Emphysema: the challenge of the remodelled lung

Intrabullous ventilation in pulmonary emphysema: assessment with dynamic xenon-133 gas SPECT

PURPOSE

Intrabullous ventilation in patients with pulmonary emphysema (PE) was cross-sectionally evaluated using dynamic xenon-133 gas single photon emission computed tomography (SPECT).

METHODS

Fifty-two patients with PE with a total of 109 bullae of more than 4 cm in maximum diameter underwent xenon-133 gas SPECT. The real xenon-133 gas half-clearance time (T1/2) at each bulla was compared with that at the surrounding lung in the same lobe. The emphysema subtype of the surrounding lung was classified into centrilobular, panlobular, and paraseptal on computed tomography (CT).

RESULTS

All bullae except for one in all patients showed xenon-133 gas wash-in. Of the 108 bullae with wash-in, 95 (87.9%) bullae in 46 (88%) patients showed marked xenon-133 gas retention with a T1/2 beyond 110 s (mean: 184 s ± 91). The surrounding lungs of these bullae also showed marked retention with a T1/2 of greater than 100 s (mean: 174 s ± 82), and the majority (N=92, 96.8%) were centrilobular or panlobular on CT. The remaining 13 (12.0%) bullae in six (11%) patients showed minimal retention with a T1/2 of less than 80 s (mean: 62 s ± 11), regardless of no significant difference in size compared with the bullae with marked retention. All the surrounding lungs of these bullae except for one also showed minimal retention with a T1/2 of less than 70 s (mean: 60 s ± 18), which was significantly less compared with that of the bullae with marked retention (P<0.0001), and the majority (N=11, 84.6%) were paraseptal with or without an interstitially fibrotic change and predominantly located at the lower lung lobe on CT. The T1/2 of the 108 bullae with xenon-133 gas wash-in was significantly correlated with that of the surrounding lungs (r=0.884, P<0.0001).

CONCLUSION

Intrabullous ventilation in patients with PE appears to depend on the ventilation status of the surrounding lung, and bullae with the surrounding lungs of paraseptal-type emphysema tend to show minimal air trapping. Xenon-133 gas SPECT is useful for assessment of the interaction between intrabullous and surrounding lung's ventilation, which is difficult on CT.

Array CGH reveals genomic aberrations in human emphysema

Emphysema is the major component of chronic obstructive pulmonary disease (COPD), which is the fourth leading cause of death in the world. Several epidemiologic studies suggest that genetic factors may have an important role in the pathogenesis of emphysema. We analyzed the gene expression profiles of chromosomal aberrations using array comparative genomic hybridization (array CGH) in 32 patients with emphysema to identify the candidate genes that might be causally involved in the pathogenesis of emphysema. Copy number gains and losses were detected in chromosomal regions, and the corresponding genes were confirmed by real-time polymerase chain reaction. Several frequently altered loci were found, including a gain at 5p15.33 (60% of the study subjects), and a loss at 7q22.1 (31% of the study subjects). DNA gains were identified at a high frequency at 1p, 5p, 11p, 12p, 15q, 17p, 18q, 21q, and 22q, whereas DNA losses were frequently found at 7q and 22q. We found that the fold change levels were highest at the CYP4B1 (1p33), JUN (1p32.1), NOTCH2 (1p12-p11.2), SDHA (5p15.33), KCNQ1 (11p15.5-p15.4), NINJ2 (12p13.33), PCSK6 (15q26.3), ABR (17p13.3), CTDP1 (18q23), RUNX1 (21q22.12) and HDAC10 (22q13.33) gene loci. We also observed losses in the MUC17 (7q22.1), COMT (22q11.21) and GSTT1 (22q11.2) genes. These studies show that array CGH is a useful tool for the identification of gene alterations in cases of emphysema and that the aforementioned genes might represent potential candidate genes involved in the pathogenesis of emphysema.

Rho kinase as a therapeutic target in the treatment of asthma and chronic obstructive pulmonary disease

Asthma is a complex inflammatory disease of the airways involving reversible bronchoconstriction. Chronic obstructive pulmonary disease is typified by inflammation and airflow limitation that has an irreversible component. There is now substantial evidence that Rho kinase is involved in many of the pathways that contribute to the pathologies associated with these respiratory diseases including bronchoconstriction, airway inflammation, airway remodelling, neuromodulation and exacerbations due to respiratory tract viral infection. Indeed the Rho kinase inhibitor Y-27632 causes bronchodilatation and reduces pulmonary eosinophilia trafficking and airways hyperresponsiveness. Furthermore, accumulating evidence suggests that inhibition of Rho kinase could have a major beneficial impact on symptoms and disease progression in asthma and COPD by modulating several other systems and processes. Thus, the Rho kinase pathway may indeed be a worthwhile therapeutic target in the treatment of asthma and chronic obstructive pulmonary disease.

Persistent effects induced by IL-13 in the lung

IL-13 overexpression in the lung induces inflammatory and remodeling responses that are prominent features of asthma. Whereas most studies have concentrated on the development of IL-13-induced disease, far fewer studies have focused on the reversibility of IL-13-induced pathologies. This is particularly important because current asthma therapy appears to be poor at reversing lung remodeling. In this manuscript, we used an externally regulatable transgenic system that targets expression of IL-13 to the lung with the aim of characterizing the reversibility process. After 4 wk of doxycycline (dox) exposure, IL-13 expression resulted in mixed inflammatory cell infiltration, mucus cell metaplasia, lung fibrosis, and airspace enlargement (emphysema). After withdrawal of dox, IL-13 protein levels were profoundly reduced by 7 d and below baseline by 14 d. During this time frame, the level of lung eosinophils returned to near normal, whereas macrophages, lymphocytes, and neutrophils remained markedly elevated. IL-13-induced mucus cell metaplasia significantly decreased (91%) 3 wk after withdrawal of dox, showing strong correlation with reduced eosinophil levels. In contrast, IL-13-induced lung fibrosis did not significantly decline 4 wk after dox withdrawal. Importantly, IL-13-induced emphysema persisted, but modestly declined 4 wk after dox. Examination of transcript expression profiles identified a subset of genes that remained increased weeks after transgene expression was no longer detected. Notably, numerous IL-13-induced cytokines and enzymes were reversible (IL-6 and cathepsins), whereas others were sustained (CCL6 and chitinases) after IL-13 withdrawal, respectively. Thus, several hallmark features of IL-13-induced lung pathology persist and are dissociated from eosinophilia after IL-13 overexpression ceases.

Fractal geometry of airway remodeling in human asthma

RATIONALE

Airway wall remodeling is an important aspect of asthma. It has proven difficult to assess quantitatively as it involves changes in several components of the airway wall.

OBJECTIVE

To develop a simple method for quantifying the overall severity of airway wall remodeling in asthmatic airways using fractal geometry.

METHODS

Negative-pressure silicone rubber casts of lungs were made using autopsy material from three groups: fatal asthma, nonfatal asthma, and nonasthma control. All subjects were lifelong nonsmokers. A fractal dimension was calculated on two-dimensional digital images of each cast.

RESULTS

Nonasthma control casts had smooth walls and dichotomous branching patterns with nontapering segments. Asthmatic casts showed many abnormalities, including airway truncation from mucous plugs, longitudinal ridges, and horizontal corrugations corresponding to elastic bundles and smooth muscle hypertrophy, respectively, and surface projections associated with ectatic mucous gland ducts. Fractal dimensions were calculated from digitized images using an information method. The average fractal dimensions of the airways of both the fatal asthma (1.72) and nonfatal asthma (1.76) groups were significantly (p<0.01 and p=0.032, respectively) lower than that of the nonasthma control group (1.83). The lower fractal dimension of asthmatic airways correlated with a decreased overall structural complexity and pathologic severity of disease.

CONCLUSION

Fractal analysis is a simple and useful technique for quantifying the chronic structural changes of airway remodeling in asthma.

What is the contribution of respiratory viruses and lung proteases to airway remodelling in asthma and chronic obstructive pulmonary disease?

It is well known that the lungs of asthmatics show airway wall remodelling and that asthma exacerbations are linked to respiratory infections. There is some evidence that respiratory infections in early childhood may increase the risk of developing asthma later in life. Chronic obstructive pulmonary disease (COPD), by definition, involves structural changes to the airways. However, very little is known about what role virus infections play in the development of this remodelling. This review considers the role of matrix metalloproteases and neutrophil elastase in remodelling, and whether the induction of proteases and other mediators during respiratory virus infections may contribute to the development of airway remodelling.