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Bessa EJC, Ribeiro FDMC, Rodrigues RS, Henrique da Costa C, Rufino R, Pinheiro GDRC, Lopes AJ. Association between clinical, serological, functional and radiological findings and ventilatory distribution heterogeneity in patients with rheumatoid arthritis. PLoS One 2023; 18:e0291659. [PMID: 37862308 PMCID: PMC10588833 DOI: 10.1371/journal.pone.0291659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 09/02/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND In rheumatoid arthritis (RA), the involvement of the pulmonary interstitium can lead to structural changes in the small airways and alveoli, leading to reduced airflow and maldistribution of ventilation. The single-breath nitrogen washout (SBN2W) test is a measure of the ventilatory distribution heterogeneity and evaluates the small airways. This study aimed to find out which clinical, serological, functional and radiological findings are useful to identify RA patients with pathological values of the phase III slope (SIII) measured by the SBN2W test. METHODS This was a cross-sectional study in which RA patients were assessed using the Health Assessment Questionnaire-Disability Index (HAQ-DI) and the Clinical Disease Activity Index (CDAI) and underwent serological analysis of autoantibodies and inflammatory markers. In addition, they underwent pulmonary function tests (including the SBN2W test) and chest computed tomography (CT). RESULTS Of the 60 RA patients evaluated, 39 (65%) had an SIII >120% of the predicted value. There were significant correlations between SIII and age (r = 0.56, p<0.0001), HAQ-DI (r = 0.34, p = 0.008), forced vital capacity (FVC, r = -0.67, p<0.0001), total lung capacity (r = -0.46, p = 0.0002), residual volume/total lung capacity (TLC) (r = 0.44, p = 0.0004), and diffusing capacity of the lungs for carbon monoxide (r = -0.45, p = 0.0003). On CT scans, the subgroup with moderate/severe disease had a significantly higher SIII than the normal/minimal/mild subgroup (662 (267-970) vs. 152 (88-283)% predicted, p = 0.0004). In the final multiple regression model, FVC, extent of moderate/severe involvement and age were associated with SIII, explaining 59% of its variability. CONCLUSIONS In patients with RA, FVC, extent of lung involvement and age, all of which are easily obtained variables in clinical practice, identify poorly distributed ventilation. In addition, the presence of respiratory symptoms and deteriorated physical function are closely related to the distribution of ventilation in these patients.
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Affiliation(s)
- Elizabeth Jauhar Cardoso Bessa
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Rosana Souza Rodrigues
- D’Or Institute for Research and Education, Rio de Janeiro, Brazil
- Department of Radiology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cláudia Henrique da Costa
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Rogério Rufino
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Agnaldo José Lopes
- Postgraduate Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, Brazil
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Gochicoa-Rangel L, Jiménez C, Lechuga-Trejo I, Benítez-Pérez RE, Thirion-Romero I, Hernández-Rocha FI, Ceballos-Zúñiga O, Cortes-Telles A, Guerrero-Zuñiga S, Díaz-García R, Hernández-Morales AP, Aguilar-Zanela JL, Torre-Bouscoulet L. [Small airway: from definition to treatment]. REVISTA ALERGIA MÉXICO 2023; 70:22-37. [PMID: 37566753 DOI: 10.29262/ram.v70i1.1190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/14/2023] [Indexed: 08/13/2023] Open
Abstract
The small airway, present since the origins of humanity and described barely a century ago, has recently been discovered as the anatomical site where inflammation begins in some obstructive lung diseases, such as asthma and Chronic Obstructive Pulmonary Disease (COPD), per se. Small airway dysfuction was identified in up to 91% of asthmatic patients and in a large proportion of COPD patients. In subjects without pathology, small airway represent 98.8% (approximately 4500 ml) of the total lung volume, contributing only between 10-25% of the total lung resistance; however, in subjects with obstruction, it can represent up to 90% of the total resistance. Despite this, its morphological and functional characteristics allow its dysfunction to remain undetected by conventional diagnostic methods, such as spirometry. Hence the importance of this review, which offers an overview of the tools available to assess small airway dysfunction and the possible therapies that act in this silent zone.
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Affiliation(s)
- Laura Gochicoa-Rangel
- Departamento de Fisiología Respiratoria, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Ciudad de México
| | - Carlos Jiménez
- Facultad de Medicina de la Universidad Autónoma de San Luis Potosí, San Luis Potosí, México
| | - Irma Lechuga-Trejo
- Departamento de Neumopediatría, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Ciudad de México
| | - Rosaura Esperanza Benítez-Pérez
- Departamento de Fisiología Respiratoria, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Ciudad de México
| | - Ireri Thirion-Romero
- Sociedad Latinoamericana de Fisiología Respiratoria (SOLAFIRE), Ciudad de México
| | | | | | - Arturo Cortes-Telles
- Clínica de Enfermedades Respiratorias, Hospital Regional De Alta Especialidad de la Península de Yucatán, Mérida, México
| | - Selene Guerrero-Zuñiga
- Unidad de Medicina del Sueño, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Ciudad de México
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3
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Alobaidi NY, Almeshari M, Stockley J, Stockley RA, Sapey E. Small airway function measured using forced expiratory flow between 25% and 75% of vital capacity and its relationship to airflow limitation in symptomatic ever-smokers: a cross-sectional study. BMJ Open Respir Res 2022; 9:9/1/e001385. [PMID: 36202407 PMCID: PMC9540854 DOI: 10.1136/bmjresp-2022-001385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/17/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is diagnosed and its severity graded by traditional spirometric parameters (forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) and FEV1, respectively) but these parameters are considered insensitive for identifying early pathology. Measures of small airway function, including forced expiratory flow between 25% and 75% of vital capacity (FEF25-75), may be more valuable in the earliest phases of COPD. This study aimed to determine the prevalence of low FEF25-75 in ever-smokers with and without airflow limitation (AL) and to determine whether FEF25-75 relates to AL severity. METHOD A retrospective analysis of lung function data of 1458 ever-smokers suspected clinically of having COPD. Low FEF25-75 was defined by z-score<-0.8345 and AL was defined by FEV1/FVC z-scores<-1.645. The severity of AL was evaluated using FEV1 z-scores. Participants were placed into three groups: normal FEF25-75/ no AL (normal FEF25-75/AL-); low FEF25-75/ no AL (low FEF25-75/AL-) and low FEF25-75/ AL (low FEF25-75/AL+). RESULTS Low FEF25-75 was present in 99.9% of patients with AL, and 50% of those without AL. Patients in the low FEF25-75/AL- group had lower spirometric measures (including FEV1 FEF25-75/FVC and FEV3/FVC) than those in the normal FEF25-75/AL- group. FEF25-75 decreased with AL severity. A logistic regression model demonstrated that in the absence of AL, the presence of low FEF25-75 was associated with lower FEV1 and FEV1/FVC even when smoking history was accounted for. CONCLUSIONS Low FEF25-75 is a physiological trait in patients with conventional spirometric AL and likely reflects early evidence of impairment in the small airways when spirometry is within the 'normal range'. FEF25-75 likely identifies a group of patients with early evidence of pathological lung damage who warrant careful monitoring and reinforced early intervention to abrogate further lung injury.
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Affiliation(s)
- Nowaf Y Alobaidi
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Respiratory Therapy Department, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Alahsa, Saudi Arabia
- King Abdullah International Medical Research Center, Alahsa, Saudi Arabia
| | - Mohammed Almeshari
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Rehabilitation Health Sciences Department, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
| | - James Stockley
- Lung Function & Sleep Department, Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Robert Andrew Stockley
- Lung Function & Sleep Department, Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Sapey
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
- Acute Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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4
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Yip KP, Stockley RA, Sapey E. Catching "Early" COPD - The Diagnostic Conundrum. Int J Chron Obstruct Pulmon Dis 2021; 16:957-968. [PMID: 33880020 PMCID: PMC8053524 DOI: 10.2147/copd.s296842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 03/21/2021] [Indexed: 01/21/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) remains a leading cause of morbidity and mortality worldwide. Despite this, there has been little progress so far in terms of disease-modifying therapies over the last few decades and this is in part due to poor understanding of the definition and mechanisms surrounding early disease before it becomes established and increasingly complex. In this review, the nuances and difficulty in defining early disease in COPD are discussed. There are clear benefits in identifying patients early; however, usually diagnosis is made in the presence of significant lung damage. We consider what can be learned of early disease from COPD studies and highlight the lack of inclusion of young smokers (who may be at risk of COPD) or those with mild disease. We discuss promising clinical measures that are being used in an effort to detect early disease. These include symptom assessment, lung physiology measures and computed tomography (CT) imaging modalities. There is emerging evidence for the role of neutrophils and their proteinases in early COPD. This may form an important biomarker to investigate the pathophysiological processes of early COPD. Given the importance of the early disease, it is recommended that future COPD studies focus on capturing the earliest manifestations of disease, to understand the initiating mechanisms and to identify novel treatment targets.
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Affiliation(s)
- Kay Por Yip
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
| | - Robert A Stockley
- Department of Respiratory Medicine, University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Elizabeth Sapey
- Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham, UK
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5
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Milne S, Jetmalani K, Chapman DG, Duncan JM, Farah CS, Thamrin C, King GG. Respiratory system reactance reflects communicating lung volume in chronic obstructive pulmonary disease. J Appl Physiol (1985) 2019; 126:1223-1231. [PMID: 30763164 DOI: 10.1152/japplphysiol.00503.2018] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Respiratory system reactance (Xrs) measured by the forced oscillation technique (FOT) is theoretically and experimentally related to lung volume. In chronic obstructive pulmonary disease (COPD), the absolute volume measured by body plethysmography includes a proportion that is inaccessible to pressure oscillations applied via the mouth, that is, a "noncommunicating" lung volume. We hypothesized that in COPD the presence of noncommunicating lung would disrupt the expected Xrs-volume relationship compared with plethysmographic functional residual capacity (FRCpleth). Instead, Xrs would relate to estimates of communicating volume, namely, expiratory reserve volume (ERV) and single-breath alveolar volume (VaSB). We examined FOT and lung function data from people with COPD (n = 51) and from healthy volunteers (n = 40). In healthy volunteers, we observed an expected inverse relationship between reactance at 5 Hz (X5) and FRCpleth. In contrast, there was no such relationship between X5 and FRCpleth in COPD subjects. However, there was an inverse relationship between X5 and both ERV and VaSB. Hence the theoretical Xrs-volume relationship is present in COPD but only when considering the communicating volume rather than the absolute lung volume. These findings confirm the role of reduced communicating lung volume as an important determinant of Xrs and therefore advance our understanding and interpretation of FOT measurements in COPD. NEW & NOTEWORTHY To investigate the determinants of respiratory system reactance (Xrs) measured by the forced oscillation technique (FOT) in chronic obstructive pulmonary disease (COPD), we examine the relationship between Xrs and lung volume. We show that Xrs does not relate to absolute lung volume (functional residual capacity) in COPD but instead relates only to the volume of lung in communication with the airway opening. This communicating volume may therefore be fundamental to our interpretation of FOT measurements in COPD and other pulmonary diseases.
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Affiliation(s)
- Stephen Milne
- The Woolcock Emphysema Centre and Airway Physiology and Imaging Group, Woolcock Institute of Medical Research and Sydney Medical School, University of Sydney, Glebe, New South Wales , Australia.,Department of Respiratory Medicine, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales , Australia.,Department of Respiratory Medicine, Concord Repatriation General Hospital, Sydney Local Health District, Concord, New South Wales , Australia
| | - Kanika Jetmalani
- The Woolcock Emphysema Centre and Airway Physiology and Imaging Group, Woolcock Institute of Medical Research and Sydney Medical School, University of Sydney, Glebe, New South Wales , Australia
| | - David G Chapman
- The Woolcock Emphysema Centre and Airway Physiology and Imaging Group, Woolcock Institute of Medical Research and Sydney Medical School, University of Sydney, Glebe, New South Wales , Australia.,Translational Airways Group, School of Life Sciences, University of Technology Sydney , Ultimo, New South Wales , Australia
| | - Joseph M Duncan
- Department of Respiratory Medicine, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales , Australia
| | - Claude S Farah
- The Woolcock Emphysema Centre and Airway Physiology and Imaging Group, Woolcock Institute of Medical Research and Sydney Medical School, University of Sydney, Glebe, New South Wales , Australia.,Department of Respiratory Medicine, Concord Repatriation General Hospital, Sydney Local Health District, Concord, New South Wales , Australia.,Faculty of Medicine and Health Sciences, Macquarie University , North Ryde, New South Wales , Australia
| | - Cindy Thamrin
- The Woolcock Emphysema Centre and Airway Physiology and Imaging Group, Woolcock Institute of Medical Research and Sydney Medical School, University of Sydney, Glebe, New South Wales , Australia
| | - Gregory G King
- The Woolcock Emphysema Centre and Airway Physiology and Imaging Group, Woolcock Institute of Medical Research and Sydney Medical School, University of Sydney, Glebe, New South Wales , Australia.,Department of Respiratory Medicine, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, New South Wales , Australia.,Centre of Research Excellence in Severe Asthma, New Lambton, New South Wales , Australia
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6
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Pirina P, Foschino Barbaro MP, Paleari D, Spanevello A. Small airway inflammation and extrafine inhaled corticosteroids plus long-acting beta 2-agonists formulations in chronic obstructive pulmonary disease. Respir Med 2018; 143:74-81. [PMID: 30261996 DOI: 10.1016/j.rmed.2018.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 07/10/2018] [Accepted: 08/27/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To summarize the evidence of small airways involvement in chronic obstructive pulmonary disease (COPD) pathophysiology, and to evaluate the efficacy of extrafine formulations of inhaled corticosteroids (ICS) in combination with long-acting beta2-agonists (LABAs) in the treatment of COPD. DATA SOURCE A search of the PubMed database was conducted using the keywords "COPD", "small airways", "inflammation" and "extrafine formulation." The search was limited to entries published in English before August 2016. Only studies conducted in humans were considered. STUDY SELECTION Publications were included on the basis of relevance. RESULTS COPD is a common preventable and treatable disease, characterized by persistent and progressive airflow limitation. With improved understanding of COPD pathophysiology, small airways (internal diameter <2 mm), a well-known major site of COPD-associated inflammation and remodeling, have emerged as a potential target for COPD pharmacologic therapies. The ability of extrafine formulations of ICS in combination with LABAs to achieve central and peripheral lung deposition, and the implications of the enhanced efficacy that this may bring, are discussed by examining findings from the development trials plan of the extrafine formulation of beclometasone dipropionate/formoterol fumarate (Foster®, Chiesi Farmaceutici, Italy) in patients with COPD. CONCLUSION There is an urgent need for improved and reliable techniques for small airways assessment in order to detect early damage, disease progression and response to treatment. Evidence from randomized clinical trials supports the benefits of extrafine ICS/LABA formulations in COPD, real world studies are necessary to confirm this.
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Affiliation(s)
- Pietro Pirina
- Lung Disease Unit, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy.
| | - Maria Pia Foschino Barbaro
- Institute of Respiratory Disease, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Davide Paleari
- Medical Department, Chiesi Farmaceutici SpA, Parma, Italy
| | - Antonio Spanevello
- Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italy; University of Insubria, Varese, Italy
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Rossi A, Butorac-Petanjek B, Chilosi M, Cosío BG, Flezar M, Koulouris N, Marin J, Miculinic N, Polese G, Samaržija M, Skrgat S, Vassilakopoulos T, Vukić-Dugac A, Zakynthinos S, Miravitlles M. Chronic obstructive pulmonary disease with mild airflow limitation: current knowledge and proposal for future research - a consensus document from six scientific societies. Int J Chron Obstruct Pulmon Dis 2017; 12:2593-2610. [PMID: 28919728 PMCID: PMC5587130 DOI: 10.2147/copd.s132236] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a leading cause of mortality and morbidity worldwide, with high and growing prevalence. Its underdiagnosis and hence under-treatment is a general feature across all countries. This is particularly true for the mild or early stages of the disease, when symptoms do not yet interfere with daily living activities and both patients and doctors are likely to underestimate the presence of the disease. A diagnosis of COPD requires spirometry in subjects with a history of exposure to known risk factors and symptoms. Postbronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity <0.7 or less than the lower limit of normal confirms the presence of airflow limitation, the severity of which can be measured by FEV1% predicted: stage 1 defines COPD with mild airflow limitation, which means postbronchodilator FEV1 ≥80% predicted. In recent years, an elegant series of studies has shown that "exclusive reliance on spirometry, in patients with mild airflow limitation, may result in underestimation of clinically important physiologic impairment". In fact, exercise tolerance, diffusing capacity, and gas exchange can be impaired in subjects at a mild stage of airflow limitation. Furthermore, growing evidence indicates that smokers without overt abnormal spirometry have respiratory symptoms and undergo therapy. This is an essential issue in COPD. In fact, on one hand, airflow limitation, even mild, can unduly limit the patient's physical activity, with deleterious consequences on quality of life and even survival; on the other hand, particularly in younger subjects, mild airflow limitation might coincide with the early stage of the disease. Therefore, we thought that it was worthwhile to analyze further and discuss this stage of "mild COPD". To this end, representatives of scientific societies from five European countries have met and developed this document to stimulate the attention of the scientific community on COPD with "mild" airflow limitation. The aim of this document is to highlight some key features of this important concept and help the practicing physician to understand better what is behind "mild" COPD. Future research should address two major issues: first, whether mild airflow limitation represents an early stage of COPD and what the mechanisms underlying the evolution to more severe stages of the disease are; and second, not far removed from the first, whether regular treatment should be considered for COPD patients with mild airflow limitation, either to prevent progression of the disease or to encourage and improve physical activity or both.
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Affiliation(s)
- Andrea Rossi
- Pulmonary Unit, University of Verona, Verona, Italy
| | | | | | - Borja G Cosío
- Department of Respiratory Medicine, Hospital Son Espases-IdISPa and CIBERES, Palma, Spain
| | - Matjaz Flezar
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Nikolaos Koulouris
- First Department of Respiratory Medicine, Medical School of National and Kapodistrian University of Athens, Greece
| | - José Marin
- Respiratory Medicine, Hospital Universitario Miguel Servet, CIBERES & IISAragon, Zaragoza, Spain
| | - Neven Miculinic
- Respiratory Department, University Hospital Centre, Zagreb, Croatia
| | | | - Miroslav Samaržija
- Jordanovac Department for Respiratory Diseases, University of Zagreb School of Medicine, University Hospital Centre, Zagreb, Croatia
| | - Sabina Skrgat
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Theodoros Vassilakopoulos
- First Department of Critical Care and Pulmonary Services, Evangelismos Hospital, University of Athens, Greece
| | - Andrea Vukić-Dugac
- Jordanovac Department for Respiratory Diseases, University of Zagreb School of Medicine, University Hospital Centre, Zagreb, Croatia
| | - Spyridon Zakynthinos
- First Department of Critical Care and Pulmonary Services, Evangelismos Hospital, University of Athens, Greece
| | - Marc Miravitlles
- Pneumology Department, Hospital Universitary Vall d'Hebron, Barcelona, Spain
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8
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Stockley JA, Cooper BG, Stockley RA, Sapey E. Small airways disease: time for a revisit? Int J Chron Obstruct Pulmon Dis 2017; 12:2343-2353. [PMID: 28848335 PMCID: PMC5557120 DOI: 10.2147/copd.s138540] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
It is increasingly acknowledged that delays in the diagnosis of chronic inflammatory lung conditions have hampered our understanding of pathogenesis and thus our ability to design efficacious therapies. This is particularly true for COPD, where most patients are diagnosed with moderate-to-severe airflow obstruction and little is known about the inflammatory processes present in early disease. There is great interest in developing screening tests that can identify those most at risk of developing COPD before airflow obstruction has developed for the purpose of research and clinical care. Landmark pathology studies have suggested that damage to the small airways precedes the development of airflow obstruction and emphysema and, thus, presents an opportunity to identify those at risk of COPD. However, despite a number of physiological tests being available to assess small airways function, none have been adopted into routine care in COPD. The reasons that tests of small airways have not been utilized widely include variability in test results and a lack of validated reference ranges from which to compare results for some methodologies. Furthermore, population studies have not consistently demonstrated their ability to diagnose disease. However, the landscape may be changing. As the equipment that delivers tests of small airways become more widely available, reference ranges are emerging and newer methodologies specifically seek to address variability and difficulty in test performance. Moreover, there is evidence that while tests of small airways may not be helpful across the full range of established disease severity, there may be specific groups (particularly those with early disease) where they might be informative. In this review, commonly utilized tests of small airways are critically appraised to highlight why these tests may be important, how they can be used and what knowledge gaps remain for their use in COPD.
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Affiliation(s)
| | | | | | - Elizabeth Sapey
- Institute of Inflammation and Ageing, Centre for Translational Inflammation Research, University of Birmingham, Edgbaston, Birmingham, UK
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9
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Pecchiari M, Santus P, Radovanovic D, DʼAngelo E. Acute effects of long-acting bronchodilators on small airways detected in COPD patients by single-breath N 2 test and lung P-V curve. J Appl Physiol (1985) 2017; 123:1266-1275. [PMID: 28775071 DOI: 10.1152/japplphysiol.00493.2017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/06/2017] [Accepted: 07/31/2017] [Indexed: 11/22/2022] Open
Abstract
Small airways represent the key factor of chronic obstructive pulmonary disease (COPD) pathophysiology. The effect of different classes of bronchodilators on small airways is still poorly understood and difficult to assess. Hence the acute effects of tiotropium (18 µg) and indacaterol (150 µg) on closing volume (CV) and ventilation inhomogeneity were investigated and compared in 51 stable patients (aged 70 ± 7 yr, mean ± SD; 82% men) with moderate to very severe COPD. Patients underwent body plethysmography, arterial blood gas analysis, tidal expiratory flow limitation (EFL), dyspnea assessment, and simultaneous recording of single-breath N2 test and transpulmonary pressure-volume curve (PL-V), before and 1 h after drug administration. The effects produced by indacaterol on each variable did not differ from those caused by tiotropium, independent of the severity of disease, assessed according to the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) scale and the presence of EFL. Bronchodilators significantly decreased the slope of phase III and CV (-5 ± 4 and -2.5 ± 2.1%, respectively, both P < 0.001), with an increase in both slope and height of phase IV and of the anatomical dead space. Arterial oxygen pressure and saturation significantly improved (3 ± 3 mmHg and 2 ± 2%, respectively, both P < 0.001); their changes negatively correlated with those of phase III slope (r = -0.659 and r = -0.454, respectively, both P < 0.01). The vital capacity (VC) increased substantially, but the PL-V/VC curve above CV was unaffected. In conclusion, bronchodilators reduce the heterogeneity of peripheral airway mechanical properties and the extent of their closure, with minor effects on critical closing pressure. This should lessen the risk of small-airway damage and positively affect gas exchange.NEW & NOTEWORTHY This is the first study investigating in stable chronic obstructive pulmonary disease patients the acute effects of two long-acting bronchodilators, a β-agonist and a muscarinic antagonist, on peripheral airways using simultaneous lung pressure-volume curve and single-breath N2 test. By lessening airway mechanical property heterogeneity, both drugs similarly reduced ventilation inhomogeneity and extent of small-airway closure, as indicated by the decrease of phase III slope, increased oxygen saturation, and fall of closing volume, often below expiratory reserve volume.
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Affiliation(s)
- Matteo Pecchiari
- Dipartimento di Fisiopatologia e dei Trapianti, Università degli Studi di Milano, Milan, Italy; and
| | - Pierachille Santus
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano, Division of Respiratory Diseases, "L. Sacco" Hospital, Azienda Socio-Sanitaria Territoriale Fatebenefratelli Sacco, Milan, Italy
| | - Dejan Radovanovic
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano, Division of Respiratory Diseases, "L. Sacco" Hospital, Azienda Socio-Sanitaria Territoriale Fatebenefratelli Sacco, Milan, Italy
| | - Edgardo DʼAngelo
- Dipartimento di Fisiopatologia e dei Trapianti, Università degli Studi di Milano, Milan, Italy; and
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10
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Palamidas A, Tsikrika S, Katsaounou PA, Vakali S, Gennimata SA, Kaltsakas G, Gratziou C, Koulouris N. Acute effects of short term use of ecigarettes on Airways Physiology and Respiratory Symptoms in Smokers with and without Airway Obstructive Diseases and in Healthy non smokers. Tob Prev Cessat 2017; 3:5. [PMID: 32432180 PMCID: PMC7232825 DOI: 10.18332/tpc/67799] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 10/31/2016] [Accepted: 12/15/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although the use of e-cigarettes is increasing worldwide, their short and long-term effects remain undefined. We aimed to study the acute effect of short-term use of e-cigarettes containing nicotine on lung function and respiratory symptoms in smokers with airways obstructive disease (COPD, asthma), "healthy" smokers, and healthy never smokers. METHODS Respiratory symptoms, vital signs, exhaled NO, airway temperature, airway resistance (Raw), specific airway conductance (sGaw) and single nitrogen breath test were assessed before and immediately after short term use of an e-cigarette containing 11mg of nicotine among adults with COPD, asthma, "healthy" smokers, and never-smokers. The effect of the use of nicotine-free e-cigarettes among "healthy" never smokers was also studied. RESULTS The majority of participants reported acute cough. Short term use of nicotine e-cigarettes was associated: a) with increased heart rate in all subjects except in the COPD group, b) decreased oxygen saturation in "healthy" and COPD smokers, c) increased Raw in asthmatic smokers, "healthy" smokers, and healthy never smokers, d) decreased sGaw in healthy subjects, and e) changed slope of phase III curve in asthmatic smokers. Short-term use of nicotine-free e-cigarettes increased Raw and decreased sGaw among healthy never smokers. CONCLUSIONS Short-term use of an e-cigarette has acute effects on airways physiology and respiratory symptoms in COPD smokers, asthmatic smokers, "healthy" smokers and healthy never smokers. E-cigarette use was associated with effects in "healthy" never smokers irrespectively of nicotine concentration. More studies are needed to investigate both short and long-term effects of e-cigarette use.
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Affiliation(s)
- Anastasios Palamidas
- 1rst Respiratory Medicine Department, "Sotiria" General Hospital of Chest Diseases, National and Kapodistrian University of Athens
| | - Stamatoula Tsikrika
- 1rst Respiratory Medicine Department, "Sotiria" General Hospital of Chest Diseases, National and Kapodistrian University of Athens
| | - Paraskevi A Katsaounou
- 1rst ICU, "Evaggelismos" General Hospital, National and Kapodistrian University of Athens
| | - Sofia Vakali
- 1rst Respiratory Medicine Department, "Sotiria" General Hospital of Chest Diseases, National and Kapodistrian University of Athens
| | - Sofia-Antiopi Gennimata
- 1rst Respiratory Medicine Department, "Sotiria" General Hospital of Chest Diseases, National and Kapodistrian University of Athens
| | - George Kaltsakas
- 1rst Respiratory Medicine Department, "Sotiria" General Hospital of Chest Diseases, National and Kapodistrian University of Athens
| | - Christina Gratziou
- 1rst Respiratory Medicine Department, "Sotiria" General Hospital of Chest Diseases, National and Kapodistrian University of Athens
| | - Nikolaos Koulouris
- 1rst Respiratory Medicine Department, "Sotiria" General Hospital of Chest Diseases, National and Kapodistrian University of Athens
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Theodorakopoulou EP, Gennimata SA, Harikiopoulou M, Kaltsakas G, Palamidas A, Koutsoukou A, Roussos C, Kosmas EN, Bakakos P, Koulouris NG. Effect of pulmonary rehabilitation on tidal expiratory flow limitation at rest and during exercise in COPD patients. Respir Physiol Neurobiol 2017; 238:47-54. [PMID: 28109942 DOI: 10.1016/j.resp.2017.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 01/04/2017] [Accepted: 01/13/2017] [Indexed: 12/12/2022]
Abstract
We hypothesized that severe COPD patients who present with the disadvantageous phenomenon of Expiratory Flow Limitation (EFL) may benefit as COPD patients without EFL do after implementation of a Pulmonary Rehabilitation (PR) program. Forty-two stable COPD patients were studied at rest and during exercise. EFL and dynamic hyperinflation (DH) were documented using the negative expiratory pressure (NEP) technique and inspiratory capacity (IC) maneuvers, respectively. Patient centered outcomes were evaluated by the Saint-George's Respiratory Questionnaire (SGRQ) and the mMRC dyspnea scale. Before PR, 16 patients presented with EFL at rest and/or during exercise. After PR, EFL was abolished in 15 out of those 16 EFL patients who exhibited a significant increase in IC values. These were mainly accomplished through a modification of the breathing pattern. In the 26 NFL patients no increase was noted in their IC or a modification of their breathing pattern. However, both NFL and EFL COPD patients improved exercise capacity and patients centered outcomes undergoing the same PR program.
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Affiliation(s)
- Elpida P Theodorakopoulou
- Pulmonary Rehabilitation Unit, 1st Department of Respiratory Medicine, National & Kapodistrian University of Athens Medical School, "Sotiria" Hospital for Chest Diseases, Athens, Greece; Pulmonary Rehabilitation Center, 3rd Department of Pulmonary Medicine, "Sotiria" Hospital for Chest Diseases, Athens, Greece
| | - Sofia-Antiopi Gennimata
- Pulmonary Rehabilitation Unit, 1st Department of Respiratory Medicine, National & Kapodistrian University of Athens Medical School, "Sotiria" Hospital for Chest Diseases, Athens, Greece
| | - Maria Harikiopoulou
- Pulmonary Rehabilitation Center, 3rd Department of Pulmonary Medicine, "Sotiria" Hospital for Chest Diseases, Athens, Greece
| | - Georgios Kaltsakas
- Pulmonary Rehabilitation Unit, 1st Department of Respiratory Medicine, National & Kapodistrian University of Athens Medical School, "Sotiria" Hospital for Chest Diseases, Athens, Greece
| | - Anastasios Palamidas
- Pulmonary Rehabilitation Unit, 1st Department of Respiratory Medicine, National & Kapodistrian University of Athens Medical School, "Sotiria" Hospital for Chest Diseases, Athens, Greece
| | - Antonia Koutsoukou
- Pulmonary Rehabilitation Unit, 1st Department of Respiratory Medicine, National & Kapodistrian University of Athens Medical School, "Sotiria" Hospital for Chest Diseases, Athens, Greece
| | - Charis Roussos
- Pulmonary Rehabilitation Unit, 1st Department of Respiratory Medicine, National & Kapodistrian University of Athens Medical School, "Sotiria" Hospital for Chest Diseases, Athens, Greece
| | - Epameinondas N Kosmas
- Pulmonary Rehabilitation Center, 3rd Department of Pulmonary Medicine, "Sotiria" Hospital for Chest Diseases, Athens, Greece
| | - Petros Bakakos
- Pulmonary Rehabilitation Unit, 1st Department of Respiratory Medicine, National & Kapodistrian University of Athens Medical School, "Sotiria" Hospital for Chest Diseases, Athens, Greece
| | - Nickolaos G Koulouris
- Pulmonary Rehabilitation Unit, 1st Department of Respiratory Medicine, National & Kapodistrian University of Athens Medical School, "Sotiria" Hospital for Chest Diseases, Athens, Greece.
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Crisafulli E, Pisi R, Aiello M, Vigna M, Tzani P, Torres A, Bertorelli G, Chetta A. Prevalence of Small-Airway Dysfunction among COPD Patients with Different GOLD Stages and Its Role in the Impact of Disease. Respiration 2016; 93:32-41. [PMID: 27852080 DOI: 10.1159/000452479] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 10/11/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND In chronic obstructive pulmonary disease (COPD) patients, small-airway dysfunction (SAD) is considered a functional hallmark of disease. However, the exact role of SAD in the clinical presentation of COPD is not yet completely understood; moreover, it is not known whether SAD may have a relationship with the impact of disease. OBJECTIVES To evaluate the prevalence of SAD among COPD patients categorized by the old and the new GOLD classification and to ascertain whether there is a relationship between SAD and impact of disease measured by the COPD Assessment Test (CAT) questionnaire. METHODS We prospectively enrolled COPD outpatients from the University Hospital of Parma. Using the impulse oscillometry system (IOS), we assessed the fall in resistance from 5 to 20 Hz (R5-R20), reactance at 5 Hz (X5), and resonant frequency (FRes) as markers of peripheral airway dysfunction. According to R5-R20 ≥0.07 or <0.07, the cohort was also categorized in patients with and without SAD, respectively. RESULTS We studied 202 patients. In both GOLD classifications, a progressive increasing distribution of R5-R20 and FRes was reported with a decreasing of X5. Moreover, there was a significant correlation between R5-R20 and CAT (r = 0.527, p < 0.001). Finally, the presence of SAD (OR 11.96; 95% CI 4.53-31.58; p < 0.001) and use of ICS + LABA + LAMA (OR 5.31; 95% CI 1.88-15.02; p = 0.002) were independent predictors of higher impact (CAT score ≥10). CONCLUSION In COPD patients, the presence of SAD, as assessed by IOS, progressively increases with GOLD classifications and it is closely related to the high impact of disease on health status.
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Affiliation(s)
- Ernesto Crisafulli
- Respiratory Disease and Lung Function Unit, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
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13
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Boeck L, Gensmer A, Nyilas S, Stieltjes B, Re TJ, Tamm M, Latzin P, Stolz D. Single-Breath Washout Tests to Assess Small Airway Disease in COPD. Chest 2016; 150:1091-1100. [DOI: 10.1016/j.chest.2016.05.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 04/18/2016] [Accepted: 05/23/2016] [Indexed: 10/21/2022] Open
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Santus P, Radovanovic D, Balzano G, Pecchiari M, Raccanelli R, Sarno N, Di Marco F, Jones PW, Carone M. Improvements in Lung Diffusion Capacity following Pulmonary Rehabilitation in COPD with and without Ventilation Inhomogeneity. Respiration 2016; 92:295-307. [PMID: 27598467 DOI: 10.1159/000448847] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 08/03/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Lung diffusing capacity (DLCO) and lung volume distribution predict exercise performance and are altered in COPD patients. If pulmonary rehabilitation (PR) can modify DLCO parameters is unknown. OBJECTIVES To investigate changes in DLCO and ventilation inhomogeneity following a PR program and their relation with functional outcomes in patients with COPD. METHODS This was a prospective, observational, multicentric study. Patients were evaluated before and after a standardized 3-week PR program. Functional assessment included body plethysmography, DLCO, transfer factor (KCO) and alveolar volume (VA), gas exchange, the 6-min walking test (6MWT) and exercise-related dyspnea. Patients were categorized according to the severity of airflow limitation and presence of ventilation inhomogeneity, identified by a VA/TLC <0.8. RESULTS Two hundred and fifty patients completed the study. Baseline forced expiratory volume in 1 s (FEV1) % predicted (mean ± SD) was 50.5 ± 20.1 (76% males); 137 patients had a severe disease. General study population showed improvements in 6MWT (38 ± 55 m; p < 0.01), DLCO (0.12 ± 0.63 mmol × min-1 kPa-1; p < 0.01), lung function and dyspnea. Comparable improvements in DLCO were observed regardless of the severity of disease and the presence of ventilation inhomogeneity. While patients with VA/TLC <0.8 improved the DLCO increasing their VA (177 ± 69 ml; p < 0.01), patients with VA/TLC >0.8 improved their KCO (8.1 ± 2.8%; p = 0.019). The latter had also better baseline lung function and higher improvements in 6MWT (14.6 ± 6.7 vs. 9.0 ± 1.8%; p = 0.015). Lower DLCO at baseline was associated with lower improvements in 6MWT, the greatest difference being between subjects with very severe and mild DLCO impairment (2.7 ± 7.4 vs. 14 ± 2%; p = 0.049). CONCLUSIONS In COPD patients undergoing a PR program, different pathophysiological mechanisms may drive improvements in DLCO, while ventilation inhomogeneity may limit improvements in exercise tolerance.
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Affiliation(s)
- Pierachille Santus
- Department of Health Science, University of Milan, Pulmonary Rehabilitation Unit, Fondazione Salvatore Maugeri, IRCCS - Scientific Institute of Milan, Milan, Italy
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15
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Pecchiari M, Radovanovic D, Santus P, D'Angelo E. Airway occlusion assessed by single breath N 2 test and lung P-V curve in healthy subjects and COPD patients. Respir Physiol Neurobiol 2016; 234:60-68. [PMID: 27612586 DOI: 10.1016/j.resp.2016.09.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 09/01/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To determine whether the analysis of the slow expiratory transpulmonary pressure-volume (PL-V) curve provides an alternative to the single-breath nitrogen test (SBN) for the assessment of the closing volume (CV). METHODS SBN test and slow deflation PL-V curve were simultaneously recorded in 40 healthy subjects and 43 COPD patients. Onset of phase IV identified CV in SBN test (CVSBN), whereas in the PL-V curve CV was identified by: a) deviation from the exponential fit (CVexp), and b) inflection point of the interpolating sigmoid function (CVsig). RESULTS In the absence of phase IV, COPD patients exhibited a clearly discernible inflection in the PL-V curve. In the presence of phase IV, CVSBN and CVexp coincided (CVSBN/CVexp=1.04±0.04 SD), whereas CVsig was systematically larger (CVsig/CVexp=2.1±0.86). CONCLUSION The coincidence between CVSBN and CVexp, and the presence of the inflection in the absence of phase IV indicate that the deviation of the PL-V curve from the exponential fit reliably assesses CV.
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Affiliation(s)
- Matteo Pecchiari
- Dipartimento di Fisiopatologia e dei Trapianti, Università degli Studi di Milano, Milan, Italy.
| | - Dejan Radovanovic
- Dipartimento di Scienze Biomediche, Università degli Studi di Milano, Milan, Italy.
| | - Pierachille Santus
- Dipartimento di Scienze Biomediche, Università degli Studi di Milano, Milan, Italy.
| | - Edgardo D'Angelo
- Dipartimento di Fisiopatologia e dei Trapianti, Università degli Studi di Milano, Milan, Italy.
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Kitaguchi Y, Yasuo M, Hanaoka M. Comparison of pulmonary function in patients with COPD, asthma-COPD overlap syndrome, and asthma with airflow limitation. Int J Chron Obstruct Pulmon Dis 2016; 11:991-7. [PMID: 27274220 PMCID: PMC4869610 DOI: 10.2147/copd.s105988] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND This study was conducted in order to investigate the differences in the respiratory physiology of patients with chronic obstructive pulmonary disease (COPD), asthma-COPD overlap syndrome (ACOS), and asthma with airflow limitation (asthma FL(+)). METHODS The medical records for a series of all stable patients with persistent airflow limitation due to COPD, ACOS, or asthma were retrospectively reviewed and divided into the COPD group (n=118), the ACOS group (n=32), and the asthma FL(+) group (n=27). All the patients underwent chest high-resolution computed tomography (HRCT) and pulmonary function tests, including respiratory impedance. RESULTS The low attenuation area score on chest HRCT was significantly higher in the COPD group than in the ACOS group (9.52±0.76 vs 5.09±1.16, P<0.01). The prevalence of bronchial wall thickening on chest HRCT was significantly higher in the asthma FL(+) group than in the COPD group (55.6% vs 25.0%, P<0.01). In pulmonary function, forced expiratory volume in 1 second (FEV1) and peak expiratory flow rate were significantly higher in the asthma FL(+) group than in the ACOS group (76.28%±2.54% predicted vs 63.43%±3.22% predicted, P<0.05 and 74.40%±3.16% predicted vs 61.08%±3.54% predicted, P<0.05, respectively). Although residual volume was significantly lower in the asthma FL(+) group than in the COPD group (112.05%±4.34% predicted vs 137.38%±3.43% predicted, P<0.01) and the ACOS group (112.05%±4.34% predicted vs148.46%±6.25% predicted, P<0.01), there were no significant differences in functional residual capacity or total lung capacity. The increase in FEV1 in response to short-acting β2-agonists was significantly greater in the ACOS group than in the COPD group (229±29 mL vs 72±10 mL, P<0.01) and the asthma FL(+) group (229±29 mL vs 153±21 mL, P<0.05). Regarding respiratory impedance, resistance at 5 Hz and resistance at 20 Hz, which are oscillatory parameters of respiratory resistance, were significantly higher in the asthma FL(+) group than in the COPD group at the whole-breath (4.29±0.30 cmH2O/L/s vs 3.41±0.14 cmH2O/L/s, P<0.01 and 3.50±0.24 cmH2O/L/s vs 2.68±0.10 cmH2O/L/s, P<0.01, respectively), expiratory, and inspiratory phases. CONCLUSION Although persistent airflow limitation occurs in patients with COPD, ACOS, and asthma FL(+), they may have distinct characteristics of the respiratory physiology and different responsiveness to bronchodilators.
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Affiliation(s)
- Yoshiaki Kitaguchi
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masanori Yasuo
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masayuki Hanaoka
- First Department of Internal Medicine, Shinshu University School of Medicine, Matsumoto, Japan
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Leitão Filho FS, Hang Chen H, Ngan DA, Tam A, Kirby M, Sin DD. Current methods to diagnose small airway disease in patients with COPD. Expert Rev Respir Med 2016; 10:417-429. [PMID: 26890226 DOI: 10.1586/17476348.2016.1155455] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The small airways are characterized by an internal diameter < 2 mm and absence of cartilage. Approximately 10-25% of total airway resistance in healthy lungs is due to the small airways, with their contribution to total airway resistance increasing substantially in chronic obstructive pulmonary disease (COPD). As the small airways are located in the lung periphery, they are not easily evaluable, which can potentially interfere with the diagnosis (especially at early stages), monitoring, detection of responses to clinical interventions, and prognostic evaluation in COPD. Here, we will discuss the currently available methods in clinical practice to evaluate small airway disease in COPD, focusing on the concept, advantages, and disadvantages of each method.
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Affiliation(s)
- Fernando Sergio Leitão Filho
- a Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine , University of British Columbia , Vancouver , British Columbia , Canada
| | - Hao Hang Chen
- a Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine , University of British Columbia , Vancouver , British Columbia , Canada
| | - David A Ngan
- a Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine , University of British Columbia , Vancouver , British Columbia , Canada
| | - Anthony Tam
- a Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine , University of British Columbia , Vancouver , British Columbia , Canada
| | - Miranda Kirby
- a Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine , University of British Columbia , Vancouver , British Columbia , Canada
| | - Don D Sin
- a Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine , University of British Columbia , Vancouver , British Columbia , Canada
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18
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Jarenbäck L, Ankerst J, Bjermer L, Tufvesson E. Acinar ventilation heterogeneity in COPD relates to diffusion capacity, resistance and reactance. Respir Med 2015; 110:28-33. [PMID: 26607879 DOI: 10.1016/j.rmed.2015.11.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 11/02/2015] [Accepted: 11/05/2015] [Indexed: 12/23/2022]
Abstract
The aim of this study was to investigate heterogenic ventilation in the acinar (Sacin) and conductive (Scond) airways of patients with varying chronic obstructive pulmonary disease (COPD) severity and how these relates to advanced lung function parameters, primarily measured by impulse oscillometry (IOS). A secondary aim was to investigate the effects of a short acting beta2-agonist and a muscarinic antagonist on the heterogenic ventilation. Eleven never smoking controls, 12 smoking controls, and 57 COPD patients (7 GOLD 1, 25 GOLD 2, 14 GOLD 3 and 11 GOLD 4) performed flow-volume spirometry, IOS, body plethysmography, single breath carbon monoxide diffusion, and N2-multiple breath washout. Six smoking controls and 13 of the COPD patients also performed double reversibility test by using salbutamol and its combination with ipratropium. Sacin was significantly higher in GOLD 2-4 compared to never smoking controls and smoking controls, but showed similar levels in GOLD 3 and 4. A factor analysis identified 4 components consisting of; 1) IOS parameters, 2) volume parameters, 3) diffusion parameters, Sacin and some IOS parameters and 4) Scond with central obstruction/air trapping. Salbutamol and its combination with ipratropium had no effect on Sacin and Scond. Increased Sacin in COPD was strongly related to diffusion capacity and lung volumes, but also weakly to resistance and reactance, showing a link between ventilation heterogeneity in the acinar airways and parameters measured by IOS.
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Affiliation(s)
- Linnea Jarenbäck
- Dept. of Clinical Sciences, Lund, Lund University, 221 84 Lund, Sweden.
| | - Jaro Ankerst
- Dept. of Clinical Sciences, Lund, Lund University, 221 84 Lund, Sweden
| | - Leif Bjermer
- Dept. of Clinical Sciences, Lund, Lund University, 221 84 Lund, Sweden
| | - Ellen Tufvesson
- Dept. of Clinical Sciences, Lund, Lund University, 221 84 Lund, Sweden
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Santus P, Radovanovic D, Di Marco F, Raccanelli R, Valenti V, Centanni S. Faster reduction in hyperinflation and improvement in lung ventilation inhomogeneity promoted by aclidinium compared to glycopyrronium in severe stable COPD patients. A randomized crossover study. Pulm Pharmacol Ther 2015; 35:42-9. [PMID: 26549785 DOI: 10.1016/j.pupt.2015.11.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 10/31/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
Standard spyrometric assessment in chronic obstructive pulmonary disease (COPD) only evaluates bronchial obstruction. However, airflow limitation and hyperinflation are the main pathophysiological factors responsible for dyspnoea and reduced exercise tolerance in patients with COPD. This study evaluated the effects of aclidinium bromide 400 μg and glycopyrronium bromide 50 μg on these parameters. Patients with stable severe/very severe COPD were randomized in this double-blind, double-dummy, crossover, Phase IV study. Patients received single doses of each drug on separate days. Primary endpoints were changes in residual volume (RV) and intra-thoracic gas volume (ITGV), assessed by full-body plethysmography. Other endpoints included changes variations in lung ventilation inhomogeneity (Phase III slope of single-breath nitrogen washout test, SBN2), dyspnoea visual analogue scale, and pulmonary specific total airway resistances. Assessments were performed at baseline and 5, 15, 30, 60, and 180 min post-administration. Thirty-seven patients were randomized (31 male; mean age 71 years). Aclidinium and glycopyrronium significantly improved ITGV versus baseline at all-time points (p < 0.05). Significant improvements in RV were observed after 5 min with aclidinium and after 60 min with glycopyrronium. RV improvements were significantly greater with aclidinium than glycopyrronium from 5 to 60 min post-administration (p < 0.05). Both treatments improved dyspnoea versus baseline at all-time points (p < 0.05). Aclidinium significantly improved ventilation inhomogeneity versus baseline at all-time points; no significant changes were observed for glycopyrronium. For the first time two long-acting muscarinic antagonists have been compared in acute conditions with body plethysmography and SBN2 test. We demonstrated that both aclidinium and glycopyrronium significantly reduce hyperinflation and dyspnoea in severe and very severe COPD patients. Aclidinium however promoted a faster reduction in RV and was the only able to reduce lung ventilation inhomogeneity. Trial Registration numbers available on Clinicaltrials.gov: NCT02181023.
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Affiliation(s)
- Pierachille Santus
- Health Science Department, University of Milan - Pulmonary Rehabilitation Unit, Fondazione, Salvatore Maugeri, IRCCS - Scientific Institute of Milan, Milan, Italy.
| | - Dejan Radovanovic
- Health Science Department, University of Milan - Pulmonary Rehabilitation Unit, Fondazione, Salvatore Maugeri, IRCCS - Scientific Institute of Milan, Milan, Italy.
| | - Fabiano Di Marco
- Health Science Department, University of Milan - Respiratory Unit, San Paolo Hospital, Milan, Italy.
| | - Rita Raccanelli
- Health Science Department, University of Milan - Pulmonary Rehabilitation Unit, Fondazione, Salvatore Maugeri, IRCCS - Scientific Institute of Milan, Milan, Italy.
| | - Vincenzo Valenti
- Department of Health Bioscience, University of Milan - Respiratory Unit, Policlinico di San Donato, IRCCS - San Donato Milanese, Milan, Italy.
| | - Stefano Centanni
- Health Science Department, University of Milan - Respiratory Unit, San Paolo Hospital, Milan, Italy.
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Bonini M, Usmani OS. The role of the small airways in the pathophysiology of asthma and chronic obstructive pulmonary disease. Ther Adv Respir Dis 2015; 9:281-93. [PMID: 26037949 DOI: 10.1177/1753465815588064] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD), represent a major social and economic burden for worldwide health systems. During recent years, increasing attention has been directed to the role of small airways in respiratory diseases, and their exact contribution to the pathophysiology of asthma and COPD continues to be clarified. Indeed, it has been suggested that small airways play a distinct role in specific disease phenotypes. Besides providing information on small airways structure and diagnostic procedures, this review therefore aims to present updated and evidence-based findings on the role of small airways in the pathophysiology of asthma and COPD. Most of the available information derives from either pathological studies or review articles and there are few data on the natural history of small airways disease in the onset or progression of asthma and COPD. Comparisons between studies on the role of small airways are hard to draw because both asthma and COPD are highly heterogeneous conditions. Most studies have been performed in small population samples, and different techniques to characterize aspects of small airways function have been employed in order to assess inflammation and remodelling. Most methods of assessing small airways dysfunction have been largely confined to research purposes, but some data are encouraging, supporting the utilization of certain techniques into daily clinical practice, particularly for early-stage diseases, when subjects are often asymptomatic and routine pulmonary function tests may be within normal ranges. In this context further clinical trials and real-life feedback on large populations are desirable.
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Affiliation(s)
- Matteo Bonini
- Lung Function Unit, Department of Public Health and Infectious Diseases, 'Sapienza' University of Rome, Viale dell'Universita', 37-00185 Rome, Italy
| | - Omar S Usmani
- Airway Disease Section, National Heart and Lung Institute, Imperial College London & Royal Brompton Hospital, London, UK
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Clini E, Beghe B, Fabbri LM. Symptomatic, frail, elderly patients: the urgent need for comprehensive assessment and management. Eur Respir J 2014; 44:1397-400. [DOI: 10.1183/09031936.00150814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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McNulty W, Usmani OS. Techniques of assessing small airways dysfunction. Eur Clin Respir J 2014; 1:25898. [PMID: 26557240 PMCID: PMC4629724 DOI: 10.3402/ecrj.v1.25898] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 09/11/2014] [Indexed: 11/17/2022] Open
Abstract
The small airways are defined as those less than 2 mm in diameter. They are a major site of pathology in many lung diseases, not least chronic obstructive pulmonary disease (COPD) and asthma. The small airways are frequently involved early in the course of these diseases, with significant pathology demonstrable often before the onset of symptoms or changes in spirometry and imaging. Despite their importance, they have proven relatively difficult to study. This is in part due to their relative inaccessibility to biopsy and their small size which makes their imaging difficult. Traditional lung function tests may only become abnormal once there is a significant burden of disease within them. This has led to the term 'the quiet zone' of the lung. In recent years, more specialised tests have been developed which may detect these changes earlier, perhaps offering the possibility of earlier diagnosis and intervention. These tests are now moving from the realms of clinical research laboratories into routine clinical practice and are increasingly useful in the diagnosis and monitoring of respiratory diseases. This article gives an overview of small airways physiology and some of the routine and more advanced tests of airway function.
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Affiliation(s)
- William McNulty
- National Heart and lung Institute, Imperial College London and Royal Brompton Hospital, London, UK
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Sanguinetti CM. The lungs need to be deflated: effects of glycopyrronium on lung hyperinflation in COPD patients. Multidiscip Respir Med 2014; 9:19. [PMID: 24690294 PMCID: PMC4229742 DOI: 10.1186/2049-6958-9-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 03/25/2014] [Indexed: 11/10/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is characterized by persistent airflow limitation caused by bronchial alterations, small airways disease and parenchymal destruction. In patients with COPD the structural and functional lung alterations can progress more or less rapidly from the initial small airways disease to an overt COPD where a severe expiratory flow limitation takes place. In these conditions, lung hyperinflation develops characterized by increase in functional residual capacity (FRC) and decrease in inspiratory capacity (IC). Thus, IC is an easy and reliable index to monitor lung hyperinflation and to assess the efficacy of bronchodilator drugs. When FRC increases, tidal volume (VT) is located in a more flatted upper part of the P -V curve of the respiratory system and respiratory muscles must sustain a greater elastic workload. Furthermore, due to inadequate time for expiration, there is a positive alveolar pressure at the end of expiration (PEEPi). This represents a further elastic workload for the inspiratory muscles. This impairment of ventilatory mechanics generates dyspnea that in most severely compromised patients occurs also for small efforts causing activity limitation and worst health-related quality of life (HRQoL). Due to these respiratory alterations, bronchodilators are the cornerstone of the long-term treatment of COPD in order to decrease airways resistances, lung hyperinflation and exacerbation rate, and improve patient's symptoms, exercise tolerance and health status. Long-acting antimuscarinic bronchodilators (LAMAs) have proven to be very useful in terms of lung deflation and exercise tolerance. Recently, new LAMAs with several positive characteristics have been introduced into clinical use among which glycopyrronium bromide has shown to be particularly effective. Glycopyrronium has a longer-lasting effect compared to other anticholinergic drugs, therefore it allows a single daily administration and facilitates the therapy of a disease that needs a chronic bronchodilation by decreasing the mechanic stress of the airways determined by repeated bronchoconstriction and increasing patient's adherence to treatment plan with better clinical results. Several studies demonstrated that glycopyrronium is able to positively and significantly decrease lung hyperinflation, symptoms, and improve psycho-physical status of COPD patients, with a low rate of adverse events, similar to that of placebo.
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Affiliation(s)
- Claudio M Sanguinetti
- Consultant Respiratory Medicine, Quisisana Clinical Center, Via G, Porro 5, Rome 00197, Italy.
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Bommart S, Marin G, Bourdin A, Molinari N, Klein F, Hayot M, Vachier I, Chanez P, Mercier J, Vernhet-Kovacsik H. Relationship between CT air trapping criteria and lung function in small airway impairment quantification. BMC Pulm Med 2014; 14:29. [PMID: 24581147 PMCID: PMC4015710 DOI: 10.1186/1471-2466-14-29] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 02/14/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Small airways are regarded as the elective anatomic site of obstruction in most chronic airway diseases. Expiratory computed tomography (CT) is increasingly used to assess obstruction at this level but there is no consensus regarding the best quantification method. We aimed to evaluate software-assisted CT quantification of air trapping for assessing small airway obstruction and determine which CT criteria better predict small airway obstruction on single breath nitrogen test (SBNT). METHODS Eighty-nine healthy volunteers age from 60 to 90 years old, underwent spirometrically-gated inspiratory (I) and expiratory (E) CT and pulmonary function tests (PFTs) using SBNT, performed on the same day. Air trapping was estimated using dedicated software measuring on inspiratory and expiratory CT low attenuation area (LAA) lung proportion and mean lung density (MLD). CT indexes were compared to SBNT results using the Spearman correlation coefficient and hierarchical dendrogram analysis. In addition, receiver operating characteristic (ROC) curve analysis was performed to determine the optimal CT air-trapping criterion. RESULTS 43 of 89 subjects (48,3%) had dN2 value above the threshold defining small airway obstruction (i.e. 2.5% N2/l). Expiratory to inspiratory MLD ratio (r = 0.40) and LAA for the range -850 -1024 HU (r = 0.29) and for the range -850 -910 HU (r = 0.37) were positively correlated with SBNT results. E/I MLD was the most suitable criterion for its expression. Expiratory to inspiratory MLD ratio (E/I MLD) showed the highest AUC value (0.733) for small airway obstruction assessment. CONCLUSION Among all CT criteria, all correlating with small airway obstruction on SBNT, E/I MLD was the most suitable criterion for its expression in asymptomatic subjects with mild small airway obstruction TRIAL REGISTRATION Registered at Clinicaltrials.gov, identifier: NCT01230879.
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Affiliation(s)
- Sébastien Bommart
- Radiology Department, CHU Montpellier, 371 avenue Doyen Gaston Giraud 34295, Montpellier cedex 05, France.
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Predictors of phase III slope of nitrogen single-breath washout in COPD. Respir Physiol Neurobiol 2013; 189:42-6. [PMID: 23816601 DOI: 10.1016/j.resp.2013.06.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2013] [Revised: 06/14/2013] [Accepted: 06/24/2013] [Indexed: 11/23/2022]
Abstract
The nitrogen (N₂) single-breath washout (SBW) test is a measure of ventilation distribution inhomogeneity and also a small airway function that offers complementary information to spirometry; however, the relevance to the forced oscillation technique (FOT) and pulmonary emphysema in COPD is not fully understood. We hypothesized that pulmonary functions, forced oscillatory parameters, and emphysema extent would contribute independently to the results of the SBW test. In this cross-sectional study we assessed the relationship between the phase III slope (delta N₂) derived from N₂ SBW and these parameters. Spirometry, lung volumes, N₂ SBW, and the broadband frequency FOT were performed in 56 patients with COPD. Emphysema extent was measured by high-resolution computed tomography and scored. In multiple regression analyses, the delta N₂ was independently predicted by forced vital capacity, resonant frequency, and emphysema score (R(2)=0.57, p<0.0001). The degree of ventilation inhomogeneity derived from N₂ SBW is independently predicted by spirometry, lung mechanics, and the degree of emphysema.
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Konstantinos Katsoulis K, Kostikas K, Kontakiotis T. Techniques for assessing small airways function: Possible applications in asthma and COPD. Respir Med 2013; 119:e2-e9. [PMID: 23764129 DOI: 10.1016/j.rmed.2013.05.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 04/08/2013] [Accepted: 05/06/2013] [Indexed: 11/28/2022]
Abstract
In recent years special interest has been expressed for the contribution of small airways in the pathophysiology, clinical manifestations and treatment of asthma and COPD. Small airways contribute little to the total respiratory resistance so that extensive damage of small airways may occur before the appearance of any symptoms, and this is the reason why they are characterized as the "silent zone" of airways. Furthermore, the peripheral localization of the small airways and their small diameter constitutes difficult their direct assessment. Thus, they are usually studied indirectly, taking advantage of the effects of their obstruction, such as premature closure, air trapping, heterogeneity of ventilation, and lung volume dependence of airflow limitation. Today, several heterogeneous methods for the assessment of small airways are available. These can be either functional (spirometry, plethysmography, resistance measurements, nitrogen washout, alveolar nitric oxide, frequency dependence of compliance, flow-volume curves breathing mixture of helium-oxygen) or imaging (mainly through high resolution computed tomography). The above-mentioned methods are summarized in Table 1. However, no method is currently considered as the "gold standard" and it seems that combinations of tests are needed. Furthermore, it is not clear whether the small airways are affected in all patients with asthma or COPD and their clinical significance remains under investigation. Well-designed future studies with large numbers of patients are expected to reveal which of the methods for assessing the small airways is the most accurate, reliable and reproducible, for which patients, and which can be used for the evaluation of the effects of treatment.
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Methods for Assessing Expiratory Flow Limitation during Tidal Breathing in COPD Patients. Pulm Med 2012; 2012:234145. [PMID: 23008769 PMCID: PMC3447366 DOI: 10.1155/2012/234145] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Accepted: 08/10/2012] [Indexed: 11/17/2022] Open
Abstract
Patients with severe COPD often exhale along the same flow-volume curve during quite breathing as during forced expiratory vital capacity manoeuvre, and this has been taken as indicating expiratory flow limitation at rest (EFLT). Therefore, EFLT, namely, attainment of maximal expiratory flow during tidal expiration, occurs when an increase in transpulmonary pressure causes no increase in expiratory flow. EFLT leads to small airway injury and promotes dynamic pulmonary hyperinflation with concurrent dyspnoea and exercise limitation. In fact, EFLT occurs commonly in COPD patients (mainly in GOLD III and IV stage) in whom the latter symptoms are common. The existing up-to-date physiological methods for assessing expiratory flow limitation (EFLT) are reviewed in the present work. Among the currently available techniques, the negative expiratory pressure (NEP) has been validated in a wide variety of settings and disorders. Consequently, it should be regarded as a simple, non invasive, most practical, and accurate new technique.
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Abstract
Noninvasive physiological measurements are reviewed that have been reported in the literature with the specific aim being to study the small airways in lung disease. This has mostly involved at-the-mouth noninvasive measurement of flow, pressure or inert gas concentration, with the intent of deriving one or more indices that are representative of small airway structure and function. While these measurements have remained relatively low-tech, the effort and sophistication increasingly reside with the interpretation of such indices. When aspiring to derive information at the mouth about structural and mechanical processes occurring several airway generations away in a complex cyclically changing cul-de-sac structure, conceptual or semi-quantitative lung models can be valuable. Two assumptions that are central to small airway structure-function measurement are that of an average airway change at a given peripheral lung generation and of a parallel heterogeneity in airway changes. While these are complementary pieces of information, they can affect certain small airways tests in confounding ways. We critically analyzed the various small airway tests under review, while contending that negative outcomes of these tests are probably a true reflection of the fact that no change occurred in the small airways. Utmost care has been taken to not favor one technique over another, given that most current small airways tests still have room for improvement in terms of rendering their content more specific to the small airways. One way to achieve this could consist of the coupling of signals collected at the mouth to spatial information gathered from imaging in the same patient.
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Affiliation(s)
- Sylvia Verbanck
- Respiratory Division, University Hospital UZ Brussel, Brussels, Belgium.
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