Is COPD an inflammatory disease?

Is COPD An Inflammatory Disease?

Gamal Rabie Agmy, MD,FCCP Professor of Chest Diseases, Assiut university

Presentation1.lnk

Global Strategy for Diagnosis, Management and Prevention of COPD

Definition of COPD

◙ COPD, a common preventable and treatable

disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.

◙ Exacerbations and comorbidities contribute to the overall severity in individual patients.

The Real Story

6 6

Angiogenesis in COPD

Reprinted f rom International Journal of COPD, 2, Siafakas NM, et al., Role of angiogenesis and vascular remodeling in

chronic obstructive pulmonary disease, 453-462, Copyright 2007, with permission f rom Dove Medical Press Ltd.

extravasated

plasma proteins

Inflammatory cells (Mac, Neu, Epith, Lymph)

Release of angiogenic

mediators

Fibrinogen products

Inflammation Tissue

hypoxia

Airway

fibrosis

Mechanical

Injury

Increased

blood flow

Vessel growth

Angiogenesis

Vascular remodeling

Up-regulation of

Angiogenic factors

Shear stress

on the endothelium

7 7

Angiogenic and Angiostatic Factors in COPD

Angiogenic CXC Chemokines, CC Chemokines, and Growth Factors:

– CXCL1

– CXCL5

– CXCL8

– CCL2

– VEGF

– bFGF

– Angiopoietin-1

– HGF

– EGF

Angiostatic CXC Chemokines, CC Chemokines, and Growth Factors:

– CXCL10

– CXCL11

Siafakas NM, et al. Int J Chron Obstruct Pulmon Dis. 2007;2:453-462.

8 8

VEGF in COPD

Santos S, et al. Am J Respir Crit Care Med. 2003;167:1250-1256. Reproduced with permission f rom American Thoracic Society.

Copyright © 2003

Moderate COPD Nonsmoker Severe emphysema

a = Pulmonary muscular artery

br = Bronchiole

http://ajrccm.atsjournals.org/content/vol167/issue9/images/large/200210-1233OCf1c.jpeg

http://ajrccm.atsjournals.org/content/vol167/issue9/images/large/200210-1233OCf1a.jpeg

http://ajrccm.atsjournals.org/content/vol167/issue9/images/large/200210-1233OCf1b.jpeg

9 9

VEGF Levels in Stable COPD

Adapted f rom Kanazawa H. Med Sci Monit. 2007;13:RA189-195.

** P<0.05 vs. controls

7000

6000

5000

4000

3000

2000

1000

0

VE

GF

le

ve

ls (p

g/m

l)

Normal

controls

Bronchitis

type

Emphysema

type

COPD patients

**

**

10 10

Serum VEGF Is Elevated in COPD

Exacerbations

Adapted f rom Valipour A, et al. Clin Sci (Lond). 2008;115:225-232.

1,500

1,000

500

0

VE

RG

Fs

er

(pg

/ml)

Exacerbation Recovery

P=0.032

11 11

SIgA Deficiency Is Associated With Airway

Remodeling

Reprinted with permission of the American Thoracic Society. Copyright © 2013 American Thoracic Society. Polosukhin

VV,et al. Am J Respir Crit Care Med. 2011;184:317-327. Of f icial journal of the American Thoracic Society.

SIgA = secretory immunoglobulin A

12 12

Remodeling Is Increased in IgA Deficient

Airways and lower SIgA Is Correlated With Lower FEV1

* P<0.01 compared with lifelong nonsmokers

(never smokers).

** P<0.01 compared with surface SIgA-

positive airways f rom the same clinical group.

Never Smokers

Former Smokers

COPD I-II

COPD III-IV

0.00

0.02

0.04

0.06

0.08

0.10

0.12

0.14

VM

sub (

mm

)

IgA-positive airways

IgA-deficient airways

Average

** **

**

** *

** ** *

*

* *

0.025

0

20

40

60

80

100

120

Inte

nsity o

f Ig

A-s

pecif

ic

Flu

ore

scent

Sig

nal (

ap

v)

Never smokers Former smokers COPD I-II

COPD I-II r = -0.847

p< 0.001

0.050 0.075 0.100 0.125 0.150 0.175

VVsub (mm)

0

0

20

40

60

80

100

Slg

A C

oncentr

atio

n

(g

/ml)

20 40 60 80 100 120

FEV1

140

r = 0.516 p< 0.05

Reprinted with permission of the American Thoracic Society. Copyright © 2013 American Thoracic Society. Polosukhin

VV,et al. Am J Respir Crit Care Med. 2011;184:317-327. Of f icial journal of the American Thoracic Society.

13 13

COPD Is a Disease Characterised

by Inflammation

Reproduced f rom The Lancet, Vol 364, Barnes PJ & Hansel TT, "Prospects for new drugs for chronic obstructive pulmonary disease",

pp985-96. Copyright © 2004, with permission f rom Elsevier.

Cigarette smoke

Epithelial

cells

CD8+ Tc cell

Emphysema

Proteases

Mucous hypersecretion

Macrophage/Dendritic cell

Neutrophil Monocyte

Fibroblast

Obstructive bronchiolitis

Fibrosis

14

COPDforum is

supported by

Inflammatory Cells in Stable COPD

15 15

Neutrophils in COPD

Mucous hypersecretion

Serine proteases Neutrophil Elastase

Cathepsin G

Proteinase-3

O2-

MPO

LTB4, IL-8, GRO-

LTB4, IL-8

Adapted f rom Barnes PJ. N Engl J Med. 2000; 343: 269-280

Adapted f rom Barnes PJ, et al. Eur Respir J. 2003; 22: 672-688

Emphysema

Severe emphysema

Images courtesy R Buhl.

16 16

Sputum Neutrophil Count

Correlates With Declining Lung Function

Reproduced with permission of Thorax f rom “Airways obstruction, chronic expectoration and rapid decline of FEV1 in smokers are

associated with increased levels of sputum neutrophils,” Stanescu et al, Vol 51, Copyright © 1996; permission conveyed through

Copyright Clearance Center, Inc.

> 30 < 20

100

0

Ne

utr

op

hils in

iIn

du

ce

d s

pu

tum

(%

)

90

20 – 30

80

60

70

50

40

FEV1 decline (mL/year)

P<0.01

17 17

Neutrophils Infiltrating Bronchial Glands

in COPD

Saetta M, et al. Am J Respir Crit Care Med. 1997;156:1633-1639. Reproduced with permission f rom American Thoracic Society.

Copyright © 1997

18 18

Reduction in Neutrophil Apoptosis in COPD

Adapted f rom Brown V, et al. Respir Res. 2009;10:24.

Apoptotic neutrophils

(arrows)

*P<0.05

*P<0.01

Morphology Tunel

NS

HS

COPD

60

50

40

30

20

10

0

Apoptotic

neutrophils [%]

Image courtesy of R Buhl.

NS: nonsmoking controls (n=9) HS:

healthy smoking controls (n=9)

TUNEL: the terminal transferase-

mediated dUTP nick end-labeling method

19 19

Alveolar Macrophages in COPD

Phagocytosis

Cigarette smoke

Wood smoke

Elastolysis MMP-9, MMP-12

Cathepsins K, L, S

Emphysema

Steroid resistance

NO

ROS ONOO-

HDAC Steroid

response

Monocytes

MCP-1

GRO-

Neutrophils

LTB4

IL-8 GRO-

CD8+ Cells

IP-10 Mig I-TAC

Adapted f rom Barnes PJ. J COPD. 2004;1:59-70. Copyright © 2004 f rom "Alveolar Macrophages as Orchestrators of COPD" by

Barnes. Reproduced by permission of Taylor & Francis Group, LLC., www.taylorandfrancis.com

Emphysema

Severe emphysema

Images courtesy of R Buhl.

Numbers

Secretion

20

COPDforum is

supported by

Inflammatory Mediators in Stable COPD

21 21

CD8+ Cells in COPD

Adapted f rom Berke G. Ann Rev Immunol. 1994; 12: 735-773. Cosio MG, et al. Chest. 2002;121:160S-165S

Adapted f rom Grumelli S, et al PLoS Med. 2004;1: 75-83. Majo J, et al. Eur Respir J. 2001;17:946-953

Cytotoxic T-Cell (CD8+: Tc1 Cell)

Macrophage

Bronchiolar epithelial cells

IP-10, Mig, I-TAC

CXCR3

Perforins Granzyme B

Emphysema

(Apoptosis of Type I pneumocytes)

IFN-

22 22

The Greater the CD8+ Infiltration,

the Greater the Airway Obstruction


Copyright © 1998.

1000

P=0.01

rho= –0.63

N=6

0

200

400

600

0 50 60 70 80 90 110

FEV1 (% predicted)

CD

8+ (

ce

lls/m

m2)

100

800

23 23

Increased CD8+ Cell Numbers in the Submucosa

of Large and Small Airways, Vessels and

Alveolar Wall of Smokers Who Develop COPD


Copyright © 1999

L

I

E

Jef fery PK. Chest. 2000; 117: 251S-260S. Courtesy of Dr Marina Saetta

Bro

nch

iole

A

lve

oli B

ron

ch

us

Pu

lmo

na

ry a

rtery

24 24 Siena L, et al. Respir Med. 2011;105:1491-500.

Apoptosis of CD8+ Cell Is Decreased in

Mild-to-Moderate COPD and Is Associated

With Lower FEV1

Background – CD8+ T-lymphocytes are crucial effector and regulatory cells in inflammation and are

increased in the central and peripheral airways in COPD.

Study Information:

– This study assessed the role of apoptosis in the accumulation of CD8+ T-lymphocytes within the airway wall in COPD.

– TUNEL and immunohistochemistry techniques were used to identify apoptosis and cell phenotype, respectively.

Key Results: – The percentage of apoptotic CD8+ T-lymphocytes was significantly lower (P

<0.0001) in smokers with mild-to-moderate COPD than in non-smokers, smokers with normal lung function, and smokers with severe/very severe COPD.

– Level of apoptotic CD8+ cells in central and peripheral airways were positively related to values of FEV1 and FEV1/FVC ratio.

These data suggest that reduced apoptosis of CD8+ T-lymphocytes may be an important mechanism that contributes to the accumulation of these cells in the

airway submucosa in smokers with mild/moderate COPD.

25 25

Emphysema Is Associated With Inflammatory

Cells in the Alveoli

Cells/mm-1

Nonsmokers

N=6

Smokers

without

emphysema

N=5

Smokers with

emphysema

N=10

Elastase+ 2.24 1.61 1.40

CD3+ 0.95 0.75 1.81

CD4+ 0.41 0.25 0.71

CD8+ 0.20 0.26 0.63

Adapted f rom Majo J, et al. Eur Respir J. 2001;17:946-953.

26 26

Numbers of Inflammatory Cells and Mediators

Increase as Disease Progresses

Percent of Airways with Measurable Cells

(%) by GOLD Stage

Cell Type I II III IV

PMNs 67 55 84 100

Macrophages 54 66 73 92

Eosinophils 25 33 29 32

CD4+ 63 87 77 94

CD8+ 85 80 88 98

B cells 7 8 45 37

Adapted f rom Hogg JC, et al. N Engl J Med. 2004;350:2645-2653.

PMN = Polymorphonuclear cells

27 27

Inflammatory Mediators in COPD – Summary

Cell

Neutrophils

Macrophages

T-cell

Epithelial cell

IL-8, TGF- 1, IP-10, Mig, I-TAC, LTB4, GRO- , MCP-1, MMP-9

Granzyme B, perforins, IFN-, TNF-

IL-8, IL-6, TGF-1 TGF-, IP-10, Mig, I-TAC, LTB4, GRO-, MCP-1, ROS, MMP-9

Serine proteases, TNF-, ROS, IL-8, MPO, LTB4

Selected Mediators

Barnes PJ, et al. Eur Respir J. 2003;22:672-888.

28 28

Examples of Chemotactic Factors in COPD

Barnes PJ. Curr Opin Pharmacol. 2004;4:263-272.

Hill AT, et al. Am J Respir Crit Care Med. 1999;160: 893-898.

Montuschi P, et al. Thorax. 2003;58:585-588.

MCP-1

GRO-

Elastin

fragments

LTB4

IL-8

GRO-

Elastin

fragments

IP-10

Mig

I-TAC

Neutrophil Monocyte T-cell

29 29

TNF- Has Pro-inflammatory

Actions in COPD

Mukhopadhyay S, et al. Respir Res. 2006;7:125. Reproduced with permission f rom Biomed Central.

Oxidative stress

Activation of NF-B and AP-1

Activation of proinflammatory molecules e.g. VCAM-1, ICAM-1 and RAGE

Subcellular ROS production

TNF-

Antioxidants

e.g. GSH, Catalase

Scavenge free radicals,

detoxify cellular hydrogen peroxide and inhibit ROS generation

Proinflammation

+

+ +

+

+

+

+

-

-

30 30

Levels of TNF-α in Exhaled Breath Condensate

in Stable COPD and Exacerbations

Reprinted f rom International Journal of COPD, 4, Ko FW, et al., Measurement of tumor necrosis factor-alpha, leukotriene B4, and

interleukin 8 in the exhaled breath condensate in patients with acute exacerbations of chronic obstructive pulmonary disease, 79-86,

Copyright 2009, with permissions f rom Dove Medical Press Ltd. Int J Chron Obstruct Pulmon Dis. 2009;4:79-86.

Exacerbation

25

20

15

10

5

0

Le

ve

l of

TN

F α

in

exh

ale

d B

rea

th

co

nd

en

sa

te (p

g/m

l)

Day 5 Day 14 Day 30 Day 60 Stable COPD Normal

P=0.017 P=0.036

P=0.045

P=0.009

31 31

COPD Inflammatory Mediators:

TGF-1

TGF-1 is elevated in airways of patients with COPD1

TGF-1 expression is partly responsible for small airway fibrosis1,2

TGF-1 mRNA correlates positively with pack-years of tobacco abuse and degree of small airway obstruction3

Several studies to show that TGF- 1 reduces -agonist receptors and function3

1. de Boer WI, et al. Am J Respir Crit Care Med. 1998;158:1951-1957.

2. Vignola AM, et al. Am J Respir Crit Care Med. 1997;156:591-599.

3. Takizawa H, et al. Am J Respir Crit Care Med. 2001;163:1476-1483.

32 32

Increased TGF-1 in COPD

Small Airway Epithelium

de Boer WI, 1998, “Transforming growth factor beta1 and recruitment of macrophages and mast cells in airways in chronic

obstructive pulmonary disease,” American Journal of Respiratory and Critical Care Medicine, Vol 158:1951-1957.

Off icial Journal of the American Thoracic Society © American Thoracic Society, Christina Shepherd, Managing Editor, 9/18/08.

Bronchiole

Macrophage

Fibrosis

33 33

IL-6 Concentrations in Exhaled

Breath Condensates

Reproduced f rom Respiratory Medicine, Vol 97, Bucchioni et al. "High levels of interleukin-6 in the exhaled breath condensate of patients

with COPD," pp1299-1302, Copyright © 2003, with permission f rom Elsevier.

Control COPD

10.0

7.5

5.0

2.5

IL-6

(p

g/m

L)

0.0

P<0.0001

34 34

Increased Bronchiolar Expression

of the T-Cell Chemokine Receptor CXCR3


Copyright © 2002

COPD

(Smoker)

Smoker

(Normal lung

function)

Non-smoker

(Normal lung

function)

Arrows indicate CXCR3+ cells. Nuclei counterstained with nuclear fast red (x40) be = Bronchiolar epithelium; bs = Bronchiolar submucosa

35 35

Elastins in the Development of Emphysema

Reproduced with permission of Nature Med, f rom “Antielastin autoimmunity in tobacco smoking-induced emphysema,” Lee et al, Vol 13,

Copyright © 2007; permission conveyed through Copyright Clearance Center, Inc.

ROS

Antigen-presenting cell

B cell Macrophage

Elastase

Cigarette smoke

Neutrophil

elastase

Macrophage

MMP12

MMP9

Cigarette smoke

Innate immunity Adaptive immunity

CD25 TRC

Tr

CXCR3

Neutrophil

TCR/MHC-11

Elastin peptides

IFN-

1AT

MMP12

MMP9 CXCL10

CXCR3

TH1 cell

CXCL9

Emphysema Normal lung

36 36

Actions of Proteinases in COPD

Reprinted f rom International Journal of COPD, 3, Owen CA, Roles for proteinases in the pathogenesis of chronic

obstructive pulmonary disease, 253-268, Copyright 2008, with permission f rom Dove Medical Press Ltd.

MMP

Inflammation

MMP SP ADAMs MMP SP ADAMs

T Cells Structural

Cells

CP CP GRZ

MMP SP CP

SP ADAMs

Proteinases Growth factor

activation

Small Airway

Fibrosis

Septal Cell

Apoptosis ECM

Degradation

Airspace Enlargement

Mucous Secretion

Bacterial Infection

Elastin Fragments

Cytokine Production or Activation

Defective Repair

IP-10

MAC PMN

COPD

37 37

Elevation of Matrix Metalloproteinase in COPD

Counts of MMP-2-Positive Macrophages

100

80

60

40

20

0 Severe COPD

(GOLD III–IV)

Mild/moderate

COPD

(GOLD I–II)

Control

smokers

Non-

smokers

MM

P-2

+ m

acro

ph

age

s (%

)

P=0.002 P=0.003

P=0.001

P=0.01

P=0.0001

Reproduced with permission of Chest, f rom “Matrix metalloproteinase-2 Protein in Lung Periphery is Related to COPD Progression,”

Baraldo et al, Vol 132, Copyright © 2007; permission conveyed through Copyright Clearance Center, Inc.

38 38

MMP-9 Is Elevated in Patients With COPD

Adapted f rom Beeh et a l. Respir Med. 2003;97:634-639.

914

44

0

100

200

300

400

500

600

700

800

900

1000

1100

COPD (N=12) Control (N=14)

Sputu

m M

MP

-9 C

on

ce

ntr

atio

n (

ng

/mL

)

P<0.001

39 39

Cathepsins Are Elevated in Smokers

0

1

2

3

4

NS

Smoking

FS

Status

S

IHC

score

* *

Nonsmoking Smoking

Elias JA, et al, 2006, “State of the art. Mechanistic heterogeneity in chronic obstructive pulmonary disease: insights f rom transgenic mice.”

Proceedings of the American Thoracic Society, Vol 3:494-498. Off icial Journal of the American Thoracic Society © American Thoracic

Society, Christina Shepherd, Managing Editor, 9/18/08.

* P=0.01

40 40 Andresen Eet al. PLoS One. 2011;6:e21898.

Defensin Gene Is Elevated in COPD and Is

Associated With Decreased FEV1

0.0

-0.5

-1.0

-1.5

-2.0

-2.5

healthy controls

COPD patients

DE

FB

1 m

RN

A e

xp

ressio

n p<0.0001

0.0

-0.5

-1.0

-1.5

-2.0

-2.5

healthy controls

COPD 3+4

DE

FB

1 m

RN

A e

xp

ressio

n

p<0.0001

COPD 1+2

0.0

-0.5

-1.0

-1.5

-2.0

-2.5

20

DE

FB

1 m

RN

A e

xp

ressio

n

Pearson r = -0.43

p = 0.0024

40 60 80 100 120

FEV1 (% predicted)

0.0

-0.5

-1.0

-1.5

-2.0

-2.5

20

DE

FB

1 m

RN

A e

xp

ressio

n

Pearson r = -0.49

p = 0.0005

40 60 80 100 120

FEV1/VC ratio (% predicted)

p = 0.0014

41 41

let-7c MicroRNA Expression and Pulmonary

Function

Reprinted with permission of the American Thoracic Society. Copyright © 2013 American Thoracic Society. Pottelberge GR, et al.

Am J Respir Crit Care Med. 2011;183:898-906. Of f icial journal of the American Thoracic Society.

7

6

5

4

3

2

Never Smokers

COPD ex-smokers

rela

tive

exp

ressio

n (L

og

2)

*

1

0

*

Smokers without COPD

COPD current

smokers

*

1250

1000

750

500

250

Never Smokers

Sp

utu

m s

TN

FR

-II

(pg

/mL

)

*

0

Current Smokers without

COPD

COPD current

smokers

-5

r = -0.43; p = 0.025

-4 -3 -2 -1 2

sputum let-7C

1250

1000

750

500

250

Sp

utu

m s

TN

FR

-II

(pg

/mL

)

0

0 1

50 75 100 125 150

FEV1 post (% pred)

5

4

3

2

1

rela

tive

exp

ressio

n (L

og

2)

0

6

42

COPDforum is

supported by

Modulation of Inflammation by Histone Deacetylase (HDAC)

43 43

Decreased HDAC Expression May Promote

Inflammation and Decrease Response to ICS

in COPD

Normal

Histone acetylation

Stimuli

Steroid sensitive

Histone hyperacetylation

nitration ubiquitination

oxidation

↑TNF

↑IL-8

↑GM-CSF

Stimuli

Steroid resistant

HAT

TF

HAT

TF

TNF IL-8 GM-CSF

Glucocorticoid

receptor

COPD

HDAC2

HDAC2

Glucocorticoid

peroxynitrite

Reproduced f rom Pharmacol Ther, Vol 116, Ito et al, “Impact of protein acetylation in inf lammatory lung diseases,” pp249-265.

Copyright © 2007, with permission f rom Elsevier.

44 44

Pulmonary HDAC Levels Decrease With

COPD Severity

Adapted f rom Ito K, et al. N Engl J Med. 2005;352:1967-1976.

S = COPD Stage

0

.5

1.0

1.5

2.0

Non-

smoker

N=11

P<0.001

HD

AC

2 e

xp

ressio

n (vs. la

min

A/C

)

P=0.04

P<0.001

P<0.001

S4

N=6

S0

N=9

S1

N=10 S2

N=10

■ ■

■

■

■

45

COPDforum is

supported by

Oxidative Stress

46 46

Airway Epithelium in COPD: Reactive Oxygen

Species and Polymorphonuclear Cells

Reproduced f rom Clin Applied Immunol Rev, Vol 5, Daheshia M, “Pathogenesis of chronic obstructive pulmonary disease (COPD)",

pp339-351. Copyright © 2005, with permission f rom Elsevier.

Toxin exposure

Alveolar macrophage

Mucous secretion

Airway epithelium

TNF

+

Neutrophil

IL-8, LTB4, MCP-1, MIP-1

Proteinase

Connective tissue destruction

TNF

Macrophage

Chemoattraction

Oxidant

E-Selectin upregulation

Tissue damage and Chromatin alteration

Proteinase

Connective tissue destruction

Tissue damage

and chromatin alteration

Perforin Granzyme TNF

Cell death

CD8+ T cell

+ +

+

+

+

+

+

+

Oxidant

+

+

+

+

47 47

Potential Reason for Limited ICS Efficacy in

COPD

Reprinted with permission of the American Thoracic Society. Copyright © 2013 American Thoracic Society. Adcock IM,

Ito K. Proc Am Thorac Soc. 2005;2:313-319. Of f icial journal of the American Thoracic Society.

HDAC2

O2-+ NO

Unknown kinases

Enhanced inflammation

Steroid sensitivity

Reduced inflammation

Steroid sensitivity

phosphorylation

phosphorylation ubiquitination

phosphatase

nitration Pl3K/Akt

peroxynitrite

Oxidative stress

48

COPDforum is

supported by

Tissue Destruction and Remodeling

49 49 Barnes PJ. N Engl J Med. 2000;343:269-280. Copyright © 2000 Massachusetts Medical Society. All rights reserved.

Histopathological Features of COPD

Normal lung

parenchyma

Chronic obstructive

bronchiolitis Emphysema

50 50

Inflammation Leads to Small

Airway Narrowing

Acute and chronic inflammation suspected to contribute to COPD-related small airway narrowing

Airway narrowing leads to airway obstruction

Narrowing results from several factors:

– Collagen deposition and increased lymphoid follicles in outer airway wall

– Mucosal thickening of airway lumen

– Inflammatory exudate in airway lumen

Barnes PJ, et al. Eur Respir J. 2003;22: 672-688.

51 51

Inflammation and Airway Destruction

Normal COPD

Reproduced f rom The Lancet, Vol 364, Hogg JC. "Pathophysiology of airf low limitation in chronic obstructive pulmonary

disease," pp709-721. Copyright © 2004, with permission f rom Elsevier.

52 52

Mucous Glands Are Enlarged in COPD

Hogg JC. Int J Tuberc Lung Dis. 2008;12:467-479. Reprinted with permission of the International Union Against Tuberculosis and

Lung Disease. Copyright © The Union.

53 53

Mucous Plugging Obstructs Small Airways

in COPD

Reproduced f rom The Lancet, Vol 364, Hogg JC. "Pathophysiology of airf low limitation in chronic obstructive pulmonary

disease,” pp709-721. Copyright © 2004, with permission f rom Elsevier.

Normal COPD

Mucous Plug

54 54

Volume of Airway Wall Tissue Correlates

Significantly With Disease Progression

Hogg JC, et al. N Engl J Med. 2004;350:2645-2653. Copyright © 2004 Massachusetts Medical Society.

All rights reserved.

0 20 40 60 80 100 120

0.25

0.20

0.15

0.10

0.05

0

GOLD

Stage 4

FEV1

V:S

A (m

m)

GOLD

Stage 3

GOLD

Stage 2

GOLD

Stages 0 and 1

55 55

Apoptotic Pathways in COPD

Demedts IK, et al. Respir Res. 2006;7:53. Reproduced with permission from Biomed Central.

Survival factor Granzyme B Perforin

TNF-α sFasL

cytoplasm

nucleus

ER Stress

Apoptosome

Apaf 1 Procasp-9

Procasp-9 Casp-9

Casp-8 CAD CAD

ICAD

Casp-8

Procasp-8 Procasp-8

FADD Bid tBid

Bax

Bak

Cyt C

ER stress

DNA fragmentation

1 2

4

3

5

?

Fas

56 56

Interaction of Apoptosis and Inflammatory

Pathways in COPD

MMPs / TIMPs Macrophages

Neutrophils

Impaired clearance of apoptotic cells

Phosphatidylserine receptor

CD8+ T-cells

Perforins

VEGF

Epithelial cell injury

Survival signals

Degradation of BM

Activation of FasL

Granzyme B

OXIDATIVE STRESS

INFLAMMATION

APOPTOSIS

NE

NE/1-AT

PROTEASE/ANTI-PROTEASE IMBALANCE

Demedts IK, et al. Respir Res. 2006;7:53. Reproduced with permission from Biomed Central.

57 57 Lim SC, et al. Yonsei Med J. 2011;52:581.587. Permission granted.

Apoptotic Lymphocytes and Exacerbation

of COPD

Compared to stable COPD, circulating apoptotic lymphocytes, CD 4+ and CD 8+ T cells were significantly increased in patients with exacerbation of COPD.

TNF-α presented a positive correlation with apoptotic lymphocytes in patients with exacerbation of COPD.

30

25

20

15

10

5

Control

Lym

ph

ocyte

s a

po

pto

sis

(%

)

p<0.001

0

Stable COPD

Exacerbation of COPD

p<0.001 p=0.015

30

25

20

15

10

5

Control C

D8

+ a

po

pto

sis

(%

)

p<0.001

0

Stable COPD


p=0.001 p=0.030

30

25

20

15

10

5

Control

CD

4+ a

po

pto

sis

(%

)

p<0.001

0

Stable COPD


p<0.001 p=0.015

300

250

200

150

100

50

Control

TN

F-α

(p

g/m

L)

p<0.001

0

Stable COPD


p=0.021 p<0.001 350

58 58 Elias JA, et al. Proc Am Thorac Soc. 2006;3:494-498. Reproduced with permission f rom American Thoracic Society.

Copyright © 2006

Multiple Pathways Lead to

Emphysema in a Murine Model

Protease-Antiprotease abnormalities

MMP-12

Cathepsins

Apoptosis

Emphysema

Inflammation

IFN-/IL-13

Injury

59 59

Macroscopic Emphysema

60 60

Alveolar Septal Cell Apoptosis and

Emphysema

Kasahara Y, et al. Am J Respir Crit Care Med. 2001;163:737-744. Reproduced with permission f rom American Thoracic Society. Copyright © 2001

Increased level of apoptosis Reduced VEGF expression

25

20

15

10

5

0

P<0.02

P<0.01

Nonsmokers Smokers Emphysema

No

. T

UN

EL

+ c

ells/N

ucle

ic a

cid

(

g)

P<0.01 300

250

200

150

100

50

0

Normal Emphysema

N=11 N=12

VE

GF

(p

g/m

L)

VEGF = Vascular endothelial growth factor.

61 61 Saetta M, et al. Am Rev Respir Dis. 1985;132:894-900. Reproduced with permission f rom American Thoracic Society. Copyright © 1985

The Greater the Airway Inflammation, the

Greater the Destruction of Alveolar Attachments

0

20

40

60

80

0 10 15 25

Number of intact attachments

Air

wa

y in

fla

mm

atio

n s

co

re (

%)

20

Smokers’ lungs

Surgical smokers’ lungs

P<0.001

r = –0.80

62

COPDforum is

supported by

Inflammation in Acute Exacerbations

63 63

Exacerbations of Chronic Bronchitis

and Inflammatory Cell Types

Saetta M, et al. Am J Respir Crit Care Med. 1994;150:1646-1652.

Maestrelli P, et al. Am J Respir Crit Care Med. 1995;152:1926-1931.

Barnes PJ. N Engl J Med. 2000;343:269-280.

COPD Exacerbation

Eosinophils

Eosinophils

T-Cells

Neutrophils

Cells Predominant in:

Induced sputum

Biopsy

Neutrophils

64 64

Increase in Neutrophils During

COPD Exacerbations

Chronic lower airway bacterial colonisation is common in stable COPD patients1

During exacerbations, bacterial numbers increase in association with an inflammatory response2

Exacerbations may be associated with isolation of new bacterial strains3

Neutrophil products can further impair the mucosal defenses4

1. Monsó E, et al. Am J Respir Crit Care Med. 1995;152:1316-1320.

2. Sethi S, et al. Am J Respir Crit Care J Med. 2007;176:356-361.

3. Sethi S, et al. Am J Respir Crit Care Med. 2004;169:448-453.

4. White AJ, et al. Thorax. 2003;58:73-80.

65 65

Exhaled 8-Isoprostane in Exacerbations

Reproduced with permission of Thorax f rom “Increased leukotriene B4 and 8-isoprostane in exhaled breath condensate of patients with

exacerbations of COPD,” Biernacki et al, Vol 58, Copyright © 2003; permission conveyed through Copyright Clearance Center, Inc.

Treated with antibiotics

Exh

ale

d 8

-iso

pro

sta

ne

(p

g/m

L)

FEV1 51% predicted

P<0.0001

0

5

10

15

20

25

Exacerbation 2 weeks Normal

n=21 subjects n=12

66 66

Increased Neutrophils During Exacerbations

of Chronic Bronchitis

* P<0.01 versus stable disease

Adapted f rom Saetta M, et al. Am J Respir Crit Care Med. 1994;150:1646-1652.

Exacerbations

*

Stable disease

300

0

250

200

100

150

50

67 67

Increased Eosinophils During Exacerbations

of Chronic Bronchitis

* P<0.001

Adapted f rom Saetta M, et al. Am J Respir Crit Care Med. 1994;150:1646-1652.

60%

150

100

50

*

EG

2 (+

) cells

/mm

2

0

200

Exacerbations Stable disease

68 68

1.55

4 3.25

15.6

0

2

4

6

8

10

12

14

16

18

IL-6 (pg/mL) CRP (g/dL)

Baseline

Exacerbation

Elevation of Serum Markers for Systemic

Inflammation in Acute Exacerbations

Adapted f rom Hurst JR, et al. Am J Respir Crit Care Med. 2006;174:867-874.

* P<0.001 versus baseline

*

Se

rum

co

nce

ntr

atio

n

*

69 69

MMP-9 Is Elevated in Acute Exacerbations

Mercer PF, et al. Respir Res. 2005;6:151. Reproduced with permission f rom Biomed Central.

P<0.01

MM

P-9

(µ

g/g

sp

utu

m)

Pre-exacerbation

0

20

40

60

80

100

Sputum Sample

120

140

Exacerbation

70

COPDforum is

supported by

Clinical Consequences of Inflammation

71 71

Telomere Dysfunction Results in Sustained

Inflammation in COPD

In situ lung specimen studies showed a higher percentage of senescent pulmonary vascular endothelial cells stained for p16 and p21 in patients with COPD than in control subjects

Adapted f rom Amsellem V, et al. Am J Respir Crit Care Med. 2011;184:1358-1356.

p16 p21

Arrowheads show p16- and p21-positive cells. Scale bar = 25 μm * P<0.0001

0

20

40

60

80

100

% o

f p

16

po

sitiv

e c

ells/

VW

F p

ositiv

e c

ells

Controls COPD

*

0

20

40

60

80

% p

21

po

sitiv

e c

ells/

VW

F p

osiitive

ce

lls

Controls COPD

*

72 72

Telomere Dysfunction Results in Sustained

Inflammation in COPD

Telomerase activity was detectable only at early cell passages and was significantly lower in patients with COPD than in control subjects at passage 4


The T/S ratio is the ratio of telomere repeat copy number over single gene copy number.

* P<0.05 versus control and † P<0.05 versus corresponding value at passage 4

Passage 4

Te

lom

ere

le

ng

th (

T/S

) ra

tio

Controls

COPD

1.5

1.0

0.5

0.0

Senescence

* †

†

73 73

Decreased Replicative Capacity of Pulmonary

Vascular Endothelial Cells From Patients With COPD


* P<0.01 PDL = population doubling level

Controls

COPD

Cu

mu

lative

PD

L

25

20

15

0

*

5

10

P4

Cu

mu

lative

PD

L

25

20

15

0

5

10

P6 P8 P10 P12 P14 P16 P18

Controls

COPD

74 74

Levels of Cytokines Are Increased in

Pulmonary Vascular Endothelial Cells From

Patients With COPD

Reprinted with permission of the American Thoracic Society. Copyright © 2013 American Thoracic Society. Amsellem V,

et al. Am J Respir Crit Care Med. 2011;184:1358-1356. Of f icial journal of the American Thoracic Society.

*P<0.05 and ***P<0.0001 versus control values; † P<0.05 and †† P<0.01 versus corresponding value at passage 6. FGF-2 = f ibroblast growth

factor-2; MCP-1 = monocyte chemotactic factor-1; PAI-1 = plasminogen activator inhibitor-1; PDGF = platelet-derived growth factor;

RANTES = regulated upon activation, normal T-cell expressed and secreted; sICAM-1 = soluble intercellular adhesion molecule-1.

100 6000 10

80

60

40

20

Passage 6

IL6 p

g/m

L

0

*

Senescene

† 4000

2000

Passage 6

MC

P-1

pg

/mL

0

***

Senescene

†

4

2

Passage 6

0

*

Senescene

††

6

8

sIC

AM

-1 n

g/m

L

††

5000

4000

3000

2000

1000

Passage 6

IL8 p

g/m

L

0

*

Senescene

†

15

10

5

Passage 6

RA

NTE

S p

g/m

L

0

Senescene

† † 6000

4000

2000

Passage 6

PD

GF

ng

/mL

0

Senescene

†

Controls

COPD

75 75

Levels of Cytokines Are Increased in

Pulmonary Vascular Endothelial Cells From

Patients With COPD

*P<0.05 and ***P<0.0001 versus control values; † P<0.05 and †† P<0.01 versus corresponding value at passage 6. FGF-2 = f ibroblast growth

factor-2; MCP-1 = monocyte chemotactic factor-1; PAI-1 = plasminogen activator inhibitor-1; PDGF = platelet-derived growth factor;

RANTES = regulated upon activation, normal T-cell expressed and secreted; sICAM-1 = soluble intercellular adhesion molecule-1.

800

600

400

200

Passage 6

Hu

-GR

O p

g/m

L

0

*

Senescene

†

250

150

100

Passage 6

PA

I-1

pg

/mL

0

Senescene

† †

25

15

5

Passage 6

FG

F-2

pg

/mL

0

Senescene

200

50

20

10

*

Controls

COPD

Reprinted with permission of the American Thoracic Society. Copyright © 2013 American Thoracic Society. Amsellem V,


76 76

Inflammation Predicts Mortality in Patients

With COPD

Reprinted with permission of the American Thoracic Society. Copyright © 2013 American Thoracic Society. Celli BR,


100%

95%

90%

85%

80%

75%

0 6 12 18 24 30 36

IL-6 <4.5 pg/mL

(n=1462)

IL-6 >4.5 pg/mL

(n=504)

p<0.001

IL -6

100%

95%

90%

85%

80%

75%

0 6 12 18 24 30 36

Neutrophils <5.8x10^9/L

(n=1386)

Neutrophils >5.8x10^9/L

(n=593)

p<0.001

Neutrophils

100%

95%

90%

85%

80%

75%

0 6 12 18 24 30 36

Fibrinogen <518 mg/dL

(n=1534)

Fibrinogen >518 mg/dL

(n=490)

p<0.001

Fibrinogen

Time Observed (Months)

Pe

rce

nt S

urv

ival

77 77

Inflammation Predicts Mortality in Patients

With COPD

100%

95%

90%

85%

80%

75%

0 6 12 18 24 30 36

hsCRP <8.7 pg/mL

(n=1572)

hsCRP >8.7 mg/dL

(n=404)

p<0.001

hsCRP

100%

95%

90%

85%

80%

75%

0 6 12 18 24 30 36

CCL-18 <153 ng/mL

(n=1432)

CCL-18 >153 ng/mL

(n=278)

p<0.001

CCL-18/PARC

100%

95%

90%

85%

80%

75%

0 6 12 18 24 30 36

SP-D <165 ng/mL

(n=1461)

SP-D >165 ng/mL

(n=524)

p<0.001

SP-D

Time Observed (Months)

Pe

rce

nt S

urv

ival

Reprinted with permission of the American Thoracic Society. Copyright © 2013 American Thoracic Society. Celli BR,


78 78

Progression From Molecular to Clinical

Events in COPD Inflammation

Chung KF, et al. Eur Respir J. 2008;31:1334-1356.

Aetiology

Cigarette smoke

Environmental pollutants

Amplifying processes

• Innate immunity

• Acquired immunity

• Oxidative stress

• Stress response

• Cellular activation

• Extrapulmonary effects

• Somatic mutations

• Genetics

• Epigenetics

Cellular processes

• Inflammatory cell recruitment/ activation

• T-cell activation

• Autoimmunity

• Transcriptional activation

• Mediator release

• Tissue repair

• Apoptosis

• Cell proliferation

• Senescence

• Systemic Inflammation

• Skeletal muscle

Death

GOLD stage IV: severe

Exacerbations

Mild

Asymptomatic

Clinical outcomes

• Mucous gland hyperplasia

• Small airways obstruction

• Centrilobular emphysema

• Corticosteroid resistance

• Bacterial colonisation

• Respiratory virus infections

Pathological processes

79 79

Clinical Impact of Inflammation in COPD

Tsoumakidou M, et al. Respir Res. 2006;7:80. Reproduced with permission f rom Biomed Central.

Increased Airway Inflammation

Increased mucous production

Airway wall thickening

Airway wall oedema

Bronchoconstriction

Airway narrowing

V’/Q’ Mismatching Hyperinflation

Worsening of gas exchange

Increased work of breathing

Increased oxygen consumption –

Decreased mixed venous oxygen

Cough, sputum, dyspnoea, Respiratory failure

80 80

Inflammation:

Clinical Consequences

Systemic

Nutritional abnormalities and weight loss

Hypoxaemia

Skeletal muscle dysfunction

Cardiovascular disease

Depression

Osteoporosis

Anaemia

Agusti AG, et al. Eur Respir J. 2003;21:347-360.

Agusti AG. Proc Am Thorac. 2006;3:478-483.

Barnes PJ, Cell BR. Eur Respir J. 2009;33:1165-1185.

Pulmonary

Dyspnoea

Cough

Sputum production

Exacerbations

Influencing the bronchial tone

Inhibitory NANC (iNANC) system is considered to be

the main neural mechanism mediating ASM relaxation

by releasing of vasoactive intestinal peptide (VIP), VIP

structure-related peptides and nitric oxide (NO) .

On the other hand, excitatory NANC (eNANC) system

mediates bronchial contraction activating the efferent

functions of bronchopulmonary-sensitive sensory

nerves. These nerves release tachykinins, such as

substance P and neurokinin A, which in turn activate

neurokinin-1 (NK-1) and NK-2 receptors located on the

ASM membrane, thus inducing bronchoconstriction

Influencing the bronchial tone

Bronchodilation may, therefore, be

obtained either by directly relaxing the

smooth muscle through stimulation of the

b2-AR with b2-AR agonists, or/and by

inhibiting the action of ACh at mAChRs.

Furthermore, an alternative approach

could be the modulation of the NANC

system.

Bronchodilators

Indacterol

Olodaterol

Vilanterol

Glycopyrronium bromide

Aclidinium bromide

Xanthines

Influencing The Cellular Components

Of Inflammation

Phosphodiesterase Inhibitors

The PDE4 isoenzyme is a major therapeutic target

because it is the predominant isoenzyme in the majority

of inflammatory cells, including neutrophils, which are

implicated in the pathogenesis of COPD. Inhibition of

PDE4 in inflammatory cells influences various specific

responses, such as the production and/or release of pro-

inflammatory mediators including cytokines and active

oxygen species , with a well-documented efficacy in

animal models of COPD .


Of Inflammation

Phosphodiesterase Inhibitors

Oral PDE4 inhibitors: roflumilast; GRC-3886;

ELB353; GRC 4039; MEM1414; oglemilast;

OX914; ASP3258; TAS-203; Zl-n-91; NIS-

62949; tetomilast

Inhaled PDE4 inhibitors; GSK256066;

SCH900182; Compound 1; tofimilast;

AWD12-281; UK500001

PDE3/4 inhibitors: RPL554

PDE4/7 inhibitors: TPI 1100


Of Inflammation

Adenosine receptors Agonist

Some evidence suggests the involvement of adenosine

receptors in inflammation. Four subtypes (A1, A2A, A2B, A3) of

adenosine receptors have been characterized. The anti-

inflammatory effect of adenosine is due to a short-term

activation of A2A receptor that elevates cAMP and,

consequently, modulates key pro-inflammatory neutrophil

functions such as superoxide generation, degranulation and

adhesion. Furthermore, adenosine A2A receptor activation

induces a shift in the profile of lipid mediator production from

leukotrienes to prostaglandin E2.This shift may contribute to

prevent the subsequent neutrophil-elicited inflammatory

events


Of Inflammation

Adenosine receptors A2a Agonists

CGS21680; ATL146e; UK371,104; GW328267X;

regadenoson (CVT-3146); 2-(cyclohexylethylthio)-AMP


Of Inflammation

Adhesion molecules Inflammatory processes in COPD are coupled to an increased

recruitment of neutrophils to the lung in response to a release of IL-8

and leukotriene B4 (LTB4) by activated epithelial cells and

macrophages . Migration of inflammatory cells from the vascular

compartment to the surrounding tissue is partly regulated by

selectins (L-, P- and E-selectin) . Selectins mediate transient adhesive

interactions pertinent to inflammation through the recognition of the

carbohydrate epitope, sialyl Lewisx (sLex), expressed on circulating

leukocytes. The rapid turnover of selectin--ligand bonds mediates the

cell tethering and rolling in shear flow. Several studies suggest that

selectins are involved in the inflammatory processes of COPD .

Therefore, targeting these molecules might reduce the inflammation

in COPD


Of Inflammation Drugs that interfere with adhesion molecules

Carbohydrate-based inhibitors: sLex antagonists

(bimosiamose); heparins and heparinoids (PGX-

100, PGX-200); synthetic glycomimetic molecule

(GMI-1070) mAb inhibitors: EL246

Influencing The Inflammatory mediators

1-TNF-a

2-Chemokines

3-NF-kB

4-p38 MAPK and MK2

5-PI3K

6-LTB4

7-PPAR

Targeting protease activity at the

enzymatic level

Drugs that may have indirect anti-

inflammatory actions

Reversing glucocorticoid resistance :

Activation of HDAC2: theophylline;

curcumin; resveratrol

Inhibition of P-glycoprotein

Inhibition of MIF

Health & Medicine

Is COPD an inflammatory disease?