Guidelines for diagnosis and management of chronic obstructive pulmonary disease: Joint ICS/NCCP (I) recommendations

MMPs as potential molecular targets in epithelial-to-mesenchymal transition driven COPD progression

Chronic obstructive pulmonary disease (COPD) is the third leading cause of mortality globally and the risk of developing lung cancer is six times greater in individuals with COPD who smoke compared to those who do not smoke. Matrix metalloproteinases (MMPs) play a crucial role in the pathophysiology of respiratory diseases by promoting inflammation and tissue degradation. Furthermore, MMPs are involved in key processes like epithelial-to-mesenchymal transition (EMT), metastasis, and invasion in lung cancer. While EMT has traditionally been associated with the progression of lung cancer, recent research highlights its active involvement in individuals with COPD. Current evidence underscores its role in orchestrating airway remodeling, fostering airway fibrosis, and contributing to the potential for malignant transformation in the complex pathophysiology of COPD. The precise regulatory roles of diverse MMPs in steering EMT during COPD progression needs to be elucidated. Additionally, the less-understood aspect involves how these MMPs bi-directionally activate or regulate various EMT-associated signaling cascades during COPD progression. This review article explores recent advancements in understanding MMPs' role in EMT during COPD progression and various pharmacological approaches to target MMPs. It also delves into the limitations of current MMP inhibitors and explores novel, advanced strategies for inhibiting MMPs, potentially offering new avenues for treating respiratory diseases.

Emotion Regulation Difficulties and Smoking Behavior among Adults with Chronic Obstructive Pulmonary Diseases

COPD is one of the leading causes of death in the United States and results in increased healthcare costs and disability. Smoking is the main determinant of COPD development and continued use increases mortality as compared to those who have stopped smoking. Research has indicated that cigarette smoking may play a role in attempts to regulate distressing emotional experiences and thus, may be an important transdiagnostic process underlying continued smoking behavior among adults with COPD. The current study investigated the role of ER difficulties in relation to smoking status and cigarettes smoked per day among adults with COPD. This cross-sectional study included a sample was adults with COPD (N = 320). Participants self-reported current smoking status, daily smoking, and the Difficulties in Emotion Regulation Scale. All analyses were adjusted for age, sex, probable depression, probable anxiety, and dyspnea severity. DERS total scores were associated with greater odds of current smoking. With the exception of impulsivity, all other dimensions of emotion regulation were significantly associated with current smoking. Greater difficulties in emotional awareness were associated with greater cigarettes smoked per day. However, neither the DERS total score nor any other dimensions of emotional regulation were significantly associated with cigarettes smoked per day. The present study provides preliminary data linking ER difficulties to smoking behavior among adults with COPD. If corroborated by future research, these findings suggest that ER might be a potential target for smoking cessation programs among adults with COPD.

Effectiveness and Outcomes of Noninvasive Positive Pressure Ventilation in Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease

BACKGROUND

Endotracheal intubation and mechanical ventilation in individuals experiencing acute exacerbations of chronic obstructive pulmonary disease (COPD) are associated with several complications. Therefore, utilizing noninvasive positive pressure ventilation (NIPPV) is the suggested initial management for these individuals. The current study was done to assess and compare the clinical and physiological parameters before and after the application of NIPPV and also to evaluate the outcomes of NIPPV.

METHODOLOGY

A prospective observational study was conducted on 50 patients with COPD experiencing acute exacerbations. These patients were treated with NIPPV. Measurements of blood pressure, respiratory rate (RR), heart rate (HR), dyspnea using the modified Borg scale, and arterial blood gas (ABG) parameters (pH, PaCO2, and PaO2) were recorded at baseline, one hour, six hours, 24 hours, and daily until discharge. The study's outcomes included the subjects who successfully underwent NIPPV and failed during NIPPV.

RESULTS

NIPPV effectively reduced the dyspnea score from 7.24 ± 1.58 at baseline to 5.53 ± 1.82 at one hour, 4.11 ± 1.75 at six hours, 2.60 ± 1.03 at 24 hours, and 1.26 ± 0.44 at the time of discharge. Significant improvements were also observed in HR and RR (P < 0.001). When compared to the baseline, the pH level was significantly maintained, PaCO2 was decreased, and PaO2 was increased at various times. Mortality was observed in four patients.

CONCLUSIONS

NIPPV was successful in 42 (84%) patients, with improvements in ABG and pH for early recovery and reduced hospital stay.

Beyond breathing: Systematic review of global chronic obstructive pulmonary disease guidelines for pain management

CONTEXT

Patients with chronic obstructive pulmonary disease (COPD) experience pain as both symptom and comorbidity. There has been no evaluation of the recommendations for pain management in updated clinical practice guidelines (CPGs).

OBJECTIVES

Update the evidence on pain management, determine alignment of pain management recommendations with best-practice, and advocate for optimal pain management in patients with COPD.

METHODS

PubMed, Guideline International Network, Guideline Portal, Agency for Healthcare Research and Quality, National Institute for Healthcare Excellence, Scottish International Guidelines Network, Institute of Medicine, grey literature, national websites, and bibliographies were searched. CPGs available online for stable COPD produced by organizations representing reputable knowledge of COPD management were included. CPGs unavailable online, not translatable into English, or not including techniques within the defined scope were excluded. Researchers performed frequency counts for the verbatim terms "pain," "physical activity," "exercise," "rehabilitation," "physical therap(ist)/(y), "physiotherap(ist)/(y)," recorded context, and collected recommendations for pain management/treatment when present.

RESULTS

Of 32 CPGs, 24 included "pain" verbatim. Of these, 13 included recommendations for pain treatment/management. Common recommendations included opioids, pharmacological management, further medical assessment, and surgical intervention. Two CPGs referred to palliative care, one CPG discussed treating cough, and one discussed massage, relaxation, and breathing.

CONCLUSIONS

Pain management recommendations vary and are not aligned with evidence. Pain should be addressed in patients with COPD, whether directly or indirectly related to the disease. Reduction of variability in pain management and the disease burden is necessary. Pain management should include referrals to providers who can maximize benefit of their services.

Burden, clinical features, and outcomes of post-tuberculosis chronic obstructive lung diseases

PURPOSE OF REVIEW

Post-tuberculosis lung disease (PTLD) is an increasingly recognized and debilitating consequence of pulmonary tuberculosis (PTB). In this review, we provide a comprehensive overview of PTLD with airflow obstruction (PTLD-AFO), focusing on its burden, pathophysiology, clinical manifestations, diagnostic methods, and management strategies.

RECENT FINDINGS

The relationship between PTLD and airflow obstruction is complex and multifactorial. Approximately 60% of the patients with PTLD have some spirometric abnormality. Obstruction is documented in 18-22% of PTLD patients. The host susceptibility and host response to mycobacterium drive the pathogenic mechanism of PTLD. A balance between inflammatory, anti-inflammatory, and fibrotic pathways decides whether an individual with PTB would have PTLD after microbiological cure. An obstructive abnormality in PTLD-AFO is primarily due to destruction of bronchial walls, aberrant healing, and reduction of mucosal glands. The most common finding on computed tomography (CT) of thorax in patients with PTLD-AFO is bronchiectasis and cavitation. Therefore, the 'Cole's vicious vortex' described in bronchiectasis applies to PTLD. A multidisciplinary approach is required for diagnosis and treatment. The disability-adjusted life-years (DALYs) attributed to PTLD represent about 50% of the total estimated burden of DALYs due to tuberculosis (TB). Patients with PTLD require comprehensive care that includes psychosocial support, pulmonary rehabilitation, and vaccination against respiratory pathogens. In the absence of trials evaluating different treatments for PTLD-AFO, therapy is primarily symptomatic.

SUMMARY

PTLD with airflow obstruction has considerable burden and causes a significant morbidity and mortality. However, many aspects of PTLD-AFO still need to be answered. Studies are required to evaluate different phenotypes, especially concerning Aspergillus -related complications. The treatment should be personalized based on the predominant phenotype of airflow obstruction. Extensive studies to understand the exact burden, pathogenesis, and treatment of PTBLD-AFO are needed.

Perspectives and Attitudes of General Practitioners Towards Pharmacological and Non-Pharmacological COPD Management in a Belgian Primary Care Setting: A Qualitative Study

Background

Chronic obstructive pulmonary disease (COPD) is a complex and heterogeneous condition that requires multidisciplinary management. In Belgium, the treatment of COPD is mainly managed by general practitioners (GPs). Several clinical practice guidelines (CPGs) recommend the use of non-pharmacological treatments, such as pulmonary rehabilitation, and interdisciplinary care for COPD patients. Although considerable research has been devoted to addressing the multitude of reasons for the lack of adherence to these aspects of the CPGs, less attention has been paid to understanding the perspectives and attitudes of GPs that lead to this suboptimal implementation.

Purpose

This study aimed to 1) explore Belgian GPs' perceptions regarding COPD management in a primary care setting and 2) collect their views on the importance of pulmonary rehabilitation and interprofessional care in COPD management.

Methods

A descriptive study, conducted between August 2014 and May 2015, used interviews from a sample of 30 Flemish GPs. Data were analyzed following the principles of thematic analysis.

Results

COPD management was patient-centered, focusing on immediate symptom relief and reducing future risks through pharmacotherapy and proper patient education. Deviations from the CPGs were noted, with only a few GPs performing spirometry themselves. Conditions to prescribe respiratory physiotherapy were not well known. Some GPs remained unconvinced about the (cost-)effectiveness of respiratory physiotherapy despite the fast-expanding scientific evidence. Interprofessional care was limited to GP-respiratory physician (re)-referral and communication. GPs showed a reactive attitude towards interprofessional collaboration for non-pharmacological therapies, which is not in line with the proactive approach recommended in CPGs.

Conclusion

GPs managed COPD patients mainly by reducing symptoms with pharmacological therapy. Integrated care regarding non-pharmacological treatments was not well implemented due to the obstacles in interprofessional collaboration. Future care models incorporating personalized care planning could provide a solution to manage COPD's complex healthcare demands.

Pulmonary Rehabilitation for Adults with Chronic Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline

Background: Despite the known benefits of pulmonary rehabilitation (PR) for patients with chronic respiratory disease, this treatment is underused. Evidence-based guidelines should lead to greater knowledge of the proven benefits of PR, highlight the role of PR in evidence-based health care, and in turn foster referrals to and more effective delivery of PR for people with chronic respiratory disease. Methods: The multidisciplinary panel formulated six research questions addressing PR for specific patient groups (chronic obstructive pulmonary disease [COPD], interstitial lung disease, and pulmonary hypertension) and models for PR delivery (telerehabilitation, maintenance PR). Treatment effects were quantified using systematic reviews. The Grading of Recommendations, Assessment, Development and Evaluation approach was used to formulate clinical recommendations. Recommendations: The panel made the following judgments: strong recommendations for PR for adults with stable COPD (moderate-quality evidence) and after hospitalization for COPD exacerbation (moderate-quality evidence), strong recommendation for PR for adults with interstitial lung disease (moderate-quality evidence), conditional recommendation for PR for adults with pulmonary hypertension (low-quality evidence), strong recommendation for offering the choice of center-based PR or telerehabilitation for patients with chronic respiratory disease (moderate-quality evidence), and conditional recommendation for offering either supervised maintenance PR or usual care after initial PR for adults with COPD (low-quality evidence). Conclusions: These guidelines provide the basis for evidence-based delivery of PR for people with chronic respiratory disease.

A qualitative evaluation of the challenges in management for patients with chronic diseases during disasters in Iran

BACKGROUND

Iran's health care system faces significant challenges in managing the growing burden of non-communicable diseases, and these are exacerbated during the frequent natural disasters. The current study was designed to understand challenges in providing healthcare services to patients with diabetes and chronic respiratory diseases during such crisis periods.

METHODS

The conventional content analysis was used in this qualitative study. Participants included 46 patients with diabetes and chronic respiratory diseases, and 36 stakeholders with knowledge and experience in disasters. Data collection was carried out employing semi-structured interviews. Data analysis was performed using Graneheim and Lundman method.

RESULTS

Four major challenges in providing care to patients with diabetes and chronic respiratory diseases during natural disasters include integrated management, physical, psychosocial health, health literacy and the behavior and barriers to healthcare delivery.

CONCLUSIONS

Developing countermeasures against medical monitoring system shutdown in order to detect medical needs and problems faced by chronic disease patients including those with diabetes and chronic obstructive pulmonary disease (COPD), is essential in preparedness for future disasters. Developing effective solutions may result in improved preparedness and better planning of diabetic and COPD patients for disasters.

Rural South Indian spirometry values show wide variation compared to existing prediction equations

Background and Objective

India, a highly heterogeneous country, has no common reference standards for predicting spirometry values, with very few recent studies from south India. This study aimed to create reference equations for rural south Indian adults, based on a population-based survey in Vellore, south India and compare it with other equations from India.

Methods

The data from 583 non-smoking, asymptomatic participants (30 years and older) from a spirometry-based survey for airflow obstruction (rural Vellore, 2018), were used to develop equations for FEV1, FEV1/FVC, and FVC. The dataset was divided for development (70%) and validation (30%), by gender. Differences between observed and predicted values were assessed using the new equations and comparisons made with other equations from India.

Results

Predictions with Vellore rural equations were closest to the previous south Indian equations from urban Bangalore. However, the Bangalore equations led to overestimation of FVC values in males, and of both FEV1 and FVC values in females. Using the rural Vellore equations also led to a higher percent of males being classified as having airflow obstruction, compared to the Bangalore equations which underestimated airflow obstruction in this rural population. Comparison with previously derived Indian equations from other parts of the country showed pronounced variations.

Conclusions

Our study reiterates the need for representative rural and urban studies of adults from various parts of India, to obtain region specific reference equations, given the wide variations in spirometry values in "normal" individuals, due to social heterogeneities of the Indian population and resulting complexities in defining normal.

Prevalence and risk factors of chronic respiratory symptoms in public and private school teachers in north-western Ethiopia: results from a multicentre cross-sectional study

OBJECTIVE

This study aimed to investigate the prevalence and risk factors of chronic respiratory symptoms among school teachers in Gondar city, north-western Ethiopia.

DESIGN

A school-based cross-sectional study was conducted from April to May 2019. A self-administered British Medical Research Council Questionnaire was used to assess chronic respiratory symptoms. Data were entered into Epi Info V.7 and Stata V.14 was used for analysis. A multivariable logistic regression analysis was conducted to identify factors associated with chronic respiratory symptoms. The association was determined using adjusted OR (AOR) with a 95% CI at a value of p<0.05.

SETTING

The study was conducted in public and private schools in Gondar city.

PARTICIPANTS

A total of 822 teachers participated in this study.

OUTCOME MEASURES

The primary outcome is the prevalence of chronic respiratory symptoms.

RESULTS

The total response rate was 97.4%. The majority, 532 (64.7%) of the participants, were male. The mean age (±SD) of the respondents was 36.69 (±6.93) years. The total prevalence of chronic respiratory symptoms in the previous 12 months among teachers in Gondar city was found to be 31.14% (95% CI 27.99% to 34.43%). A family history of respiratory problems (AOR=1.90; 95% CI 1.07 to 3.37), an overweight body mass index (AOR=2.57; 95% CI 1.57 to 4.21), exposure to secondhand cigarette smoke at home (AOR=9.85; 95% CI 4.77 to 20.33), use of chalk (AOR=1.97; 95% CI 1.25 to 3.09), and failure to open windows during class (AOR=2.15; 95% CI 1.02 to 4.52) were risk factors for chronic respiratory symptoms.

CONCLUSION

This study concluded that the prevalence of chronic respiratory symptoms was high among teachers. Making a smoking-free zone, avoiding smoking in public places, improving the ventilation conditions of the classrooms and controlling the chalk dust are all necessary actions to take to reduce chronic respiratory symptoms.

Silica-associated lung disease in developing countries

PURPOSE OF REVIEW

There is a considerable burden of silica-associated lung diseases in the developing world. This review summarizes the epidemiology of these diseases, especially silicosis and silico-tuberculosis, mitigative efforts and treatment, especially in the context of developing countries.

RECENT FINDINGS

In 2017, the highest incidence of silicosis was in China, India and Brazil among the developing countries. The prevalence of silicosis amongst exposed workers may vary from 4 to 55%; there is a risk of underestimation because of the 'healthy worker effect'. The permissible exposure limit for respirable silica adopted by governments in developing countries remains higher than the proposed 0.025 mg/m3. Silica exposure in informal or unorganized industries is challenging, as it falls outside statutory controls. Recent efforts on regulation and compensation by various governments in developing countries are encouraging but need proper implementation on the ground. Biomarkers such as club cell protein 16 and imaging methods such as computed tomography may offer earlier and easier detection of silicosis. Advanced silicosis remains incurable; novel treatments such as antifibrotics agents may be potentially effective.

SUMMARY

Silica-associated lung diseases are prevalent in developing countries. Efforts directed at preventing or minimizing exposure to respirable crystalline silica are required for mitigation.

Long-term indoor gunshot exposure of special police forces induces bronchitic reactions and elevated blood lead levels-The Berlin shooting range study

BACKGROUND

Gunshot emissions contain toxic elements that can harm those frequently exposed, such as police officers. Several years ago, police indoor firing ranges were closed by the Berlin municipality in response to police officer health complaints, and an investigation was launched into the possible respiratory health risks of frequent gunshot emission exposure. We, therefore, conducted an exploratory cross-sectional study to investigate clinical and functional parameters of respiratory health as well as the burden of trace elements in policemen with long-term high exposure to indoor gunshot emissions, compared to low-exposure and control groups.

METHODS

We conducted lung function tests and collected blood and urine samples from Berlin police officers and government employees who were divided into three subject groups based on exposure to gunshot emissions: high exposure (n = 53), low exposure (n = 94) and no exposure (n = 76). Lung function was examined using body plethysmography. Blood and urine samples were tested via inductively coupled plasma mass spectrometry for the presence of common gunshot powder elements (antimony, lead and manganese). Exposure and symptoms were assessed using records as well as questionnaires.

RESULTS

Higher exposure was associated with more respiratory symptoms during gun shooting practice (64% vs. 21%, P < 0.001) compared to the low-exposure group. Headache, cough, discoloured mucous and shortness of breath were also more common as were some other symptoms. The cough symptomatology of the high-exposure group also persisted significantly longer (median: 0.67 vs. 0.01 days, range: 0 to 5 days, P = 0.029) compared to the low-exposure group. They also showed a lower forced expiratory volume in 1 s/forced vital capacity quotient (Tiffeneau index), P = 0.018 between the three groups and P = 0.005 for the high-exposure group, a possible marker of early, subclinical bronchial obstruction. We observed increased blood lead concentrations depending on subject's age (+1.2% per year, 95% confidence interval: 0.5-1.9%, P < 0.001) and cumulative gunshot exposure (+0.34% per 100 000 shots, 0.02-0.66%, P = 0.037).

CONCLUSIONS

These first results suggest that long-term exposure to indoor gunshot emissions induces bronchitic reactions due to repeated irritation of the airways. Higher levels of exposure lead to more negatively impacted lung function and higher blood lead levels with the possible reason that more frequent exposure may mean shorter regeneration phases for the respiratory mucous membrane. We recommend a reduction of exposure to gunshot emissions in order to decrease symptoms and avoid any-even small-deterioration in spirometry.

A randomized controlled trial comparing non-invasive ventilation delivered using neurally adjusted ventilator assist (NAVA) or adaptive support ventilation (ASV) in patients with acute exacerbation of chronic obstructive pulmonary disease

PURPOSE

No study has compared neurally adjusted ventilator assist (NAVA) with adaptive support ventilation (ASV) during non-invasive ventilation (NIV) in subjects with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

MATERIALS AND METHODS

In this randomized controlled trial, we compared NAVA-NIV with ASV-NIV for delivering NIV in consecutive subjects with AECOPD. The primary outcome was NIV failure rate (invasive mechanical ventilation). The key secondary outcomes were number of NIV manipulations, asynchrony index, and 90-day mortality.

RESULTS

We enrolled 76 subjects (NAVA-NIV, n = 36, ASV-NIV, n = 40; 74% males) with a mean ± SD age of 61.4 ± 8.2 years. We found no difference in NIV failure rates between the two arms (NAVA-NIV vs. ASV-NIV; 8/36 [22.2%] vs. 8/40 [20%]; p = 0.83). The median physician manipulations for NIV were significantly less in the ASV-NIV arm than in the NAVA-NIV arm (2 [0.8-4] vs. 3 [2-5]; p= 0.014) during the initial 24-h. We found no difference in median asynchrony index (NAVA-NIV vs. ASV-NIV, 16.6% vs. 16.4%, p = 0.5) and 90-day mortality (22.2% vs. 17.5%, p = 0.67).

CONCLUSION

The use of NAVA-NIV was not superior to ASV-NIV in reducing NIV failure rates in AECOPD. Both NAVA-NIV and ASV-NIV had similar asynchrony index and 90-day mortality.

TRIAL REGISTRY

www.

CLINICALTRIALS

gov (NCT04414891).

Challenges in Providing Care for Patients with Chronic Diseases during Disasters: A Qualitative Study with Focus on Diabetes and Chronic Respiratory Diseases in Iran

Background

Non-communicable diseases are of the major health challenges and the leading cause of death in Iran and at the global level. Moreover, Iran is a disaster-prone country and considering the exacerbation of diabetes and chronic respiratory diseases in natural disasters, its healthcare system is facing challenges. This study was designed to explore challenges in providing healthcare services to patients with diabetes and chronic respiratory diseases during disasters in Iran.

Materials and Methods

The conventional content analysis is used in this qualitative study. Participants included 46 patients with diabetes and chronic respiratory diseases, and 36 of stakeholders were experienced and had theoretical knowledge. Participants' selection started by means of purposive sampling and continued to the point of data saturation. Data collection was carried out employing semi-structured interviews. Data analysis was performed using Graneheim and Lundman method.

Results

Based on participants' experiences, four major challenges in providing care to patients with diabetes and chronic respiratory diseases during natural disasters include integrated management (with three subcategories: control and supervision, patient data management, volunteer management), physical, psychosocial health (with three subcategories: psychological impacts, exacerbation of signs and symptoms, special patient characteristics), health literacy and the behavior (with three subcategories: risk perception, values and beliefs, education and awareness) and barriers to healthcare delivery (with three subcategories: facilities and human resources, financial and living problems and insurances, accessibilities and geographic access).

Conclusion

Developing countermeasures against medical monitoring system shutdown in order to detect medical needs and problems faced by chronic disease patients including those with diabetes and chronic obstructive pulmonary disease (COPD), is essential in preparedness for future disasters. Developing effective solutions may result in improved preparedness and better planning of diabetic and COPD patients for disasters, and potentially promote health outcomes during and after disasters.

Respiratory questionnaire-based analysis of awareness of COPD in a large multicenter rural population-based study in India

Background

Chronic obstructive pulmonary disease (COPD) is a more prevalent chronic lung disease with a significant health burden, and the majority of these cases receive inadequate treatment.

Methods

Prospective, observational, interview (questionnaire) based complete workup COPD study, screened 12,000 cases with chronic respiratory symptoms with cough, sputum production, and shortness of breath. A total of 6000 COPD cases were enrolled after the spirometry test. COPD cases were assessed as disease knowledge and methods of treatment offered by applying questionnaires to patients and treating physicians.

Results

In the present study, 3% of study cases were aware of their COPD illness, 54% were not having knowledge about the disease, and 43% cases were not accepting the COPD diagnosis (p < 0.0001). A total of 58% of cases received inhalation treatment as levosalbutamol monotherapy in 31% cases, levosalbutamol plus beclometasone in 18% cases, and formoterol plus budesonide or salmeterol plus fluticasone only in 9% of COPD cases (p < 0.0001). Total 42% cases received oral treatment as theophylline in 16% cases, salbutamol in 7% cases, oral steroids in 19% cases (p < 0.0001).

Conclusion

"Doctor-patient-drug trio" discordance clubbed as "difficult doctor, difficult patient, and difficult treatment" is a very crucial issue observed during diagnosis and management of COPD in peripheral settings in India.

Indian Guidelines on Nebulization Therapy

Inhalational therapy, today, happens to be the mainstay of treatment in obstructive airway diseases (OADs), such as asthma, chronic obstructive pulmonary disease (COPD), and is also in the present, used in a variety of other pulmonary and even non-pulmonary disorders. Hand-held inhalation devices may often be difficult to use, particularly for children, elderly, debilitated or distressed patients. Nebulization therapy emerges as a good option in these cases besides being useful in the home care, emergency room and critical care settings. With so many advancements taking place in nebulizer technology; availability of a plethora of drug formulations for its use, and the widening scope of this therapy; medical practitioners, respiratory therapists, and other health care personnel face the challenge of choosing appropriate inhalation devices and drug formulations, besides their rational application and use in different clinical situations. Adequate maintenance of nebulizer equipment including their disinfection and storage are the other relevant issues requiring guidance. Injudicious and improper use of nebulizers and their poor maintenance can sometimes lead to serious health hazards, nosocomial infections, transmission of infection, and other adverse outcomes. Thus, it is imperative to have a proper national guideline on nebulization practices to bridge the knowledge gaps amongst various health care personnel involved in this practice. It will also serve as an educational and scientific resource for healthcare professionals, as well as promote future research by identifying neglected and ignored areas in this field. Such comprehensive guidelines on this subject have not been available in the country and the only available proper international guidelines were released in 1997 which have not been updated for a noticeably long period of over two decades, though many changes and advancements have taken place in this technology in the recent past. Much of nebulization practices in the present may not be evidence-based and even some of these, the way they are currently used, may be ineffective or even harmful. Recognizing the knowledge deficit and paucity of guidelines on the usage of nebulizers in various settings such as inpatient, out-patient, emergency room, critical care, and domiciliary use in India in a wide variety of indications to standardize nebulization practices and to address many other related issues; National College of Chest Physicians (India), commissioned a National task force consisting of eminent experts in the field of Pulmonary Medicine from different backgrounds and different parts of the country to review the available evidence from the medical literature on the scientific principles and clinical practices of nebulization therapy and to formulate evidence-based guidelines on it. The guideline is based on all possible literature that could be explored with the best available evidence and incorporating expert opinions. To support the guideline with high-quality evidence, a systematic search of the electronic databases was performed to identify the relevant studies, position papers, consensus reports, and recommendations published. Rating of the level of the quality of evidence and the strength of recommendation was done using the GRADE system. Six topics were identified, each given to one group of experts comprising of advisors, chairpersons, convenor and members, and such six groups (A-F) were formed and the consensus recommendations of each group was included as a section in the guidelines (Sections I to VI). The topics included were: A. Introduction, basic principles and technical aspects of nebulization, types of equipment, their choice, use, and maintenance B. Nebulization therapy in obstructive airway diseases C. Nebulization therapy in the intensive care unit D. Use of various drugs (other than bronchodilators and inhaled corticosteroids) by nebulized route and miscellaneous uses of nebulization therapy E. Domiciliary/Home/Maintenance nebulization therapy; public & health care workers education, and F. Nebulization therapy in COVID-19 pandemic and in patients of other contagious viral respiratory infections (included later considering the crisis created due to COVID-19 pandemic). Various issues in different sections have been discussed in the form of questions, followed by point-wise evidence statements based on the existing knowledge, and recommendations have been formulated.

Association of geriatric syndromes in older adults with chronic obstructive pulmonary disease

Background

Geriatric syndromes (GS) are multi-factorial conditions that make older adults vulnerable to morbidities and poor outcomes. The main objective was to observe the frequency of GS in older patients with COPD.

Methods

A case-control study was conducted in the Geriatric department of a tertiary care hospital in India to evaluate geriatric syndromes including falls, cognitive impairment, frailty, functional impairment, urinary incontinence, malnutrition, and depression in patients with COPD and controls without COPD. The factors having a significant association with the occurrence of these GS in COPD patients were observed.

Results

In this study, 150 cases and 150 controls were included. The mean age of the participant was 65.85±5.54, with 76% males. Functional impairment, cognitive impairment, frailty, urinary incontinence, and malnutrition were significantly higher in COPD patients. The independent variables which increased the odds of geriatric syndromes were dyspnoea (≥2 mMRC grade) (AOR:3.54,95% CI:1.06-11.8) and low socioeconomic status (AOR: 4.14, 95% CI: 1.03-16.54), while male gender showed inverse association (AOR: 0.08,95% CI: 0.01-0.99).

Conclusion

Geriatric syndromes are common in older COPD patients, and assessment for them should be done routinely in these patients.

Study on comparison of the effectiveness of Glycopyrrolate/Formoterol versus Tiotropium/Formoterol in patients with Chronic Obstructive Pulmonary Disease

Background

Chronic Obstructive Pulmonary Disease (COPD) has several implications on health, lifestyle, and economic burden. Combinational therapy using muscarinic antagonists and beta-₂ agonists has long been warranted for use as maintenance therapy. A lack of studies directly comparing Glycopyrrolate/Formoterol (GFF) versus Tiotropium/Formoterol (TFF) was observed which led us to analyze the effectiveness of these combinations.

Methods

In this pilot, prospective, randomized, open-label, parallel-arm, 12-week period study, 60 patients with COPD (moderate-severe) were randomized in a 1:1 ratio to receive either GFF or TFF (n = 30 each). The primary outcome was to demonstrate non-inferiority between the two groups concerning FEV₁ for 12 weeks. The secondary outcome was the assessment of the ratio of FEV₁/FVC and state of health evaluation by St. George's Respiratory Questionnaire (SGRQ).

Results

Out of 60 participants, 58 subjects completed the study. At week 12, the mean and standard deviation value of FEV₁ between groups were 1.49 ± 0.38 and 1.38 ± 0.30 (p > 0.05) and FEV₁/FVC ratio were 0.67 ± 0.09 and 0.74 ± 0.08 (p < 0.01) respectively. A significant difference was observed in the FEV₁ and FEV₁/FVC values in comparison with baseline versus last follow up in both the groups (p < 0.01). However, no remarkable variation was identified in the FEV₁ values over the two groups. The health status assessment by SGRQ showed significant improvement in both groups after the treatment.

Conclusion

Non-inferiority of GFF when compared to TFF was established along with good tolerability and comparable adverse effect profile.

Use of single-inhaler triple therapy in the management of obstructive airway disease: Indian medical experts' review

Obstructive airway disease (OAD), which includes COPD and asthma, is the leading cause of morbidity and mortality in India. Long-acting bronchodilators (long-acting β2 agonists (LABAs) and/or long-acting muscarinic antagonists (LAMAs)) and inhaled corticosteroids (ICS) have a vital role in the management of patients with OAD. While symptom burden and exacerbations are common amongst treated patients, poor adherence to inhaler therapy is a frequent challenge. Better treatment options that optimise symptom control, improve quality of life, reduce exacerbation risk and improve adherence are desired. Triple therapy (ICS/LABA/LAMA) is recommended in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2021 guidelines for symptomatic COPD patients on ICS/LABA or LABA/LAMA, and who are at increased risk for frequent or severe exacerbations. Similarly, add-on LAMA is recommended in uncontrolled asthma patients on medium- to high-dose ICS/LABA by the Global Initiative for Asthma (GINA) 2021 guideline. In the real world, high-risk and overlapping phenotypes exist, which necessitate early initiation of triple therapy. We aim to provide an expert review on the use of single-inhaler triple therapy (SITT) for OAD management in global and Indian settings, knowledge from which can be extrapolated for appropriate treatment of Indian patients. The OAD population in India may benefit from early optimisation to SITT characterised by a high burden of exacerbating OAD, nonsmoker COPD and asthma-COPD overlap.

Clinical Value of FeNO for Pulmonary Hypertension Diagnosis in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Objective

To investigate the clinical value of fractional exhaled nitric oxide (FeNO) in the diagnosis of pulmonary hypertension (PH) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

In this study, the medical records of AECOPD patients were retrospectively reviewed. The patients were divided into AECOPD and AECOPD + PH groups based on the absence or presence of PH. Moreover, FeNO and other indexes were compared between the two groups. The value of FeNO in diagnosing AECOPD with PH was determined using the ROC curve.

Results

A total of 83 patients were enrolled (56 in the AECOPD group and 27 in the AECOPD + PH group). The level of FeNO was significantly lower in the AECOPD + PH group than in the AECOPD group (P = 0.022). Moreover, FeNO level (25.22 ± 8.45 ppb) was higher in the mild PH subgroup than in the moderate (16.64 ± 5.67 ppb, P = 0.005) or severe (11.75 ± 2.36, P = 0.002) PH subgroups. FeNO level was positively correlated with C-reactive protein in AECOPD patients while negatively correlated with brain natriuretic peptide in the AECOPD + PH group. ROC analysis showed that the optimal cutoff value of FeNO in the diagnosis of AECOPD with PH was 24.5 ppb.

Conclusion

FeNO level at admission can act as an indicator for PH diagnosis in AECOPD patients.

Secular trends in chronic respiratory diseases mortality in Brazil, Russia, China, and South Africa: a comparative study across main BRICS countries from 1990 to 2019

Background

As the emerging economies, the BRICS (Brazil, Russia, India, China, and South Africa) shared 61.58% of the global chronic respiratory diseases (CRD) deaths in 2017. This study aimed to assess the secular trends in CRD mortality and explore the effects of age, period, and cohort across main BRICS countries.

Methods

Data were obtained from the Global Burden of Disease Study (GBD) 2019 and analyzed using the age-period-cohort (APC) model to estimate period and cohort effects between 1990 and 2019. The net drifts, local drifts, longitudinal age curves, period/cohort rate ratios (RRs) were obtained through the APC model.

Results

In 2019, the CRD deaths across the BRICS were 2.39 (95%UI 1.95 to 2.84) million, accounting for 60.07% of global CRD deaths. Chronic obstructive pulmonary disease (COPD) and asthma remained the leading causes of CRD deaths. The age-standardized mortality rates (ASMR) have declined across the BRICS since 1990, with the most apparent decline in China. Meanwhile, the downward trends in CRD death counts were observed in China and Russia. The overall net drifts per year were obvious in China (-5.89%; -6.06% to -5.71%), and the local drift values were all below zero in all age groups for both sexes. The age effect of CRD presented increase with age, and the period and cohort RRs were following downward trends over time across countries. Similar trends were observed in COPD and asthma. The improvement of CRD mortality was the most obvious in China, especially in period and cohort effects. While South Africa showed the most rapid increase with age across all CRD categories, and the period and cohort effects were flat.

Conclusions

BRICS accounted for a large proportion of CRD deaths, with China and India alone contributing more than half of the global CRD deaths. However, the declines in ASMR and improvements of period and cohort effects have been observed in both sexes and all age groups across main BRICS countries. China stands out for its remarkable reduction in CRD mortality and its experience may help reduce the burden of CRD in developing countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12484-z.

National Plan for Chronic Respiratory Diseases Prevention and Control in Iran

Background

Lower respiratory tract infections, chronic obstructive pulmonary disease (COPD), tuberculosis, and lung cancer are among the leading 10 causes of death worldwide. The Board of Respiratory Diseases Research Network (RDRN), a sub-committee of the Iranian Non-Communicable Diseases Committee (INCDC) is particularly concerned that there should be a coordinated National strategy to address the burden caused by chronic respiratory diseases.

Methods

Iranian Ministry of Health and Medical Education (MoHME) has decided to give promotion to the establishment of research networks and use them as the milestones for research management, particularly for the national health priorities.

Results

National Service Framework (NSF), which was designed for Chronic Respiratory Diseases, is one of the main outcomes of the chronic respiratory diseases sub-committee of INCDC. The main seven strategies were represented by the Steering Committee in 2010 for a period of 10 years. Successful development and implementation of our goals provide the CRDs sub-committee of INCDC with the opportunity to develop a paradigm to prevent chronic respiratory diseases.

Conclusion

A stronger national plan for controlling chronic respiratory diseases will ensure stronger advocacy to support respiratory health at national, sub-national, and regional levels.

COPD awareness in the urban slums and rural areas around Pune city in India

COPD is the second leading cause of death and disability adjusted life years (DALYs) in India, yet, it remains poorly recognized. We aimed to study the level of awareness of COPD in urban slums of Pune city in India and its neighboring rural areas. All male and female subjects above the age of 30 years residing in 13 randomly selected slums of Pune city (total population of 3000) and 7 randomly selected neighboring rural villages (total population of 3000) were invited to participate in this cross-sectional community survey. After obtaining written informed consent, 13 trained community health workers (CHWs) administered a questionnaire that captured their level of awareness of COPD. Of the 6000 subjects approached, 5420 residents (mean age ± SD = 48.0 ± 13.5 years; 38% males) consented and answered all questions. The number of people who had ever heard the word COPD was 49/5420 [0.9% (0.6–1.1%); 0.7% (0.5–1.3%) of the urban slum dwellers and 1.15% (0.5–1.3%) of rural residents]. Among those who had never heard the word COPD (n = 5371), when asked what was the name of the disease caused by long-term tobacco smoking, 38% said cancer, 16.7% said asthma, and 4.4% said TB. Among those who had heard the word COPD (n = 49), 6.1% said it was a disease of the heart, and 61% attributed COPD to smoke and dust pollution and 20% to tobacco smoking. The level of awareness of COPD in the Indian community is extremely low, highlighting the need to have nationwide mass awareness programs in India.

Distribution of sources of household air pollution: a cross-sectional study in Cameroon

Background

Household air pollution (HAP) is a recognised risk factor for many diseases, including respiratory diseases, cardiovascular/circulatory disorders, adverse pregnancy outcomes and cataracts. Population exposure to biomass fuels, including wood, varies among countries and from one fuel source to the other. This study aimed to investigate the different sources of HAP in peri-urban and rural communities in Cameroon.

Methods

A cross-sectional survey was conducted in a representative sample of households from the Dschang Health District (DHD) region. This included 848 homes in which a range of fuels for cooking including biomass (firewood, charcoal, sawdust), kerosene and liquefied petroleum gas (LPG) were used both indoors and outdoors.

Results

Of the study households, 651 (77%) reported exclusive use of firewood and 141 (17%) reported using more than one source of fuel. Exclusive use of firewood was greater in rural communities (94%) than in peri-urban communities (38%). In peri-urban communities, use of multiple fuels including LPG, wood, sawdust and kerosene, was more common (44.75%). A total of 25.03% of households in both peri-urban and rural communities reported using bottled gas (or liquified petroleum gas (LPG) for cooking. Motivations for choice of fuel included, affordability, availability, rapidity, and cultural factors.

Conclusion

Wood is the main cooking fuel in both peri-urban and rural communities in the Dschang Health District. Supporting households (especially those with limited resources) to adopt LPG equipment for cooking, and use in a more exclusive way is required to help reduce household air pollution.

Study of respiratory viruses and their coinfection with bacterial and fungal pathogens in acute exacerbation of chronic obstructive pulmonary diseases

Background:

Patients with chronic obstructive pulmonary disease (COPD) develop acute exacerbations (AE), with varying natural history. The exacerbation is triggered by infection, leading to increased morbidity and mortality. The study on infectious aetiology of AECOPD is largely restricted to only viral or only bacterial aetiology. There are no studies from India that have investigated multiple viral, bacterial, and fungal associations from the same group of patients. This prospective study was conducted over 2 years to estimate the incidence and profile of viral infections in AECOPD patients, their coinfection with other bacterial and fungal agents, and association of the type and pattern of infective agent with the clinical severity.

Materials and Methods:

Seventy-four AECOPD cases were included in the study. Multiplex polymerase chain reaction was performed from nasopharyngeal swab using Fast Track Diagnostics Respiratory Pathogens 21 Plus Kit. Ziehl–Neelsen (ZN) stain, Modified ZN, and potassium hydroxide (KOH) mount were performed for Mycobacteria, Nocardia, and fungal elements. Bacterial cultures and fungal cultures were done as per the standard techniques. Serum samples were tested for Mycoplasma and Chlamydia pneumoniae immunoglobulin M enzyme-linked immunosorbent assay.

Results:

The number of AECOPD events involving only viral infection, only bacterial infection, bacterial–viral coinfection, and no infection were 43 (58.1%), 32 (43.2%), 20 (27%), and 19 (25.7%), respectively. Influenza A virus was the most common virus (22/43, 51%) identified. In 26 patients, monoviral infections were found, and in 17 patients, polyviral infections were identified, the most common pattern being influenza A and B virus, followed by human rhinovirus and human parainfluenza. The most common bacteria isolated were Pseudomonas aeruginosa (9/32,28%) followed by Acinetobacter baumanii and Klebsiella pneumoniae (7/32, 21%). Among the viral–bacterial coinfection, human coronavirus NL63 infection was always associated with a bacterial infection.

Conclusion:

This information on the various viral and bacterial etiologies of respiratory infections in AECOPD in this part of India will improve the understanding of the management of AECOPD using a timely institution of antivirals and reduce the overuse of antibiotics and the implementation of routine influenza vaccination.

Efficiency of Nebulizing Furosemide in the Treatment of Chronic Pulmonary Obstructive Disease: A Systematic Review and Meta-Analysis of Clinical Trials

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is one of the most common chronic illnesses in humans. Among both oral and intravenous diuretics, nebulizing furosemide (Lasix) is the most commonly used agent. The purpose of this study was to ascertain the therapeutic effects of nebulizing furosemide compared with placebo in the treatment of COPD using a systematic review and meta-analysis of clinical trials.

MATERIALS AND METHODS

This review was performed based on the preferred reporting items for systematic reviews and meta-analyses (PRISMA) protocol. The databases of Web of Science, Google Scholar, PubMed, and Scopus were independently searched by two researchers using MeSH keywords. Studies published between 2002 and 2018 in different parts of the world were considered. The meta-analysis was performed through STATA 14 software and the heterogeneity was assessed using Q statistic or I² index.

RESULTS

From 40 selected articles, 8 articles were finally included in the systematic review process. The analyses were performed considering two groups; nebulizing furosemide treatment (i.e. case) and placebo (i.e. control). Based on the forest plots, the average values of PaCO₂ were 48.3 (39.04-57.56) and 46.56 (39.94-53.18) in the case and control groups, respectively. Also, the mean forced expiratory volume in the first second (FEV1) was 49 (31.32-66.67) and 46.87 (31.44-62.30) in the case and control groups, respectively. Meta-regression analysis showed that both heart and pulse rates in the nebulizing furosemide group decreased by increasing the year of study and sample size (P <0.001). The heterogeneity among the studies was found to be 72.2%, which is classified as severe heterogeneity.

CONCLUSION

nebulizing furosemide can improve and normalize the vital signs and other respiratory variables in patients with COPD.

T. cruzi infection among aged rats: Melatonin as a promising therapeutic molecule

Although T. cruzi was identified as the cause of Chagas disease more than 100 years ago, satisfactory treatments still do not exist, especially for chronic disease. Here we review work suggesting that melatonin could have promise as a Chagas therapeutic. Melatonin has remarkably diverse actions. It is an immunomodulator, an anti-inflammatory, an antioxidant, a free radical scavenger, and has antiapoptotic and anti-aging effects. The elderly (aged 60 years or more) as a group are growing faster than any other age group. Here we discuss the major effects and the mechanisms of action of melatonin on aged T. cruzi-infected rats. Melatonin's protective effects may be consequences of its cooperative antioxidant and immunomodulatory actions. Melatonin modulates oxidative damage, inducing an antioxidant response and reversing age-related thymus regression. Its protective actions could be the result of its anti-apoptotic activity, and by its counteracting the excessive production of corticosterone. This review describes our work showing that host age plays an important and variable influence on the progression of systemic T. cruzi infection and supporting the hypothesis that melatonin should be considered as a powerful therapeutic compound with multiple activities that can improve host homeostasis during experimental T. cruzi infection.

German recommendations for physical activity and physical activity promotion in adults with noncommunicable diseases

Background

Existing physical activity guidelines predominantly focus on healthy age-stratified target groups. The objective of this study was to develop evidence-based recommendations for physical activity (PA) and PA promotion for German adults (18–65 years) with noncommunicable diseases (NCDs).

Methods

The PA recommendations were developed based on existing PA recommendations. In phase 1, systematic literature searches were conducted for current PA recommendations for seven chronic conditions (osteoarthrosis of the hip and knee, chronic obstructive pulmonary disease, stable ischemic heart disease, stroke, clinical depression, and chronic non-specific back pain). In phase 2, the PA recommendations were evaluated on the basis of 28 quality criteria, and high-quality recommendations were analysed. In phase 3, PA recommendations for seven chronic conditions were deducted and then synthesised to generate generic German PA recommendations for adults with NCDs. In relation to the recommendations for PA promotion, a systematic literature review was conducted on papers that reviewed the efficacy/effectiveness of interventions for PA promotion in adults with NCDs.

Results

The German recommendations for physical activity state that adults with NCDs should, over the course of a week, do at least 150 min of moderate-intensity aerobic PA, or 75 min of vigorous-intensity aerobic PA, or a combination of both. Furthermore, muscle-strengthening activities should be performed at least twice a week. The promotion of PA among adults with NCDs should be theory-based, specifically target PA behaviour, and be tailored to the respective target group. In this context, and as an intervention method, exercise referral schemes are one of the more promising methods of promoting PA in adults with NCDs.

Conclusion

The development of evidence-based recommendations for PA and PA promotion is an important step in terms of the initiation and implementation of actions for PA-related health promotion in Germany. The German recommendations for PA and PA promotion inform adults affected by NCDs and health professionals on how much PA would be optimal for adults with NCDs. Additionally, the recommendations provide professionals entrusted in PA promotion the best strategies and interventions to raise low PA levels in adults with NCDs. The formulation of specific PA recommendations for adults with NCDs and their combination with recommendations on PA promotion is a unique characteristic of the German recommendations.

Type 2 innate lymphoid cells participate in IL-33-stimulated Th2-associated immune response in chronic obstructive pulmonary disease

The aim of the present study was to investigate the roles of type 2 innate lymphoid cells (ILC2s) and interleukin-33 (IL-33) in chronic obstructive pulmonary disease (COPD). Serum and peripheral blood mononuclear cells (PBMCs) were isolated from healthy controls and COPD patients. ILC2 cells from the peripheral blood of COPD patients were stimulated with IL-33 or neutralizing ST2 antibody+IL-33 in vitro. The cell viability was assessed using a Cell Counting Kit-8 assay. ELISA was used to detect serum IL-33 and the levels of IL-4, IL-5, IL-6, IL-13 and soluble ST2 (sST2) in the culture supernatant. The percentage of ILC2 cells was measured by flow cytometry. The mRNA expression levels of GATA binding protein 3 (GATA3), RAR-related orphan receptor (ROR)α, ST2 and prostaglandin D2 receptor 2 (CRTH2) were detected by reverse transcription-quantitative PCR. It was revealed that IL-33, IL-5, IL-6 and IL-13 were significantly elevated in peripheral blood of patients with COPD. The proportion of ILC2s in peripheral blood of COPD patients was significantly increased, and the expression of RORA and CRTH2 was increased. The proportion of ST2⁺ ILC2 cells was significantly increased. After 48 h of IL-33 stimulation in vitro, the ratio of linage^-CD45⁺CD127⁺CRTH2⁺ cells reached a maximum. In addition, the viability of ILC2 cells, the expression levels of RORA, GATA3, ST2 and CRTH2 mRNA and the cytokines IL-4, IL-6, IL-5, IL-13 and sST2 were significantly increased. These effects were abrogated by treatment with anti-ST2. In conclusion, IL-33 is upregulated in the serum of patients with COPD and the proportion of ILC2s among the PBMCs is increased. IL-33 may promote the proliferation of ILC2 cells and secrete type 2 T-helper cell cytokines to participate in the immune response in COPD.

A Randomized Controlled Trial of Noninvasive Ventilation with Pressure Support Ventilation and Adaptive Support Ventilation in Acute Exacerbation of COPD: A Feasibility Study

Whether the use of adaptive support ventilation (ASV) during noninvasive ventilation (NIV) is as effective as pressure support ventilation (PSV) remains unknown. In this exploratory study, we compared the delivery of NIV with PSV vs. ASV. We randomized consecutive subjects with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) to receive NIV either with the PSV or the ASV mode. The primary outcome was NIV failure (endotracheal intubation, re-institution of NIV within 48 h of discontinuation or mortality). The secondary outcomes were the duration of mechanical ventilation (invasive and noninvasive), the number of NIV manipulations, the visual analogue score (VAS) for physician's ease of use and patient's comfort, and the complications of NIV use. We enrolled 74 subjects (n = 38, PSV; n = 36, ASV; 78.4% males) with a mean (SD) age of 60.5 (9.5) years. The baseline characteristics were similar between the two groups. The overall NIV failure rate was 28.4% and was similar between the two groups (PSV vs. ASV: 34.2% vs. 22.2%, p = 0.31). There was a 9% reduction in the intubation rate with ASV. There were six deaths (PSV vs. ASV: 2 vs 4, p =0.311). There was no difference in the secondary outcomes. The application of NIV using ASV was associated with a similar success rate as PSV in subjects with AECOPD. Due to the small sample size, the results of our study should be confirmed in a larger trial. Trial registry: ww.clinicaltrials.gov (NCT02877524).

A Reliable Preclinical Model to Study the Impact of Cigarette Smoke in Development and Disease

The World Health Organization has estimated that, worldwide, cigarette smoking has caused more than 100 million deaths in the last century, a number that is expected to increase in the future. Understanding cigarette smoke toxicity is key for research and development of proper public health policies. The current challenge is to establish a reliable preclinical model to evaluate the effects of cigarette smoke. In this work, we describe a simple method that allows for quantifying the toxic effects of cigarette smoke using zebrafish. Here, viability of larvae and adult fish, as well as the effects of cigarette smoke extracts on vascular development and tissue regeneration, can be easily assayed. © 2019 by John Wiley & Sons, Inc.

Joint Indian Chest Society-National College of Chest Physicians (India) guidelines for spirometry

Although a simple and useful pulmonary function test, spirometry remains underutilized in India. The Indian Chest Society and National College of Chest Physicians (India) jointly supported an expert group to provide recommendations for spirometry in India. Based on a scientific grading of available published evidence, as well as other international recommendations, we propose a consensus statement for planning, performing and interpreting spirometry in a systematic manner across all levels of healthcare in India. We stress the use of standard equipment, and the need for quality control, to optimize testing. Important technical requirements for patient selection, and proper conduct of the vital capacity maneuver, are outlined. A brief algorithm to interpret and report spirometric data using minimal and most important variables is presented. The use of statistically valid lower limits of normality during interpretation is emphasized, and a listing of Indian reference equations is provided for this purpose. Other important issues such as peak expiratory flow, bronchodilator reversibility testing, and technician training are also discussed. We hope that this document will improve use of spirometry in a standardized fashion across diverse settings in India.

Recent advances in aerosolised drug delivery

Pulmonary route is extensively studied for the diagnosis and treatment of pulmonary and extra pulmonary disease conditions such as asthma, tuberculosis, emphysema, and bronchitis. Formulation design, inhalation device and particle size play key role in determining the aerosol performance. The lack of desired clinical outcome along with the problem regarding efficacy or any adverse drug effect may arise due to improper training and education in use of the device to control the actuation and aerosol inhalation. This review summarizes the difference in the mechanistic features of current marketed aerosol delivery devices with respect to mechanism of aerosol generation with possible advancements in the aerosol design. The delivery options in the pulmonary route and its merits together with the limitations are also discussed. An update is provided regarding the current research and clinical outcome of the use of inhalational technology.

Systematic Review of Pain in Clinical Practice Guidelines for Management of COPD: A Case for Including Chronic Pain?

Chronic pain is highly prevalent and more common in people with chronic obstructive pulmonary disease (COPD) than people of similar age/sex in the general population. This systematic review aimed to describe how frequently and in which contexts pain is considered in the clinical practice guidelines (CPGs) for the broad management of COPD. Databases (Medline, Scopus, CiNAHL, EMbase, and clinical guideline) and websites were searched to identify current versions of COPD CPGs published in any language since 2006. Data on the frequency, context, and specific recommendations or strategies for the assessment or management of pain were extracted, collated, and reported descriptively. Of the 41 CPGs (English n = 20) reviewed, 16 (39%) did not mention pain. Within the remaining 25 CPGs, pain was mentioned 67 times (ranging from 1 to 10 mentions in a single CPG). The most frequent contexts for mentioning pain were as a potential side effect of specific pharmacotherapies (22 mentions in 13 CPGs), as part of differential diagnosis (14 mentions in 10 CPGs), and end of life or palliative care management (7 mentions in 6 CPGs). In people with COPD, chronic pain is common; adversely impacts quality of life, mood, breathlessness, and participation in activities of daily living; and warrants consideration within CPGs for COPD.

The burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden of Disease Study 1990-2016

BACKGROUND

India has 18% of the global population and an increasing burden of chronic respiratory diseases. However, a systematic understanding of the distribution of chronic respiratory diseases and their trends over time is not readily available for all of the states of India. Our aim was to report the trends in the burden of chronic respiratory diseases and the heterogeneity in their distribution in all states of India between 1990 and 2016.

METHODS

Using all accessible data from multiple sources, we estimated the prevalence of major chronic respiratory diseases and the deaths and disability-adjusted life-years (DALYs) caused by them for every state of India from 1990 to 2016 as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016. We assessed heterogeneity in the burden of chronic obstructive pulmonary disease (COPD) and asthma across the states of India. The states were categorised into four groups based on their epidemiological transition level (ETL). ETL was defined as the ratio of DALYs from communicable diseases to those from non-communicable diseases and injuries combined, with a low ratio denoting high ETL and vice versa. We also assessed the contribution of risk factors to DALYs due to COPD. We compared the burden of chronic respiratory diseases in India against the global average in GBD 2016. We calculated 95% uncertainty intervals (UIs) for the point estimates.

FINDINGS

The contribution of chronic respiratory diseases to the total DALYs in India increased from 4·5% (95% UI 4·0-4·9) in 1990 to 6·4% (5·8-7·0) in 2016. Of the total global DALYs due to chronic respiratory diseases in 2016, 32·0% occurred in India. COPD and asthma were responsible for 75·6% and 20·0% of the chronic respiratory disease DALYs, respectively, in India in 2016. The number of cases of COPD in India increased from 28·1 million (27·0-29·2) in 1990 to 55·3 million (53·1-57·6) in 2016, an increase in prevalence from 3·3% (3·1-3·4) to 4·2% (4·0-4·4). The age-standardised COPD prevalence and DALY rates in 2016 were highest in the less developed low ETL state group. There were 37·9 million (35·7-40·2) cases of asthma in India in 2016, with similar prevalence in the four ETL state groups, but the highest DALY rate was in the low ETL state group. The highest DALY rates for both COPD and asthma in 2016 were in the low ETL states of Rajasthan and Uttar Pradesh. The DALYs per case of COPD and asthma were 1·7 and 2·4 times higher in India than the global average in 2016, respectively; most states had higher rates compared with other locations worldwide at similar levels of Socio-demographic Index. Of the DALYs due to COPD in India in 2016, 53·7% (43·1-65·0) were attributable to air pollution, 25·4% (19·5-31·7) to tobacco use, and 16·5% (14·1-19·2) to occupational risks, making these the leading risk factors for COPD.

INTERPRETATION

India has a disproportionately high burden of chronic respiratory diseases. The increasing contribution of these diseases to the overall disease burden across India and the high rate of health loss from them, especially in the less developed low ETL states, highlights the need for focused policy interventions to address this significant cause of disease burden in India.

FUNDING

Bill & Melinda Gates Foundation; and Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India.

Patient characteristics and outcome of end-stage lung diseases referred for lung transplantation in North India

Objective:

Most countries worldwide have transplant registries for patients with end-stage lung diseases (ESLD) requiring lung transplantation. There is no such lung transplant registry in India. Herein, we describe the demographic profile and clinical outcomes among patients referred for lung transplantation at a tertiary care center in North India.

Materials and Methods:

This was a prospective, observational study of consecutive patients with chronic respiratory diseases who were referred for lung transplantation between July 2013 and December 2016. Patients were evaluated using standard criteria for listing for lung transplantation.

Results:

Of the 176 patients assessed for lung transplantation, 167 were included in the study. The mean (standard deviation [SD]) age of the study population (52.1% females) was 53.2 (14.7) years. Interstitial lung disease (ILD, 46.7%), chronic obstructive pulmonary disease (COPD, 25.7%), and bronchiectasis (10.2%) were the most common diseases in this population. The median (interquartile range, IQR) survival was worst for patients with bronchiolitis (78.5 [9–208] days) and idiopathic pulmonary fibrosis (IPF, 93.5 [19–239] days) and best for patients with idiopathic pulmonary arterial hypertension (757 [340–876] days) and COPD (578 [184–763] days). Only 13% of the patients expressed willingness for lung transplantation. Patients willing for transplantation died earlier than those unwilling (median [IQR], 102 [36-224] days vs. 310 [41-713] days, P < 0.001).

Conclusion:

ILD was the most common cause of ESLD in patients referred for lung transplantation. The waitlist mortality was highest for patients with bronchiolitis and IPF. Despite having ESLD, very few patients were willing for lung transplantation. Patients willing for lung transplantation died earlier than those who were unwilling.

Comparison of efficiency of inhaled and intravenous corticosteroid on pregnant women with COPD and the effects on the expression of PCT and hs-CRP

The efficiency of inhaled and systemic corticosteroids on pregnant women with chronic obstructive pulmonary disease (COPD) was investigated. The study also compared the effects of the administration on the expression of inflammatory mediator procalcitonin (PCT) and high-sensitivity C-reactive protein (hs-CRP). A total of 120 pregnant COPD patients were recruited and randomly allocated into the following three groups: Intravenous corticosteroid treatment group (n=42), inhaled corticosteroid treatment group (n=38), and control group (without any corticosteroid treatment, n=40). Patients of the all three groups received symptomatic supportive treatments including oxygen therapy, anti-infection therapy, expectorant, and bronchodilator. The serum PCT and hs-CRP expression levels were measured before treatment and after 7 days of treatment. Moreover, the clinical parameters such as symptoms, blood gas analysis parameters, pulmonary function indexes, fasting blood glucose (FBG) and adverse reactions were recorded. The overall clinical effective rates of the group received budesonide inhalation and the group receiving systemic methylprednisolone treatment were comparable. Both treatments were able to reduce the levels of inflammatory mediators, hs-CRP and PCT. On the other hand, treatments increased PaO₂ of arterial blood gas while reducing PaCO₂, thereby improving the lung function (FEV1% pred and FEV1/FVC) (P>0.05). The study observed that the FBG levels in COPD patients receiving systemic corticosteroid treatment were significantly increased, while budesonide inhalation did not significantly affect the FBG levels. In addition, rates of adverse events (such as mouth dry, oral ulcers, hoarseness) of systemic corticosteroid treatment group were significantly higher than those in inhaled corticosteroid treatment group and control group (38.1% vs. 17.5% vs. 5.0%, comparison between groups: P<0.05). In conclusion, inhaled and systemic use of corticosteroid both significantly improved dyspnea and other clinical symptoms of pregnant COPD patients by increasing oxygen partial pressure, correcting hypoxemia, and enhancing lung function. Moreover, fewer adverse reactions were observed with inhaled corticosteroid treatment, suggesting that inhaled administration is a relatively good, safe and effective treatment for pregnant COPD patients.

Clinical practice guidelines in India: Quality appraisal and the use of evidence in their development

BACKGROUND

Guideline development in India has come under increased scrutiny with a growing interest in the use of evidence for guideline development.

METHODS

Guidelines on the four leading causes of disability adjusted life years in India (ischemic heart disease, lower respiratory infections, chronic obstructive pulmonary diseases, tuberculosis), published on or after 2010 was searched in electronic databases and by other methods and their quality appraised by using the AGREE-II appraisal tool. In-depth, semistructured interviews were conducted with 15 individuals involved with the development of the included guidelines and the transcripts were analyzed using the framework approach.

RESULTS

We included eleven guidelines. The median AGREE II domain scores was highest for "scope and purpose" (81%) and "clarity of presentation" (76%), and lowest for "rigor of development" (31%) and "editorial independence" (33%). Four main themes emerged from the interviews: (1) Guideline development in India was undergoing transition toward adoption of systematic, transparent and evidence-based approaches but several barriers in the form of attitudes toward use of evidence, lack of methodological capacity, inadequate governance structure and funding exist; (2) guideline development was an academic activity restricted to elite institutions and this affects panel composition, the consultative process and implementation of guidelines; (3) mixed views on patient involvement in guideline development; and (4) Taboo & Poor understanding of issues surrounding conflict of interests.

CONCLUSION

A multitude of efforts is needed by issuing agencies and the government to ensure development of guidelines in transparent, evidence-based and a systematic manner with high quality in India.

Could age and aging change the host response to systemic parasitic infections? A systematic review of preclinical evidence

The impact of age and aging in the evolution of systemic parasitic infections remains poorly understood. We conducted a systematic review from preclinical models of Chagas disease, leishmaniasis, malaria, sleeping sickness and toxoplasmosis. From a structured and comprehensive search in electronic databases, 29 studies were recovered and included in the review. Beyond the characteristics of the experimental models, parasitological and immunological outcomes, we also discussed the quality of current evidence. Our findings indicated that throughout aging, parasitemia and mortality were consistently reduced in Chagas disease and malaria, but were similar or increased in leishmaniasis and highly variable in toxoplasmosis. While a marked humoral response in older animals was related to the anti-T. cruzi protective phenotype, cellular responses mediated by a polarized Th1 phenotype were associated with a more effective defense against Plasmodium infection. Conversely, in leishmaniasis, severe infections and high mortality rates were potentially related to attenuation of humoral response and an imbalance between Th1 and Th2 phenotypes. Due to the heterogeneous parasitological outcomes and limited immunological data, the role of aging on toxoplasmosis evolution remains unclear. From a detailed description of the methodological bias, more controlled researches could avoid the systematic reproduction of inconsistent and poorly reproducible experimental designs.

Physical activity, sedentary behaviour and sleep in COPD guidelines: A systematic review

OBJECTIVES

Physical activity, sedentary and sleep behaviours have strong associations with health. This systematic review aimed to identify how clinical practice guidelines (CPGs) for the management of chronic obstructive pulmonary disease (COPD) report specific recommendations and strategies for these movement behaviours.

METHODS

A systematic search of databases (Medline, Scopus, CiNAHL, EMbase, Clinical Guideline), reference lists and websites identified current versions of CPGs published since 2005. Specific recommendations and strategies concerning physical activity, sedentary behaviour and sleep were extracted verbatim. The proportions of CPGs providing specific recommendations and strategies were reported.

RESULTS

From 2370 citations identified, 35 CPGs were eligible for inclusion. Of these, 21 (60%) provided specific recommendations for physical activity, while none provided specific recommendations for sedentary behaviour or sleep. The most commonly suggested strategies to improve movement behaviours were encouragement from a healthcare provider (physical activity n = 20; sedentary behaviour n = 2) and referral for a diagnostic sleep study (sleep n = 4).

CONCLUSION

Since optimal physical activity, sedentary behaviour and sleep durations and patterns are likely to be associated with mitigating the effects of COPD, as well as with general health and well-being, there is a need for further COPD-specific research, consensus and incorporation of recommendations and strategies into CPGs.

Study of oxidative stress biomarkers in chronic obstructive pulmonary disease and their correlation with disease severity in north Indian population cohort

Background:

Oxidant-antioxidant imbalance forms a prime component in pathogenesis of chronic obstructive pulmonary disease (COPD). Studies of oxidative stress markers in South Asians were sparse.

Methods:

One hundred and eighty COPD patients and eighty healthy nonsmokers were enrolled in the study. Serum malondialdehyde (MDA) and iron levels were estimated for oxidative stress. Three antioxidant markers evaluated-catalase, superoxide dismutase (SOD), and serum copper. Patients on antioxidant therapy and with sepsis and chronic illness were excluded from the study.

Results:

The mean age of COPD patients was 59.29 ± 10.3 years. Serum levels of MDA and iron were significantly higher in COPD patients compared to controls (5.21 ± 1.9 vs. 0.71 ± 0.29 nmol MDA/ml, P = 0.0001 and 69.85 ± 85.49 vs. 79.32 ± 24.39 μg/dl, P = 0.0001, respectively). Mean level of all antioxidant enzymes catalase, SOD, and copper were significantly diminished in cases when compared to control population (P = 0.001). Levels of MDA and iron were found to be significantly elevated in higher Global Initiative for Chronic Obstructive Lung Disease (GOLD) classes (III, IV) when compared to lower GOLD Classes (I, II). The levels of serum antioxidants were significantly depleted in higher GOLD grades too. COPD patients who were male and smoked had significantly higher levels of oxidants and depleted antioxidant levels compared to female and nonsmoking compatriots. Serum MDA levels negatively correlated with forced expiratory volume 1 s and forced vital capacity (r = −0.19 and r = −0.21, P ≤ 0.01). The presence of a cough significantly correlated with higher levels of MDA and iron (P = 0.001). The levels of MDA negatively correlated with SOD and catalase levels.

Conclusion:

Oxidative markers (MDA and iron) are higher whereas antioxidants (catalase, copper, and SOD) are significantly reduced in patients of COPD. Serum MDA levels correlate with lung functions and disease severity.

A prospective randomized controlled study: Theophylline on oxidative stress and steroid sensitivity in chronic obstructive pulmonary disease patients

Objective:

Oxidative stress is involved in the pathogenesis of chronic obstructive pulmonary disease (COPD). Corticosteroid fails to suppress inflammation and oxidative stress due to steroid resistance. Theophylline has an effect on histone deacetylase (HDAC) activity and improves steroid sensitivity in COPD. Given changes in oxidative stress associated with diminished corticosteroid effects, a clinical study in which antioxidants and free radicals are estimated can suggest a correlation between antioxidants, theophylline, and corticosteroid sensitivity.

Materials and Methods:

A randomized controlled study was conducted in 60 participants divided into 4 groups: Group I (controls) - 15 normal healthy volunteers, Group II - COPD patients who received theophylline 300 mg + salbutamol 8 mg, Group III - patients who inhaled budesonide 400 μg + salbutamol 8 mg, and Group IV – theophylline 300 mg + inhaled budesonide 400 μg + salbutamol 8 mg 12 weeks. Blood samples were collected at the time of diagnosis and at 4-week interval for 3 months from all the groups and antioxidant parameters, spirometric % forced expiratory volume in 1 s (FEV₁) were measured.

Results:

The mean difference between groups was analyzed using one-way ANOVA. There was a significant increase in antioxidant enzymes such as catalase, glutathione (GSH) serum transferase, (P < 0.05), reduced GSH, and superoxide dismutase (P < 0.01) and a significant decrease in lipid peroxidation (P < 0.01) at 12 weeks of the study period. Postbronchodilator FEV₁ values have also shown a significant increase at 12 weeks (P < 0.01).

Conclusion:

Theophylline increases the expression and activity of HDAC and improves steroid sensitivity thereby decreases oxidative stress. Hence, novel therapeutic strategy is therefore the reversal of this corticosteroid resistance by increasing the expression and activity of HDAC achieved using corticosteroids along with theophylline.

Pharmacological strategies to reduce exacerbation risk in COPD: a narrative review

Identifying patients at risk of exacerbations and managing them appropriately to reduce this risk represents an important clinical challenge. Numerous treatments have been assessed for the prevention of exacerbations and their efficacy may differ by patient phenotype. Given their centrality in the treatment of COPD, there is strong rationale for maximizing bronchodilation as an initial strategy to reduce exacerbation risk irrespective of patient phenotype. Therefore, in patients assessed as frequent exacerbators (>1 exacerbation/year) we propose initial bronchodilator treatment with a long-acting muscarinic antagonist (LAMA)/ long-acting β2-agonist (LABA). For those patients who continue to experience >1 exacerbation/year despite maximal bronchodilation, we advocate treating according to patient phenotype. Based on currently available data on adding inhaled corticosteroids (ICS) to a LABA, ICS might be added to a LABA/LAMA combination in exacerbating patients who have an asthma-COPD overlap syndrome or high blood eosinophil counts, while in exacerbators with chronic bronchitis, consideration should be given to treating with a phosphodiesterase (PDE)-4 inhibitor (roflumilast) or high-dose mucolytic agents. For those patients who experience frequent bacterial exacerbations and/or bronchiectasis, addition of mucolytic agents or a macrolide antibiotic (e.g. azithromycin) should be considered. In all patients at risk of exacerbations, pulmonary rehabilitation should be included as part of a comprehensive management plan.