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Evidence suggests damage to small airways is a key pathologic lesion in chronic obstructive pulmonary disease (COPD). Computed tomography densitometry has been demonstrated to identify emphysema, but no such studies have been performed linking an imaging metric to small airway abnormality. To correlate parametric response mapping (PRM) analysis to lung tissue measurements of patients with severe COPD treated by lung transplantation and control subjects. Resected lungs were inflated, frozen, and systematically sampled, generating 33 COPD (  = 11 subjects) and 22 control tissue samples (  = 3 subjects) for micro-computed tomography analysis of terminal bronchioles (TBs; last generation of conducting airways) and emphysema. PRM analysis was conducted to differentiate functional small airways disease (PRM ) from emphysema (PRM ). In COPD lungs, TB numbers were reduced (  = 0.01); surviving TBs had increased wall area percentage (  < 0.001), decreased circularity (  < 0.001), reduced cross-sectional luminal area (  < 0.001), and greater airway obstruction (  = 0.008). COPD lungs had increased airspace size (  < 0.001) and decreased alveolar surface area (  < 0.001). Regression analyses demonstrated unique correlations between PRM and TBs, with decreased circularity (  < 0.001), decreased luminal area (  < 0.001), and complete obstruction (  = 0.008). PRM correlated with increased airspace size (  < 0.001), decreased alveolar surface area (  = 0.003), and fewer alveolar attachments per TB (  = 0.01). PRM identifies areas of lung tissue with TB loss, luminal narrowing, and obstruction. This is the first confirmation that an imaging biomarker can identify terminal bronchial pathology in established COPD and provides a noninvasive imaging methodology to identify small airway damage in COPD.

There is overlap in symptoms and airway pathobiology between COPD and e-cigarette (e-cig) users. We sought to determine if young adult e-cig users have similar sputum soluble mediator profiles to COPD and if this is related to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage and generation of e-cig device. Experimental groups (n = 20–30/group) included non-smokers, smokers at risk of COPD (“pre-COPD”), mild/moderate COPD (GOLD 1/2), and severe COPD (GOLD 3) from the SPIROMICS cohort and healthy e-cig users of 3 rd and 4 th generation devices (previously published). Sputum soluble mediator profiles were compared between COPD GOLD stages and then between e-cig users of both generation devices and COPD participants by GOLD stage using a suite of computational approaches, including correlation analyses, unsupervised machine learning, and multivariate distance metrics. Inflammatory mediators were significantly increased in pre-COPD and GOLD 3 versus non-smokers and GOLD 1/2. Soluble mediator profiles of e-cig users showed patterns of overlap with COPD that were GOLD stage specific and based on shared biological functions that included proteases (MMP9, MMP2) and elastases (neutrophil elastase, myeloperoxidase). These findings indicate similarities in soluble mediator profiles between e-cig users and patients with COPD, highlighting potentially similar biological mechanisms relating to inflammation and tissue remodeling. Future studies with younger COPD cohorts, and those with preserved ratio impaired spirometry (PRISm) or bronchitis versus apical emphysema are needed to fully understand the extent of biological mechanisms that are shared between e-cig users and COPD. This pilot study represents a first step in understanding potential similarities between mediator changes in the airways of COPD patients and otherwise healthy young adult e-cig users.

Background In patients with acute respiratory distress syndrome undergoing mechanical ventilation, positive end-expiratory pressure (PEEP) can lead to recruitment or overdistension. Current strategies utilized for PEEP titration do not permit the distinction. Electric impedance tomography (EIT) detects and quantifies the presence of both collapse and overdistension. We investigated whether using EIT-guided PEEP titration leads to decreased mechanical power compared to high-PEEP/FiO2 tables. Methods A single-center, randomized crossover pilot trial comparing EIT-guided PEEP selection versus PEEP selection using the High-PEEP/FiO 2 table in patients with moderate–severe acute respiratory distress syndrome. The primary outcome was the change in mechanical power after each PEEP selection strategy. Secondary outcomes included changes in the 4 × driving pressure + respiratory rate (4 ΔP, + RR index) index, driving pressure, plateau pressure, PaO 2 /FiO 2 ratio, and static compliance. Results EIT was consistently associated with a decrease in mechanical power compared to PEEP/FiO 2 tables (mean difference − 4.36 J/min, 95% CI − 6.7, − 1.95, p  = 0.002) and led to lower values in the 4ΔP + RR index (− 11.42 J/min, 95% CI − 19.01, − 3.82, p  = 0.007) mainly driven by a decrease in the elastic–dynamic power (− 1.61 J/min, − 2.99, − 0.22, p  = 0.027). The elastic–static and resistive powers were unchanged. Similarly, EIT led to a statistically significant change in set PEEP (− 2 cmH 2 O, p  = 0.046), driving pressure, (− 2.92 cmH2O, p  = 0.003), peak pressure (− 6.25 cmH 2 O, p  = 0.003), plateau pressure (− 4.53 cmH 2 O, p  = 0.006), and static respiratory system compliance (+ 7.93 ml/cmH 2 O, p  = 0.008). Conclusions In patients with moderate–severe acute respiratory distress syndrome, EIT-guided PEEP titration reduces mechanical power mainly through a reduction in elastic–dynamic power. Trial registration This trial was prospectively registered on Clinicaltrials.gov (NCT 03793842) on January 4th, 2019.

Despite being a major cause of morbidity and mortality, chronic obstructive pulmonary disease (COPD) is frequently undiagnosed. Yet the burden of disease among the undiagnosed is significant, as these individuals experience symptoms, exacerbations, and excess mortality compared to those without COPD. The U.S. Preventive Services Task Force recommends against routine screening of asymptomatic individuals with spirometry. Hence, case-finding approaches are needed. A recently developed instrument, the five-item COPD Assessment in Primary Care to Identify Undiagnosed Respiratory Disease and Exacerbation Risk questionnaire plus peak expiratory flow, demonstrates good sensitivity and specificity for distinguishing cases from control subjects and is being studied prospectively in primary care settings to determine its impact on patient outcomes. However, finding the undiagnosed is only half the battle. Mounting evidence suggests significant COPD-like respiratory burden among individuals without airflow obstruction. Many experience dyspnea, mucus production, and exacerbation events and have emphysema and airway abnormalities on computed tomographic (CT) imaging of the chest. However, it is still unclear how to best treat these individuals and which individuals go on to develop spirometric obstruction. These challenges underline the importance of defining what constitutes “early disease.” A recently proposed definition characterizes early COPD as either: 1) airflow limitation, 2) compatible CT imaging abnormalities, or 3) accelerated forced expiratory volume in 1 second decline in persons younger than 50 years and with greater than a 10 pack-year smoking history. Although it is recognized that this definition does not encompass all individuals who will develop COPD, it is an attempt to identify a group of individuals with most rapid decline to better understand mechanisms of disease development and where disease-modifying interventions are most likely to be successful. Ultimately, leveraging tools such as chest CT imaging, the electronic medical record, and machine learning algorithms may aid in the identification of such individuals.

Abstract Rationale Cor pulmonale (right ventricular [RV] dilation) and cor pulmonale parvus (RV shrinkage) are both described in chronic obstructive pulmonary disease (COPD). The identification of emphysema as a shared risk factor suggests that additional disease characterization is needed to understand these widely divergent cardiac processes. Objectives To explore the relationship between computed tomography measures of emphysema and distal pulmonary arterial morphology with RV volume, and their association with exercise capacity and mortality in ever-smokers with COPD enrolled in the COPDGene Study. Methods Epicardial (myocardium and chamber) RV volume (RVEV), distal pulmonary arterial blood vessel volume (arterial BV5: vessels <5 mm2 in cross-section), and objective measures of emphysema were extracted from 3,506 COPDGene computed tomography scans. Multivariable linear and Cox regression models and the log-rank test were used to explore the association between emphysema, arterial BV5, and RVEV with exercise capacity (6-min-walk distance) and all-cause mortality. Measurements and Main Results The RVEV was approximately 10% smaller in Global Initiative for Chronic Obstructive Lung Disease stage 4 versus stage 1 COPD (P < 0.0001). In multivariable modeling, a 10-ml decrease in arterial BV5 (pruning) was associated with a 1-ml increase in RVEV. For a given amount of emphysema, relative preservation of the arterial BV5 was associated with a smaller RVEV. An increased RVEV was associated with reduced 6-minute-walk distance and in those with arterial pruning an increased mortality. Conclusions Pulmonary arterial pruning is associated with clinically significant increases in RV volume in smokers with COPD and is related to exercise capacity and mortality in COPD. Clinical trial registered with www.clinicaltrials.gov (NCT 00608764).

Chronic obstructive pulmonary disease (COPD) is heterogenous in its clinical manifestations and disease progression. Patients often have disease courses that are difficult to predict with readily available data, such as lung function testing. The ability to better classify COPD into well-defined groups will allow researchers and clinicians to tailor novel therapies, monitor their effects, and improve patient-centered outcomes. Different modalities of assessing these COPD phenotypes are actively being studied, and an area of great promise includes the use of quantitative computed tomography (QCT) techniques focused on key features such as airway anatomy, lung density, and vascular morphology. Over the last few decades, companies around the world have commercialized automated CT software packages that have proven immensely useful in these endeavors. This article reviews the key features of several commercial platforms, including the technologies they are based on, the metrics they can generate, and their clinical correlations and applications. While such tools are increasingly being used in research and clinical settings, they have yet to be consistently adopted for diagnostic work-up and treatment planning, and their full potential remains to be explored.

Individual socioeconomic status has been shown to influence the outcomes of patients with chronic obstructive pulmonary disease (COPD). However, contextual factors may also play a role. The objective of this study is to evaluate the association between neighborhood socioeconomic disadvantage measured by the area deprivation index (ADI) and COPD-related outcomes. Residential addresses of SubPopulations and InteRmediate Outcome Measures in COPD Study (SPIROMICS) subjects with COPD (FEV /FVC <0.70) at baseline were geocoded and linked to their respective ADI national ranking score at the census block group level. The associations between the ADI and COPD-related outcomes were evaluated by examining the contrast between participants living in the most-disadvantaged (top quintile) to the least-disadvantaged (bottom quintile) neighborhood. Regression models included adjustment for individual-level demographics, socioeconomic variables (personal income, education), exposures (smoking status, packs per year, occupational exposures), clinical characteristics (FEV % predicted, body mass index) and neighborhood rural status. A total of 1800 participants were included in the analysis. Participants residing in the most-disadvantaged neighborhoods had 56% higher rate of COPD exacerbation (P<0.001), 98% higher rate of severe COPD exacerbation (P=0.001), a 1.6 point higher CAT score (P<0.001), 3.1 points higher SGRQ (P<0.001), and 24.6 meters less six-minute walk distance (P=0.008) compared with participants who resided in the least disadvantaged neighborhoods. Participants with COPD who reside in more-disadvantaged neighborhoods had worse COPD outcomes compared to those residing in less-disadvantaged neighborhoods. Neighborhood effects were independent of individual-level socioeconomic factors, suggesting that contextual factors could be used to inform intervention strategies targeting high-risk persons with COPD.