratory Unit, Department of Medicine, Tropicana Medical Centre, Petaling Jaya, Selangor, 47810, Malaysia
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10
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Wolfe MG, Zhang Q, Hui C, Radford K, Nair P, Brennan JD. Development of a functional point-of-need diagnostic for myeloperoxidase detection to identify neutrophilic bronchitis. Analyst 2016; 141:6438-6443. [DOI: 10.1039/c6an01563h] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A paper-based analytical device was developed to rapidly detect myeloperoxidase in processed sputum for diagnosis of neutrophilic bronchitis.
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Affiliation(s)
| | - Qiang Zhang
- Biointerfaces Institute
- McMaster University
- Hamilton
- Canada
| | - Christy Hui
- Biointerfaces Institute
- McMaster University
- Hamilton
- Canada
| | - Katherine Radford
- Firestone Institute for Respiratory Health
- St. Joseph's Healthcare
- Hamilton
- Canada
| | - Parameswaran Nair
- Firestone Institute for Respiratory Health
- St. Joseph's Healthcare
- Hamilton
- Canada
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11
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Metabolomic profiling of asthma and chronic obstructive pulmonary disease: A pilot study differentiating diseases. J Allergy Clin Immunol 2015; 136:571-580.e3. [PMID: 26152317 DOI: 10.1016/j.jaci.2015.05.022] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Revised: 05/01/2015] [Accepted: 05/07/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Differentiating asthma from other causes of chronic airflow limitation, such as chronic obstructive pulmonary disease (COPD), can be difficult in a typical outpatient setting. The inflammation of asthma typically is different than that of COPD, and the degree of inflammation and cellular damage varies with asthma severity. Metabolomics is the study of molecules created by cellular metabolic pathways. OBJECTIVES We hypothesized that the metabolic activity of adults with asthma would differ from that of adults with COPD. Furthermore, we hypothesized that nuclear magnetic resonance spectroscopy (NMR) would measure such differences in urine samples. METHODS Clinical and urine-based NMR data were collected on adults meeting the criteria of asthma and COPD before and after an exacerbation (n = 133 and 38, respectively) and from patients with stable asthma or COPD (n = 54 and 23, respectively). Partial least-squares discriminant analysis was performed on the NMR data to create models of separation (86 metabolites were measured per urine sample). Some subjects' metabolomic data were withheld from modeling to be run blindly to determine diagnostic accuracy. RESULTS Partial least-squares discriminant analysis of the urine NMR data found unique differences in select metabolites between patients with asthma and those with COPD seen in the emergency department and even in follow-up after exacerbation. By using these select metabolomic profiles, the model could correctly diagnose blinded asthma and COPD with greater than 90% accuracy. CONCLUSION This is the first report showing that metabolomic analysis of human urine samples could become a useful clinical tool to differentiate asthma from COPD.
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12
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Liapikou A, Toumbis M, Torres A. Managing the safety of inhaled corticosteroids in COPD and the risk of pneumonia. Expert Opin Drug Saf 2015; 14:1237-47. [DOI: 10.1517/14740338.2015.1057494] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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13
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Chu DK, Al-Garawi A, Llop-Guevara A, Pillai RA, Radford K, Shen P, Walker TD, Goncharova S, Calhoun WJ, Nair P, Jordana M. Therapeutic potential of anti-IL-6 therapies for granulocytic airway inflammation in asthma. Allergy Asthma Clin Immunol 2015; 11:14. [PMID: 25878673 PMCID: PMC4397814 DOI: 10.1186/s13223-015-0081-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 04/07/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Determining the cellular and molecular phenotypes of inflammation in asthma can identify patient populations that may best benefit from targeted therapies. Although elevated IL-6 and polymorphisms in IL-6 signalling are associated with lung dysfunction in asthma, it remains unknown if elevated IL-6 levels are associated with a specific cellular inflammatory phenotype, and how IL-6 blockade might impact such inflammatory responses. METHODS Patients undergoing exacerbations of asthma were phenotyped according to their airway inflammatory characteristics (normal cell count, eosinophilic, neutrophilic, mixed granulocytic), sputum cytokine profiles, and lung function. Mice were exposed to the common allergen, house dust-mite (HDM), in the presence or absence of endogenous IL-6. The intensity and nature of lung inflammation, and levels of pro-granulocytic cytokines and chemokines under these conditions were analyzed. RESULTS Elevated IL-6 was associated with a lower FEV1 in patients with mixed eosinophilic-neutrophilic bronchitis. In mice, allergen exposure increased lung IL-6 and IL-6 was produced by dendritic cells and alveolar macrophages. Loss-of-function of IL-6 signalling (knockout or antibody-mediated neutralization) abrogated elevations of eosinophil and neutrophil recruiting cytokines/chemokines and allergen-induced airway inflammation in mice. CONCLUSIONS We demonstrate the association of pleiotropic cellular airway inflammation with IL-6 using human and animal data. These data suggest that exacerbations of asthma, particularly those with a combined eosinophilic and neutrophilic bronchitis, may respond to therapies targeting the IL-6 pathway and therefore, provide a rational basis for initiation of clinical trials to evaluate this.
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Affiliation(s)
- Derek K Chu
- Department of Pathology & Molecular Medicine, McMaster Immunology Research Centre, Hamilton, ON Canada
| | - Amal Al-Garawi
- Department of Pathology & Molecular Medicine, McMaster Immunology Research Centre, Hamilton, ON Canada
| | - Alba Llop-Guevara
- Department of Pathology & Molecular Medicine, McMaster Immunology Research Centre, Hamilton, ON Canada
| | - Regina A Pillai
- Division of Pulmonary and Critical Care Medicine, and Institute for Translational Sciences, University of Texas Medical Branch, Galveston, Texas USA
| | - Katherine Radford
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, Ontario Canada
| | - Pamela Shen
- Department of Pathology & Molecular Medicine, McMaster Immunology Research Centre, Hamilton, ON Canada
| | - Tina D Walker
- Department of Pathology & Molecular Medicine, McMaster Immunology Research Centre, Hamilton, ON Canada
| | - Susanna Goncharova
- Department of Pathology & Molecular Medicine, McMaster Immunology Research Centre, Hamilton, ON Canada
| | - William J Calhoun
- Division of Pulmonary and Critical Care Medicine, and Institute for Translational Sciences, University of Texas Medical Branch, Galveston, Texas USA
| | - Parameswaran Nair
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, Ontario Canada
| | - Manel Jordana
- Department of Pathology & Molecular Medicine, McMaster Immunology Research Centre, Hamilton, ON Canada
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14
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Agarwal R, Dhooria S, Aggarwal AN, Maturu VN, Sehgal IS, Muthu V, Prasad KT, Yenge LB, Singh N, Behera D, Jindal SK, Gupta D, Balamugesh T, Bhalla A, Chaudhry D, Chhabra SK, Chokhani R, Chopra V, Dadhwal DS, D’Souza G, Garg M, Gaur SN, Gopal B, Ghoshal AG, Guleria R, Gupta KB, Haldar I, Jain S, Jain NK, Jain VK, Janmeja AK, Kant S, Kashyap S, Khilnani GC, Kishan J, Kumar R, Koul PA, Mahashur A, Mandal AK, Malhotra S, Mohammed S, Mohapatra PR, Patel D, Prasad R, Ray P, Samaria JK, Singh PS, Sawhney H, Shafiq N, Sharma N, Sidhu UPS, Singla R, Suri JC, Talwar D, Varma S. Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations. Lung India 2015; 32:S3-S42. [PMID: 25948889 PMCID: PMC4405919 DOI: 10.4103/0970-2113.154517] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Venkata N Maturu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Kuruswamy T Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Lakshmikant B Yenge
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Navneet Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Digambar Behera
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surinder K Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dheeraj Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Thanagakunam Balamugesh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashish Bhalla
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dhruva Chaudhry
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sunil K Chhabra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ramesh Chokhani
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Vishal Chopra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Devendra S Dadhwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - George D’Souza
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Mandeep Garg
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Shailendra N Gaur
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Bharat Gopal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Aloke G Ghoshal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Randeep Guleria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Krishna B Gupta
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Indranil Haldar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sanjay Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Nirmal K Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Vikram K Jain
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashok K Janmeja
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surya Kant
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Surender Kashyap
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Gopi C Khilnani
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jai Kishan
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Raj Kumar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Parvaiz A Koul
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Ashok Mahashur
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Amit K Mandal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Samir Malhotra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Sabir Mohammed
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Prasanta R Mohapatra
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Dharmesh Patel
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Rajendra Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Pallab Ray
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jai K Samaria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Potsangbam Sarat Singh
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Honey Sawhney
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Nusrat Shafiq
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Navneet Sharma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Updesh Pal S Sidhu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Rupak Singla
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Jagdish C Suri
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Deepak Talwar
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
| | - Subhash Varma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India
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15
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MouthLab: A Tricorder Concept Optimized for Rapid Medical Assessment. Ann Biomed Eng 2015; 43:2175-84. [DOI: 10.1007/s10439-015-1247-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 01/08/2015] [Indexed: 11/26/2022]
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16
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Ernst P, Saad N, Suissa S. Inhaled corticosteroids in COPD: the clinical evidence. Eur Respir J 2014; 45:525-37. [PMID: 25537556 DOI: 10.1183/09031936.00128914] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this article, we focus on the scientific evidence from randomised trials supporting treatment with inhaled corticosteroids (ICS) in chronic obstructive pulmonary disease (COPD), including treatment with combinations of long-acting β-agonist (LABA) bronchodilators and ICS. Our emphasis is on the methodological strengths and limitations that guide the conclusions that may be drawn. The evidence of benefit of ICS and, therefore, of the LABA/ICS combinations in COPD is limited by major methodological problems. From the data reviewed herein, we conclude that there is no survival benefit independent of the effect of long-acting bronchodilation and no effect on FEV1 decline, and that the possible benefit on reducing severe exacerbations is unclear. Our interpretation of the data is that there are substantial adverse effects from the use of ICS in patients with COPD, most notably severe pneumonia resulting in excess deaths. Currently, the most reliable predictor of response to ICS in COPD is the presence of eosinophilic inflammation in the sputum. There is an urgent need for better markers of benefit and risk that can be tested in randomised trials for use in routine specialist practice. Given the overall safety and effectiveness of long-acting bronchodilators in subjects without an asthma component to their COPD, we believe use of such agents without an associated ICS should be favoured.
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Affiliation(s)
- Pierre Ernst
- Dept of Medicine, Pulmonary Division, Jewish General Hospital, Montreal, Canada Centre for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, Montreal, Canada
| | - Nathalie Saad
- Dept of Medicine, Pulmonary Division, Jewish General Hospital, Montreal, Canada
| | - Samy Suissa
- Centre for Clinical Epidemiology, Lady Davis Research Institute, Jewish General Hospital, Montreal, Canada Dept of Epidemiology and Biostatistics, McGill University, Montréal, Canada
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17
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Abramson MJ, Perret JL, Dharmage SC, McDonald VM, McDonald CF. Distinguishing adult-onset asthma from COPD: a review and a new approach. Int J Chron Obstruct Pulmon Dis 2014; 9:945-62. [PMID: 25246782 PMCID: PMC4166213 DOI: 10.2147/copd.s46761] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Adult-onset asthma and chronic obstructive pulmonary disease (COPD) are major public health burdens. This review presents a comprehensive synopsis of their epidemiology, pathophysiology, and clinical presentations; describes how they can be distinguished; and considers both established and proposed new approaches to their management. Both adult-onset asthma and COPD are complex diseases arising from gene-environment interactions. Early life exposures such as childhood infections, smoke, obesity, and allergy influence adult-onset asthma. While the established environmental risk factors for COPD are adult tobacco and biomass smoke, there is emerging evidence that some childhood exposures such as maternal smoking and infections may cause COPD. Asthma has been characterized predominantly by Type 2 helper T cell (Th2) cytokine-mediated eosinophilic airway inflammation associated with airway hyperresponsiveness. In established COPD, the inflammatory cell infiltrate in small airways comprises predominantly neutrophils and cytotoxic T cells (CD8 positive lymphocytes). Parenchymal destruction (emphysema) in COPD is associated with loss of lung tissue elasticity, and small airways collapse during exhalation. The precise definition of chronic airflow limitation is affected by age; a fixed cut-off of forced expiratory volume in 1 second/forced vital capacity leads to overdiagnosis of COPD in the elderly. Traditional approaches to distinguishing between asthma and COPD have highlighted age of onset, variability of symptoms, reversibility of airflow limitation, and atopy. Each of these is associated with error due to overlap and convergence of clinical characteristics. The management of chronic stable asthma and COPD is similarly convergent. New approaches to the management of obstructive airway diseases in adults have been proposed based on inflammometry and also multidimensional assessment, which focuses on the four domains of the airways, comorbidity, self-management, and risk factors. Short-acting beta-agonists provide effective symptom relief in airway diseases. Inhalers combining a long-acting beta-agonist and corticosteroid are now widely used for both asthma and COPD. Written action plans are a cornerstone of asthma management although evidence for self-management in COPD is less compelling. The current management of chronic asthma in adults is based on achieving and maintaining control through step-up and step-down approaches, but further trials of back-titration in COPD are required before a similar approach can be endorsed. Long-acting inhaled anticholinergic medications are particularly useful in COPD. Other distinctive features of management include pulmonary rehabilitation, home oxygen, and end of life care.
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Affiliation(s)
- Michael J Abramson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jennifer L Perret
- Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Australia
| | - Shyamali C Dharmage
- Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, Australia
| | - Vanessa M McDonald
- Priority Research Centre for Asthma and Respiratory Disease, University of Newcastle, Newcastle, Australia
| | - Christine F McDonald
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Australia
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18
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Ernst P. Taking airway disease seriously. Thorax 2014; 69:307-8. [PMID: 24399629 DOI: 10.1136/thoraxjnl-2013-204709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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