Early Origins of Chronic Obstructive Pulmonary Disease: Prenatal and Early Life Risk Factors

A CT-Based Lung Radiomics Nomogram for Classifying the Severity of Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) is a major global health concern, and while traditional pulmonary function tests are effective, recent radiomics advancements offer enhanced evaluation by providing detailed insights into the heterogeneous lung changes.

Purpose

To develop and validate a radiomics nomogram based on clinical and whole-lung computed tomography (CT) radiomics features to stratify COPD severity.

Patients and Methods

One thousand ninety-nine patients with COPD (including 308, 132, and 659 in the training, internal and external validation sets, respectively), confirmed by pulmonary function test, were enrolled from two institutions. The whole-lung radiomics features were obtained after a fully automated segmentation. Thereafter, a clinical model, radiomics signature, and radiomics nomogram incorporating radiomics signature as well as independent clinical factors were constructed and validated. Additionally, receiver-operating characteristic (ROC) curve, area under the ROC curve (AUC), decision curve analysis (DCA), and the DeLong test were used for performance assessment and comparison.

Results

In comparison with clinical model, both radiomics signature and radiomics nomogram outperformed better on COPD severity (GOLD I-II and GOLD III-IV) in three sets. The AUC of radiomics nomogram integrating age, height and Radscore, was 0.865 (95% CI, 0.818-0.913), 0.851 (95% CI, 0.778-0.923), and 0.781 (95% CI, 0.740-0.823) in three sets, which was the highest among three models (0.857; 0.850; 0.774, respectively) but not significantly different (P > 0.05). Decision curve analysis demonstrated the superiority of the radiomics nomogram in terms of clinical usefulness.

Conclusion

The present work constructed and verified the novel, diagnostic radiomics nomogram for identifying the severity of COPD, showing the added value of chest CT to evaluate not only the pulmonary structure but also the lung function status.

Sulfur hexafluoride multiple breath washin and washout outcomes in infants are not interchangeable

Objective.Sulfur hexafluoride (SF6) multiple-breath washout (MBW) assesses ventilation inhomogeneity, as an early marker of obstructive respiratory diseases. Primary outcomes are customarily washout-derived, and it is unclear whether the preceding SF6-washin can provide similar estimates. We aimed to assess comparability of primary SF6-MBW outcomes between washin and washout phases of infant SF6-MBW data measured with the WBreath (ndd Medizintechnik AG, Zurich, Switzerland) and Spiroware (Eco Medics AG, Duernten, Switzerland) MBW-setups, respectively.Approach.We assessed mean relative differences in lung clearance index (LCI) and functional residual capacity (FRC) between the washin and washout of existing SF6-MBW data from healthy infants and infants with cystic fibrosis (CF). We assessed whether these differences exceeded the mean relative within-test between-trial differences of washout-derived outcomes, which can be attributed to natural variability. We also explored non-physiological factors using a pediatric lung simulator.Main results.LCI and FRC from washin and washout were not comparable, for both setups. The mean difference (SD) in LCI between washin and washout was 2.3(10.8)% for WBreath and -9.7(8.0)% for Spiroware, while in FRC it was -4.7(8.4)% for WBreath and -2.3(9.7)% for Spiroware. These differences exceeded the within-test between-trial differences in washout-derived outcomes. Outcomes from washin and washout were also not comparable in a pediatric lung simulator.Significance.Outcomes of the washin and washout were not comparable due to an interplay of physiological and non-physiological factors, and cannot be used interchangeably.

Association between frailty status and risk of chronic lung disease: an analysis based on two national prospective cohorts

BACKGROUND

The association between the frailty index (FI) and the risk of chronic lung diseases (CLDs) remains unexplored, warranting further research.

METHODS AND MATERIALS

This study investigated the relationship between FI and CLD risk using data from the China Health and Retirement Longitudinal Study (CHARLS) and English Longitudinal Study of Ageing (ELSA), comprising a combined sample of 9642 individuals. Propensity score weighting was used to ensure similar distribution of covariates across FI groups. The Wilcoxon rank-sum test was used to analyze differences in FI scores between groups with and without CLD. Kaplan-Meier curves and Cox regression analysis were employed to explore the association between frailty status and CLD incidence, with sensitivity analyses conducted for validation.

RESULTS

Higher FI scores were significantly associated with increased CLD risk in both cohorts (p < .05). Kaplan-Meier survival and Cox regression analyses indicated that frail individuals have a significantly elevated risk of CLD compared to robust individuals, particularly in certain subgroups (e.g., female) within the CHARLS cohort (p < .05). The ELSA cohort yielded similar results (p < .05), affirming FI as a strong predictor of CLD. Additional risk factors identified included age, smoking, and unmarried status (p < .05). Frail individuals consistently exhibited the highest risk in both cohorts (CHARLS HR = 1.54, p = .003; ELSA HR = 6.64, p < .001). The sensitivity analysis did not substantially alter the significant associations.

CONCLUSION

These findings emphasize the critical role of frailty in the development of CLD, suggesting that targeted interventions could reduce CLD risk.

Overcoming challenges of managing chronic obstructive pulmonary disease in low- and middle-income countries

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) ranks among the top three global causes of death, with 90% of fatalities concentrated in low- and middle-income countries (LMICs). The projected rise in COPD burden, especially in LMICs, emphasizes the need to address the challenges for effective control and reversal of this trend. We aimed to provide an overview, and propose potential solutions to these challenges.

AREAS COVERED

We highlight the challenges faced in managing COPD in LMICs and put forward the potential approaches to mitigate the same.

EXPERT OPINION

In LMICs, the effective management of COPD encounters numerous barriers. These include limited access to critical diagnostic services, inadequately trained healthcare personnel, shortages of inhaler medications, oxygen therapy, insufficient access to vaccines, and pulmonary rehabilitation programs. Compounding the above challenges is the late presentation due to misdiagnosis by health workers, and limited access to vital diagnostics. Moreover, the pharmacological armamentarium for optimal COPD therapy, notably inhaled therapies, face constraints in both access and affordability. We propose multi-level and multifaceted interventions to address the urgent need for enhanced respiratory care, human resource capacity building, relevant diagnostic approaches, increased access to medications, government, regional and global efforts to achieve optimal COPD management in LMICs.

The association of maternal smoking around birth with chronic respiratory diseases in adult offspring: A Mendelian randomization study

INTRODUCTION

Maternal smoking during pregnancy disturbs fetal lung development, and induces in their offspring childhood respiratory diseases. Whether it has a continued impact on offspring adult lung health and exerts a casual effect of chronic respiratory diseases (CRDs), remains uncertain. We seek to determine the causal relationships between maternal smoking around birth and offspring adult CRDs, using summary data from previously described cohorts.

METHODS

Mendelian randomization (MR) study was used to analyze the genome-wide associations of maternal smoking around birth and offspring adult CRDs, including respiratory insufficiency, chronic obstructive pulmonary disease (COPD), related respiratory insufficiency, emphysema, COPD, COPD hospital admissions, early onset of COPD, later onset of COPD, asthma, idiopathic pulmonary fibrosis (IPF), lung cancer (LC), small cell lung carcinoma (SCLC), and lung squamous cell carcinoma (LUSC).

RESULTS

After removing single-nucleotide polymorphisms (SNPs) associated with smoking by the offspring, maternal smoking around birth was associated with increased risk of offspring adult respiratory diseases (OR=1.14; 95% CI: 1.013-1.284; p=0.030), respiratory insufficiency (OR=2.413; 95% CI: 1.039-5.603; p=0.040), COPD (OR=1.14; 95% CI: 1.013-1.284; p=0.003), and asthma (OR=1.336; 95% CI: 1.161-1.538; p<0.001). Besides, maternal smoking during pregnancy was associated with a greater risk of LUSC (OR=1.229; 95% CI: 0.992-1.523; p=0.059) than the risk of IPF (OR=1.001; 95% CI: 0.999-1.003; p=0.224), LC (OR=1.203; 95% CI: 0.964-1.501; p=0.103), or SCLC (OR=1.11; 95% CI: 0.77-1.601; p=0.577).

CONCLUSIONS

In this MR analysis, maternal smoking around birth caused a strong risk factor for the offspring to develop lung problems and CRDs in adulthood. The policy related to smoking cessation for mothers during pregnancy should be encouraged.

What is pre-COPD and do we know how to treat it?

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD) is one of the leading causes of morbidity and mortality worldwide. The lung damage in COPD is associated with an enhanced chronic inflammatory response in the airways and lung tissue to harmful particles or gases. Early detection and treatment of COPD can help manage symptoms and slow the progression of the disease.

AREAS COVERED

Status of knowledge regarding early diagnosis, definition of pre-COPD, possible new tools for early diagnosis, possibilities of early treatment, and the results of studies in this population are discussed. Literature search (2014-2024) was done in PubMed, EMBASE, and WoS databases using the keywords COPD, early diagnosis, treatment, smoking, prevention; with additional search of literature in found articles.

EXPERT OPINION

No early case-finding programs have been proposed or validated, so we still have many patients diagnosed in the late stage of the disease. Clinically manifest COPD is characterized as typically progressive and irreversible with current therapeutic options. If we aim to reduce the mortality and morbidity from COPD we should target these steps: Prevention; Early diagnosis; Form registries of persons at risk for COPD development; Diagnose preclinical COPD; and discover new preventive therapeutic interventions.

Phenotype to Treatable Traits-Based Management in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD), a heterogeneous respiratory disease driven by various genetic and environmental factors, presents significant challenges in diagnosis and management. Traditional approaches focused on phenotypic classification, but recent paradigms emphasize identifying and addressing treatable traits to personalize treatment strategies. Treatable traits facilitate personalized interventions, optimizing symptom control, and reducing exacerbation risk. Dyspnea and exacerbations, recognized as key traits, guide treatment decisions and follow-up management. Various interventions, including bronchodilators, corticosteroids, and lifestyle modifications, target specific traits like airway inflammation, mucus overproduction, and emphysema. Strategies for assessing and addressing treatable traits during initial encounters and follow-up visits enhance disease monitoring and treatment efficacy. Comprehensive trait assessment demands resources and specialized monitoring, posing barriers to widespread implementation. The lack of standardized protocols and evolving evidence further complicates decision-making and clinical practice. Despite these challenges, the shift toward treatable traits-based management signifies a pivotal advancement in COPD care, emphasizing holistic approaches tailored to individual patient needs. Recognizing and addressing treatable traits offers personalized interventions, enhancing symptom control and disease management. Embracing treatable traits-based approaches holds promise for improving clinical outcomes and enhancing the quality of life for individuals living with COPD.

Feasibility of Home-Based Pulmonary Rehabilitation of Pediatric Patients with Chronic Respiratory Diseases

BACKGROUND AND OBJECTIVE

Chronic respiratory diseases in children deteriorate their daily life due to dyspnea and reduced lung function. We aimed to evaluate the feasibility of home-based pulmonary rehabilitation in pediatric chronic respiratory diseases.

METHODS

This prospective, single-arm, cohort study included children with chronic lung disease. They were instructed to perform home-based pulmonary rehabilitation 30 min/session, three sessions/week for three months. Pulmonary function test (PFT) using spirometry, respiratory muscle strength (RMT), cardiopulmonary exercise test (CPET), 6 min walk test (6MWT), dyspnea questionnaires, speech evaluation, and pediatric quality of life inventory (PedsQL) were assessed pre- and post-pulmonary rehabilitation. Compliance and satisfaction of the program were also evaluated.

RESULTS

Twenty children (mean age: 11.2 ± 3.1 years) with chronic respiratory diseases without cardiopulmonary instability participated. The overall compliance was 71.1% with no related adverse events. After pulmonary rehabilitation, forced expiratory volume in one second (FEV1), peak expiratory flow (PEF), RMT, 6MWT, dyspnea questionnaire, speech rate, and PedsQL (child) significantly improved (p < 0.05), particularly better in the FEV1 < 60% group than in the FEV1 ≥ 60% group and in the high-compliance group (compliance ≥ 50%) than in the low-compliance group (compliance < 50%).

CONCLUSIONS

Home-based pulmonary rehabilitation for children with chronic lung disease was feasible with high compliance and effective in terms of objective functions, subjective dyspnea symptom, and quality of life.

Rate of severe exacerbations, healthcare resource utilisation and clinical outcomes in patients with COPD in low-income and middle-income countries: results from the EXACOS International Study

INTRODUCTION

The EXAcerbations of Chronic obstructive lung disease (COPD) and their OutcomeS (EXACOS) International Study aimed to quantify the rate of severe exacerbations and examine healthcare resource utilisation (HCRU) and clinical outcomes in patients with COPD from low-income and middle-income countries.

METHODS

EXACOS International was an observational, cross-sectional study with retrospective data collection from medical records for a period of up to 5 years. Data were collected from 12 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Guatemala, Hong Kong, Mexico, Panama, Russia and Taiwan. The study population comprised patients ≥40 years of age with COPD. Outcomes/variables included the prevalence of severe exacerbations, the annual rate of severe exacerbations and time between severe exacerbations; change in lung function over time (measured by the forced expiratory volume in 1 s (FEV1)); peripheral blood eosinophil counts (BECs) and the prevalence of comorbidities; treatment patterns; and HCRU.

RESULTS

In total, 1702 patients were included in the study. The study population had a mean age of 69.7 years, with 69.4% males, and a mean body mass index of 26.4 kg/m2. The mean annual prevalence of severe exacerbations was 20.1%, and 48.4% of patients experienced ≥1 severe exacerbation during the 5-year study period. As the number of severe exacerbations increased, the interval between successive exacerbations decreased. A statistically significant decrease in mean (SD) FEV1 from baseline to post-baseline was observed in patients with ≥1 severe exacerbation (1.23 (0.51) to 1.13 (0.52) L; p=0.0000). Mean BEC was 0.198 x109 cells/L, with 64.7% of patients having a BEC ≥0.1 x109 cells/L and 21.3% having a BEC ≥0.3 x109 cells/L. The most common comorbidity was hypertension (58.3%). An increasing number of severe exacerbations per year was associated with greater HCRU.

DISCUSSION

The findings presented here indicate that effective treatment strategies to prevent severe exacerbations in patients with COPD remain a significant unmet need in low-income and middle-income countries.

The role of chest computed tomography in the evaluation and management of chronic obstructive pulmonary disease

PURPOSE OF REVIEW

The purpose of this review is to compile recent data on the clinical associations of computed tomography (CT) scan findings in the literature and potential avenues for implementation into clinical practice.

RECENT FINDINGS

Airways dysanapsis, emphysema, chronic bronchitis, and pulmonary vascular metrics have all recently been associated with poor chronic obstructive pulmonary disease (COPD) outcomes when controlled for clinically relevant covariables, including risk of mortality in the case of emphysema and chronic bronchitis. Other authors suggest that CT scan may provide insight into both lung parenchymal damage and other clinically important comorbidities in COPD.

SUMMARY

CT scan findings in COPD relate to clinical outcomes. There is a continued need to develop processes to best implement the results of these studies into clinical practice.

Maternal smoking around birth and its influence on offspring allergic diseases: A mendelian randomization study

Objective

The influence of maternal smoking around birth (MSAB) on offspring allergic diseases, specifically childhood asthma (CA), allergic rhinitis (AR), allergic conjunctivitis (AC), and atopic dermatitis (AD) remains incompletely understood. We performed a rigorous mendelian randomization (MR) study to obtain the unconfounded association between MSAB and allergic diseases in offspring with and without adjustment for the effect of breastfeeding.

Methods

Utilizing publicly available information of MSAB, breastfeeding, CA, AR, AC, and AD from large-scale genome-wide association studies (GWAS), we performed a two-sample mendelian randomization (TSMR) analysis to assess the respective causal relationship of MSAB and breastfeeding to allergic diseases in offspring. To get a reliable conclusion, MR Egger regression, weighted median, and inverse variance weighted (IVW) were employed to estimate the causality, with IVW as the primary analysis. Multivariate MR (MVMR) analysis was used to assess the effect of MSAB on allergic diseases after adjusting for breastfeeding's impact. Sensitivity analysis was conducted using the Cochran Q test, MR-Egger, and leave-one-out approaches to ensure the reliability and stability of results.

Results

The TSMR analysis demonstrated MSAB increased the risks of CA (PIVW = 0.013, OR: 1.018, 95%CI: 1.004 to 1.033) and AD (PIVW = 0.006, OR: 8.293, 95%CI: 1.815 to 37.884) in offspring. Conversely, breastfeeding decreased the risk of CA (PIVW <0.001, OR: 0.946, 95%CI: 0.918 to 0.974). MSAB still increased the risks of CA (P = 0.0497, OR: 1.013, 95%CI: 1.000017 to 1.026) and AD (P = 0.003, OR: 13.800, 95%CI: 2.490 to 269.246) after adjusting for breastfeeding. We observed no strong indication of a negative causality between MSAB and AC and AR.

Conclusion

Our findings provided robust evidence of the adverse effects of MSAB on offspring. We emphasized the urgency of smoking cessation around birth and the importance of breastfeeding even in smoking mothers.

Managing Asthma During Pregnancy and the Postpartum Period

Asthma is one of the most common chronic diseases in pregnancy and is associated with adverse perinatal outcomes. Asthma symptoms worsen in approximately 40% of women, and exacerbations requiring medical intervention occur in at least 20% of women. Factors associated with exacerbation and worsening asthma include multiparity, obesity, Black race, exacerbations before pregnancy, and poor asthma control. Exacerbations are associated with further increased risks for poor perinatal outcomes, including low birth weight, preterm birth, and small for gestational age (SGA) status, as well as an increase in the development of asthma in early childhood. Common medications used for asthma, including short-acting β-agonists and inhaled corticosteroids, are considered safe to use in pregnancy. Whereas guidelines generally suggest traditional step therapy for managing asthma in pregnancy, there are alternative models of care and management approaches that may be effective in pregnancy, but require more research. These include single-inhaler maintenance and reliever therapy, treatment adjustment with FeNO, treatable traits personalized medicine approaches, and telemedicine. Little is known about changes to asthma in the postpartum period. However, low adherence to medication and the potential effects of postpartum depression on asthma exacerbation risk warrant further research.

Evidence for Wnt signaling's central involvement in perinatal nicotine exposure-induced offspring lung pathology and its modulation by electroacupuncture

OBJECTIVE

Many factors during pregnancy can induce intrauterine growth restriction (IUGR), resulting in various adverse perinatal outcomes such as low birth weight and multiple organ disorders. Among these factors, prenatal smoke/nicotine exposure is a common cause of IUGR, often associated with altered fetal lung development. The classical Wnt signaling pathway plays a vital role in lung development, and its alterations are commonly associated with developmental lung pathologies. The purpose of this study was to determine whether electroacupuncture (EA) at "Zusanli" (ST 36) points protects perinatal nicotine exposure (PNE)-induced offspring lung dysplasia through Wnt/β-catenin signaling pathway and to identify specific Wnt signaling pathway targets of EA.

METHODS

Following a well-established protocol, nicotine (1 mg/kg/ body weight) was administered subcutaneously to pregnant Sprague Dawley rat dams from gestational day 6 to postnatal day 21. In the EA group, dams were treated with EA at both ST 36 acupoints, while in another experimental group, Wnt/β-catenin signaling pathway agonist was injected subcutaneously (2 mg/kg/ body weight). Offspring body weight (PND 1, 7, 14, and 21), lung weight, Wnt signaling markers, pulmonary function, and lung morphology were determined at sacrifice on PND 21. Specifically, Western blotting and Real-time PCR were used to detect the protein and mRNA levels of critical Wnt signaling markers Wnt2, Wnt7b, FZD4, FZD7, LRP5, and LRP6 in the offspring lung. The protein levels of β-catenin in lung tissue of offspring rats were detected by ELISA that of LEF-1 by Western blotting.

RESULTS

Compared to the control group, the body and lung weights of the offspring rats were significantly decreased in the nicotine-only exposed group. The pulmonary function determined as FVC, PEF, TV, and Cdyn was also significantly decreased, while PIF was significantly increased. The protein levels and mRNA expression of Wnt2, Wnt7b, FZD4, FZD7, LRP5, and LRP6 in the lung tissue of the PNE offspring rats were significantly increased. With EA administration at ST 36 acupoints concomitant with nicotine administration, the body and lung weights, pulmonary function (FVC, PEF, PIF, TV, and Cdyn), protein and mRNA levels Wnt signaling pathway markers (Wnt2, Wnt7b, FZD4, FZD7, LRP5, LRP6, β-catenin, and LEF-1) normalized and were not different from the control group. Notably, Wnt agonists agonist administration blocked the protective effects of EA against PNE-induced lung morphological, molecular, and function changes, highlighting the central significance of Wnt pathway signaling in PNE-induced offspring pulmonary pathology and its modulation by EA at ST 36 acupoints.

CONCLUSION

Concomitant maternal EA at ST 36 acupoints from gestational day 6 to PND 21 protects against offspring PNE-induced lung phenotype. The protective effect is achieved by regulating the expression of Wnt ligand proteins (Wnt2 and Wnt7b) and receptor proteins (FZD4, FZD7, LRP5, and LRP6) upstream of the Wnt/β-catenin signaling pathway intermediates β-catenin, and LEF-1.

Ivy leaf dry extract EA 575 for the treatment of acute and chronic cough in pediatric patients: review and expert survey

OBJECTIVES

EA 575 (Prospan) is a herbal medicine containing a dried extract of ivy leaves (drug extract ratio 5-7.5:1; extraction solvent, 30% ethanol). Although widely used for the treatment of cough, there remains a lack of clarity on the effects of EA 575 in children. This study aimed to evaluate the efficacy and tolerability of EA 575 in pediatric patients with cough, via a literature review and expert survey.

METHODS

A MEDLINE/PubMed database search was performed to identify articles evaluating the efficacy and tolerability of EA 575 in pediatric patients with cough. An online survey of international pediatric cough experts was conducted to gather expert opinion regarding the use of EA 575 for pediatric cough.

RESULTS

Ten controlled clinical trials and nine observational studies were identified. Controlled trials reported improvements in lung function and subjective cough symptoms with EA 575, while observational studies indicated overall favorable efficacy. EA 575 was generally well tolerated, with a low incidence of adverse events in children of all ages, including those aged <1 year. Survey responses from ten experts aligned with findings from the reviewed studies. Most experts agreed that EA 575 may improve quality of life, and highlighted its potential benefits on sleep.

CONCLUSIONS

EA 575 has minimal side effects in pediatric patients with cough, as demonstrated by large, real-world studies. EA 575 may provide clinical benefits in pediatric patients; however, more robust clinical trials are needed to confirm its efficacy.

The effect of "smoky" coal bans on chronic lung disease among older people in Ireland

Globally, coal is still widely used for heating. However, there are concerns about its effect on ambient air quality and health. We estimated the effect of bans prohibiting the sale and use of so-called "smoky coal" on the prevalence of chronic lung disease in older people. Our identification strategy relied on the phased extension of smoky coal bans to Irish towns after 2010. We examined five waves of The Irish Longitudinal Study on Ageing (TILDA), a large nationally representative survey containing detailed information on health, housing, and socio-economic status. Controlling for relevant factors, smoky coal bans reduced the probability that an older person reports being diagnosed with chronic lung disease by between three and five percentage points. In models where we estimated the effect of the ban on the incidence of new cases of chronic lung disease, rather than existing cases, we found the effect was between -0.96 and -2.5 percentage points. Our findings were robust to estimating the model using different sub-samples and control variables. Furthermore, to address potential endogeneity of the ban, we examined subsamples defined by whether participants lived in towns within a range of the population threshold at which the ban was imposed. Estimating our model using these subsamples showed a consistently negative effect of the ban. We also showed parallel trends in health outcomes before the treatment, and that the treatment did not affect attrition from the sample.