The role of respiratory infections in airway hyperresponsiveness and asthma

Severe bronchial hyperresponsiveness along with house dust mite allergy indicates persistence of asthma in young children

BACKGROUND

Significant risk factors for persistence of asthma later in life are family history of allergies, early allergic sensitization and bronchial hyperresponsiveness (BHR). The evolution of BHR in young children without allergic sensitization and with house dust mite allergy (HDM) was investigated.

METHODS

In this retrospective analysis, electronic charts of 4850 young children with asthma and wheezy bronchitis between 2005 and 2018 were reviewed in order to study all patients ≤6 years with BHR assessed by methacholine provocation tests (MCT) at least once (n = 1175). Patients with more than two follow-up measurements were divided in group 1 (no allergic sensitization; n = 110) and group 2 (HDM allergy; n = 88). Additionally, skin prick test, exhaled nitrite oxide (eNO), and asthma treatment were analyzed.

RESULTS

Forty-seven patients of group 1 aged median 4.3 years and 48 patients of group 2 aged median 4.7 years showed initially severe BHR <0.1 mg. At follow-up, patients with HDM were more likely to show persistence of severe BHR than non-sensitized patients (severe BHR group 1: n = 5 (10.6%) vs. group 2: n = 21 (43.8%), p < .001). In addition, 89.4% of group 1 had mild to moderate or no BHR, compared to only 56.2% of group 2. There was a significant difference in eN0 (median group 1: 9 ppb vs. group 2: 26 ppb, p < .001), at last follow-up. Age, sex, and asthma therapy had no effect on BHR.

CONCLUSION

In young children without sensitization BHR normalizes, whereas HDM allergy indicates a persistence of asthma beyond infancy.

Fat mass index and airway hyperresponsiveness in Korean adults

OBJECTIVE

Airway hyperresponsiveness (AHR) is associated with asthma and obesity, which is defined as a high body mass index. Body mass mainly comprises fat mass (FM) and muscle mass (MM), which are independent of each other. We investigated the effect of changes in FM over time on the development of asymptomatic AHR in adults.

METHODS

This long-term longitudinal study included adults who were underwent health checkups at the Seoul National University Hospital Gangnam Center. The participants underwent two methacholine bronchial provocation tests with a follow-up period (between the first and second tests) of more than 3 years and bioelectrical impedance analysis (BIA) at all visits. FM index (FMI; FM normalized for height) and MM index (MMI; MM normalized for height) were calculated using BIA.

RESULTS

The study included 328 adult participants (61 women and 267 men). The mean number of BIA measurements was 6.96 and the follow-up duration was 6.69 years. In total, 13 participants showed a positive conversion of AHR. Multivariate analysis indicated that a high rate of change in FMI ([g/m²]/year), not MMI, was significantly associated with the risk of AHR development (P = 0.037) after adjustment for age, sex, smoking status, and FEV1 predicted.

CONCLUSION

A rapid gain of FM over time may be a risk factor for developing AHR in adults. Prospective studies are needed to confirm our results and evaluate the role of FM reduction in preventing AHR development in obese adults.

Airway hyperresponsiveness, peak flow variability and inflammatory markers in non-asthmatic subjects with respiratory infections

OBJECTIVE

The aim of this study was to characterise non-asthmatic subjects with asthma-like symptoms during a common cold, particularly in relation to airway hyperresponsiveness (AHR).

MATERIALS AND METHODS

Subjects with acute respiratory infections and a group of controls (n = 20 + 20), age 20-65 years, underwent bronchial provocations with methacholine, adenosine and cold air. All were non-smokers and had no history of asthma or heart disease. Those with infection had asthma-like symptoms (>2). Measurements of exhaled nitric oxide (eNO), serum levels of eosinophil cationic protein (ECP), eosinophil peroxidase, myeloperoxidase and human neutrophil lipocalin were made at each provocation. A 17-day symptom and peak flow diary was calculated.

RESULTS

No differences between the two groups were found, regarding responsiveness to methacholine, adenosine or cold air challenge, as well as the inflammatory markers measured. In the infected group, the mean (standard deviation) ECP was higher in those with AHR to methacholine or cold air [15.7 (6.5) and 11.4 (4.2) microg/L, respectively; P < 0.05]; furthermore, eNO was higher in the infected group [116 (54) and 88 (52) nL/min, respectively; P = 0.055]. The infected group had, at all times, more symptoms and higher peak flow, with a decrease in the symptoms (P = 0.02) and a tendency to change in peak flow variation (P = 0.06).

CONCLUSION

AHR does not seem to be the main cause of asthma-like symptoms in adults with infectious wheezing. Peak flow variation and symptom prevalence during the post-infection period may imply airway pathology different from AHR.

[The new insight into the pathogenic unity of the upper and lower airways]

Between the upper and the lower respiratory tracts exists a link. Numerous epidemiological, immunological studies and clinical observations suggest the pathogenic unity of the upper and lower airways. The most important observations regarding the nose-lung interaction is rhinitis and asthma. The inflammatory process in the nose is the same as in the bronchi, clinically defined as rhinosinusitis, nasal polyps, asthma, bronchial hyperreactivity, allergy, viral infections. The strict link between the rhinosinusitis and asthma implies new possibility of influencing one of the two complaints by treating the other one with an integrated therapy (pharmacotherapy, endonasal microsurgery).

Interleukin 13 and the beta-adrenergic blockade theory of asthma revisited 40 years later

BACKGROUND

Beta2-Adrenergic agonists are the most potent agents clinically used in inhibiting and preventing the immediate response to bronchoconstricting agents and in inhibiting mast cell mediator release. This raises the possibility that an abnormality in beta-adrenergic receptor function or circulating catecholamine levels could contribute to airway hyperresponsiveness.

OBJECTIVE

To link interleukin 13 (IL-13) to the pathogenesis of asthma.

METHODS

Almost 4 decades ago, Andor Szentivanyi published a beta-adrenergic theory of atopic abnormality in bronchial asthma. He proposed 9 characteristics to define bronchial asthma. Because he published these 9 tenets of the beta-adrenergic blockade theory of asthma in 1968, it is appropriate and important to evaluate their relevance in light of advances in pharmacology, inflammation, and immunology.

RESULTS

We describe the effects of the allergic reaction on beta-adrenergic responses and airway responsiveness. Both IL-1beta and tumor necrosis factor a have been detected in increased amounts in bronchial lavage fluids in allergic airway inflammation. Both IL-13 and the proinflammatory cytokines IL-1beta and tumor necrosis factor a have been demonstrated in airway smooth muscle to cause a decreased relaxation response to beta-adrenergic agonist. However, IL-13 has been shown to be necessary and sufficient to produce the characteristics of asthma.

CONCLUSION

The decreased adrenergic bronchodilator activity and associated hypersensitivity to mediators put forth by Szentivanyi can be elicited with IL-13 and support its role in the pathogenesis of asthma.

Airway hyperresponsiveness: a story of mice and men and cytokines

Bronchial hyperresponsiveness (BHR) is an essential part of the definition of asthma. Although our understanding of the allergic inflammatory and immunologic mechanisms of asthma have markedly increased, the mechanism of BHR remains to be elucidated. Increased BHR is associated temporally with exposure to allergens, certain respiratory viruses, pollutants such as ozone, and certain occupational chemicals. An important research use of determining the degree of BHR to direct and indirect challenge is to determine the efficacy of pharmacologic and immunodulatory agents. Beta-adrenergic agents inhibit BHR and certain genetic polymorphisms of the beta-adrenergic receptor are associated with increased BHR. When beta-adrenergic receptors are blocked, sensitivity to allergens is markedly increased in patients with asthma and animal models of asthma. Allergen challenge and clinical asthma are associated with synthesis and release of pro-inflammatory cytokines such as IL-1 and TNF-alpha which have been shown to decrease the response to beta-agonists and increased the reactivity to methacholine and the airways neutrophils and alveolar macrophages. The Th2 cytokine IL-13 is increased in the airways of asthmatics and increases BHR in normal unsensitized animals. The mechanisms of this effect of IL-13 are being intensively investigated. Our group has shown that IL-13 induced BHR persisted for at least 7 days and the soluble receptor IL-13R2alpha protected against their BHR. Other investigators have demonstrated that IL-13 is necessary and sufficient for the induction of BHR and that eosinophilic airway inflammation in the absence of IL-13 fails to induce BHR. These studies indicate that treatment of human asthma with antagonists of IL-13 may be very effective.

Treatment of allergic asthma

Asthma is a chronic inflammatory disorder of the airways that causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. The airway inflammation also increases bronchial hyperresponsiveness to a variety of stimuli. After evaluation that includes spirometry, patients with intermittent asthma are treated with a short-acting bronchodilator on an as-needed basis. Patients with persistent asthma should receive inhaled corticosteroids as first-line anti-inflammatory therapy and long-acting inhaled beta(2)-agonists as preferred adjunctive therapy. Leukotriene modifiers can be used as maintenance therapy in patients with mild persistent asthma, or added to the regimen of patients with moderate or severe persistent asthma. In patients with asthma and concomitant allergic rhinitis, antihistamines may be useful as adjunctive therapy.

Chemokines and inflammation in the nasal passages of infants with respiratory syncytial virus bronchiolitis

This study measured chemokines in nasal lavage fluids (NLF) from infants with respiratory syncytial virus (RSV) bronchiolitis, defined by lung hyperinflation and wheezing. Comparison was made to RSV-positive infants without bronchiolitis and RSV-negative infants with acute respiratory illnesses. RSV-positive illnesses were associated with increased epithelial shedding, increased RANTES/protein ratios, and increased IL-8/protein ratios in NLF compared to RSV-negative illnesses. Among RSV-positive infants, bronchiolitics had greater total cell counts and percentage epithelial cells in NLF than nonbronchiolitics. Bronchiolitics also had roughly twice the NLF RANTES/IL-8 ratio than nonbronchiolitics (P =.043). Semiquantitative reverse transcriptase-polymerase chain reaction of nasal epithelium suggested similar RANTES/IL-8 ratio increases among bronchiolitics. A more mildly affected, RSV-positive outpatient population showed none of these differences. We conclude that RSV bronchiolitis is associated with a shift toward relatively more RANTES in nasal secretions of infants sick enough to require hospitalization, and mucosal epithelium may contribute to this process. Similar processes in the lower airways may enhance inflammation due to RANTES-responsive cell types and affect clinical manifestations.

Interleukin-15 Prevents Mouse Mast Cell Apoptosis through STAT6-mediated Bcl-xL Expression

Interleukin (IL)-15 is a member of the cytokine family with T and natural killer (NK) cell growth-promoting activity. In mast cells, however, IL-15 uses a distinct receptor system different from that used in T and NK cells. We recently reported that IL-15 induces STAT6 activation and IL-4 production in a mouse mast cell line (MC/9) and bone marrow-derived mast cells. In the present study, we have demonstrated that IL-15 prevents MC/9 and bone marrow-derived mast cell apoptosis induced by factor withdrawal or anti-Fas antibody treatment. IL-15 increased mRNA and protein levels of an anti-apoptotic protein (Bcl-x(L)) in these cells, whereas bcl-2 mRNA remained unchanged. In addition, the transcriptional activity of the bcl-x(L) promoter was increased by IL-15 in MC/9 cells. In an electrophoretic mobility shift assay, IL-15 induced STAT6 binding to the STAT recognition site in the bcl-x(L) gene promoter. Furthermore, the expression of a dominant-negative form of STAT6 abrogated the effects of IL-15 on both bcl-x(L) mRNA up-regulation and prevention of apoptosis in mast cells. Altogether, our results suggest that IL-15 plays an important role in maintaining the number of mast cells through Bcl-x(L) expression mediated by STAT6.

Chemokines in nasal secretions of normal adults experimentally infected with respiratory syncytial virus

The goal of this study was to determine time courses of upregulation of several chemokines in nasal secretions after inoculation of human subjects with a low dose of live respiratory syncytial virus (RSV). Healthy, nonsmoking young adults were admitted to an inpatient clinical research unit. After baseline studies, subjects were nasally inoculated with approximately 10(3) plaque-forming units of RSV (strain A2), followed by daily nasal lavages. Nasal lavage fluid (NLF) was assayed for chemokines by specific ELISA. Of 10 subjects inoculated with RSV, 3 developed clinical symptoms of upper respiratory infection and also shed virus. Among infected subjects, there was a transient postinoculation increase in interleukin-8 (IL-8) in NLF to an average of 2.7-fold compared to baseline, followed by a prolonged increase (maximum mean 5.4-fold) during virus shedding. RANTES, MIP-1alpha, and MCP-1 all increased during virus shedding only (maximum mean increases of 5.3-fold, 13-fold, and 7.2-fold, respectively). Semiquantitative RT-PCR in brushed nasal epithelial cells on day 6 after inoculation suggested upregulation of RANTES, but not IL-8, mRNA during virus shedding. We conclude that chemokines IL-8, RANTES, MIP-1alpha, and MCP-1 are all increased in nasal secretions in human RSV infection at the time of virus shedding and symptomatic illness and that the epithelium lining the nasal turbinate contributes to the increase in RANTES.

Modification of the inflammatory response to allergen challenge after exposure to bacterial lipopolysaccharide

The potential role of respiratory infections in altering the development of atopy and asthma is complex. Infections have been suggested to be effective in preventing the induction of T-helper 2-polarized allergen-specific immunity in early life, but also to exacerbate asthma in older, sensitized individuals. The mechanism(s) underlying these effects are poorly defined. The aim of this work was to determine the influence of lipopolysaccharide (LPS) exposure on the development of sensitization to allergen and the response to allergen challenge in vivo. Piebald-Virol-Glaxo rats were exposed to a single aerosol of LPS 1 d before or 1, 2, 4, 6, 8, or 10 d after sensitization with ovalbumin (OVA). On Day 11 animals were exposed to 1% OVA and responses to allergen were measured 24 h later, monitoring inflammatory cell influx and microvascular leakage into bronchoalveolar lavage (BAL) fluid as well as pulmonary responses to methacholine using the forced oscillation technique. Histologic analysis was included to complement the BAL results. Single aerosol exposure to LPS 1 d before and up to 4 d after intraperitoneal injection of OVA protected against the development of OVA-specific immunoglobulin (Ig) E. LPS exposure 6, 8, or 10 d after sensitization further exacerbated the OVA-induced cellular influx, resulting in neutrophilia and increased Evans Blue dye leakage with no effect on serum IgE levels. In addition, LPS abolished the OVA-induced hyperresponsiveness in sensitized animals when given 18 h after OVA challenge. This study demonstrates that exposure to LPS can modify the development of allergic inflammation in vivo by two independent mechanisms. Exposure early in the sensitization process, up to Day 6 after exposure to allergen, prevented allergen sensitization. Exposure to LPS after allergen challenge in sensitized animals abolished the hyperresponsiveness and modified the inflammatory cell influx characteristic of late-phase response to allergen.

Treatment of recurrent respiratory tract infections with a polyvalent bacterial lysate: results of an open, prospective, multinational study

This multicenter, open study, carried out in 14 countries in Europe, Latin America, and Asia, recruited 4965 patients suffering from recurrent respiratory tract infections to investigate the safety and acceptability of the oral bacterial lysate immunomodulator LW 50020. Patients remained in the study for 4 months (two 4-week courses of LW 50020 separated by a 28-day treatment-free interval and follow-up). The incidence of all adverse events was 7.2%; that of adverse drug reactions was 0.6%. Adverse drug reactions were mild to moderate and not more frequent in the large subgroup of patients (77%) with a known history of allergies or underlying respiratory diseases; however, the incidence of adverse events in this subgroup was twofold higher than in the study population as a whole, probably indicating a generally increased vulnerability to disease. No clinically relevant changes in laboratory variables followed treatment. Comparison of the first study period (first course of LW 50020 and drug-free interval) with the second study period (second course of LW 50020 and follow-up) showed an overall reduction of at least 50% in the number, severity, and duration of respiratory tract infections, the number of antibiotic and symptomatic treatments, and the number of days absent from school or work. Tolerability and acceptability were assessed as good or very good in 99% of patients who completed the study.

Effects of inhaled corticosteroids on the consequences of asthma

Asthma is a chronic inflammatory disease of the airways involving a characteristic pattern of airway infiltration with lymphocytes, eosinophils, and mast cells, subepithelial deposition of collagen, and hypertrophy and hyperplasia of smooth muscle and of goblet cells and submucosal glands. The consequences of this chronic process include episodic or persistent symptoms, bronchial hyperreactivity, attacks of bronchoconstriction that may require emergency care or hospitalization and can lead to death, impairment in quality of life, and the development of irreversible airflow obstruction. Careful pathologic studies have shown that inhaled corticosteroid therapy can reverse or suppress airway inflammation, and prospective controlled clinical trials have proven that it can also improve symptoms, reduce bronchial hyperreactivity, and reduce the frequency and severity of attacks. It is also highly likely, although it is not yet proven, that inhaled corticosteroid therapy reduces the risk of asthma fatality and prevents or retards airway wall remodeling. These beneficial effects are easily shown in patients with moderate or severe asthma. Although inhaled corticosteroid therapy also benefits patients with mild asthma, it is less certain that the costs and risks of continuous therapy are justified. For these patients, the most important issues that remain to be resolved are the nature of the risk of development of permanent airflow obstruction and the effects of early, sustained treatment on the chances of sustained remission of asthma after all therapy has been stopped.

Airway hyperresponsiveness: first eosinophils and then neuropeptides

Airway hyperreactivity to bronchoconstrictor mediators is a main characteristic in the majority of asthmatic patients and correlates well with the severity of the disease. The airways of asthmatic patients are characterized by an inflammatory state resulting in activation of lung tissue cells and attraction and infiltration of leukocytes from the blood. The accumulation of eosinophilic leukocytes is a prominent feature of inflammatory reactions that occurs in allergic asthma. The increase in number of eosinophils is important since it correlates in time with an increase in bronchial hyperresponsiveness. Viral respiratory infections can also induce eosinophilia and airway hyperresponsiveness in humans and animals and can worsen asthmatic reactions. This report reviews current opinions on the relationship between inflammation-induced eosinophil accumulation/activation and the development of airway hyperresponsiveness and the possible role for sensory neuropeptides in this process. Firstly, CC chemokines play an important role in allergic airway inflammation and respiratory viral infections leading to eosinophil recruitment. Secondly, it can be concluded that IL5 is involved in the development in airway hyperresponsiveness. IL5 has profound effects on eosinophils as promoter of growth, differentiation and proliferation, chemoattractant, activator and primer. However, it is conceivable that in animal models for allergic asthma besides IL5 other regulatory mediators may be involved in eosinophil migration and activation in the lung, which in turn will lead to airway hyperresponsiveness. Recent data support the possible role of eotaxin and its eosinophil-specific receptor CCR-3 in eosinophil chemotaxis and activation in allergic asthma. Moreover, it is suggested that the development of airway eosinophilia in vivo involves a two-step mechanism, elicited by eotaxin and IL5. The precise mechanism by which eosinophils induce bronchial hyperresponsiveness is at present unknown. Sensory neuropeptides could be important mediators in this process, since it has been demonstrated that airway nerves are surrounded by and infiltrated with eosinophils after antigen challenge. Sensory neuropeptides could be the final, more downstream, common pathway after eosinophil infiltration and activation in inducing airway hyperresponsiveness due to allergen inhalation or respiratory viral infections. In conclusion, in the process of the development of airway hyperresponsiveness observed during viral infections or in allergic asthma, the IL5/eotaxin-induced infiltration and activation of eosinophils in the airways is evident. Following this step, eosinophil-derived inflammatory mediators will induce the release of sensory neuropeptides (possibly NK2-receptor activating tachykinins) which in turn will lead to airway hyperresponsiveness.

The Pathophysiology of Asthma

Atopy predisposes an individual to the development of asthma, whereby specific triggers may repeatedly cause acute exacerbations and contribute to chronic inflammation. This IgE-mediated response to common allergens is the strongest predisposing factor for developing asthma. Airway inflammation involves release of immunological mediators via T lymphocyte dependent, and IgE dependent and independent mechanisms which attract inflammatory cells from the circulation. The role of the eicosanoids as pivotal mediators in promoting some of the changes in asthma has only recently been fully explored. Inflammatory reactions result when mediators and cytokines released from resident and infiltrating cells interact. This interaction also contributes to the bronchoconstriction, hypersecretion, and mucosal edema in the airways.

Perioperative management for childhood asthma

BACKGROUND

Children with asthma have been reported to be at increased risk for intraoperative bronchospasm. Current medical literature focuses on this problem in adult patients. This is a report of our experience in children.

OBJECTIVE

The purpose of this study was to discern whether children with reactive airways disease (asthma) actually had a high likelihood of perioperative bronchospasm as the medical literature suggests.

METHODS

A retrospective chart review of 386 asthmatic children and 51 with bronchopulmonary dysplasia seen perioperatively between 1987 and 1992 was instituted. Children with asthma were classified as mild, moderate or severe based on the number of hospitalizations, emergency room visits, intensive care unit admissions and medications at the time of evaluation. Patients with bronchopulmonary dysplasia were included in a separate category. Individualized asthma management was recommended for all patients in preparation for surgery. Blood gases, chest radiographs and pulmonary function studies were not routinely ordered.

RESULTS

Only 3 of 437 children in a five-year period (0.13%) had intraoperative bronchospasm, easily controlled with the use of beta-2 agonists.

CONCLUSIONS

This study demonstrates that asthmatic children appropriately prepared for surgery do not appear to have an increased risk for adverse outcome. The children treated with more than inhaled beta-2 agonists were those who had more severe asthma, recent viral infection, recent exacerbation of asthma, or recent hospitalization for asthma.

The pathogenesis of chronic obstructive pulmonary disease of horses

Present evidence suggests that chronic obstructive pulmonary disease (COPD) of horses is a delayed hypersensitivity response to inhaled antigens, particularly the thermophilic moulds and actinomycetes that grow in damp hay. Within several hours of exposing COPD-susceptible horses to such hay, neutrophils invade the lung and accumulate in the lumens of airways, particularly bronchioles. The inflammatory response is accompanied by increased levels of histamine in bronchoalveolar lavage fluid, increased plasma levels of the inflammatory mediators thromboxane and 15-hydroxyeicosatetraenoic acid (15-HETE), and a decrease in the production of prostaglandin (PG) E2 by the airway mucosa. During acute exacerbations of COPD, airways exhibit nonspecific hyperresponsiveness and become obstructed as a result of bronchospasm and the accumulation of mucus and exudates. Bronchospasm is due largely to activation of smooth muscle muscarinic receptors by acetylcholine (ACh). Because the in vitro response of smooth muscle to ACh is unaltered, the increase in airway smooth muscle tone is probably a result of activation of airway reflexes by inflammatory mediators and decreases in inhibitory mechanisms such as the intrapulmonary nonadrenergic noncholinergic nervous system and the production of PGE2 in affected horses. The diffuse airway obstruction leads to uneven distribution of ventilation, ventilation/perfusion mismatching, and hypoxaemia. As a result of the increased respiratory drive caused by hypoxaemia and the presence of airway obstruction, horses adopt a characteristic breathing strategy in which very high peak flows at the start of exhalation rapidly diminish as exhalation proceeds.

The effects of rhinovirus infections on allergic airway responses

Although it has long been recognized that the common cold is a potent trigger for symptoms of asthma, the mechanisms underlying the association between upper respiratory infection and increased lower airway obstruction remain obscure. The use of experimental infection of volunteers with or without respiratory allergies has enabled direct comparisons of common cold symptoms in these two groups. Furthermore, techniques such as bronchoalveolar lavage and segmental antigen challenge have been used to directly sample lower airway fluids and tissues during acute viral infection. This review summarizes the findings of studies examining the separate and combined effects of rhinovirus infection and allergen exposure on airway physiology and inflammation.