Progression of chronic obstructive pulmonary disease: impact of inflammation, comorbidities and therapeutic intervention

Serum levels of erythropoietin in patients with chronic obstructive pulmonary disease and anemia

The important association of erythropoietin (EPO) serum levels and chronic obstructive pulmonary disease (COPD) with anemia has been inadequately studied and remains a controversial issue. We aimed to shed light on this matter by comparing EPO levels in anemic and non-anemic COPD patients, along with a review of published literature. This cross-sectional study was conducted on COPD patients referred to the pulmonary clinic of Shahid Faghihi Hospital and Motahari clinic, Shiraz, Iran, for one year. We measured complete blood count, red blood cell indices, serum iron, TIBC and ferritin levels, serum EPO levels, and body mass index. Among 35 patients in this study, 28 males and 7 females were enrolled with a mean age of 54.57 ± 8.07 years. The average Forced expiratory volume in first second (FEV1) was 37.26 ± 7.33% and FEV1/FVC was 0.46 ± 0.12. Mean EPO levels were 30.29 ± 2.066 mU/mL. No statistically significant association was observed among erythropoietin levels and Hb, COPD severity, and age. There was no significant difference in EPO levels between anemic and non-anemic patients. EPO level, against the traditional expectation, didn't increase in COPD patients. EPO production also didn't compensate for the anemia of chronic disease which considers as a common comorbid disorder in these patients.

Respiratory neuroplasticity: Mechanisms and translational implications of phrenic motor plasticity

Widespread appreciation that neuroplasticity is an essential feature of the neural system controlling breathing has emerged only in recent years. In this chapter, we focus on respiratory motor plasticity, with emphasis on the phrenic motor system. First, we define related but distinct concepts: neuromodulation and neuroplasticity. We then focus on mechanisms underlying two well-studied models of phrenic motor plasticity: (1) phrenic long-term facilitation following brief exposure to acute intermittent hypoxia; and (2) phrenic motor facilitation after prolonged or recurrent bouts of diminished respiratory neural activity. Advances in our understanding of these novel and important forms of plasticity have been rapid and have already inspired translation in multiple respects: (1) development of novel therapeutic strategies to preserve/restore breathing function in humans with severe neurological disorders, such as spinal cord injury and amyotrophic lateral sclerosis; and (2) the discovery that similar plasticity also occurs in nonrespiratory motor systems. Indeed, the realization that similar plasticity occurs in respiratory and nonrespiratory motor neurons inspired clinical trials to restore leg/walking and hand/arm function in people living with chronic, incomplete spinal cord injury. Similar application may be possible to other clinical disorders that compromise respiratory and non-respiratory movements.

Nutrition as a modifiable factor in the onset and progression of pulmonary function impairment in COPD: a systematic review

CONTEXT

Chronic obstructive lung disease (COPD) is a progressive lung disease characterized by persistent airflow limitation. An increasing amount of evidence suggests an effect of dietary quality on the risk of COPD in the general population and pulmonary function decline in patients with COPD.

OBJECTIVE

The association of dietary intake and nutrient status with COPD risk and onset, as well as pulmonary function decline (change in forced expiratory volume in 1 second, forced vital capacity, or the ratio of the former to the latter) in patients with COPD was investigated in this systematic review.

DATA SOURCES

The PubMed database was searched by combining terms of pulmonary function or COPD with diet, nutrient status, or nutritional supplementation.

DATA EXTRACTION

Original studies and systematic reviews and meta-analyses were included. Articles obtained were independently screened for relevance on the bases of title and abstract by 2 researchers. Eventually, 89 articles were included in the analysis.

RESULTS

The unhealthy Western-style diet is associated with an increased risk of COPD and an accelerated decline of pulmonary function. Intake of fruit, vegetables, dietary fibers, vitamins C and E, polyphenols, and β-carotene were individually associated with lower COPD risk, whereas consumption of processed meat was associated with higher COPD risk. Data on the effect of dietary quality on pulmonary function decline in patients with COPD are limited and inconsistent. Strong evidence for beneficial effects on pulmonary function decline was found only for vitamin D supplementation.

CONCLUSION

Considering the increasing burden of COPD, more attention should be given to dietary quality as a modifiable factor in disease development and progression in patients with COPD.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42021240183.

Prevalence and Predictors of Metabolic Syndrome among Patients with Bronchial Asthma: A Cross Sectional Study

Background

Recent studies have reported the epidemiological link between Metabolic Syndrome (MS) and asthma, but it has rarely been studied in Egypt. The study aimed to investigate the prevalence of MS and its predictors among asthma patients in Egypt.

Methods

In total, 320 patients with bronchial asthma were included. The following were assessed: spirometric evaluation, anthropometric indices, blood pressure, fasting blood sugar and serum lipid profile. We analyzed the correlation between metabolic scores and patient characteristics. Predictors of MS were identified using logistic regression analysis.

Results

The prevalence of MS was 57.5% in asthma patients. For asthma patients, low High-Density Lipoprotein (HDL) and abdominal obesity were the commonest metabolic abnormality. Waist circumference, Fasting Blood Sugar (FBS) and triglyceride correlated significantly with asthma (P ‹ 0.05). FBS and DBP were the best predictors of MS.

Conclusion

MS is frequent in asthma patients in Egypt. Obesity and lipid abnormalities were the commonest metabolic abnormality. Screening of these patients for components of metabolic syndrome should be a part of routine workup.

Xiaoqinglong decoction (a traditional Chinese medicine) combined conventional treatment for acute exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

A traditional Chinese medicine classic herbal formula named Xiaoqinglong decoction (XQLD) is widely used in China for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The efficacy and safety of XQLD for AECOPD was evaluated in this systematic review.

METHODS

Five databases, including the Cochrane Library, PubMed, China National Knowledge Infrastructure, Wanfang database, and Chinese Science and Technology Periodical Database were searched up to October 5, 2018 for randomized control trials in treating AECOPD with XQLD.

RESULT

Thirty-eight trials were identified. Compared with conventional therapy (CT), XQLD plus CT significantly improve the total clinical efficacy rate (Risk Ratio [RR] = 1.22, 95% confidence interval [CI] = 1.18-1.26, P < .00001). Forced expiratory volume in the first second (FEV1) (mean difference [MD] = 0.37, 95% CI = 0.27-0.46; P < .00001), FEV1%pre (MD = 4.52, 95% CI = 2.42-6.62; P < .00001), FEV1/forced vital capacity (MD = 5.11, 95% CI = 4.21-6.00; P < .00001), PaO2 (MD = 7.17, 95% CI = 4.80-9.54; P < .00001); lowered cough symptom score (MD = -0.65; 95% CI = -0.70 to -0.59; P < .00001), sputum symptom score (MD = -0.41; 95% CI = -0.45 to -0.37; P < .00001), wheezing symptom score (MD = -0.49; 95% CI = -0.60 to -0.38; P < .00001); reduce cough relief time (MD = -1.28; 95% CI = -1.53 to -1.02; P < .00001), sputum relief time (MD = -1.19; 95% CI = -1.42 to -0.96; P < .00001), wheezing relief time (MD = -1.65; 95% CI = -2.63 to -0.68; P = .0009), lassitude relief time (MD = -2.16; 95% CI = -3.44 to -0.89; P = .0009), and PaCO2 (MD = -7.63, 95% CI = -9.62 to -5.63; P < .00001). Benefit for interleukin (IL)-4 (MD = -9.20, 95% CI = -13.59 to -4.81; P < .00001), IL-6 (MD = -5.07, 95% CI = -8.14 to -2.01; P = .001), IL-8 (MD = -5.59, 95% CI = -6.09 to -5.08; P < .00001), tumor necrosis factor (TNF)-α (MD = -5.93, 95% CI = -6.97 to -4.89; P < .00001), Interferon (INF)-γ (MD = 18.03, 95% CI = 13.22-22.84; P < .00001), and C-reactive protein (MD = -3.93, 95% CI = -5.97 to -1.89; P = .0002). For adverse events, there were no difference between XILD plus CT and CT.

CONCLUSION

XQLD plus CT was more effective than CT alone for treating chronic obstructive pulmonary disease. Further higher quality trials are needed. The safety of XQLD remained uncertain.

Traditional Chinese medicine classic herbal formula Xiaoqinglong decoction for acute exacerbation of chronic obstructive pulmonary disease: A systematic review protocol

BACKGROUND

Xiaoqinglong decoction (XQLD) is 1 of the traditional Chinese medicine (TCM) classic herbal formula that is widely used in Asian for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). In recent years, there has been increasing interest in the use of XQLD to treat COPD in China. So it is necessary to update the research and re-evaluate the efficacy and safety of XQLD to provide up-to-date evidence for COPD management. Therefore, we provide a protocol for a systematic review of XQLD for COPD. This protocol is described for a systematic review to investigate the beneficial effects and safety of XQLD for AECOPD.

METHODS

A systematic literature search for article up to October 2018 will be performed in 3 Chinese electronic databases and 2 English electronic databases: Pubmed, Cochrane library, China national knowledge infrastructure (CNKI), Chinese science and technology periodical database (VIP), and Wanfang database. Inclusion criteria are randomized control trials of XQLD in treating AECOPD. The primary outcomes were total clinical efficacy rate, TCM symptom scores, TCM Symptom relief time. The secondary outcome was lung function, blood gas analysis, inflammatory cytokines and C-reactive protein (CRP). The summary results will be pooled using the random-effects model or fixed-effects model according to the heterogeneity of the included studies.

RESULT

This systematic review will provide an evidence of XQLD for AECOPD, and will submit to a peer-reviewed journal for publication.

CONCLUSION

The conclusion of this systematic review will provide evidence to judge whether XQLD is an effective intervention for AECOPD patients.

Traditional Chinese medicine tonifying kidney therapy (Bu shen) for stable chronic obstructive pulmonary disease: Protocol for a systematic review and meta-analysis

BACKGROUND

Traditional Chinese medicine (TCM) is commonly used to combine with pharmacotherapy for stable chronic obstructive pulmonary disease (COPD) in China and other Asian countries such as South Korea and Japan. The objective of this systematic review is to evaluate the efficacy and safety of tonifying kidney therapy (Bushen, TK) for stable COPD.

METHODS

Randomized controlled trials (RCTs) of TK for stable COPD were searched from 4 databases including Pubmed, the Cochrane library, CBM (China Biology Medicine disc, CBMdisc), CNKI (China National Knowledge Infrastructure) from inception to December 2017. Two reviewers independently screened the literature, extracted the data and assessed the risk of bias in included studies. RevMan 5.3 software was used for meta-analysis. The primary outcomes analyzed in this meta-analysis were effectiveness, TCM Syndrome Score, dyspnea (modified Medical Research Council questionnaire [mMRC]), COPD health status (COPD Assessment Test [CAT]), exercise capacity (6-min walk distance in meters [6mWD]), and respiratory-specific quality of life (St George's Respiratory Questionnaire [SGRQ]). Second outcomes analyzed for this meta-analysis were lung function (forced expiratory volume in 1 second [FEV1], FEV1%, forced vital capacity [FVC], FEV1/FVC), the frequency of acute exacerbation, T-lymphocyte subsets (CD4, CD8, CD4/CD8), and immunoglobulin (IgA, IgG, and IgM). The summary results will be pooled using the random-effects model or fixed-effects model according to the heterogeneity of the included studies.

RESULT

This systematic review will provide an evidence of TK for stable COPD, and will submit to a peer-reviewed journal for publication.

CONCLUSION

The conclusion of this systematic review will provide evidence to judge whether TK is an effective intervention for stable COPD patients.

PROSPERO REGISTRATION NUMBER

PROSPERO CRD 42018090328.

Serum endocan levels in patients with stable COPD

Background

Endothelial cell specific molecule-1, also called as endocan, is a dermatan sulfate proteoglycan, which is expressed by endothelial cells in alveolar walls of the lung and kidney. High endocan levels are found associated with endothelial dysfunction and inflammation. We hypothesize that endocan level is also high in COPD due to systemic inflammation and endothelial dysfunction. We aimed to investigate the expression of endocan in patients with stable COPD.

Material and methods

The study included patients with COPD and control subjects. COPD patients were classified according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 criteria. Demographics, body mass index, smoking history, and comorbidities were recorded. Endocan levels of COPD patients and controls were compared.

Results

Totally, 88 subjects (47 stable COPD patients, 41 controls) were evaluated. Endocan levels were significantly higher in COPD patients than control group (860.1±259.8 vs 647.3±316.9 pg/mL, P=0.001). There was no relationship between GOLD COPD categories and endocan levels. Also endocan levels were similar between COPD patients with or without hypoxemia.

Conclusion

Serum endocan level was significantly higher in patients with stable COPD. Further studies should be performed to better understand the relationship between endocan and COPD.

Pharmacokinetic and Pharmacodynamic Modelling to Characterize the Tolerability of Alternative Up-Titration Regimens of Roflumilast in Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

In the OPTIMIZE study, 4 weeks of roflumilast 250 µg once daily before escalation to the approved 500 µg once daily maintenance dose reduced treatment discontinuations and improved tolerability to roflumilast among patients with chronic obstructive pulmonary disease (COPD). In this study, we present the pharmacokinetic (PK) results and PK/pharmacodynamic (PD) modelling data from OPTIMIZE.

METHODS

OPTIMIZE was a multicentre, double-blind, phase III study in which patients with severe COPD were randomized 1:1:1 to receive oral roflumilast 250 μg once daily, 500 μg every other day, or 500 μg once daily for 4 weeks, followed by 500 μg once daily for 8 weeks. A population PK (popPK) model characterized roflumilast exposure levels (total phosphodiesterase-4 inhibition [tPDE4i]). Furthermore, models characterized the percentage of patients with adverse events (AEs) of interest (PK/AE model), and time to discontinuation due to such AEs (PK/time-to-event model).

RESULTS

The popPK model adequately described average plasma concentrations and variability from 1238 patients. The percentage of patients with AEs of interest increased with predicted tPDE4i exposure (logit scale slope 0.484; confidence interval 0.262-0.706; p = 2 × 10-5). PK/time-to-event model analysis predicted that patients receiving the 250 μg up-titration regimen had significantly lower discontinuation rates and longer time to discontinuation compared with roflumilast 500 μg every other day or 500 μg once daily (p = 0.0014).

CONCLUSIONS

In this PK/PD model, a 4-week up-titration regimen with roflumilast 250 µg once daily was found to reduce discontinuations and improve tolerability, confirming the main clinical findings of the OPTIMIZE study. However, use of this lower dose as long-term maintenance therapy may not induce sufficient phosphodiesterase-4 inhibition to exert clinical efficacy, supporting the approval of 500 µg as maintenance dose.

TRIAL REGISTRATION

OPTIMIZE: NCT02165826; REACT: NCT01329029.

Association of meteorological factors and air NO2 and O3 concentrations with acute exacerbation of elderly chronic obstructive pulmonary disease

We studied the combined effect of air pollutant concentrations and meteorological factors [e.g., temperature and atmospheric pressure (AP)] on the acute exacerbation of coronary obstructive pulmonary disease (COPD) in 277 older patients with COPD (240 men and 37 women; average age, 75.3 ± 9.3 years). Average air pollutant concentrations, AP, temperature, and relative humidity corresponding to each of the 7 days before the date of hospitalisation were identified as the case and the two other weekly averages, 4 and 8 weeks prior to admission, were considered the controls. During the warming-up season, COPD exacerbation more likely occurred on days of temperature increase or AP decrease than on other days. Increments in CO, NO₂ and O₃ concentrations were significantly associated with 5%, 11% and 4% increases in COPD exacerbation risks, respectively. During the cooling-down season, increments in PM₁₀ concentrations were significant risk factors; the exacerbation likely occurred on days of temperature decreases than on other days. Air pollution with increased NO₂, CO, O₃ and PM₁₀ concentrations and continual temperature changes (colder during cooling-down seasons or hotter during warning-up seasons) were associated with acute exacerbation of COPD in older patients.

Hospitalization Trends in Adult Patients with COPD and Other Respiratory Diseases in Northeast China from 2005 to 2015

Chronic obstructive pulmonary disease (COPD), pneumonia, asthma, and lung cancer are four common respiratory diseases that impose a substantial economic burden on both patients and government in China. The objective of our study is to analyze the temporal trends of several clinical tracking metrics for hospitalization regarding these diseases. Hospital discharge data of 54 hospitals for the period 2005–2015 were derived from the Health and Family Planning Commission in Northeast China. The age-adjusted rate of discharge for the four respiratory diseases increased significantly (COPD, pneumonia, asthma: P trend <  .001; lung cancer: P trend =  .046). The mean LOS for the four diseases all showed a significant decline (P trend <  .001), whereas the mean charge per stay and aggregate charge followed an upward trend over time (P trend <  .001). There was a clear upward trend for the readmission rate for asthma patients (P trend =  .001), while the trend for COPD patients was unclear (P trend =  .224). Age-adjusted discharge rates, LOS, and charges for hospitalization regarding several common respiratory diseases in China showed different patterns of change over the past decade. Our results should aid government and administrators in making informed decisions about the management and treatment of respiratory diseases.

T-cell profile and systemic cytokine levels in overweight-obese patients with moderate to very-severe COPD

This study aimed to evaluate the immune profile of lean and overweight-obese COPD patients. Forty patients with moderate to very severe COPD were divided into lean group (n=20; aged 62.00±8.91years; BMI 22.26±1.65kg/m²) or overweight-obese group (n=20; aged 65.40±6.69years; BMI 29.19±3.55kg/m²). The cytokine profile (IL-2, IL-4, IL-6, IL-10, INF-γ, and TNF-α) was evaluated through the Cytometric Bead Array technique, and the expression of CD4, CD8, CD25, CD45ra, CD45ro, CD69, CD195(CCr5) and HLA-DR were evaluated in CD3+ T-cells. Overweight-obese COPD group had lower levels of IL-2 (p=0.01) and higher INF-γ levels (p=0.02) and IL-6 (p=0.003) than lean COPD. Lean COPD patients had higher CD25+ (p=0.01), CCr5 (p=0.04) and HLA-DR (p=0.007) expression on T cell surface compared to overweight-obese COPD participants. These changes are related to immune dysfunction of obesity, and excess of fat mass in COPD can be a key factor to low T-cells activation.

Ectopic fat accumulation in patients with COPD: an ECLIPSE substudy

BACKGROUND

Obesity is increasingly associated with COPD, but little is known about the prevalence of ectopic fat accumulation in COPD and whether this can possibly be associated with poor clinical outcomes and comorbidities. The Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) substudy tested the hypothesis that COPD is associated with increased ectopic fat accumulation and that this would be associated with COPD-related outcomes and comorbidities.

METHODS

Computed tomography (CT) images of the thorax obtained in ECLIPSE were used to quantify ectopic fat accumulation at L2-L3 (eg, cross-sectional area [CSA] of visceral adipose tissue [VAT] and muscle tissue [MT] attenuation, a reflection of muscle fat infiltration) and CSA of MT. A dose-response relationship between CSA of VAT, MT attenuation and CSA of MT and COPD-related outcomes (6-minute walking distance [6MWD], exacerbation rate, quality of life, and forced expiratory volume in 1 second [FEV₁] decline) was addressed with the Cochran-Armitage trend test. Regression models were used to investigate possible relationships between CT body composition indices and comorbidities.

RESULTS

From the entire ECLIPSE cohort, we identified 585 subjects with valid CT images at L2-L3 to assess body composition. CSA of VAT was increased (P<0.0001) and MT attenuation was reduced (indicating more muscle fat accumulation) in patients with COPD (P<0.002). Progressively increasing CSA of VAT was not associated with adverse clinical outcomes. The probability of exhibiting low 6MWD and accelerated FEV₁ decline increased with progressively decreasing MT attenuation and CSA of MT. In COPD, the probability of having diabetes (P=0.024) and gastroesophageal reflux (P=0.0048) at baseline increased in parallel with VAT accumulation, while the predicted MT attenuation increased the probability of cardiovascular comorbidities (P=0.042). Body composition parameters did not correlate with coronary artery scores or with survival.

CONCLUSION

Ectopic fat accumulation is increased in COPD, and this was associated with relevant clinical outcomes and comorbidities.

The place of inhaled corticosteroids in the treatment of chronic obstructive pulmonary disease: a narrative review

Inhaled corticosteroids (ICSs) belong to the armament for treatment of chronic obstructive pulmonary disease (COPD) and as such, they are widely used in real life. This is a narrative review on evidence-based papers published in the English language listed in Medline between 1990 and March 2016 discussing ICS application in COPD. Recent meta-analyses clearly show that ICSs are able to decrease the rate of exacerbation and to delay the decline of lung function, although they do not prolong life, nor stop the progression of the disease. ICSs are included in guidelines for COPD treatment, exclusively in combination with bronch-15 odilators. However, adverse effects as pneumonia, cataracts, osteoporosis, etc. seem obvious. Newer studies show that patients with COPD are not a homogeneous population, and recently several phenotypes were identified, including asthma-COPD overlap syndrome (ACOS), among others. The efficacy of ICSs seems to be unequal for different subpopulations of patients with COPD and further research is needed to address a personalized approach in the treatment of COPD patients, and to 20 identify predictors for ICS treatment success. Usage of ICSs in patients with COPD needs to be précised especially in patients with COPD without asthma.

Serum Cystatin C as an Inflammatory Marker in Exacerbated and Convalescent COPD Patients

Chronic obstructive pulmonary disease (COPD) is a common chronic inflammatory disease with high morbidity and mortality rates. Cystatin C (Cys C) is a sensitive indicator for various chronic inflammatory diseases. In this study, we aimed to evaluate the role of Cys C in COPD patients comparing with the other well-known inflammatory markers. Ninety patients with acute exacerbated COPD were studied and were reassessed when convalescent. Ninety controls were matched for age, gender, body mass index, smoking index, and comorbidity. Serum Cys C was significantly increased in convalescent COPD patients compared with healthy controls and further increased in COPD patients with an acute exacerbation. Serum Cys C was positively correlated with hsCRP both in the exacerbation and convalescence periods of COPD and negatively correlated with FEV1% predicted and FEV1/FVC in the convalescent COPD patients. In conclusion, serum Cys C is a positive acute-phase reactant in COPD patients and might indicate systemic inflammation during the progression of COPD.

Simvastatin requires activation in accessory cells to modulate T-cell responses in asthma and COPD

T-cell-dependent airway and systemic inflammation triggers the progression of chronic obstructive pulmonary disease (COPD) and asthma. Retrospective studies suggest that simvastatin has anti-inflammatory effects in both diseases but it is unclear, which cell types are targeted. We hypothesized that simvastatin modulates T-cell activity. Circulating CD4+ and CD8+ T-cells, either pure, co-cultured with monocytes or alveolar macrophages (AM) or in peripheral blood mononuclear cells (PBMCs), were ex vivo activated towards Th1/Tc1 or Th2/Tc2 and incubated with simvastatin. Markers for Th1/Tc1 (IFNγ) and Th2/Tc2 (IL-5, IL-13) were measured by ELISA; with PBMCs this was done comparative between 11 healthy never-smokers, 11 current smokers without airflow limitation, 14 smokers with COPD and 11 never-smokers with atopic asthma. T-cell activation induced IFNγ, IL-5 and IL-13 in the presence and absence of accessory cells. Simvastatin did not modulate cytokine expression in pure T-cell fractions. β-hydroxy-simvastatin acid (activated simvastatin) suppressed IL-5 and IL-13 in pure Th2- and Tc2-cells. Simvastatin suppressed IL-5 and IL-13 in Th2-cells co-cultivated with monocytes or AM, which was partially reversed by the carboxylesterase inhibitor benzil. Simvastatin suppressed IL-5 production of Th2/Tc2-cells in PBMCs without differences between cohorts and IL-13 stronger in never-smokers and asthma compared to COPD. Simvastatin induced IFNγ in Th1/Tc1-cells in PBMCs of all cohorts except asthmatics. Simvastatin requires activation in accessory cells likely by carboxylesterase to suppress IL-5 and IL-13 in Th2/Tc2-cells. The effects on Il-13 are partially reduced in COPD. Asthma pathogenesis prevents simvastatin-induced IFNγ up-regulation. Simvastatin has anti-inflammatory effects that could be of interest for asthma therapy.

The Importance of Neutrophil-to-Lymphocyte Ratio in Chronic Obstructive Pulmonary Disease

OBJECTIVES

Chronic obstructive pulmonary disease (COPD) is a common lung disease characterized by airflow limitation and systemic inflammation. Recently, neutrophil-to-lymphocyte ratio (NLR) has gathered increasing interest in the detection of inflammation in inflammatory diseases. This study aimed to investigate the role of NLR in COPD for identifying the detection of inflammation and recognition of acute exacerbation.

MATERIAL AND METHODS

The laboratory results of 103 COPD patients were included into the study, of which 47 patients were in acute exacerbation and 56 patients were at stable period, and there were 40 gender and age-matched healthy controls. Complete blood count (CBC), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were evaluated. NLR was calculated from CBC.

RESULTS

NLR values of patients with COPD (both acutely exacerbated and stable) were found significantly higher than those of the controls (p< 0.001, p< 0.05; respectively). In all patients with COPD, NLR values positively correlated with serum CRP (r= 0.641, p< 0.001) and ESR (r= 0.276, p= 0.005) levels and negatively correlated with forced vital capacity (r= -0.20, p= 0.043) and forced expiratory volume in the 1st second (r= -0.288, p= 0.003). For an NLR cutoff of 3.34, sensitivity for detecting exacerbation of COPD was 78.7% and specificity was 73.2% (AUC 0.863, p< 0.001).

CONCLUSION

Our results suggest that NLR may be considered as a reliable and simple indicator in the determination of increased inflammation in patients with COPD. Furthermore, NLR could be useful for the early detection of possible acute exacerbations in patients with COPD.

Neutrophil-to-lymphocyte ratio in chronic obstructive pulmonary disease: a retrospective study

Chronic obstructive pulmonary disease (COPD) is a common chronic inflammatory disease of the lung with a high mortality and morbidity rate. Some of the inflammatory markers such as C-reactive protein (CRP), leukocyte count are associated with COPD. In this study, we aimed to evaluate the role of neutrophil-to-lymphocyte ratio (NLR) in COPD patients comparing with the other well-known inflammatory markers. We retrospectively enrolled the laboratory results of 269 COPD patients of which 178 patients at stable period and 91 patients during acute exacerbation and 50 sex- and age- matched healthy controls. We found that NLR values of the stable COPD patients were significantly higher than those of the controls (P < 0.001). During acute exacerbation of the disease there was a further increase compared to stable period (P < 0.001). NLR values were also positively correlated with serum CRP levels and red cell distribution width (RDW) and negatively correlated with mean platelet volume (MPV) in both COPD groups. In conclusion, NLR could be considered as a new inflammatory marker for assessment of inflammation in COPD patients with its quick, cheap, easily measurable property with routine complete blood count analysis.

The pharmacological approach to the elderly COPD patient

The elderly patient (65 years and older) with chronic obstructive pulmonary disease (COPD) can be a challenge to the clinician. This begins with the correct and early diagnosis, the assessment of disease severity, recognizing complicating comorbidities, determining the burden of symptoms, and monitoring the frequency of acute exacerbations. Comprehensive management of COPD in the elderly patient should improve health-related quality of life, lung function, reduce exacerbations, and promote patient compliance with treatment plans. Only smoking cessation and oxygen therapy in COPD patients with hypoxemia reduce mortality. Bronchodilators, corticosteroids, methylxanthines, phosphodiesterase-4 inhibitors, macrolide antibiotics, mucolytics, and pulmonary rehabilitation improve some outcome measures such as spirometry measures and the frequency of COPD exacerbations without improving mortality. International treatment guidelines to reduce symptoms and reduce the risk of acute exacerbations exist. Relief of dyspnea and control of anxiety are important. The approach to each patient is best individualized. Earlier use of palliative care should be considered when traditional pharmacotherapy fails to achieve outcome measures and before consideration of end-of-life issues.

The discovery of potent, orally bioavailable pyrimidine-5-carbonitrile-6-alkyl CXCR2 receptor antagonists

A hit-to-lead optimisation programme was carried out on the Novartis archive screening hit, pyrimidine 2-((2,6-dichlorobenzyl)thio)-5-isocyano-6-phenylpyrimidin-4-ol 4, resulting in the discovery of CXCR2 receptor antagonist 2-((2,3-difluorobenzyl)thio)-6-(2-(hydroxymethyl)cyclopropyl)-5-isocyanopyrimidin-4-ol 24. The SAR was investigated by systematic variation of the aromatic group at c-6, the linker between c-2 and the halogenated ring, and the c-5 nitrile moiety.

Clinical manifestations and pulmonary histopathological analysis related to different diseases in patients with fatal pulmonary thromboembolism: an autopsy study

Background

To correlate underlying diseases, in autopsies of patients with pulmonary thromboembolism (PTE) to histological findings and manifestations reviewed in the medical records.

Methods

The autopsy records between 2001 and 2008 of 291 patients whose cause of death was PTE were reviewed. The following data were obtained: age, sex, clinical “in vivo” manifestations, postmortem pathological patterns, and main associated underlying diseases, cancers, and surgeries performed in the last hospitalization. The pulmonary histopathological changes were categorized as diffuse alveolar damage, pulmonary edema, alveolar hemorrhage, and lymphoid interstitial pneumonia. Odds ratios of positive relations were obtained by logistic regression and were considered significant when P<0.05.

Results

The median age was 64 years old. About 64% of patients presented cardiovascular illness associated with PTE. The most prevalent pulmonary finding was pulmonary edema. Only 13% of cases had clinical suspicion of PTE. Acute respiratory failure was positively related to pulmonary edema, alveolar hemorrhage, and diffuse alveolar damage as well as hemodynamic instability to alveolar hemorrhage and diffuse alveolar damage.

Conclusion

We found important relations between clinical data and histological findings of patients with fatal PTE. A greater understanding of the pulmonary physiopathological mechanisms involved with each disease associated to PTE could improve its diagnosis and treatment.

Common mechanisms of compensatory respiratory plasticity in spinal neurological disorders

In many neurological disorders that disrupt spinal function and compromise breathing (e.g. ALS, cervical spinal injury, MS), patients often maintain ventilatory capacity well after the onset of severe CNS pathology. In progressive neurodegenerative diseases, patients ultimately reach a point where compensation is no longer possible, leading to catastrophic ventilatory failure. In this brief review, we consider evidence that common mechanisms of compensatory respiratory plasticity preserve breathing capacity in diverse clinical disorders, despite the onset of severe pathology (e.g. respiratory motor neuron denervation and/or death). We propose that a suite of mechanisms, operating at distinct sites in the respiratory control system, underlies compensatory respiratory plasticity, including: (1) increased (descending) central respiratory drive, (2) motor neuron plasticity, (3) plasticity at the neuromuscular junction or spared respiratory motor neurons, and (4) shifts in the balance from more to less severely compromised respiratory muscles. To establish this framework, we contrast three rodent models of neural dysfunction, each posing unique problems for the generation of adequate inspiratory motor output: (1) respiratory motor neuron death, (2) de- or dysmyelination of cervical spinal pathways, and (3) cervical spinal cord injury, a neuropathology with components of demyelination and motor neuron death. Through this contrast, we hope to understand the multilayered strategies used to "fight" for adequate breathing in the face of mounting pathology.

Premature lung aging and cellular senescence in the pathogenesis of idiopathic pulmonary fibrosis and COPD/emphysema

Different anatomic and physiological changes occur in the lung of aging people that can affect pulmonary functions, and different pulmonary diseases, including deadly diseases such as chronic obstructive pulmonary disease (COPD)/emphysema and idiopathic pulmonary fibrosis (IPF), can be related to an acceleration of the aging process. The individual genetic background, as well as exposure to a variety of toxic substances (cigarette smoke in primis) can contribute significantly to accelerating pulmonary senescence. Premature aging can impair lung function by different ways: by interfering specifically with tissue repair mechanisms after damage, thus perturbing the correct crosstalk between mesenchymal and epithelial components; by inducing systemic and/or local alteration of the immune system, thus impairing the complex mechanisms of lung defense against infections; and by stimulating a local and/or systemic inflammatory condition (inflammaging). According to recently proposed pathogenic models in COPD and IPF, premature cellular senescence likely affects distinct progenitors cells (mesenchymal stem cells in COPD, alveolar epithelial precursors in IPF), leading to stem cell exhaustion. In this review, the large amount of data supporting this pathogenic view are discussed, with emphasis on the possible molecular and cellular mechanisms leading to the severe parenchymal remodeling that characterizes, in different ways, these deadly diseases.

Chronic obstructive pulmonary disease and bronchiectasis

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) and bronchiectasis are two different but related diseases that occur separately, but can coexist. In this review, we will examine the recent research regarding patients with COPD who have coexisting bronchiectasis.

RECENT FINDINGS

Recent research has focused on defining distinct COPD phenotypes with the ultimate goal of changing the outcomes using tailored therapies. A frequent exacerbator phenotype has been identified. COPD patients with Pseudomonas aeruginosa are a phenotype with worse outcomes. Patients with coexisting COPD and bronchiectasis may represent a unique phenotype.

SUMMARY

Patients with coexisting COPD and bronchiectasis could represent a unique phenotype with more severe disease, worse outcomes, more isolation of potentially pathogenic microorganisms, and more frequent exacerbations, with the potential for targeted therapies.

COPD surveillance--United States, 1999-2011

This report updates surveillance results for COPD in the United States. For 1999 to 2011, data from national data systems for adults aged≥25 years were analyzed. In 2011, 6.5% of adults (approximately 13.7 million) reported having been diagnosed with COPD. From 1999 to 2011, the overall age-adjusted prevalence of having been diagnosed with COPD declined (P=.019). In 2010, there were 10.3 million (494.8 per 10,000) physician office visits, 1.5 million (72.0 per 10,000) ED visits, and 699,000 (32.2 per 10,000) hospital discharges for COPD. From 1999 to 2010, no significant overall trends were noted for physician office visits and ED visits; however, the age-adjusted hospital discharge rate for COPD declined significantly (P=.001). In 2010 there were 312,654 (11.2 per 1,000) Medicare hospital discharge claims submitted for COPD. Medicare claims (1999-2010) declined overall (P=.045), among men (P=.022) and among enrollees aged 65 to 74 years (P=.033). There were 133,575 deaths (63.1 per 100,000) from COPD in 2010. The overall age-adjusted death rate for COPD did not change during 1999 to 2010 (P=.163). Death rates (1999-2010) increased among adults aged 45 to 54 years (P<.001) and among American Indian/Alaska Natives (P=.008) but declined among those aged 55 to 64 years (P=.002) and 65 to 74 years (P<.001), Hispanics (P=.038), Asian/Pacific Islanders (P<.001), and men (P=.001). Geographic clustering of prevalence, Medicare hospitalizations, and deaths were observed. Declines in the age-adjusted prevalence, death rate in men, and hospitalizations for COPD since 1999 suggest progress in the prevention of COPD in the United States.

Endothelin-1 downregulates angiotensin-converting enzyme-2 expression in human bronchial epithelial cells

BACKGROUND/AIMS

Both endothelin-1 (ET-1) and the renin-angiotensin system (RAS) are implicated in the pathogenesis and progression of chronic obstructive pulmonary disease (COPD). In the present study, we explored the interaction between ET-1 and the RAS by examining the effect of ET-1 on angiotensin-converting enzyme-2 (ACE2) expression and activity in human bronchial epithelial cells (HBEpCs).

METHODS

HBEpCs were treated with ET-1 (1, 10, 20, 40 or 50 nmol/l) for 6, 12, 18, 24 or 30 h with or without the transcription inhibitor actinomycin D, endothelin A (ETA) receptor blocker BQ123, endothelin B receptor blocker BQ788, or different kinase inhibitors.

RESULTS

ET-1 decreased the ACE2 mRNA level in a dose- and time-dependent manner within 24 h, which led to dose-dependent downregulation of the ACE2 promoter activity, protein level and the cell membrane ACE2 activity. Actinomycin D (1 mg/ml), BQ123 (1 μmol/l), and the p38 mitogen-activated protein kinase (MAPK) siRNA and inhibitor PD169316 (25 μmol/l) completely abolished the effect of ET-1 on ACE2 expression in HBEpCs.

CONCLUSION

ET-1 downregulates ACE2 expression and activity at the transcription level in HBEpCs via the ETA receptor by a p38 MAPK-dependent mechanism. This is the first evidence of crosstalk between the ET-1/ETA axis and the RAS in regard to the pathogenesis and progression of COPD.

Systemic LPS induces spinal inflammatory gene expression and impairs phrenic long-term facilitation following acute intermittent hypoxia

Although systemic inflammation occurs in most pathological conditions that challenge the neural control of breathing, little is known concerning the impact of inflammation on respiratory motor plasticity. Here, we tested the hypothesis that low-grade systemic inflammation induced by lipopolysaccharide (LPS, 100 μg/kg ip; 3 and 24 h postinjection) elicits spinal inflammatory gene expression and attenuates a form of spinal, respiratory motor plasticity: phrenic long-term facilitation (pLTF) induced by acute intermittent hypoxia (AIH; 3, 5 min hypoxic episodes, 5 min intervals). pLTF was abolished 3 h (vehicle control: 67.1 ± 27.9% baseline; LPS: 3.7 ± 4.2%) and 24 h post-LPS injection (vehicle: 58.3 ± 17.1% baseline; LPS: 3.5 ± 4.3%). Pretreatment with the nonsteroidal anti-inflammatory drug ketoprofen (12.5 mg/kg ip) restored pLTF 24 h post-LPS (55.1 ± 12.3%). LPS increased inflammatory gene expression in the spleen and cervical spinal cord (homogenates and isolated microglia) 3 h postinjection; however, all molecules assessed had returned to baseline by 24 h postinjection. At 3 h post-LPS, cervical spinal iNOS and COX-2 mRNA were differentially increased in microglia and homogenates, suggesting differential contributions from spinal cells. Thus LPS-induced systemic inflammation impairs AIH-induced pLTF, even after measured inflammatory genes returned to normal. Since ketoprofen restores pLTF even without detectable inflammatory gene expression, "downstream" inflammatory molecules most likely impair pLTF. These findings have important implications for many disease states where acute systemic inflammation may undermine the capacity for compensatory respiratory plasticity.

Inflammation in COPD: implications for management

Chronic obstructive pulmonary disease (COPD) is recognized by the Global Initiative for Chronic Obstructive Lung Disease guidelines as an inflammatory disease state, and treatment rationales are provided accordingly. However, not all physicians follow or are even aware of these guidelines. Research has shown that COPD inflammation involves multiple inflammatory cells and mediators and the underlying pathology differs from asthma inflammation. For these reasons, therapeutic agents that are effective in asthma patients may not be optimal in COPD patients. COPD exacerbations are intensified inflammatory events compared with stable COPD. The clinical and systemic consequences believed to result from the chronic inflammation observed in COPD suggest that inflammation intensity is a key factor in COPD and exacerbation severity and frequency. Although inhaled corticosteroids are commonly used and are essential in asthma management, their efficacy in COPD is limited, with only a modest effect at reducing exacerbations. The importance of inflammation in COPD needs to be better understood by clinicians, and the differences in inflammation in COPD versus asthma should be considered carefully to optimize the use of anti-inflammatory agents.

Melatonin reduces lung oxidative stress in patients with chronic obstructive pulmonary disease: a randomized, double-blind, placebo-controlled study

Chronic obstructive pulmonary disease (COPD), a major cause of death and disability, is attributed to an abnormal inflammatory response by the lungs to noxious substances, primarily from cigarette smoke. Although oxidative stress is regarded as central to the pathogenesis of COPD, very few studies have examined the effects of antioxidants in this condition. This was a randomized, double-blind, placebo-controlled study on the effects of melatonin in COPD. Thirty-six consecutive patients with clinically stable moderate to very severe COPD (30 men; mean±S.D.=66.6±7.8yr) were randomized to receive 3mg melatonin (N=18) or placebo for 3 months. Oxidative stress was evaluated by 8-isoprostane levels in exhaled breath condensate at baseline (T0) and after one (T1), two (T2), and three months (T3) of treatment. Additionally, exhaled breath condensate levels of IL-8, dyspnea severity (Medical Research Council scale), lung function (spirometry), and functional exercise capacity (six min walk test) were compared at baseline and after treatment. Patients receiving melatonin showed a decrease in 8-isoprostane (T0: mean±S.E.M.=20.41±2.92pg/mL; T1: 18.56±2.68pg/mL; T2: 12.68±2.04pg/mL; T3: 12.70±2.18pg/mL; P=0.04; repeated measures ANOVA) with significant differences from baseline after 2 (P=0.03) and 3months (P=0.01). Dyspnea was improved by melatonin (P=0.01), despite no significant changes in lung function or exercise capacity. Placebo-treated patients, but not those who were given melatonin, showed an increase in IL-8 (P=0.03). In summary, melatonin administration reduced oxidative stress and improved dyspnea in COPD. Further studies are necessary to determine the potential role for melatonin in the long-term management of these patients.

Protein Arginine Methyltransferases (PRMTs): promising targets for the treatment of pulmonary disorders

Protein arginine methylation is a novel posttranslational modification that plays a pivotal role in a variety of intracellular events, such as signal transduction, protein-protein interaction and transcriptional regulation, either by the direct regulation of protein function or by metabolic products originating from protein arginine methylation that influence nitric oxide (NO)-dependent processes. A growing body of evidence suggests that both mechanisms are implicated in cardiovascular and pulmonary diseases. This review will present and discuss recent research on PRMTs and the methylation of non-histone proteins and its consequences for the pathogenesis of various lung disorders, including lung cancer, pulmonary fibrosis, pulmonary hypertension, chronic obstructive pulmonary disease and asthma. This article will also highlight novel directions for possible future investigations to evaluate the functional contribution of arginine methylation in lung homeostasis and disease.

Renin-angiotensin system blockade: a novel therapeutic approach in chronic obstructive pulmonary disease

ACE (angiotensin-converting enzyme) inhibitors and ARBs (angiotensin II receptor blockers) are already widely used for the treatment and prevention of cardiovascular disease and their potential role in other disease states has become increasingly recognized. COPD (chronic obstructive pulmonary disease) is characterized by pathological inflammatory processes involving the lung parenchyma, airways and vascular bed. The aim of the present review is to outline the role of the RAS (renin-angiotensin system) in the pathogenesis of COPD, including reference to results from fibrotic lung conditions and pulmonary hypertension. The review will, in particular, address the emerging evidence that ACE inhibition could have a beneficial effect on skeletal muscle function and cardiovascular co-morbidity in COPD patients. The evidence to support the effect of RAS blockade as a novel therapeutic approach in COPD will be discussed.

Prevalence of cardiovascular disease in subjects hospitalized due to chronic obstructive pulmonary disease in Beijing from 2000 to 2010

OBJECTIVES

To investigate the overall prevalence of cardiovascular disease (CVD) in subjects hospitalized for chronic obstructive pulmonary disease (COPD), and explore the prevalence of the major CVD complications and trends in patients with COPD over a 10-year period.

METHODS

Medical records in the PLA General Hospital, Beijing Union Medical College Hospital, and Beijing Hospital from 2000/01/01 to 2010/03/03 were retrospectively reviewed. A total of 4960 patients with COPD were reviewed in the study (3570 males, mean age, 72.2 ± 10.5 years; 1390 females, mean age, 72.0 ± 10.4 years).

RESULTS

The prevalence of CVD in COPD patients was 51.7%. The three most prevalent CVDs were ischemic heart disease (28.9%), heart failure (19.6%), and arrhythmia (12.6%). During the 10-year study period, the prevalence of various CVDs in COPD patients showed a gradual increasing trend with increasing age. There was higher morbidity due to ischemic heart disease (P < 0.01) in male COPD patients than in the female counterparts. However, heart failure (P < 0.01) and hypertension (P < 0.01) occurred less frequently in male COPD patients than in female COPD patients. Furthermore, the prevalence of ischemic heart disease decreased year by year. In addition to heart failure, various types of CVD complications in COPD patients tended to occur in younger subjects. The prevalence of all major types of CVD in women tended to increase year by year.

CONCLUSIONS

The prevalence of CVD in patients hospitalized for COPD in Beijing was high. Age, sex and CVD trends, as well as life style changes, should be considered when prevention and control strategies are formulated.

Cardiopulmonary function in individuals with HIV infection in the antiretroviral therapy era

OBJECTIVE

To determine relationship of echocardiographic measures of pulmonary hypertension to lung function and inflammatory biomarkers in HIV-infected individuals.

DESIGN

Cross-sectional study of 116 HIV-infected outpatients.

METHODS

Doppler-echocardiography and pulmonary function testing were performed. Induced sputum and plasma cytokines, sputum cell counts and differentials, markers of peripheral T-cell activation, and serum N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured. Univariate and multivariate analyses determined relationship of echocardiographic variables to pulmonary function, inflammation, and NT-proBNP.

RESULTS

Mean estimated pulmonary artery systolic pressure (PASP) was 34.3 mmHg (SD 6.9) and mean tricuspid regurgitant jet velocity (TRV) was 2.5 m/s (SD 0.32). Eighteen participants (15.5%) had PASP of at least 40 mmHg, and nine (7.8%) had TRV of at least 3.0 m/s. Elevated TRV was significantly associated with CD4 cell counts below 200 cells/μl and higher log HIV-RNA levels. Forced expiratory volume in 1 s (FEV(1)) percentage predicted, FEV(1)/forced vital capacity, and diffusing capacity for carbon monoxide (DLco) percentage predicted were significantly lower in those with elevated PASP or TRV. Sputum interleukin-8, peripheral interleukin-8, peripheral interferon-γ levels, and CD8(+) T-cell expression of CD69(+) were associated with increasing PASP and TRV. Log NT-proBNP was significantly higher with increasing PASP and TRV. Left ventricular function was not associated with PASP or TRV.

CONCLUSION

Echocardiographic manifestations of pulmonary hypertension are common in HIV and are associated with respiratory symptoms, more advanced HIV disease, airway obstruction, abnormal DLco, and systemic and pulmonary inflammation. Pulmonary hypertension and chronic obstructive pulmonary disease coexist in HIV and may arise secondary to common inflammatory mechanisms.

Systemic inflammation impairs respiratory chemoreflexes and plasticity

Many lung and central nervous system disorders require robust and appropriate physiological responses to assure adequate breathing. Factors undermining the efficacy of ventilatory control will diminish the ability to compensate for pathology, threatening life itself. Although most of these same disorders are associated with systemic and/or neuroinflammation, and inflammation affects neural function, we are only beginning to understand interactions between inflammation and any aspect of ventilatory control (e.g. sensory receptors, rhythm generation, chemoreflexes, plasticity). Here we review available evidence, and present limited new data suggesting that systemic (or neural) inflammation impairs two key elements of ventilatory control: chemoreflexes and respiratory motor (versus sensory) plasticity. Achieving an understanding of mechanisms whereby inflammation undermines ventilatory control is fundamental since inflammation may diminish the capacity for natural, compensatory responses during pathological states, and the ability to harness respiratory plasticity as a therapeutic strategy in the treatment of devastating breathing disorders, such as during cervical spinal injury or motor neuron disease.

FUMEPOC: early detection of chronic obstructive pulmonary disease in smokers

BACKGROUND

Currently is not feasible using conventional spirometry as a screening method in Primary Care especially among smoking population to detect chronic obstructive pulmonary disease in early stages. Therefore, the FUMEPOC study protocol intends to analyze the validity and reliability of Vitalograph COPD-6 spirometer as simpler tool to aid screening and diagnosis of this disease in early stages in primary care surgery.

METHODS / DESIGN

STUDY DESIGN

An observational, descriptive study of diagnostic tests, undertaken in Primary Care and Pneumology Outpatient Care Centre at San Juan Hospital and Elda Hospital. All smokers attending the primary care surgery and consent to participate in the study will undergo a test with Vitalograph COPD-6 spirometer. Subsequently, a conventional spirometry will be performed in the hospital and the results will be compared with those of the Vitalograph COPD-6 test.

DISCUSSION

It is difficult to use the spirometry as screening for early diagnose test in real conditions of primary care clinical practice. The use of a simpler tool, Vitalograph COPD-6 spirometer, can help in the early diagnose and therefore, it could improve the clinical management of the disease.

LPS-stimulated MUC5AC production involves Rac1-dependent MMP-9 secretion and activation in NCI-H292 cells

Chronic obstructive pulmonary disease (COPD) is an inflammatory process characterized by airway mucus hypersecretion. Previous studies have reported that lipopolysaccharides (LPS) stimulate mucin 5AC (MUC5AC) production via epidermal growth factor receptor (EGFR) in human airway cells. Moreover, this production was shown to depend on the expression and activity of matrix metalloproteinase 9 (MMP-9), which is increased in COPD patients' serum. In the present study we investigated the signaling pathway mediating LPS-stimulated secretion and activation of MMP-9, and the regulatory effects of this pathway on the production of MUC5AC in the human airway cells NCI-H292. Using specific inhibitors, we found that LPS-stimulated cells secreted and activated MMP-9 via EGFR. Our results also indicate that signaling events downstream of EGFR involved PI3K-dependent activation of Rac1, which mediated the NADPH-generated reactive oxygen species responsible for MMP-9 secretion and activation. Finally, we observed that EGFR/PI3K/Rac1/NADPH/ROS/MMP-9 regulate MUC5AC production in LPS-challenged NCI-H292 cells.