Airway responsiveness to methacholine and incidence of COPD: an international prospective cohort study

Spirometric patterns in young and middle-aged adults: a 20-year European study

BACKGROUND

Understanding the natural history of abnormal spirometric patterns at different stages of life is critical to identify and optimise preventive strategies. We aimed to describe characteristics and risk factors of restrictive and obstructive spirometric patterns occurring before 40 years (young onset) and between 40 and 61 years (mid-adult onset).

METHODS

We used data from the population-based cohort of the European Community Respiratory Health Survey (ECRHS). Prebronchodilator forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were assessed longitudinally at baseline (ECRHS1, 1993-1994) and again 20 years later (ECRHS3, 2010-2013). Spirometry patterns were defined as: restrictive if FEV1/FVC≥LLN and FVC<10th percentile, obstructive if FEV1/FVC

RESULTS

Among 3502 participants (mean age=30.4 (SD 5.4) at ECRHS1, 50.4 (SD 5.4) at ECRHS3), 2293 (65%) had a normal, 371 (11%) a young restrictive, 301 (9%) a young obstructive, 187 (5%) a mid-adult onset restrictive and 350 (10%) a mid-adult onset obstructive spirometric pattern. Being lean/underweight in childhood and young adult life was associated with the occurrence of the young spirometric restrictive pattern (relative risk ratio (RRR)=1.61 95% CI=1.21 to 2.14, and RRR=2.43 95% CI=1.80 to 3.29; respectively), so were respiratory infections before 5 years (RRR=1.48, 95% CI=1.05 to 2.08). The main determinants for young obstructive, mid-adult restrictive and mid-adult obstructive patterns were asthma, obesity and smoking, respectively.

CONCLUSION

Spirometric patterns with onset in young and mid-adult life were associated with distinct characteristics and risk factors.

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Key Words

• COPD epidemiology
• Clinical Epidemiology

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MESH Headings

• Middle Aged
• Young Adult
• Humans
• Adult
• Pulmonary Disease, Chronic Obstructive
• Spirometry
• Respiratory Function Tests
• Asthma/complications
• Risk Factors
• Forced Expiratory Volume
• Vital Capacity

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Grants

• CEX2018-000806-S Spanish Ministry of Science and Innovation

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Affiliation(s)

Anne-Elie Carsin ISGlobal, Campus mar, Barcelona, Catalunya, Spain Universita Pompeu Fabra (UPF), Barcelona, Spain CIBER Epidemiología y Salud Pública (CIBERESP), Spain, Spain Biometrics, RTI-Health Solutions, Barcelona, Spain
Judith Garcia-Aymerich ISGlobal, Campus mar, Barcelona, Catalunya, Spain Universita Pompeu Fabra (UPF), Barcelona, Spain CIBER Epidemiología y Salud Pública (CIBERESP), Spain, Spain
Simone Accordini Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
Shyamali Dharmage Allergy and Lung Health Unit, School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
Bénédicte Leynaert Université Paris-Saclay, UVSQ, Univ Paris-Sud, Inserm, INSERM, Paris, France
Marti de Las Heras ISGlobal, Campus mar, Barcelona, Catalunya, Spain Universita Pompeu Fabra (UPF), Barcelona, Spain CIBER Epidemiología y Salud Pública (CIBERESP), Spain, Spain
Lidia Casas Social Epidemiology and Health Policy, Department of Family Medicine and Population Health, University of Antwerp, Antwerpen, Belgium Institute for Environment and Sustainable Development (IMDO), University of Antwerp, Antwerpen, Belgium
Seraina Caviezel Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
Pascal Demoly Département de Pneumologie et Addictologie, University Hospital of Montpellier, Montpellier, France IDESP, University of Montpellier - Inserm UMR UA11, Montpellier, France
Bertil Forsberg Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
Thorarinn Gislason Department of Sleep, Landspitali University Hospital, Reykjavik, Iceland Medical Faculty, University of Iceland, Iceland, Iceland
Angelo Guido Corsico Department of Internal Medicine and Therapeutics, University of Pavia, Italy, Italy Division of Respiratory Diseases, Fondazione IRCCS Policlinico San Matteo-University of Pavia, Pavia, Italy
Christer Janson Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
Rain Jogi Lung Clinic, Tartu University Hospital, Tartu, Estonia
Jesús Martínez-Moratalla Faculty of Medicine of Albacete, General University Hospital of Albacete, Albacete, Spain
Dennis Nowak Institute and Clinic for Occupational and Environmental Medicine, University Hospital, LMU Munich, Comprehensive Pneumology Centre Munich, member DZL, German Centre for Lung Research, Munich, Germany
Leopoldo Palacios Gómez Distrito Sanitario Huelva-Costa, Huelva, Spain
Isabelle Pin Department of Pediatrics, CHU de Grenoble Alpes, Grenoble, France Inserm, UMR 1209, Institute for Advanced Biosciences, Grenoble, France
Nicole Probst-Hensch Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Basel, Switzerland
Chantal Raherison-Semjen Inserm, UMR 1219, Université de Bordeaux, Bordeaux, France
Giulia Squillacioti Department of Public Health and Pediatrics, University of Turin, Torino, Piemonte, Italy
Cecilie Svanes Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway Department of Occupational Medicine, Haukeland University Hospital, Bergen, Norway
Kjell Torén Department of Occupational and Environmental, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden Department of Occupational and Environmental Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
Isabel Urrutia Pulmonology Department, Galdakao Hospital, Biocruces Bizkaia, Spain
Ismael Huerta Epidemiological Surveillance Section, Directorate General of Public Health, Oviedo, Spain
Josep Maria Anto ISGlobal, Campus mar, Barcelona, Catalunya, Spain Universita Pompeu Fabra (UPF), Barcelona, Spain CIBER Epidemiología y Salud Pública (CIBERESP), Spain, Spain
Debbie Jarvis National Heart and Lung Institute, Imperial College, London, UK
Stefano Guerra ISGlobal, Campus mar, Barcelona, Catalunya, Spain Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona, USA

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Endotoxin-Induced Sepsis on Ceftriaxone-Treated Rats' Ventilatory Mechanics and Pharmacokinetics

Sepsis can trigger acute respiratory distress syndrome (ARDS), which can lead to a series of physiological changes, modifying the effectiveness of therapy and culminating in death. For all experiments, male Wistar rats (200-250 g) were split into the following groups: control and sepsis-induced by endotoxin lipopolysaccharide (LPS); the control group received only intraperitoneal saline or saline + CEF while the treated groups received ceftriaxone (CEF) (100 mg/kg) IP; previously or not with sepsis induction by LPS (1 mg/kg) IP. We evaluated respiratory mechanics, and alveolar bronchial lavage was collected for nitrite and vascular endothelial growth factor (VEGF) quantification and cell evaluation. For pharmacokinetic evaluation, two groups received ceftriaxone, one already exposed to LPS. Respiratory mechanics shows a decrease in total airway resistance, dissipation of viscous energy, and elastance of lung tissues in all sepsis-induced groups compared to the control group. VEGF and NOx values were higher in sepsis animals compared to the control group, and ceftriaxone was able to reduce both parameters. The pharmacokinetic parameters for ceftriaxone, such as bioavailability, absorption, and terminal half-life, were smaller in the sepsis-induced group than in the control group since clearance was higher in septic animals. Despite the pharmacokinetic changes, ceftriaxone showed a reduction in resistance in the airways. In addition, CEF lowers nitrite levels in the lungs and acts on their adverse effects, reflecting pharmacological therapy of the disease.

Novel Lung Growth Strategy with Biological Therapy Targeting Airway Remodeling in Childhood Bronchial Asthma

Anti-inflammatory therapy, centered on inhaled steroids, suppresses airway inflammation in asthma, reduces asthma mortality and hospitalization rates, and achieves clinical remission in many pediatric patients. However, the spontaneous remission rate of childhood asthma in adulthood is not high, and airway inflammation and airway remodeling persist after remission of asthma symptoms. Childhood asthma impairs normal lung maturation, interferes with peak lung function in adolescence, reduces lung function in adulthood, and increases the risk of developing chronic obstructive pulmonary disease (COPD). Early suppression of airway inflammation in childhood and prevention of asthma exacerbations may improve lung maturation, leading to good lung function and prevention of adult COPD. Biological drugs that target T-helper 2 (Th2) cytokines are used in patients with severe pediatric asthma to reduce exacerbations and airway inflammation and improve respiratory function. They may also suppress airway remodeling in childhood and prevent respiratory deterioration in adulthood, reducing the risk of COPD and improving long-term prognosis. No studies have demonstrated a suppressive effect on airway remodeling in childhood severe asthma, and further clinical trials using airway imaging analysis are needed to ascertain the inhibitory effect of biological drugs on airway remodeling in severe childhood asthma. In this review, we describe the natural prognosis of lung function in childhood asthma and the risk of developing adult COPD, the pathophysiology of allergic airway inflammation and airway remodeling via Th2 cytokines, and the inhibitory effect of biological drugs on airway remodeling in childhood asthma.

Occupational COPD-The most under-recognized occupational lung disease?

Chronic obstructive pulmonary disease (COPD) is caused by exposure to noxious particles and gases. Smoking is the main risk factor, but other factors are also associated with COPD. Occupational exposure to vapours, gases, dusts and fumes contributes to the development and progression of COPD, accounting for a population attributable fraction of 14%. Workplace pollutants, in particular inorganic dust, can initiate airway damage and inflammation, which are the hallmarks of COPD pathogenesis. Occupational COPD is still underdiagnosed, mainly due to the challenges of assessing the occupational component of the disease in clinical settings, especially if other risk factors are present. There is a need for specific education and training for clinicians, and research with a focus on evaluating the role of occupational exposure in causing COPD. Early diagnosis and identification of occupational causes is very important to prevent further decline in lung function and to reduce the health and socio-economic burden of COPD. Establishing details of the occupational history by general practitioners or respiratory physicians could help to define the occupational burden of COPD for individual patients, providing the first useful interventions (smoking cessation, best therapeutic management, etc.). Once patients are diagnosed with occupational COPD, there is a wide international variation in access to specialist occupational medicine and public health services, along with limitations in workplace and income support. Therefore, a strong collaboration between primary care physicians, respiratory physicians and occupational medicine specialists is desirable to help manage COPD patients' health and social issues.

The coexistence of asthma and COPD: risk factors, clinical history and lung function trajectories

RATIONALE

Patients with concomitant features of asthma and chronic obstructive pulmonary disease (COPD) have a heavy disease burden.

OBJECTIVES

Using data collected prospectively in the European Community Respiratory Health Survey, we compared the risk factors, clinical history, and lung function trajectories from early adulthood to the late sixties of middle aged subjects having asthma+COPD (n=179), past (n=263) or current (n=808) asthma alone, COPD alone (n=111), or none of these (n=3477).

METHODS

Interview data and prebronchodilator FEV₁ and FVC were obtained during three clinical examinations in 1991-1993, 1999-2002, and 2010-2013. Disease status was classified in 2010-2013, when the subjects were aged 40-68, according to the presence of fixed airflow obstruction (postbronchodilator FEV₁/FVC below the lower limit of normal), a lifetime history of asthma, and cumulative exposure to tobacco or occupational inhalants. Previous lung function trajectories, clinical characteristics, and risk factors of these phenotypes were estimated.

MAIN RESULTS

Subjects with asthma+COPD reported maternal smoking (28.2%) and respiratory infections in childhood (19.1%) more frequently than subjects with COPD alone (20.9 and 14.0%, respectively). Subjects with asthma+COPD had an impairment of lung function at age 20 that tracked over adulthood, and more than half of them had asthma onset in childhood. Subjects with COPD alone had the highest lifelong exposure to tobacco smoking and occupational inhalants, and they showed accelerated lung function decline during adult life.

CONCLUSIONS

The coexistence between asthma and COPD seems to have its origins earlier in life compared to COPD alone. These findings suggest that prevention of this severe condition, which is typical at older ages, should start in childhood.

Regular Physical Activity Levels and Incidence of Restrictive Spirometry Pattern: A Longitudinal Analysis of 2 Population-Based Cohorts

We estimated the association between regular physical activity and the incidence of restrictive spirometry pattern. Forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and physical activity were assessed in 2 population-based European cohorts (European Community Respiratory Health Survey: n = 2,757, aged 39-67 years; and Swiss Study on Air Pollution and Lung and Heart Diseases in Adults: n = 2,610, aged 36-82 years) first in 2000-2002 and again approximately 10 years later (2010-2013). Subjects with restrictive or obstructive spirometry pattern at baseline were excluded. We assessed the association of being active at baseline (defined as being physically active at least 2-3 times/week for ≥1 hour) with restrictive spirometry pattern at follow-up (defined as a postbronchodilation FEV1/FVC ratio of at least the lower limit of normal and FVC of <80% predicted) using modified Poisson regression, adjusting for relevant confounders. After 10 years of follow-up, 3.3% of participants had developed restrictive spirometry pattern. Being physically active was associated with a lower risk of developing this phenotype (relative risk = 0.76, 95% confidence interval: 0.59, 0.98). This association was stronger among those who were overweight and obese than among those of normal weight (P for interaction = 0.06). In 2 large European studies, adults practicing regular physical activity were at lower risk of developing restrictive spirometry pattern over 10 years.

Observational studies assessing the pharmacological treatment of obstructive lung disease: strengths, challenges and considerations for study design

Randomised controlled trials (RCTs) are the gold standard for evaluating treatment efficacy in patients with obstructive lung disease. However, due to strict inclusion criteria and the conditions required for ascertaining statistical significance, the patients included typically represent as little as 5% of the general obstructive lung disease population. Thus, studies in broader patient populations are becoming increasingly important. These can be randomised effectiveness trials or observational studies providing data on real-world treatment effectiveness and safety data that complement efficacy RCTs. In this review we describe the features associated with the diagnosis of asthma and chronic obstructive pulmonary disease (COPD) in the real-world clinical practice setting. We also discuss how RCTs and observational studies have reported opposing outcomes with several treatments and inhaler devices due to differences in study design and the variations in patients recruited by different study types. Whilst observational studies are not without weaknesses, we outline recently developed tools for defining markers of quality of observational studies. We also examine how observational studies are capable of providing valuable insights into disease mechanisms and management and how they are a vital component of research into obstructive lung disease. As we move into an era of personalised medicine, recent observational studies, such as the NOVEL observational longiTudinal studY (NOVELTY), have the capacity to provide a greater understanding of the value of a personalised healthcare approach in patients in clinical practice by focussing on standardised outcome measures of patient-reported outcomes, physician assessments, airway physiology, and blood and airway biomarkers across both primary and specialist care.

Mechanism of PM2.5-induced human bronchial epithelial cell toxicity in central China

Exposure to PM_2.5 has been linked to respiratory disorders, yet knowledge of the molecular mechanism is limited. Here, PM_2.5 was monitored and collected in central China, and its cytotoxicity mechanism on human bronchial epithelial cells (BEAS-2B) was investigated. With the average concentration of 109 ± 69 μg/m³, PM_2.5 was rich in heavy metals and organic pollutants. After exposure to PM_2.5, the viability of BEAS-2B cells decreased, where 510 dysregulated genes were predicted to induce necroptosis via inhibiting ATP synthesis through the oxidative phosphorylation signaling pathway. Cellular experiments demonstrated that the content of ATP was downregulated, while the expression of RIP3, a necroptosis indicator, was upregulated. Besides, four enzymes in charge of ATP synthesis were downregulated, including ATP5F, NDUF, COX7A, and UQCR, while two genes of RELA and CAPN1 responsible for necroptosis were upregulated. Furthermore, N-acetylcysteine was applied as an enhancer for ATP synthesis, which reversed the downregulation of ATP5F, NDUF, and COX7A, and consequently alleviated the elevation of RELA, CAPN1, and RIP3. In conclusion, PM_2.5 exposure downregulates ATP5F, NDUF, COX7A, and UQCR, and that inhibits ATP synthesis via the oxidative phosphorylation signaling pathway, which subsequently upregulates RELA and CAPN1 and ultimately leads to necroptosis of BEAS-2B cells.

Global Burden of Chronic Respiratory Diseases

Background: Noncommunicable diseases (NCDs) and chronic respiratory diseases (CRDs) are the main causes of mortality and morbidity worldwide. Methods: The main evidences about the NCDs and CRDs burden and related risk factors, from updated international reports and results of original researches, were collected and described in this review. Results: Most recent evidence is available from the Global Burden of Diseases Study (GBD) 2017 reports. There were 3.2 million deaths due to chronic obstructive pulmonary disease (COPD) and 495,000 deaths due to asthma. COPD was the seventh leading cause of years of life lost (YLLs). Overall, prevalent cases of CRDs were 545 million: about 50% for COPD and 50% for asthma. Incident cases of CRDs were 62 million, mostly due to asthma (69%) and COPD (29%). COPD accounted for 81.6 million disability-adjusted life years, asthma for 22.8 million. COPD prevalence of 9.1% has been found in a recent general population sample of North-Eastern Italy, while in Central Italy a 25-year follow-up of a general population sample has shown an increased prevalence of COPD and asthma up to 6.8% and 7.8%, respectively. In Central Italy, a COPD incidence of 8% and an asthma incidence of 3.2% have been found in adult subjects at an 18-year follow-up. Among the risk factors, a relevant role is played by smoking and high body mass index for asthma, while smoking, particulate matter pollution, ambient ozone pollution, occupational exposure to particulate matter, gases and fumes, as well as second-hand smoke, play an important role for COPD. Forecasting the YLLs by 2040 indicates a rising toll from several NCDs due to population growth and aging, with COPD expected to reach the fourth leading cause. Conclusions: Several recent studies and international reports highlighted the huge global health burden of CRDs and other major NCDs, pointing out the need for implementing international collaborations to fight this epidemic trend.

Atopy Modifies the Association Between Inhaled Corticosteroid Use and Lung Function Decline in Patients with Asthma

BACKGROUND

Inhaled corticosteroids (ICSs) are the mainstay of asthma treatment, but response to medication is variable. Patients with allergic inflammation generally show a better short-term response to ICSs; however, studies on predictors of long-term response are few.

OBJECTIVE

To assess whether allergic sensitization can modify the association between ICS use and lung function decline over 20 years in adult asthma.

METHODS

We used data from the 3 clinical examinations of the European Community Respiratory Health Survey. We measured ICS use (no use, and use for <1.3, 1.3-8, and >8 years) and FEV₁ decline among subjects with asthma over the 2 periods between consecutive examinations. We conducted a cohort study combining data of the 2 periods (906 observations from 745 subjects) to assess whether the association between ICS use and FEV₁ decline was modified by allergic sensitization (IgE > 0.35 kU/L for any of house-dust mite, timothy grass, cat, or Cladosporium).

RESULTS

FEV₁ decline was similar for non-ICS users, as well as ICS users for less than 1.3 years, with and without allergic sensitization. However, among subjects on ICSs for a longer period, sensitization was associated with an attenuated decline (P_interaction = .006): in the group treated for more than 8 years, FEV₁ decline was on average 27 mL/y (95% CI_{Bonferroni-adjusted}, 11-42) lower for subjects with sensitization compared with nonsensitized subjects.

CONCLUSIONS

Our study suggests that biomarkers of atopy can predict a more favorable long-term response to ICSs. Randomized controlled studies are needed to confirm these findings.

18-yr cumulative incidence of respiratory/allergic symptoms/diseases and risk factors in the Pisa epidemiological study

BACKGROUND

Few population-based studies on the effects of environmental exposure variation exist.

AIM

Assessing respiratory symptom/disease incidence related to risk factor exposure changes.

METHODS

A longitudinal general population sample from two surveys (PISA2:1991-1993; PISA3:2009-2011; no. = 970), aged ≥20 years at baseline, completed a questionnaire on respiratory symptoms/diseases, risk factor exposure and performed spirometry. 18-year follow-up cumulative incidence of respiratory symptoms/diseases and longitudinal changes (persistence, incidence, remittance) in risk factor exposure were computed.

RESULTS

Cumulative incidence values were: 3.2% (corresponding to a 1.8‰/year incidence rate), asthma; 6.6% (3.8‰/year), asthma attacks; 4.5% (2.6‰/year), wheeze; 31.7% (21.0‰/year), allergic rhinitis-AR; 7.6% (4.4‰/year), chronic obstructive pulmonary disease-COPD; 16.1% (9.7‰/year), usual cough; 18.5% (11.3‰/year), usual phlegm; 30.7% (20.1‰/year), dyspnoea 1+; 13.9% (8.3‰/year), airway obstruction. The following associations emerged among respiratory symptom/disease cumulative incidence and risk factor exposure changes: a two-to-five fold higher risk for COPD, phlegm, cough, dyspnoea, asthma attacks, airway obstruction in persistent smokers; a two-to-three fold higher risk for COPD in remittent smokers; a two-fold higher risk for AR, phlegm and a four-fold higher risk for asthma in subjects with persistent occupational exposure; a two-fold higher risk for cough, phlegm, dyspnoea, AR in subjects with incident occupational exposure; a two-fold higher risk for AR, asthma attacks, COPD in subjects with incident traffic exposure.

CONCLUSIONS

Our study showed noteworthy respiratory symptom/disease incidence values and indicated that life-style and environmental exposure changes can differently influence onset. This information could be useful for primary prevention strategies in order to reduce the chronic disease burden in the general population.