The natural history of chronic airflow obstruction

Smoking exposure trajectories and pulmonary function in early adulthood in a Brazilian cohort

OBJECTIVES

To investigate smoking trajectories and their association with pulmonary function (PF) and respiratory symptoms at age 22.

METHODS

Data from a population-based cohort study of 3350 individuals and their spirometries were analysed. The outcomes were: forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), forced expiratory flow at the mid expiratory phase (FEF25-75 %), FEV1/FVC and FEF25-75/FVC ratio. Smoking data were collected at perinatal follow-up (gestational exposure) and 15, 18 and 22 years. Group-based trajectory model was applied.

RESULTS

Four groups were identified: no exposure (NE), gestational (GE), gestational and adulthood (GAE) and continuous (CE) exposure. Both CE and GAE trajectories were associated with lower values of FEV1/FVC (-1.77pp; p = 0.01 and -1.58 pp; p<0.001 respectively) and FEF25-75/FVC ratio (-7.27pp; p = 0.019 and -6.04pp; p<0.001 respectively) compared to the NE trajectory. Lower FEV1 and FEF25-75 % values were also related to the GAE trajectory (-68 ml; p = 0.03 and -253 ml/s; p<0.001 respectively). Compared to those who never smoked, individuals who smoked 10 or more cigarettes daily presented a reduction in the FEV1/FVC ratio by 1.37pp (p<0.001), FEF25-75 % by 126 ml (p = 0.012) and FEF25-75 %/FVC ratio by 3.62pp (p = 0.011). CE trajectory showed higher odds of wheezing (OR 4.14; p<0.001) and cough (OR 2.39; p = 0.002) compared to the non-exposed group.

CONCLUSIONS

The in-uterus exposure to maternal smoking reduces PF later in life. However, the perpetuation of smoking behaviour throughout adolescence and early adulthood is determinant for PF main reduction and the emergence of respiratory-related symptoms.

Comparing Heterogenous Phenotypes of Chronic Obstructive Pulmonary Disease: Network Analysis and Penalized Generalized Linear Model

Background and Objective

Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease, with chronic bronchitis (CB) and emphysema phenotypes. The aim of our study was to compare the distinct patterns of correlation networks for respiratory symptoms and predictors of future exacerbations of different COPD phenotypes.

Methods

CB and emphysema were identified using a questionnaire and computed tomography images, respectively, and also included patients with preserved ratio impaired spirometry (PRISm). We constructed separate correlation networks for each subgroup using Spearman correlation coefficients. Predictors of future exacerbations were selected via least absolute shrinkage and selection operation regression analyses in multivariable analysis.

Results

Among the 3436 patients, 2232 were non-CB, 1131 were CB, 1116 were emphysema, and 73 were PRISm groups. The forced expiratory volume in one second (FEV1) and respiratory symptoms worsened in the following order: PRISm, non-CB, emphysema, and CB groups. During the 1-year follow-up, 17.3%, 21.3%, and 18.9% of patients in the non-CB, CB, and emphysema groups, respectively, experienced exacerbation. Each group showed a distinct correlation pattern between demographic characteristics, comorbidities, pulmonary function, blood biomarkers, respiratory symptoms, and exercise capacity. Across all groups, lower FEV1 (%), higher white blood cell count, higher erythrocyte sedimentation rate, and worse Saint George's Respiratory Questionnaire symptom and total scores were identified as common risk factors for future exacerbations. However, each group showed distinct predictors for future exacerbations.

Conclusion

The correlation network patterns and predictors of future exacerbations varied significantly depending on the COPD phenotype. Further research is required to understand the heterogeneous COPD pathophysiology and facilitate personalized medicine.

Phenotypes and Trajectories of Tobacco-exposed Persons with Preserved Spirometry: Insights from Lung Volumes

Rationale: Among tobacco-exposed persons with preserved spirometry (TEPSs), we previously demonstrated that different lung volume indices-specifically, elevated total lung capacity (TLC) versus elevated ratio of functional residual capacity to TLC (FRC/TLC)-identify different lung disease characteristics in the COPDGene cohort. Objective: We sought to determine differential disease characteristics and trajectories associated with lung volume indices among TEPSs in the SPIROMICS cohort. Methods: We categorized TEPSs (n = 814) by tertiles (low, intermediate, and high) of TLC or residual volume-to-TLC ratio (RV/TLC) derived from baseline computed tomography images and then examined clinical and spirometric disease trajectories in mutually exclusive categories of participants with high TLC without high RV/TLC ([TLC]high) versus high RV/TLC without high TLC ([RV/TLC]high). We examined differences in computed tomography-measured emphysema (Hounsfield units [HU] ⩽-950; parametric response mapping [PRM] of emphysema), air trapping (HU⩽-856; PRM of functional small airway disease; a disease probability measure for non-emphysematous gas trapping), airway geometry (the mean square root of wall area of a hypothetical airway with 10 mm internal perimeter), respiratory symptoms (on the modified Medical Research Council Dyspnea Scale; COPD Assessment Test [CAT]; St. George's Respiratory Questionnaire [SGRQ]; and Short Form-12 [SF12]), and outcomes (annualized exacerbation rate) between the two categories at baseline and over follow-up time up to 8.5 years, using regression modeling adjusted for age, sex, height, weight, and smoking status (current vs. former smoker) and burden (pack-years). Results: In TEPSs, the pattern of spirometric disease progression differed between participants with [TLC]high and those with [RV/TLC]high: There was increased forced vital capacity with stable forced expiratory volume in 1 second in participants with [TLC]high, versus unchanged forced vital capacity but nominally decreased forced expiratory volume in 1 second in those with [RV/TLC]high. Compared with participants with [TLC]high, TEPSs with [RV/TLC]high had less emphysema (by HU ⩽-950) but more airway disease (by HU ⩽-856; PRM of functional small airway disease; disease probability measure for gas trapping, and mean square root of wall area of a hypothetical airway with 10 mm internal perimeter), more respiratory symptoms (on the modified Medical Research Council Dyspnea Scale, CAT, SGRQ, and SF12), and more severe exacerbations at baseline. Over an average follow-up of 4.1 ± 2.4 years (range = 0.5-8.5 yr), TEPSs with [RV/TLC]high also had a higher likelihood of developing more severe spirometric disease (preserved ratio impaired spirometry or Global Initiative for Chronic Obstructive Lung Disease Classification 2) and worsening of their respiratory symptoms (on the CAT and SGRQ). Although the incidence rates of respiratory exacerbations, hospitalizations, and mortality were not significantly different between the two categories over the follow-up period, TEPSs with [RV/TLC]high were more likely to have been prescribed a respiratory inhaler at their last follow-up visit. Conclusions: In these TEPSs from the SPIROMICS cohort, lung volume stratification by TLC versus RV/TLC identifies two pre-COPD phenotypes with distinct respiratory symptoms, radiographic features, and clinical trajectories. The characteristics of these pre-COPD phenotypes match those previously described in the COPDGene cohort using TLC versus FRC/TLC stratification.

Inferring forced expiratory volume in 1 second (FEV1) from mobile ECG signals collected during quiet breathing

Objective.Forced expiratory volume in one second (FEV1) is an important metric for patients to track at home for their self-management of asthma and chronic obstructive pulmonary disease (COPD). Unfortunately, the state-of-the-art for measuring FEV1 at home either depends on the patient's physical effort and motivation, or relies on bulky wearable devices that are impractical for long-term monitoring. This paper explores the feasibility of using a machine learning model to infer FEV1 from 270 seconds of a single-lead electrocardiogram (ECG) signal measured on the fingers with a mobile device.Methods.We evaluated the model's inferred FEV1 values against the ground truth of hospital-grade spirometry tests, which were performed by twenty-five patients with obstructive respiratory disease.Results.The model-inferred FEV1 compared to the spirometry-measured FEV1 with a correlation coefficient ofr = 0.73, a mean absolute percentage error of 23% and a bias of -0.08.Conclusions.These results suggest that the ECG signal contains useful information about FEV1, although a larger, richer dataset might be necessary to train a machine learning model that can extract this information with better accuracy.Significance.The benefit of a mobile ECG-based solution for measuring FEV1 is that it would require minimal effort, thus encouraging patient adherence and promoting successful self-management of asthma and COPD.

Nonlinear association between serum 25-hydroxyvitamin D concentrations and lung function in the United States adult population with COPD

Vitamin D has been studied for its potential protective effects against lung function decline in patients with COPD. However, conflicting results exist, the actual effect of vitamin D on lung function remains controversial. This study aimed to determine whether serum 25-hydroxyvitamin D (25-OHD) levels are correlated with lung function in community-dwelling individuals with COPD. We used data from the National Health and Nutrition Examination Survey (NHANES) to explore the relationship between serum 25-OHD concentration and the severity of airflow obstruction. Multivariable logistic regression, stratified analysis with interaction, restricted cubic splines (RCS), and threshold effect analysis were used to investigate the association between serum 25-OHD concentration and lung function.A total of 1384 patients with COPD were analyzed. Accordingly, the association between serum 25-OHD concentrations and lung function exhibited an inverse L-shaped curve in the RCS. Threshold analysis showed that in participants with 25-OHD concentrations < 90 nmol/L, lung function decreased with decrease in serum 25-OHD concentrations, whereas no significant association was observed in those with serum 25-OHD concentrations ≥ 90 nmol/L. An inverse L-shaped relationship was observed between serum 25-OHD concentration and airflow obstruction severity in the adult population with COPD in the United States.

Association of neutrophil-to-lymphocyte ratio and CRP with spirometry in COPD patients in North India

Background

Patients with chronic obstructive pulmonary disease (COPD) who have high serum levels of C-reactive protein (CRP), a marker of low-grade systemic inflammation, exhibit reduced lung functions and a worse prognosis. The neutrophil-to-lymphocyte ratio (N/L ratio, NLR), obtained from a complete blood count, is an inexpensive and easily accessible inflammation marker. The NLR has proven useful in assessing the risk for patients with various cardiovascular conditions, different types of solid tumours, sepsis, and infectious diseases. Research indicates that COPD patients have significantly higher NLR values compared to healthy controls of the same age and sex, with these values increasing even more during acute COPD exacerbations compared to stable periods. Hence, identifying non-invasive and cost-effective tools to assess the severity of COPD in the PHC/CHC level would be beneficial as an early intervention.

Aim

To study the relationship between N/L ratio and CRP levels and spirometry in COPD patients.

Settings and Study Design

Observational cross-sectional study.

Methods and Material

A total of 100 patients of an age > 40 years with a confirmed diagnosis of COPD according to GOLD (Global Initiative COPD patients) criteria were selected. With an informed consent, blood sample collection for N/L ratio and CRP along with spirometry was performed in all the patients.

Statistical Analysis Used

SPSS software with Student t-test, Chi-square t-test, ANOVA, and Spearman correlation with 95% CI is used. P <0.05 is considered significant.

Results

NLR was observed to be higher in the moderate grade of COPD patients. All the patients were observed with an abnormal (>5 mg/L) CRP level. FEV1, FVC%, FEV1/FVC%, N/L ratio, and CRP were significantly (P < 0.0001*) associated with severity COPD according to GOLD criteria.

Conclusions

This study concludes that the FEV1, FVC, and FEV1/FVC ratio were lower in severe COPD patients, and it also reveals that individuals with severe COPD have elevated levels of serum CRP and N/L ratio, which correlates with the severity of COPD. Elevated N/L ratio and CRP level may be used as non invasive predictors and cost-effective tools for COPD patients at the Primary health centre level for screening of the severity of COPD patients.

Molecular Approaches to Treating Chronic Obstructive Pulmonary Disease: Current Perspectives and Future Directions

Chronic obstructive pulmonary disease (COPD) is a clinical syndrome that presents as airflow limitation with poor reversibility accompanied by dynamic hyperinflation of the lung. It is a complex disease with chronic inflammatory airway changes caused by exposure to noxious particles or gases, such as cigarette smoke. The disease involves persistent inflammation and oxidative stress, perpetuated by frequent exacerbations. The prevalence of COPD is on the rise, with the prediction that it will be the leading cause of morbidity and mortality over the next decade. Despite the global burden of COPD and its associated morbidity and mortality, treatment remains limited. Although the understanding of the pathogenesis of COPD has increased over the last two decades, molecular approaches to develop new therapies for the treatment of COPD have lagged. Here, we review the molecular approaches that have the potential for developing novel therapies for COPD.

Diffusion capacity and static hyperinflation as markers of disease progression predict 3-year mortality in COPD: Results from COSYCONET

BACKGROUND AND OBJECTIVE

Chronic obstructive pulmonary disease (COPD) exhibits diverse patterns of disease progression, due to underlying disease activity. We hypothesized that changes in static hyperinflation or KCO % predicted would reveal subgroups with disease progression unidentified by preestablished markers (FEV1, SGRQ, exacerbation history) and associated with unique baseline biomarker profiles. We explored 18-month measures of disease progression associated with 18-54-month mortality, including changes in hyperinflation parameters and transfer factor, in a large German COPD cohort.

METHODS

Analysing data of 1364 patients from the German observational COSYCONET-cohort, disease progression and improvement patterns were assessed for their impact on mortality via Cox hazard regression models. Association of biomarkers and COPD Assessment test items with phenotypes of disease progression or improvement were evaluated using logistic regression and random forest models.

RESULTS

Increased risk of 18-54-month mortality was linked to decrease in KCO % predicted (7.5% increments) and FEV1 (20 mL increments), increase in RV/TLC (2% increments) and SGRQ (≥6 points), and an exacerbation grade of 2 at 18 months. Decrease in KCO % predicted ≥7.5% and an increase of RV/TLC ≥2% were the most frequent measures of 18-month disease progression occurring in ~52% and ~46% of patients, respectively. IL-6 and CRP thresholds exhibited significant associations with medium- and long-term disease measures.

CONCLUSION

In a multicentric cohort of COPD, new markers of current disease activity predicted mid-term mortality and could not be anticipated by baseline biomarkers.

Remote Spirometry, Education, and Action for COPD Diagnosis and Management in Rural and Medically Underserved Settings in South Carolina: Protocol for an Observational Feasibility Study

Individuals living in rural or medically underserved areas (MUA) with chronic obstructive pulmonary disease (COPD) face significant barriers to specialised pulmonary care, including pulmonologists, diagnostic spirometry, and pulmonary rehabilitation. Remote spirometry for diagnostic screening and disease monitoring may mitigate access barriers and contribute to improved COPD management in this population. This study protocol describes the proposed implementation of a Mobile Health (mHealth) intervention using Bluetooth-enabled portable spirometry combined with a mobile disease management platform.

OBJECTIVE

The purpose of this study is to evaluate the acceptability and feasibility of an mHealth intervention with Bluetooth-enabled remote spirometry for remote patient monitoring of patients with COPD who are living in rural and/or medically underserved areas of South Carolina. Our exploratory aim is to investigate the potential benefits of remote monitoring and telehealth education on disease symptoms, dyspnoea, and COPD management. Our long-term goal is to expand access, employ evidence-based data, and support shared decision-making in diagnosing and managing underserved patients with COPD.

METHODS

This is a 2-stage prospective observational study. In stage 1, healthcare providers who care for this population will participate in a focus group to explore provider perspectives and preferences toward implementation of remote spirometry in a medically underserved setting. Potential barriers and facilitators will be identified, and if needed, study implementation procedures will be refined based on provider feedback. In stage 2, a target of 120 adults with COPD will be recruited using a combination of direct study referrals, cold contact methods, community partners' recruitment, flyers, and social media posts. Screened and consented subjects will receive training on using the mHealth application and remote spirometer. Survey measures will be collected at baseline and repeated at months 1, 3, and 6, followed by an exit survey at the study conclusion. Using end-of-study questionnaire and repeated measures, we will evaluate feasibility by obtaining variability estimates for secondary outcome measures. Semi-structured key informant interviews will be conducted to explore patient preferences, potential barriers, acceptability, and recommendations for future intervention refinement.

CONCLUSION

An mHealth intervention using Bluetooth-enabled remote portable spirometry is a potential solution to expanding healthcare access and improving outcomes in under-resourced populations at risk for increased morbidity and mortality. This study will evaluate the acceptability and feasibility of mHealth and remote monitoring, including symptom reporting among at-risk under-resourced adults with COPD.

Comparative analysis of pulmonary function decline in patients undergoing bronchoscopic lung volume reduction with endobronchial valves versus conservative treatment in emphysema management: A longitudinal coarsened exact matched analysis

BackgroundChronic obstructive pulmonary disease (COPD) and emphysema display a chronic and progressive disease for the individual patient. The forced expiratory volume in one second (FEV1) is declining with age as displayed in the Fletcher-Peto curve. Despite established benefits of bronchoscopic lung volume reduction (BLVR) using endobronchial valves (EBVs), long-term data suggest a gradual reduction in the magnitude of these benefits.PurposeThis study aimed to compare the rate of lung function change in emphysema patients undergoing BLVR versus those receiving conservative management, utilizing coarsened exact matching to ensure balanced baseline characteristics.Patients and MethodsIn this retrospective single center study data between 2015 and 2021 was analyzed. BLVR patients achieving significant volume reduction (≥563 mL) were matched to conservatively managed controls based on age, sex, BMI, and smoking history. Pulmonary function changes after successful BLVR with valves, including forced expiratory volume in one second (FEV1) and residual volume (RV), were monitored and analyzed over a 3-year period.ResultsA total of 60 patients, evenly distributed between the two groups (30 each), were included in the analysis. Median FEV1 change was -0.063 L/year for BLVR patients and -0.066 L/year for controls. No statistically significant differences in annual FEV1 and RV changes were observed (-0.07 vs -0.08, p = 0.492; -0.07 vs -0.07, p = 0.569; -0.05 vs -0.04, p = 0.636 at follow-ups in years 1, 2, and 3, respectively for FEV1 and +0.20 vs +0.25, p = 0.643; +0.80 vs +0.65, p = 0.960; +1.0 vs +0.85, p = 0.963 at follow-ups in years 1, 2, and 3, respectively for RV).ConclusionIn this matched cohort analysis, no significant differences in annual changes in FEV1 or RV progression were observed between patients after successful BLVR with valves and patients under conservative treatment. The results indicate that COPD progression is the main factor for the decline in functional improvement after successful BLVR with valves.

Contrasting the clinical and biological characteristics of young and old COPD patients

Background

The ECLIPSE study was a large, international, prospective, controlled, observational study that included COPD patients (Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades 2-4), as well as smoking and non-smoking participants with normal spirometry, aged 40-75 years, who were followed-up regularly for 3 years. Here we sought to contrast the clinical and biological characteristics of young COPD versus controls of similar age and older COPD patients included in ECLIPSE.

Methods

We compared 106 young (<50 years) and 488 old (>70 years) COPD patients, as well as 119 young smokers and 92 nonsmoker controls (<50 years) with normal spirometry.

Results

Young COPD patients: 1) were more symptomatic than young controls, often reported a family history of chronic bronchitis, emphysema and asthma, as well as a personal history of asthma and bronchitis, and suffered from a similar disease burden to older patients; 2) were at higher risk of substantial forced expiratory volume in 1 s decline over time; and 3) had reduced serum levels of CC16 (a lung-derived anti-inflammatory protein that relates to lung damage) and, at the same time, reduced pro-inflammatory markers compared to older COPD patients.

Conclusions

Young COPD patients suffer from significant disease burden, display an altered biomarker and disease progression profile reflected by an accelerated risk of lung function decline highlighting the need for early life diagnosis, prevention approaches and treatment.

Clinical Characteristics of Chronic Obstructive Pulmonary Disease according to Smoking Status

Chronic obstructive pulmonary disease (COPD) can be caused by various factors, including lung infections, asthma, air pollution, childhood growth disorders, and genetic factors, though smoking is the predominant risk factor. The main pathological mechanisms in COPD involve small airway disease, emphysema, mucus hypersecretion, and vascular disorders. COPD in non-smokers is characterized by a normal 1-second forced expiratory volume decline, equal sex distribution, younger age of onset, fewer comorbidities, milder airflow obstruction, preserved diffusing capacity of the lungs for carbon monoxide, and radiological features such as more air-trapping and less severe emphysema compared to COPD in smokers. Nevertheless, non-smokers with COPD still experience a high prevalence of acute exacerbations, nearly equal to that of smokers with COPD. Moreover, COPD itself is an independent risk factor for developing lung cancer, regardless of smoking status. Given that COPD coexists with numerous comorbidities, effectively managing these comorbidities is crucial, requiring multifaceted efforts for comprehensive treatment.

Comparison of STAR and GOLD in Assessing Disease Severity Among High-Risk and COPD Patients: Evidence from Enjoying Breathing Program in China

Background

The STAR staging standard has been demonstrated to have good performance in distinguishing mortality among patients at different stages. However, the effectiveness of STAR and GOLD staging in distinguishing disease severity in high-risk and COPD patients remained unclear.

Methods

Based on Enjoying Breathing Program data through June 2023, a total of 7.924 high-risk and COPD patients were included. STAR and GOLD severity stages were based on FEV1/FVC (0.6-0.7, 0.5-0.6, 0.4-0.5, and <0.4 for stage 1 to 4 in STAR) and the proportion of predicted FEV1 value (≥80%, 50%-80%, 30%-50%, and <30% for stage 1 to 4 in GOLD), respectively. The cox regression model was used to assess the risk of medical visit due to severe respiratory symptoms according to STAR and GOLD.

Results

The current study included 1603 high-risk individuals and 6321 COPD patients. The proportions of STAR 1-4 in COPD patients were 37.1%, 33.2%, 20.5%, and 9.2%, respectively. In COPD patients only, GOLD stage distinguished disease severity well, but there was no difference in the risk of exacerbation between the different STAR stage groups. In addition, in COPD patients, by considering of GOLD and STAR together, GOLD 3 and 4 can provide more information about the exacerbation based on each STAR level, and STAR 1 and 2 can provide more information about the exacerbation in GOLD 2-4. COPD patients with GOLD 4 and STAR 2 (HR=4.08, 95% CI: 2.75-6.04) had the highest risk of exacerbation, followed by COPD patients with GOLD 4 and STAR 1 (HR=3.94, 95% CI: 2.49-6.23).

Conclusion

In COPD patients, GOLD performs better than STAR in predicting exacerbation risk. In addition, the combination of GOLD and STAR can provide more information, especially for COPD patients with GOLD 4 and STAR 1-2, which should be paid more attention in treatment and disease management.

Prenatal Origins of Obstructive Airway Disease: Starting on the Wrong Trajectory?

From the results of well-performed population health studies, we now have excellent data demonstrating that deficits in adult lung function may be present early in life, possibly as a result of developmental disorders, incurring a lifelong risk of obstructive airway diseases such as asthma and chronic obstructive pulmonary disease. Suboptimal fetal development results in intrauterine growth restriction and low birth weight at term (an outcome distinct from preterm complications), which are associated with subsequent obstructive disease. Numerous prenatal exposures and disorders compromise fetal development and these are summarized herein. Various physiological, structural, and mechanical abnormalities may result from prenatal disruption, including changes to airway smooth muscle structure-function, goblet cell biology, airway stiffness, geometry of the bronchial tree, lung parenchymal structure and mechanics, respiratory skeletal muscle contraction, and pulmonary inflammation. The literature therefore supports the need for early life intervention to prevent or correct growth defects, which may include simple nutritional or antioxidant therapy. © 2024 American Physiological Society. Compr Physiol 14:5729-5762, 2024.

Duration and Frequency of Spirometry Needed to Accurately Reflect Annualized Change of FEV1 in Chronic Obstructive Pulmonary Disease

Rationale: The slope of decline in forced expiratory volume in 1 second (FEV1) is commonly used to reflect the rate of disease progression for descriptive studies and therapeutic trials in chronic obstructive pulmonary disease (COPD). The frequency and duration of spirometric testing needed to report the true slope are unknown. Objectives: We sought to define the minimum frequency and follow-up duration needed to accurately describe the annualized rate of FEV1 change among patients with moderate to very severe COPD. Methods: We performed a post hoc analysis of the annualized rate of FEV1 change among 4,412 subjects previously enrolled in the 4-year Understanding Potential Long-Term Impacts on Function with Tiotropium-or, UPLIFT-trial of tiotropium versus placebo. Slope estimates were modeled for different iterations of semiannual or annual testing over a variable duration up to 42 months. All models were compared with a reference of semiannual spirometry for 42 months. Results: The overall annual rate of postbronchodilator FEV1 decline measured semiannually for 42 months (44.6 ml; 95% confidence interval [CI] = 42.5-46.6) did not differ significantly from annual spirometry over the same period (43.7 ml; 95% CI = 41.3-46.1) or semiannual spirometry over the first 2 years (44.3 ml; 95% CI = 41.1-47.5). Agreement was consistent for two follow-up values as far as 24 months apart (43.3 ml; 95% CI = 39.9-46.8). Models that are based on less than two follow-up values or a duration less than 18 months were characterized by relative underestimation of the slope. Conclusions: In a large cohort of patients with moderate to very severe COPD, the annualized rate of change in FEV1 was accurately represented by a minimum of two annual follow-up measurements over 18 months compared with semiannual testing over 42 months.

Informing community pharmacists on COPD case-finding methods: A scoping review

Background

Early detection of chronic obstructive pulmonary disease (COPD) is a strategy to address the increasing human and economic costs of this condition. This study aimed to inform pharmacists' case-finding strategies by providing an overview of case-finding approaches by health care practitioners.

Methods

A scoping review was conducted based on the Joanna Briggs Institute and the PRISMA Extension for Scoping Reviews (PRISMA ScR) guidelines. Included studies were analyzed under the following themes: population characteristics, inclusion and exclusion criteria, setting, case-finding strategies and yield, health care practitioners involved, interprofessional collaboration and the provision of preventive services. Studies were then characterized by highest yields (the weighted average of each approach expressed as a percentage of the total number of new COPD cases divided by the total number of patients screened using the same approach).

Results

The screening process produced 170 eligible studies. Twenty case-finding approaches with average yields of new COPD cases ranging from 3.8% to 29% were identified. The approach with the highest yield involved the use of a questionnaire, peak flow meter and pre-post spirometry. In 14 of these approaches, the process was initiated with the use of questionnaires. In many of the studies, case-finding was targeted at high-risk and/or symptomatic patients. Characteristics of studies with the highest case-finding yields included provider education/training, patient education, active screening, multistep approaches to case-finding, provider engagement, diagnostic criteria by guidelines and engagement of other health care practitioners.

Conclusion

In our scoping review of case-finding methods for patients with COPD, we found the greatest yield from pre-post spirometry following initial screening with a peak flow meter and questionnaire. Pharmacists and health researchers can use these approaches to identify high-risk patients for interventions.

Estimating rate of lung function change using clinical spirometry data

RATIONALE

In chronic obstructive pulmonary disease (COPD), accurately estimating lung function from electronic health record (EHR) data would be beneficial but requires addressing complexities in clinically obtained testing. This study compared analytic methods for estimating rate of forced expiratory volume in one second (FEV1) change from EHR data.

METHODS

We estimated rate of FEV1 change in patients with COPD from a single centre who had ≥3 outpatient tests spanning at least 1 year. Estimates were calculated as both an absolute mL/year and a relative %/year using non-regressive (Total Change, Average Change) and regressive (Quantile, RANSAC, Huber) methods. We compared distributions of the estimates across methods focusing on extreme values. Univariate zero-inflated negative binomial regressions tested associations between estimates and all-cause or COPD hospitalisations. Results were validated in an external cohort.

RESULTS

Among 1417 participants, median rate of change was approximately -30 mL/year or -2%/year. Non-regressive methods frequently generated erroneous estimates due to outlier first measurements or short intervals between tests. Average change yielded the most extreme estimates (minimum=-3761 mL/year), while regressive methods, and Huber specifically, minimised extreme estimates. Huber, Total Change and Quantile FEV1 slope estimates were associated with all-cause hospitalisations (Huber incidence rate ratio 0.98, 95% CI 0.97 to 0.99, p<0.001). Huber estimates were also associated with smoking status, comorbidities and prior hospitalisations. Similar results were identified in an external validation cohort.

CONCLUSIONS

Using EHR data to estimate FEV1 rate of change is clinically applicable but sensitive to challenges intrinsic to clinically obtained data. While no analytic method will fully overcome these complexities, we identified Huber regression as useful in defining an individual's lung function change using EHR data.

Predictors of lung function in early adulthood: A population-based cohort study

BACKGROUND AND OBJECTIVE

Lung function reaches a peak/plateau in early adulthood before declining with age. Lower early adult lung function may increase the risk for chronic obstructive pulmonary disease (COPD) in mid-late adult life. Understanding the effects of multiple childhood/adolescent exposures and their potential interactions on plateau lung function would provide insights into the natural history of COPD.

METHODS

Longitudinal spirometry data from 688 participants with complete data from a population-based birth cohort (original n = 1037) were used to investigate associations between a wide range of childhood/adolescent exposures and repeated measures of FEV1, FVC and FEV1/FVC during the early-adult plateau phase. Generalized estimating equations were used to accommodate the multiple timepoints per participant.

RESULTS

FEV1 reached a peak/plateau between ages 18 and 26 and FVC from 21 to 32 years, whereas FEV1/FVC declined throughout early adulthood. Childhood asthma and airway hyperresponsiveness were associated with lower early adult FEV1 and FEV1/FVC. Smoking by age 18 was associated with lower FEV1/FVC. Higher BMI during early adulthood was associated with lower FEV1 and FVC and lower FEV1/FVC. Physical activity during adolescence was positively associated with FEV1 and FEV1/FVC but this was only statistically significant in men. There was no convincing evidence of interactions between exposures.

CONCLUSION

Childhood asthma and airway hyperresponsiveness are associated with lower lung function in early adulthood. Interventions targeting these may reduce the risk of COPD in mid-late adult life. Promotion of physical activity during adolescence, prevention of cigarette smoking and maintenance of a healthy body weight in early adulthood are also priorities.

Reducing the risk of death - a possible outcome in COPD patients

INTRODUCTION

COPD is a leading cause of global mortality, particularly under-recognized and under-diagnosed. In 2020, it was the sixth leading cause of death in the US and has contributed to 4.72% of all-cause mortality (ACM) according to the Global Burden of Disease Study 2017. Factors influencing COPD-related mortality include smoking, aging populations, comorbidities, sarcopenia, physical capacity, and lack of effective treatments.

AREAS COVERED

This review discusses various factors influencing COPD-related mortality and analyzes observational studies and pivotal RCTs evaluating the impact of different therapies on ACM.

EXPERT OPINION

COPD significantly impacts ACM, necessitating effective management strategies. Smoking cessation is crucial in reducing mortality risk. Exacerbation management and comorbidity treatment are essential to improve patient outcomes. Various therapeutic interventions, such as smoking cessation, vaccination, long-term oxygen therapy, and lung volume reduction surgery, have shown benefits in reducing mortality. Pharmacotherapies might reduce the risk of mortality, although the current scientific evidences remain inconclusive. Advances in pharmacological interventions, tailored treatment plans, and physical activity programs are vital. More robust and long-term studies, focusing on real-world data and addressing biases in treatment allocation, are needed to conclusively determine the efficacy of different therapies in reducing ACM in COPD patients.

Single-Breath Simultaneous Measurement of DLNO and DLCO as Predictor of the Emphysema Component in COPD - A Retrospective Observational Study

Background

Chronic Obstructive Pulmonary Disease (COPD) is a respiratory condition characterized by heterogeneous abnormalities of the airways and lung parenchyma that cause different clinical presentations. The assessment of the prevailing pathogenetic components underlying COPD is not usually pursued in daily practice, also due to technological limitations and cost.

Aim

To assess non-invasively the lung emphysema component of COPD by the simultaneous measurement of DLNO and DLCO via a single-breath (sDLNO and sDLCO).

Methods

COPD patients aged ≥40 years of both genders were recruited consecutively and labelled by computed tomography as "with significant" emphysema (>10% of CT lung volume) or "with negligible" emphysema otherwise. Current lung function tests such as sDLNO, sDLCO and Vc (the lung capillary blood volume) were measured. All possible subsets of independent spirometric and diffusive parameters were tested as predictors of emphysema, and their predicted power compared to each parameter alone by ROC analysis and area under the curve (AUC).

Results

Thirty-one patients with "significant emphysema" were compared to thirty-one with "negligible emphysema". FEV1 and FEV1/FVC seemed to be the best spirometric predictors (AUC 0.80 and 0.81, respectively), while sDLCO and Vc had the highest predicted power among diffusive parameters (AUC 0.92 and 0.94, respectively). sDLCO and Vc values were the parameters most correlated to the extent of CT emphysema. Six subsets of independent predictors were identified and included at least one spirometric and one diffusive parameter. According to goodness-to-fit scores (AIC, BIC, log-likelihood and pseudo R2), RV coupled with sDLCO or Vc proved the best predictors of emphysema.

Conclusion

When investigating the parenchymal destructive component due to emphysema occurring in COPD, sDLNO, sDLCO and Vc do enhance the predictive power of current spirometric measures substantially. sDLNO, sDLCO and Vc contribute to phenotype of the main pathogenetic components of COPD easily and with high sensitivity. Organizational problems, radiation exposure, time and costs could be reduced, while personalized and precision medicine could be noticeably implemented.

Proteomic Risk Score of Increased Respiratory Susceptibility: A Multi-Cohort Study

RATIONALE

Accelerated decline in lung function is associated with incident COPD, hospitalizations and death. However, identifying this trajectory with longitudinal spirometry measurements is challenging in clinical practice.

OBJECTIVE

To determine whether a proteomic risk score trained on accelerated decline in lung function can assess risk of future respiratory disease and mortality.

METHODS

In CARDIA, a population-based cohort starting in young adulthood, longitudinal measurements of FEV1 percent predicted (up to six timepoints over 30 years) were used to identify accelerated and normal decline trajectories. Protein aptamers associated with an accelerated decline trajectory were identified with multivariable logistic regression followed by LASSO regression. The proteomic respiratory susceptibility score was derived based on these circulating proteins and applied to the UK Biobank and COPDGene studies to examine associations with future respiratory morbidity and mortality.

MEASUREMENTS AND RESULTS

Higher susceptibility score was independently associated with all-cause mortality (UKBB: HR 1.56, 95%CI 1.50-1.61; COPDGene: HR 1.75, 95%CI 1.63-1.88), respiratory mortality (UKBB: HR 2.39, 95% CI 2.16-2.64; COPDGene: HR 1.83, 95%CI 1.33-2.51), incident COPD (UKBB: HR 1.84, 95%CI 1.71-1.98), incident respiratory exacerbation (COPDGene: OR 1.11, 95%CI 1.03-1.20), and incident exacerbation requiring hospitalization (COPDGene: OR 1.18, 95%CI 1.08-1.28).

CONCLUSIONS

A proteomic signature of increased respiratory susceptibility identifies people at risk of respiratory death, incident COPD, and respiratory exacerbations. This susceptibility score is comprised of proteins with well-known and novel associations with lung health and holds promise for the early detection of lung disease without requiring years of spirometry measurements.

Corticosteroid Prescribing Patterns in the Emergency Department for Acute COPD Exacerbations: A Retrospective Analysis Following an Educational Intervention

INTRODUCTION

COPD is a progressive lung disease with marked airflow limitation. It has a large global prevalence and is managed with antibiotics, bronchodilators, and corticosteroids. Despite the prevalence, corticosteroid prescribing regimens differ widely amongst providers. This study aims to evaluate baseline corticosteroid prescribing patterns, the ability to change corticosteroid prescribing patterns with the utilization of an educational initiative, and to evaluate the effect of corticosteroid dose on length of stay, 30-day hospital readmission, mortality, and total hospital insulin dosing.

METHODS

This study was conducted via a retrospective observational study. Providers at a single institution answered a baseline questionnaire on COPD corticosteroid prescribing patterns and subsequently received an educational presentation regarding evidence-based corticosteroid recommendations. Data were then retrospectively obtained and analyzed evaluating corticosteroid prescribing patterns both pre- and post-educational intervention. Data were analyzed using IBM SPSS Version 25.

RESULTS

The provider survey revealed that most (95.3%) administered 125 mg of methylprednisolone to patients treated for AECOPD. The most common reason a particular dose of corticosteroid was administered was due to previous teaching or practice patterns. The mean initial steroid dose of methylprednisolone decreased following the educational initiative from 114.24 mg to 72.8 mg (p < 0.01). This corresponded to a 69% (n=41) decrease of providers using 125 mg methylprednisolone (p < 0.01), and increased prescribing of 62.5 mg methylprednisolone by 42.6% (n=66). The mean LOS following hospital admission for AECOPD in the pre-intervention group was 5.80 days, while the mean LOS following the targeted educational intervention decreased to 4.82 days (p = 0.01).

CONCLUSIONS

The implementation of an educational intervention may change provider corticosteroid prescribing patterns. Additionally, lower corticosteroid dose in the Emergency Department may decrease patient length of stay. Keywords: Corticosteroid, COPD, LOS, recommendations, steroid.

SPECT/CT to quantify early small airway disease and its relationship to clinical symptoms in smokers with normal lung function: a pilot study

Introduction

Smokers frequently display respiratory symptoms despite the fact that their pulmonary function tests (PFTs) can be normal. Quantitative lung ventilation single-photon emission computed tomography (SPECT/CT) can provide a quantification of lung ventilatory homogeneity and could prove useful as an early marker of airway disease in smokers. We measured the effects of smoking on regional ventilation distribution in subjects with normal lung function and evaluated whether ventilation distribution in these subjects is related to lung function tests results and clinical symptoms.

Methods

Subjects without any history of respiratory disease were prospectively recruited and separated in two groups: active smokers (AS: ≥10 cigarettes/day and history of ≥15 pack-years) and never smokers (NS: lifetime exposure of <5 cigarettes). All subjects performed PFTs (which had to be normal, defined as z-score values of forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC ratio, total lung capacity (TLC) residual volume and diffusion capacity (DLCO) all falling between -1.65 and +1.65) and underwent SPECT/CT with Technegas, which generated subject- specific ventilation heterogeneity maps. The area under the compensated coefficient of variation (CV) density curve for CV values > 40%, (AUC-CV40%) was used as the measure of ventilation heterogeneity.

Results

30 subjects were recruited (15 per group). Subjects in the AS group displayed higher dyspnea levels (1 [1-2] vs. 0 [0-1] units on mMRC scale, p < 0.001). AUC- CV40% was significantly higher in the AS group (0.386 ± 0.106 vs. 0.293 ± 0.069, p = 0.004). AUC-CV40% was significantly correlated to FEV1 (rho = -0.47, p = 0.009), DLCO (rho = -0.49, p = 0.006), CAT score (rho = 0.55, p = 0.002) and mMRC score (rho = 0.54, p = 0.002). Subjects with mMRC >0 had higher AUC-CV40% values than those without dyspnea (0.289 ± 0.071 vs. 0.378 ± 0.102, p = 0.006), while FEV1 and DLCO were not different between those groups. ROC analyses showed that the AUC for AUC-CV40% in identifying subjects with mMRC score >0 was 0.78 (95%CI 0.61-0.95, p = 0.009), which was significantly higher than that of FEV1 and DLCO.

Discussion

In smokers with normal lung function, ventilatory inhomogeneities can be quantified using SPECT/CT. AUC-CV40% values are related to lung function decline and to respiratory symptomatology, suggesting a potential role for this marker in the evaluation of symptomatic smokers.

The cGAS-STING pathway in COPD: targeting its role and therapeutic potential

Chronic obstructive pulmonary disease(COPD) is a gradually worsening and fatal heterogeneous lung disease characterized by airflow limitation and increasingly decline in lung function. Currently, it is one of the leading causes of death worldwide. The consistent feature of COPD is airway inflammation. Several inflammatory factors are known to be involved in COPD pathogenesis; however, anti-inflammatory therapy is not the first-line treatment for COPD. Although bronchodilators, corticosteroids and roflumilast could improve airflow and control symptoms, they could not reverse the disease. The cyclic GMP-AMP synthase-stimulator of interferon genes (cGAS-STING) signaling pathway plays an important novel role in the immune system and has been confirmed to be a key mediator of inflammation during infection, cellular stress, and tissue damage. Recent studies have emphasized that abnormal activation of cGAS-STING contributes to COPD, providing a direction for new treatments that we urgently need to develop. Here, we focused on the cGAS-STING pathway, providing insight into its molecular mechanism and summarizing the current knowledge on the role of the cGAS-STING pathway in COPD. Moreover, we explored antagonists of cGAS and STING to identify potential therapeutic strategies for COPD that target the cGAS-STING pathway.

Causal inference analysis of the radiologic progression in the chronic obstructive pulmonary disease

There is limited evidence regarding the causal inference of emphysema and functional small airway disease in the subsequent progression of chronic obstructive pulmonary disease (COPD). Patients consisting of two independent cohorts diagnosed with COPD and underwent two serial chest CT scans were included. Total percent emphysema (PRMEmph) and fSAD (PRMfSAD) was quantified via PRM. To investigate the progression of emphysema, we divided COPD patients with PRMEmph < 10% into low and high PRMfSADgroup, matched with similar baseline characteristics, and conducted nonparametric hypothesis tests based on randomization inference using Wilcoxon signed rank test and Huber's M statistics. In patients with baseline PRMEmph < 10%, there were 26 and 16 patients in the low PRMfSA group and 52 and 64 patients in the high PRMfSA in the derivation and validation cohorts, respectively. In the both low and high PRMfSAD groups, there were 0.11 and 1.43 percentage point increases (Huber's M statistic p = 0.016) and 0.58 and 2.09 percentage point increases (p = 0.038) in the proportion of emphysema in the derivation and validation cohorts, respectively. On the contrary, among patients with baseline PRMfSAD < 20%, there was no significant differences in the interval changes of PRMfSAD between the low and high PRMEmph groups in both cohorts. In COPD patients with low emphysema, group with baseline high PRMfSAD showed greater change of PRMEmph than those with low PRMfSAD in both the derivation and validation cohorts. Imaging-based longitudinal quantitative analysis may provide important evidence that small airway disease precedes emphysema in CT-based early COPD patients.

Distinct trajectories of lung function from childhood to mid-adulthood

RATIONALE

Life course trajectories of lung function development and decline influence the risk for lung disease but are poorly documented.

OBJECTIVE

To document lung function trajectories from childhood to mid-adult life.

METHODS

We modelled forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and FEV1/FVC at ages 9, 11, 13, 15, 18, 21, 26, 32, 38 and 45 years from a population-based cohort using latent profile analysis to identify distinct subgroups of participants with similar lung function trajectories. Regression analyses were used to assess associations between the trajectories, early life factors and postbronchodilator airflow obstruction at age 45.

RESULTS

Among 865 participants with ≥6 measures of lung function, we identified 10 distinct FEV1 trajectories. Most were approximately parallel except for a childhood airway hyper-responsiveness-related persistently low trajectory (3% of study population); two accelerated-decline trajectories, one of which (8%) was associated with smoking and higher adult body mass index (BMI) and a catch-up trajectory (8%). Findings for FEV1/FVC trajectories were similar. Nine trajectories were identified for FVC: most were also approximately parallel except for a higher BMI-related accelerated-decline trajectory. The three FEV1 trajectories leading to the lowest FEV1 values comprised 19% of the cohort but contributed 55% of airflow obstruction at age 45.

CONCLUSIONS

Lung function trajectories to mid-adult life are largely established before adolescence, with a few exceptions: a childhood airway hyper-responsiveness-related persistently low trajectory, which starts low and gets worse with age, and accelerated adult decline trajectories associated with smoking and obesity. Adverse trajectories are associated with a high risk of airflow obstruction in mid-adult life.

The severity of non-smoking chronic obstructive pulmonary disease is correlated with biomass fuel exposure and COPD assessment test score

BACKGROUND AND OBJECTIVE

Tobacco smoking is an established risk factor for chronic obstructive pulmonary disease (COPD). Current evidence suggests that non-tobacco-related risk factors vary geographically and are less understood than smoking. This study aims to compare the risk factors, symptoms, and clinical features of smoking (S-COPD) and non-smoking (NS-COPD) in a COPD population.

MATERIALS AND METHODS

In this retrospective cross-sectional study, 489 COPD patients were screened. Data on socio-demographics, smoking and medical history, other risk factors, symptoms, and clinical characteristics including COPD Assessment Test (CAT) score, and Modified Medical Research Council (mMRC) Dyspnea Scale were examined.

RESULTS

Of the total selected 416 COPD patients, 35.34% were NS-COPD while 64.66% were S-COPD. S-COPD was predominant in males, whereas NS-COPD was predominant in females (P < 0.0001). In NS-COPD, biomass fuel exposure was a major risk factor (P < 0.0001), and 61% of subjects had a biomass fuel exposure index of >60. In bivariate and multivariate analyses, no risk factors were correlated with forced expiratory volume in 1 second (FEV1)% predicted, while among clinical features, duration of illness (P = 0.001) was correlated with lower values of FEV1 in the multivariate table of S-COPD. In the multivariate analysis, biomass fuel exposure (P = 0.039) and CAT score (P < 0.0001) were correlated with FEV1(%) in NS-COPD.

CONCLUSION

Biomass fuel exposure is a substantial risk factor for NS-COPD and was correlated with FEV1(%) predicted. In addition, the CAT score correlated with disease severity in patients with NS-COPD. The development of COPD in non-smokers is being recognized as a separate phenotype and it should be managed according to risk factors.

Antitrypsin deficiency: still more to learn about the lung after 60 years

The past 60 years have seen multiple publications related to lung disease in α1-antitrypsin deficiency largely reflecting the pathophysiology, biochemical effect and outcomes of augmentation therapy. However, the complexity of disease phenotype and the impact of the natural history presents problems of patient management, study design and hence interpretation of outcome. Although many national and some international registries exist, the lack of consistent in-depth assessment and importantly, the impact of augmentation therapy likely influences our perception of the true natural history. Development of new therapeutic strategies, and even assessment of the role and efficacy of augmentation, remain a challenge as powering such studies for conventional COPD outcomes is impractical due to relative rarity of the genetic condition and the presence of clinical phenotypic variation. The current review approaches these issues, discusses the nature and complexity of assessing patient variability, and provides guidance on further studies required to address them.

Endoscopic reflux esophagitis and decline in pulmonary function in nonsmokers: A retrospective cohort study

BACKGROUND

The association between reflux esophagitis and pulmonary function remains controversial. Thus, evaluating the relationship between endoscopic reflux esophagitis and changes in pulmonary function over time in a nonsmoking population is an important clinical issue.

METHODS

In this single-center retrospective cohort study, a medical examination database at Kameda Medical Center Makuhari was employed to identify nonsmokers who underwent upper gastrointestinal endoscopy and spirometry in 2010 and were followed up in 2015. Gastroenterologists carefully double-checked the diagnosis of reflux esophagitis. Multiple linear regression analyses were performed to compare the decline in the percentage of predicted vital capacity (%VC), forced vital capacity (%FVC), and forced expiratory volume in 1 s (%FEV1) between participants with reflux esophagitis and those without. Furthermore, using multivariable logistic regression analyses, we evaluated the factors associated with rapid decline in %VC, %FVC, and %FEV1, which is defined as a decrease of >10% in each parameter over the 5-year observation period.

RESULTS

We identified 3098 eligible subjects, including 72 and 44 participants who had a Los Angeles classification grade A and B-C (severe) reflux esophagitis in 2010, respectively. The decline in %VC was significantly larger in the participants with severe reflux esophagitis than in the control subjects (standardized coefficient, -0.037; 95% confidence interval, -0.071 to -0.004). Moreover, reflux esophagitis was significantly associated with a rapid decline in %VC and %FVC but not in %FEV1 (P for trend: 0.009, 0.009, and 0.276, respectively).

CONCLUSIONS

Severe reflux esophagitis among nonsmokers had clinical disadvantages in terms of a decline in %VC.

Treatable traits in pre-COPD: Time to extend the treatable traits paradigm beyond established disease

To date, the treatable traits (TTs) approach has been applied in the context of managing diagnosed diseases. TTs are clinical characteristics and risk factors that can be identified clinically and/or biologically, and that merit treatment if present. There has been an exponential increase in the uptake of this approach by both researchers and clinicians. Realizing the potential of the TTs approach to pre-clinical disease, this expert review proposes that it is timely to consider acting on TTs present before a clinical diagnosis is made, which might help to prevent development of the full disease. Such an approach is ideal for diseases where there is a long pre-clinical phase, such as in chronic obstructive pulmonary disease (COPD). The term 'pre-COPD' has been recently proposed to identify patients with respiratory symptoms and/or structural or functional abnormalities without airflow limitation. They may eventually develop airflow limitation with time but patients with pre-COPD are likely to have traits that are already treatable. This review first outlines the contribution of recently generated knowledge into lifetime lung function trajectories and the conceptual framework of 'GETomics' to the field of pre-COPD. GETomics is a dynamic and cumulative model of interactions between genes and the environment throughout the lifetime that integrates information from multi-omics to understand aetiology and mechanisms of diseases. This review then discusses the current evidence on potential TTs in pre-COPD patients and makes recommendations for practice and future research. At a broader level, this review proposes that introducing the TTs in pre-COPD may help reenergize the preventive approaches to health and diseases.

A review on current advancement in zebrafish models to study chronic inflammatory diseases and their therapeutic targets

Chronic inflammatory diseases are caused due to prolonged inflammation at a specific site of the body. Among other inflammatory diseases, bacterial meningitis, chronic obstructive pulmonary disease (COPD), atherosclerosis and inflammatory bowel diseases (IBD) are primarily focused on because of their adverse effects and fatality rates around the globe in recent times. In order to come up with novel strategies to eradicate these diseases, a clear understanding of the mechanisms of the diseases is needed. Similarly, detailed insight into the mechanisms of commercially available drugs and potent lead compounds from natural sources are also important to establish efficient therapeutic effects. Zebrafish is widely accepted as a model to study drug toxicity and the pharmacokinetic effects of the drug. Moreover, researchers use various inducers to trigger inflammatory cascades and stimulate physiological changes in zebrafish. The effect of these inducers contrasts with the type of zebrafish used in the investigation. Hence, a thorough analysis is required to study the current advancements in the zebrafish model for chronic inflammatory disease suppression. This review presents the most common inflammatory diseases, commercially available drugs, novel therapeutics, and their mechanisms of action for disease suppression. The review also provides a detailed description of various zebrafish models for these diseases. Finally, the future prospects and challenges for the same are described, which can help the researchers understand the potency of the zebrafish model and its further exploration for disease attenuation.

Economic burden of chronic obstructive pulmonary disease and post-tuberculosis sequelae in low- and middle-income countries: a database compiled from a systematic review and meta-analysis

Background

Chronic obstructive pulmonary disease (COPD) and tuberculosis (TB) impose a substantial economic burden globally. This systematic review summarised the evidence on the costs of COPD, including post-TB diseases in low- and middle-income countries.

Methods

A systematic review was conducted and studies published between 1 January 2013 and 28 March 2022 (the date of the search) were identified using various electronic databases without language restrictions. Titles, abstracts and full texts were screened in duplicate and data were extracted and verified by reviewers. Eligible studies were categorised as cost analysis and/or economic burden studies, and costs were converted to 2021 United State dollar. Meta-analysis was conducted on the costs of hospitalisations, medication and outpatient visits.

Results

128 cost studies and 65 economic burden studies were included in this review. The data collected are presented in the Cost Database of COPD and Post-TB (CD-CPTB). The majority of studies were from Asia, Eastern Europe and Latin America, with a few from other middle-income countries. There were extremely limited data on the costs of post-TB sequelae and only a few studies were from Africa (n=6) and low-income (n=5) countries. The direct medical costs of COPD ranged from $26 per hospitalisation in India to $2694 per year per patient with severe disease in Mexico, while the costs of acute exacerbation of COPD ranged from $137 to $4207 per exacerbation with both the minimum and maximum costs occurring in Turkey. The costs were lower in lower middle-income countries compared with upper middle-income countries. Finally, considerable economic burden was attributable to smoking and air pollution.

Conclusion

The review and the CD-CPTB database give a thorough snapshot of the current evidence of the costs and economic burden of COPD and post-TB diseases. Future research is needed to investigate the economic impact after TB treatment and should be prioritised in Africa and low-income countries where there has been a lack of data collection.

Protocol registration number

CRD42022326609.

Smoking, respiratory symptoms, lung function and life expectancy: A longitudinal study of ageing

BACKGROUND AND OBJECTIVE

Prognostic indices have been developed to predict various outcomes, including mortality. These indices and hazard ratios may be difficult for patients to understand. We investigated the association between smoking, respiratory symptoms and lung function with remaining life expectancy (LE) in older adults.

METHODS

Data were from the 2004/05 English Longitudinal Study of Ageing (ELSA) (n = 8930), participants aged ≥50-years, with mortality data until 2012. Respiratory symptoms included were chronic phlegm and shortness of breath (SOB). The association between smoking, respiratory symptoms and FEV1/FVC, and remaining LE was estimated using a parametric survival function and adjusted for covariates including age at baseline and sex.

RESULTS

The extent to which symptoms and FEV1/FVC predicted differences in remaining LE varied by smoking. Compared to asymptomatic never smokers with normal lung function (the reference group), in never smokers, only those with SOB had a significant reduction in remaining LE. In former and current smokers, those with respiratory symptoms had significantly lower remaining LE compared to the reference group if they had FEV1/FVC <0.70 compared to those with FEV1/FVC ≥0.70. Males aged 50-years, current smokers with SOB and FEV1/FVC <0.70, had a remaining LE of 19.2 (95%CI: 16.5-22.2) years, a decrease of 8.1 (5.3-10.8) years, compared to the reference group.

CONCLUSION

Smoking, respiratory symptoms and FEV1/FVC are strongly associated with remaining LE in older people. The use of remaining LE to communicate mortality risk to patients needs further investigation.

Factors Affecting Survival in Severe and Very Severe COPD after Admission in ICUs of Tertiary Care Centers of India (FAST COPD): Study Protocol for a Multicentric Cohort Study

Background

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. However, there is a lack of comprehensive data from low- and middle-income countries (LMICs) regarding factors influencing COPD outcomes, particularly in regions where biomass exposure is prevalent.

Objective

The Factors Affecting Survival in Severe and Very Severe COPD Patients Admitted to Tertiary Centers of India (FAST) study aims to address this gap by evaluating factors impacting survival and exacerbation rates among COPD patients in LMICs like India, with a specific focus on biomass exposure, clinical phenotypes, and nutritional status in patients admitted to the Intensive Care Unit (ICU).

Methods

The FAST study is an observational cohort study conducted in university teaching hospitals across India. The study aims to enroll 1000 COPD patients admitted to the ICU meeting specific inclusion criteria, with follow-up assessments conducted every 6 months over a 2-year period. Data collection includes demographic information, clinical manifestations, laboratory investigations, pulmonary function tests, medications, nutritional status, mental health, and health-related quality of life. Adjudication of exacerbations and mortality will also be undertaken. The FAST study seeks to provide crucial insights into COPD outcomes in LMICs, informing more precise management strategies and mitigating the burden of COPD in these settings. By evaluating factors such as biomass exposure, clinical phenotypes, and nutritional status, the study aims to address key knowledge gaps in COPD research.

How to cite this article

Arunachala S, Devapal S, Swamy DSN, Greeshma MV, Ul Hussain I, Siddaiah JB, et al. Factors Affecting Survival in Severe and Very Severe COPD after Admission in ICUs of Tertiary Care Centers of India (FAST COPD): Study Protocol for a Multicentric Cohort Study. Indian J Crit Care Med 2024;28(6):552-560.

Prevalence, stability, and clinical significance of an isolated low FEV1 spirometry pattern in children

OBJECTIVES

In adults, an isolated low FEV1 pattern (an FEV1 below the lower limit of normal with a preserved FVC and FEV1/FVC) has been associated with the risk of developing airway obstruction. Our objective was to examine the prevalence, stability, and clinical significance of an isolated low FEV1 pattern in the pediatric population.

METHODS

We conducted a retrospective study of spirometries from children ages 6-21 years and categorized tests into spirometry patterns according to published guidelines and recent literature. In a subgroup of tests with an isolated low FEV1 pattern, we evaluated spirometry technique. We also examined the association of having a test with an isolated low FEV1 pattern with clinical markers of disease severity in a subgroup of children with cystic fibrosis (CF).

RESULTS

The isolated low FEV1 pattern was uncommon across the 29,979 tests included (n = 645 [2%]). In the 263 children with an isolated low FEV1 pattern who had a follow-up test performed, the most frequent spirometry pattern at last test was normal (n = 123 [47%]). A primary diagnosis of CF was associated with increased odds of having at least one test with an isolated low FEV1 pattern (OR = 8.37, 95% CI = 4.70-15.96, p < .001). The spirometry quality in a subgroup of tests with an isolated low FEV1 pattern (n = 50) was satisfactory. In the subgroup of children with CF (n = 102), those who had a test with an isolated low FEV1 pattern had higher odds of using oral antibiotics in the last 12 months than those who had a normal pattern (OR = 3.50, 95% CI = 1.15-10.63, p = .03).

CONCLUSIONS

The isolated low FEV1 pattern can occur repeatedly over time, usually transitions to a normal pattern, is not due to a poor spirometry technique, and could be clinically relevant in children with chronic lung diseases.

Effect of Cigarette Smoking on Clinical and Molecular Endpoints in COPD Patients

Cigarette smoking is a primary contributor to mortality risks and is associated with various diseases. Among these, COPD represents a significant contributor to global mortality and disability. The objective of this study is to investigate the effect of smoking on a selected battery of variables, with an emphasis on DNA damage. A total of 87 elderly patients diagnosed with COPD, divided into three groups based on their smoking history (current, former, never-smokers), were evaluated using a cross-sectional approach. Clinical features including mortality and inflammatory/oxidative parameters (Lymphocytes/Monocytes, Neutrophils/Lymphocytes, Platelets/Lymphocytes ratio), SII, MDA, 8-Oxo-dG, and IL6 (ELISA assay), as well as DNA damage (comet assay), were investigated. Virus infection, i.e., influenza A virus subtype H1N1, JC polyomavirus (JCPyV), BK polyomavirus (BKPyV), and Torquetenovirus (TTV), was also tested. Current smokers exhibit higher levels of comorbidity (CIRS; p < 0.001), Platelets/Lymphocytes ratio (p < 0.001), systemic immune inflammation (p < 0.05), and DNA damage (p < 0.001). Former smokers also showed higher values for parameters associated with oxidative damage and showed a much lower probability of surviving over 5 years compared to never- and current smokers (p < 0.0017). This study showed a clear interaction between events which are relevant to the oxidative pathway and cigarette smoking. A category of particular interest is represented by former smokers, especially for lower survival, possibly due to the presence of more health problems. Our findings raise also the attention to other parameters which are significantly affected by smoking and are useful to monitor COPD patients starting a program of pulmonary rehabilitation (DNA damage, inflammation parameters, and selected viral infections).

Structural Predictors of Lung Function Decline in Young Smokers with Normal Spirometry

Rationale: Chronic obstructive pulmonary disease (COPD) due to tobacco smoking commonly presents when extensive lung damage has occurred. Objectives: We hypothesized that structural change would be detected early in the natural history of COPD and would relate to loss of lung function with time. Methods: We recruited 431 current smokers (median age, 39 yr; 16 pack-years smoked) and recorded symptoms using the COPD Assessment Test (CAT), spirometry, and quantitative thoracic computed tomography (QCT) scans at study entry. These scan results were compared with those from 67 never-smoking control subjects. Three hundred sixty-eight participants were followed every six months with measurement of postbronchodilator spirometry for a median of 32 months. The rate of FEV1 decline, adjusted for current smoking status, age, and sex, was related to the initial QCT appearances and symptoms, measured using the CAT. Measurements and Main Results: There were no material differences in demography or subjective CT appearances between the young smokers and control subjects, but 55.7% of the former had CAT scores greater than 10, and 24.2% reported chronic bronchitis. QCT assessments of disease probability-defined functional small airway disease, ground-glass opacification, bronchovascular prominence, and ratio of small blood vessel volume to total pulmonary vessel volume were increased compared with control subjects and were all associated with a faster FEV1 decline, as was a higher CAT score. Conclusions: Radiological abnormalities on CT are already established in young smokers with normal lung function and are associated with FEV1 loss independently of the impact of symptoms. Structural abnormalities are present early in the natural history of COPD and are markers of disease progression. Clinical trial registered with www.clinicaltrials.gov (NCT03480347).

Prevalence, Medicaid use and mortality risk of low FEV1 in adults aged 20-35 years old in the USA: evidence from a population-based retrospective cohort study

BACKGROUND

The prevalence, Medicaid use and mortality risk associated with low forced expiratory volume in 1 s (FEV1) among young adults aged 20-35 years are not well understood, despite its potential implications for the development of chronic pulmonary disease and overall prognosis.

METHODS

A retrospective cohort study was conducted among young adults aged 20-35 years old, using data from the National Health and Nutrition Examination Survey, National Death Index and Centers for Medicare & Medicaid Services. Participants were categorised into a low FEV1 group (pre-bronchodilator FEV1%pred <80%) and a normal FEV1 group (FEV1%pred ≥80%). Weighted logistic regression analysis was employed to identify the risk factors associated with low FEV1, while Cox proportional hazard models were used to calculate the hazard ratio (HR) for Medicaid use and the all-cause mortality between the two groups.

RESULTS

A total of 5346 participants aged 20-35 were included in the study, with 329 in the low FEV1 group and 5017 in the normal group. The weighted prevalence of low FEV1 among young adults was 7.1% (95% CI 6.0 to 8.2). Low body mass index (OR=3.06, 95% CI 1.79 to 5.24), doctor-diagnosed asthma (OR=2.25, 1.28 to 3.93), and wheezing or whistling (OR=1.57, 1.06 to 2.33) were identified as independent risk factors for low FEV1. Over a 15-year follow-up, individuals in the low FEV1 group exhibited a higher likelihood of Medicaid use compared with those in the normal group (HR=1.73, 1.07 to 2.79). However, there was no statistically significant increase in the risk of all-cause mortality over a 30-year follow-up period (HR=1.48, 1.00 to 2.19).

CONCLUSIONS

A considerable portion of young adults demonstrated low FEV1 levels, a characteristic that was associated with a higher risk of Medicaid use over a long-term follow-up, yet not linked to an augmented risk of all-cause mortality.

Hepatitis C Virus Clearance and Diffusing Capacity for Carbon Monoxide in Women With and Without Human Immunodeficiency Virus

Hepatitis C virus (HCV) infection is associated with extrahepatic effects, including reduced diffusing capacity of the lungs. It is unknown whether clearance of HCV infection is associated with improved diffusing capacity. In this sample of women with and without human immunodeficiency virus, there was no association between HCV clearance and diffusing capacity.

[Take-home messages from the 2nd COPD 2023 Biennial of the French Society of Respiratory Diseases. Placing the patient at the center of the care pathway]

INTRODUCTION

The second COPD Biennial organized by the COPD working group of the French Society of Respiratory Diseases took place in Paris (Cochin) on 13th December 2023.

STATE OF THE ART

Major trends in 2023 were discussed; they encompassed concepts, definitions, biologics, care pathways, pulmonary rehabilitation and complex situations entailed by respiratory infections, cardiovascular comorbidities and pulmonary hypertension, and modalities of oxygen therapy and ventilation.

PERSPECTIVES

The different talks underlined major changes in COPD including the concepts of pre-COPD, etiotypes, health trajectories and new definitions of exacerbation. Recent results in biologics for COPD open the door to new pharmacological options. Assessment of current care pathways in France highlighted some causes for concern. For example, pulmonary rehabilitation is a key but insufficiently practiced element. Respiratory infections require careful assessment and treatments. Diagnosis and treatment of cardiovascular comorbidities and pulmonary hypertension are of paramount importance. As of late, oxygen therapy and ventilation modalities have evolved, and are beginning to afford more personalized options.

CONCLUSIONS

As regards COPD, a personalized approach is crucial, placing the patient at the center of the care pathway and facilitating coordination between healthcare providers.

The association between alcohol consumption and pulmonary function: a scoping review

INTRODUCTION

The health effects of alcohol are well established but the influence on pulmonary function remains debated. Studies indicate that small amounts of alcohol are beneficial and heavy consumption is harmful, suggesting a U-shaped association. Our objective is to determine whether there is an association between alcohol intake and changes in pulmonary function parameters, exploring the potential protective effect of moderate alcohol consumption and the harm caused by heavy drinking.

METHODS

A comprehensive search from PubMed, Embase, Cochrane and CINAHL was carried out, and studies were evaluated using the JBI methodological framework for scoping reviews. Two independent reviewers conducted parallel screening and data extraction. A data extraction form was utilised to organise key themes, with qualitative analysis and visual representation of the results.

RESULTS

Among 4427 screened abstracts, 179 underwent full-text review, resulting in 30 eligible studies. Of these, 10 showed a negative effect, nine reported no impact, nine exhibited a positive effect and two indicated a nonlinear U-shaped association between alcohol consumption and pulmonary function parameters.

CONCLUSION

While the U-shaped curve hypothesis remains unconfirmed by the current literature, there are notable associations. Heavy alcohol consumption appears to negatively affect pulmonary function, while low to moderate intake shows a positive influence in included studies. However, the diversity in study quality, the nonstandardised alcohol intake quantification and the confounding role of smoking challenge definitive conclusions. The need for consistent, long-term international studies is evident to further explore this relationship while addressing the complex interplay between alcohol and smoking.

Lung-function trajectories: relevance and implementation in clinical practice

Lung development starts in utero and continues during childhood through to adolescence, reaching its peak in early adulthood. This growth is followed by gradual decline due to physiological lung ageing. Lung-function development can be altered by several host and environmental factors during the life course. As a result, a range of lung-function trajectories exist in the population. Below average trajectories are associated with respiratory, cardiovascular, metabolic, and mental health comorbidities, as well as with premature death. This Review presents progressive research into lung-function trajectories and assists the implementation of this knowledge in clinical practice as an innovative approach to detect poor lung health early, monitor respiratory disease progression, and promote lung health. Specifically, we propose that, similar to paediatric height and weight charts used globally to monitor children's growth, lung-function charts could be used for both children and adults to monitor lung health status across the life course. To achieve this proposal, we introduce our free online Lung Function Tracker tool. Finally, we discuss challenges and opportunities for effective implementation of the trajectory concept at population level and outline an agenda for crucial research needed to support such implementation.

Documento de consenso sobre tabaquismo y riesgo vascular

Consensus statement on smoking and vascular risk About 22% of the Spanish population are daily smokers. Men are more likely to smoke than women. In Spain, women between 15-25 years of age smoke as much or more than men. Every smoker should be assessed for: physical dependence on nicotine (Fagerström test), social and psychological dependence (Glover Nilsson test), level of motivation to quit (Richmond test), probability of therapy success (Henri-Mondor and Michael-Fiore tests), and stage of behavioral change development (Prochaska and DiClementi). Advice on smoking cessation is highly cost-effective and should always be provided. Smoking is an enhancer of cardiovascular risk because it acts as a pathogen agent in the development of arteriosclerosis and is associated with ischemic heart disease, stroke, and peripheral artery disease. Smoking increases the risk of chronic lung diseases (COPD) and is related to cancers of the lung, female genitalia, larynx, oropharynx, bladder, mouth, esophagus, liver and biliary tract, and stomach, among others. Combined oral contraceptives should be avoided in women smokers older than 35 years of age due to the risk of thromboembolism. In smoking cessation, the involvement of physicians, nurses, psychologists, etc. is important, and their multidisciplinary collaboration is needed. Effective pharmacological treatments for smoking cessation are available. Combined treatments are recommended when smoker's dependence is high. For individuals who are unable to quit smoking, a strategy based on tobacco damage management with a total switch to smokeless products could be a less dangerous alternative for their health than continuing to smoke.

The Natural History of Severe Chronic Obstructive Pulmonary Disease: The SPOCCAT Study Protocol

Introduction

Patients with severe chronic obstructive pulmonary disease (COPD) are often underrepresented in cohorts, creating uncertainty about the natural history and prognostic factors of this subgroup. Our goal was to describe the SPOCCAT (Severe COPD: Prospective Observational study of COPD in Catalonia) study protocol.

Material and methods

SPOCCAT is a non-interventional, multicenter, prospective cohort study of patients with severe COPD (FEV1% predicted < 50%). The study aims to: (1) establish a five-year prospective cohort; (2) identify demographic and clinical characteristics; (3) describe treatment patterns; (4) better understand the natural history of severe COPD, including lung function decline, exacerbation rates, and mortality; and (5) identify prognostic factors for poor outcomes.Recruitment began in January 2024, and the cohort will be followed for a minimum of five years (or until death or lung transplant) with follow-up visits every 12 months. Baseline data include demographics, laboratory analyses, comorbidities, lung function, respiratory symptoms, respiratory disease exacerbations and etiology, quality of life, physical activity, chest computed tomography, and treatment. Annual follow-up visits will assess changes in treatment, exacerbation frequency and severity, microbiological outcomes, complementary tests, and mortality. Participation requires written informed consent from all patients, with data collected in an anonymized electronic Case Report Form.

Results

The results of the SPOCCAT study will provide relevant information about the characteristics, treatment, and prognostic factors of severe COPD.

Conclusions

SPOCCAT has the potential to enhance understanding of severe COPD, exploring innovative aspects and establishing a robust research framework for future COPD-related projects.

The memory of airway epithelium damage in smokers and COPD patients

Chronic obstructive pulmonary disease (COPD), a devastating and irreversible lung disease, causes structural and functional defects in the bronchial epithelium, the (ir)reversibility of which remains unexplored in vitro. This study aimed to investigate the persistence of COPD-related epithelial defects in long-term airway epithelial cultures derived from non-smokers, smokers, and COPD patients. Barrier function, polarity, cell commitment, epithelial-to-mesenchymal transition, and inflammation were evaluated and compared with native epithelium characteristics. The role of inflammation was explored using cytokines. We show that barrier dysfunction, compromised polarity, and lineage abnormalities observed in smokers and COPD persisted for up to 10 wk. Goblet cell hyperplasia was associated with recent cigarette smoke exposure. Conversely, increased IL-8/CXCL-8 release and abnormal epithelial-to-mesenchymal transition diminished over time. These ex vivo observations matched surgical samples' abnormalities. Cytokine treatment induced COPD-like changes in control cultures and reactivated epithelial-to-mesenchymal transition in COPD cells. In conclusion, these findings suggest that the airway epithelium of smokers and COPD patients retains a multidimensional memory of its original state and previous cigarette smoke-induced injuries, maintaining these abnormalities for extended periods.

Cause-specific mortality in COPD subpopulations: a cohort study of 339 647 people in England

BACKGROUND

Identifying correlates of cause-specific mortality in patients with chronic obstructive pulmonary disease (COPD) may aid the targeting of therapies to reduce mortality. We determined factors associated with causes of death in a primary care COPD population.

METHODS

Clinical Practice Research Datalink Aurum was linked to Hospital Episode Statistics and death certificate data. People with COPD alive between 1 January 2010 and 1 January 2020 were included. Patient characteristics were defined before the start of follow-up: (a) frequency and severity of exacerbations; (b) emphysema or chronic bronchitis; (c) Global Obstructive Lung Disease (GOLD) groups A-D; and (d) airflow limitation. We used Cox Proportional Hazards regression and competing risks to investigate the association between patient characteristics and risk of all-cause, COPD and cardiovascular (CV) mortality.

RESULTS

339 647 people with COPD were included of which 97 882 died during follow-up (25.7% COPD related and 23.3% CV related). Airflow limitation, GOLD group, exacerbation frequency and severity, and COPD phenotype were associated with all-cause mortality. Exacerbations, both increased frequency and severity, were associated with COPD-related mortality (≥2 exacerbations vs none adjusted HR: 1.64, 1.57-1.71; 1 severe vs none adjusted HR: 2.17, 2.04-2.31, respectively). Patients in GOLD groups B-D had a higher risk of COPD and CV mortality compared with GOLD group A (GOLD group D vs group A, adjusted HR for COPD mortality: 4.57, 4.23-4.93 and adjusted HR for CV mortality: 1.53, 1.41-1.65). Increasing airflow limitation was also associated with both COPD and CV mortality (GOLD 4 vs 1, adjusted HR: 12.63, 11.82-13.51 and adjusted HR: 1.75, 1.60-1.91, respectively).

CONCLUSION

Poorer airflow limitation, worse functional status and exacerbations had substantial associations with risk of all-cause mortality. Differing results for CV and COPD-related mortality suggests interventions to prevent mortality may need to target particular characteristics or time points in the disease course.