Maria G. Belvisi

Nitric oxide is the endogenous neurotransmitter of bronchodilator nerves in humans.

In human airways, there is a prominent neural bronchodilator mechanism which is non-adrenergic. In human tracheal segments, we have demonstrated that this response is mediated entirely by nitric oxide (NO), since an inhibitor of NO synthesis, L-NG-nitroarginine methyl ester (L-NAME) (10(-4) M) abolishes this neural response. Identification of the neurotransmitter of this bronchodilator pathway may now make it possible to study its role in physiological control of airway calibre and in airway disease.

ERS guidelines on the assessment of cough

### Cough 1) All basic scientific articles should refer to cough as a three-phase motor act. For the purposes of acoustic recordings in clinical studies, however, cough should be described as a forced expulsive manoeuvre or manoeuvres against a closed glottis that are associated with a characteristic sound or sounds. 2) All scientific articles should include a clear definition of what the authors have used as their definition of cough. ### Capsaicin and citric acid inhalation cough challenge 1) The methodology for the performance of inhalation cough challenge should be standardised so as to facilitate universal interpretation and comparison of data generated by different laboratories. 2) Comprehensive normal ranges need to be developed using the standardised methodology advocated in the present document. 3) The single-breath concentration–response method using a flow-limited dosimeter is recommended for most experimental protocols. 4) Both C2 and C5 should be recorded. 5) Since there is wide inter-individual variation, cough challenge data have no intrinsic significance, but may usefully be used to follow change in cough reflex sensitivity in an individual. ### Cough induced by inhalation of aqueous solutions 1) Aerosolised aqueous solutions represent a useful experimental tool in cough research. 2) The cough challenge with ultrasonic distilled water (fog) is difficult to standardise since it is highly dependent upon nebuliser output. 3) Consideration should be given to potential adverse events, such as bronchoconstriction and cross-infection. ### Cough monitors 1) No cough monitor is currently the gold standard. 2) Monitors should be developed that are ambulatory, are capable of being digitally processed and permit prolonged (24-h) recording. 3) There is little to commend any particular method of quantifying cough over any other. ### Assessment of quality of life of patients with chronic cough 1) Cough can have profound effects on health status, which can be assessed by cough-specific health status questionnaires. 2) Cough visual analogue scale (VAS, 0–100 mm) should be used to assess cough severity in patients with chronic cough. 3) Patients with chronic cough should be assessed with cough-specific quality-of-life questionnaires in clinical studies. ### Animal models of cough 1) The most useful animal model of cough is …

The diagnosis and management of chronic cough

Fig. 1.— Overview of the evaluation of chronic cough in an adult. ACE-I: angiotensin converting enzyme inhibitor; PEF: peak expiratory flow; PNDS: post-nasal drip syndrome; GORD: gastro-oesophageal reflux disease. Fig. 2.— Therapeutic algorithm. ACE: angiotensin-converting enzyme; GORD: gastro-oesophageal reflux disease. Fig. 3.— Investigational algorithm. CT: computed tomography. Fig. 4.— Diagnostic algorithm for the approach to children with chronic cough. ENT: ear, nose and throat; PFT: pulmonary function testing; BAL: bronchoalveolar lavage; CT: computed tomography; tbc: total blood count; CMV: cytomegalovirus; PCR: polymerase chain reaction; MRI: magnetic resonance imaging; NO: nitric oxide; BHR: bronchial hyperresponsiveness. CONTENTS Chronic cough, here defined as a cough of >8 weeks duration, is a common and frequently debilitating symptom 1, 2 that is often viewed as an intractable problem. However, theexperience of specialist cough clinics is that a very high success rate, in the order of 90%, can be achieved (table 1⇓) 3–15. The key to successful management is to establish a diagnosis and to treat the cause of cough. Truly idiopathic cough is rare and misdiagnosis common, particularly because of the failure to recognise that cough is often provoked from sites outside the airway. These guidelines aim to distil the lessons from these reports and provide a framework for a logical care pathway for patients with this highly disabling symptom. View this table: Table 1— Commonest causes of chronic cough in patients investigated in specialist clinics There are three common causes of chronic cough that arise from three different anatomical areas. This varied presentation explains the major reason for the success of multidisciplinary cough clinics compared with general clinics 16. As asthma, reflux and rhinitis are the realms of different specialists who have little experience in the diagnosis of conditions outside their expertise, a patient with chronic cough may not undergo full evaluation. This problem is exacerbated by the frequently atypical presentation of …

Induction of cyclo‐oxygenase‐2 by cytokines in human pulmonary epithelial cells: regulation by dexamethasone

1 Cyclo‐oxygenase metabolizes arachidonic acid to prostaglandin H2 (PGH2) and exists in at least two isoforms. Cyclo‐oxygenase‐1 (COX‐1) is expressed constitutively whereas COX‐2 is induced by lipopolysaccharide (LPS) and some cytokines in vitro and at the site of inflammation in vivo. Epithelial cells may be an important source of prostaglandins in the airways and we have, therefore, investigated the expression of COX‐1 or COX‐2 isoforms in primary cultures of human airway epithelial cells or in a human pulmonary epithelial cell line (A549). 2 COX‐1 or COX‐2 protein was measured by western blot analysis using specific antibodies to COX‐2 and selective antibodies to COX‐1. The activity of COX was assessed by the conversion of either endogenous or exogenous arachidonic acid to four metabolites, PGE2, PGF2α, thromboxane B2 or 6‐oxo PGF1α measured by radioimmunoassay. Thus, COX‐1 or COX‐2 activity was measured under two conditions; initially the accumulation of the COX metabolites formed from endogenous arachidonic acid was measured after 24 h. In other experiments designed to measure COX activity directly, cells were treated with cytokines for 12 h before fresh culture medium was added containing exogenous arachidonic acid (30 μm) for 15min after which COX metabolites were measured. 3 Untreated primary cells or A549 cells contained low amounts of COX‐1 or COX‐2 protein. Bacterial LPS (1 μg ml−1 for 24 h) induced COX‐2 protein in the primary cells, a process which was enhanced by interferon‐γ, with no further increase in the presence of a mixture of cytokines (interleukin‐1β, tumour necrosis factor‐α and interferon‐γ, 10 ng ml−1 for all). In contrast, A549 cells contained only low levels of COX‐2 protein after exposure to LPS or LPS plus interferon‐γ, but contained large amounts of COX‐2 protein after exposure to the mixture of cytokines. 4 Untreated human pulmonary primary cells or A549 cells released low levels of all COX metabolites measured over a 24 h incubation period. This release was enhanced by treatment of either cell type with the mixture of cytokines (interleukin‐10, tumour necrosis factor‐α and interferon‐γ, 10ng ml−1 for all). PGE2 was the principal COX metabolite released by cytokine‐activated epithelial cells. The release of PGE2 induced by cytokines occurred after a lag period of more than 6 h. 5 The glucocorticosteroid, dexamethasone (1 μm; 30 min prior to cytokines) completely suppressed the cytokine‐induced expression of COX‐2 protein and activity in both primary cells and A549 cells. 6 In experiments where COX‐2 activity was supported by endogenous stores of arachidonic acid, treatment of A549 cells with interleukin‐10 but not tumour necrosis factor‐α or interferon‐γ alone caused a similar release of PGE2 to that seen when the cytokines were given in combination. However, both interleukin‐10 and necrosis factor‐α alone produced similar increases in COX‐2 activity (measured in the presence of exogenous arachidonic acid) as seen when the mixture of interleukin‐1β, tumour necrosis factor‐α and interferon‐γ were used to stimulate the cells. 7 These findings show that COX‐2 expression correlates with the exaggerated release of prostaglandins from cytokine‐activated human pulmonary epithelial cells and that the induction of the enzyme is suppressed by a glucocorticosteroid. These findings may be relevant to inflammatory diseases of the lung, such as asthma.

Epigenome-wide association study in the European Prospective Investigation into Cancer and Nutrition (EPIC-Turin) identifies novel genetic loci associated with smoking

A single cytosine-guanine dinucleotide (CpG) site within coagulation factor II (thrombin) receptor-like 3 (F2RL3) was recently found to be hypomethylated in peripheral blood genomic DNA from smokers compared with former and non-smokers. We performed two epigenome-wide association studies (EWAS) nested in a prospective healthy cohort using the Illumina 450K Methylation Beadchip. The two populations consisted of matched pairs of healthy individuals (n = 374), of which half went on to develop breast or colon cancer. The association was analysed between methylation and smoking status, as well as cancer risk. In addition to the same locus in F2RL3, we report several loci that are hypomethylated in smokers compared with former and non-smokers, including an intragenic region of the aryl hydrocarbon receptor repressor gene (AHRR; cg05575921, P = 2.31 × 10(-15); effect size = 14-17%), an intergenic CpG island on 2q37.1 (cg21566642, P = 3.73 × 10(-13); effect size = 12%) and a further intergenic region at 6p21.33 (cg06126421, P = 4.96 × 10(-11), effect size = 7-8%). Bisulphite pyrosequencing validated six loci in a further independent population of healthy individuals (n = 180). Methylation levels in AHRR were also significantly decreased (P < 0.001) and expression increased (P = 0.0047) in the lung tissue of current smokers compared with non-smokers. This was further validated in a mouse model of smoke exposure. We observed an association with breast cancer risk for the 2q37.1 locus (P = 0.003, adjusted for the smoking status), but not for the other loci associated with smoking. These data show that smoking has a direct effect on the epigenome in lung tissue, which is also detectable in peripheral blood DNA and may contribute to cancer risk.

Expression profiling in vivo demonstrates rapid changes in lung microRNA levels following lipopolysaccharide-induced inflammation but not in the anti-inflammatory action of glucocorticoids

BackgroundAt present, nothing is known of the role of miRNAs in the immune response in vivo despite the fact that inflammation is thought to underlie multiple acute and chronic diseases. In these circumstances, patients are commonly treated with corticosteroids such as dexamethasone.ResultsTo address this question, we have examined the differential expression of 104 miRNAs using real-time PCR during the innate immune response in mouse lung following exposure to aerosilised lipopolysaccharide (LPS). Following challenge, we observed rapid and transient increase in both the mean (4.3-fold) and individual levels of miRNA expression (46 miRNAs) which peaked at 3 hrs. Crucially, this increase was correlated with a reduction in the expression of tumour necrosis factor (TNF)-α, keratinocyte-derived chemokine (KC) and macrophage inflammatory protein (MIP)-2, suggesting a potential role for miRNAs in the regulation of inflammatory cytokine production. Examination of the individual miRNA expression profiles showed time dependent increases in miR-21, -25, -27b, -100, 140, -142-3p, -181c, 187, -194, -214, -223 and -224. Corticosteroid studies showed that pre-treatment with dexamethasone at concentrations that inhibited TNF-α production, had no effect either alone or upon the LPS-induced miRNA expression profile.ConclusionWe have shown that the LPS-induced innate immune response is associated with widespread, rapid and transient increases in miRNA expression in the mouse lung and we speculate that these changes might be involved in the regulation of the inflammatory response. In contrast, the lack of effect of dexamethasone in either control or challenged animals implies that the actions of glucocorticoids per se are not mediated through changes in miRNAs expression and that LPS-induced increases in miRNA expression are not mediated via classical inflammatory transcription factors.

Bradykinin–evoked sensitization of airway sensory nerves: A mechanism for ACE–inhibitor cough

Cough accompanied by an increased sensitivity of the cough reflex is the most common symptom of inflammatory airway disease1,5. This symptom is also frequently reported in patients receiving angiotensin–converting enzyme (ACE) inhibitors as therapy for heart failure or hypertension2–4, although the underlying mechanism is unknown. We have investigated the possibility that the inflammatory peptide bradykinin, normally degraded by ACE, causes sensitization of airway sensory nerves and an enhancement of the cough reflex in conscious guinea pigs. Treatment of guinea pigs for two weeks with captopril led to an increased cough response to inhaled citric acid, which was prevented by concomitant treatment with the bradykinin receptor antagonist icatibant. A similar icatibant–sensitive enhancement of citric acid–evoked cough was seen in untreated animals after prior inhalation of bradykinin, although cough evoked by hypertonic saline was unaffected. In electrophysiological studies performed in vitro, responses of single vagal C fibers to capsaicin, applied to receptive fields of single–fiber units in the trachea, were also markedly increased after perfusion with bradykinin, whereas Aδ fiber responses to hypertonic saline were unaffected. These results indicate that bradykinin–evoked sensitization of airway sensory nerves may underlie the pathogenesis of ACE–inhibitor cough. Bradykinin receptor antagonists may be of benefit in treating chronic cough seen with this and other inflammatory conditions.

Targeting the NF-κB pathway in asthma and chronic obstructive pulmonary disease

Abstract Asthma and chronic obstructive pulmonary disease are inflammatory lung disorders responsible for significant morbidity and mortality worldwide. While the importance of allergic responses in asthma is well known, respiratory viral and bacterial infections and pollutants especially cigarette smoke are important factors in the pathogenesis of both diseases. Corticosteroid treatment remains the first preference of treatment in either disease, however these therapies are not always completely effective, and are associated with side effects and steroid resistance. Due to such limitations, development of new treatments represents a major goal for both the pharmaceutical industry and academic researchers. There are now excellent reasons to promote NF-κB signalling intermediates and Rel family proteins as potential therapeutic targets for both asthma and chronic obstructive pulmonary disease. This notion is supported by the fact that much of the underlying inflammation of both diseases independent of stimuli, is mediated at least in part, by NF-κB mediated signalling events in several cell types. Also, a range of inhibitors of NF-κB signalling intermediates are now available, including DNA oligonucleotides and DNA-peptide molecules that act as NF-κB decoy sequences, small molecule inhibitors such as IKK-β inhibitors, and proteasome inhibitors affecting NF-κB signalling, that have either shown promise in animal models or have begun clinical trials in other disorders. This review will focus on the role of NF-κB in both diseases, will discuss its suitability as a target, and will highlight recent key studies that support the potential of NF-κB as a therapeutic target in these two important inflammatory lung diseases.

Modulation of neurogenic inflammation: novel approaches to inflammatory disease

Neurogenic inflammation, which involves the release of neuropeptides from capsaicin-sensitive sensory nerves, may contribute to inflammatory diseases of the airways, joints, bladder, skin, eye and gut. Peter Barnes and colleagues review some of the therapeutic strategies that can be used to inhibit this neurogenic inflammation, with particular reference to the respiratory tract.

Co-ordinated Role of TLR3, RIG-I and MDA5 in the Innate Response to Rhinovirus in Bronchial Epithelium

The relative roles of the endosomal TLR3/7/8 versus the intracellular RNA helicases RIG-I and MDA5 in viral infection is much debated. We investigated the roles of each pattern recognition receptor in rhinovirus infection using primary bronchial epithelial cells. TLR3 was constitutively expressed; however, RIG-I and MDA5 were inducible by 8–12 h following rhinovirus infection. Bronchial epithelial tissue from normal volunteers challenged with rhinovirus in vivo exhibited low levels of RIG-I and MDA5 that were increased at day 4 post infection. Inhibition of TLR3, RIG-I and MDA5 by siRNA reduced innate cytokine mRNA, and increased rhinovirus replication. Inhibition of TLR3 and TRIF using siRNA reduced rhinovirus induced RNA helicases. Furthermore, IFNAR1 deficient mice exhibited RIG-I and MDA5 induction early during RV1B infection in an interferon independent manner. Hence anti-viral defense within bronchial epithelium requires co-ordinated recognition of rhinovirus infection, initially via TLR3/TRIF and later via inducible RNA helicases.