Promotion of lung health: NHLBI Workshop on the Primary Prevention of Chronic Lung Diseases

Ecuadorian Provinces with High Morbidity and Mortality Rates Due to Asthma among the Working-Age Population: An Ecological Study to Promote Respiratory Health

Asthma is a significant public health concern. This study identified the provinces with the highest morbidity and mortality rates due to asthma among the working-age population (15-69 years) in the Republic of Ecuador. The secondary objective was to explain the possible differences attributable to occupational exposure. This nationwide ecological study was conducted in 24 provinces between 2016 and 2019. Government databases were used as sources of information. Age-standardized rates were calculated for codes J45 and J46. The hospitalization morbidity rate for asthma decreased from 6.51 to 5.76 cases per 100,000 working-age population, and the mortality rate has consistently been low and stable from 0.14 to 0.15 deaths per 100,000 working-age population. Geographic differences between the provinces were evident. The risk of hospitalization and death due to asthma was higher in the Pacific coast (Manabí with 7.26 and 0.38, Esmeraldas with 6.24 and 0.43, Los Ríos with 4.16 and 0.40, El Oro with 7.98 and 0.21, Guayas with 4.42 and 0.17 and the Andean region (Azuay with 6.33 and 0.45, Cotopaxi (5.84 and 0.48)). The high rates observed in provinces with greater agricultural and industrial development could be national heterogeneity's main determinants and act as occupational risk factors. The contribution of occupational hazards in each province should be examined in depth through ad hoc studies. The findings presented here provide valuable information that should prompt further detailed studies, which will assist in designing public policies aimed at promoting and safeguarding the respiratory health of the population, particularly that of workers. We believe that this study will inspire the creation of regional networks for the research and surveillance of occupational health.

Proteomic Biomarkers of Quantitative Interstitial Abnormalities in COPDGene and CARDIA Lung Study

Rationale: Quantitative interstitial abnormalities (QIAs) are early measures of lung injury automatically detected on chest computed tomography scans. QIAs are associated with impaired respiratory health and share features with advanced lung diseases, but their biological underpinnings are not well understood. Objectives: To identify novel protein biomarkers of QIAs using high-throughput plasma proteomic panels within two multicenter cohorts. Methods: We measured the plasma proteomics of 4,383 participants in an older, ever-smoker cohort (COPDGene [Genetic Epidemiology of Chronic Obstructive Pulmonary Disease]) and 2,925 participants in a younger population cohort (CARDIA [Coronary Artery Disease Risk in Young Adults]) using the SomaLogic SomaScan assays. We measured QIAs using a local density histogram method. We assessed the associations between proteomic biomarker concentrations and QIAs using multivariable linear regression models adjusted for age, sex, body mass index, smoking status, and study center (Benjamini-Hochberg false discovery rate-corrected P ⩽ 0.05). Measurements and Main Results: In total, 852 proteins were significantly associated with QIAs in COPDGene and 185 in CARDIA. Of the 144 proteins that overlapped between COPDGene and CARDIA, all but one shared directionalities and magnitudes. These proteins were enriched for 49 Gene Ontology pathways, including biological processes in inflammatory response, cell adhesion, immune response, ERK1/2 regulation, and signaling; cellular components in extracellular regions; and molecular functions including calcium ion and heparin binding. Conclusions: We identified the proteomic biomarkers of QIAs in an older, smoking population with a higher prevalence of pulmonary disease and in a younger, healthier community cohort. These proteomics features may be markers of early precursors of advanced lung diseases.

Automated detection of airflow obstructive diseases: A systematic review of the last decade (2013-2022)

BACKGROUND AND OBJECTIVE

Obstructive airway diseases, including asthma and Chronic Obstructive Pulmonary Disease (COPD), are two of the most common chronic respiratory health problems. Both of these conditions require health professional expertise in making a diagnosis. Hence, this process is time intensive for healthcare providers and the diagnostic quality is subject to intra- and inter- operator variability. In this study we investigate the role of automated detection of obstructive airway diseases to reduce cost and improve diagnostic quality.

METHODS

We investigated the existing body of evidence and applied Preferred Reporting Items for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to search records in IEEE, Google scholar, and PubMed databases. We identified 65 papers that were published from 2013 to 2022 and these papers cover 67 different studies. The review process was structured according to the medical data that was used for disease detection. We identified six main categories, namely air flow, genetic, imaging, signals, and miscellaneous. For each of these categories, we report both disease detection methods and their performance.

RESULTS

We found that medical imaging was used in 14 of the reviewed studies as data for automated obstructive airway disease detection. Genetics and physiological signals were used in 13 studies. Medical records and air flow were used in 9 and 7 studies, respectively. Most papers were published in 2020 and we found three times more work on Machine Learning (ML) when compared to Deep Learning (DL). Statistical analysis shows that DL techniques achieve higher Accuracy (ACC) when compared to ML. Convolutional Neural Network (CNN) is the most common DL classifier and Support Vector Machine (SVM) is the most widely used ML classifier. During our review, we discovered only two publicly available asthma and COPD datasets. Most studies used private clinical datasets, so data size and data composition are inconsistent.

CONCLUSIONS

Our review results indicate that Artificial Intelligence (AI) can improve both decision quality and efficiency of health professionals during COPD and asthma diagnosis. However, we found several limitations in this review, such as a lack of dataset consistency, a limited dataset and remote monitoring was not sufficiently explored. We appeal to society to accept and trust computer aided airflow obstructive diseases diagnosis and we encourage health professionals to work closely with AI scientists to promote automated detection in clinical practice and hospital settings.

Associations between GrimAge acceleration and pulmonary function in the Coronary Artery Risk Development in Young Adults (CARDIA) study

Background: The objective of this research was to determine whether pulmonary function is associated with epigenetic aging (GrimAge) and whether GrimAge predicts emphysema. Methods: This prospective study examined 1042 participants enrolled as part of a community-based longitudinal cohort. The cross-sectional associations between pulmonary function and GrimAge, measured at study year (Y) 20 (participant ages 40-45 years), and prospective associations with emphysema at Y25 were examined. Results: At Y20, forced expiratory volume in 1 s (FEV1) and FEV1/forced vital capacity (FVC) were negatively associated with GrimAge; for Y0-Y10 cumulative measures, only the FEV1/FVC ratio was associated with GrimAge at Y15 and Y20. Emphysema at Y25 was associated with GrimAge at Y15 and Y20. Conclusion: Pulmonary function was associated with GrimAge during early and mid-life; GrimAge partially mediated the association between pulmonary function and emphysema.

Healthful and Unhealthful Plant-Based Diets and Chronic Obstructive Pulmonary Disease in U.S. Adults: Prospective Study

BACKGROUND

Despite the potential protective effect of a plant-based diet against chronic obstructive pulmonary disease (COPD), it remains unknown whether intake of different types of plant foods is beneficial for COPD. Our aims were to determine whether adherence to the healthful version of a plant-based diet (healthful Plant-based Diet Index (hPDI)) is associated with a lower COPD risk, whereas adherence to the unhealthful version (unhealthful Plant-based Diet Index (uPDI)) is associated with a higher COPD risk.

METHODS

46,948 men from the Health Professionals Follow-up Study, 73,592 women from the Nurses' Health Study, and 85,515 women from the Nurses' Health Study II who completed biennial questionnaires from 1984-2018. We derived diet scores from repeated validated food frequency questionnaires. Among 5,661,994 person-years of follow-up, we documented 2605 validated COPD cases between 1984-2018.

RESULTS

After tight control for smoking and other potential confounders, COPD risk was 46% lower among participants with the highest hPDI score compared to those with the lowest score. Conversely, COPD risk was 39% higher among participants with the highest uPDI. Further adjustment for processed meat intake led to similar results.

CONCLUSIONS

These findings provide further evidence for consuming a diet that emphasizes healthful plant foods to optimize lung health.

Pulmonary and physical function limitations in aging men with and without HIV from the Multicenter AIDS Cohort Study (MACS)

PURPOSE

We examined the associations between pulmonary impairments and physical function and whether age, HIV serostatus, or smoking modified these relationships.

METHODS

Using Multicenter AIDS Cohort Study data, we examined associations between pulmonary function (diffusing capacity for carbon monoxide [DLCO], one-second forced expiratory volume [FEV1]) and subsequent physical outcomes (gait speed, grip strength, frailty [non-frail, pre-frail, frail]) using mixed models.

RESULTS

Of 1,048 men, 55% were living with HIV, median age was 57(IQR=48,64) and median cumulative pack-years was 1.2(IQR = 0,18.1); 33% and 13% had impaired DLCO and FEV1(<80% predicted), respectively. Participants with impaired DLCO had 3.5 kg (95%CI: -4.6, -2.4) weaker grip strength, 0.04 m/sec (95%CI: -0.06, -0.02) slower gait speed and 4.44-fold (95%CI: 1.81, 10.93) greater odds of frailty compared to participants with normal DLCO. Participants with impaired FEV1 had 3.1 kg (95%CI: -4.8, -1.4) weaker grip strength, similar gait speed (-0.001 m/sec [95%CI: -0.04, 0.03]) and 5.72-fold (95%CI: 1.90, 17.19) greater odds of frailty compared to participants with normal FEV1. Age, but not smoking or HIV, significantly modified the DLCO effect on gait speed and grip strength.

CONCLUSIONS

Pulmonary impairment and decreased physical function were associated. Preserving pulmonary function may help preserve physical function in aging men with and without HIV.

Arsenic exposure and respiratory outcomes during childhood in the INMA study

Ingested inorganic arsenic (iAs) is a human carcinogen that is also linked to other adverse health effects, such as respiratory outcomes. Yet, among populations consuming low-arsenic drinking water, the impact of iAs exposure on childhood respiratory health is still uncertain. For a Spanish child study cohort (INfancia y Medio Ambiente—INMA), low-arsenic drinking water is usually available and ingestion of iAs from food is considered the major source of exposure. Here, we explored the association between iAs exposure and children’s respiratory outcomes assessed at 4 and 7 years of age (n = 400). The summation of 4-year-old children’s urinary iAs, monomethylarsonic acid (MMA), and dimethylarsinic acid (DMA) was used as a biomarker of iAs exposure (∑As) (median of 4.92 μg/L). Children’s occurrence of asthma, eczema, sneeze, wheeze, and medication for asthma and wheeze at each assessment time point (i.e., 4- and 7-year) was assessed with maternal interviewer-led questionnaires. Crude and adjusted Poisson regression models using Generalized Estimating Equation (GEE) were performed to account for the association between natural logarithm transformed (ln) urinary ∑As in μg/L at 4 years and repeated assessments of respiratory symptoms at 4 and 7 years of age. The covariates included in the models were child sex, maternal smoking status, maternal level of education, sub-cohort, and children’s consumption of vegetables, fruits, and fish/seafood. The GEE—splines function using Poisson regression showed an increased trend of the overall expected counts of respiratory symptoms with high urinary ∑As. The adjusted expected counts (95% confidence intervals) at ln-transformed urinary ∑As 1.57 (average concentration) and 4.00 (99^th percentile concentration) were 0.63 (0.36, 1.10) and 1.33 (0.61, 2.89), respectively. These exploratory findings suggest that even relatively low-iAs exposure levels, relevant to the Spanish and other populations, may relate to an increased number of respiratory symptoms during childhood.

Prenatal exposure to arsenic and lung function in children from the New Hampshire Birth Cohort Study

Prenatal arsenic exposure is associated with an increased risk of lung cancer along with multiple non-carcinogenic outcomes, including respiratory diseases in arsenic-contaminated areas. Limited epidemiologic data exist on whether in utero arsenic exposure influences lung development and subsequent respiratory health. We investigated the association between gestational arsenic exposure and childhood lung function in the New Hampshire Birth Cohort Study. Urinary arsenic speciation including inorganic arsenic (iAs), monomethylarsonic acid (MMA), dimethylarsinic acid (DMA) and arsenobetaine was measured in maternal urine samples collected during pregnancy and spirometry was performed in offspring at a median age of 7.4 years. Forced vital capacity (FVC), forced expiratory volume in the first second of exhalation (FEV1), and forced expiratory flow between 25% and 75% of FVC (FEF25-75) standardized z-scores were assessed in linear models as dependent variables with the log2-transformed summation of urinary arsenic species (ΣAs = iAs + MMA + DMA) corrected for specific gravity as an independent variable and with adjustment for maternal smoking status, children's age, sex and height. Among the 358 children in the study, a doubling of ΣAs was associated with a -0.08 (ß) decrease in FVC z-scores (95% confidence interval (CI) from -0.14 to -0.01) and -0.10 (ß) (95% CI from -0.18 to -0.02) decrease in FEV1 z-scores. The inverse association appeared stronger among those mothers with lower secondary methylation index (urinary DMA/MMA), especially among girls. No association was observed for FEF25-75 z-scores. Our results suggest that gestation arsenic exposure at levels relevant to the general US population during the vulnerable period of lung formation may adversely affect lung function in childhood.

Impaired Respiratory Health and Life Course Transitions From Health to Chronic Lung Disease

Primary prevention and interception of chronic lung disease are essential in the effort to reduce the morbidity and mortality caused by respiratory conditions. In this review, we apply a life course approach that examines exposures across the life span to identify risk factors that are associated with not only chronic lung disease but also an intermediate phenotype between ideal lung health and lung disease, termed "impaired respiratory health." Notably, risk factors such as exposure to tobacco smoke and air pollution, as well as obesity and physical fitness, affect respiratory health across the life course by being associated with both abnormal lung growth and lung function decline. We then discuss the importance of disease interception and identifying those at highest risk of developing chronic lung disease. This work begins with understanding and detecting impaired respiratory health, and we review several promising molecular biomarkers, predictive symptoms, and early imaging findings that may lead to a better understanding of this intermediate phenotype.

Effect of 6p21 region on lung function is modified by smoking: a genome-wide interaction study

Smoking is a major risk factor for chronic obstructive pulmonary disease (COPD); however, more than 25% of COPD patients are non-smokers, and gene-by-smoking interactions are expected to affect COPD onset. We aimed to identify the common genetic variants interacting with pack-years of smoking on FEV₁/FVC ratios in individuals with normal lung function. A genome-wide interaction study (GWIS) on FEV₁/FVC was performed for individuals with FEV₁/FVC ratio ≥ 70 in the Korea Associated Resource cohort data, and significant SNPs were validated using data from two other Korean cohorts. The GWIS revealed that rs10947231 and rs8192575 met genome-wide significant levels; For \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${\text{H}}_{0} :\beta_{SNP} = \beta_{SNP*pack - years} = 0{\text{ vs H}}_{1} : not {\text{H}}_{0} ,$$\end{document}H0:βSNP=βSNP∗pack-years=0vs H1:notH0, the likelihood ratio (LR) test was conducted, and its P values, P_LR, for rs10947231 and rs8192575 were 2.23 × 10^–12 and 1.18 × 10^–8, respectively. Interaction between rs8192575 and smoking is significantly replicated with two additional data (P_INT = 0.0454, 0.0131). Expression quantitative trait loci, topologically associated domains, and PrediXcan analyses revealed that rs8192575 is significantly associated with AGER expression. SNPs on the 6p21 region are associated with FEV₁/FVC, and the effect of smoking on FEV₁/FVC differs among the associated genotypes.

Determinants of Lung Function at Age 8.5 Years in a Birth Cohort of Thai Children

BACKGROUND AND AIMS

Early life factors have reported the associations with impaired lung function in later life. In the present study, the birth cohort was followed up longitudinally to investigate the determinants of lung function in Thai children.

METHODS

Cohort subjects were recruited from children born in Songkhla Province in southern Thailand. Data collections were obtained starting from antenatal, at birth, and at 1, 5 and 8.5 years of age. Spirometry was assessed at age 8.5 years. The variables investigated included birth weight, smoke exposure, respiratory diseases during the newborn period and during the first year of life, and asthma diagnosed at age 5 or 8.5 years.

RESULTS

Of 1056 subjects, 892 (84.5%) subjects completed the spirometric measurements. The presence of asthma was the only factor that was significantly associated with a lower forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio, forced expiratory flow at 25-75% vital capacity (FEF25-75%VC) and peak expiratory flow rate (PEFR). The regression analysis found that asthma was significantly associated with a lower FEV1/FVC ratio, FEF25-75%VC, and PEFR value with estimated coefficients ± standard error of -1.27 ± 0.55%, p = 0.02; -131.8 ± 48.2 ml/s, p = 0.006; and -166.2 ± 65.0 ml/s, p = 0.01, respectively. Asthma diagnosed at age 5 or 8.5 years was more likely among children who had lower respiratory tract illness during the first year of life. The odds ratio for the association was 4.81 (95% confidence interval 2.14-10.83, p < 0.001).

CONCLUSION

The main factor associated with lower lung function in Thai cohort subjects was the present of asthma by age 5 or 8.5 years and early respiratory illness was the risk factor for asthma in childhood period.

Harmonization of Respiratory Data From 9 US Population-Based Cohorts: The NHLBI Pooled Cohorts Study

Chronic lower respiratory diseases (CLRDs) are the fourth leading cause of death in the United States. To support investigations into CLRD risk determinants and new approaches to primary prevention, we aimed to harmonize and pool respiratory data from US general population-based cohorts. Data were obtained from prospective cohorts that performed prebronchodilator spirometry and were harmonized following 2005 ATS/ERS standards. In cohorts conducting follow-up for noncardiovascular events, CLRD events were defined as hospitalizations/deaths adjudicated as CLRD-related or assigned relevant administrative codes. Coding and variable names were applied uniformly. The pooled sample included 65,251 adults in 9 cohorts followed-up for CLRD-related mortality over 653,380 person-years during 1983-2016. Average baseline age was 52 years; 56% were female; 49% were never-smokers; and racial/ethnic composition was 44% white, 22% black, 28% Hispanic/Latino, and 5% American Indian. Over 96% had complete data on smoking, clinical CLRD diagnoses, and dyspnea. After excluding invalid spirometry examinations (13%), there were 105,696 valid examinations (median, 2 per participant). Of 29,351 participants followed for CLRD hospitalizations, median follow-up was 14 years; only 5% were lost to follow-up at 10 years. The NHLBI Pooled Cohorts Study provides a harmonization standard applied to a large, US population-based sample that may be used to advance epidemiologic research on CLRD.

Respiratory Symptoms in Young Adults and Future Lung Disease. The CARDIA Lung Study

RATIONALE

There are limited data on factors in young adulthood that predict future lung disease.

OBJECTIVES

To determine the relationship between respiratory symptoms, loss of lung health, and incident respiratory disease in a population-based study of young adults.

METHODS

We examined prospective data from 2,749 participants in the CARDIA (Coronary Artery Risk Development in Young Adults) study who completed respiratory symptom questionnaires at baseline and 2 years later and repeated spirometry measurements over 30 years.

MEASUREMENTS AND MAIN RESULTS

Cough or phlegm, episodes of bronchitis, wheeze, shortness of breath, and chest illnesses at both baseline and Year 2 were the main predictor variables in models assessing decline in FEV1 and FVC from Year 5 to Year 30, incident obstructive and restrictive lung physiology, and visual emphysema on thoracic computed tomography scan. After adjustment for covariates, including body mass index, asthma, and smoking, report of any symptom was associated with -2.71 ml/yr excess decline in FEV1 (P < 0.001) and -2.18 in FVC (P < 0.001) as well as greater odds of incident (prebronchodilator) obstructive (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.24-2.14) and restrictive (OR, 1.40; 95% CI, 1.09-1.80) physiology. Cough-related symptoms (OR, 1.56; 95% CI, 1.13-2.16) were associated with greater odds of future emphysema.

CONCLUSIONS

Persistent respiratory symptoms in young adults are associated with accelerated decline in lung function, incident obstructive and restrictive physiology, and greater odds of future radiographic emphysema.

Does physical fitness enhance lung function in children and young adults?

Although physical activity is important for lung health, it is unclear whether physical fitness influences lung function. We investigated associations between lung function and fitness in two population-based cohort studies of children and young adults.Aerobic fitness was measured using a maximal cycle ergometer test at ages 9, 15, 21 and 29 years in Odense, Denmark and using a submaximal cycle test at ages 15, 26, 32 and 38 years in Dunedin, New Zealand.Aerobic fitness was positively associated with forced expiratory volume in 1 s (FEV₁) and forced vital capacity (FVC) in cross-sectional analyses at all ages in both cohorts, independently of height, weight, sex, asthma and smoking. Each standard deviation difference in fitness was associated with 2-3% predicted higher values of FEV₁ and FVC. Improvements in fitness during childhood and adolescence were associated with growth in lung volumes in longitudinal analyses. These associations tended to be stronger in males than females. No longitudinal associations were found after peak adult lung function had been attained. Fitness was not significantly associated with FEV₁/FVC ratios.Aerobic fitness is positively associated with lung volumes. Improving fitness during childhood and adolescence is associated with greater adult lung volumes, but not with airway calibre.

Effect of Monthly, High-Dose, Long-Term Vitamin D on Lung Function: A Randomized Controlled Trial

Although observational studies suggest positive vitamin D-lung function associations, randomized trials are inconsistent. We examined effects of vitamin D supplementation on lung function. We recruited 442 adults (50–84 years, 58% male) into a randomized, double-blinded, placebo-controlled trial. Participants received, for 1.1 years (median; range = 0.9–1.5 years), either (1) vitamin D₃ 200,000 IU, followed by monthly 100,000 IU doses (n = 226); or (2) placebo monthly (n = 216). At baseline and follow-up, spirometry yielded forced expiratory volume in 1 s (FEV1; primary outcome). Mean (standard deviation) 25-hydroxyvitamin D increased from 61 (24) nmol/L at baseline to 119 (45) nmol/L at follow-up in the vitamin D group, but was unchanged in the placebo group. There were no significant lung function improvements (vitamin D versus placebo) in the total sample, vitamin D-deficient participants or asthma/chronic obstructive pulmonary disease (COPD) participants. However, among ever-smokers (n = 217), the mean (95% confidence interval) FEV1 increase in the vitamin D versus placebo was 57 (4, 109) mL (p = 0.03). FEV1 increases were larger among vitamin D-deficient ever-smokers (n = 54): 122 (8, 236) mL (p = 0.04). FEV1 improvements were largest among ever-smokers with asthma/COPD (n = 60): 160 (53, 268) mL (p = 0.004). Thus, vitamin D supplementation did not improve lung function among everyone, but benefited ever-smokers, especially those with vitamin D deficiency or asthma/COPD.

Association between Cardiorespiratory Fitness and Lung Health from Young Adulthood to Middle Age

RATIONALE

Beyond the risks of smoking, there are limited data on factors associated with change in lung function over time.

OBJECTIVES

To determine whether cardiorespiratory fitness was longitudinally associated with preservation of lung health.

METHODS

Prospective data were collected from 3,332 participants in the Coronary Artery Risk Development in Young Adults study aged 18-30 in 1985 who underwent treadmill exercise testing at baseline visit, and 2,735 participants with a second treadmill test 20 years later. The association between cardiorespiratory fitness and covariate adjusted decline in lung function was evaluated.

MEASUREMENTS AND MAIN RESULTS

Higher baseline fitness was associated with less decline in lung function. When adjusted for age, height, race-sex group, peak lung function, and years from peak lung function, each additional minute of treadmill duration was associated with 1.00 ml/yr less decline in FEV1 (P < 0.001) and 1.55 ml/yr less decline in FVC (P < 0.001). Greater decline in fitness was associated with greater annual decline in lung function. Each 1-minute decline in treadmill duration between baseline and Year 20 was associated with 2.54 ml/yr greater decline in FEV1 (P < 0.001) and 3.27 ml/yr greater decline in FVC (P < 0.001). Both sustaining higher and achieving relatively increased levels of fitness over 20 years were associated with preservation of lung health.

CONCLUSIONS

Greater cardiopulmonary fitness in young adulthood, less decline in fitness from young adulthood to middle age, and achieving increased fitness from young adulthood to middle age are associated with less decline in lung health over time. Clinical trial registered with www.clinicaltrials.gov (NCT 00005130).

Coordination of care for patients with COPD: Clinical points of interest

The management of care of chronic obstructive pulmonary disease improved over the last years but is still very complex. Both over- and underdiagnosis are often reported and misclassification of disease severity is common. Differentiating between chronic obstructive pulmonary disease, asthma and asthma-chronic obstructive pulmonary disease overlap syndrome remains difficult. Much is known about the effectiveness of treatment approaches in chronic obstructive pulmonary disease, but patients are often not treated according to the guidelines, and we need more evidence on effectiveness in phenotypes of chronic obstructive pulmonary disease. Care coordination is of great importance and can help to further improve care for chronic obstructive pulmonary disease patients. Pulmonary rehabilitation and self-management are considered important aspects of chronic obstructive pulmonary disease care. In our opinion, there is a major role for eHealth to improve coordination of care of chronic obstructive pulmonary disease.

Early chronic obstructive pulmonary disease: definition, assessment, and prevention

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide. COPD, however, is a heterogeneous collection of diseases with differing causes, pathogenic mechanisms, and physiological effects. Therefore a comprehensive approach to COPD prevention will need to address the complexity of COPD. Advances in the understanding of the natural history of COPD and the development of strategies to assess COPD in its early stages make prevention a reasonable, if ambitious, goal.