Systemic Inflammation in Older Adults With Asthma-COPD Overlap Syndrome

Impact of Controlled Versus Uncontrolled mFI-5 Frailty on Perioperative Complications After Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective review.

OBJECTIVES

We substratified the mFI-5 frailty index to reflect controlled and uncontrolled conditions and assess their relationship to perioperative complications.

SUMMARY OF BACKGROUND DATA

Risk assessment before adult spinal deformity (ASD) surgery is critical because the surgery is highly invasive with a high complication rate. Although frailty is associated with risk of surgical complications, current frailty measures do not differentiate between controlled and uncontrolled conditions.

METHODS

Frailty was calculated using the mFI-5 index for 170 ASD patients with fusion of ≥5 levels. Uncontrolled frailty was defined as blood pressure >140/90 mm Hg, HbA1C >7% or postprandial glucose >180 mg/dL, or recent chronic obstructive pulmonary disease (COPD) exacerbation, while on medication. Patients were divided into nonfrailty, controlled frailty, and uncontrolled frailty cohorts. The primary outcome measure was perioperative major and wound complications. Bivariate analysis was performed. Multivariable analysis assessed the relationship between frailty and perioperative complications.

RESULTS

The cohorts included 97 nonfrail, 54 controlled frail, and 19 uncontrolled frail patients. Compared with nonfrail patients, patients with uncontrolled frailty were more likely to have age older than 60 years (84% vs. 24%), hyperlipidemia (42% vs. 20%), and Oswestry Disability Index (ODI) score >42 (84% vs. 52%) (P<0.05 for all). Controlled frailty was associated with those older than 60 years (41% vs. 24%) and hyperlipidemia (52% vs. 20%) (P<0.05 for all). On multivariable regression analysis controlling for hyperlipidemia, functional independence, motor weakness, ODI>42, and age older than 60 years, patients with uncontrolled frailty had greater odds of major complications (OR 4.24, P=0.03) and wound complications (OR 9.47, P=0.046) compared with nonfrail patients. Controlled frailty was not associated with increased risk of perioperative complications (P>0.05 for all).

CONCLUSIONS

Although patients with uncontrolled frailty had higher risk of perioperative complications compared with nonfrail patients, patients with controlled frailty did not, suggesting the importance of controlling modifiable risk factors before surgery.

LEVEL OF EVIDENCE

3.

Association between neutrophil lymphocyte ratio and status of symptom control in children and adolescents with bronchial asthma

Neutrophil lymphocyte ratio (NLR), an easy and readily available biomarker of systemic inflammation, has been less studied so far as a putative marker of asthma control. Our study aimed to assess its feasibility. A total of 90 asthmatic children, aged 5-18 years, diagnosed according to Global Initiative for Asthma (GINA) guidelines, were. Control status of asthma was assessed using the asthma control test (ACT) or childhood ACT and categorized as controlled group-1 (ACT > 19) and uncontrolled group-2 (ACT ≤ 19). The difference between mean values in both groups was analysed, finding a significant difference between children with and without a family history (p = 0.004) and those with and without a need for admission (p = 0.045). Also, a significant association was established between NLR and the type of severity of asthma (p = 0.049), but none between NLR and age, gender, BMI, coexisting allergic rhinitis, or asthma exacerbation. Thus we found no significant association between NLR and symptom control status. However, NLR has the potential to be a putative marker of inflammation, although its relative status to CRP needs further studies.

Predictive Value of COPD History on In-Stent Restenosis in Coronary Arteries Following Percutaneous Coronary Intervention

Objective

Chronic obstructive pulmonary disease (COPD) is a prevalent chronic respiratory disease that poses a significant health risk to individuals. Patients with COPD are predisposed to a higher incidence of coronary artery disease (CAD) than the general population. This study aims to investigate the correlation between COPD and the incidence of in-stent restenosis (ISR) after percutaneous coronary intervention (PCI).

Methods

This study retrospectively analyzed the clinical data and laboratory test results of patients who underwent PCI at our hospital between January 2018 and December 2021 to investigate the relationship between COPD and drug-Eluting Stents (DES) postoperative ISR. We employed the best subset method to select the most suitable combination of predictive factors, utilizing the data, and verified the precision of the model by means of internal validation. We ultimately assessed the performance of the prediction model using an ROC curve.

Results

The research indicates that COPD is an independent risk factor for ISR after PCI (OR=2.437, 95% CI [1.336, 4.495], P=0.004). The analysis revealed an area under the receiver operating characteristic (ROC) curve of 0.783 for the training group and 0.705 for the testing group, indicating a model fitting for both groups (both > 0.5).

Conclusion

COPD history is a dependable predictor of stent restenosis post percutaneous coronary intervention.

Effects of theophylline combined with inhaled corticosteroids on patients with moderate and severe asthma and changes of T lymphocyte subsets in peripheral blood

Introduction

Asthma is a common respiratory disease. Theophylline combined with inhaled corticosteroids (ICS) is a promising therapy for asthma. This study explored the therapeutic effects of ICS combined with theophylline on moderate and severe asthma patients and T lymphocyte subsets (CD3+CD8+ T cells) in peripheral blood.

Material and methods

A total of 202 moderate and severe asthma patients were selected, with 101 treated with theophylline combined with ICS and 101 treated with ICS alone as controls. Lung function [forced expiratory volume within 1 second (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF)] were tested using a spirometer. Asthma symptom control was evaluated by asthma control tests (ACT). The life quality was evaluated using the Asthma Quality of Life Questionnaire (AQLQ). The number and percentage of CD3+ T, CD3+CD4+ T and CD3+CD8+ T cells in peripheral blood mononuclear cells were assessed by flow cytometry. The correlation between CD3+CD8+ T cells and lung function and asthma control of patients after combination therapy was analyzed by Pearson correlation analysis.

Results

Compared with moderate and severe patients treated with ICS alone, theophylline improved the efficacy of ICS. Theophylline combined with ICS decreased IL-4 and IL-6 levels, and CD3+ T and CD3+CD8+ T cell number and percentage. After combined treatment, CD3+ CD8+ T cells in peripheral blood of patients were positively correlated with lung function and negatively correlated with asthma control.

Conclusions

The additional use of theophylline improved the efficacy of corticosteroids in asthma patient treatment and reduced inflammation level and CD3+ T and CD3+CD8+ T cell contents in peripheral blood.

Exploring the role of neutrophils in infectious and noninfectious pulmonary disorders

With the change in global environment, respiratory disorders are becoming more threatening to the health of people all over the world. These diseases are closely linked to performance of immune system. Within the innate arm of immune system, Neutrophils are an important moiety to serve as an immune defense barrier. They are one of the first cells recruited to the site of infection and plays a critical role in pathogenesis of various pulmonary diseases. It is established that the migration and activation of neutrophils can lead to inflammation either directly or indirectly and this inflammation caused is very crucial for the clearance of pathogens and resolution of infection. However, the immunopathological mechanisms involved to carry out the same is very complex and not well understood. Despite there being studies concentrating on the role of neutrophils in multiple respiratory diseases, there is still a long way to go in order to completely understand the complexity of the participation of neutrophils and mechanisms involved in the development of these respiratory diseases. In the present article, we have reviewed the literature to comprehensively provide an insight in the current development and advancements about the role of neutrophils in infectious respiratory disorders including viral respiratory disorders such as Coronavirus disease (COVID-19) and bacterial pulmonary disorders with a focused review on pulmonary tuberculosis as well as in noninfectious disorders like Chronic obstructive pulmonary disease (COPD) and asthma. Also, future directions into research and therapeutic targets have been discussed for further exploration.

Using inflammatory index to distinguish asthma, asthma-COPD overlap and COPD: A retrospective observational study

BACKGROUND

Although asthma and chronic obstructive pulmonary disease (COPD) are two well-defined and distinct diseases, some patients present combined clinical features of both asthma and COPD, particularly in smokers and the elderly, a condition termed as asthma-COPD overlap (ACO). However, the definition of ACO is yet to be established and clinical guidelines to identify and manage ACO remain controversial. Therefore, in this study, inflammatory biomarkers were established to distinguish asthma, ACO, and COPD, and their relationship with the severity of patients' symptoms and pulmonary function were explored.

MATERIALS AND METHODS

A total of 178 patients, diagnosed with asthma (n = 38), ACO (n = 44), and COPD (n = 96) between January 2021 to June 2022, were enrolled in this study. The patients' pulmonary function was examined and routine blood samples were taken for the analysis of inflammatory indexes. Logistic regression analysis was used to establish inflammatory biomarkers for distinguishing asthma, ACO, and COPD; linear regression analysis was used to analyze the relationship between inflammatory indexes and symptom severity and pulmonary function.

RESULT

The results showed that, compared with ACO, the higher the indexes of platelet, neutrophil-lymphocyte ratio (NLR) and eosinophil-basophil ratio (EBR), the more likely the possibility of asthma and COPD in patients, while the higher the eosinophils, the less likely the possibility of asthma and COPD. Hemoglobin and lymphocyte-monocyte ratio (LMR) were negatively correlated with the severity of patients' symptoms, while platelet-lymphocyte ratio (PLR) was negatively correlated with forced expiratory volume in the 1 s/forced vital capacity (FEV1/FVC) and FEV1 percent predicted (% pred), and EBR was positively correlated with FEV1% pred.

CONCLUSION

Inflammatory indexes are biomarkers for distinguishing asthma, ACO, and COPD, which are of clinical significance in therapeutic strategies and prognosis evaluation.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Transcriptome analysis of sputum cells reveals two distinct molecular phenotypes of “asthma and chronic obstructive pulmonary disease overlap” in the elderly

Background

Little is known about the pathogenesis of asthma and chronic obstructive pulmonary disease (COPD) overlap (ACO). This study examined the molecular phenotypes of ACO in the elderly.

Methods

A genome-wide investigation of gene expression in sputum cells from the elderly with asthma, ACO, or COPD was performed using gene set variation analysis (GSVA) with predefined asthma- or COPD-specific gene signatures. We then performed a subsequent cluster analysis using enrichment scores (ESs) to identify molecular clusters in the elderly with ACO. Finally, a second GSVA was conducted with curated gene signatures to gain insight into the pathogenesis of ACO associated with the identified molecular clusters.

Results

Seventy elderly individuals were enrolled (17 with asthma, 41 with ACO, and 12 with COPD). Two distinct molecular clusters of ACO were identified. Clinically, ACO cluster 1 (N = 23) was characterized by male and smoker dominance, more obstructive lung function, and higher proportions of both neutrophil and eosinophil in induced sputum compared to ACO cluster 2 (N = 18). ACO cluster 1 had molecular features similar to both asthma and COPD, with mitochondria and peroxisome dysfunction as important mechanisms in the pathogenesis of these diseases. The molecular features of ACO cluster 2 differed from those of asthma and COPD, with enhanced innate immune reactions to microorganisms identified as being important in the pathogenesis of this form of ACO.

Conclusion

Recognition of the unique biological pathways associated with the two distinct molecular phenotypes of ACO will deepen our understanding of ACO in the elderly.

Clinical Indicators for Asthma-COPD Overlap: A Systematic Review and Meta-Analysis

Background

Some clinical indicators have been reported to be useful in differentiating asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) from pure asthma/COPD, but the results were inconsistent. This study aims to evaluate the diagnostic value of these indicators for ACO.

Methods

Databases of PubMed, EMBASE, Ovid and Web of Science were retrieved. Pooled standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated in random-effects models.

Results

48 eligible studies were included. The pooled results indicated, compared with pure asthma, ACO patients had lower levels of forced expiratory volume in the first second (FEV₁)% predicted (pred) (SMD=−1.09, 95% CI −1.3 to −0.87), diffusion lung capacity for carbon monoxide (DLCO)% pred (SMD=−0.83, 95% CI −1.24 to −0.42), fractional exhaled nitric oxide (FeNO) (SMD=−0.23, 95% CI −0.36 to −0.11), and higher levels of induced sputum neutrophil (SMD = 0.51, 95% CI 0.21 to 0.81), circulating YKL-40 (SMD = 0.96, 95% CI 0.27 to 1.64). However, relative to COPD alone, ACO patients had higher levels of FEV₁% pred (SMD = 0.15, 95% CI 0.05 to 0.26), DLCO% pred (SMD = 0.38, 95% CI 0.16 to 0.6), FeNO (SMD = 0.59, 95% CI 0.40 to 0.78), serum total immunoglobulin (Ig)E (SMD = 0.42, 95% CI 0.1 to 0.75), blood eosinophil (SMD = 0.44, 95% CI 0.29 to 0.59), induced sputum eosinophil (SMD = 0.62, 95% CI 0.42 to 0.83), and lower levels of induced sputum neutrophil (SMD=−0.48, 95% CI −0.7 to −0.27), circulating YKL-40 (SMD=−1.09, 95% CI −1.92 to −0.26).

Conclusion

Compared with pure asthma/COPD, ACO patients have different levels of FEV₁% pred, DLCO% pred, FeNO, serum total IgE, blood eosinophil, induced sputum eosinophil/neutrophil, and circulating YKL-40, which could be helpful to establish a clinical diagnosis of ACO.

Selected hematological abnormalities and their associated factors among asthmatic patients in Northwest Ethiopia: a cross-sectional study

Background

Asthma is a chronic inflammatory disease that affects the lungs. Variation in whole blood cell lines is caused by the progression and severity of asthma. Common hematological abnormalities encountered during asthma include eosinophilia, neutrophilia, leukocytosis, and increased erythrocyte sedimentation rate. The main aim of this study was to assess the selected hematological abnormalities and their associated factors among asthmatic patients in Northwest Ethiopia from March to May 2021.

Methodology

A hospital-based cross-sectional study was conducted on a total of 320 asthmatic patients in Northwest Ethiopia. A simple random sampling technique was employed to select study participants. A pre-tested structured questionnaire and a checklist were used to collect data. Blood samples were collected from asthmatic patients for complete blood count and erythrocyte sedimentation rate determination. Hematological profiles were analyzed by Unicel DxH 800 (Beckman Coulter, Ireland). The erythrocyte sedimentation rate was determined by using the Westergren method. The data were entered into EpiData version 3.0.4 and analyzed with a statistical package for social science version 20 software. The bi-variable and multi-variable binary logistic regression models were used to assess the factors associated with hematological abnormalities. A p value of less than 0.05 in the multivariable logistic regression analysis was considered statistically significant.

Results

The overall prevalence of neutrophilia, eosinophilia, thrombocytopenia, leukocytosis, and basophilia was 35.3%, 20%, 11.9%, 10.3%, and 4.1%, respectively. Neutrophilia was associated with a lack of physical activity (AOR = 3.25; 95% CI 1.43–7.37) and a history of taking non-asthmatic drugs within the previous three months (AOR = 2.63; 95% CI 1.22–5.65). Being admitted to the emergency department (AOR = 0.27; 95% CI 0.11–5.67) was found to be associated with eosinophilia. In addition, being admitted to the emergency department (AOR = 5.44; 95%CI: 2.6–11.3) was associated with thrombocytopenia.

Conclusion

The current study demonstrated the predominant prevalence of neutrophilia, followed by eosinophilia, among asthma patients. Therefore, hematological abnormalities should be taken into account for proper monitoring and management of asthmatic patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-02020-z.

Prevalence of asthma—chronic obstructive pulmonary disease overlap in patients with airflow limitation

Background

Asthma-COPD overlap (ACO) according to GINA and GOLD is not a single disease and is described by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD. Some different protocols were proposed to diagnose ACO, besides those reported in GINA and GOLD guidelines. Despite the discrepancy between all the proposed diagnostic protocols, the diagnosis of ACO is still worthy as it may lead to a more appropriate treatment plan. In Egypt, prevalence of ACO is hardly estimated due to lack of database of patients. Our aim of work was to detect the prevalence of ACO in patients diagnosed as having a chronic airflow limiting disease.

Results

In asthma group (75 patients), 53.3% (40 patients) were diagnosed as ACO with 3 statistically significant favoring diagnostic criteria; post-BDR test FEV1/FVC < 70%, longer disease duration, and sputum neutrophilia ≥ 57%. While in COPD group (75 patients), 42.7% (32 patients) were diagnosed as ACO with four statistically significant favoring diagnostic criteria; higher BDR, presence of personal history of either asthma or atopy and sputum eosinophils > 1%.

Conclusions

ACO has an underestimated prevalence among those diagnosed with either asthma or COPD. More consensus guidelines are needed to focus on the more effective and the more practical criteria to diagnose such hidden disease.

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

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

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

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

Hemopexin: A Novel Anti-inflammatory Marker for Distinguishing COPD From Asthma

Purpose

Systemic inflammatory biomarkers can improve diagnosis and assessment of chronic obstructive pulmonary disease (COPD) and asthma. We aimed to validate an airway disease biomarker panel of 4 systemic inflammatory biomarkers, α2-macroglobulin, ceruloplasmin, haptoglobin and hemopexin, to establish their relationship to airway disease diagnosis and inflammatory phenotypes and to identify an optimized biomarker panel for disease differentiation.

Methods

Participants with COPD or asthma were classified by inflammatory phenotypes. Immunoassay methods were used to measure levels of validation biomarkers in the sera of participants with disease and non-respiratory disease controls. Markers were analyzed individually and in combination for disease differentiation and compared to established biomarkers (C-reactive protein, interleukin-6, and white blood cell/blood eosinophil count).

Results

The study population comprised of 141 COPD, 127 severe asthma, 54 mild-moderate asthma and 71 control participants. Significant differences in ceruloplasmin, haptoglobin and hemopexin levels between disease groups and between systemic inflammatory phenotypes were observed. However, no differences were found between airway inflammatory phenotypes. Hemopexin was the best performing individual biomarker and could diagnose COPD versus control participants (area under the curve [AUC], 98.3%; 95% confidence interval [CI], 96.7%–99.9%) and differentiate COPD from asthmatic participants (AUC, 97.0%; 95% CI, 95.4%–98.6%), outperforming established biomarkers. A biomarker panel, including hemopexin, haptoglobin and other established biomarkers, could diagnose asthma versus control participants (AUC, 87.5%; 95% CI, 82.8%–92.2%).

Conclusions

Hemopexin can be a novel biomarker with superior diagnostic ability in differentiating COPD and asthma. We propose an anti-inflammatory axis between the airways and systemic circulation, in which hemopexin is a protective component in airway disease.

Asthma-Chronic Obstructive Pulmonary Disease Overlap

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) defines a subgroup of patients with asthma who have persistent airflow obstruction or patients with COPD who may exhibit variable airflow limitation and/or evidence of type 2 inflammation. Additional investigations are needed to determine whether ACO represents a distinct disorder with unique underlying pathophysiology, whether ACO patients should be managed differently from those with asthma or COPD, and whether the diagnosis affects long-term outcomes. This article presents the data about the clinical features of ACO, the current information regarding the underlying pathophysiology of the syndrome, and current understanding of therapeutic options.

Comorbidity profile of patients with concurrent diagnoses of asthma and COPD in Germany

The aim of this study was to estimate the prevalence of concurrent diagnoses of asthma/COPD and examine its full spectrum of comorbid disorders in Germany. We used nationwide outpatient claims data comprising diagnoses of all statutory health insurees (40+ years) in 2017 (N = 40,477,745). The ICD-10 codes J44 (COPD) and J45 (asthma) were used to identify patients. The odds of 1,060 comorbid disorders were examined in a case-control study design. Of all insurees, 4,632,295 (11%) were diagnosed with either asthma or COPD. Of them, 43% had asthma only, 44% COPD only and 13% both diseases. The prevalence of concurrent asthma/COPD was 1.5% with a slightly higher estimate among females than males (1.6% vs. 1.4%) and constant increase by age in both sexes. Comorbid disorders were very common among these patients. 31 disorders were associated with a strong effect size (odds ratio > 10), including other respiratory diseases, but also bacterial (e.g., mycobacteria, including tuberculosis) and fungal infections (e.g., sporotrichosis and aspergillosis). Patients with concurrent asthma/COPD suffer from comorbid disorders involving various body systems, which points to the need of a multidisciplinary care approach. Regular screening for common comorbid disorders may result in better clinical course and prognosis as well as improvement of patients' quality of life.

Clinical Features of Chronic Obstructive Pulmonary Disease with High Fractional Exhaled Nitric Oxide

Background

The fractional exhaled nitric oxide (FENO) test is useful in asthma patients. However, a few studies on its usefulness in chronic obstructive pulmonary disease (COPD) patients have been reported. We analyzed the FENO level distribution and clinical characteristics according to the FENO level in COPD patients.

Methods

From December 2014 to June 2019, COPD patients who underwent pulmonary function and FENO tests at Chonnam National University Hospital were retrospectively evaluated for FENO, comorbidities, asthma history, blood eosinophil, and pulmonary function test. The high FENO group was defined as those with FENO level>25 parts per billion (ppb).

Results

A total of 849 COPD patients (mean age, 70.3±9.4 years) were included. The mean forced expiratory volume at 1 second was 66.5±21.7% and the mean FENO level was 24.3±20.5 ppb. Patients with FENO ≤25 ppb were 572 (67.4%) and those with FENO >25 ppb were 277 (32.6%). Blood eosinophil percentage was significantly higher (4.2±4.8 vs. 2.7±2.5, p<0.001) in patients with the high FENO group than the low FENO group. The high FENO group revealed a significantly higher frequency of patients with blood eosinophil percentage >3% (46.9% vs. 34.8%, p=0.001) and asthma history (25.6% vs. 8.6%, p<0.001) than the lower FENO group. Asthma history, blood eosinophil percentage >3%, and positive bronchodilator response (BDR) were independent risk factors for the high FENO level (adjusted odds ratio [aOR], 3.85; p<0.001; aOR, 1.46; p=0.017; and aOR, 1.57, p=0.034, respectively) in the multivariable analysis.

Conclusion

The FENO level distribution varied in COPD patients and the mean FENO value was slightly elevated. Asthma history, eosinophil percent, and positive BDR were independent risk factors for the high FENO level.

Metabolomic fingerprinting and systemic inflammatory profiling of asthma COPD overlap (ACO)

Background

Asthma-COPD overlap (ACO) refers to a group of poorly studied and characterised patients reporting with disease presentations of both asthma and COPD, thereby making both diagnosis and treatment challenging for the clinicians. They exhibit a higher burden in terms of both mortality and morbidity in comparison to patients with only asthma or COPD. The pathophysiology of the disease and its existence as a unique disease entity remains unclear. The present study aims to determine whether ACO has a distinct metabolic and immunological mediator profile in comparison to asthma and COPD.

Methods

Global metabolomic profiling using two different groups of patients [discovery (D) and validation (V)] were conducted. Serum samples obtained from moderate and severe asthma [n = 34(D); n = 32(V)], moderate and severe COPD [n = 30(D); 32(V)], ACO patients [n = 35(D); 40(V)] and healthy controls [n = 33(D)] were characterized using gas chromatography mass spectrometry (GC-MS). Multiplexed analysis of 25 immunological markers (IFN-γ (interferon gamma), TNF-α (tumor necrosis factor alpha), IL-12p70 (interleukin 12p70), IL-2, IL-4, IL-5, IL-13, IL-10, IL-1α, IL-1β, TGF-β (transforming growth factor), IL-6, IL-17E, IL-21, IL-23, eotaxin, GM-CSF (granulocyte macrophage-colony stimulating factor), IFN-α (interferon alpha), IL-18, NGAL (neutrophil gelatinase-associated lipocalin), periostin, TSLP (thymic stromal lymphopoietin), MCP-1 (monocyte chemoattractant protein- 1), YKL-40 (chitinase 3 like 1) and IL-8) was also performed in the discovery cohort.

Results

Eleven metabolites [serine, threonine, ethanolamine, glucose, cholesterol, 2-palmitoylglycerol, stearic acid, lactic acid, linoleic acid, D-mannose and succinic acid] were found to be significantly altered in ACO as compared with asthma and COPD. The levels and expression trends were successfully validated in a fresh cohort of subjects. Thirteen immunological mediators including TNFα, IL-1β, IL-17E, GM-CSF, IL-18, NGAL, IL-5, IL-10, MCP-1, YKL-40, IFN-γ, IL-6 and TGF-β showed distinct expression patterns in ACO. These markers and metabolites exhibited significant correlation with each other and also with lung function parameters.

Conclusions

The energy metabolites, cholesterol and fatty acids correlated significantly with the immunological mediators, suggesting existence of a possible link between the inflammatory status of these patients and impaired metabolism. The present findings could be possibly extended to better define the ACO diagnostic criteria, management and tailoring therapies exclusively for the disease.

Analysis of Blood Biomarkers in Patients with Chronic Obstructive Pulmonary Disease (COPD) and with Asthma-COPD Overlap (ACO)

Chronic obstructive pulmonary disease (COPD) is a heterogeneous entity with different clinical phenotypes, such as asthma-COPD overlap (ACO). The aim of this retrospective study was to compare routine blood biomarkers in patients with ACO and the remaning COPD phenotypes. Data were collected from stable COPD patients visited in during 2018, including C-reactive protein (CRP), fibrinogen, neutrophyl/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR).A total of 77 patients with COPD were included, 24 (31%) fulfilled the diagnosis of ACO. Clinically, patients with ACO presented more dyspnoea and wheezing. Regarding laboratory parameters, both groups had low levels of lymphocytes, especially the non-ACO group (24.2% vs. 29.3%; p = 0.031), patients with ACO had significantly higher eosinophil counts (4.7% vs. 1.9%; p < 0.001) but a lower percentage of neutrophils (56.8% vs. 64.7%; p = 0.003), NLR and PLR (2.5 vs. 3.8; p = 0.013 and 115 vs. 160; p = 0.063, respectively). In conclusion, besides the expected eosinophilic inflammation in patients with ACO, both groups had low levels of lymphocytes, especially the non-ACO group. The low levels of lymphocytes, in particular in non-ACO patients, should be confirmed in larger studies.

Long-Term Mortality and Medical Burden of Patients with Chronic Obstructive Pulmonary Disease with and without Subsequent Stroke Episodes

Background: We used the Taiwan National Health Insurance Research Database (NHIRD) to determine the differences in mortality and medical burden between patients with chronic obstructive pulmonary disease (COPD) with and without stroke. Methods: We enrolled participants aged ≥20 years and defined four subgroups in this study, namely patients with COPD (International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM): 491, 492, 494, and 496), patients with COPD with stroke (ICD-9 CM: 430–438), with COPD without stroke, and comparison subgroups. We calculated the hazard ratios and 95% CIs for all-cause mortality risk, average duration of hospitalization, and frequency of medical visits in these subgroups after adjustments were made for age, sex, and comorbidities. All participants were followed until the date of death, the date they were censored, the date they withdrew from the NHIRD, or 31 December, 2013. Results: In total, 9.70% (men vs. women, 11.19% vs. 8.28%) of patients with COPD developed subsequent stroke during the 14 year follow-up. After a stroke, the risk of mortality exhibited a 2.66- to 5.05-fold increase, especially in the younger ones. COPD with stroke was also a leading factor in the increase in the average number of hospitalization days and frequency of medical visits. Conclusion: The mortality risk of patients with COPD is considerably increased by stroke independent of the other effects of COPD. Moreover, the average number of hospitalization days and frequency of medical visits dramatically increased in patients with COPD after stroke.

Ratio of Maximal Inspiratory to Expiratory Flow Aids in the Separation of COPD from Asthma

Patients who have chronic obstructive pulmonary disease (COPD) and bronchial asthma (BA) share symptoms such as, dyspnoea, cough and wheeze. Differentiating these diseases in the ambulatory setting can be challenging especially in older adult smokers who are being treated with a variety of medications. The objective of this study was to test the value of adding a maximal inspiratory manoeuvre to basic spirometry to differentiate COPD and BA. One hundred forty-three COPD patients and 142 BA patients had measurements of maximal inspiratory and expiratory flow during routine spirometry. Parameters from these tests were used to assess diagnostic accuracy using receiver-operating characteristic (ROC) analyses followed by logistic regression. The association of two independent parameters were analyzed using linear regression analyses. Results show that forced expiratory volume in one second/forced vital capacity (FEV₁/FVC%) <62.4 was the best independent predictor to diagnose COPD. The combination of FEV₁/FVC% <62.4 and the ratio of peak inspiratory flow/maximal expiratory flow at 50% FVC (PIF/MEF₅₀) >3.06 significantly predicted COPD. Post-test probability for prediction of COPD was 82.0% when patients had both parameters. When asthmatic patients with a smoking history were compared with COPD patients, FEV₁/FVC% <63.4 and PIF/MEF₅₀ >3.29 were both independent predictors of COPD. The post-test probability for COPD was 94.4% when patients had both parameters. The association between FEV₁/FVC% and PIF/MEF₅₀ was significantly different between COPD and BA. In conclusion, the addition of the maximal inspiratory effort to routine pulmonary function measurements provides a simple test to help differentiate COPD and BA.

The Correlation Between Asthma Severity and Neutrophil to Lymphocyte Ratio

Background—The prognosis is essential in management and follows up of asthmatic patients. Neutrophil to lymphocyte ratio is considered as the common prognostic marker for many diseases especially the asthma. Aim of study—To assess the relationship between asthma severity and neutrophil to lymphocyte ratio in comparison to healthy controls. Patients and methods—This study is a cross sectional study conducted in Respiratory Consultancy Clinic in Baghdad Teaching Hospital in Medical City during the period from 1st of October, 2018 to 31st of March, 2019 on sample of 50 asthmatic patients and 50 healthy controls. The diagnosis of asthma was confirmed by the supervisor through clinical symptoms, signs, spirometery with reversibility test (according to GINA guideline.). Results—A highly significant difference was observed between asthmatic cases and controls regarding age (p<0.001). A significant association was observed between obesity and asthmatic cases (p=0.001). There was a highly significant association between high neutrophil/lymphocyte ratio and asthmatic cases (p<0.001). The neutrophil/lymphocyte ratio was significantly increased with advanced age, females, severe and uncontrolled asthma. Conclusions—The neutrophil to lymphocyte ratio is useful biomarker in assessment of asthma severity.

Triple Therapy with Budesonide/Glycopyrrolate/Formoterol Fumarate Improves Inspiratory Capacity in Patients with Asthma-Chronic Obstructive Pulmonary Disease Overlap

Purpose

Asthma-chronic obstructive pulmonary disease overlap (ACO), characterized by airway limitation, is an important condition with high incidence and mortality. Although some guidelines recommend triple therapy with inhaled corticosteroids/long-acting muscarinic antagonists/long-acting β2 agonists, this treatment approach is based on the extrapolation of data from studies of asthma or chronic obstructive pulmonary disease (COPD) alone.

Methods

A 12-week, randomized, open-label cross-over pilot study was conducted in 19 patients with ACO to investigate the effect of triple therapy with glycopyrrolate (GLY) 50 µg/day on budesonide/formoterol fumarate (BUD/FORM) 640/18 µg/day. The study period included a 4-week wash-out, 4-week run-in, and 4-week treatment period. Respiratory function tests, fractional exhaled nitric oxide (FeNO), a COPD assessment test (CAT) and an asthma control questionnaire (ACQ) were carried out 0, 4, and 8 weeks after randomization.

Results

A total of 19 patients with stable ACO (19 males and no females) with a mean age of 70.7 ± 7.6 years (± standard deviation, SD; range 55-83 years) participated in this study. All patients were ex-smokers with a smoking history of 63.1 ± 41.1 pack-years (± SD). Mean values for inspiratory capacity (IC), an index of hyperinflation of the lung that causes exertional dyspnea and reduced exercise, were 1.93 L (± 0.47 L) after the run-in, 1.85 L (± 0.51 L) after the BUD/FORM dual therapy period and 2.11 L (± 0.58 L) after the BUD/GLY/FORM triple therapy period. IC values after the BUD/GLY/FORM triple therapy were significantly higher than those after the run-in (p < 0.02). FeNO values, ACQ, and CAT scores were not significantly different among the run-in, wash-out, and triple-therapy periods.

Conclusion

The present pilot study showed that triple therapy with BUD/GLY/FORM results in an improvement in lung function parameters including IC, indicating the potential value of triple therapy as standard treatment for ACO.

Effect of triple therapy in patients with asthma-COPD overlap

OBJECTIVE

Asthma-chronic obstructive pulmonary disease (COPD) overlap (ACO) is of increasing interest because ACO patients have significantly worse outcomes, leading to greater social and economic burdens compared with asthma or COPD alone. Some guidelines for ACO recommend triple therapy with inhaled corticosteroids, long-acting β2 agonists, and long-acting muscarinic antagonists. However, this approach is based on extrapolating data from patients with asthma or COPD alone. Therapeutic studies for ACO have not previously been conducted.

MATERIALS AND METHODS

A 12-week, randomized, open-label cross-over pilot study was conducted in 17 ACO patients to evaluate the effect of umeclidinium (UMEC) 62.5 µg once-daily added to fluticasone furoate/vilanterol (FF/VI) 200/25 µg once-daily. A 4-week run-in, a first and a second 4-week treatment period were included. Respiratory function, respiratory impedance, fractional exhaled nitric oxide, COPD assessment test, and asthma control test scores were evaluated 0, 4, and 8 weeks after randomization.

RESULTS

Mean values of post-bronchodilator forced expiratory volume in 1 second as a percentage of the predicted value (%FEV1), after UMEC was added to FF/VI, were significantly higher than after the run-in (p < 0.01). Mean values of resonant frequency during inspiration (Fres), after UMEC was added to FF/VI, were significantly lower than after the run-in (p < 0.01).

CONCLUSION

Adding UMEC to FF/VI provides greater improvement in lung function, indicating that triple therapy is a suitable regular treatment for ACO.

Effects of statins on anxiety and depression in patients with asthma-chronic obstructive pulmonary disease overlap syndrome

BACKGROUND

The effects of statins on anxiety and depression in patients with asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS) have not been reported. This population-based study investigated these effects.

METHODS

Taiwan's National Health Insurance Research Database between 2000 and 2010. We enrolled two ACOS cohorts, one of statin users (n = 1252) and one of nonstatin users matched by age, sex, and index date (n = 7887). The cumulative incidence of anxiety and depression was analyzed using time-dependent Cox proportional regression analysis.

RESULTS

After adjustment for multiple confounding factors, including age, sex, comorbidities, and medications-statins, inhaled corticosteroids (ICSs), and oral steroids (OSs)-the ACOS cohort with statin use had significantly lower risks of anxiety and depression (anxiety: adjusted hazard ratio [aHR] = 0.34, 95% confidence interval [CI] = 0.28-0.42; depression: aHR = 0.36, 95% CI = 0.25-0.53). The aHRs (95% CIs) for statin use with ICSs or OSs were 0.32 (0.13-0.78) and 0.37 (0.24-0.57), respectively.

CONCLUSION

The ACOS cohort with statin use had lower risks of anxiety and depression, regardless of age, sex, commodities, or ICSs and OSs. The incidences of anxiety and depression were relatively low among users of statins with ICSs or OSs in the ACOS cohort.

Inflammatory Cytokines and T-Lymphocyte Subsets in Serum and Sputum in Patients with Bronchial Asthma and Chronic Obstructive Pulmonary Disease

BACKGROUND It can be difficult to distinguish between bronchial asthma and chronic obstructive pulmonary disease (COPD) clinically, although these conditions are associated with different profiles of inflammatory cytokines and immune cells. This study aimed to compare T-lymphocyte subsets and inflammatory cytokines in the serum and sputum of patients with bronchial asthma and COPD who had respiratory function testing. MATERIAL AND METHODS The study included 42 patients with bronchial asthma, 48 patients with COPD, and 45 patients with bronchial asthma complicated with COPD. The percentage predicted values of the forced expiratory volume in one second (FEV1), the forced vital capacity (FVC), and the peak expiratory flow (PEF) rate were measured. Serum and sputum levels of interleukin (IL)-4, IL-5, IL-9, IL-13, IL-1ß, IL-6 and tumor necrosis factor-alpha (TNF-alpha) were measured using an enzyme-linked immunosorbent assay (ELISA). Flow cytometry measured the CD4 and CD8 T-lymphocyte subsets, and the CD4: CD8 ratio was calculated. RESULTS The FEV1, FVC, and PEF were significantly lower in patients with COPD compared with the other two patient groups. Serum and sputum levels of IL-4, IL-5, IL-9 and IL-13 were significantly increased in the COPD patient group, and levels of TNF-alpha, IL-1ß and IL-6 were significantly increased in the bronchial asthma patient group. The CD4: CD8 ratio in sputum was lowest in bronchial asthma patient group and highest in COPD patient group. CONCLUSIONS The detection of serum and sputum inflammatory cytokines and T-lymphocyte subsets may distinguish between bronchial asthma and COPD.

Neighborhood air pollution and household environmental health as it relates to respiratory health and healthcare utilization among elderly persons with asthma

Objective: The study investigated the associations between fine particulate matter (PM_2.5; <2.5 μm in diameter), indoor environment, pulmonary function, and healthcare utilization in a vulnerable group of elderly persons with asthma. We hypothesized that environmental conditions were associated with adverse pulmonary health outcomes. Methods: The study involved elderly (n = 76; mean age 64.6 years; 48 women) vulnerable persons in Detroit, Michigan, USA, with physician-diagnosed asthma. Exposure variables included measured outdoor PM_2.5, self-rated outdoor and household environmental pollutants. Outcome variables were self-rated and measured pulmonary function, and asthma-related healthcare utilization. Results: Mean ambient PM_2.5 concentrations during the study was 14.14 ± (S.D. 6.36) µg/m³ during the summer and 14.20 (6.33) during the winter (p = 0.95). In multiple regression analyses, adjusting for age and gender, mean 6-month concentration of PM_2.5 was related to shortness of breath (SHOB; standardized β = 0.26, p = 0.02) and inversely with self-rated respiratory health (SRRH; β = 0.28, p = 0.02). However, PM_2.5 did not predict lung function (FEV₁% predicted and FEV₁/FVC). However, PM_2.5 was related to use of asthma controller drugs (β = 0.38, p = 0.001). Participants' air pollution ratings predicted total healthcare utilization (β = 0.33, p = 0.01). Conclusions: In elderly persons with asthma, living near heavy industry and busy highways, objective and perceived environmental pollution relate to participants' respiratory health and healthcare utilization. Importantly, air pollution might increase use of asthma controller drugs containing corticosteroids with implication for elderly persons' risk to develop osteoporosis and cardiovascular disease.

Associations between statins and coronary artery disease and stroke risks in patients with asthma-chronic obstructive pulmonary disease overlap syndrome: A time-dependent regression study

BACKGOUND AND AIMS

We aimed at determining the effects of statin use on coronary artery disease (CAD) and stroke risks in patients with asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS).

METHODS

We retrospectively enrolled patients with ACOS treated with (N = 916) and without (N = 6338) statins. The cumulative incidence of CAD and stroke (ischemic and hemorrhagic) was analyzed through time-dependent Cox proportional regression. After adjustment for sex, age, comorbidities, inhaled corticosteroid steroid (ICS) use, and oral steroid (OS) use, we calculated the adjusted hazard ratios (aHRs) and their 95% confidence intervals (CIs) for CAD or stroke in the statin users (long-term [>600 days] and short-term [≤600 days]) compared with the non-users.

RESULTS

Among the statin users, aHRs (95% CIs) for CAD and stroke were 0.50 (0.41-0.62) and 0.83 (0.63-1.09), respectively; moreover, aHRs were 0.30 (0.09-0.99) and 0.90 (0.68-1.20) for ischemic and hemorrhagic stroke, respectively. aHRs (95% CIs) for CAD and stroke were 0.58 (0.47-0.71) and 0.93 (0.70-1.23), respectively, in the short-term users and 0.23 (0.13-0.41) and 0.42 (0.19-0.89), respectively, in the long-term users.

CONCLUSIONS

CAD risk was lower in all statin users, regardless of the duration of use, whereas ischemic stroke risk was lower only in the long-term statin users. No association was observed between hemorrhagic stroke risk and statin use.

Asthma COPD overlap: Impact of associated comorbidities

Asthma and chronic obstructive pulmonary disease (COPD) are common chronic pulmonary conditions worldwide which often coexist. Patients with asthma COPD overlap (ACO) may have worse outcomes than those with either disease alone, for example, more respiratory symptoms and frequent exacerbations, and worse lung function. Additionally, there is a growing interest in factors that affect the disease including comorbid conditions. Indeed, recent studies have demonstrated higher rates of comorbid conditions in the ACO population, but the mechanisms behind these observations remain unclear. The objective of this review is to describe current knowledge and clinical implications of the overlapping features of asthma and COPD, and discuss the prevalence and impact of comorbidities, such as osteoporosis, cardiovascular disease, gastroesophageal reflux disease, and depression, in this subgroup of patients.

The relationship between pulmonary function and suicidal ideation in Korean adults: a nationwide survey

Controversy surrounds the association between lung function and mental health in the general population, and previous reported results were confounded by the effect of other chronic illnesses. This study aimed to investigate whether reduced lung function was related to mental health issues, taking into consideration the relevant potential confounders. We used data from the 2008-2013 Korean National Health and Nutrition Examination Survey to examine the relationship between lung function and three mental issues (recognized stress, depressive mood, and suicidal ideation) among 22,068 Korean adults. A multiple logistic regression with adjustment for potential covariates including chronic illnesses revealed that a .5-L decrement of forced vital capacity increased the risk for suicidal ideation in both genders, but there was no significant association with recognized stress or depressive mood. We found an inverse relationship between lung function and suicidal ideation in the Korean general population.

Osteoporosis in Patients with Asthma-Chronic Obstructive Pulmonary Disease Overlap Syndrome

Background

Osteoporosis is a common disease that occurs comorbidly in patients with chronic inflammatory airway diseases, including asthma, chronic obstructive pulmonary disease (COPD), and asthma-COPD overlap syndrome (ACOS). However, the prevalence of osteoporosis in patients with ACOS has not widely been evaluated. Therefore, we investigated the prevalence of osteoporosis and its relationship with the clinical parameters of patients with asthma, COPD, and ACOS.

Methods

This was a retrospective, cross-sectional study. Bone mineral density (BMD), lung function tests, and disease status evaluations were conducted.

Results

A total of 321 patients were enrolled: 138 with asthma, 46 with ACOS, and 137 with COPD. One hundred and ninety-three patients (60.1%) were diagnosed with osteoporosis (53.6% of asthma, 65.2% of ACOS, and 65.0% of COPD). Patients with ACOS showed a significantly lower BMD and T-score than did those with asthma. In addition to age, sex, and body mass index (BMI), which were previously reported to be associated with BMD, BMD also had a negative correlation with the diagnosis of ACOS, as compared to a diagnosis of asthma, after adjusting for age, sex, BMI, smoking, and inhaled corticosteroid use (p=0.001). Among those patients with COPD and ACOS, BMD was negatively associated with the COPD Assessment Test (CAT) after adjustment (p<0.001). Inhaled corticosteroid was not associated with the prevalence of osteoporosis and BMD.

Conclusion

Patients with ACOS, particularly aged and lean women, should be more carefully monitored for osteoporosis as compared to patients with asthma.

Geroprotectors as a therapeutic strategy for COPD - where are we now?

Although current therapies in chronic obstructive pulmonary disease (COPD) improve the quality of life, they do not satisfactorily reduce disease progression or mortality. There are still many gaps in knowledge about the cellular, molecular, and genetic mechanisms contributing to pathobiology of this disease. However, increasing evidence suggests that accelerated aging, chronic systemic inflammation, and oxidative stress play major roles in pathogenesis in COPD, thus opening new opportunities in therapy. Therefore, the aim of our review was to describe and discuss some of the most widely used therapeutics that affect the root cause of aging and oxidative stress (metformin, melatonin, sirolimus, statins, vitamin D, and testosterone) in context of COPD therapy.

Association of asthma-chronic obstructive pulmonary disease overlap syndrome with coronary artery disease, cardiac dysrhythmia and heart failure: a population-based retrospective cohort study

OBJECTIVES

Patients with asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) and cardiovascular diseases (CVDs) share common risk factors. However, the association between ACOS and the incidence of CVDs has not been reported. This study investigated the relationship between CVDs and ACOS in the general population.

SETTING

Data were obtained from Taiwan's National Health Insurance Research Database for the period 2000 to 2010.

PARTICIPANTS

The ACOS cohort comprised patients (n=5814) who had received a diagnosis of asthma and COPD. The non-ACOS cohort comprised patients who had not received a diagnosis of asthma or COPD and were matched to the ACOS cohort (2:1) by age, sex and index date (n=11 625).

PRIMARY AND SECONDARY OUTCOME MEASURES

The cumulative incidence of CVDs-coronary artery disease (CAD), cardiac dysrhythmia (CD) and heart failure (HF)-was calculated. Cox proportional regression analysis was employed to examine the relationship between ACOS and CVDs.

RESULTS

After adjustment for multiple confounding factors-age, sex, comorbidities and medications-patients with ACOS were associated with a significantly higher risk of CVDs; the adjusted HRs (aHRs; 95% CI) for CAD, CD and HF were 1.62 (1.50 to 1.76), 1.44 (1.30 to 1.61) and 1.94 (1.73 to 2.19), respectively, whereas those of beta-blockers treatment for CAD, CD and HF were 1.19 (0.92 to 1.53), 0.90 (0.56 to 1.45) and 0.82 (0.49 to 1.38). The aHR of atenolol treatment for CD was 1.72 (1.01 to 2.93). The aHRs (95% CIs) of ACOS without acute exacerbation of COPD (AE-COPD) for CAD, CD and HF were 1.85 (1.70 to 2.01), 1.57 (1.40 to 1.77) and 2.07 (1.82 to 2.35), respectively.

CONCLUSION

ACOS was associated with higher CVD risk, even without the presence of previous comorbidities or AE-COPD. No significant differences in CVD events were observed in the ACOS cohort using beta-blockers, except for those using atenolol for treating CD.

Presence of sarcopenia in asthma-COPD overlap syndrome may be a risk factor for decreased bone-mineral density, unlike asthma: Korean National Health and Nutrition Examination Survey (KNHANES) IV and V (2008-2011)

Background

Sarcopenia and decreased bone-mineral density (BMD) are common in elderly people, and are major comorbidities of obstructive airway disease (OAD). However, the relationship between sarcopenia and BMD in each OAD phenotype, especially asthma–COPD overlap syndrome (ACOS), is not yet clear. We aimed to evaluate differences in BMD according to the presence of sarcopenia in each OAD phenotype.

Materials and methods

Among the research subjects in KNHANES IV and V (2008–2011), 5,562 were ≥50 years old and underwent qualified spirometry and dual-energy X-ray absorptiometry. A total of 947 subjects were included in the study: 89 had asthma, 748 COPD, and 110 ACOS.

Results

In the COPD and ACOS phenotypes, T-scores were lower in the sarcopenia group than the nonsarcopenia group. Prevalence rates of osteopenia and osteoporosis were higher in the sarcopenia group than the nonsarcopenia group. (P<0.001 and P=0.017, respectively). The sarcopenia group had higher risks of developing osteopenia, osteoporosis, and low BMD than the nonsarcopenia group in the ACOS phenotype (OR 6.620, 95% CI 1.129–38.828 [P=0.036], OR 9.611, 95% CI 1.133–81.544 [P=0.038], and OR 6.935, 95% CI 1.194–40.272 [P=0.031], respectively). However, in the asthma phenotype, the sarcopenia group showed no increased risk compared with the nonsarcopenia group.

Conclusion

In the ACOS phenotype, individuals with sarcopenia had a higher prevalence rate and higher risks of osteopenia and osteoporosis than those without sarcopenia among all OAD phenotypes.

A clustering approach to identify and characterize the asthma and chronic obstructive pulmonary disease overlap phenotype

BACKGROUND

Asthma and chronic obstructive pulmonary disease (COPD) are heterogeneous diseases. The phenotypes that have clinical features of both asthma and COPD are still incompletely understood.

OBJECTIVE

To clarify the best discriminators of the asthma-COPD overlap phenotype from asthma and COPD subgroups using a clustering approach.

METHODS

This study assessed pathophysiological parameters, including mRNA expression levels of T helper cell-related transcription factors, namely TBX21 (Th1), GATA3 (Th2), RORC (Th17) and FOXP3 (Treg), in peripheral blood mononuclear cells in asthma patients (n=152) and in COPD patients (n=50). Clusters were determined using k-means clustering. Exacerbations of asthma and COPD were recorded during the 1-year follow-up period.

RESULTS

The cluster analysis revealed four biological clusters: cluster 1, predominantly patients with COPD; cluster 2, patients with an asthma-COPD overlap phenotype; cluster 3, patients with non-atopic and late-onset asthma; and cluster 4, patients with early-onset atopic asthma. Hazard ratios for exacerbation were 2.5 (95% confidence interval [CI], 1.1-5.6) in cluster 1 and 2.3 (95% CI, 1.0-5.0) in cluster 2 compared with patients in other clusters. Cluster 2 was discriminated from other clusters by total serum IgE level ≥310 IU/mL, blood eosinophil counts ≥280 cells/μL, a higher ratio of TBX21/GATA3, FEV₁ /FVC ratio <0.67 and smoking ≥10 pack-years with an area under the curve of 0.94 (95% CI, 0.90-0.98) in the receiver operating characteristic analysis.

CONCLUSIONS AND CLINICAL RELEVANCE

The asthma-COPD overlap phenotype was characterized by peripheral blood eosinophilia and higher levels of IgE despite the Th2-low endotype.

Differences between asthma-COPD overlap syndrome and adult-onset asthma

Differences between asthma-COPD overlap syndrome (ACOS) and adult-onset asthma are poorly understood. This study aimed to evaluate these differences in a clinical cohort of patients with adult-onset asthma, as a part of the Seinäjoki Adult Asthma Study (SAAS).188 patients were diagnosed with adult-onset asthma and re-evaluated 12 years after diagnosis. They were divided into three groups based on smoking history and post bronchodilator spirometry values: 1) never- and ex-smokers with <10 smoked pack-years; 2) non-obstructive (forced expiratory volume in 1 s (FEV₁)/forced vital capacity (FVC) ≥0.7) patients with ≥10 pack-years; and 3) ACOS patients with ≥10 pack-years and FEV₁/FVC <0.7.ACOS patients had lower diffusing capacity (D_LCO/V_A 86% predicted versus 98 or 96% predicted; p<0.001), higher blood neutrophil levels (4.50 versus 3.60 or 3.85×10⁹ L^-1; p=0.008), and higher IL-6 levels (2.88 versus 1.52 or 2.10 pg·mL^-1, p<0.001) as compared to never- and ex-smokers with <10 pack-years, or non-obstructive patients with ≥10 pack-years smoking history, respectively. ACOS patients also showed reduced lung function, higher remaining bronchial reversibility and a higher number of comorbidities.This study shows distinct differences in diffusing capacity, blood neutrophil and IL-6 levels, bronchial reversibility, lung function and comorbidities between ACOS and adult-onset asthma. The present findings should be considered in the comprehensive assessment of adult asthma patients.

Comparative prevalence of co-morbidities in smoking and non-smoking asthma patients with incomplete reversibility of airway obstruction, non-smoking asthma patients with complete reversibility of airway obstruction and COPD patients

BACKGROUND

Asthma with incomplete reversibility of airway obstruction (IRAO) may often be associated to smoking-induced changes. Nevertheless, a high proportion of patients showing IRAO have never smoked. These patients with IRAO often share features of patients with chronic obstructive pulmonary disease (COPD). Although IRAO is still a poorly defined condition, it has been associated with a higher morbidity and mortality than asthma with complete reversibility of airway obstruction (CRAO) or even COPD alone. A high prevalence of comorbidities could contribute to the reported poorer clinical outcome in IRAO, in comparison to CRAO or COPD alone.

AIM

To determine the prevalence of past and current comorbidities in IRAO patients compared to patients with CRAO or COPD.

METHODS

This was a retrospective, cross-sectional study. Demographic data, clinical characteristics and 36 predetermined comorbidities documented from self-report and chart review, were recorded from smoking-associated IRAO (S-IRAO), non-smoking IRAO (NS-IRAO), CRAO and COPD patients.

RESULTS

A total of 199 patients were included in the final analysis (111F/88M, mean (±SD) age of 63 ± 10 years). The CRAO group had more comorbidities than the three other groups, but this difference was significant only with the NS-IRAO group (P = 0.04). For most comorbidities, the prevalence of comorbidities in both IRAO sub-groups was intermediate between CRAO and COPD, with significant differences between S-IRAO and NS-IRAO only for hypertension (P = 0.03), nasal polyps (P = 0.002) and pneumonia (P = 0.04). Typical asthma-associated comorbidities tended to be more prevalent in NS-IRAO patients and COPD-associated comorbidities in S-IRAO patients.

CONCLUSION

In this study, the prevalence of comorbidities was not superior in patients with IRAO, compared to those with CRAO or COPD alone. The prevalence of comorbidities in the two main types of IRAO patients reflects exposure to cigarette smoke and asthma-related mechanisms.

Associations of IL-4, IL-6, and IL-12 levels in peripheral blood with lung function, cellular immune function, and quality of life in children with moderate-to-severe asthma

BACKGROUND

Pediatric asthma has gained increasing concerns with poorly understood pathogenesis. The purpose of this study was to explore the associations of interleukin-4 (IL-4), IL-6, and IL-12 levels in peripheral blood (PB) with lung function, cellular immune function, and children's quality of life (QOL) with moderate-to-severe asthma.

METHODS

A total of 1158 children with moderate-to-severe asthma (the experimental group) and 1075 healthy children (the control group) were recruited for our study. Enzyme-linked immunosorbent assay was used to detect IL-4, IL-6, and IL-12 levels. T lymphocytes were detected by alkaline phosphatase antialkaline phosphatase, and erythrocyte immune was measured by red blood cell C 3b receptor (RBC-C3bR) rosette-forming test. The forced expiratory volume in 1 second (FEV1) and peak expiratory flow (PEF) were detected, after which FEV1/forced vital capacity (FVC) was calculated before and after treatment. PedsQL3.0 was used to measure the effect of asthma on QOL of children, and the correlation between IL-4, IL-6, and IL-12 levels and the lung function and QOL was measured. Logistic regression analysis was applied to detect related factors of moderate-to-severe asthma of children.

RESULTS

After treatment, the decreased IL-4 and IL-6 levels and increased IL-12 level were revealed in the experimental group. The cellular immune function's disorder was significantly decreased, and an elevated CD3, CD4, CD8, and declined CD4/CD8 level was performed in T lymphocytes. RBC-C3bR was increased, and red blood cell immune complex (RBC-IC) was reduced in erythrocyte immune in comparison with those before treatment. Lung function parameters all increased. After treatment, the symptoms of asthma in children reduced with scores of increased QOL. IL-4 was positively related to RBC-IC, but negatively associated with the QOL score. IL-6 showed negative connection with CD4/CD8, RBC-C3bR, FEV1/FVC, and QOL score, and had positive connection with PEF. In addition, IL-12 was negatively correlated with PEF. The levels of IL-4, RBC-C3bR, FEV1/FVC, and PEF were independent risk factors for the prognosis of treatment for children with moderate-to-severe asthma.

CONCLUSION

This study demonstrated that IL-4, IL-6, and IL-12 levels in PB were associated with lung function, cellular immune function, and QOL in children with moderate-to-severe asthma.

A Belgian survey on the diagnosis of asthma-COPD overlap syndrome

INTRODUCTION

Patients with chronic airway disease may present features of both asthma and COPD, commonly referred to as asthma-COPD overlap syndrome (ACOS). Recommendations on their diagnosis are diffuse and inconsistent. This survey aimed to identify consensus on criteria for diagnosing ACOS.

METHODS

A Belgian expert panel developed a survey on ACOS diagnosis, which was completed by 87 pulmonologists. Answers chosen by ≥70% of survey respondents were considered as useful criteria for ACOS diagnosis. The two most frequently selected answers were considered as major criteria, others as minor criteria. The expert panel proposed a minimal requirement of two major criteria and one minor criterion for ACOS diagnosis. Respondents were also asked which criteria are important for considering inhaled corticosteroids prescription in a COPD patient.

RESULTS

To diagnose ACOS in COPD patients, major criteria were "high degree of variability in airway obstruction over time (change in forced expiratory volume in 1 second ≥400 mL)" and "high degree of response to bronchodilators (>200 mL and ≥12% predicted above baseline)". Minor criteria were "personal/family history of atopy and/or IgE sensitivity to ≥1 airborne allergen", "elevated blood/sputum eosinophil levels and/or increased fractional exhaled nitric oxide", "diagnosis of asthma <40 years of age"; "symptom variability", and "age (in favor of asthma)". To diagnose ACOS in asthma patients, major criteria were "persistence of airflow obstruction over time (forced expiratory volume in 1 second/forced vital capacity ratio <0.7)" and "exposure to noxious particles/gases, with ≥10 pack-years for (ex-)smokers"; minor criteria were "lack of response on acute bronchodilator test"; "reduced diffusion capacity"; "limited variability in airway obstruction"; "age >40 years"; "emphysema on chest computed tomography scan".

CONCLUSION

Specific criteria were identified that may guide physicians to a more uniform diagnostic approach for ACOS in COPD or asthma patients. These criteria are largely similar to those used to prescribe inhaled corticosteroids in COPD.

Asthma-chronic obstructive pulmonary disease overlap syndrome - Literature review and contributions towards a Portuguese consensus

INTRODUCTION

Phenotypic overlap between the two main chronic airway pulmonary diseases, asthma and chronic obstructive pulmonary disease (COPD), has been the subject of debate for decades, and recently the nomenclature of asthma-COPD overlap syndrome (ACOS) was adopted for this condition. The definition of this entity in the literature is, however, very heterogeneous, it is therefore important to define how it applies to Portugal.

METHODS

A literature review of ACOS was made in a first phase resulting in the drawing up of a document that was later submitted for discussion among a panel of chronic lung diseases experts, resulting in reflexions about diagnosis, treatment and clinical guidance for ACOS patients.

RESULTS

There was a consensus among the experts that the diagnosis of ACOS should be considered in the concomitant presence of: clinical manifestations characteristic of both asthma and COPD, persistent airway obstruction (post-bronchodilator FEV₁/FVC<0.7), positive response to bronchodilator test (increase in FEV₁ of ≥200mL and ≥12% from baseline) and current or past history of smoking or biomass exposure. In reaching diagnosis, the presence of peripheral eosinophilia (>300eosinophils/μL or >5% of leukocytes) and previous history of atopy should also be considered. The recommended first line pharmacological treatment in these patients is the ICS/LABA association; if symptomatic control is not achieved or in case of clinical severity, triple therapy with ICS/LABA/LAMA may be used. An effective control of the exposure to risk factors, vaccination, respiratory rehabilitation and treatment of comorbidities is also important.

CONCLUSIONS

The creation of initial guidelines on ACOS, which can be applied in the Portuguese context, has an important role in the generation of a broad nationwide consensus. This will give, in the near future, a far better clinical, functional and epidemiological characterization of ACOS patients, with the ultimate goal of achieving better therapeutic guidance.

Asthma-COPD Overlap Shows Favorable Clinical Outcomes Compared to Pure COPD in a Korean COPD Cohort

Purpose

Comparisons of the characteristics of chronic obstructive pulmonary disease (COPD) and asthma-COPD overlap syndrome (ACOS) have been the focus of several studies since the diseases were defined by the Global Initiative for Asthma and Global Initiative for Chronic Obstructive Lung Disease guidelines. However, no consensus is available yet. In this study, we aimed to compare the characteristics of asthma-COPD overlap (ACO) and COPD.

Methods

We retrospectively reviewed 1,504 patients with COPD in a Korean COPD Subtype Study cohort. The occurrence of ACO was defined as a positive response to a bronchodilator (an increase in forced expiratory volume in 1 second [FEV1] of 12% and 200 mL).

Results

Among 1,504 patients with COPD, 223 (14.8%) were diagnosed with ACO. Men (95.5%) and current smokers (32.9%) were more prevalent in the ACO group compared with the pure COPD group (90.5% and 25.3%, respectively; P=0.015 and P=0.026, respectively). Patients with ACO had a better quality of life (St. George's Respiratory Questionnaire for COPD score=31.0±18.0 [mean±standard deviation]) than those with pure COPD (35.3±19.1) (P=0.002). Although the prevalence of acute exacerbation was not different between the 2 groups, patients with severe exacerbation required hospital admission significantly more frequently in the pure COPD group than in the ACO group. Patients with ACO showed a higher likelihood of FEV1 recovery than those with pure COPD (P<0.001).

Conclusions

We suggest that ACO is characterized by less severe symptoms, and therefore it might lead to rare severe exacerbation and the possibility of lung function recovery.

Effect of Radix Stemonae concentrated decoction on the lung tissue pathology and inflammatory mediators in COPD rats

Background

Chronic obstructive pulmonary disease (COPD) is a common and frequently occurring respiratory disease. At present, western medicine treatment of COPD mainly focuses on symptomatic treatment. Using Chinese medicines or integrated Chinese and Western medicines to treat stable COPD has significant efficacy. In this study, we aimed to observe the effect of Radix Stemonae concentrated decoction on the lung tissue pathology and inflammatory mediators in COPD rats and explore its possible mechanism.

Methods

SD rats were randomized into blank group, COPD model group and Radix Stemonae group, 10 cases in each group. Rats were fed for 112 days. Before the rats were sacrificed, lung function of the animals was tested. The right lower lung was fixed for morphologic observation. The inflammatory mediators in serum were determined using enzyme-linked immuno sorbent assay.

Results

Body weight of animals in the model group was significantly decreased compared with blank group (P < 0.05). After gavage therapy with Radix Stemonae, body weight was significantly increased (P < 0.05). Compared with the blank group, pulmonary functions of rats in the model group were significantly abnormal (P < 0.05), while in Radix Stemonae group, these indicators turned much better than model group (P < 0.05). As for pathological changes in lungs, airway inflammation in the model group was aggravated. In the Radix Stemonae group, inflammation and emphysema were much milder. The concentrations of TNF-α, IL-8 and LTB4 in both model group and Radix Stemonae group were increased significantly (P < 0.05). But the levels in Radix Stemonae group were decreased significantly than model group (P < 0.05).

Conclusion

Radix Stemonae concentrated decoction may mitigate and improve airway rebuilding in the lungs of COPD rats by inhibiting the release of inflammatory mediators.

Characterization of sputum biomarkers for asthma-COPD overlap syndrome

Asthma–COPD overlap syndrome (ACOS) is a commonly encountered chronic airway disease. However, ACOS is still a consensus-based clinical phenotype and the underlying inflammatory mechanisms are inadequately characterized. To clarify the inflammatory mediatypical for ACOS, five biomarkers, namely interleukin (IL)-13, myeloperoxidase (MPO), neutrophil gelatinase-associated lipocalin (NGAL), chitinase-like protein (YKL-40), and IL-6, were selected. This study hypothesized that sputum biomarkers relevant for airway inflammation in asthma (IL-13), COPD (MPO, NGAL), or in both asthma and COPD (YKL-40, IL-6) could be used to differentiate ACOS from COPD and asthma. The aim of this study was to characterize the inflammatory profile and improve the recognition of ACOS. Induced sputum levels of IL-13, MPO, NGAL, YKL-40, and IL-6 were measured by enzyme-linked immunosorbent assay/Luminex assay in a Finnish discovery cohort (n=90) of nonsmokers, smokers, and patients with asthma, COPD, and ACOS and validated in a Japanese cohort (n=135). The classification accuracy of potential biomarkers was compared with area under the receiver operating characteristic curves. Only sputum NGAL levels could differentiate ACOS from asthma (P<0.001 and P<0.001) and COPD (P<0.05 and P=0.002) in the discovery and replication cohorts, respectively. Sputum NGAL levels were independently correlated with the percentage of pre-bronchodilator forced expiratory volume in 1 second predicted in multivariate analysis in the discovery and replication cohorts (P=0.001 and P=0.002, respectively). In conclusion, sputum biomarkers reflecting both airway inflammation and remodeling of the tissue show potential in differentiation between asthma, COPD, and ACOS.

Comorbidities and elevated IL-6 associate with negative outcome in adult-onset asthma

The effect of systemic inflammation and comorbidities on treatment and outcome of adult-onset asthma remains unknown and is the objective of this study.As part of the Seinäjoki Adult Asthma Study (SAAS) with a 12-year follow-up, serum interleukin (IL)-6, high-sensitivity C-reactive protein (hsCRP) and lung function were measured and clinical information on comorbidities and medication collected from 170 patients with adult-onset asthma without chronic obstructive pulmonary disease.At follow-up visit, 54% of the patients had systemic inflammation as indicated by elevated IL-6 or hsCRP, 58% had at least one comorbidity and 30% at least two comorbidities (other than asthma related). Patients with systemic inflammation were treated with higher dose of inhaled corticosteroid (ICS) and they had lower lung function and higher blood neutrophils compared with patients without. Patients having ≥2 comorbidities had lower Asthma Control Test score and this association remained significant in adjusted analysis. Patients with both systemic inflammation and comorbidities showed poorest outcome of asthma. In multivariate regression analysis, high ICS dose was predicted by elevated IL-6, elevated blood neutrophils and eosinophils and poorer lung function at baseline and follow-up.Altogether, in patients with adult-onset asthma, elevated IL-6 was associated with use of high-dose ICS while multi-morbidity was linked to worse symptoms of asthma.

Plasma Inflammatory Cytokine IL-4, IL-8, IL-10, and TNF-α Levels Correlate with Pulmonary Function in Patients with Asthma-Chronic Obstructive Pulmonary Disease (COPD) Overlap Syndrome

Background

The aim of this study was to investigate the plasma inflammatory cytokine levels and their correlations with pulmonary function in patients with asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS).

Material/Methods

Between January 2013 and December 2014, a total of 96 patients with asthma, acute exacerbation of chronic obstructive pulmonary disease (AECOPD), or ACOS were enrolled, and 35 healthy people were included as a control group. Fasting plasma interleukin (IL)-4, IL-8, IL-10, and tumor necrosis factor alpha (TNF-α) levels were detected using enzyme-linked immunosorbent assay (ELISA). Correlations between the plasma inflammatory cytokine levels and forced expiratory volume in 1 second (FEV1), FEV1/predicted value ratio (FEV1%pred), and FEV1/forced vital capacity (FVC) were analyzed.

Results

IL-4 and IL-8 levels showed statistically significant differences among the 3 groups of patients (both P<0.001); IL-4 level was significantly lower, while IL-8 level was significantly higher in the AECOPD group and ACOS group than those in the asthma group (all P<0.05). IL-10 level and TNF-α level were significantly different among the 3 patient groups (both P<0.001). IL-10 level was significantly different between each of the 2 groups (all P<0.001). TNF-α level in the asthma group was higher than in the AECOPD group and ACOS group (both P<0.001). IL-4 and IL-10 were positively and IL-8 and TNF-α were negatively related with FEV1, FEV1%pred, and FEV1/FVC.

Conclusions

Plasma levels of inflammatory cytokines IL-4, IL-8, IL-10, and TNF-α are related with severity of airway diseases and could be potential markers for the evaluation of asthma, COPD, and ACOS.

Study design for a randomised controlled trial to explore the modality and mechanism of Tai Chi in the pulmonary rehabilitation of chronic obstructive pulmonary disease

INTRODUCTION

Although pulmonary rehabilitation (PR) is associated with significant clinical benefits in chronic obstructive pulmonary disease (COPD) and has been recommended by guidelines, PR with conventional exercise training has not been widely applied in the clinic because of its inherent limitations. Alternative exercise such as Tai Chi has been investigated and the results are promising. However, the strengths and weaknesses of the exercise modality of Tai Chi, conventional PR and a combination of Tai Chi and conventional PR and the possible mechanisms underlying Tai Chi exercise remain unclear. This study aims to address the above research gaps in a well-designed clinical trial.

METHODS AND ANALYSIS

This study is a single-blind, randomised controlled trial. Participants with stable COPD will be recruited and randomly assigned to one of four groups receiving Tai Chi exercise, conventional PR using a total body recumbent stepper (TBRS), combined Tai Chi and TBRS, or usual care (control) in a 1:1:1:1 ratio. Participants will perform 30 min of supervised exercise three times a week for 8 weeks; they will receive sequential follow-ups until 12 months after recruitment. The primary outcome will be health-related quality of life as measured by the St George's Respiratory Questionnaire. Secondary outcomes will include 6 min walking distance, pulmonary function, the modified Medical Research Council Dyspnoea Scale, the COPD Assessment Test, the Hospital Anxiety and Depression Scale, the Berg Balance Scale, exacerbation frequency during the study period, and systemic inflammatory and immune markers.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Clinical Trial and Biomedical Ethics Committee of West China Hospital of Sichuan University (No TCM-2015-82). Written informed consent will be obtained from each participant before any procedures are performed. The study findings will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR-IOR-15006874; Pre-results.