Development of a Semiquantitative Histological Score for the Diagnosis of Heaves Using Endobronchial Biopsy Specimens in Horses

Differences in pulmonary function measured by oscillometry between horses with mild-moderate equine asthma and healthy controls

BACKGROUND

The diagnosis of mild-moderate equine asthma (MEA) can be confirmed by airway endoscopy, bronchoalveolar lavage fluid (BALf) cytology, and lung function evaluation by indirect pleural pressure measurement. Oscillometry is a promising pulmonary function test method, but its ability to detect subclinical airway obstruction has been questioned.

OBJECTIVES

To evaluate the differences in lung function measured by oscillometry between healthy and MEA-affected horses.

STUDY DESIGN

Prospective case-control clinical study.

METHODS

Thirty-seven horses were divided into healthy and MEA groups, based on history and clinical score; the diagnosis of MEA was confirmed by airway endoscopy and BALf cytology. Horses underwent oscillometry at frequencies ranging from 2 to 6 Hz. Obtained parameters included whole-breath, inspiratory, expiratory, and the difference between inspiratory and expiratory resistance (Rrs) and reactance (Xrs). Differences between oscillometry parameters at different frequencies were evaluated within and between groups by repeated-measures two-way ANOVA and post hoc tests with Bonferroni correction. Frequency dependence was compared between groups by t test. For significant parameters, a receiver operating characteristics curve was designed, cut-off values were identified and their sensitivity and specificity were calculated. Statistical significance was set at p < 0.05.

RESULTS

No significant differences in Xrs and Rrs were observed between groups. The frequency dependence of whole-breath and inspiratory Xrs significantly differed between healthy (respectively, -0.03 ± 0.02 and -0.05 ± 0.02 cmH2O/L/s) and MEA (-0.1 ± 0.03 and -0.2 ± 0.02 cmH2O/L/s) groups (p < 0.05 and p < 0.01). For inspiratory Xrs frequency dependence, a cut-off value of -0.06 cmH2O/L/s was identified, with 86.4% (95% CI: 66.7%-95.3%) sensitivity and 66.7% (95% CI: 41.7%-84.8%) specificity.

MAIN LIMITATIONS

Sample size, no BALf cytology in some healthy horses.

CONCLUSIONS

Oscillometry can represent a useful non-invasive tool for the diagnosis of MEA. Specifically, the evaluation of the frequency dependence of Xrs may be of special interest.

Influence of climatic changes on respiratory health in a teaching herd of outdoor-housed horses

Horses maintained outdoors may experience a lower-allergenic environment compared to their stabled counterparts. This study hypothesizes that climatic changes in southern Brazil can influence respiratory status. To test this hypothesis, we evaluated the lower airways of 17 horses from a teaching herd in southern Brazil, maintained outdoors, during winter, spring, and summer. Except for one mare with a history of severe asthma, all horses were considered healthy and underwent a physical examination. Airway endoscopic evaluation included scoring for tracheal mucus (0-5) and bronchial septum thickness (1-5). Bronchoalveolar lavage fluid (BALF) was collected at three time points, while bronchial septum biopsies were performed during spring and summer for airway epithelial investigation. Data analysis involved repeated measures ANOVA and Wilcoxon tests (p < 0.05). Tracheal mucus score and septal thickness did not differ across investigation periods. In BALF cytology, the mean percentage of neutrophils was higher in spring than summer (7.9 ± 13.4 % vs. 4.5 ± 11.7 %, P = 0.037), and eosinophil count was higher in winter than spring (0.64 ± 1.29 % vs. 0.03 ± 0.13 %, P = 0.034) and summer (0.64 ± 1.29 % vs. 0.14 ± 0.60 %, P = 0.023). Histopathological observations showed no differences between time points, and no correlations were observed with BALF analyses (P > 0.05). This study demonstrates that, even in an outdoor environment, horses' airways exhibit cytological modifications associated with different seasons, indicating a need for deeper investigation; endobronchial biopsy did not contribute to the clinical diagnosis.

The amount of hyaluronic acid and airway remodelling increase with the severity of inflammation in neutrophilic equine asthma

BACKGROUND

Equine asthma (EA) is a chronic lower airway inflammation that leads to structural and functional changes. Hyaluronic acid (HA) has crucial functions in the extracellular matrix homeostasis and inflammatory mediator activity. HA concentration in the lungs increases in several human airway diseases. However, its associations with naturally occurring EA and airway remodelling have not been previously studied. Our aim was to investigate the association of equine neutrophilic airway inflammation (NAI) severity, airway remodelling, and HA concentration in horses with naturally occurring EA. We hypothesised that HA concentration and airway remodelling would increase with the severity of NAI. HA concentrations of bronchoalveolar lavage fluid supernatant (SUP) and plasma of 27 neutrophilic EA horses, and 28 control horses were measured. Additionally, remodelling and HA staining intensity were assessed from endobronchial biopsies from 10 moderate NAI horses, 5 severe NAI horses, and 15 control horses.

RESULTS

The HA concentration in SUP was higher in EA horses compared to controls (p = 0.007). Plasma HA concentrations were not different between the groups. In the endobronchial biopsies, moderate NAI horses showed epithelial hyperplasia and inflammatory cell infiltrate, while severe NAI horses also showed fibrosis and desquamation of the epithelium. The degree of remodelling was higher in severe NAI compared to moderate NAI (p = 0.048) and controls (p = 0.016). Intense HA staining was observed in bronchial cell membranes, basement membranes, and connective tissue without significant differences between the groups.

CONCLUSION

The release of HA to the airway lumen increases in naturally occurring neutrophilic EA without clear changes in its tissue distribution, and significant airway remodelling only develops in severe NAI.

Clinical predictive models in equine medicine: A systematic review

Clinical predictive models use a patient's baseline demographic and clinical data to make predictions about patient outcomes and have the potential to aid clinical decision making. The extent of equine clinical predictive models is unknown in the literature. Using PubMed and Google Scholar, we systematically reviewed the predictive models currently described for use in equine patients. Models were eligible for inclusion if they were published in a peer-reviewed article as a multivariable model used to predict a clinical/laboratory/imaging outcome in an individual horse or herd. The agreement of at least two authors was required for model inclusion. We summarised the patient populations, model development methods, performance metric reporting, validation efforts, and, using the Predictive model Risk of Bias Assessment Tool (PROBAST), assessed the risk of bias and applicability concerns for these models. In addition, we summarised the index conditions for which models were developed and provided detailed information on included models. A total of 90 predictive models and 9 external validation studies were included in the final systematic review. A plurality of models (41%) was developed to predict outcomes associated with colic, for example, need for surgery or survival to discharge. All included models were at high risk of bias, defined as failing one or more PROBAST signalling questions, primarily for analysis-related reasons. Importantly, a high risk of bias does not necessarily mean that models are unusable, but that they require more careful consideration prior to clinical use. Concerns about applicability were low for the majority of models. Systematic reviews such as this can serve to increase veterinarians' awareness of predictive models, including evaluation of their performance and their use in different patient populations.

The Immune Mechanisms of Severe Equine Asthma-Current Understanding and What Is Missing

Severe equine asthma is a chronic respiratory disease of adult horses, occurring when genetically susceptible individuals are exposed to environmental aeroallergens. This results in airway inflammation, mucus accumulation and bronchial constriction. Although several studies aimed at evaluating the genetic and immune pathways associated with the disease, the results reported are inconsistent. Furthermore, the complexity and heterogeneity of this disease bears great similarity to what is described for human asthma. Currently available studies identified two chromosome regions (ECA13 and ECA15) and several genes associated with the disease. The inflammatory response appears to be mediated by T helper cells (Th1, Th2, Th17) and neutrophilic inflammation significantly contributes to the persistence of airway inflammatory status. This review evaluates the reported findings pertaining to the genetical and immunological background of severe equine asthma and reflects on their implications in the pathophysiology of the disease whilst discussing further areas of research interest aiming at advancing treatment and prognosis of affected individuals.

A portable fan-based device for evaluating lung function in horses by the forced oscillation technique

OBJECTIVE

The assessment of lung mechanics in horses is nowadays based on invasive methods that may require sedation. The forced oscillation technique (FOT) allows the non-invasive assessment of respiratory mechanics during spontaneous breathing, but current devices are complex, cumbersome, expensive, and difficult to be applied in horses.

APPROACH

We developed a portable FOT device based on a novel approach in which the pressure waveforms are generated by a servo-controlled ducted fan. This new approach allows the design of devices that are more sturdy, compact, and portable compared to already existing approaches. The prototype includes 1) a small microcontroller-based electronic board for controlling the fan and measuring flow and pressure and 2) an optimized data processing algorithm.

MAIN RESULTS

This device provides a maximum error of 0.06 cmH2O∙s/L and 0.15 cmH2O∙s/L in measuring respiratory resistance and reactance during in-vitro validation. A pilot study was also performed on three healthy horses and three horses with severe equine asthma (SEA) and it demonstrated good tolerability and feasibility of the new device. Total respiratory system resistance (Rrs) and reactance (Xrs) significantly differed (p<0.05) between groups. At 5Hz, Rrs was 0.66±0.02 cmH2O∙s/L and 0.94±0.07 cmH2O∙s/L in healthy and in SEA, respectively. Xrs 0.38±0.02 cmH2O∙s/L and -0.27±0.05 cmH2O∙s/L.

SIGNIFICANCE

This novel approach for applying FOT allowed the development of a small, affordable and portable device for the non-invasive evaluation of respiratory mechanics in spontaneously breathing horses, providing a useful new tool for improving veterinary respiratory medicine. Moreover, our results provide supporting evidence of the value of this novel approach for developing portable FOT devices also for applications in humans.

Effects of azithromycin on bronchial remodeling in the natural model of severe neutrophilic asthma in horses

Steroid resistance in asthma has been associated with neutrophilic inflammation and severe manifestations of the disease. Macrolide add-on therapy can improve the quality of life and the exacerbation rate in refractory cases, possibly with greater effectiveness in neutrophilic phenotypes. The mechanisms leading to these beneficial effects are incompletely understood and whether macrolides potentiate the modulation of bronchial remodeling induced by inhaled corticosteroids (ICS) is unknown. The objective of this study was to determine if adding azithromycin to ICS leads to further improvement of lung function, airway inflammation and bronchial remodeling in severe asthma. The combination of azithromycin (10 mg/kg q48h PO) and inhaled fluticasone (2500 µg q12h) was compared to the sole administration of fluticasone for five months in a randomized blind trial where the lung function, airway inflammation and bronchial remodeling (histomorphometry of central and peripheral airways and endobronchial ultrasound) of horses with severe neutrophilic asthma were assessed. Although the proportional reduction of airway neutrophilia was significantly larger in the group receiving azithromycin, the lung function and the peripheral and central airway smooth muscle mass decreased similarly in both groups. Despite a better control of airway neutrophilia, azithromycin did not potentiate the other clinical effects of fluticasone.

Within-Breath Oscillatory Mechanics in Horses Affected by Severe Equine Asthma in Exacerbation and in Remission of the Disease

Oscillometry is a technique that measures the resistance (R) and the reactance (X) of the respiratory system. In humans, analysis of inspiratory and expiratory R and X allows to identify the presence of tidal expiratory flow limitation (EFLt). The aim of this study was to describe inspiratory and expiratory R and X measured by impulse oscillometry system (IOS) in horses with severe asthma (SEA) when in clinical remission (n = 7) or in exacerbation (n = 7) of the condition. Seven healthy, age-matched control horses were also studied. Data at 3, 5, and 7 Hz with coherence > 0.85 at 3 Hz and >0.9 at 5 and 7 Hz were considered. The mean, inspiratory and expiratory R and X and the difference between inspiratory and expiratory X (ΔX) were calculated at each frequency. The data from the three groups were statistically compared. Results indicated that in horses during exacerbation of severe asthma, X during expiratory phase is more negative than during inspiration, such as in humans in presence of EFLt. The evaluation of X during inspiration is promising in discriminating between horses with SEA in remission and control horses.

Bronchial brush cytology, endobronchial biopsy, and SALSA immunohistochemistry in severe equine asthma

Horses with severe equine asthma (SEA), also known as heaves and recurrent airway obstruction, have persistent neutrophilic inflammation of the lower airways. Cytologic evaluation of bronchoalveolar lavage (BAL) fluid is commonly used to confirm the clinical diagnosis of SEA. However, the utility of microscopic assessment of bronchial brushings, endobronchial biopsies, and immunohistochemical detection of disease-associated biomarkers for the diagnosis of SEA remain poorly characterized. Salivary scavenger and agglutinin (SALSA) has anti-inflammatory properties and downregulated gene expression in SEA; therefore, it was investigated as a tissue biomarker for airway and systemic inflammation. Six asthmatic and 6 non-asthmatic horses were exposed to an inhaled challenge. Before and after challenge, samples of BAL fluid, bronchial brushing, and endobronchial biopsy were collected. Location of SALSA in biopsies was determined, and immunohistochemical label intensity was computed using image analysis software. Serum amyloid A (SAA) was measured to assess systemic inflammation. After challenge, neutrophil proportions were significantly higher in asthmatic versus non-asthmatic horses in BAL fluid (least squares means, 95% confidence interval: 80.9%, 57.2% to 93.1%, vs 3.6%, 1.1% to 10.7%) and in brush cytology slides (39.5%, 7.7% to 83.6%, vs 0.2%, 0% to 2.3%), illustrating the potential of brush cytology as an alternate modality to BAL for assessing intraluminal inflammation. Bronchial histopathologic findings and intensity of SALSA immunolabeling in surface and glandular epithelium were similar in asthmatic and non-asthmatic horses, indicating limited changes in bronchial tissue from the inhaled challenge. Increases in SAA indicated systemic inflammation, but SALSA immunolabeling did not change significantly.

Airway remodeling in horses with mild and moderate asthma

Background

There is a remodeling of the central airways in horses with severe asthma but whether a similar process occurs in horses with the mild or moderate asthma (MMA) is unknown.

Objectives

To evaluate lesions affecting the central airways of horses with MMA.

Animals

Twelve horses with MMA and 8 control horses.

Methods

Case‐control retrospective study of horses classified as MMA affected or controls based on history and bronchoalveolar lavage fluid cytology. Endobronchial biopsies were analyzed using histomorphometry and a semiquantitative histologic scoring system.

Results

Histomorphometry identified epithelial hyperplasia (47 μm²/μm [34‐57 μm²/μm]; P = .02), a thickened lamina propria (166 μm [73‐336 μm]; P = .04), and smooth muscle fibrosis (42% [33%‐78%]; P = .04) in horses with MMA when compared to controls horses (24 μm²/μm [21‐80 μm²/μm]; 76 μm [36‐176 μm]; and 33% [26%‐52%], respectively). The semiquantitative score results indicated, in horses with MMA, the presence of epithelial hyperplasia (7 of the 12 horses with MMA and only 1 of the 8 control horses had a score of 1/1), and submucosal inflammatory leucocytes in the central airway (11 of the 12 horses with MMA and only 4 of the 8 control horses had a score ≥ 1/2).

Conclusions and Clinical Relevance

Tissue remodeling of the bronchial lamina propria, epithelium, and smooth muscle was present in horses with MMA.

Immunohistochemical Expression of Neurokinin-A and Interleukin-8 in the Bronchial Epithelium of Horses with Severe Equine Asthma Syndrome during Asymptomatic, Exacerbation, and Remission Phase

Severe equine asthma (EA) syndrome is a chronic obstructive disease characterized by exaggerated contraction, inflammation, and structural alteration of the airways in adult horses, when exposed to airborne molds and particulate material. However, little is known about the relationship between the degree and type of inflammation on one hand, and the severity of the disease and the response to treatment on the other. Furthermore, to date, very few studies evaluate the diagnostic value of histology and immunohistochemical features of endoscopic biopsies on subjects with severe equine asthma. To investigate the expression of two inflammatory markers (NKA and IL-8) before, during, and after the exacerbation of severe EA, a histological and immunohistochemical study was carried out on a series of biopsy samples collected by bronchoscopy from six EA-affected horses subjected to process exacerbation through environmental stimuli and then to pharmacological treatment. The application of a histological biopsy scoring system revealed a significant difference between control cases and the EA-affected horses in all experimental phases (asymptomatic, early exacerbation phase, late exacerbation phase, and remission phase). For immunohistochemistry (IHC), only the intensity of NKA positivity increases significantly between control horses and the EA horses at late exacerbation and remission phases. In EA-affected horses, a difference was detected by comparing histology between asymptomatic and remission phase, meanwhile, NKA and IL-8 showed no differences between the experimental phases. Based on these results we can assert that: (1) The endoscopic biopsies generate reliable and homogeneous samples in the entire bronchial tree; (2) the clinical improvement associated with treatment is characterized by a significant worsening of the histological findings; and (3) the NKA immunopositivity seems to increase significantly rather than decrease, as one would have expected, after pharmacological treatment. Further studies are necessary both to implement the number of samples and to use other markers of inflammation to characterize the potential role of cytokines in the diagnosis and therapeutic approach of severe equine asthma.

Equine Asthma: Current Understanding and Future Directions

The 2019 Havemeyer Workshop brought together researchers and clinicians to discuss the latest information on Equine Asthma and provide future research directions. Current clinical and molecular asthma phenotypes and endotypes in humans were discussed and compared to asthma phenotypes in horses. The role of infectious and non-infectious causes of equine asthma, genetic factors and proposed disease pathophysiology were reviewed. Diagnostic limitations were evident by the limited number of tests and biomarkers available to field practitioners. The participants emphasized the need for more accessible, standardized diagnostics that would help identify specific phenotypes and endotypes in order to create more targeted treatments or management strategies. One important outcome of the workshop was the creation of the Equine Asthma Group that will facilitate communication between veterinary practice and research communities through published and easily accessible guidelines and foster research collaboration.

Randomised study of the immunomodulatory effects of azithromycin in severely asthmatic horses

Neutrophilic inflammation is believed to contribute to the airway obstruction and remodelling in equine asthma. Azithromycin, an antibiotic with immunomodulatory properties, reduces pulmonary neutrophilia and hyper-responsiveness in human asthmatics and decreases airway remodelling in rodent models of asthma. It was therefore hypothesised that azithromycin would improve lung function, mucus accumulation and central airway remodelling by decreasing luminal neutrophilia in severe equine asthma. The effects of a 10-day treatment with either azithromycin or ceftiofur, an antimicrobial without immune-modulating activity, were assessed using a blind, randomised, crossover design with six severe asthmatic horses in clinical exacerbation. Lung function, tracheal mucus accumulation, tracheal wash bacteriology, bronchial remodelling, airway neutrophilia and mRNA expression of proinflammatory cytokines (interleukin (IL)-8, IL-17A, IL-1β, tumour necrosis factor-α) in bronchoalveolar lavage fluid were evaluated. Azithromycin decreased the expression of IL-8 (P=0.03, one-tailed) and IL-1β (P=0.047, one-tailed) but failed to improve the other variables evaluated. Ceftiofur had no effect on any parameter. The reduction of neutrophilic chemoattractants (IL-8, IL-1β) justifies further efforts to investigate the effects of a prolonged treatment with macrolides on airway neutrophilia and remodelling. The lack of efficacy of ceftiofur suggests that severe equine asthma should not be treated with antibiotics at first-line therapy.

Salivary Scavenger and Agglutinin (SALSA) Is Expressed in Mucosal Epithelial Cells and Decreased in Bronchial Epithelium of Asthmatic Horses

The Salivary Scavenger and Agglutinin (SALSA) protein is an innate immune protein with various alleged functions, including the regulation of inflammation and tissue remodeling. Transcriptomic studies of severe equine asthma (SEA) showed downregulation of the gene encoding SALSA in bronchial epithelium of asthmatic compared to non-asthmatic horses. This study aimed to characterize expression of SALSA in equine tissues by immunohistochemistry (IHC), corroborate potential differences in epithelial gene expression between asthmatic and non-asthmatic horses, and assess the structure of equine SALSA. An antibody against SALSA was validated through immunoprecipitation followed by mass spectrometry and Western blotting to recognize the equine protein. This antibody was applied to tissue microarrays (TMAs) containing 22 tissues each from four horses. A quantitative PCR assay was designed to compare gene expression for SALSA between six asthmatic and six non-asthmatic horses, before and after an asthmatic challenge, using cDNA from endoscopic bronchial biopsies as source material. The SALSA gene from bronchial cDNA samples of 10 horses, was amplified and sequenced, and translated to characterize the protein structure. Immunostaining for SALSA was detected in the mucosal surfaces of the trachea, bronchi, bronchioles, stomach, small intestine and bladder, in pancreatic and salivary gland ducts, and in uterine gland epithelium. Staining was strongest in the duodenum, and the intercalated ducts and Demilune cells of the salivary gland. SALSA was concentrated in the apical regions of the epithelial cell cytoplasm, suggestive of a secreted protein. Gene expression was significantly lower (p = 0.031) in asthmatic compared to non-asthmatic horses. Equine SALSA consisted of three to five scavenger receptor cysteine-rich (SRCR) domains, two CUB (C1r/C1s, uegf, bmp-1) domains and one Zona Pellucida domain. These domains mediate the binding of ligands involved in innate immunity. Varying numbers of SRCR domains were identified in different horses, indicating different isoforms. In summary, equine SALSA has a predilection for mucosal sites, has multiple isoforms, and has decreased expression in asthmatic horses, suggesting alterations in innate immunity in equine asthma.

The equine asthma model of airway remodeling: from a veterinary to a human perspective

Human asthma is a complex and heterogeneous disorder characterized by chronic inflammation, bronchospasm and airway remodeling. The latter is a major determinant of the structure-function relationship of the respiratory system and likely contributes to the progressive and accelerated decline in lung function observed in patients over time. Corticosteroids are the cornerstone of asthma treatment. While their action on inflammation and lung function is well characterized, their effect on remodeling remains largely unknown. An important hindrance to the study of airway remodeling as a major focus in asthma research is the lack of reliable non-invasive biomarkers. In consequence, the physiologic and clinical consequences of airway wall thickening and altered composition are not well understood. In this perspective, equine asthma provides a unique and ethical (non-terminal) preclinical model for hypothesis testing and generation. Severe equine asthma is a spontaneous disease affecting adult horses characterized by recurrent and reversible episodes of disease exacerbations. It is associated with bronchoalveolar neutrophilic inflammation, bronchospasm, and excessive mucus secretion. Severe equine asthma is also characterized by bronchial remodeling, which is only partially improved by prolonged period of disease remission induced by therapy or antigen avoidance strategies. This review will focus on the similarities and differences of airway remodeling in equine and human asthma, on the strengths and limitations of the equine model, and on the challenges the model has to face to keep up with human asthma research.