The coexistence of asthma and chronic obstructive pulmonary disease (COPD): prevalence and risk factors in young, middle-aged and elderly people from the general population

Examining the effectiveness of artificial intelligence applications in asthma and COPD outpatient support in terms of patient health and public cost: SWOT analysis

This research aimed to examine the effectiveness of artificial intelligence applications in asthma and chronic obstructive pulmonary disease (COPD) outpatient treatment support in terms of patient health and public costs. The data obtained in the research using semiotic analysis, content analysis and trend analysis methods were analyzed with strengths, weakness, opportunities, threats (SWOT) analysis. In this context, 18 studies related to asthma, COPD and artificial intelligence were evaluated. The strengths of artificial intelligence applications in asthma and COPD outpatient treatment stand out as early diagnosis, access to more patients and reduced costs. The points that stand out among the weaknesses are the acceptance and use of technology and vulnerabilities related to artificial intelligence. Opportunities arise in developing differential diagnoses of asthma and COPD and in examining prognoses for the diseases more effectively. Malicious use, commercial data leaks and data security issues stand out among the threats. Although artificial intelligence applications provide great convenience in the outpatient treatment process for asthma and COPD diseases, precautions must be taken on a global scale and with the participation of international organizations against weaknesses and threats. In addition, there is an urgent need for accreditation for the practices to be carried out in this regard.

Systematic Review: Singing-Based Interventions to Improve Physical Functions Related to Aging Voice in Older Adults

PURPOSE

This systematic review aimed to evaluate the effects of singing as an intervention for aging voice.

METHOD

Quantitative studies of interventions for older adults with any medical condition that involves singing as training were reviewed, measured by respiration, phonation, and posture, which are the physical functions related to the aging voice. English and Chinese studies published until April 2024 were searched using 31 electronic databases, and seven studies were included. The included articles were assessed according to the Grading of Recommendations, Assessment, Development, and Evaluations rubric.

RESULTS

Seven studies were included. These studies reported outcome measures that were related to respiratory functions only. For the intervention effect, statistically significant improvements were observed in five of the included studies, among which three studies had large effect sizes. The overall level of evidence of the included studies was not high, with three studies having moderate levels and the rest having lower levels. The intervention activities included trainings other than singing. These non-singing training items may have caused co-intervention bias in the study results.

CONCLUSIONS

This systematic review suggests that singing as an intervention for older adults with respiratory and cognitive problems could improve respiration and respiratory-phonatory control. However, none of the included studies covers the other two of the physical functions related to aging voice (phonatory and postural functions). The overall level of evidence of the included studies was not high either. There is a need for more research evidence in singing-based intervention specifically for patient with aging voice.

Measuring burden of disease in both asthma and COPD by merging the ACQ and CCQ: less is more?

Symptoms of asthma and COPD often overlap, and both diseases can co-exist in one patient. The asthma control questionnaire (ACQ) and clinical COPD questionnaire (CCQ) were developed to assess disease burden in respectively asthma or COPD. This study explores the possibility of creating a new questionnaire to assess disease burden in all obstructive lung diseases by integrating and reducing questions of the ACQ and CCQ. Data of patients with asthma, COPD and asthma-COPD overlap (ACO) were collected from a primary and secondary care center. Patients completed ACQ and CCQ on the same day. Linear regression tested correlations. Principal Component Analysis (PCA) was used for item reduction. The secondary cohort with asthma and COPD patients was used for initial question selection (development cohort). These results were reproduced in the primary care cohort and secondary cohort of patients with ACO. The development cohort comprised 252 patients with asthma and 96 with COPD. Correlation between ACQ and CCQ in asthma was R = 0.82, and in COPD R = 0.83. PCA determined a selection of 9 questions. Reproduction in primary care data (asthma n = 1110, COPD n = 1041, ACO = 355) and secondary care data of ACO patients (n = 53) resulted in similar correlations and PCA-derived selection of questions. In conclusion, PCA determined a selection of nine questions of the ACQ and CCQ: working title 'the Obstructive Lung Disease Questionnaire'. These results suggest that this pragmatic set of questions might be sufficient to assess disease burden in obstructive lung disease in both primary as secondary care.

PPARγ attenuates cellular senescence of alveolar macrophages in asthma-COPD overlap

BACKGROUND

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) represents a complex condition characterized by shared clinical and pathophysiological features of asthma and COPD in older individuals. However, the pathophysiology of ACO remains unexplored. We aimed to identify the major inflammatory cells in ACO, examine senescence within these cells, and elucidate the genes responsible for regulating senescence.

METHODS

Bioinformatic analyses were performed to investigate major cell types and cellular senescence signatures in a public single-cell RNA sequencing (scRNA-Seq) dataset derived from the lung tissues of patients with ACO. Similar analyses were carried out in an independent cohort study Immune Mechanisms Severe Asthma (IMSA), which included bulk RNA-Seq and CyTOF data from bronchoalveolar lavage fluid (BALF) samples.

RESULTS

The analysis of the scRNA-Seq data revealed that monocytes/ macrophages were the predominant cell type in the lung tissues of ACO patients, constituting more than 50% of the cells analyzed. Lung monocytes/macrophages from patients with ACO exhibited a lower prevalence of senescence as defined by lower enrichment scores of SenMayo and expression levels of cellular senescence markers. Intriguingly, analysis of the IMSA dataset showed similar results in patients with severe asthma. They also exhibited a lower prevalence of senescence, particularly in airway CD206 + macrophages, along with increased cytokine expression (e.g., IL-4, IL-13, and IL-22). Further exploration identified alveolar macrophages as a major subtype of monocytes/macrophages driving cellular senescence in ACO. Differentially expressed genes related to oxidation-reduction, cytokines, and growth factors were implicated in regulating senescence in alveolar macrophages. PPARγ (Peroxisome Proliferator-Activated Receptor Gamma) emerged as one of the predominant regulators modulating the senescent signature of alveolar macrophages in ACO.

CONCLUSION

The findings suggest that senescence in macrophages, particularly alveolar macrophages, plays a crucial role in the pathophysiology of ACO. Furthermore, PPARγ may represent a potential therapeutic target for interventions aimed at modulating senescence-associated processes in ACO.Key words ACO, Asthma, COPD, Macrophages, Senescence, PPARγ.

Asthma prevalence among United States population insights from NHANES data analysis

Asthma is a prevalent respiratory condition that poses a substantial burden on public health in the United States. Understanding its prevalence and associated risk factors is vital for informed policymaking and public health interventions. This study aims to examine asthma prevalence and identify major risk factors in the U.S.

POPULATION

Our study utilized NHANES data between 1999 and 2020 to investigate asthma prevalence and associated risk factors within the U.S.

POPULATION

We analyzed a dataset of 64,222 participants, excluding those under 20 years old. We performed binary regression analysis to examine the relationship of demographic and health related covariates with the prevalence of asthma. The study found that asthma affected 8.7% of the U.S.

POPULATION

Gender emerged as a significant factor, with 36.0% of asthma patients being male and 64.0% female (p < 0.001). Individuals aged 60 and older having the highest asthma prevalence at 34.0%. Non-Hispanic whites had the highest prevalence at 46.4%, followed by non-hispanic blacks at 26.0%. In contrast, Mexican Americans and other hispanic individuals had lower rates, at 9.6% and 9.0%, respectively. Females were 1.76 times more likely to have asthma than males (p < 0.001). Obese individuals had a 1.74 times higher likelihood of current asthma compared to underweight individuals (p < 0.001). Notably, both Non-Hispanic Whites and Non-Hispanic Blacks showed higher odds of current asthma compared to Mexican Americans (with adjusted odds ratios of 2.084 and 2.096, respectively, p < 0.001). The research findings indicate that asthma is prevalent in 8.7% of the U.S.

POPULATION

Our study highlights that individuals who are female, have low income, are obese, and smoke have the highest likelihood of being affected by asthma. Therefore, public health policies should prioritize addressing these risk factors in their preventive strategies.

PPARγ Attenuates Cellular Senescence of Alveolar Macrophages in Asthma- COPD Overlap

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) represents a complex condition characterized by shared clinical and pathophysiological features of asthma and COPD in older individuals. However, the pathophysiology of ACO remains unexplored. We aimed to identify the major inflammatory cells in ACO, examine senescence within these cells, and elucidate the genes responsible for regulating senescence. Bioinformatic analyses were performed to investigate major cell types and cellular senescence signatures in a public single-cell RNA sequencing (scRNA-Seq) dataset derived from the lung tissues of patients with ACO. Similar analyses were carried out in an independent cohort study Immune Mechanisms Severe Asthma (IMSA), which included bulk RNA-Seq and CyTOF data from bronchoalveolar lavage fluid (BALF) samples. The analysis of the scRNA-Seq data revealed that monocytes/ macrophages were the predominant cell type in the lung tissues of ACO patients, constituting more than 50% of the cells analyzed. Lung monocytes/macrophages from patients with ACO exhibited a lower prevalence of senescence as defined by lower enrichment scores of SenMayo and expression levels of cellular senescence markers. Intriguingly, analysis of the IMSA dataset showed similar results in patients with severe asthma. They also exhibited a lower prevalence of senescence, particularly in airway CD206 + macrophages, along with increased cytokine expression (e.g., IL-4, IL-13, and IL-22). Further exploration identified alveolar macrophages as a major subtype of monocytes/macrophages driving cellular senescence in ACO. Differentially expressed genes related to oxidation-reduction, cytokines, and growth factors were implicated in regulating senescence in alveolar macrophages. PPARγ (Peroxisome Proliferator-Activated Receptor Gamma) emerged as one of the predominant regulators modulating the senescent signature of alveolar macrophages in ACO. Collectively, the findings suggest that senescence in macrophages, particularly alveolar macrophages, plays a crucial role in the pathophysiology of ACO. Furthermore, PPARγ may represent a potential therapeutic target for interventions aimed at modulating senescence-associated processes in ACO.

Assessment of functional diversities in patients with Asthma, COPD, Asthma-COPD overlap, and Cystic Fibrosis (CF)

The objectives of the present study were to evaluate the discriminating power of spirometric and plethysmographic lung function parameters to differenciate the diagnosis of asthma, ACO, COPD, and to define functional characteristics for more precise classification of obstructive lung diseases. From the databases of 4 centers, a total of 756 lung function tests (194 healthy subjects, 175 with asthma, 71 with ACO, 78 with COPD and 238 with CF) were collected, and gradients among combinations of target parameters from spirometry (forced expiratory volume one second: FEV1; FEV1/forced vital capacity: FEV1/FVC; forced expiratory flow between 25-75% FVC: FEF25-75), and plethysmography (effective, resistive airway resistance: sReff; aerodynamic work of breathing at rest: sWOB), separately for in- and expiration (sReffIN, sReffEX, sWOBin, sWOBex) as well as static lung volumes (total lung capacity: TLC; functional residual capacity: FRCpleth; residual volume: RV), the control of breathing (mouth occlusion pressure: P0.1; mean inspiratory flow: VT/TI; the inspiratory to total time ratio: TI/Ttot) and the inspiratory impedance (Zinpleth = P0.1/VT/TI) were explored. Linear discriminant analyses (LDA) were applied to identify discriminant functions and classification rules using recursive partitioning decision trees. LDA showed a high classification accuracy (sensitivity and specificity > 90%) for healthy subjects, COPD and CF. The accuracy dropped for asthma (~70%) and even more for ACO (~60%). The decision tree revealed that P0.1, sRtot, and VT/TI differentiate most between healthy and asthma (68.9%), COPD (82.1%), and CF (60.6%). Moreover, using sWOBex and Zinpleth ACO can be discriminated from asthma and COPD (60%). Thus, the functional complexity of obstructive lung diseases can be understood, if specific spirometric and plethysmographic parameters are used. Moreover, the newly described parameters of airway dynamics and the central control of breathing including Zinpleth may well serve as promising functional marker in the field of precision medicine.

Comparison between patients with COPD and healthy subjects on spatiotemporal, moment and kinematic parameters: A quasi-experimental study

Background and Aims

Chronic obstructive respiratory diseases (COPD) not only cause damage to the respiratory system as well as the heart and blood vessels of the patient but also have a direct effect on the condition of the musculoskeletal system. The risk of falling is increasing due to dysfunction of the joints as well as aging, which occurs frequently in this population. Gait deficits are known as an important risk factor for falls. This research aimed to investigate the gait of COPD patients compared to healthy people to gain a better understanding of the reasons for falls.

Methods

Twenty patients with COPD and 20 age and BMI-matched healthy individuals were included in this study. Sixteen markers were applied to the lower body of the subjects. Spatio-temporal, kinematic, and maximum moment parameters were measured in different phases in three lower body joints, including the hip, knee, and ankle.

Results

The results showed that all spatio-temporal parameters in patients were significantly lower than in healthy people. The ankle angle in the sagittal plane at initial contact was significantly difference (p = 0.03). As well as, in the frontal plane the hip angle in the mid-stance showed a significant difference (p = 0.02). There was also a significant difference in maximum hip moment in the sagittal plane between the two groups (p = 0.01).

Conclusion

The larger hip angle of the patients can be related to the balance problems in the mediolateral direction. The moment showed a significant difference in the hip joint. Since the hip muscles are directly in a synergistic relationship with the trunk muscles, it seems the performance of these muscles is likely to be seriously damaged due to respiratory diseases.

Sex-Specific Genetic Determinants of Asthma-COPD Phenotype and COPD in Middle-Aged and Older Canadian Adults: An Analysis of CLSA Data

The etiology of sex differences in the risk of asthma-COPD phenotype and COPD is still not completely understood. Genetic and environmental risk factors are commonly believed to play an important role. This study aims to identify sex-specific genetic markers associated with asthma-COPD phenotype and COPD using the Canadian Longitudinal Study on Aging (CLSA) Baseline Comprehensive and Genomic data. There were a total of 1,415 COPD cases. Out of them, 504 asthma-COPD phenotype cases were identified. 20,524 participants without a diagnosis of asthma and COPD served as controls. We performed genome-wide SNP-by-sex interaction analysis. SNPs with an interaction p-value < 10^-5 were included in a sex-stratified multivariable logistic regression for asthma-COPD phenotype and COPD outcomes. 18 and 28 SNPs had a significant interaction term p-value < 10^-5 with sex in the regression analyses of asthma-COPD phenotype and COPD outcomes, respectively. Sex-stratified multivariable analysis of asthma-COPD phenotype showed that 7 SNPs in/near SMYD3, FHIT, ZNF608, RIMBP2, ZNF133, BPIFB1, and S100B loci were significant in males. Sex-stratified multivariable analysis of COPD showed that 8 SNPs in/near MAGI1, COX18, OSTC, ELOVL5, C7orf72 FGF14, and NKAIN4 were significant in males, and 4 SNPs in/near genes CAMTA1, SATB2, PDE10A, and LINC00908 were significant in females. An SNP in the ZPBP gene was associated with COPD in both males and females. Identification of sex-specific loci associated with asthma-COPD phenotype and COPD may offer valuable evidence toward a better understanding of the sex-specific differences in the pathophysiology of the diseases.

Short-acting β2-agonist prescription patterns in patients with asthma treated by specialists in Thailand: results from SABINA III

OBJECTIVE

Short-acting β2-agonist (SABA) overuse is associated with poor asthma outcomes; however, the extent of SABA use in Thailand is largely unknown. As part of the SABA use IN Asthma (SABINA) III study, we describe asthma treatment patterns, including SABA prescriptions, in patients treated by specialists in Thailand.

METHODS

In this observational, cross-sectional study, patients (aged ≥12 years) with an asthma diagnosis were recruited by specialists from three Thai tertiary care centers using purposive sampling. Patients were classified by investigator-defined asthma severity (per 2017 Global Initiative for Asthma [GINA] recommendations). Data on sociodemographics, disease characteristics, and asthma treatment prescriptions were collected from existing medical records by healthcare providers and transcribed onto electronic case report forms. Analyses were descriptive.

RESULTS

All 385 analyzed patients (mean age: 57.6 years; 69.6% female) were treated by specialists. Almost all (91.2%) patients were classified with moderate-to-severe asthma (GINA treatment steps 3-5), 69.1% were overweight/obese, and 99.7% reported partially/fully reimbursed healthcare. Asthma was partly controlled/uncontrolled in 24.2% of patients; 23.1% experienced ≥1 severe asthma exacerbation in the preceding 12 months. Overall, SABAs were over-prescribed (≥3 canisters/year) in 28.3% of patients. Inhaled corticosteroids (ICS), ICS/long-acting β2-agonists, oral corticosteroid (OCS) burst treatment, and long-term OCS were prescribed to 7.0, 93.2, 19.2, and 6.2% of patients, respectively. Additionally, 4.2% of patients reported purchasing SABA over the counter.

CONCLUSIONS

Despite receiving specialist treatment, 28.3% of patients were over-prescribed to SABA in the previous 12 months, highlighting a public health concern and the need to align clinical practices with current evidence-based recommendations.

Polygenic risk scores identify heterogeneity in asthma and chronic obstructive pulmonary disease

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) have distinct and overlapping genetic and clinical features.

OBJECTIVE

We sought to test the hypothesis that polygenic risk scores (PRSs) for asthma (PRSAsthma) and spirometry (FEV1 and FEV1/forced vital capacity; PRSspiro) would demonstrate differential associations with asthma, COPD, and asthma-COPD overlap (ACO).

METHODS

We developed and tested 2 asthma PRSs and applied the higher performing PRSAsthma and a previously published PRSspiro to research (Genetic Epidemiology of COPD study and Childhood Asthma Management Program, with spirometry) and electronic health record-based (Mass General Brigham Biobank and Genetic Epidemiology Research on Adult Health and Aging [GERA]) studies. We assessed the association of PRSs with COPD and asthma using modified random-effects and binary-effects meta-analyses, and ACO and asthma exacerbations in specific cohorts. Models were adjusted for confounders and genetic ancestry.

RESULTS

In meta-analyses of 102,477 participants, the PRSAsthma (odds ratio [OR] per SD, 1.16 [95% CI, 1.14-1.19]) and PRSspiro (OR per SD, 1.19 [95% CI, 1.17-1.22]) both predicted asthma, whereas the PRSspiro predicted COPD (OR per SD, 1.25 [95% CI, 1.21-1.30]). However, results differed by cohort. The PRSspiro was not associated with COPD in GERA and Mass General Brigham Biobank. In the Genetic Epidemiology of COPD study, the PRSAsthma (OR per SD: Whites, 1.3; African Americans, 1.2) and PRSspiro (OR per SD: Whites, 2.2; African Americans, 1.6) were both associated with ACO. In GERA, the PRSAsthma was associated with asthma exacerbations (OR, 1.18) in Whites; the PRSspiro was associated with asthma exacerbations in White, LatinX, and East Asian participants.

CONCLUSIONS

PRSs for asthma and spirometry are both associated with ACO and asthma exacerbations. Genetic prediction performance differs in research versus electronic health record-based cohorts.

Incidence, prevalence and characteristics of multimorbidity in different age groups among urban hospitalized patients in China

The aim of the study was to investigate the incidence, prevalence and characteristics of multimorbidity in urban inpatients of different age groups. This study used data from the National Insurance Claim for Epidemiology Research (NICER) to calculate the overall incidence, prevalence, geographic and age distribution patterns, health care burden, and multimorbidity patterns for multimorbidity in 2017. According to our study, the overall prevalence of multimorbidity was 6.68%, and the overall prevalence was 14.87% in 2017. The prevalence of multimorbidity increases with age. The pattern of the geographic distribution of multimorbidity shows that the prevalence of multimorbidity is relatively high in South East China. The average annual health care expenditure of patients with multimorbidity increased with age and rose rapidly, especially among older patients. Patients with cancer and chronic kidney disease have higher treatment costs. Patients with hypertension or ischemic heart disease had a significantly higher relative risk of multimorbidity than other included noncommunicable diseases (NCDs). Hyperlipidemia has generated the highest number of association rules, which may suggest that hyperlipidemia may be both a risk factor for other NCDs and an outcome of them.

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Use and persistence of single and multiple inhaler triple therapy prescribed for patients with COPD in France: a retrospective study on THIN database (OPTI study)

INTRODUCTION

From 2018 single inhaler triple therapy (SITT) became available in France to treat moderate-to-severe chronic obstructive pulmonary disease (COPD). Given its simplified inhaler use compared with multiple inhaler triple therapy (MITT), this therapeutic option has the potential to offer benefit in terms of improved persistence and adherence. Given the lack of real-world evidence of the effectiveness of triple therapy, this study was designed to evaluate the use of MITT and SITT in France and compare persistence.

METHODS

A retrospective cohort study was performed. Patients with COPD who initiated triple therapy between 1 July 2017 and 31 December 2019 were included from The Health Improvement Network, a large electronic medical database in France, which includes pharmacy data. A 60-day treatment gap defined discontinuation and thereby persistence.

RESULTS

A total of 3134 patients initiated triple therapy for COPD in the study period, among them 485 with SITT. In 2019, the rate of use of SITT was 28.2%. The mean age (67.3 years) and sex (44.2% female) of patients initiating triple therapy was similar between MITT and SITT, and most patients had escalated from dual therapy (84.1%). However, SITT was more frequently initiated by a pulmonologist (59.8%) and a higher prevalence of comorbid asthma was observed for SITT (47.0% vs 37.9%). Persistence was assessed among patients who did not discontinue after a single dispensation of triple therapy (n=1674). Median persistence was 181 days for SITT and 135 days for MITT, and the covariate-adjusted HR for persistence was 1.47 (p<0.001) and the estimated persistence at 1 year was 33% for SITT compared with 18% for MITT.

DISCUSSION

This study suggests that persistence was higher for the patients treated with SITT compared with MITT in France. Moreover, most patients initiated with triple therapy were previously treated with dual therapy and had exacerbations in the previous year.

Long-term residential exposure to air pollution and risk of chronic respiratory diseases in Italy: The BIGEPI study

Long-term exposure to air pollution has adverse respiratory health effects. We investigated the cross-sectional relationship between residential exposure to air pollutants and the risk of suffering from chronic respiratory diseases in some Italian cities. In the BIGEPI project, we harmonised questionnaire data from two population-based studies conducted in 2007-2014. By combining self-reported diagnoses, symptoms and medication use, we identified cases of rhinitis (n = 965), asthma (n = 328), chronic bronchitis/chronic obstructive pulmonary disease (CB/COPD, n = 469), and controls (n = 2380) belonging to 13 cohorts from 8 Italian cities (Pavia, Turin, Verona, Terni, Pisa, Ancona, Palermo, Sassari). We derived mean residential concentrations of fine particulate matter (PM₁₀, PM_2.5), nitrogen dioxide (NO₂), and summer ozone (O₃) for the period 2013-2015 using spatiotemporal models at a 1 km resolution. We fitted logistic regression models with controls as reference category, a random-intercept for cohort, and adjusting for sex, age, education, BMI, smoking, and climate. Mean ± SD exposures were 28.7 ± 6.0 μg/m³ (PM₁₀), 20.1 ± 5.6 μg/m³ (PM_2.5), 27.2 ± 9.7 μg/m³ (NO₂), and 70.8 ± 4.2 μg/m³ (summer O₃). The concentrations of PM₁₀, PM_2.5, and NO₂ were higher in Northern Italian cities. We found associations between PM exposure and rhinitis (PM₁₀: OR 1.62, 95%CI: 1.19-2.20 and PM_2.5: OR 1.80, 95%CI: 1.16-2.81, per 10 μg/m³) and between NO₂ exposure and CB/COPD (OR 1.22, 95%CI: 1.07-1.38 per 10 μg/m³), whereas asthma was not related to environmental exposures. Results remained consistent using different adjustment sets, including bi-pollutant models, and after excluding subjects who had changed residential address in the last 5 years. We found novel evidence of association between long-term PM exposure and increased risk of rhinitis, the chronic respiratory disease with the highest prevalence in the general population. Exposure to NO₂, a pollutant characterised by strong oxidative properties, seems to affect mainly CB/COPD.

Asthma, COPD, Respiratory, and Allergic Health Effects in an Adult Population Living near an Italian Refinery: A Cross-Sectional Study

BACKGROUND AND AIM

Asthma and chronic obstructive pulmonary disease (COPD) are leading causes of morbidity and mortality worldwide. Globally, 545 million people suffer from chronic respiratory diseases with a wide geographical variability. Risk factors for asthma are both genetic and related to several environmental factors (internal and external pollutants); these also have an important role in the occurrence of COPD. The aim of this study was to describe the prevalence of asthma, COPD, and asthma/COPD overlap (ACO) in an adult population living in two municipalities located in the Po Valley.

METHODS

A standardized questionnaire on respiratory symptoms and sociodemographic characteristics was self-administered to a random sample of the adult population aged 20-64 years, living near a refinery in Northern Italy during the period between 2016 and 2019. Logistic and multinomial regression were implemented to explore factors associated with asthma, COPD, and ACO.

RESULTS

In total, 1108 subjects filled out the questionnaire, the mean age was 48.02 ± 12.34 years (range 21-68), and 53% of the respondents/participants were female. Half of the responders were non-smokers, but the frequency of current and former smokers was significantly greater in men than in women (p < 0.001). The likelihood of being a probable case of asthma decreased with increasing age and increased for smokers. Tobacco smoke was associated with the presence of COPD and ACO.

CONCLUSION

Respiratory diseases such as asthma and COPD are common in the general population, with differences among countries worldwide. Our findings show, on the basis of the main confirmed risk factor, namely smoking, that it is useful to plan target programs and actions in order to reduce smoking, thus improving the quality of life in public health.

The Impact of Primary Care Practice Models on Indicators of Unplanned Health Care Utilization for Ontario Adults Newly Diagnosed With Chronic Obstructive Pulmonary Disease: A Retrospective Cohort Study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a highly prevalent chronic disease. Most of the care for this population occurs within the primary care setting; however, the extent to which different primary care practice models influence the outcomes of patients with COPD remains unclear.

OBJECTIVE

The study aimed to compare and analyze the influence of different primary care practice models on indicators of unplanned health care utilization among newly diagnosed COPD patients in Ontario.

DESIGN

A retrospective cohort study was conducted using health administrative database within the Institute for Clinical Evaluative Sciences. The cohort included persons who were 35 years and older with physician-diagnosed COPD between January 1, 2014 and December 31, 2019. Patients were assigned into 3 practice models: team-based, traditional, and no enrolment. The primary outcomes examined was unplanned health care utilization, specifically emergency department (ED) visits and hospitalizations. To account for excessive zero values, the zero inflated negative binomial (ZINB) models were used to analyze the association between different practice models and unplanned health care utilization.

RESULTS

Among 57,145 individuals who met the inclusion criteria, 55,994 were included in the regression analysis. Of the included participants, 62.8% of patients were in the traditional group, 30.3% were in the team-based group, and 6.9% were in the no enrolment group. Between 2014 and 2019, 70.7% of the cohort had at least 1 all-cause ED visit without hospitalization. The adjusted ZINB models showed no significant difference in risks of experiencing an unplanned health care utilization between the team-based and traditional groups. However, patients in the no enrolment group had a significantly higher risk of ED visit without hospitalization regardless of cause, ED visit with hospitalization regardless of cause, and 30-day readmissions regardless of cause.

CONCLUSIONS

Primary care practice models are complex, influenced by remuneration and organizational structures, reinforcing the need for further research to enhance our understanding of primary care reforms. Furthermore, given the growing shortage of primary care providers, patients with COPD and other chronic conditions are particularly vulnerable.

A Proposal to Differentiate ACO, Asthma and COPD in Vietnam

BACKGROUND

In low- and middle-income countries, such as Vietnam, the population is exposed to multiple risks, leading to frequent allergic asthma, COPD and their overlap (ACO). We aimed to differentiate asthma and COPD, so that recommended treatments can be applied.

METHODS

We hypothesized that during life, the cumulative exposure to noxious particles increases the relative prevalence of COPD, while due to immuno-senescence, the prevalence of allergic asthma decreases with age. Among 568 patients with chronic respiratory symptoms, five phenotypes were defined, based on responsiveness to a bronchodilator (BD), diffusion capacity and cumulative smoking. Then the relative prevalence of each phenotype was related with age.

RESULTS

the smoker BD irreversible patients were considered "COPD", while the full BD responders and non-smoking BD incomplete responders were "asthmatics". The other patients were ACO, distributed as "like-COPD" or "like-asthma", based on decreased or normal diffusion capacity. The relative prevalence of asthma, COPD and ACO were 26, 42 and 32% (18% "like-asthma", 14% "like-COPD").

CONCLUSION

Vietnamese patients with chronic respiratory symptoms were considered as falling into asthma or COPD groups, based on cumulative smoking, spirometry with reversibility and diffusion capacity. The relative prevalence of asthma and COPD were 44 and 56%, respectively, most of which did not require corticosteroids.

Multi-ancestry meta-analysis of asthma identifies novel associations and highlights the value of increased power and diversity

Asthma is a complex disease that varies widely in prevalence across populations. The extent to which genetic variation contributes to these disparities is unclear, as the genetics underlying asthma have been investigated primarily in populations of European descent. As part of the Global Biobank Meta-analysis Initiative, we conducted a large-scale genome-wide association study of asthma (153,763 cases and 1,647,022 controls) via meta-analysis across 22 biobanks spanning multiple ancestries. We discovered 179 asthma-associated loci, 49 of which were not previously reported. Despite the wide range in asthma prevalence among biobanks, we found largely consistent genetic effects across biobanks and ancestries. The meta-analysis also improved polygenic risk prediction in non-European populations compared with previous studies. Additionally, we found considerable genetic overlap between age-of-onset subtypes and between asthma and comorbid diseases. Our work underscores the multi-factorial nature of asthma development and offers insight into its shared genetic architecture.

Sex-specific characteristics for the coexistence of asthma and COPD in the Canadian population: a cross-sectional analysis of CLSA data

Objective: The coexistence of asthma and COPD (asthma + COPD) is a condition found among patients who present with clinical features of both asthma and COPD. Epidemiological evidence points to an increasingly disproportionate burden of asthma + COPD and COPD in females. The objective of this cross-sectional study is to identify female and male-specific epidemiological and clinical characteristics associated with asthma + COPD.Methods: Baseline data from the comprehensive cohort of Canadian Longitudinal Study on Aging (CLSA) were used in this cross-sectional study which included 30,097 subjects between the ages of 45- and 85-years Participants were categorized into four mutually exclusive groups: asthma + COPD, COPD-only, asthma-only and neither asthma nor COPD.Results: The prevalence was significantly greater in females than males for asthma + COPD (2.71% vs. 1.41%; p < 0.001), COPD-only (3.22% vs. 2.87%; p < 0.001) and asthma-only (13.31% vs. 10.11%; p < 0.001). The association between smoking and asthma + COPD was modified by age in females. Osteoporosis and underactive thyroid disease were significantly more prevalent in females than in males in asthma + COPD, COPD-only and asthma-only groups. In asthma + COPD group, a greater proportion of respiratory symptoms associated with asthma was observed in females whereas a greater proportion of respiratory symptoms associated with COPD was observed in males. Severity of airway obstruction determined by spirometry measurements was greater in males than females.Conclusions: In the Canadian adult population, several epidemiological and clinical characteristics in asthma + COPD varied between females and males. The findings in this study will help healthcare professional in the recognition and management of coexisting asthma and COPD in females and males.

Characteristics and difference of respiratory diseases in Korean adults aged ≥40 years: A cross-sectional study

PURPOSE

National big data pertaining to the status of common respiratory diseases is essential to devising appropriate policies to promote proper treatment and prevention of respiratory diseases amid the prolonged coronavirus disease 2019 (COVID-19) pandemic. The aim of this study is to investigate the prevalence of common respiratory diseases and their association with sociodemographic characteristics, comorbidities, and medical history using 11 years (2008-2018) of the Korea National Health and Nutrition Examination Survey (KNHANES) data, ultimately to present foundational data for policy decision making and disease prevention measures.

METHODS

Among the participants of the KNHANES survey (2008-2018), 93 028 adults aged ≥40 years who underwent a lung function test were included in this cross-sectional study. The participants were divided into four groups: Asthma, chronic obstructive pulmonary disease (COPD), asthma + COPD, and no respiratory disease. Their data were analyzed for demographic factors, health behavior, and disease-related factors. Multiple logistic regression was used to calculate the odds ratio (OR) adjusted for sex, age, household income, educational level, occupation, body mass index (BMI), smoking status, alcohol consumption, physical activity, and comorbidities.

RESULTS

Of all participants, 1.83%, 12.63%, and 1.27% had only asthma, only COPD, and asthma + COPD, respectively. With respect to the patients with asthma who also had asthma + COPD, the OR of asthma + COPD was 5.272 in underweight patients and 6.479 in patients aged ≥70 years. Meanwhile, a high association between COPD and asthma + COPD was found in female patients, whereas asthma was more highly associated with asthma + COPD in male patients.

CONCLUSION

The study confirmed that old age, sex, smoking status, BMI, previous history of atopic dermatitis, and lung cancer were independent risk factors for asthma, COPD, and asthma + COPD. The present study demonstrated the need for a multidisciplinary integrative approach to respiratory diseases, and the findings could be used for developing policies for the treatment of COVID-19 and respiratory diseases and the prevention of infectious diseases.

Functional Predictors Discriminating Asthma-COPD Overlap (ACO) from Chronic Obstructive Pulmonary Disease (COPD)

Background

A significant proportion of patients with obstructive lung disease have clinical and functional features of both asthma and chronic obstructive pulmonary disease (COPD), referred to as the asthma–COPD overlap (ACO). The distinction of these phenotypes, however, is not yet well-established due to the lack of defining clinical and/or functional criteria. The aim of our investigations was to assess the discriminating power of various lung function parameters on the assessment of ACO.

Methods

From databases of 4 pulmonary centers, a total of 540 patients (231 males, 309 females), including 372 patients with asthma, 77 patients with ACO and 91 patients with COPD, were retrospectively collected, and gradients among combinations of explanatory variables of spirometric (FEV₁, FEV₁/FVC, FEF_25-75), plethysmographic (sR_eff, sG_eff, the aerodynamic work of breathing at rest; sWOB), static lung volumes, including trapped gases and measurements of the carbon monoxide transfer (DL_CO, K_CO) were explored using multiple factor analysis (MFA). The discriminating power of lung function parameters with respect to ACO was assessed using linear discriminant analysis (LDA).

Results

LDA revealed that parameters of airway dynamics (sWOB, sR_eff, sG_eff) combined with parameters of static lung volumes such as functional residual capacity (FRC_pleth) and trapped gas at FRC (V_TG^FRC) are valuable and potentially important tools discriminating between asthma, ACO and COPD. Moreover, sWOB significantly contributes to the diagnosis of obstructive airway diseases, independent from the state of pulmonary hyperinflation, whilst the diffusion capacity for carbon monoxide (DL_CO) significantly differentiates between the 3 diagnostic classes.

Conclusion

The complexity of COPD with its components of interaction and their heterogeneity, especially in discrimination from ACO, may well be differentiated if patients are explored by a whole set of target parameters evaluating, interactionally, flow limitation, airway dynamics, pulmonary hyperinflation, small airways dysfunction and gas exchange disturbances assessing specific functional deficits.

Assessment of prevalence and characteristics of asthma-COPD overlap among patients with chronic airflow obstruction

Given the paucity of research on asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) and the high prevalence of co-morbidities and healthcare utilization associated with it, the current study looked at the prevalence of ACO and its clinico-radiological phenotype in patients with chronic airflow obstruction. The study was conducted at a tertiary care hospital in North India. Patients over 40 with COPD or asthma were screened for inclusion in the ACO, asthma, and COPD groups. The ACO and COPD groups were further investigated. The clinical characteristics, lung functions, health-related quality of life, and radiological features of both groups were investigated and compared. ACO was discovered in 16.3% of patients with chronic airflow obstruction (asthma and COPD). The most commonly observed symptoms at presentation in the evaluated ACO patients (n=77) were shortness of breath, wheezing, cough, and expectoration (mean age at presentation: 57.9; mean duration of illness: 8.62 years). Exacerbation rates in ACO patients were significantly higher than in COPD patients (p<0.001). The ACO group had a significantly greater mean change in FEV1 post-bronchodilator in millilitres (ml) and percentage (379.61 ml and 37.72%) than the COPD group (p<0.001). The proportion of patients with emphysema was lower in the ACO group than in the COPD group (p<0.001). The ACO and COPD groups did not differ significantly in major airway wall thickness (p=0.3), but the COPD group had a significantly higher proportion of patients with vascular attenuation and distortion (p<0.001). Patients with COPD had a higher degree of hyperinflation, according to high resolution computed tomography (HRCT) indices. This study found that patients with ACO have a distinct phenotype in terms of clinical presentation and HRCT features. More research on the radiological features of ACO is required to identify the anatomical abnormalities involved in the disease's pathogenesis and to validate the radiological features of ACO.

Longitudinal follow-up of the asthma status in a French-Canadian cohort

Asthma affects 340 million people worldwide and varies in time. Twenty years ago, in Canada, the Saguenay–Lac-Saint-Jean asthma family cohort was created to study the genetic and environmental components of asthma. This study is a follow-up of 125 participants of this cohort to explore the appearance, persistence, and progression of asthma over 10–20 years. Participants answered a clinical standardized questionnaire. Lung function was assessed (forced expiratory volume in 1 s, forced vital capacity, bronchial reversibility, and methacholine bronchoprovocation), skin allergy testing was performed, blood samples were obtained (immunoglobulin E, white blood cell counts) and phenotypes were compared between recruitment and follow-up. From the participants without asthma at recruitment, 12% developed a phenotype of adult-onset asthma with the presence of risk factors, such as atopy, high body mass index, and exposure to smoking. A decrease of PC₂₀ values in this group was observed and a decrease in the FEV₁/FVC ratio in all groups. Also, 7% of individuals with asthma at recruitment developed chronic obstructive pulmonary disease, presenting risk factors at recruitment, such as moderate-to-severe bronchial hyperresponsiveness, exposure to smoking, and asthma. This study allowed a better interpretation of the evolution of asthma. Fine phenotypic characterization is the first step for meaningful genetic and epigenetic studies.

Pharmacologic Management Strategies of Asthma-Chronic Obstructive Pulmonary Disease Overlap

The best therapeutic approach to patients with asthma-chronic obstructive pulmonary disease overlap (ACO) is unknown. Current treatment recommendations rely on expert opinions, roundtable discussions, and strategy documents, because patients with ACO have been excluded from most clinical studies in asthma and COPD. Because of the underlying asthma initial therapy, early use of inhaled corticosteroids along with a long-acting bronchodilator is recommended. If maintenance inhaler therapy is not effective, advanced therapies based on phenotyping and identification of treatable traits may be considered.

When Asthma and Chronic Obstructive Pulmonary Disease Overlap; Current Knowledge and Unmet Needs

Asthma and chronic obstructive pulmonary disease (COPD) are common diseases that often overlap. The term asthma-COPD overlap (ACO) has been used to define this entity but there remain several speculations on its exact definition, impact, pathophysiology, and clinical features. Patients with ACO have greater morbidity than those with asthma or COPD alone, but the information on the best therapeutic approach to this group of patients is still limited. Current treatment recommendations rely on expert opinions, roundtable discussions, and strategy documents. It is prudent to examine existing knowledge about ACO and determine the path for future research.

Epidemiology of Asthma-Chronic Obstructive Pulmonary Disease Overlap

Asthma COPD Overlap has consistently reported to be associated with an increase burden of disease but the impact on lung function decline and mortality varies by study. The prevalence increases with age but the relationship with gender also varies with the study population. The variability in the prevalence and clinical characteristics of ACO is linked to differences in how chronic obstructive pulmonary disease (COPD) and asthma are defined, including diagnostic criteria (spirometry-based vs. clinical or symptom-based diagnoses vs. claims data), the population studied, the geographic region and environment and a consensus approach to the diagnosis of ACO is needed to allow meaningful and consistent epidemiologic information to be generated about this condition.

Defining Asthma-Chronic Obstructive Pulmonary Disease Overlap

Much interest has been given to the asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) in the past 2 decades, but the condition is still ill-defined. There is general agreement that a patient with longstanding asthma who develops fixed airflow obstruction after years of smoking has ACO although defining asthma in the face of COPD can be challenging. Many features of asthma are also found in patients with COPD without indicating an overlap and no consensus exists on which characteristics should be included in the definition of ACO. Nevertheless, some guidance has been issued to help clinicians and researchers to make a diagnosis of ACO and these will be reviewed here.

Tests for confounding with cigarette smoking in the association of E-cigarette use with respiratory disorder: 2020 National-Sample Data

Associations of e-cigarette use with respiratory disorder have been demonstrated but it has been unclear whether these are confounded by current or previous cigarette smoking. We address this question through studying different time frames for e-cigarette use and respiratory disorders in 2020 BRFSS data (N = 214,945). E-cigarette use and combustible cigarette smoking were classified into four categories: Participant never used either (Nonuse); used e-cigarettes/cigarettes but not in the past 30 days (Former Use), used in past 30 days on some days (Nondaily Use), or used past 30 days on all days (Daily Use). Contrasts for e-cigarette status and cigarette status (with nonuse as reference group) were entered with covariates in logistic regression with asthma or COPD as criterion. Stratified analyses of e-cigarette use were also performed for smokers and nonsmokers. In the total sample, results showed independent positive associations with both lifetime and current asthma for Former, Nondaily, and Daily e-cigarette use (mostly p < .0001) and the three cigarette indices. Significant positive associations with COPD were found for the three e-cigarette indices (p < .0001) and all the cigarette indices. Stratified analyses showed significant associations of e-cigarette use with respiratory disorder among nonsmokers as well as among smokers. We conclude that independent associations for former e-cigarette use (controlling for current/former smoking) and significant associations of e-cigarette use with respiratory disorder among nonsmokers indicate these associations are not confounded with cigarette smoking and suggest reverse causation is implausible. Findings for former use are discussed with reference to possible mechanisms including sensitization effects.

State-specific Prevalence and Factors Associated With Current Marijuana, ENDS, and Cigarette use Among US Adults With Asthma

Background

The use of marijuana (MJ), combustible cigarettes (hereafter cigarettes), and electronic nicotine delivery systems (ENDS) is widespread among United States (US) adults and linked to worsening respiratory symptoms, especially among adults with asthma. This study examined state-specific prevalence and factors associated with MJ, ENDS, and cigarette use among US adults with asthma.

Methods

We analyzed data of 41 974 adults aged ≥18 years having self-reported current asthma from the 2018 Behavioral Risk Factor Surveillance System (BRFSS). We reported weighted prevalence to account for complex survey design and performed multivariable logistic regression models to examine factors associated with current use of MJ, ENDS, and cigarettes.

Results

Overall prevalence of current MJ, ENDS, and cigarette use among adults with asthma was 14.5%, 6.6%, and 27.2%, respectively. Our results showed the US states and territories with highest and lowest use prevalence for MJ (California: 23.6% vs Guam: 3.2%), ENDS (Indiana: 12.8% vs North Dakota: 4.0%), and cigarettes (West Virginia: 42.1% vs Guam: 12.3%). Both MJ and ENDS users were more likely to be male, younger, and live in an urban area, but MJ users were more likely and ENDS users less likely to be Non-Hispanic (NH) American Indian/Alaskan Native. Cigarette users were more likely to be older, have at least 1 health condition, and were less likely to be NH Black or Hispanic and college-educated.

Conclusion

Many US adults with asthma use MJ, ENDS, and cigarettes. Our findings provide insights for clinicians about the urgent need for effective interventions to reduce tobacco and MJ use among adults with asthma.

Advances in inhaled corticosteroids for the treatment of chronic obstructive pulmonary disease: what is their value today?

INTRODUCTION

As of today, there is still a need to determine which COPD patients may benefit from ICS therapy, whether ICSs are useful in COPD patients without chronic bronchitis, and whether long-acting bronchodilators can reduce the risk of exacerbations in frequent exacerbators even if ICSs are not used, and whether combination therapy including ICSs is helpful in infrequent exacerbators to optimise the use of ICSs in COPD. Nevertheless, in recent years, a fair amount of evidence has been produced that, at least in part, can help define the role of ICSs in COPD better.

AREAS COVERED

Herein, the authors provide an overview of current use of ICS in COPD and discuss their value to the current treatment armamentarium. The article includes discussion of which patients will benefit best from the use of ICSs, their potential uses and adverse effects.

EXPERT OPINION

There is growing agreement on why, in whom, and when ICS therapy can be used in COPD, although the consensus is still lacking because of the heterogeneity of COPD. The use of blood eosinophil counts (BECs) is only helpful in T2 inflammation, while there is a lack of biomarkers indicating the presence of T1 and T17 immunity, which is poorly responsive to ICS. Identifying ICS-sensitive endotypes using specific biomarkers that have yet to be identified and validated is likely to demonstrate that ICSs can influence the natural course of COPD in at least a subset of patients.

Chronic Obstructive Pulmonary Disease With Asthma-Like Features in the General Population in China

Background

Patients with features of both asthma and chronic obstructive pulmonary disease (COPD) are seen commonly in the clinic but less is known in the general population. We investigated the prevalence and the heterogeneity of COPD with concomitant features of asthma in Chinese adult population.

Methods

COPD was defined as post-bronchodilator ratio of forced expiratory volume in 1s (FEV₁) to forced vital capacity of less than the lower limits of normal. COPD with concomitant features of asthma was defined as either COPD with asthma diagnosed by self-reported physician-diagnosis or by presence of current wheeze, or as COPD with high bronchodilator response (HBR) defined as an increase in FEV₁ >15% and >400 ml after bronchodilator.

Results

COPD with concomitant features of asthma was found in 1.62% (95% CI 1.31–2.00) of adults (≥20 years) or in 15.2% (95% CI 13.0–17.7) of COPD patients. Compared with COPD with HBR, COPD with asthma diagnosis or wheeze were older (61.8 ± 1.1 years vs. 47.4 ± 2.8 years, P < 0.001), and with a lower post-bronchodilator FEV₁%pred (68.2 ± 2.3 vs. 96.6 ± 3.4, P < 0.001). Age, smoking status, biomass use and allergic rhinitis were associated with increasing prevalence of COPD with asthma diagnosis or wheeze, and had greater impaired health status, more comorbidities and more acute exacerbations in the preceding 12 months.

Conclusions

COPD with concomitant features of asthma is common in people with COPD and those with COPD with asthma diagnosis or wheeze experience worse clinical severity than COPD with HBR. These findings will help toward the definition of the asthma-COPD overlap condition.

A cross-sectional analysis of associations between environmental indices and asthma in U.S. counties from 2003 to 2012

BACKGROUND

To capture the impacts of environmental stressors, environmental indices like the Air Quality Index, Toxic Release Inventory, and Environmental Quality Index have been used to investigate the environmental quality and its association with public health issues. However, past studies often rely on relatively small sample sizes, and they have typically not adjusted for important individual-level disease risk factors.

OBJECTIVE

We aim to estimate associations between existing environmental indices and asthma prevalence over a large population and multiple years.

METHODS

Based on data availability, we assessed the predictive capability of these indices for prevalent asthma across U.S. counties from 2003 to 2012. We gathered asthma data from the U.S. CDC Behavioral Risk Factor Surveillance System by county and used multivariable weighted logistic regression models to estimate the associations between the environmental indices and asthma, adjusting for individual factors such as smoking, income level, and obesity.

RESULTS

Environmental indices showed little to no correlation with one another and with prevalent asthma over time. Associations of environmental indices with prevalent asthma were very weak; whereas individual factors were more substantially associated with prevalent asthma.

SIGNIFICANCE

Our study suggests that an improved environmental index is needed to predict population-level asthma prevalence.

Similarities in Quantitative Computed Tomography Imaging of the Lung in Severe Asthma with Persistent Airflow Limitation and Chronic Obstructive Pulmonary Disease

Background: Severe asthma with persistent airflow limitation (SA-PAL) and chronic obstructive pulmonary disease (COPD) are characterised by irreversible airflow limitation and the remodelling of the airways. The phenotypes of the diseases overlap and may cause diagnostic and therapeutic concerns. Methods: There were 10 patients with SA-PAL, 11 patients with COPD, and 10 healthy volunteers (HV) enrolled in this study. The patients were examined with a 128-multislice scanner at full inspiration. Measurements were taken from the third to ninth bronchial generations. Results: The thickness of the bronchial wall was greater in the SA-PAL than in the COPD group for most bronchial generations (p < 0.05). The mean lung density was the lowest in the SA-PAL group (−846 HU), followed by the COPD group (−836 HU), with no statistical difference between these two groups. The low-attenuation volume percentage (LAV% < −950 HU) was significantly higher in the SA-PAL group (15.8%) and COPD group (10.4%) compared with the HV group (7%) (p = 0.03). Conclusion: Severe asthma with persistent airflow limitation and COPD become similar with time within the functional and morphological dimensions. Emphysema qualities are present in COPD and in SA-PAL patients.

A unique population of neutrophils generated by air pollutant-induced lung damage exacerbates airway inflammation

BACKGROUND

Diesel exhaust particles (DEPs) are the main component of traffic-related air pollution and have been implicated in the pathogenesis and exacerbation of asthma. However, the mechanism by which DEP exposure aggravates asthma symptoms remains unclear.

OBJECTIVE

This study aimed to identify a key cellular player of air pollutant-induced asthma exacerbation and development.

METHODS

We examined the distribution of innate immune cells in the murine models of asthma induced by house dust mite and DEP. Changes in immune cell profiles caused by DEP exposure were confirmed by flow cytometry and RNA-Seq analysis. The roles of sialic acid-binding, Ig-like lectin F (SiglecF)-positive neutrophils were further evaluated by adoptive transfer experiment and in vitro functional studies.

RESULTS

DEP exposure induced a unique population of lung granulocytes that coexpressed Ly6G and SiglecF. These cells differed phenotypically, morphologically, functionally, and transcriptionally from other SiglecF-expressing cells in the lungs. Our findings with murine models suggest that intratracheal challenge with DEPs induces the local release of adenosine triphosphate, which is a damage-associated molecular pattern signal. Adenosine triphosphate promotes the expression of SiglecF on neutrophils, and these SiglecF⁺ neutrophils worsen type 2 and 3 airway inflammation by producing high levels of cysteinyl leukotrienes and neutrophil extracellular traps. We also found Siglec8- (which corresponds to murine SiglecF) expressing neutrophils, and we found it in patients with asthma-chronic obstructive pulmonary disease overlap.

CONCLUSION

The SiglecF⁺ neutrophil is a novel and critical player in airway inflammation and targeting this population could reverse or ameliorate asthma.

Current Knowledge of Asthma-COPD Overlap (ACO) Genetic Risk Factors, Characteristics, and Prognosis

Asthma-COPD overlap (ACO) is a newly identified phenotype of chronic obstructive airway diseases with shared asthma and COPD features. Patients with ACO are poorly defined, and some evidence suggests that they have worse health outcomes and greater disease burden than patients with COPD or asthma. Generally, there is no evidence-based and universal definition for ACO; several consensus documents have provided various descriptions of the phenotype. In addition, the mechanisms underlying the development of ACO are not fully understood. Whether ACO is a distinct clinical entity with its particular discrete genetic determinant different from asthma and COPD alone or an intermediate phenotype with overlapping genetic markers within asthma and COPD spectrum of obstructive airway disease remains unproven. This review summarizes the current knowledge of the genetic risk factors, characteristics, and prognosis of ACO.

Health expenditures of asthma-COPD overlap in Northern Jordan

Objective

To investigate the characteristics and medical expenditures of patients with Asthma- chronic obstructive pulmonary disease (COPD) overlap (ACO) compared to asthma and COPD patients.

Methods

This was a retrospective cohort study involving patients diagnosed with ACO, asthma or COPD as of January 2016. Medical records for patients attending King Abdullah University Hospital (KAUH), in northern Jordan, during the years 2015–2016 were used to identify eligible patients and all relevant clinical characteristics. Both respiratory and all-cause charges were extracted from KAUH billing system during the year 2016. Total, inpatient, outpatient, and pharmacy charges were described and compared across the three disease categories. Charges were measured in Jordanian Dinar (JOD, equal to 1.41 US Dollar).

Results

Of a total of 761, 87 ACO patients, 494 asthmatic patients and 180 COPD patients were identified and included in this study. The average total respiratory-related charges were significantly higher in patients with ACO compared to patients with asthma (601.4 versus 354.3 JODs; P value < 0.001). Average all-cause charges were higher in case of ACO and COPD compared to patients with asthma (1830.8 and 1705.4 versus 1251.7 JODs; P value < 0.001). ACO was a significant predictor of higher respiratory and all-cause related charges. Respiratory charges were also higher in older patients and those with higher disease severity.

Conclusions

ACO is a risk factor for incurring higher health expenditures in Jordan. Higher respiratory expenditures are also associated with older ages and higher disease severity.

Bronchodilator Response in Patients with COPD, Asthma-COPD-Overlap (ACO) and Asthma, Evaluated by Plethysmographic and Spirometric z-Score Target Parameters

BACKGROUND

Airflow reversibility criteria in COPD are still debated - especially in situations of co-existing COPD and asthma. Bronchodilator response (BDR) is usually assessed by spirometric parameters. Changes assessed by plethysmographic parameters such as the effective, specific airway conductance (sGeff), and changes in end-expiratory resting level at functional residual capacity (FRCpleth) are rarely appreciated. We aimed to assess BDR by spirometric and concomitantly measured plethysmographic parameters. Moreover, BDR on the specific aerodynamic work of breathing (sWOB) was evaluated.

METHODS

From databases of 3 pulmonary centers, BDR to 200 g salbutamol was retrospectively evaluated by spirometric (∆FEV1 and ∆FEF25-75), and plethysmographic (∆sGeff, ∆FRCpleth, and ∆sWOB) parameters in a total of 843 patients diagnosed as COPD (478 = 57%), asthma-COPD-overlap (ACO) (139 = 17%), or asthma (226 = 27%), encountering 1686 BDR-measurement-sets (COPD n = 958; ACO n = 276; asthma n = 452).

RESULTS

Evaluating z-score improvement taking into consideration the whole pre-test z-score range, highest BDR was achieved by combining ∆sGeff and ∆FRC detecting BDR in 62.2% (asthma: 71.4%; ACO: 56.7%; COPD: 59.8%), by ∆sGeff in 53.4% (asthma: 69.1%; ACO: 51.6%; COPD: 47.4%), whereas ∆FEV1 only distinguished in 10.6% (asthma: 21.8%; ACO: 18.6%; COPD: 4.2%). Remarkably, ∆sWOB detected BDR in 49.4% (asthma: 76.2%; ACO: 47.8%; COPD: 46.9%).

CONCLUSION

BDR largely depends on the pre-test functional severity and, therefore, should be evaluated in relation to the pre-test conditions expressed as ∆z-scores, considering changes in airway dynamics, changes in static lung volumes and changes in small airway function. Plethysmographic parameters demonstrated BDR at a significant higher rate than spirometric parameters.

Multimorbidity in the elderly in China based on the China Health and Retirement Longitudinal Study

This study aimed to investigate the spatial distribution and patterns of multimorbidity among the elderly in China. Data on the occurrence of 14 chronic diseases were collected for 9710 elderly participants in the 2015 waves of the China Health and Retirement Longitudinal Study (CHARLS). Web graph, Apriori algorithm, age-adjusted Charlson comorbidity index (AAC), and Spatial autocorrelation were used to perform the multimorbidity analysis. The multimorbidity prevalence rate was estimated as 49.64% in the elderly in China. Three major multimorbidity patterns were identified: [Asthma/Chronic lungs diseases]: (Support (S) = 6.17%, Confidence (C) = 63.77%, Lift (L) = 5.15); [Asthma, Arthritis, or rheumatism/ Chronic lungs diseases]: (S = 3.12%, C = 64.03%, L = 5.17); [Dyslipidemia, Hypertension, Arthritis or rheumatism/Heart attack]: (S = 3.96%, C = 51.56, L = 2.69). Results of the AAC analysis showed that the more chronic diseases an elderly has, the lower is the 10-year survival rate (P < 0.001). Global spatial autocorrelation showed a positive spatial correlation distribution for the prevalence of the third multimorbidity pattern in China (P = 0.032). The status of chronic diseases and multimorbidity among the elderly with a spatial correlation is a significant health issue in China.

Association between Physical Activity and Comorbidities in Spanish People with Asthma-COPD Overlap

Asthma and chronic obstructive pulmonary disease (COPD) are important conditions which often coexist. Higher rates of comorbidities among people with asthma-COPD overlap (ACO) may complicate clinical management. The aim of this study was to determine the prevalence of 30 different comorbidities and to analyze associations between these comorbidities and physical activity (PA) in Spanish people with ACO. Cross-sectional data from the Spanish National Health Survey 2017 were analyzed. A total of 198 Spanish people with ACO aged 15–69 years (60.6% women) were included in this study. PA was measured with the International Physical Activity Questionnaire (IPAQ) short form. Diagnosis of chronic conditions were self-reported. Associations between PA and comorbidities were analyzed using multivariable logistic regression models. The most prevalent comorbidities were chronic allergy (58.1%), chronic lumbar pain (42.4%), chronic cervical pain (38.4%), hypertension (33.3%) and arthrosis (31.8%). A PA level lower than 600 MET·min/week was significantly associated with urinary incontinence (OR = 3.499, 95% CI = 1.369–8.944) and osteoporosis (OR = 3.056, 95% CI = 1.094–8.538) in the final adjusted model. Therefore, the potential influence of PA on reducing the risk of these conditions among people with ACO should be considered, not only because of the health benefits, but also because PA can contribute to a more sustainable world.

Update on Asthma-COPD Overlap (ACO): A Narrative Review

Although chronic obstructive pulmonary disease (COPD) and asthma are well-characterized diseases, they can coexist in a given patient. The term asthma-COPD overlap (ACO) was introduced to describe patients that have clinical features of both diseases and may represent around 25% of COPD patients and around 20% of asthma patients. Despite the increasing interest in ACO, there are still substantial controversies regarding its definition and its position within clinical guidelines for patients with obstructive lung disease. In general, most definitions indicate that ACO patients must present with non-reversible airflow limitation, significant exposure to smoking or other noxious particles or gases, together with features of asthma. In patients with a primary diagnosis of COPD, the identification of ACO has therapeutic implication because the asthmatic component should be treated with inhaled corticosteroids and some studies suggest that the most severe patients may respond to biological agents indicated for severe asthma. This manuscript aims to summarize the current state-of-the-art of ACO. The definitions, prevalence, and clinical manifestations will be reviewed and some innovative aspects, such as genetics, epigenetics, and biomarkers will be addressed. Lastly, the management and prognosis will be outlined as well as the position of ACO in the COPD and asthma guidelines.

Concurrent asthma and chronic obstructive pulmonary disease in adult ED patients: A national perspective

OBJECTIVES

Emergency department (ED) visits for Asthma and Chronic Obstructive Pulmonary Disease (COPD) are common. The designation of Asthma-COPD overlap (ACO) has been used to describe patients with features of both diseases. Studies show that ACO patients may be at increased risk of poor outcomes relative to patients with either disease alone. We sought to characterize ED visits and ED-related outcomes of patients with ACO compared to patients with Asthma or COPD alone.

METHODS

We conducted a secondary analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS, 2005-2018) characterizing ED visits in patients ≥35 years of age with Asthma Only, COPD Only or ACO. We performed univariable and multivariable analyses adjusting for demographics to assess relevant ED outcome variables.

RESULTS

From 2005 to 2018, there were an estimated 8.15, 17.78 and 0.56 million ED visits for Asthma Only, COPD Only and ACO, respectively. ACO patients were younger than COPD Only patients (mean age 50.18 versus 61.79; p < 0.001). ACO patients differed in terms of sex, race and ethnicity from patients with either disease alone. When triaged, Asthma Only (adjusted odds ratio (aOR) = 11.45; 95% confidence interval (CI), 1.20-109.38) patients were more likely to require immediate care than ACO patients. Although admission rates were comparable between groups, ACO patients had a decreased mean length of ED visit compared to both Asthma Only (p < 0.001) and COPD Only (p < 0.05) patients. COPD Only patients were less likely than ACO patients to be seen in the ED in the last 72 h (aOR = 0.22; 95% CI, 0.056-0.89), receive nebulizer therapy (aOR = 0.55; 95% CI, 0.31-0.97), bronchodilators (aOR = 0.24; 95% CI, 0.12-0.48) and systemic corticosteroids (aOR = 0.18; 95% CI, 0.091-0.35). Asthma Only patients were less likely than ACO patients to undergo any imaging (aOR = 0.55; 95% CI, 0.31-0.96) and receive antibiotics (aOR = 0.46; 95% CI, 0.23-0.93).

CONCLUSIONS

ACO patients appear to differ demographically from patients with either disease alone in the ED. After adjustment for these demographic differences, ACO patients appear to differ with respect to several ED variables, notably respiratory therapies; however, clinical outcomes including admission and mortality rates appear to be comparable between groups.

How different combinations of comorbidities affect healthcare use by elderly patients with obstructive lung disease

Previous research had shown the number of comorbidities is a major factor influencing the burden of care for elderly patients with obstructive lung disease (OLD). This retrospective cohort study on a large population of elderly patients (age > 65 years) with OLD in northern Italy measures the use of healthcare resources associated with the most frequent combinations of comorbidities and investigates the most common reasons for hospitalization. Total health costs, pharmacy costs, emergency department (ED) visits, outpatient visits, and hospital admissions are assessed for every subject. The most common causes of hospitalization by a number of comorbidities and the most common sets of three comorbidities are identified. For each comorbidity group, we rank a list of the most frequent causes of hospitalization, both overall and avoidable with effective ambulatory care. A small group of patients suffering from major comorbidities accounts for the use of most healthcare resources. The most frequent causes of hospitalization are respiratory failure, heart failure, chronic bronchitis, and bronchopneumonia. The most common conditions manageable with ambulatory care among causes of hospitalizations are heart failure, bacterial pneumonia, and COPD. The set of three comorbidities responsible for the highest average total costs, and the highest average number of hospitalizations and outpatient visits comprised hypertension, cardiac arrhythmias, and heart failure. The main reasons for hospitalization proved to remain linked to heart failure and acute respiratory disease, regardless of specific combinations of comorbidities. Based on these findings, specific public health interventions among patients with OLD cannot be advised on the basis of specific sets of comorbidities only.

Syk-Targeted, a New 3-Arylbenzofuran Derivative EAPP-2 Blocks Airway Inflammation of Asthma-COPD Overlap in vivo and in vitro

Introduction

Asthma–chronic obstructive pulmonary (COPD) overlap (ACO) coexists with asthma and COPD syndrome characteristics, with more frequent exacerbations, heavier disease burden, higher medical utilization, and even lower quality of life. However, the ACO standard medications supported by evidence-based medicine have not yet appeared.

Methods

By using an ACO mouse model established previously and LPS-stimulated RAW264.7 macrophages in vitro, a potential therapeutic candidate, EAPP-2, was screened from derivatives of 3-arylbenzofuran, and its effect and mechanism on ACO inflammation were evaluated.

Results

EAPP-2 significantly alleviated airway inflammation in ACO mice and also inhibited the inflammatory reactions in LPS-induced RAW264.7 macrophages in vitro. Furthermore, EAPP-2 significantly inhibited the expression and phosphorylation of spleen tyrosine kinase (Syk), a common target regulating both eosinophils and neutrophils inflammation. In addition to this, EAPP-2 significantly down-regulates the expression of NF-κB, p-NF-κB, and NLRP3 in vivo and in vitro. Moreover, by using specific inhibitors in vitro, it was validated that EAPP-2 targeted on Syk and then regulated its downstream NF-κB and NLRP3.

Conclusion

EAPP-2 is shown to be a potentially useful therapeutic candidate for ACO, and its mechanism is at least partially achieved by targeting on Syk and then inhibiting NF-κB or NLRP3. Moreover, this study suggests that Syk may be a potentially effective target for ACO therapy.

The coexistence of asthma and COPD: risk factors, clinical history and lung function trajectories

RATIONALE

Patients with concomitant features of asthma and chronic obstructive pulmonary disease (COPD) have a heavy disease burden.

OBJECTIVES

Using data collected prospectively in the European Community Respiratory Health Survey, we compared the risk factors, clinical history, and lung function trajectories from early adulthood to the late sixties of middle aged subjects having asthma+COPD (n=179), past (n=263) or current (n=808) asthma alone, COPD alone (n=111), or none of these (n=3477).

METHODS

Interview data and prebronchodilator FEV₁ and FVC were obtained during three clinical examinations in 1991-1993, 1999-2002, and 2010-2013. Disease status was classified in 2010-2013, when the subjects were aged 40-68, according to the presence of fixed airflow obstruction (postbronchodilator FEV₁/FVC below the lower limit of normal), a lifetime history of asthma, and cumulative exposure to tobacco or occupational inhalants. Previous lung function trajectories, clinical characteristics, and risk factors of these phenotypes were estimated.

MAIN RESULTS

Subjects with asthma+COPD reported maternal smoking (28.2%) and respiratory infections in childhood (19.1%) more frequently than subjects with COPD alone (20.9 and 14.0%, respectively). Subjects with asthma+COPD had an impairment of lung function at age 20 that tracked over adulthood, and more than half of them had asthma onset in childhood. Subjects with COPD alone had the highest lifelong exposure to tobacco smoking and occupational inhalants, and they showed accelerated lung function decline during adult life.

CONCLUSIONS

The coexistence between asthma and COPD seems to have its origins earlier in life compared to COPD alone. These findings suggest that prevention of this severe condition, which is typical at older ages, should start in childhood.

Physical activity behavior in people with asthma and COPD overlap residing in Spain: a cross-sectional analysis

OBJECTIVES

To identify levels of physical activity (PA) among the Spanish population with asthma and chronic obstructive pulmonary disease overlap (ACO). A further aim was to analyze differences in PA levels by sex, age, education, marital status, cohabiting, smoking habits, alcohol consumption and body mass index (BMI).

METHODS

In this cross sectional study, data from the Spanish National Health Survey 2017 were analyzed. A total of 198 people with ACO aged 15-69 years were included in the analyses. The short version of the international physical activity questionnaire (IPAQ) was used to measure total PA (MET·min/week). PA was further classified as low, moderate and high, and analyzed according to sample characteristics. Data were analyzed using the Mann-Whitney U test, Kruskal-Wallis H test and chi squared test. Statistical significance was set at p < 0.05.

RESULTS

People with ACO engaged in a mean volume of 2038.1 MET·min/week. Those aged 30-60 years and those with normal weight were significantly more active than those aged ≥60 and those with obesity. When classifying PA level in low, moderate and high, results showed no significant differences between sample characteristics. Overall, moderate and high levels of PA were the most and least frequent levels (48.0% and 16.2%, respectively).

CONCLUSIONS

More than three out of ten Spanish adults with ACO do not achieve PA recommendations. Therefore, it is recommended to implement programs that promote the importance and benefits of PA among the Spanish population with ACO, and such programs should focus on older adults and those who are obese.