COPD Guidelines: A Review of the 2018 GOLD Report

Sarcopenia in pulmonary diseases is associated with elevated sarcoplasmic reticulum stress and myonuclear disorganization

Chronic obstructive pulmonary disease (COPD) is frequently associated with age-related muscle loss or sarcopenia. However, the exact molecular mechanism of muscle loss in COPD remains elusive. We investigated the association of chronic dysregulation of sarcoplasmic reticulum (SR) protein homeostasis (a condition called SR stress) and myonuclear disorganization with sarcopenia in patients with COPD. Markers of SR stress and their downstream consequences, including apoptosis and inflammation, were upregulated in patients with COPD. The maximal SR Ca²⁺ ATPase (SERCA) activity was significantly reduced in advanced COPD as compared to healthy controls. Single muscle fiber diameter and cytoplasmic domain per myonucleus were significantly smaller in patients with advanced COPD than in healthy controls. Increased disruption of myonuclear organization was found in the COPD patients as compared to healthy controls. These changes in SR dysfunction were accompanied by elevated global levels of oxidative stress, including lipid peroxidation and mitochondrial reactive oxygen species (ROS) production. Altogether, our data suggest that muscle weakness in advanced COPD is in part associated with the disruption of SR protein and calcium homeostasis and their pathological consequences.

Prevalence of depression and anxiety in patients with chronic obstructive pulmonary disease and their association with psychosocial outcomes: A cross-sectional study from Pakistan

Objectives:

Chronic obstructive pulmonary disease contributes to substantial health and economic burden worldwide. Co-morbid depression and anxiety are highly prevalent in patients with chronic obstructive pulmonary disease. Depressive symptoms in chronic obstructive pulmonary disease are associated with poorer survival, longer hospitalisation and impaired quality of life. Literature on chronic obstructive pulmonary disease is largely derived from high-income countries; yet 90% of deaths related to chronic obstructive pulmonary disease occur in low- and middle-income countries. We aimed to establish the prevalence of anxiety and depression in patients with chronic obstructive pulmonary disease, as well as the association with psychosocial outcomes.

Methods:

This was a cross-sectional study of chronic obstructive pulmonary disease patients attending outpatient primary care clinics in Karachi, Pakistan. The Patient Health Questionnaire-9 was used to assess depression and the Generalised Anxiety Disorder-7 scale was used for the assessment of anxiety. Health-related quality of life was assessed with EuroQol–Five Dimensions, social support with Oslo-3 and social stress with Life Events Checklist. We recruited 293 subjects.

Results:

The prevalence of depression and anxiety in the sample was 51% (n = 149) and 20% (n = 59), respectively. Depressed chronic obstructive pulmonary disease patients reported significantly lower health-related quality of life scores as compared to non-depressed patients. Participants with depression had significantly higher levels of anxiety, less social support, higher social stress and more subjective impairment in quality of life.

Conclusion:

Given the association with reduced social support and increased perceived stress, the role of psychosocial interventions must be explored in improving outcomes of chronic obstructive pulmonary disease patients in Pakistan.

Prediction of readmission in patients with acute exacerbation of chronic obstructive pulmonary disease within one year after treatment and discharge

Background

To investigate the risk factors and construct a logistic model and an extreme gradient boosting (XGBoost) model to compare the predictive performances for readmission in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients within one year.

Methods

In total, 636 patients with AECOPD were recruited and divided into readmission group (n = 449) and non-readmission group (n = 187). Backward stepwise regression method was used to analyze the risk factors for readmission. Data were divided into training set and testing set at a ratio of 7:3. Variables with statistical significance were included in the logistic model and variables with P < 0.1 were included in the XGBoost model, and receiver operator characteristic (ROC) curves were plotted.

Results

Patients with acute exacerbations within the previous 1 year [odds ratio (OR) = 4.086, 95% confidence interval (CI) 2.723–6.133, P < 0.001), long-acting β agonist (LABA) application (OR = 4.550, 95% CI 1.587–13.042, P = 0.005), inhaled corticosteroids (ICS) application (OR = 0.227, 95% CI 0.076–0.672, P = 0.007), glutamic-pyruvic transaminase (ALT) level (OR = 0.985, 95% CI 0.971–0.999, P = 0.042), and total CAT score (OR = 1.091, 95% CI 1.048–1.136, P < 0.001) were associated with the risk of readmission. The AUC value of the logistic model was 0.743 (95% CI 0.692–0.795) in the training set and 0.699 (95% CI 0.617–0.780) in the testing set. The AUC value of XGBoost model was 0.814 (95% CI 0.812–0.815) in the training set and 0.722 (95% CI 0.720–0.725) in the testing set.

Conclusions

The XGBoost model showed a better predictive value in predicting the risk of readmission within one year in the AECOPD patients than the logistic regression model. The findings of our study might help identify patients with a high risk of readmission within one year and provide timely treatment to prevent the reoccurrence of AECOPD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01692-3.

Zanthoxylum bungeanum Seed Oil Attenuates LPS-Induced BEAS-2B Cell Activation and Inflammation by Inhibiting the TLR4/MyD88/NF-κB Signaling Pathway

Background

Zanthoxylum bungeanum seed oil (ZBSO) is a natural essential oil derived from the seeds of the Chinese medicinal plant Zanthoxylum bungeanum, which has been investigated for antitumor and anti-inflammatory effects. However, little is known regarding the effects of ZBSO in chronic obstructive pulmonary disease (COPD).

Methods

In this study, lung epithelial cells (BEAS-2B) were induced by lipopolysaccharide (LPS) to establish an in vitro model of COPD, and cytotoxicity was detected by a cell counting kit 8 (CCK-8) assay. Griess test, enzyme-linked immunosorbent assay (ELISA), reverse transcriptase quantitative polymerase chain reaction (RT-qPCR), western blot, immunofluorescence, and molecular docking analyses were used to investigate the effects of ZBSO and its potential mechanisms.

Results

The results showed that LPS promoted the expression of nitric oxide (NO), reactive oxygen species (ROS), malondialdehyde (MDA), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1), matrix metalloproteinase-2 (MMP-2), MMP-9, cyclooxygenase-2 (COX-2), and prostaglandin E₂ (PGE2), suggesting that LPS can induce inflammation and oxidative stress in BEAS-2B cells. ZBSO inhibits the LPS-induced expression of inflammatory mediators and proinflammatory cytokines in BEAS-2B cells. The molecular docking results indicated that active components in ZBSO could successfully dock with toll-like receptor 4 (TLR4), myeloid differentiation factor 88 (MyD88), and p65. Immunofluorescence and western blot analyses further demonstrated that ZBSO repressed protein expression associated with the TLR4/MyD88/nuclear factor-κB (NF-κB) signaling pathway.

Conclusions

ZBSO reduced the inflammatory response and oxidative stress induced by LPS by inhibiting the TLR4/MyD88/NF-κB signaling pathway, thereby suppressing COPD. ZBSO may represent a promising therapeutic candidate for COPD treatment.

Prevention of acute exacerbation of chronic obstructive pulmonary disease after bronchoscopic lung volume reduction with endobronchial valves

INTRODUCTION

Bronchoscopic lung volume reduction (BLVR) with endobronchial valves (EBVs) has emerged as an important treatment method for patients with severe chronic obstructive pulmonary disease (COPD). Acute exacerbations of COPD (AECOPD) are a frequent complication following BLVR with EBV. However, there is no consensus on the prevention of AECOPD.

OBJECTIVES

Our study aims to compare the outcomes of different prophylactic measures on the occurrence of AECOPD after BLVR with EBV.

METHODS

We conducted a multicenter, retrospective study of patients who underwent BLVR with EBV at six different institutions. Emphasis was directed towards the specific practices aimed at preventing AECOPD: antibiotics, steroids, antibiotics plus steroids, or no prophylaxis. Subgroups were compared, and odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were calculated.

RESULTS

A total of 170 patients were reviewed. The rate of AECOPD was 21.2% for the full cohort. Patients who received prophylaxis had a significantly lower rate of AECOPD compared with those who did not (16.7% vs. 46.2%; p = 0.001). The rate was lowest in patients who received antibiotics alone (9.2%). There was no significant difference in the rate of AECOPD between patients who received steroids alone or antibiotics plus steroids, compared with the other subgroups. The OR for AECOPD was 4.3 (95% CI: 1.8-10.4; p = 0.001) for patients not receiving prophylaxis and 3.9 (95% CI: 1.5-10.1; p = 0.004) for prophylaxis other than antibiotics alone.

CONCLUSIONS

Administration of antibiotics after BLVR with EBV was associated with a lower rate of AECOPD. This was not observed with the use of steroids or in combination with antibiotics.

A nomogram for preoperative prediction of prolonged air leak after pulmonary malignancy resection

Background

Prolonged air leak (PAL) is one of the most common postoperative complications after lung surgery. This study aimed to identify risk factors of PAL after lung resection and develop a preoperative predictive model to estimate its risk for individual patients.

Methods

Patients with pulmonary malignancies or metastasis who underwent pulmonary resection between January 2014 and January 2018 were included. PAL was defined as an air leak more than 5 days after surgery, risk factors were analyzed. Forward stepwise multivariable logistic regression analysis was performed to identify independent risk factors, and a derived nomogram was built. Data from February 2018 to September 2018 were collected for internal validation.

Results

A total of 1,511 patients who met study criteria were enrolled in this study. The overall incidence of PAL was 9.07% (137/1,511). Age, percent forced expiratory volume in 1 second, surgical type, surgical approach and smoking history were included in the final model. A nomogram was developed according to the multivariable logistic regression results. The C-index of the predictive model was 0.70, and the internal validation value was 0.77. The goodness-of-fit test was non-significant for model development and internal validation.

Conclusions

The predictive model and derived nomogram achieved satisfied preoperative prediction of PAL. Using this nomogram, the risk for an individual patient can be estimated, and preventive measures can be applied to high-risk patients.

Prediction of Sarcopenia Using Multiple Biomarkers of Neuromuscular Junction Degeneration in Chronic Obstructive Pulmonary Disease

Patients with chronic obstructive pulmonary disease (COPD) present with an advanced form of age-related muscle loss or sarcopenia. Among multiple pathomechanisms of sarcopenia, neuromuscular junction (NMJ) degradation may be of primary relevance. We evaluated the circulating biomarkers of NMJ degradation, including c-terminal agrin fragment -22 (CAF22), brain-derived neurotrophic factor (BDNF), and glial cell line-derived neurotrophic factor (GDNF) as predictors of sarcopenia in COPD during pulmonary rehabilitation (PR). Male, 61-77-year-old healthy controls and patients of COPD (n = 77-84/group) were recruited for measurements of circulating CAF22, BDNF, and GDNF levels. Functional assessment and measurements of plasma biomarkers were performed at diagnosis and following six months of PR. CAF22 levels were elevated while BDNF and GDNF levels were reduced in COPD patients at diagnosis, which were incompletely restored to normal levels following PR. These biomarkers showed varying degrees of associations with indexes of sarcopenia and functional recovery during PR. Logistic regression revealed that the combined use of three biomarkers enhanced the diagnostic accuracy of sarcopenia better than single biomarkers. Altogether, measurements of plasma CAF22, BDNF, and GDNF may be helpful for the accurate diagnosis of sarcopenia and functional capacity in COPD during PR.

Paradoxical effects of cigarette smoke and COPD on SARS-CoV-2 infection and disease

BACKGROUND

How cigarette smoke (CS) and chronic obstructive pulmonary disease (COPD) affect severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) infection and severity is controversial. We investigated the effects of COPD and CS on the expression of SARS-CoV-2 entry receptor ACE2 in vivo in COPD patients and controls and in CS-exposed mice, and the effects of CS on SARS-CoV-2 infection in human bronchial epithelial cells in vitro.

METHODS

We quantified: (1) pulmonary ACE2 protein levels by immunostaining and ELISA, and both ACE2 and/or TMPRSS2 mRNA levels by RT-qPCR in two independent human cohorts; and (2) pulmonary ACE2 protein levels by immunostaining and ELISA in C57BL/6 WT mice exposed to air or CS for up to 6 months. The effects of CS exposure on SARS-CoV-2 infection were evaluated after in vitro infection of Calu-3 cells and differentiated human bronchial epithelial cells (HBECs), respectively.

RESULTS

ACE2 protein and mRNA levels were decreased in peripheral airways from COPD patients versus controls but similar in central airways. Mice exposed to CS had decreased ACE2 protein levels in their bronchial and alveolar epithelia versus air-exposed mice. CS treatment decreased viral replication in Calu-3 cells, as determined by immunofluorescence staining for replicative double-stranded RNA (dsRNA) and western blot for viral N protein. Acute CS exposure decreased in vitro SARS-CoV-2 replication in HBECs, as determined by plaque assay and RT-qPCR.

CONCLUSIONS

ACE2 levels were decreased in both bronchial and alveolar epithelial cells from COPD patients versus controls, and from CS-exposed versus air-exposed mice. CS-pre-exposure potently inhibited SARS-CoV-2 replication in vitro. These findings urge to investigate further the controversial effects of CS and COPD on SARS-CoV-2 infection.

Predictors of Successful Weaning from Noninvasive Ventilation in Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Single-Center Retrospective Cohort Study

Purpose

Noninvasive ventilation (NIV) is often required for patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and it can significantly reduce the need for endotracheal intubation. Currently, there is no standard method for predicting successful weaning from NIV. Therefore, we aimed to evaluate whether a weaning index can predict NIV outcomes of patients with AECOPD.

Methods

This study was conducted at a single academic public hospital in northern Taiwan from February 2019 to January 2021. Patients with AECOPD admitted to the hospital with respiratory failure who were treated with NIV were included in the study. Univariate and multivariate logistic regression analyses were used to identify independent predictors of successful weaning from NIV. Receiver operating characteristic curve methodology was used to assess the predictive capacity.

Results

A total of 85 patients were enrolled, 65.9% of whom were successfully weaned from NIV. The patients had a mean age of 75.8 years and were mostly men (89.4%). The rapid shallow breathing index (RSBI) (P < 0.001), maximum inspiratory pressure (P = 0.014), and maximum expiratory pressure (P = 0.004) of the successful group were significant while preparing to wean. The area under the receiver operating characteristic curve for the RSBI was 0.804, which was considered excellent discrimination.

Conclusion

The RSBI predicted successful weaning from NIV in patients with AECOPD with hypercapnic respiratory failure. This index may be useful for selecting patients with AECOPD that are suitable for NIV weaning.

Rehabilitation effects of land and water-based aerobic exercise on lung function, dyspnea, and exercise capacity in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

We sought to synthesize the evidence about aerobic exercise intervention during pulmonary rehabilitation, and to further explore the difference in rehabilitation effects between water and land-based aerobic exercise. This review's purpose is to provide a basis by which practitioners and therapists can select and create appropriate therapeutic programs.

METHODS

Data of randomized and quasi-randomized controlled trials comparing training group (TG, aerobic exercise in water or land) and control group (CG, usual care) in chronic obstructive pulmonary disease (COPD) patients (January 1, 2000-December 28, 2019) were obtained from the Cochrane Library, PubMed, Embase, China National Knowledge Infrastructure, and Wanfang databases. Two researchers independently reviewed the literature, extracted the data, and evaluated the quality of the literature. Review Manager software (Rev Man 5.3; Cochrane, London, UK) was used for meta-analysis. The rehabilitation effect of water- or land based aerobic exercise was evaluated by subgroup analysis. The proposed systematic review details were registered in PROSPERO (CRD 42020168331).

RESULTS

Eighteen studies (1311 cases of COPD) were included. Meta-analysis results show that compared with the control group, the dyspnea level and functional and endurance exercise capacity in COPD patients were significantly improved after aerobic exercise (P < .05), but there was no significant change in lung function (P > .05). Compared with land-based aerobic exercise, water-based aerobic exercise significantly improved the endurance exercise capacity in COPD patients (mean difference [MD]: 270.18, 95% CI: 74.61-465.75).

CONCLUSION

Medium to high-quality evidence shows that aerobic exercise can effectively improve dyspnea and exercise capacity in COPD patients. Compared with land-based aerobic exercise, water-based aerobic exercise had a significant additional effect in improving the endurance exercise capacity of COPD patients.

Experiences of Pulmonary Rehabilitation in People Living with Chronic Obstructive Pulmonary Disease and Frailty. A Qualitative Interview Study

Rationale: People living with both chronic obstructive pulmonary disease (COPD) and frailty have high potential to benefit from pulmonary rehabilitation but face challenges completing programs. However, research to understand ways to optimize participation in this group is lacking.

Objectives: To explore the experiences, needs, and preferences of people with COPD and frailty referred for outpatient pulmonary rehabilitation.

Methods: Semistructured interviews with people with COPD and physical frailty, purposively sampled by age, living status, level of frailty, and completion of pulmonary rehabilitation. Thematic analysis with a critical realist perspective was used, involving relevant stakeholders with clinical, academic, and lived experience for interpretive rigor.

Results: Nineteen people with COPD and frailty were interviewed, with a median age of 78 years (range, 58–88). Nine did not complete their pulmonary rehabilitation program. Four themes were identified: striving to adapt to multidimensional loss, tensions of balancing support with independence, pulmonary rehabilitation as a challenge worth facing, and overcoming unpredictable disruptions to participation. Participants described constantly adapting to their changing health and resulting multidimensional losses (e.g., functional abilities, relationships, confidence). This involved traversing between independence and seeking support, set against a mismatch between their needs and what support is available. People with COPD and frailty can be highly motivated to participate in pulmonary rehabilitation, despite the physical and mental demands it entails, and report a range of benefits. Yet in the context of changeable health, they must often overcome multiple unpredictable disruptions to completing rehabilitation programs. Participant determination and flexibility of services can facilitate ongoing attendance, but for some, these unpredictable disruptions erode their motivation to attend.

Conclusions: People with COPD and frailty experience accumulating, multidimensional loss. This group are motivated to complete pulmonary rehabilitation but often require additional support and flexibility owing to fluctuating and unpredictable health. Person-centered approaches should be considered to minimize disruptive health events and support pulmonary rehabilitation participation and completion. Service adaptations could allow more flexibility to meet the changing needs of this group and enable communication around how pulmonary rehabilitation might align with their priorities.

Exploring the barriers to pulmonary rehabilitation for patients with chronic obstructive pulmonary disease: a qualitative study

BACKGROUND

The complexity of chronic obstructive pulmonary disease (COPD) and its different physical, mental, familial, occupational, and social complications highlight the necessity of pulmonary rehabilitation (PR) for afflicted patients. However, PR for patients with COPD usually faces some barriers. The aim of this study was to explore the barriers to PR for patients with COPD.

METHODS

This qualitative descriptive study was conducted in January 2019 to October 2020. Participants were 19 patients with COPD, 11 family caregivers of patients with COPD, and 12 healthcare providers, who all were recruited purposively from two teaching hospitals in Isfahan, Iran. Data were collected through semi-structured interviews and were analyzed through conventional content analysis.

RESULTS

The barriers to PR for patients with COPD fell into three main categories, namely barriers related to patients and their families, inefficiency of PR services, and inappropriate organizational context for PR. Each category had four subcategories, namely patients' and families' lack of knowledge, complexity and chronicity of COPD, heavy financial burden of COPD, patients' frustration and discontinuation of PR, lack of patient-centeredness, lack of coordination in PR team, inadequate professional competence of PR staff, lack of a holistic approach to PR, limited access to PR services, inadequate insurance for PR services, ineffective PR planning, and discontinuity of care.

CONCLUSION

PR for patients with COPD is a complex process which faces different personal, familial, social, financial, organizational, and governmental barriers. Strategies for managing these barriers are needed in order to improve the effectiveness and the quality of PR services for patients with COPD.

Low-pressure Pneumoperitoneum With Abdominal Wall Lifting Versus Standard Pressure Pneumoperitoneum in Laparoscopic Fundoplication for Gastroesophageal Reflux Disease: A Propensity Score-matched Analysis

OBJECTIVE

The objective of this study was to compare the treatment results of low-pressure pneumoperitoneum with abdominal wall lifting (AWL+LP, 6 mm Hg) versus standard pressure pneumoperitoneum (SP, 12 mm Hg) during laparoscopic fundoplication for gastroesophageal reflux disease (GERD), using propensity score matching (PSM).

MATERIALS AND METHODS

A retrospective analysis was made of 362 patients, 123 in the AWL+LP group and 239 in the SP group, who underwent laparoscopic fundoplication for GERD from January 2010 to December 2017. Perioperative and prognostic outcomes were compared after PSM with 1:1 match.

RESULTS

After PSM, 107 matched pairs were obtained. Compared with the SP group at 30 and 60 minutes after pneumoperitoneal initiation, the AWL+LP group showed significantly lower end-tidal carbon dioxide value (P<0.001, <0.001, respectively), lower partial pressure of carbon dioxide value (P<0.001, 0.016, respectively) and significantly higher pH value (P<0.001, <0.001, respectively). However, postoperative shoulder pain, abdominal pain, and arrhythmia in the AWL+LP group were less than those in SP group (P=0.01, 0.017, 0.005, respectively). There was no significant difference in operative time (106.54±27.80 vs. 107.38±24.78 min), blood loss [15 mL (interquartile range: 12.5 to 20 mL) vs.15 mL (interquartile range: 10 to 20 mL)], length of stay (4 vs. 4 d), the wound ecchymosis [2 (1.87%) vs. 3 (2.80%)] and rates of recurrence [8 (7.48%) vs. 5 (4.67%)] between AWL+LP group and SP group.

CONCLUSION

AWL+LP resulted in comparable perioperative and prognostic outcomes with less impact on changes in cardiorespiratory function compared with SP approaches of laparoscopic fundoplication for GERD.

Static and dynamic balance impairment and relationship with disease-related factors in patients with chronic obstructive pulmonary disease : A cross-sectional study

BACKGROUND

Disease and aging-related factors may predispose chronic obstructive pulmonary disease (COPD) patients to impaired balance, although the underlying determinants of impaired balance in COPD patients are still unknown. The purpose of this study was to identify the determinants of impaired balance in COPD patients. Also, we aimed to determine which balance measures (clinical or laboratory tests) are more indicative in determining balance impairment in these patients.

METHODS

This cross-sectional study recruited 24 patients with moderate to severe COPD and 24 age-matched healthy subjects. Participants were evaluated regarding demographic and clinical data, previous falls history, lower limb muscle strength, exercise capacity, physical activity and balance level.

RESULTS

COPD patients exhibited significantly a longer test duration on timed up and go test, a higher sway index on the postural stability and lower directional control score on the limit of stability of Biodex balance system (all, p < 0.001) compared to healthy controls, whereas there was no difference in Berg balance scale score between groups (p > 0.05). Balance impairment of the patient group was significantly associated with nonpulmonary conditions, such as physical activity level, exercise capacity, lower limb muscle strength, and with fall history. Also, COPD patients represented significantly lower physical activity level and exercise capacity, weaker lower limb muscle strength than healthy controls (all, p < 0.001).

CONCLUSIONS

Patients with moderate to severe COPD exhibit apparently important reductions in balance control that is directly associated with nonpulmonary consequences and fall history. These results may be extremely important to fall prevention and to guide the development of interventions for this population.

RANKL Mediates Muscle Atrophy and Dysfunction in a Cigarette Smoke-induced Model of Chronic Obstructive Pulmonary Disease

Skeletal muscle dysfunction is one of the important comorbidities of chronic obstructive pulmonary disease (COPD); however, the underlying mechanisms remain largely unknown. RANKL (receptor activator of nuclear factor κB ligand), a key mediator in osteoclast differentiation, was also found to play a role in skeletal muscle pathogenesis. Whether RANKL is involved in COPD-related skeletal muscle dysfunction is as-of-yet unknown. We examined the expression of RANKL/RANK in skeletal muscles from mice exposed to cigarette smoke (CS) for 24 weeks. Grip strength and exercise capacity as well as muscular morphology were evaluated in CS-exposed mice with or without anti-RANKL treatment. The expressions of protein synthesis- or muscle growth-related molecules (IGF-1, myogenin, and myostatin), muscle-specific ubiquitin E3 ligases (MuRF1 and atrogin-1), and the NF-κb inflammatory pathway were also evaluated in skeletal muscles. The effect of CS extract on RANKL/RANK expression and that of exogenous RANKL on the ubiquitin-proteasome pathway in C2C12 myotubes were investigated in vitro. Long-term CS exposure induced skeletal muscle dysfunction and atrophy together with upregulation of RANKL/RANK expression in a well-established mouse model of COPD. RANKL neutralization prevented skeletal muscle dysfunction and atrophy. RANKL inhibition decreased expressions of myostatin and MuRF1/Atrogin1 and suppressed the NF-κb pathway in skeletal muscles from CS-exposed mice. In in vitro experiments with C2C12 myotubes, CS extract induced expression of RANKL/RANK, and exogenous RANKL induced activation of the ubiquitin-proteasome pathway and NF-κb pathway via RANK. Our results revealed an important role of the RANKL/RANK pathway in muscle atrophy induced by CS exposure, suggesting that RANKL may be a potential therapeutic target in COPD-related skeletal muscle dysfunction.

Community-based intervention for prevention and management of chronic obstructive pulmonary disease in Nepal (COBIN-P trial): study protocol for a cluster-randomized controlled trial

Background

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of death worldwide and the commonest of non-communicable diseases (NCDs) in Nepal. Risk factors like indoor and outdoor air pollution, a high prevalence of smoking, and the lack of awareness of COPD make it a serious public health concern. However, no attempt has been made in Nepal to estimate its burden and address the disease at the community level.

Method

This study aims to evaluate the effect of a community-based health educational intervention administered by Female Community Health Volunteers (FCHVs) on the prevention and management of COPD. An open-label, two-group, community-based, cluster-randomized controlled trial will be implemented in the semi-urban area of Pokhara Metropolitan city (former Lekhnath Municipality) located in the Kaski district of Nepal. The estimated sample size of the intervention will be 1143. The unit of randomization is the ward (administrative unit) of the study area. The follow-up survey will be conducted immediately after 12 months of FCHVs-led interventions. The difference in the rate of decline of forced expiratory volume in 1 s (FEV₁) and FEV₁/FVC (forced vital capacity) ratio are the primary outcomes and the change in the proportion of modifiable risk factors of COPD, health-related quality of life scores, and change in knowledge of COPD will be secondary outcomes.

Discussion

This study will estimate the burden of COPD, the magnitude of risk factors and generate evidence to mobilize community health workers for COPD prevention and management at the community level in Nepal.

Trial registration

ClinicalTrials.gov NCT03797768. Registered on January 9, 2019.

Multi-Omics study on biomarker and pathway discovery of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common heterogeneous respiratory disease characterized by persistent and incompletely reversible airflow limitation. Due to the heterogeneity and phenotypes complexity of COPD, traditionally diagnostic methods can only give limited information on predicted results and treatment, which are not sufficient for accurate diagnosis and evaluation. With the development of omics technologies in recent years, genomics, proteomics, and metabolomics are widely used in the study of COPD, providing good tools for discovering biomarkers to diagnose and elucidate the complex mechanism of COPD. In this review, we summarized the biomarkers of COPD based on metabolomic, proteomic and transcriptomic studies that have been reported in recent years. Furthermore, protein-protein interactions and multi-omics integrated analysis were carried out to explore the important metabolites and proteins that involved in significant pathways in the progression of COPD for explanation the pathogenesis of COPD. Finally, the prospective and challenges in the study of COPD were proposed. It is expected that this review will provide some references for the development of diagnostic methods and elucidation of the pathogenesis of COPD.

Association between dual use of e-cigarette and cigarette and chronic obstructive pulmonary disease: an analysis of a nationwide representative sample from 2013 to 2018

BACKGROUND

The association between the dual use of electronic cigarette (e-cigarette) and conventional cigarettes (c-cigarette) and spirometry-defined chronic obstructive pulmonary disease (COPD) has not been studied thoroughly.

METHODS

A total of 47,217 participants were identified in the 2013-2018 Korea National Health and Nutrition Examination Survey; of them, 12,919 participants aged ≥ 40 who underwent spirometry and had no missing data were enrolled. Pulmonary function testing, urinary cotinine, and urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) levels were compared between dual users, current smokers, former smokers, and non-users using complex sample linear regression analysis. The odds ratio (OR) for COPD was calculated using a complex sample logistic regression model after adjusting for covariates.

RESULTS

Among current e-cigarette users, approximately 85% of the participants used c-cigarette concurrently, and 1.3% of all the participants were dual users (2.3% in males and 0.1% in females). Both dual users and current smokers showed higher levels of urine cotinine and NNAL than non-users and former smokers. The weighted prevalence of COPD was the highest in dual users (13.8% for all participants and 14.1% for males). The multivariate-adjusted OR of COPD for male dual users, compared to non-users, was 3.46 (P_trend < 0.001). The OR for COPD was 3.10 (P_trend < 0.001) in middle-aged (40-64 years) and 3.70 (P_trend < 0.001) in older (≥ 65 years) men. In females, the association was not observed and could not be precisely measured because of the small proportion of the smoking population.

CONCLUSIONS

Dual use of e-cigarette and c-cigarette is associated with COPD in males.

Classification of COPD patients and compliance to recommended treatment in Greece according to GOLD 2017 report: the RELICO study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a multifactorial clinical condition, characterized by chronic progressive (or worsening) respiratory symptoms, structural pulmonary abnormalities, and impaired lung function, and is often accompanied by multiple, clinically significant comorbid disorders. In 2017, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) issued a new report on COPD prevention, diagnosis and management, aiming at personalizing the maintenance therapeutic approach of the stable disease, based on the patients' symptoms and history of exacerbations (ABCD assessment approach). Our objective was to evaluate the implementation of GOLD suggestions in everyday clinical practice in Greece.

METHODS

This was a cross-sectional observational study. Sixty-five different variables (demographics, vital sign measurements, COPD-related medical history parameters, comorbidities, vaccination data, COPD severity based on spirometry measurements, COPD stage based on the ABCD assessment approach, COPD treatments) were collected from 3615 nation-wide COPD patients (Greece).

RESULTS

The mean age at the time of initial COPD diagnosis was 63.8 (± 10.2). Almost 60% of the subjects were classified into group B, while the remaining patients were falling into groups A (18%) and D (21%), and only a small minority of patients belonged to Group C, according to the ABCD assessment approach. The compliance of respiratory physicians to the GOLD 2017 therapeutic suggestions is problematic, especially when it comes to COPD patients belonging to Group A.

CONCLUSION

Our data provide valuable information regarding the demographic and medical profile of COPD patients in Greece, the domains which the revised ABCD assessment approach may show some clinical significance on, and the necessity for medical practitioners dealing with COPD patients to adhere closer to international recommendations for the proper management of the disease.

Association between ICS use and risk of hyperglycemia in COPD patients: systematic review and meta-analysis

BACKGROUND

The effect of inhaled corticosteroids (ICS) on risk of hyperglycemia in patients with chronic obstructive pulmonary disease (COPD) remains ambiguous. The aim of this study is to evaluate the association between ICS use and the incidence of hyperglycemia related adverse effects in COPD patients.

METHODS

Medline/PubMed, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov were searched from inception to 25 May 2020. Randomized controlled trials (RCTs) of ICS versus control (non-ICS) treatment for COPD patients reporting on risk of hyperglycemia were included. The Mantel-Haenszel method with fixed-effects modeling was used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

Seventeen RCTs with 43,430 subjects were included in the meta-analysis. Pooled results suggested that there was no statistically significant difference in the risk of hyperglycemia between the ICS group and the control group (RR 1.02, 95% CI 0.90-1.16, P = 0.76). In addition, no significant difference was noted in the effect on glucose level (RR 1.20, 95% CI 0.79-1.82, P = 0.40), risk of diabetes progression (RR 0.84, 95% CI 0.20-3.51, P = 0.81) and new onset diabetes mellitus (RR 1.0, 95% CI 0.88-1.15, P = 0.95) between the ICS group and the control group. These findings also were consistent across all subgroup analyses.

CONCLUSIONS

Use of ICS does not have an effect on the blood glucose and is not associated with the risk of new onset diabetes mellitus and diabetes progression in patients with COPD. Further RCTs exploring the association between ICS use and risk of hyperglycemia in COPD patients are still needed to verify our results of this analysis.

Identification of VEGFA-centric temporal hypoxia-responsive dynamic cardiopulmonary network biomarkers

AIMS

Hypoxia, a pathophysiological condition, is profound in several cardiopulmonary diseases (CPD). Every individual's lethality to a hypoxia state differs in terms of hypoxia exposure time, dosage units and dependent on the individual's genetic makeup. Most of the proposed markers for CPD were generally aim to distinguish disease samples from normal samples. Although, as per the 2018 GOLD guidelines, clinically useful biomarkers for several cardio pulmonary disease patients in stable condition have yet to be identified. We attempt to address these key issues through the identification of Dynamic Network Biomarkers (DNB) to detect hypoxia induced early warning signals of CPD before the catastrophic deterioration.

MATERIALS AND METHODS

The human microvascular endothelial tissues microarray datasets (GSE11341) of lung and cardiac expose to hypoxia (1% O₂) for 3, 24 and 48 h were retrieved from the public repository. The time dependent differentially expressed genes were subjected to tissue specificity and promoter analysis to filtrate the noise levels in the networks and to dissect the tissue specific hypoxia induced genes. These filtered out genes were used to construct the dynamic segmentation networks. The hypoxia induced dynamic differentially expressed genes were validated in the lung and heart tissues of male rats. These rats were exposed to hypobaric hypoxia (simulated altitude of 25,000 or PO₂ - 282 mm of Hg) progressively for 3, 24 and 48 h.

KEY FINDINGS

To identify the temporal key genes regulated in hypoxia, we ranked the dominant genes based on their consolidated topological features from tissue specific networks, time dependent networks and dynamic networks. Overall topological ranking described VEGFA as a single node dynamic hub and strongly communicated with tissue specific genes to carry forward their tissue specific information. We named this type of VEGFAcentric dynamic networks as "V-DNBs". As a proof of principle, our methodology helped us to identify the V-DNBs specific for lung and cardiac tissues namely V-DNB^L and V-DNB^C respectively.

SIGNIFICANCE

Our experimental studies identified VEGFA, SLC2A3, ADM and ENO2 as the minimum and sufficient candidates of V-DNB^L. The dynamic expression patterns could be readily exploited to capture the pre disease state of hypoxia induced pulmonary vascular remodelling. Whereas in V-DNB^C the minimum and sufficient candidates are VEGFA, SCL2A3, ADM, NDRG1, ENO2 and BHLHE40. The time dependent single node expansion indicates V-DNB^C could also be the pre disease state pathological hallmark for hypoxia-associated cardiovascular remodelling. The network cross-talk and expression pattern between V-DNB^L and V-DNB^C are completely distinct. On the other hand, the great clinical advantage of V-DNBs for pre disease predictions, a set of samples during the healthy condition should suffice. Future clinical studies might further shed light on the predictive power of V-DNBs as prognostic and diagnostic biomarkers for CPD.

Factors Influencing the Length of Hospital Stay Among Patients with Chronic Obstructive Pulmonary Disease (COPD) in Macao Population: A Retrospective Study of Inpatient Health Record

Purpose

This study aims to identify the effects of patient and clinical therapy factors on the length of hospital stay (LOS) for admission due to chronic obstructive pulmonary disease (COPD) in Macao.

Patients and Methods

Health record of patients with COPD admitted to Kiang Wu Hospital from January 2017 to December 2019 was retrospectively analyzed. Demographic information, blood test results, clinical therapies, and LOS were described and analyzed by multivariable regression.

Results

A total of 1116 admissions were included with the average LOS being 12.28 (±9.23) days. Among them, 735 (66.6%) were male with mean age 79.42 (±10.35) years old, 697 were current or previous smokers (62.5%), and 360 (32.2%) had 3 or more comorbidities. During hospitalization, the most common treatments received were oxygen therapy (n=991,88.8%), antibiotics (n=828,74.2%), and systemic steroids (n=596,53.4%); only 120 (10.8%) had pulmonary rehabilitation (PR) and 128 (11.5%) received noninvasive ventilation (NIV). Inhaled medications were used during nearly 95% of hospitalization cases, while 2 and 3 types of inhaled medications were used during 230 (20.6%) and 582 (52.2%) hospitalization cases, respectively. Patient factors including age (B=0.178, 95% CI:0.535–1.072), being female (B=−1.147, 95% CI:-0.138–0.056), being current (B=−0.086, 95% CI:-0.124–0.018) or previous smoker (B=0.072, 95% CI:0.004–0.087), having 1, 2, 3 and over 3 comorbidities (B=0.126, 95% CI:0.034–0.147; B=0.125, 95% CI:0.031–0.144; B=0.116, 95% CI:0.028–0.146, B=0.090, 95% CI:0.021–0.166) and having low hemoglobin level (B=−0.118, 95% CI:-0.629- −0.214) exhibited significant associations with LOS. The use of NIV (B=0.080, 95% CI:0.022–0.138), pulmonary rehabilitation (B=0.269, 95% CI:0.212–0.327), two and three types of inhaled medications (B=0.109, 95% CI:0.003–0.166, B=0.255, 95% CI:0.083–0.237) were significantly associated with longer LOS (P<0.05).

Conclusion

NIV, PR and combined inhaled medications, which are often used for AECOPD, are the main clinical therapies associated with longer LOS in Macao. Smoking cessation, early treatments of comorbidities may be crucial to avoiding AECOPD and reducing LOS and disease burden.

Cylindrical Microparticles Composed of Mesoporous Silica Nanoparticles for the Targeted Delivery of a Small Molecule and a Macromolecular Drug to the Lungs: Exemplified with Curcumin and siRNA

The transport of macromolecular drugs such as oligonucleotides into the lungs has become increasingly relevant in recent years due to their high potency. However, the chemical structure of this group of drugs poses a hurdle to their delivery, caused by the negative charge, membrane impermeability and instability. For example, siRNA to reduce tumour necrosis factor alpha (TNF-α) secretion to reduce inflammatory signals has been successfully delivered by inhalation. In order to increase the effect of the treatment, a co-transport of another anti-inflammatory ingredient was applied. Combining curcumin-loaded mesoporous silica nanoparticles in nanostructured cylindrical microparticles stabilized by the layer-by-layer technique using polyanionic siRNA against TNF-α was used for demonstration. This system showed aerodynamic properties suited for lung deposition (mass median aerodynamic diameter of 2.85 ± 0.44 µm). Furthermore, these inhalable carriers showed no acute in vitro toxicity tested in both alveolar epithelial cells and macrophages up to 48 h incubation. Ultimately, TNF-α release was significantly reduced by the particles, showing an improved activity co-delivering both drugs using such a drug-delivery system for specific inhibition of TNF-α in the lungs.

Epidemiology, burden, and policy of chronic obstructive pulmonary disease in South Korea: a narrative review

Chronic obstructive pulmonary disease (COPD) is a global health problem and a significant cause of mortality and morbidity worldwide. COPD also occupies a significant and considerable economic burden on individuals and society in South Korea. We investigated the epidemiology and burden of COPD in South Korea and reviewed the policy regarding COPD. In South Korea, a national COPD prevalence survey has been conducted for two decades. The prevalence of COPD has increased with increasing age, particularly among males, and those also with a higher smoking history and with lower income. The total societal cost of COPD increased by 1.85 times between 2004 and 2013. As the use of inhaled medications has increased, the total medical cost per person has increased. The trends of increasing numbers of patients diagnosed with COPD and the total societal costs are expected to continue. There is one universal-health-coverage system in South Korea. The costs and reimbursement criteria of COPD drugs are established and controlled by the Health Insurance Review and Assessment Service (HIRA). The HIRA has also implemented quality assessment, including evaluating the appropriateness of a COPD diagnosis and treating all COPD patients to reduce the severity of illness and improve the adequacy of medical-care benefits.

Circulatory cadmium positively correlates with epithelial-mesenchymal transition in patients with chronic obstructive pulmonary disease

Environmental cadmium (Cd) exposure can cause several pulmonary diseases. Epithelial-mesenchymal transition (EMT) involved in the process of chronic obstructive pulmonary disease (COPD). However, the association between environmental Cd exposure and EMT was unclear in COPD patients. This study aimed to analyze the associations among circulatory Cd, EMT and COPD based on case-control study. Four hundred COPD patients and 400 control subjects were recruited. Circulatory Cd was detected using atomic adsorption spectrometer. MicroRNA-30 (miR-30) was measured by RT-PCR and the markers of pulmonary EMT were evaluated through western blotting. Circulatory Cd concentration was increased and serum miR-30 was decreased in COPD patients. Circulatory Cd was inversely associated with pulmonary function in COPD patients. Moreover, serum miR-30 was gradually decreased in parallel with FEV1 in COPD patients. Meanwhile, there was a negative association between serum miR-30 and circulatory Cd in COPD patients. Further analysis found that E-cadherin, one of epithelial biomarkers, was reduced in lung tissues of COPD patients with higher circulatory Cd. On the contrary, pulmonary N-cadherin, Vimentin and α-SMA, three of mesenchymal biomarkers, were increased in COPD patients with higher circulatory Cd. In vitro experiments revealed that Cd exposure repressed miR-30 levels and promoted EMT in BEAS-2B cells. Our results provide evidence that miR-30 reduction contributing to pulmonary EMT may involve in the process of Cd-induced COPD.

Macro and meso level influences on distributed integrated COPD care delivery: a social network perspective

Background

Care guidelines for people with chronic obstructive pulmonary disease (COPD) recommend an integrated approach for holistic, flexible, and tailored interventions. Continuity of care is also emphasised. However, many patients with COPD experience fragmented care. Discontinuities in healthcare and related social services are likely to result in disjointed rather than integrated care which can negatively affect patient health outcomes. The purpose of this qualitative study was to improve our understanding of, and how, contextual features pertaining to structures and processes of COPD integrated care influence delivery of care within patients’ healthcare networks.

Methods

We conducted individual interviews with 28 participants (9 patients, 16 healthcare professionals, and 3 spousal caregivers). Participants were recruited through the lung clinic at a city hospital in western Canada. We employed a social network paradigm to analyse and interpret the data.

Results

The analysis revealed an overarching theme of fragmented COPD care with two sub-themes: (1) Funding shortfalls and availability of resources, and (2) Dis(mis)connected communication pathways. The overarching theme depicts variations, delays, and discontinuities in patient care. The sub-themes describe how macro level influences and meso level shortfalls were perceived to influence the availability of respiratory care resources that contributed to fragmented COPD care.

Conclusions

Employing a social network lens drew particular attention to family physicians’ pivotal role in delivering community-based COPD care. While an integrated approach to care is recommended by care guidelines, institutional and organizational structures and processes, such as financial and communication structures, may inhibit delivery of integrated care. Thus, macro and meso level structures and processes have the potential to shape patient care by constraining family physicians’ purposive and communication actions necessary for facilitating an integrated distributed approach to care. We propose a context of care which fosters a context for family physicians’ delivery of patient-centered care. Integrated care delivery may improve patients’ wellbeing and alleviate financial constraints on the healthcare system.

Understanding potential mechanisms of harm: the drivers of electronic cigarette-induced changes in alveolar macrophages, neutrophils, and lung epithelial cells

Electronic (e-) cigarettes are growing in popularity despite uncertainties regarding their long-term health implications. The link between cigarette smoking and initiation of chronic lung disease took decades to unpick so in vitro studies mimicking e-cigarette exposure aim to detect early indicators of harm. In response to e-cigarette exposure, alveolar macrophages adopt a proinflammatory phenotype of increased secretion of proinflammatory cytokines, reduction in phagocytosis, and efferocytosis and reactive oxygen species generation. These effects are largely driven by free radical exposure, changes in PI3K/Akt signaling pathways, nicotine-induced reduction in phagocytosis receptors, and impaired lipid homeostasis leading to a foam-like lipid-laden phenotype. Neutrophils exhibit disrupted chemotaxis and transmigration to chemokines, reduced phagocytosis and bacterial killing, and an increase in protease secretion without corresponding antiproteases in response to e-cigarette exposure. This is driven by an altered ability to respond and to polarize toward chemoattractants, an activation of the p38 MAPK signaling pathway and inability to assemble NADPH oxidase. E-cigarettes induce lung epithelial cells to display decreased ciliary beat frequency and ion channel conductance as well as changes in chemokine secretion and surface protein expression. Changes in gene expression, mitochondrial function, and signaling pathways have been demonstrated in lung epithelial cells to explain these changes. Many functional outputs of alveolar macrophages, neutrophils, and lung epithelial cells have not been fully explored in the context of e-cigarette exposure and the underlying driving mechanisms are poorly understood. This review discusses current evidence surrounding the effects of e-cigarettes on alveolar macrophages, neutrophils, and lung epithelial cells with particular focus on the cellular mechanisms of change.

Metabolic Fingerprinting Uncovers the Distinction Between the Phenotypes of Tuberculosis Associated COPD and Smoking-Induced COPD

Background: Although smoking is considered the main cause of chronic obstructive pulmonary disease (COPD), several other risk factors, including pulmonary tuberculosis (TB), contribute significantly to disease causation, particularly in developing countries. However, the underlying pathogenesis of TB-associated COPD (T-COPD) is unclear. Moreover, the need for prompt diagnosis and treatment of T-COPD to decrease the future burden of inflammation is underestimated. This study aimed to identify distinctive endogenous metabotypes of T-COPD, compared to smoking-associated COPD (S-COPD). Methods: Cross-sectional metabolomic analyses and clinical examinations of serum samples were performed for three groups of 168 male subjects: T-COPD (n = 59), S-COPD (n = 70), and healthy normal controls (n = 39). To retain a broad spectrum of metabolites, we performed technically distinct analyses (global metabolomic profiling using LC-QTOFMS and targeted analyses using LC-MS/MS). Results: Higher levels of IL-6 and C-reactive protein and St. George Respiratory Questionnaire scores were seen in the T-COPD group, compared to those in the S-COPD group. Global metabolomic profiling showed elevated metabolites, including arachidonic and eicosanoic acids, in the T-COPD group. Typical changes in tryptophan catabolism were observed through targeted profiling. Additionally, in the T-COPD group, kynurenine was elevated, and serotonin levels were reduced; therefore, indoleamine dioxygenase (IDO)/tryptophan hydroxylase (TPH) activities were dysregulated. Correlation analyses showed that changes in oxylipins were positively correlated with serum levels of IL-6 and C-reactive protein. Conclusion: Patients with TB-related COPD have enhanced inflammatory responses that may be linked to fatty acid pathways and tryptophan catabolism, which could be novel therapeutic targets for T-COPD.

Untargeted metabolomics of human plasma reveal lipid markers unique to chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis

Chronic obstructive pulmonary disease (COPD) is characterised by airway inflammation and progressive airflow limitation, whereas idiopathic pulmonary fibrosis (IPF) is characterised by a restrictive pattern due to fibrosis and impaired gas exchange. We undertook metabolomic analysis of blood samples in IPF, COPD and healthy controls (HC) to determine differences in circulating molecules and identify novel pathogenic pathways. An untargeted metabolomics using an ultra-high-performance liquid chromatography-quadrupole time-of-flight mass spectrometer (UHPLC-QTOF-MS) was performed to profile plasma of patients with COPD (n = 21), and IPF (n = 24) in comparison to plasma from healthy controls (HC; n = 20). The most significant features were identified using multiple database matching. One-way ANOVA and variable importance in projection (VIP) scores were also used to highlight metabolites that influence the specific disease groups. Non-polar metabolites such as fatty acids (FA) and membrane lipids were well resolved and a total of 4805 features were identified. The most prominent metabolite composition differences in lipid mediators identified at ∼2-3 fold higher in both diseases compared to HC were palmitoleic acid, oleic acid and linoleic acid; and dihydrotestosterone was lower in both diseases. We demonstrated that COPD and IPF were characterised by systemic changes in lipid constituents such as essential FA sampled from circulating plasma.

The effect of nitrogen dioxide and atmospheric pressure on hospitalization risk for chronic obstructive pulmonary disease in Guangzhou, China

BACKGROUND

The relationship between air pollution and meteorological factors on diseases has become a research hotspot recently. Nevertheless, few studies have touched the inferences of nitrogen dioxide (NO₂) and atmospheric pressure (AP) on hospitalization risk for chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To investigate the short-term impact of particulate air pollutants and meteorology factors on hospitalizations for COPD and quantify the corresponding risk burden of hospital admission.

METHODS

In our study, COPD cases were collected from Guangzhou Panyu Central Hospital (n = 11,979) from Dec of 2013 to Jun 2019. The 24-h average temperature, relative humidity (RH), wind speed (V), AP and other meteorological data were obtained from Guangzhou Meteorological Bureau. Air pollution data were collected from Guangzhou Air Monitoring Station. The influence of different NO₂ and AP values on COPD risk was quantified by a distributed lag nonlinear model (DLNM) combined with Poisson Regression and Time Series analysis.

RESULTS

We found that NO₂ had a non-linear relationship with the incidence of COPD, with an approximate "M" type, appearing at the peaks of 126 μg/m³ (RR = 1.32, 95%CI, 1.07 to 1.64) and 168 μg/m³ (RR = 1.21, 95%CI, 0.94 to 1.55), respectively. And the association between AP and COPD incidence exhibited an approximate J-shape with a peak occurring at 1035 hPa (RR = 1.16, 95% CI, 1.02 to 1.31).

CONCLUSIONS

The nonlinear relationship of NO₂ and AP on COPD admission risk in different periods of lag can be used to establish an early warning system for diseases and reduce the possible outbreaks and burdens of COPD in a sensitive population.

Prediction of sarcopenia using a battery of circulating biomarkers

Loss of muscle mass and strength with aging, termed sarcopenia is accelerated in several comorbidities including chronic heart failure (CHF) and chronic obstructive pulmonary diseases (COPD). However, the effective circulating biomarkers to accurately diagnose and assess sarcopenia are not known. We recruited male healthy controls and patients with CHF and COPD (n = 81–87/group), aged 55–74 years. Sarcopenia was clinically identified based on hand-grip strength, appendicular skeletal muscle index and physical capacity as recommended by the European working group for sarcopenia. The serum levels of amino-terminal pro-peptide of type-III procollagen, c-terminal agrin fragment-22, osteonectin, irisin, fatty acid-binding protein-3 and macrophage migration inhibitory factor were significantly different between healthy controls and patients with CHF and COPD. Risk scores for individual biomarkers were calculated by logistic regressions and combined into a cumulative risk score. The median cutoff value of 3.86 was used to divide subjects into high- and low-risk groups for sarcopenia with the area under the curve of 0.793 (95% CI = 0.738–0.845, p < 0.001). A significantly higher incidence of clinical sarcopenia was found in high-risk group. Taken together, the battery of biomarkers can be an effective tool in the early diagnosis and assessment of sarcopenia.

Elevated sputum IL-36 levels are associated with neutrophil-related inflammation in COPD patients

BACKGROUND

Interleukin (IL)-36, including IL-36α, IL-36β, and IL-36γ in the IL-1 family, are agonists of their receptors. IL-36 expression is associated with inflammation, including lung infection in humans. However, there is no information on its role in the inflammation of different types of chronic obstructive pulmonary disease (COPD).

OBJECTIVE

This study focused on the sputum IL-36α, IL-36β, and IL-36γ levels in stable COPD patients and their relationship with lung function and other cytokines in different inflammatory types of COPD patients.

METHODS

Sputum specimens were collected from 73 stable COPD patients and 20 age- and gender-matched healthy controls. The levels of sputum IL-36α, IL-36β, and IL-36γ and other cytokines were quantified and sputum cells were characterized. The potential relationship between the levels of sputum IL-36α, IL-36β, or IL-36γ and lung functional measures, inflammatory cells, and cytokines was analyzed.

RESULTS

In comparison with the healthy controls, sputum IL-36α and IL-36γ levels significantly increased in COPD (106.8 pg/mL vs. 76.9 pg/mL P =.001, 397.9 pg/mL vs. 359.5 pg/mL P =.006). The sputum IL-36α and IL-36γ levels were significantly higher in the neutrophilic and mixed granulocytic types than that in the eosinophilic and paucigranulocytic types of COPD patients. The sputum IL-36α levels were positively correlated with sputum IL-36γ levels and the numbers of sputum neutrophils, and the sputum IL-36γ levels were positively correlated with the numbers of sputum lymphocytes in COPD patients.

CONCLUSIONS

Elevated levels of sputum IL-36α and IL-36γ were detected in COPD patients and may provide insights into the inflammatory pathways in neutrophilic COPD.

Aerosol delivery via invasive ventilation: a narrative review

In comparison with spontaneously breathing non-intubated subjects, intubated, mechanically ventilated patients encounter various challenges, barriers, and opportunities in receiving medical aerosols. Since the introduction of mechanical ventilation as a part of modern critical care medicine during the middle of the last century, aerosolized drug delivery by jet nebulizers has become a common practice. However, early evidence suggested that aerosol generators differed in their efficacies, and the introduction of newer aerosol technology (metered dose inhalers, ultrasonic nebulizer, vibrating mesh nebulizers, and soft moist inhaler) into the ventilator circuit opened up the possibility of optimizing inhaled aerosol delivery during mechanical ventilation that could meet or exceed the delivery of the same aerosols in spontaneously breathing patients. This narrative review will catalogue the primary variables associated with this process and provide evidence to guide optimal aerosol delivery and dosing during mechanical ventilation. While gaps exist in relation to the appropriate aerosol drug dose, discrepancies in practice, and cost-effectiveness of the administered aerosol drugs, we also present areas for future research and practice. Clinical practice should expand to incorporate these techniques to improve the consistency of drug delivery and provide safer and more effective care for patients.

Blended Self-Management Interventions to Reduce Disease Burden in Patients With Chronic Obstructive Pulmonary Disease and Asthma: Systematic Review and Meta-analysis

Background

Chronic obstructive pulmonary disease (COPD) and asthma have a high prevalence and disease burden. Blended self-management interventions, which combine eHealth with face-to-face interventions, can help reduce the disease burden.

Objective

This systematic review and meta-analysis aims to examine the effectiveness of blended self-management interventions on health-related effectiveness and process outcomes for people with COPD or asthma.

Methods

PubMed, Web of Science, COCHRANE Library, Emcare, and Embase were searched in December 2018 and updated in November 2020. Study quality was assessed using the Cochrane risk of bias (ROB) 2 tool and the Grading of Recommendations, Assessment, Development, and Evaluation.

Results

A total of 15 COPD and 7 asthma randomized controlled trials were included in this study. The meta-analysis of COPD studies found that the blended intervention showed a small improvement in exercise capacity (standardized mean difference [SMD] 0.48; 95% CI 0.10-0.85) and a significant improvement in the quality of life (QoL; SMD 0.81; 95% CI 0.11-1.51). Blended intervention also reduced the admission rate (relative ratio [RR] 0.61; 95% CI 0.38-0.97). In the COPD systematic review, regarding the exacerbation frequency, both studies found that the intervention reduced exacerbation frequency (RR 0.38; 95% CI 0.26-0.56). A large effect was found on BMI (d=0.81; 95% CI 0.25-1.34); however, the effect was inconclusive because only 1 study was included. Regarding medication adherence, 2 of 3 studies found a moderate effect (d=0.73; 95% CI 0.50-0.96), and 1 study reported a mixed effect. Regarding self-management ability, 1 study reported a large effect (d=1.15; 95% CI 0.66-1.62), and no effect was reported in that study. No effect was found on other process outcomes. The meta-analysis of asthma studies found that blended intervention had a small improvement in lung function (SMD 0.40; 95% CI 0.18-0.62) and QoL (SMD 0.36; 95% CI 0.21-0.50) and a moderate improvement in asthma control (SMD 0.67; 95% CI 0.40-0.93). A large effect was found on BMI (d=1.42; 95% CI 0.28-2.42) and exercise capacity (d=1.50; 95% CI 0.35-2.50); however, 1 study was included per outcome. There was no effect on other outcomes. Furthermore, the majority of the 22 studies showed some concerns about the ROB, and the quality of evidence varied.

Conclusions

In patients with COPD, the blended self-management interventions had mixed effects on health-related outcomes, with the strongest evidence found for exercise capacity, QoL, and admission rate. Furthermore, the review suggested that the interventions resulted in small effects on lung function and QoL and a moderate effect on asthma control in patients with asthma. There is some evidence for the effectiveness of blended self-management interventions for patients with COPD and asthma; however, more research is needed.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42019119894; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=119894

Rhodiola rosea L. Attenuates Cigarette Smoke and Lipopolysaccharide-Induced COPD in Rats via Inflammation Inhibition and Antioxidant and Antifibrosis Pathways

The root cause behind the development of chronic obstructive pulmonary disease (COPD) is cigarette smoke that induces the inflammation of the lung tissue and alveolar destruction. Long-term cigarette smoking can lead to deterioration in lung parenchymal function and cause structural changes in the lung, further resulting in pulmonary fibrosis. Rhodiola rosea L., a traditional medicinal perennial herb, is well known for its numerous pharmacological benefits, including anti-inflammation, antioxidant, antifatigue, antidepressive, and antifibrotic properties. Here, we evaluated the pharmacological effects and mechanisms of the Rhodiola rosea L. (RRL) macroporous resin extract on COPD caused by lipopolysaccharide (LPS) and cigarette smoke (CS) in rats. The RRL significantly improved the pathological structure of the lung tissue. Additionally, RRL decreased the infiltration of inflammatory cells and, subsequently, oxidative stress. Furthermore, the RNAseq assay indicated that RRL attenuated the CS and LPS-induced COPD via anti-inflammatory, antifibrotic, and antiapoptotic activities. Western blot analysis substantiated that the RRL resulted in upregulated levels of Nrf2 and HO-1 as well as downregulated levels of IκBα, NF-κB p65, α-SMA, and TGF-β1. Interestingly, the RRL could protect rats from CS and LPS-induced COPD by inhibiting the ERK1/2 and Smad3 signaling pathways and apoptosis. Thus, the RRL could attenuate CS and LPS-induced COPD through inflammation inhibition and antioxidant and antifibrosis pathways.

Electroacupuncture inhibits IL-17/IL-17R and post-receptor MAPK signaling pathways in a rat model of chronic obstructive pulmonary disease

OBJECTIVE

Interleukin (IL)-17, as a T-helper 17 cell (Th17) cytokine, plays a key role in chronic obstructive pulmonary disease (COPD) pathophysiology including chronic inflammation and airway obstruction, which lead to decreased pulmonary function. The aim of this study was to investigate the effect of acupuncture on IL-17, its receptor (IL-17R) and the mitogen-activated protein kinase (MAPK) signaling pathway, in a rat model of COPD.

METHODS

The COPD model was induced in Sprague Dawley rats by exposure to cigarette smoke for 12 weeks. The model rats were treated with electroacupuncture (EA) at BL13 and ST36. The lung function and histology of the rats were observed. IL-17, tumor necrosis factor (TNF)-α, and IL-10 were detected by enzyme-linked immunosorbent assay (ELISA) in bronchoalveolar lavage fluid (BALF) and in plasma. The leukocytes and macrophages in the BALF were counted. The expression levels of IL-17R were assayed in lung tissue by real-time polymerase chain reaction (PCR), western blotting, and immunohistochemistry. MAPK signaling pathway molecules including c-Jun N-terminal kinase (JNK), extracellular signal-regulated kinase (ERK)1/2 and p38, and their phosphorylated forms, were observed in the lung by western blotting.

RESULTS

Compared with the control group rats, lung function decreased and there was a severe inflammatory infiltration of the pulmonary parenchyma in the COPD rats. EA effectively improved lung function and alleviated the inflammatory infiltration in the lungs of COPD rats. EA also reversed the elevated total leukocyte and macrophage counts, the high levels of IL-17 and TNF-α, and the low IL-10 content in COPD rats. Meanwhile, EA downregulated the increased mRNA and protein expression of IL-17R, and significantly inhibited the elevated levels of phosphorylated JNK, ERK1/2, and p38 in the lungs of COPD rats.

CONCLUSION

Our results suggest that the protective effects of acupuncture therapy on the lungs of COPD rats are likely related to inhibition of IL-17/IL-17R and the post-receptor MAPK signaling pathways.

Cigarette smoke extract induces pyroptosis in human bronchial epithelial cells through the ROS/NLRP3/caspase-1 pathway

AIMS

Pyroptosis and inflammation are involved in the development of chronic obstructive pulmonary disease (COPD). However, the cigarette smoke-mediated mechanism of COPD remains unclear. In this study, we aimed to investigate the role of nucleotide-binding domain-like receptor protein-3 (NLRP3) inflammasome-mediated pyroptosis in the death of human bronchial epithelial (HBE) cells after cigarette smoke extract (CSE) exposure.

MAIN METHODS

The protein level of NLRP3 in lung tissue was measured after cigarette smoke exposure in vivo. In vitro, HBE cells were treated with CSE. Subsequently, the activity of caspase-1, lactate dehydrogenase (LDH) release, release of interleukin (IL)-1β and NLRP3 expression levels were measured. The involvement of reactive oxygen species (ROS) was also explored.

KEY FINDINGS

After exposure to CSE, increased release of LDH, the transcriptional and translational upregulation of NLRP3, the caspase-1 activity levels, and enhanced IL-1β and IL-18 release were observed in 16HBE cells. In addition, NLRP3 was required to activate the caspase-1. Our results suggested that pre-stimulated of 16HBE with a caspase-1 inhibitor, or using NLRP3 siRNA to silence NLRP3 expression, also caused the decrease of IL-1β release and pyroptosis.

SIGNIFICANCES

CSE induced inflammation and contributed to pyroptosis through the ROS/NLRP3/caspase-1 pathway in 16HBE cells. The NLRP3 inflammasome participates in CSE-induced HBE cell damage and pyroptosis, which could provide new insights into COPD.

Clinical Significance of Procalcitonin, C-Reactive Protein, and Interleukin-6 in Helping Guide the Antibiotic Use for Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease

Background

Currently, standards of antibiotic use in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients are controversial.

Objective

The aim of the present study was to analyze the value of procalcitonin (PCT), C-reactive protein (CRP), and interleukin-6 (IL-6) levels to guide the antibiotic treatment of AECOPD patients.

Methods

A total of 371 patients with COPD or AECOPD were included in the study. Clinical and laboratory data were obtained at admission, 325 AECOPD patients and 46 sCOPD patients treated with antibiotics. The receiver operating curve (ROC) was used to evaluate the relationship between CRP, PCT, and IL-6.

Results

This study included medical record/case control 1, the COPD group (n = 46) and the AECOPD group (n = 325), and medical record control 2, the nonchanged antibiotic group (n = 203) and the changed antibiotic group (n = 61). In case 1, CRP, PCT, and IL-6 levels in the AECOPD group were higher than that in the control group (P < 0.05), while the result of ROC showed that IL-6 had higher AUC values (0.773) and higher sensitivity (71.7%) than other indicators. The specificity of PCT (93.5%) is higher than other indicators. In case 2, ROC curve results showed that the AUC value of IL-6 (0.771) was slightly higher than PCT and CRP. The sensitivity (85.2%) and specificity (65.5%) of CRP were higher than other indicators.

Conclusions

IL-6 and PCT were elevated in AECOPD patients, resulting in a higher diagnostic value for AECOPD. CRP had a higher diagnostic value for antibiotic use in AECOPD patients.

Oxidative Stress-Derived Mitochondrial Dysfunction in Chronic Obstructive Pulmonary Disease: A Concise Review

Chronic obstructive pulmonary disease (COPD) is a progressive and disabling disorder marked by airflow limitation and extensive destruction of lung parenchyma. Cigarette smoke is the major risk factor for COPD development and has been associated with increased oxidant burden on multiple cell types in the lungs. Elevated levels of reactive oxygen species (ROS) may significantly affect expression of biological molecules, signaling pathways, and function of antioxidant defenses. Although inflammatory cells, such as neutrophils and macrophages, contribute to the release of large quantities of ROS, mitochondrial dysfunction plays a critical role in ROS production due to oxidative phosphorylation. Although mitochondria are dynamic organelles, excess oxidative stress is able to alter mitochondrial function, morphology, and RNA and protein content. Indeed, mitochondria may change their shape by undergoing fusion (regulated by mitofusin 1, mitofusin 2, and optic atrophy 1 proteins) and fission (regulated by dynamin-related protein 1), which are essential processes to maintain a healthy and functional mitochondrial network. Cigarette smoke can induce mitochondrial hyperfusion, thus reducing mitochondrial quality control and cellular stress resistance. Furthermore, diminished levels of enzymes involved in the mitophagy process, such as Parkin (a ubiquitin ligase E3) and the PTEN-induced putative kinase 1 (PINK1), are commonly observed in COPD and correlate directly with faulty removal of dysfunctional mitochondria and consequent cell senescence in this disorder. In this review, we highlight the main mechanisms for the regulation of mitochondrial quality and how they are affected by oxidative stress during COPD development and progression.

The Dollar or Disease Burden: Caps on Healthcare Spending May Save Money, but at What "Cost" to Patients?

OBJECTIVES

Various strategies to address healthcare spending and medical costs continue to be debated and implemented in the United States. To date, these efforts have failed to adequately contain the growth of healthcare cost. An alternative strategy that has elicited rising interest among policymakers is budget caps. As budget caps become more prevalent, it is important to identify which features are needed to ensure success, both in terms of cost reduction and health improvement.

METHODS

We explored the impacts of different features of budget caps by comparing hypothetical service level and global budget caps across 3 annual budget cap growth strategies over a 10-year timeframe in 2005-2015 for 8 of the most commonly occurring conditions in the United States. Health was assessed by a measure of disease burden (disability-adjusted life years).

RESULTS

The results indicate that budget caps have the potential for creating savings but can also result in patient harm if not designed well. As a result of these findings, 5 principles were developed for designing budget caps and should guide the use of budget caps to address medical spending.

CONCLUSIONS

As public discussion grows about the use of budget caps to constrain health spending, it is critical to recognize that the budget cap design and the resulting healthcare provider behavior will determine whether there is potential harm to public health. Budget cap design should consider variability at the condition level, including patient population, improvements in health, treatment costs, and the innovations available, to both create savings and maximize patient health. In assessing the impact of healthcare spending caps on costs and disease burden, we demonstrate that budget cap design determines potential harm to public health.

Development and Assessment of Prediction Models for the Development of COPD in a Typical Rural Area in Northwest China

Objective

This study aimed to construct and evaluate a clinical predictive model for the development of COPD in northwest China's rural areas.

Methods

A cross-sectional study of a natural population was performed in rural northwest China. After assessing demographic and disease characteristics, a clinical prediction model was developed. First, we used the least absolute shrinkage and selection operator regression model to screen possible factors influencing COPD. Then construct a logistic regression model and draw a nomogram. The discriminability of the model was further evaluated by the calibration diagram, C-index and ROC curve system. Clinical benefit was analyzed using the decision curve. Finally, the 1000 bootstrap resamples and Harrell's C-index was used for internal verification of the nomogram.

Results

Among 3249 patients in the local rural natural population, 394 (12.13%) were diagnosed with COPD. The LASSO regression model was used to find the optimal combination of parameters, and the screened influencing factors included age, gender, barbeque, smoking, passive smoking, energy type, ventilation system and Post-Bronchodilator FEV1. These predictors are used to construct a nomogram. C index is 0.81 (95% confidence interval:0.79-0.83). The combination of the calibration curve and ROC curve indicates that the model has high discriminability. The decision curve shows benefits in clinical practice when the threshold probability is >6% and <58%, respectively. The internal verification results using Harrell's C-Index were 0.80 (95% confidence interval: 0.78-0.83).

Conclusion

Combining information such as age, sex, barbeque, smoking, passive smoking, type of energy, ventilation systems, and Post-Bronchodilator FEV1 can be easily used to predict the risk of COPD in local rural areas.

Inflammation-associated factors for predicting in-hospital mortality in patients with COVID-19

The aim is to explore the relation between inflammation-associated factors and in-hospital mortality and investigate which factor is an independent predictor of in-hospital death in patients with coronavirus disease-2019. This study included patients with coronavirus disease-2019, who were hospitalized between February 9, 2020, and March 30, 2020. Univariate Cox regression analysis and least absolute shrinkage and selection operator regression (LASSO) were used to select variables. Multivariate Cox regression analysis was applied to identify independent risk factors in coronavirus disease-2019. A total of 1135 patients were analyzed during the study period. A total of 35 variables were considered to be risk factors after the univariate regression analysis of the clinical characteristics and laboratory parameters (p < .05), and LASSO regression analysis screened out seven risk factors for further study. The six independent risk factors revealed by multivariate Cox regression were myoglobin (HR, 5.353; 95% CI, 2.633-10.882; p < .001), C-reactive protein (HR, 2.063; 95% CI, 1.036-4.109; p = .039), neutrophil count (HR, 2.015; 95% CI, 1.154-3.518; p = .014), interleukin 6 (Il-6; HR, 9.753; 95% CI, 2.952-32.218; p < .001), age (HR, 2.016; 95% CI, 1.077-3.773; p = .028), and international normalized ratio (HR, 2.595; 95% CI, 1.412-4.769; p = .002). Our results suggested that inflammation-associated factors were significantly associated with in-hospital mortality in coronavirus disease-2019 patients. C-reactive protein, neutrophil count, and interleukin 6 were independent factors for predicting in-hospital mortality and had a better independent predictive ability. We believe these findings may allow early identification of the patients at high risk for death, and can also assist in better management of these patients.

Influence of Lung Hyperinflation on Respiratory Muscles Pressures During a Submaximal Test in Patients With COPD: A Clinical Perspective

Background and Objective:

Reduction of exercise tolerance is associated with expiratory flow-limitation (EFL) and lung hyperinflation; those are only partially reversible to bronchodilator. Lung hyperinflation lowers the diaphragm muscle provoking a mechanical disadvantage that, eventually, reduces maximal inspiratory (MIP) and expiratory (MEP) pressures. We aimed to assess the influence of the dynamic lung hyperinflation on respiratory pressures changes at rest and after a submaximal exercise test in COPD patients with and without a bronchodilator.

Methods::

We prospectively analyzed 16 COPD patients (FEV1 36.4±10% pred.; age 61.0±8 years, height 165±12 cm and BMI 25.9±6 kg/m2). MIP and MEP were measured before and after performing the six minutes walking test (6MWT) with and without bronchodilator (400 mcg of albuterol).

Results::

Nine of 16 patients increased IC more than 150 ml after bronchodilator use. Right after the 6MWT was accomplished without bronchodilator, IC decreased by 7.05% as compared to the 6MWT baseline value (p<0.01). Nine patients decreased IC more than 150ml. After bronchodilator use, patients performed the 6MWT without any IC significant reduction (p>0.05). Twelve patients increased the MIP (ranging from 70±11cmH2O to 77±10cmH2O, p = 0.0043) using 400mcg of albuterol. Thirteen patients reduced MIP after the 6MWT without bronchodilator use (p <0.007). There was no significant reduction (p> 0.05) in MIP when patients performed the 6MWT after bronchodilator use. We also found a significant correlation between MIP and inspiratory capacity (IC) and MEP and the IC before and after the 6MWT (r=0.61, p=0.0054; r=0.60, p=0.0031, respectively).

Conclusions::

Dynamic pulmonary hyperinflation directly interferes with the ability of respiratory muscles to generate inspiratory and expiratory pressures. The previous use of bronchodilators in patients with COPD reduced dynamic hyperinflation when accomplishing a sub-maximal exercise.

Effect of nutritional risk on cognitive function in patients with chronic obstructive pulmonary disease

Objective

We aimed to clarify the cognitive function of patients with chronic obstructive pulmonary disease (COPD) and different nutritional status.

Methods

Among 95 patients with COPD in this retrospective study, we administered the Nutritional Risk Screening 2002 (NRS 2002) and Mini-Mental State Examination (MMSE). We recorded patients’ clinical characteristics, comorbidities, and laboratory measurements. According to NRS 2002 scores, patients were divided into two groups: no nutritional risk with NRS 2002 < 3 (n = 54) and nutritional risk, with NRS 2002 ≥ 3 (n = 41).

Results

We found a negative correlation between NRS 2002 and MMSE scores in participants with COPD (r = −0.313). Patients with nutritional risk were more likely to be cognitively impaired than those with no nutritional risk. Multivariate logistic regression analysis indicated that malnutrition was an independent risk factor for cognitive impairment, after adjusting for confounders (odds ratio [OR] = 4.120, 95% confidence interval [CI]: 1.072–15.837). We found a similar association between NRS 2002 and MMSE scores at 90-day follow-up using a Pearson’s correlation test (r = −0.493) and logistic regression analysis (OR = 7.333, 95% CI: 1.114–48.264).

Conclusions

Patients with COPD at nutritional risk are more likely to have cognitive impairment.

WeChat as a Platform for Baduanjin Intervention in Patients With Stable Chronic Obstructive Pulmonary Disease in China: Retrospective Randomized Controlled Trial

Background

Pulmonary rehabilitation is a crucial part of the nonpharmacological treatment of stable chronic obstructive pulmonary disease (COPD), but management remains problematic. WeChat could serve as a useful tool in patient management. Baduanjin is a popular exercise in China that is usually applied in pulmonary rehabilitation, which has been confirmed to be effective in improving lung function and life quality.

Objective

This study aimed to explore the efficiency of WeChat in the management of Baduanjin exercise in COPD patients.

Methods

A total of 200 patients from the respiratory department of Putuo Hospital participated in the Baduanjin rehabilitation project from September 2018 to October 2019, and were randomly assigned to the WeChat and control groups and followed up using the WeChat platform or telephone for 12 weeks. The frequency of Baduanjin exercise, lung function (percentage of forced expiratory volume in 1 second predicted, FEV1% predicted), and COPD assessment test (CAT) scores were collected and compared between the two groups. The number of message exchanges and a satisfaction survey on the WeChat platform were used to assess the feasibility of WeChat management outside the hospital.

Results

The Baduanjin exercise frequency significantly differed between the control group and WeChat group (F=33.82, P<.001) and across various time points (F=214.87, P<.001). After the follow-up on WeChat, there were fewer patients not performing Baduanjin exercise. The FEV1% predicted value significantly differed before and after Baduanjin exercise in the control group (Z=−3.686, P<.001) and the WeChat group (Z=−6.985, P<.001). A significant difference in the FEV1% predicted value was observed after Baduanjin exercise between the two groups (Z=−3.679, P<.001). The CAT score significantly differed before and after Baduanjin exercise in the control group (Z=−4.937, P<.001) and the WeChat group (Z=−5.246, P<.001). A significant difference in the CAT score was observed after Baduanjin exercise between the two groups (Z=−5.246, P<.001). The number of completed Baduanjin exercises, lung function, and CAT scores in active patients were higher than those in nonactive patients. All satisfaction survey items were scored with more than 4 points. Among the items, the highest score (mean 4.54, SD 0.77) was for continued WeChat management, followed by the effective management of Baduanjin exercise (mean 4.46, SD 0.87). The patients in the WeChat group showed much higher enthusiasm for and compliance with Baduanjin exercise, resulting in better life quality and lung function. The patients were very satisfied with the WeChat management because of the obvious curative effect and home feeling.

Conclusions

The WeChat platform provided a feasible, effective, and sustainable management plan for Baduanjin rehabilitation.

Trial Registration

Chinese Clinical Trial Registry ChiCTR1900028248; http://www.chictr.org.cn/showprojen.aspx?proj=46995

Cathelicidin induces epithelial-mesenchymal transition to promote airway remodeling in smoking-related chronic obstructive pulmonary disease

Background

Epithelial-mesenchymal transition (EMT) is an important characteristic in the remodeling of airways that occurs in chronic obstructive pulmonary disease (COPD). Cigarette smoke is a potential driving factor of this EMT in COPD. However, the mechanisms by which cigarette smoke induce EMT remain uncertain. Cathelicidin has been implicated as a causal factor of airway inflammation and mucus hypersecretion in smoking-related COPD. This study aimed to investigate whether cathelicidin induces EMT to promote airway remodeling in this disease.

Methods

Human lung tissue was collected from smokers with COPD and smokers without COPD. The EMT markers E-cadherin and vimentin were examined by immunohistochemistry. Mouse models of COPD were established by taking mice with airway cathelin-related antimicrobial peptide (CRAMP), the murine homologue of cathelicidin, either upregulated or downregulated by intranasal introduction of lentiviral vectors and then exposing them to cigarette smoke. E-cadherin and vimentin expression in the airways of the model mice was examined using immunofluorescence. Tumor necrosis factor alpha (TNF-α) converting enzyme (TACE), transforming growth factor alpha (TGF-α), and epidermal growth factor receptor (EGFR) expression was analyzed by Western blot. Additionally, NCI-H292 human airway epithelial cells, both with and without cathelicidin downregulation, were stimulated with cigarette smoke extract (CSE) and LL-37 synthetic peptide, a bioactive fragment of cathelicidin. This was done to confirm that the TACE/TGF-α/EGFR signaling pathway is activated in humans exposed to cigarette smoke.

Results

Significant EMT was found in the small airways of smokers both with and without COPD, as well as in the airways of COPD model mice. Downregulation of CRAMP in COPD mice, however, ameliorated airway EMT induced by cigarette smoke. Conversely, upregulation of CRAMP enhanced airway EMT in vivo; TACE, TGF-α, and EGFR were found to be involved in this process. In vitro, EMT induced by CSE and LL-37 was inhibited by blocking TACE, TGF-α, and EGFR expression.

Conclusions

Cathelicidin promotes airway EMT by activating the TACE/TGF-α/EGFR signaling pathway. This mediates smoking-induced airway remodeling in the pathogenesis of COPD.

Distinct effects of asthma and COPD comorbidity on disease expression and outcome in patients with COVID-19

BACKGROUND

The impacts of chronic airway diseases on coronavirus disease 2019 (COVID-19) are far from understood.

OBJECTIVE

To explore the influence of asthma and chronic obstructive pulmonary disease (COPD) comorbidity on disease expression and outcomes, and the potential underlying mechanisms in COVID-19 patients.

METHODS

A total of 961 hospitalized COVID-19 patients with a definite clinical outcome (death or discharge) were retrospectively enrolled. Demographic and clinical information were extracted from the medical records. Lung tissue sections from patients suffering from lung cancer were used for immunohistochemistry study of angiotensin-converting enzyme II (ACE2) expression. BEAS-2B cell line was stimulated with various cytokines.

RESULTS

In this cohort, 21 subjects (2.2%) had COPD and 22 (2.3%) had asthma. After adjusting for confounding factors, COPD patients had higher risk of developing severe illness (OR: 23.433; 95% CI 1.525-360.135; P < .01) and acute respiratory distress syndrome (OR: 19.762; 95% CI 1.461-267.369; P = .025) than asthmatics. COPD patients, particularly those with severe COVID-19, had lower counts of CD4⁺ T and CD8⁺ T cells and B cells and higher levels of TNF-α, IL-2 receptor, IL-10, IL-8, and IL-6 than asthmatics. COPD patients had increased, whereas asthmatics had decreased ACE2 protein expression in lower airways, compared with that in control subjects without asthma and COPD. IL-4 and IL-13 downregulated, but TNF-α, IL-12, and IL-17A upregulated ACE2 expression in BEAS-2B cells.

CONCLUSION

Patients with asthma and COPD likely have different risk of severe COVID-19, which may be associated with different ACE2 expression.

Clinico-epidemiological characteristics of men and women with a new diagnosis of chronic obstructive pulmonary disease: a database (SIDIAP) study

BACKGROUND

The risk of developing Chronic Obstructive Pulmonary Disease (COPD), the associated comorbidities and response to bronchodilators might differ in men and women. The objective of this study was to determine the prevalence of COPD and the clinic-epidemiological characteristics of primary care patients with COPD according to gender.

METHODS

This is a cross-sectional study using electronic healthcare records Catalonia (Spain), during the 01/01/2012-31/12/2017 period. Patients from the SIDIAP database (System for the Development of Research in Primary Care) were included (5,800,000 patients registered in 279 primary care health centres). Clinic-demographic characteristics, comorbidities and blood tests results were collected for each patient. Adjusted OR (ORa) with logistic regression methods were used to determine variables associated with men and women.

RESULTS

From an initial sample of 800,899 people, 24,135 (3%) were considered COPD patients, and 22.9%were women. The most common risk factors in women were bronchiectasis (ORa = 20.5, SD = 19.5-21.6), age > 71 years (ORa = 18.8; SD = 17.3-20.5), cor pulmonale (ORa = 5.2; SD = 4.3-6.7) and lung cancer (ORa = 3.6, SD = 3.2-4.0). Men and women presented the same comorbidities, though the strength of association was different for each gender.

CONCLUSIONS

Patients suffering high comorbidity rates. Comorbidities are similar in men and women, although the strength of association varies according to gender. Women are more susceptible to the harmful effects of smoking and present a higher proportion of bronchiectasis and OSAS.

Physical Frailty, Multimorbidity, and All-Cause Mortality in an Older Population From Southern Italy: Results from the Salus in Apulia Study

OBJECTIVES

We first estimated the prevalence of physical frailty in older subjects from the population-based Salus in Apulia Study (Apulia, Southern Italy), and its impact on all-cause mortality. Second, we explored the relationship between multimorbidity and physical frailty.

DESIGN

Cross-sectional and longitudinal analyses from a population-based study.

SETTING AND PARTICIPANTS

We analyzed data from the Salus in Apulia study, a population-based sample of 1929 subjects aged 65 years and older.

METHODS

These older participants underwent clinical, physical, and laboratory assessments. Physical frailty was operationalized using slightly modified Fried criteria. Multimorbidity status was defined as the co-presence of 2 or more chronic conditions.

RESULTS

The overall prevalence of physical frailty in this older population from Southern Italy was 14.8% [95% confidence interval (CI): 13.26-16.49]. Physical frailty subjects were significantly older (P < .01), had a lower educational level (P < .01), increased executive dysfunction (P < .01), higher serum levels interleukin-6 (P < .01), and white blood cells (P = .01). Multimorbidity status (P < .01), diabetes mellitus (P = .05), peripheral age-related hearing loss (P < .01), cognitive impairment (P < .01), chronic obstructive pulmonary disease (P = .02), and metabolic syndrome (P = .02) were also directly related to physical frailty. Apathy increased according to the severity of physical frailty status (P = .02). There was a significant increased risk of all-cause mortality for physical frailty subjects (hazard ratio: 1.48; 95% CI: 1.03-2.12, adjusted for age and sex) during the observation from the date of enrollment to the date of death (mean ± SD: 55.70 ± 22.19 months, median: 54 months).

CONCLUSIONS AND IMPLICATIONS

Frailty is the consequence of the contributory action of the aging process and some chronic diseases that hasten some of the changes concurrent with aging.