Alessandro Radaeli

Bronchoalveolar lavage, sputum and exhaled clinically relevant inflammatory markers: values in healthy adults

Bronchoalveolar lavage (BAL), induced sputum and exhaled breath markers (exhaled nitric oxide and exhaled breath condensate) can each provide biological insights into the pathogenesis of respiratory disorders. Some of their biomarkers are also employed in the clinical management of patients with various respiratory diseases. In the clinical context, however, defining normal values and cut-off points is crucial. The aim of the present review is to investigate to what extent the issue of defining normal values in healthy adults has been pursued for the biomarkers with clinical value. The current authors reviewed data from literature that specifically addressed the issue of normal values from healthy adults for the four methodologies. Most studies have been performed for BAL (n = 9), sputum (n = 3) and nitric oxide (n = 3). There are no published studies for breath condensate, none of whose markers yet has clinical value. In healthy adult nonsmokers the cut-off points (mean+2sd) for biomarkers with clinical value were as follows. BAL: 16.7% lymphocytes, 2.3% neutrophils and 1.9% eosinophils; sputum: 7.7×106·mL−1 total cell count and 2.2% eosinophils; nitric oxide: 20.2 ppb. The methodologies differ concerning the quantity and characteristics of available reference data. Studies focusing on obtaining reference values from healthy individuals are still required, more evidently for the new, noninvasive methodologies.

Usefulness of Exhaled Nitric Oxide and Sputum Eosinophils in the Long-term Control of Eosinophilic Asthma

BACKGROUND The aim of the present study was to treat unstable asthma according to exhaled nitric oxide (eNO) and induced-sputum eosinophils (sEos) levels to assess if this strategy is better than the conventional approach based on symptoms and function to achieve asthma control. METHODS Fourteen patients with mild-to-moderate persistent asthma (6 men, 8 women) were recruited. During the recruitment visit, the patients, previously treated for asthma following Global Initiative for Asthma recommendations, underwent clinical evaluation and pulmonary function tests (PFTs). Then, after 4 weeks of washout from inhaled antiinflammatory treatment, the patients underwent a basal visit performing PFTs, challenge test to methacholine, and determination of eNO and sEos counts. These procedures were repeated after 3, 6, and 12 months while the patients were treated with inhaled steroids in a stepwise fashion according to eNO and sEos values. RESULTS At the end of the study, a significant decrease in eNO and sEos was observed (57.2 +/- 32.8 parts per billion [ppb] vs 22.1 +/- 10.8 ppb, p < 0.01; and 27.1 +/- 27.1% vs 3.7 +/- 3.5%, p < 0.01, respectively). A close correlation (r2 = 0.41, p < 0.01) between the percentage change of eNO and sEos was observed only after 6 months. Patients treated according to the levels of these inflammatory markers had fewer symptoms and fewer exacerbations compared to those the year before when they were conventionally treated. CONCLUSIONS Our results show the usefulness of eNO and sEos for titrating treatment in asthmatic patients in order to achieve better long-term control of the disease. The eNO decrease reflects adequately the reduction of sEos only after 6 months.

Neutrophilic inflammation and IL-8 levels in induced sputum of alpha-1-antitrypsin PiMZ subjects

Background: Severe alpha-1-antitrypsin deficiency (AATD), due to homozygosity for the protease inhibitor (Pi) Z allele, is a genetic risk factor for chronic obstructive pulmonary disease (COPD). In a previous study the sputum of severe AATD subjects with airflow obstruction showed a pattern of cellular inflammation similar to COPD patients. It is uncertain whether heterozygotes for the Z allele or intermediate deficiency (PiMZ) have an increased risk of developing COPD. Methods: Sputum cell counts and the supernatant level of the neutrophil chemoattractant interleukin (IL)-8 were investigated by sputum induction in 10 non-smoker asymptomatic PiMZ subjects with normal pulmonary function, 10 patients with stable COPD, and 10 age matched normal subjects. Data are expressed as mean (SD). Results: The mean (SD) number of neutrophils was significantly higher (p<0.01) in the sputum of PiMZ subjects (84.5 (22.2) ×104/ml) and patients with COPD (126.9 (18.8) ×104/ml) than in matched normal subjects (55.0 (8.7) ×104/ml). IL-8 levels were increased in PiMZ subjects (828.5 (490.6) ng/ml; median 1003.0 ng/ml; range 1260–100 ng/ml) and in COPD patients (882.5 (524.3) ng/ml; median 934.9 ng/ml; range 1506–258 mg/ml) compared with normal subjects (3.5 (0.5) ng/ml; median 3.5 ng/ml; range 4.5–2.5 ng/ml). There was a significant positive correlation between IL-8 supernatant concentration and neutrophil count in PiMZ subjects (p = 0.036; r = 0.66). An inverse correlation was observed between the percentage of neutrophils and forced expiratory volume in 1 second (% predicted) in patients with COPD (p = 0.04; r = −0.43). Conclusions: These findings indicate that PiMZ subjects without airflow obstruction may have an IL-8 related neutrophilic inflammation in the airways, similar to stable COPD patients, suggesting an increased risk of developing pulmonary changes.

Exhaled Nitric Oxide as a Biomarker in COPD and Related Comorbidities

Chronic Obstructive Pulmonary Disease (COPD) is defined as a disease characterized by persistent, progressive airflow limitation. Recent studies have underlined that COPD is correlated to many systemic manifestations, probably due to an underlying pattern of systemic inflammation. In COPD fractional exhaled Nitric Oxide (FeNO) levels are related to smoking habits and disease severity, showing a positive relationship with respiratory functional parameters. Moreover FeNO is increased in patients with COPD exacerbation, compared with stable ones. In alpha-1 antitrypsin deficiency, a possible cause of COPD, FeNO levels may be monitored to early detect a disease progression. FeNO measurements may be useful in clinical setting to identify the level of airway inflammation, per se and in relation to comorbidities, such as pulmonary arterial hypertension and cardiovascular diseases, either in basal conditions or during treatment. Finally, some systemic inflammatory diseases, such as psoriasis, have been associated with higher FeNO levels and potentially with an increased risk of developing COPD. In these systemic inflammatory diseases, FeNO monitoring may be a useful biomarker for early diagnosis of COPD development.

COPD and the metabolic syndrome: an intriguing association

Chronic Obstructive Pulmonary Disease (COPD) has been recently recognized as a condition involving more than the lungs. The presence of common factors in COPD and in other chronic extra-pulmonary diseases, as well as the co-existence of these conditions in the same adult individual, supports the hypothesis of a shared pathogenetic pathway. We will here review the interplay between coexisting COPD and the metabolic syndrome (MS), based on the most updated knowledge. We will discuss this clinical condition from the definition, to the pathophysiology and to the clinical implications. Basically, MS is more likely to be present in a COPD patients, and increased levels of circulatory pro-inflammatory proteins from both the lung and adipose tissue coincide in these patients. The relative impact of the coexisting COPD and MS may depend on several factors: the presence of physical inactivity and of systemic inflammation related to a smoking habit, sedentary lifestyle, airway inflammation and obstruction, adipose tissue and inflammatory marker activation. More studies will be required to elucidate the association between COPD and MS and to formulate individualized management approaches for this specific disease phenotype.

Differential pharmacology and clinical utility of emerging combination treatments in the management of COPD – role of umeclidinium/vilanterol

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease characterized by airflow limitation that is not fully reversible. Bronchodilator therapy is the cornerstone in COPD treatment. Bronchodilation in COPD is mainly achieved via administration of long- and ultralong-acting β2-agonists and with long-acting muscarinic antagonists. New combinations of bronchodilators with dual-acting muscarinic antagonist and β2-agonist properties have been licensed, and others are currently being developed with the aim of achieving once-daily dosing, and therefore may improve the likelihood of treatment compliance. These combination bronchodilators include glycopyrronium bromide/indacaterol maleate, umeclidinium (UMEC) bromide/vilanterol trifenatate (VI), aclidinium bromide/formoterol and tiotropium bromide/olodaterol (Boehringer Ingelheim, Germany). This review will focus mainly on studies and clinical trials involving the novel fixed-dose combination of UMEC/VI at doses of 125/25 μg and 62.5/25 μg in patients with COPD. Data from large clinical trials involving more than 4,500 COPD patients indicate that UMEC/VI is an effective once-daily treatment in COPD with improved pulmonary function. Future studies assessing the impact of this combination on exacerbations, delay in disease progression, and health status in patients with COPD are warranted.

Airway hyperresponsiveness in a large group of subjects with α1-antitrypsin deficiency: a cross-sectional controlled study

Abstract.  Malerba M, Radaeli A, Ceriani L, Tantucci C, Grassi V (University of Brescia, Brescia, Italy). Airway hyperresponsiveness in a large group of subjects with α1‐antitrypsin deficiency: a cross‐sectional controlled study. J Intern Med 2003; 253: 351–358.

Narrowband ultraviolet B phototherapy in psoriasis reduces proinflammatory cytokine levels and improves vitiligo and neutrophilic asthma

DEAR EDITOR, Psoriasis, neutrophilic asthma and vitiligo vulgaris are three immune-mediated diseases in which raised serum levels of proinflammatory T helper (Th) 1/Th17 cytokines have been detected. Psoriasis is considered a systemic disease with several comorbidities, and the role of high levels of cytokines referable to Th1–Th17 patterns in the pathogenesis of these comorbidities remains to be clarified. Monozygotic twins, aged 69 years, affected by psoriasis and vitiligo were referred to the outpatient clinic of the internal medicine department of the University of Brescia, Brescia, Italy, because of poorly controlled asthma. Both twins had asthma, which had been treated with montelukast 10 mg daily, inhaled corticosteroid and a long-acting b2 agonist (fluticasone 250 lg/ formoterol 10 lg) twice daily in the preceding 6 months. Physical examination revealed high respiratory rates (22 and 26 breaths per min, respectively) with signs of accessory muscle use and, on auscultation, decreased breathing sounds with inspiratory and expiratory wheezing. Pulse oximetry was 94% and 92%, respectively, on room air. A chest radiograph of both twins showed bronchial thickening, hyperinflation and focal atelectasis consistent with asthma. Spirometry detected, respectively, a forced expiratory volume in the first second (FEV1) of 64% and 66% of the predicted volume, and a Tiffeneau index of 70% and 71% of the predicted value. The patients reported moderate limitations of daily activities and a mean of three asthma attacks weekly, suggesting the presence of severe uncontrolled asthma. In both twins a chest computer tomography scan was performed during inspiration, and demonstrated air trapping. Immunology examinations resulted in negative antinuclear antibody, extractable nuclear antigen and rheumatoid factor, no eosinophilia and normal total IgE, erythrocyte sedimentation rate, C-reactive protein and procalcitonin levels. Serum levels of interleukin (IL)-17, IL-1b, IL-6, IL-8, IL-12 and tumour necrosis factor (TNF)-a were higher than normal, whereas IL-4 was in the normal range (Table 1). Hence, sputum induction was performed to characterize asthma inflammatory phenotype showing a neutrophilic pattern. Afterwards, the twins underwent an exhaled breath condensate test, analysed with an enzyme-linked immunosorbent assay, which showed a lymphocyte Th1/Th17 cytokine pattern (Table 1). After these assessments the dose of formoterol and fluticasone was doubled, and an anticholinergic (tiotropium bromide 18 lg) once daily was added. Associated Table 1 Values of exhaled breath condensate, induced sputum, fractional exhaled nitric oxide and spirometric data before and after psoriasis treatment in monozygotic twins

The combined impact of exhaled nitric oxide and sputum eosinophils monitoring in asthma treatment: a prospective cohort study

BACKGROUND Inhaled corticosteroids (ICS) treatment for asthma control is generally focused on lung function and symptoms, but inadequately correlated with airway inflammation. OBJECTIVE To compare asthma control in a group of patients whose treatment was based on fraction of exhaled nitric oxide (FENO) and sputum eosinophils (intervention group) with a group in whom treatment was based on clinical score (control group). Study design and primary outcome: Randomized parallel-group longitudinal 24-month study including 5 visits every 6 months. A combination of asthma exacerbation rate and symptom score at 24 months was the primary outcome. PARTICIPANTS Fourteen patients with eosinophilic asthma per group were included. RESULTS In the intervention group, exacerbation rate/patient/year was reduced at 12 months (0.82) (-73%) and, to a greater extent at 24 months (0.5) (-84%) compared with baseline (3.21, p<0.01). In the control group, a significant reduction in exacerbation rate/patient/year was only observed between month 12 (3.0) and 24 (2.0, -33%, p<0.01). At 24 months, exacerbation rate was lower (-75%) in the intervention (0.5) than in the control group (2.0, p<0.05). Compared with baseline, mean symptom scores at 24 months were reduced in both groups (intervention group: -72%; control group: - 60%), but were lower in the intervention (8.1±1.0, p<0.05; -27%) than in the control group (11±2.6). ICS dose gradually increased in both groups throughout the study, with no between-group differences. CONCLUSION Compared with conventional strategy, longitudinal monitoring of FENO and sputum eosinophils improves eosinophilic asthma control in terms of reduced symptoms and exacerbations without additional increase e in ICS treatment.

Increased airway inflammation in patients with psoriasis.

DEAR EDITOR, Psoriasis, currently the most common dermatitis, is considered a systemic chronic inflammatory disease with an unclear pathogenesis. In the literature, psoriasis has been demonstrated to increase the incidence of a large number of diseases that share an inflammatory origin. While several hypotheses have been proposed, the currently most accepted is that of proinflammatory cytokine spillover from active psoriatic lesions, which may cause inflammation in distant tissues. Recently, increased tissue positivity to several proinflammatory cytokines, including tumour necrosis factor-a, has been observed in psoriasis plaques and blood. This cytokine is able to develop and maintain inflammation by increasing the transcription of several enzymes, such as the inducible form of nitric oxide synthase (iNOS), which synthesizes nitric oxide (NO) from arginine, and arginase. However, in psoriatic plaques both iNOS and arginase are overexpressed, allowing low levels of NO to be produced locally. Furthermore, psoriasis affects vessels in the form of endothelial dysfunction, causing an accumulation of NOS inhibitors in the blood of patients with psoriasis, and also determining decreased free NO content in blood. Simultaneously, blood transports the locally produced proinflammatory cytokines that act on other systems, creating inflammation. NO is also produced physiologically by respiratory epithelium and endothelium. Inflammation can further increase the amount of NO by implementing iNOS expression. Thus, fractional exhaled NO (FeNO) has been accepted in the literature as an indirect marker of airway inflammation, and is currently used in the clinical monitoring and management of asthma inflammation levels. Owing to five studies that published inconsistent findings on the possible increased risk of patients with psoriasis having chronic obstructive pulmonary disease (COPD), the respiratory implications of psoriasis are not fully understood. Only one study has underlined a higher prevalence of asthma in people with psoriasis. The possibility of subclinical airway inflammation remains open and unevaluated. Thus, we examined this by comparing the FeNO levels of patients with psoriasis before and after treatment. In this observational study, we enrolled 59 patients with psoriasis who were admitted to our department in 2012–13. All patients had a Psoriasis Area Severity Index (PASI) score > 10, and were subdivided into two groups: moderate (10 < PASI < 20; n = 42) and severe (PASI > 10; n = 17). Diagnosis was based on a dermatological examination of the typical primary lesions. Exclusion criteria included nicotine dependence, atopy and other conditions that can change FeNO levels, while inclusion criteria included a Tiffeneau index > 80% and average forced expiratory flow during the mid (25–75%) portion of the forced vital capacity of > 65%, routinely measured with spirometry. Patients performed the FeNO test before and after treatments, and FeNO levels were detected by a high-resolution chemiluminescence NO analyser at flow rates of 30, 50, 100 and 200 mL s . The result was the mean of three measurements acquired at each flow rate. Demographic characteristics were grouped with descriptive statistics and analysed by SPSS 21 (IBM, Armonk, NY, USA). All continuous data were expressed with the mean and SD. If normally distributed, the means were compared by Student’s t-test for independent samples and correlation between variables by linear regression with Pearson Index. Categorical variables were estimated by the v test. A P-value < 0 05 was considered significant. Patient data and descriptive statistics are shown in Tables 1 and 2, respectively. Before treatment, for all flows, patients had higher-thannormal FeNO levels compared with post-treatment flows, when patients had normal FeNO levels. This difference was statistically significant and is shown in Figure 1(a). There was positive correlation between PASI score and FeNO, especially for flow rates of 30 and 50 mL s 1 (Fig. 1b,c). A statistically significant difference was also seen between FeNO values for all flows and moderate and severe PASI scores, particularly at a flow of 50 mL s 1 (Fig. 1d–g). Furthermore, before and after treatment, FeNO scores were significantly different at all flow rates in both the moderate and severe PASI groups (Fig. 1a). In contrast to the literature,