Phenotypes, Etiotypes, and Endotypes of Exacerbations of Chronic Obstructive Pulmonary Disease

Personal exposure to PM2.5 and O3 induced heterogeneous inflammatory responses and modifying effects of smoking: A prospective panel study in COPD patients

Air pollution and smoking are major contributors to chronic obstructive pulmonary disease (COPD), primarily through inflammatory responses. We performed this prospective panel study among 107 COPD patients (372 repeated measurements) with personal monitoring of fine particulate matter (PM2.5) and ozone (O3), two primary pollutants contributing to the COPD disease burden, to investigate the interactive effects of air pollutants and smoking on inflammatory profiles. Exhaled nitric oxide and hydrogen sulfide were detected to assess airway eosinophilic and neutrophilic inflammation, respectively. Fasting blood was collected to count inflammatory cells and detect type-1, type-2, type-17, and regulatory T (Treg) cytokines. We found PM2.5 mainly induced neutrophilic inflammation, manifesting as stronger airway inflammation in non-smokers and greater increases in blood neutrophils in current smokers (P-interaction<0.05), particularly those with neutrophilic phenotype. Conversely, O3 primarily induced nasal and circulating eosinophilic inflammation, with non-smokers showing heightened susceptibility. These effects were modified by type-1/type-2 and type-17/Treg immune imbalances in both non-smokers and current smokers. Specifically, type-1 and type-17-skewed immunity exacerbated the neutrophilic effects of PM2.5, while type-2 and Treg-skewed immunity aggravated the eosinophilic responses to O3. This study emphasizes the need for personalized prevention strategies to protect COPD patients from the detrimental impacts of air pollution and smoking.

Phenotypes of Exacerbations in Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease with an important public health challenge and a major burden on health-care resources, having a progressive character with constant deterioration of lung function. During the course of the disease, patients experience acute episodes of exacerbation, which are characterized by worsening symptoms, and require additional treatment during these exacerbating episodes. Given the heterogeneity of exacerbations, their phenotyping is of great interest in order to administer the most effective treatment with the aim of reducing mortality and preventing future exacerbation episodes. The lack of specific biomarkers for the diagnosis of acute exacerbations of COPD maintains researchers' interest in trying to identify such a biomarker. In this review, we explore the different phenotypes of COPD exacerbation, and we also evaluated the ability of various biomarkers to establish the etiology of exacerbations in association with clinical manifestations. Furthermore, we addressed the main therapeutic measures necessary according to each phenotype. Overall, phenotyping exacerbations allows for an individualized approach to these patients, thus avoiding the side effects of some treatments.

The Clinical significance of Peripheral Blood-related Inflammatory Markers in patients with AECOPD

OBJECTIVE

Peripheral blood-related inflammatory markers, including systemic immune inflammation index (SII), inflammatory response index (SIRI), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR), have received increasing clinical attention over the years. This study aims to investigate the clinical significance of peripheral blood-related inflammatory markers in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We hope that this study will provide guidance for clinical individualized treatment and management of AECOPD patients.

METHODS

A total of 254 patients with AECOPD admitted between January 2021 and December 2022 were enrolled in this study and categorized into mild and moderate-to-severe groups. Univariate analysis, Spearman correlation analysis, and receiver operating characteristic curve (ROC) were performed to study the clinical value of peripheral blood-related inflammatory markers. Then, the relationship between the peripheral blood-related inflammatory markers and the risk of readmission owing to acute exacerbation during the first year after discharge was further studied through survival analysis and multivariate Cox regression.

RESULTS

The levels of peripheral blood-related inflammatory markers in patients with moderate-to-severe AECOPD were significantly higher than patients in the mild group, and the levels of peripheral blood-related inflammatory markers are positively correlated with the severity of disease. The highest diagnostic accuracy for moderate-to-severe AECOPD was achieved by combining five indexes, with a cut-off value of 0.38 and an AUC of 0.837 (95 % CI: 0.789-0.885). Higher levels of peripheral blood-related inflammatory markers may indicate a higher risk of readmission within one year of hospital discharge in patients with AECOPD, and SII (HR = 3.478, P < 0.001) was an independent risk factor. Besides, higher levels of peripheral blood-related inflammatory markers also suggest impaired pulmonary ventilation function and enlarged right ventricular diameter.

CONCLUSIONS

Peripheral blood-related inflammatory markers (SII, SIRI, NLR, PLR, MLR) can serve as a reference for identifying patients with moderate-to-severe AECOPD. Patients with higher levels of peripheral blood-related inflammatory markers are more susceptible to experiencing acute exacerbation and readmission events within one year after hospital discharge. Peripheral blood-related inflammatory markers can assist clinicians in evaluating the condition and predicting the risk of readmission in patients with AECOPD more scientifically and objectively.

Pharmacologic Therapies for Preventing Chronic Obstructive Pulmonary Disease Exacerbations: A Comprehensive Review

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory disorder characterized by acute exacerbations that accelerate disease progression, increase hospitalizations, and elevate mortality. Effective management focuses on preventing these exacerbations owing to their significant impact on long-term outcomes. This review compiles current evidence regarding pharmacologic interventions aimed at reducing exacerbations, which include inhaled therapies, oral treatments, and novel agents. Established inhaled agents, such as long-acting beta-agonists, long-acting muscarinic antagonists, and combinations of inhaled corticosteroids, are fundamental, with the personalized selection based on patient-specific factors like blood eosinophil levels and history of exacerbations. Oral treatments, including roflumilast and azithromycin, confer additional benefits for patients with particular characteristics, such as chronic bronchitis or frequent exacerbations. Roflumilast effectively reduces exacerbations as a phosphodiesterase 4 (PDE-4) inhibitor in conjunction with inhaled therapies, while azithromycin provides anti-inflammatory and antimicrobial properties, particularly advantageous for elderly former smokers. Innovative therapies such as ensifentrine, a dual PDE-3/4 inhibitor, and dupilumab, which targets type 2 inflammation, demonstrate potential for lowering exacerbations in specific subgroups. This body of evidence endorses a personalized, phenotype-driven approach to COPD management, aimed at optimizing therapeutic strategies to decrease exacerbation frequency and enhance patient outcomes.

Risk of acute exacerbation of chronic obstructive pulmonary disease after COVID-19 recovery: a nationwide population-based cohort study

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is associated with severe Coronavirus disease 2019 (COVID-19) outcomes. However, it is uncertain whether the risk of acute exacerbation of COPD (AECOPD) increases after recovering from COVID-19.

METHODS

This study included 2,118 individuals with COPD from the Korea National Health Insurance Service database who were also diagnosed with COVID-19. Matched controls were chosen using 1:1 propensity score (PS) matching. We compared the risk of AECOPD after COVID-19 recovery between the COVID-19 cohort and matched controls between October 8, 2020, and December 31, 2021, using PS-matched Cox proportional hazard regression models.

RESULTS

During a median follow-up of 62 days (interquartile range, 29-179 days), including a median of 14 days of recovery time after COVID-19, 68 people (5.6%) in the COVID-19 cohort and 50 (3.9%) in the matched control group experienced AECOPD. Compared to the matched controls, the COVID-19 cohort had a significantly higher risk of overall AECOPD (hazard ratio [HR] = 1.45, 95% confidence interval [CI] = 1.09-1.92). This increased risk was particularly evident for severe AECOPD among individuals who had severe COVID-19 within the first 30days post-recovery (aHR = 8.14, 95% CI = 3.32-19.97). When classified by COVID-19 severity, while severe COVID-19 significantly increased this risk (aHR = 2.97, 95% CI = 2.15-4.11), non-severe COVID did not significantly influence the risk of AECOPD, regardless of time duration or exacerbation severity.

CONCLUSION

Individuals with COPD who had severe COVID-19 have increased risk of AECOPD after COVID-19 recovery, especially within the first 30 days after COVID-19 recovery.

Investigation of the efficacy and potential pharmacological mechanism of Yupingfeng in treating chronic obstructive pulmonary disease: A meta-analysis and in silico study

ETHNOPHARMACOLOGICAL RELEVANCE

Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death globally, significantly burdening healthcare and economies. Studies show Yupingfeng (YPF) combined with conventional treatments (CT) can effectively control COPD progression, improving lung function and quality of life.

AIM OF THE STUDY

This study aims to comprehensively explore the multiple therapeutic effects and potential pharmacological mechanisms of YPF in the treatment of COPD through various approaches, including meta-analysis, network pharmacology, molecular docking, and molecular dynamics simulations.

MATERIALS AND METHODS

We searched PubMed, Embase, Cochrane Library, Web of Science, CNKI, Wanfang Data, VIP, and CBM databases up to June 2024. Meta-analysis was conducted using Review Manager 5.4 and Stata 16.0. The certainty of evidence was assessed using the GRADE system. Network pharmacology, molecular docking, and dynamics simulations were employed to explore mechanisms and evaluate the binding of YPF's active components to targets.

RESULTS

The meta-analysis showed that YPF combined with CT significantly improved COPD treatment efficacy compared to CT alone (moderate certainty). Lung function markers, including FEV1% pred (high certainty), FVC (moderate certainty), and FEV1/FVC (high certainty), also improved significantly. Secondary outcomes, such as Traditional Chinese Medicine (TCM) syndrome scores, CAT scores, and inflammatory and immune biomarkers, also showed improvement (low certainty). Network pharmacology identified potential YPF targets, including ESR1, SRC, EP300 and HSP90AA1, possibly involving calcium and cAMP signaling pathways. Molecular docking and dynamics simulations suggested that YPF may exert its effects by stabilizing the binding of isoflavanone to HSP90AA1.

CONCLUSIONS

This study demonstrates that YPF combined with CT can enhance the treatment efficacy for COPD, improving lung function and quality of life, with strong anti-inflammatory and immunomodulatory effects, and good safety. The molecular docking and molecular dynamics simulation results suggest that isoflavanone, isorhamnetin, and 14_acetyl_12_senecioyl_2E_8E_10E_atractylentriol may be the active components with strong binding affinity for COPD treatment, with HSP90AA1_isoflavanone showing the best performance in terms of stability and binding energy, second only to the standard ligand, and possibly being one of the key mechanisms of YPF in treating COPD.

The Role of Yes-Associated Protein in Inflammatory Diseases and Cancer

Yes-associated protein (YAP) plays a central role in the Hippo pathway, primarily governing cell proliferation, differentiation, and apoptosis. Its significance extends to tumorigenesis and inflammatory conditions, impacting disease initiation and progression. Given the increasing relevance of YAP in inflammatory disorders and cancer, this study aims to elucidate its pathological regulatory functions in these contexts. Specifically, we aim to investigate the involvement and molecular mechanisms of YAP in various inflammatory diseases and cancers. We particularly focus on how YAP activation, whether through Hippo-dependent or independent pathways, triggers the release of inflammation and inflammatory mediators in respiratory, cardiovascular, and digestive inflammatory conditions. In cancer, YAP not only promotes tumor cell proliferation and differentiation but also modulates the tumor immune microenvironment, thereby fostering tumor metastasis and progression. Additionally, we provide an overview of current YAP-targeted therapies. By emphasizing YAP's role in inflammatory diseases and cancer, this study aims to enhance our understanding of the protein's pivotal involvement in disease processes, elucidate the intricate pathological mechanisms of related diseases, and contribute to future drug development strategies targeting YAP.

Characterizing COPD phenotypes with a targeted signaling lipids metabolomics approach

AIMS

This study aimed to elucidate clinically-relevant classifications of COPD using a targeted metabolomics approach focusing on signaling lipids.

MATERIALS AND METHODS

Using a targeted LC-MS/MS platform, 166 metabolites including free fatty acids, prostaglandins, isoprostanes, lysophospholipids, endocannabinoids, and bile acids were profiled in a cohort of 49 COPD patients. The study integrated metabolomic data with clinical parameters to identify key metabolites and related pathways for various COPD classification systems including Global Initiative for Chronic Obstructive Lung Disease (GOLD) grading stages, Koninklijk Nederlands Genootschap voor Fysiotherapie (KNGF, Royal Dutch Society for Physiotherapy) profiles, and Systemic (SYS) subtypes and explored the association of these classification systems.

KEY FINDINGS

The GOLD stages showed correlations with 15 metabolites, including lysophospholipids, oxylipins, and bile acids. KNGF profiles were linked to 13 metabolites, predominantly lysophospholipids, while SYS subtypes were associated with 9 metabolites, mainly oxylipins. A specific cluster of oxylipins, including HETEs and HDoHEs, was notably correlated to prognostic factors of COPD.

SIGNIFICANCE

This study identified distinct metabolic patterns associated with GOLD stages, KNGF profiles, and SYS subtypes. Additionally, the findings indicate that 14-HDoHE/DHA may serve as a potential biomarker for COPD exacerbation and suggest possible therapeutic targets for COPD, including pathways involving lipoxygenases, G-protein coupled receptors, and the Farnesoid X receptor.

Symptom Network and Subgroup Analysis in Patients with Exacerbation of Chronic Obstructive Pulmonary Disease: A Cross-Sectional Study

Purpose

This study aims to construct a contemporaneous symptom network of inpatients with Exacerbation of Chronic Obstructive Pulmonary Disease (ECOPD) based on the symptom cluster, identify core and bridge symptoms, and patient subgroups with different symptom clusters based on individual differences in the intensity of patient symptom experiences.

Patients and Methods

This study used convenience sampling to collect demographic, symptom, auxiliary examination, and prognosis information of 208 inpatients with ECOPD from April 2022 to October 2023. The data underwent exploratory factor analysis (EFA), symptom network analysis, latent class analysis (LCA), Spearman correlation analysis, Wilcoxon signed-rank test, single-factor regression and multiple-factor stepwise regression.

Results

In hospitalized patients with ECOPD, symptom network analysis revealed that loss of appetite was the core symptom, while chest distress was the bridge symptom. Through LCA analysis, two symptom subgroups were identified: a high-symptom group (53.8%) and a low-symptom group (46.2%). This suggests that there is significant heterogeneity in symptom experience among ECOPD individuals. Patients in the high-symptom group had a higher probability of experiencing symptom clusters related to nutrition-sleep.

Conclusion

The combination of symptom network analysis and LCA comprehensively captures the symptom/symptom cluster characteristics and accounts for the heterogeneity of ECOPD patients from both individual and group perspectives. This study identifies core symptoms, bridge symptoms, and symptom subgroups, offering valuable insights for precision symptom management in ECOPD.

Protocol for the enhanced management of multimorbid patients with COPD and severe asthma: role of indoor air quality

INTRODUCTION

Reducing unplanned hospital admissions in chronic patients at risk is a key area for action due to the high healthcare and societal burden of the phenomenon. The inconclusive results of preventive strategies in patients with chronic obstructive respiratory disorders and comorbidities are explainable by multifactorial but actionable factors.The current protocol (January 2024-December 2025) relies on the hypothesis that intertwined actions in four dimensions: (1) management change, (2) personalisation of the interventions based on early detection/treatment of acute episodes and enhanced management of comorbidities, (3) mature digital support and (4) comprehensive assessment, can effectively overcome most of the limitations shown by previous preventive strategies. Accordingly, the main objective is to implement a novel integrated care preventive service for enhanced management of these patients, as well as to evaluate its potential for value generation.

METHODS AND ANALYSIS

At the end of 2024, the specifics of the novel service will be defined through the articulation of its four main components: (1) enhanced lung function testing through oscillometry, (2) continuous monitoring of indoor air quality as a potential triggering factor, (3) digital support with an adaptive case management (ACM) approach and (4) predictive modelling for early identification and management of exacerbations. During 2025, the novel service will be assessed using a Quintuple Aim approach. Moreover, the Consolidated Framework for Implementation Research will be applied to assess the implementation. The service components will be articulated through four sequential 6-month plan-do-study-act cycles. Each cycle involves a targeted cocreation process following a mixed-methods approach with the active participation of patients, health professionals, managers and digital experts.

ETHICS AND DISSEMINATION

The Ethics Committee for Human Research at Hospital Clinic de Barcelona approved the protocol on 29 June 2023 (HCB/2023/0126). Before any procedure, all patients in the study must sign an informed consent form.

TRIAL REGISTRATION NUMBER

NCT06421402.

Identification and Construction of a R-loop Mediated Diagnostic Model and Associated Immune Microenvironment of COPD through Machine Learning and Single-Cell Transcriptomics

Chronic obstructive pulmonary disease (COPD) is a prevalent chronic inflammatory airway disease with high incidence and significant disease burden. R-loops, functional chromatin structure formed during transcription, are closely associated with inflammation due to its aberrant formation. However, the role of R-loop regulators (RLRs) in COPD remains unclear. Utilizing both bulk transcriptome data and single-cell RNA sequencing data, we assessed the diverse expression patterns of RLRs in the lung tissues of COPD patients. A lower R-loop score was found in patients with COPD and in neutrophils. 12 machine learning algorithms (150 combinations) identified 14 hub RLRs (CBX8, EHD4, HDLBP, KDM6B, NFAT5, NLRP3, NUP214, PAFAH1B3, PINX1, PLD1, POLB, RCC2, RNF213, and VIM) associated with COPD. A RiskScore based on 14 RLRs identified two distinct COPD subtypes. Patient groups at high risk of COPD (low R-loop scores) had a higher immune score and a significant increase in neutrophils in their immune microenvironment compared to low-risk groups. PD-0325901 and QL-X-138 represent prospective COPD treatments for high-risk (low R-loop score) and low-risk (high R-loop score) patients. Finally, RT-PCR experiments confirmed expression differences of 8 RLRs (EHD4, HDLBP, NFAT5, NLRP3, PLD1, PINX1, POLB, and VIM) in COPD mice lung tissue. R-loops significantly contribute to the development of COPD and constructing predictive models based on RLRs may provide crucial insight into personalized treatment strategies for patients with COPD.

Impact of seasonal biometeorological conditions and particulate matter on asthma and COPD hospital admissions

Climate change and air pollution are pressing public health concerns, necessitating monitoring of their impact, particularly on respiratory diseases like obstructive lung diseases. This retrospective study analyzed medical records of patients hospitalized at the Warmia and Mazury Centre for Pulmonary Diseases in Olsztyn, Poland (2012-2021) for asthma and chronic obstructive pulmonary disease (COPD) exacerbations. Data included meteorological factors such as temperature, humidity, wind speed, precipitation, and levels of PM2.5 and PM10. The Humidex was utilized to assess thermal discomfort, considering various meteorological and thermal seasons. Findings indicated seasonal variability in asthma and COPD exacerbations. During winter, poorer air quality due to higher PM2.5 and PM10 levels correlated with increased exacerbations (r = 0.283, p < 0.05; r = 0.491, p < 0.001). In summer, discomfort from meteorological conditions led to more hospital admissions. Humidex values strongly correlated with admissions for obstructive diseases (R2 = 0.956 for asthma; R2 = 0.659 for COPD), with July and August showing statistically higher admission rates (p < 0.05). The study highlights the significant impact of air pollution and meteorological conditions on exacerbations of asthma and COPD, with Humidex serving as a valuable predictor during summer months.

Qingke Pingchuan granules alleviate airway inflammation in COPD exacerbation by inhibiting neutrophil extracellular traps in mice

BACKGROUND

Chronic obstructive pulmonary disease (COPD) imposes a significant global health and socioeconomic burden. Exacerbations of COPD (ECOPD), characterized by heightened airway inflammation and mucus hypersecretion, adversely affect patient health and accelerate disease progression. Qingke Pingchuan (QKPC) granules, a formulation from Traditional Chinese Medicine initially prescribed for acute bronchitis, have shown unexplored potential in ECOPD management, with mechanisms of action yet to be clarified.

PURPOSE

This study investigates the therapeutic effects of QKPC in a mouse model of ECOPD, focusing on underlying molecular mechanisms.

METHODS

COPD was induced in mice through chronic cigarette smoke (CS) exposure, followed by intratracheal administration of Pseudomonas aeruginosa lipopolysaccharide (LPS) to trigger exacerbation, after which mice were treated with QKPC granules. Major compounds in QKPC were identified via UHPLC-QE-MS, and high-throughput RNA sequencing of lung tissue samples identified differentially expressed genes. Transcriptomic data were integrated with network pharmacology analysis to pinpoint potential pathways, bioactive compounds, and target genes through which QKPC might attenuate ECOPD. Molecular docking, protein-small molecule binding assays, and in vitro analyses further validated interactions between key compounds and target genes, shedding light on plausible signaling pathways.

RESULTS

QKPC treatment led to significant reductions in airway leukocyte infiltration and goblet cell metaplasia in CS- and LPS-exposed mice, accompanied by decreased levels of inflammatory cytokines (IL-6, IL-1β, CXCL1, and TNF-α) and mucin MUC5AC in bronchoalveolar lavage fluid. The integrative transcriptomic and network pharmacology analysis identified the neutrophil extracellular trap (NET) formation pathway as a key mechanism underlying QKPC's protective effect against ECOPD. In vitro assays demonstrated that epigallocatechin-3-gallate (EGCG) and quercetin, two important bioactive compounds in QKPC, significantly inhibited NETosis induced by cigarette smoke extract (CSE) plus LPS in human neutrophils. The two compounds were found to interact directly with the reactive oxidative species (ROS)-generating enzyme NOX2 and its regulatory subunit p47phox. Subsequent in vitro studies further confirmed EGCG and quercetin's capacity to reduce ROS production and downregulate NOX2 and p47phox protein levels in neutrophils stimulated with CSE and LPS. Additionally, in vivo studies confirmed QKPC's efficacy in reducing NET formation, oxidative stress, and NOX2/p47phox protein expression in the lung tissue of ECOPD mice.

CONCLUSION

These findings suggest that QKPC granules alleviate airway inflammation in ECOPD, potentially through inhibition of pulmonary NET formation via the NOX2/p47phox-ROS pathway, underscoring their potential therapeutic application for ECOPD management in clinical settings.

Modeling respiratory tract diseases for clinical translation employing conditionally reprogrammed cells

Preclinical models serve as indispensable tools in translational medicine. Specifically, patient-derived models such as patient-derived xenografts (PDX), induced pluripotent stem cells (iPSC), organoids, and recently developed technique of conditional reprogramming (CR) have been employed to reflect the host characteristics of diseases. CR technology involves co-culturing epithelial cells with irradiated Swiss-3T3-J2 mouse fibroblasts (feeder cells) in the presence of a Rho kinase (ROCK) inhibitor, Y-27632. CR technique facilitates the rapid conversion of both normal and malignant cells into a "reprogrammed stem-like" state, marked by robust in vitro proliferation. This is achieved without reliance on exogenous gene expression or viral transfection, while maintaining the genetic profile of the parental cells. So far, CR technology has been used to study biology of diseases, targeted therapies (precision medicine), regenerative medicine, and noninvasive diagnosis and surveillance. Respiratory diseases, ranking as the third leading cause of global mortality, pose a significant burden to healthcare systems worldwide. Given the substantial mortality and morbidity rates of respiratory diseases, efficient and rapid preclinical models are imperative to accurately recapitulate the diverse spectrum of respiratory conditions. In this article, we discuss the applications and future potential of CR technology in modeling various respiratory tract diseases, including lung cancer, respiratory viral infections (such as influenza and Covid-19 and etc.), asthma, cystic fibrosis, respiratory papillomatosis, and upper aerodigestive track tumors. Furthermore, we discuss the potential utility of CR in personalized medicine, regenerative medicine, and clinical translation.

[Efficacy and toxicity of short-course corticosteroid therapy in chronic bronchial diseases]

Chronic respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) are characterized by airway inflammation. While corticosteroids (CS) are frequently prescribed during exacerbations of these conditions, their repeated use is associated with numerous side effects. The aim of this review is to synthesize the recent literature on the indications, benefits, and risks of short-term CS therapy for these two diseases. French guidelines recommend short-term CS as a first-line treatment during asthma exacerbation (0,5 to 1mg/kg/day, not exceeding 60mg/day, for at least 5 to 7 days) or as a second-line treatment for COPD exacerbation (5 days, 30 to 40mg/day). However, these recommendations are not without limitations; they are primarily based on studies conducted in hospital settings, raising questions about the generalizability of their results to primary care, and as they employ a "one size fits all" strategy, they do not take into account the phenotypic heterogeneity of different patients. Moreover, repeated short-term CS courses generate side effects that even at low doses can appear early in young asthma patients, and they can exacerbate pre-existing comorbidities in COPD patients. The concept of a threshold dose should be employed in routine practice in view of accurately assessing the risk of side effects. In the near future, it will be important to consider recently published data supporting the use of predictive biomarkers for responses to CS, particularly in COPD cases.

Airway Mucus Plugs on Chest Computed Tomography Are Associated with Exacerbations in COPD

Rationale/Objective: Acute exacerbations (AEs) of chronic obstructive pulmonary disease (COPD) are associated with significant morbidity and mortality. Whether mucus plugs are associated with prospective exacerbations has not been examined extensively.

METHODS

Mucus plugs were visually-identified on baseline chest computed tomography (CT) scans from smokers with Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades 2-4 COPD enrolled in two multicenter cohort studies: Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) and COPDGene. Associations between ordinal mucus plug score categories (0/1-2/≥3) and prospectively-ascertained AEs, defined as worsening respiratory symptoms requiring systemic steroids and/or antibiotics (moderate-to-severe) and/or ER/hospitalization (severe), were assessed using multivariable-adjusted zero-inflated Poisson regression; subjects were exacerbation-free at enrollment.

RESULTS

Among 3,250 participants in COPDGene (mean±SD age 63.7±8.4 years, FEV1 50.6%±17.8% predicted, 45.1% female) and 1,716 participants in ECLIPSE (age 63.3±7.1 years, FEV1 48.3%±15.8% predicted, 36.2% female), 44.4% and 46.0% had mucus plugs, respectively. The incidence rates of AEs were 61.0 (COPDGene) and 125.7 (ECLIPSE) per 100 person-years. Relative to those without mucus plugs, the presence of 1-2 and ≥3 mucus plugs was associated with increased risk (adjusted rate ratio, aRR [95%CI]=1.07[1.05-1.09] and 1.15[1.1-1.2] in COPDGene; aRR=1.06[1.02-1.09] and 1.12[1.04-1.2] in ECLIPSE, respectively) for prospective moderate-to-severe AEs. The presence of 1-2 and ≥3 mucus plugs was also associated with increased risk for severe AEs during follow-up (aRR=1.05[1.01-1.08] and 1.09[1.02-1.18] in COPDGene; aRR=1.17[1.07-1.27] and 1.37[1.15-1.62] in ECLIPSE, respectively).

CONCLUSION

CT-based mucus plugs are associated with an increased risk for future COPD AEs.

Personalized COPD Care: The Future of Precision-Based Therapies

Chronic obstructive pulmonary disease (COPD) is a progressive respiratory illness characterized by long-standing respiratory symptoms and airflow limitation. It is a major contributor to respiratory disease-related deaths and currently ranked as the sixth leading cause of mortality in the United States. Approved pharmacological therapies for the stable disease primarily consist of inhaled short and long-acting bronchodilators, inhaled corticosteroids, azithromycin, and roflumilast. In recent years, significant progress has been made in the management of COPD through the identification of different COPD phenotypes and endotypes, which allows for a more personalized treatment approach. While earlier studies investigating targeted therapies were less promising, recent data on drugs targeting type 2 inflammatory pathways have shown promising results in carefully selected patients. In this article, we will review the available data on targeted therapies as well as the ongoing clinical studies of novel targeted therapies for COPD. Understanding and implementing these advancements hold promise for improving outcomes and quality of life for individuals living with COPD.

Serum pentraxin-3 in patients with chronic obstructive pulmonary disease: A meta-analysis

The association between serum pentraxin-3 (PTX-3) levels and chronic obstructive pulmonary disease (COPD) has been explored in several studies. However, the results remain inconsistent. This meta-analysis aims to evaluate the differences in serum PTX-3 levels between COPD patients and healthy controls, as well as between patients with acute exacerbations of COPD (AECOPD) and stable COPD. Databases including PubMed, Embase, Web of Science, Wanfang, and China National Knowledge Infrastructure (CNKI) were systematically searched. A random-effects model was used to pool the results, accounting for the potential impact of heterogeneity. Subgroup and meta-regression analyses were performed to evaluate the influence of study characteristics on the outcome. The initial search identified 274 articles, with 17 studies meeting the inclusion criteria. These studies included a total of 996 AECOPD patients, 1414 stable COPD patients, and 1016 healthy controls. The meta-analysis showed significantly higher serum PTX-3 levels in COPD patients compared to healthy controls (standardized mean difference [SMD]: 0.51, 95% confidence interval [CI]: 0.30 to 0.73, P < 0.001; I² = 85%). Subgroup and meta-regression analyses suggested that the results were not significantly affected by the age, sex, or smoking status of the patients. Additionally, serum PTX-3 levels were higher in AECOPD patients compared to stable COPD patients (SMD: 0.58, 95% CI: 0.41 to 0.74, P < 0.001; I² = 59%). In conclusion, serum PTX-3 levels are elevated in COPD patients, particularly during acute exacerbations, compared to stable COPD patients and healthy controls. PTX-3 may serve as a potential biomarker for COPD severity and exacerbation status.

New methods to detect bacterial or viral infections in patients with chronic obstructive pulmonary disease

INTRODUCTION

Patients with chronic obstructive pulmonary disease (COPD) are frequently colonized and infected by respiratory pathogens. Identifying these infectious etiologies is critical for understanding the microbial dynamics of COPD and for the appropriate use of antimicrobials during exacerbations.

AREAS COVERED

Traditional methods, such as bacterial and viral cultures, have been standard in diagnosing respiratory infections. However, these methods have significant limitations, including lack of sensitivity and prolonged turnaround time. Modern molecular approaches offer rapid, sensitive, and specific detection, though they also come with their own challenges. This review explores and evaluates the clinical utility of the latest advancements in detecting bacterial and viral respiratory infections in COPD, encompassing molecular techniques, biomarkers, and emerging technologies.

EXPERT OPINION

In the evolving landscape of COPD management, integrating molecular diagnostics and emerging technologies holds great promise. The enhanced sensitivity of molecular techniques has significantly advanced our understanding of the role of microbes in COPD. However, many of these technologies have primarily been developed for pneumonia diagnosis or research applications, and their clinical utility in managing COPD requires further evaluation.

Expression of human Interferon Regulatory Factor 3 (IRF-3) in alveolar macrophages relates to clinical and functional traits in COPD

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a frequent cause of morbidity and mortality. Dysregulated and enhanced immune-inflammatory responses have been described in COPD. Recent data showed impaired immune responses and, in particular, of interferon (IFNs) signaling pathway in these patients.

AIM

To evaluate in peripheral lung of COPD patients, the expression of some of the less investigated key components of the innate immune responses leading to IFN productions including: IFN-receptors (IFNAR1/IFNAR2), IRF-3 and MDA-5. Correlations with clinical traits and with the inflammatory cell profile have been assessed.

METHODS

Lung specimens were collected from 58 subjects undergoing thoracic surgery: 22 COPD patients, 21 smokers with normal lung function (SC) and 15 non-smoker controls (nSC). The expression of IFNAR1, IFNAR2, IRF-3 and MDA-5, of eosinophils and activated NK cells (NKp46+) were quantified in the peripheral lung by immunohistochemistry.

RESULTS

A significant increase of IRF-3 + alveolar macrophages were observed in COPD and SC compared with nSC subjects. However, in COPD patients, the lower the levels of IRF-3 + alveolar macrophages the lower the FEV1 and the higher the exacerbation rate. The presence of chronic bronchitis (CB) was also associated with low levels of IRF-3 + alveolar macrophages. NKp46 + cells, but not eosinophils, were increased in COPD patients compared to nSC patients (p < 0.0001).

CONCLUSIONS

Smoking is associated with higher levels of innate immune response as showed by higher levels of IRF-3 + alveolar macrophages and NKp46 + cells. In COPD, exacerbation rates, severe airflow obstruction and CB were associated with lower levels of IRF-3 expression, suggesting that innate immune responses characterize specific clinical traits of the disease.

T3 Intratracheal Therapy Alleviates Pulmonary Pathology in an Elastase-Induced Emphysema-Dominant COPD Mouse Model

Chronic obstructive pulmonary disease (COPD) is a complex pulmonary condition characterized by bronchitis, emphysema, and mucus stasis. Due to the variability in symptoms among patients, traditional approaches to treating COPD as a singular disease are limited. This led us to focus on phenotype/endotype classifications. In this study, we explore the potential therapeutic role of thyroid hormone (T3) by using mouse models: emphysema-dominant elastase-induced COPD and airway-dominant C57BL/6-βENaC-Tg to represent different types of the disease. Here, we showed that intratracheal T3 treatment (40, 80 μg/kg, i.t., every other day) resulted in significant improvements regarding emphysema and the enhancement of respiratory function in the elastase-induced COPD model. T3-dependent improvement is likely linked to the up-regulation of Ppargc1a, a master regulator of mitochondrial biogenesis, and Gclm, a factor associated with oxidative stress. Conversely, neither short- nor long-term T3 treatments improved COPD pathology in the C57BL/6-βENaC-Tg mice. Because the up-regulation of extrathyroidal T3-producing enzyme Dio2, which is also considered a marker of T3 requirement, was specifically observed in elastase-induced COPD lungs, these results demonstrate that exogenous T3 supplementation may have therapeutic potential for acute but not chronic COPD exacerbation. Moreover, this study highlights the relevance of considering not only COPD phenotypes but also COPD endotypes (expression levels of Ppargc1a and/or Dio2) in the research and development of better treatment approaches for COPD.