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The lipoxygenase and cyclooxygenase pathways are involved in airway inflammation and remodelling in asthma. Previously we showed that downstream factors of the lipoxygenase pathway are more abundant in the central than in peripheral airways. Therefore, we aimed to assess the mRNA expression of upstream factors of both pathways in cells from bronchial and alveolar lavage. Allergic asthmatics undertook a bronchial allergen challenge, 9 patients had an early allergic reaction (EAR) and 6 patients also had a late allergic reaction (EAR+LAR). Bronchial and alveolar lavages were sampled at baseline and 24 h post allergen challenge. mRNA expression of 5-LO, FLAP, LTA4h and LTC4s in the lipoxygenase pathway and COX-1, COX-2, PGD2s and PTGEs2 in the cyclooxygenase pathway were analysed (relative to GAPDH) in the lavage cells. At baseline, LTA4h (p=0.008), LTC4s (p=0.03) and PGD2s (p=0.03) were significantly higher in the bronchial than the alveolar lavage cells. The higher bronchial expression seen in the LTC4s was only observed in the EAR+LAR group. At 24 h post challenge, FLAP (p=0.04), LTA4h (p=0.02), COX-2 (p=0.01) and PGD2s (p=0.02) were significantly higher in the bronchial lavage cells. Overall, all genes (except PTGEs2) tended to be expressed higher in the bronchial than the alveolar lavage cells. In addition, higher PGD2s expression post challenge correlated with increased need for rescue medication (ACT, Q4 prior to the challenge) (p=0.009, r=-0.8). As these pathways are highly expressed in the bronchial lumen cells of allergic asthmatics, further investigation is needed to confirm this is reflected in the tissue before central airway targeting is proposed.

Background: Mast cells play an important role in asthma, however, the interactions between mast cells, fibroblasts and epithelial cells in idiopathic pulmonary fibrosis (IPF) are less known. The objectives were to investigate the effect of mast cells on fibroblast activity and migration of epithelial cells. Methods: Primary distally-derived lung fibroblasts obtained from IPF patients and healthy individuals were cultured with LAD2 mast cells or stimulated with the mast cell proteases tryptase and chymase for 72 hours. Human lung fibroblasts and mast cells were cultured on traditional cell culture plastics or decellularized human lung tissue slices (lung scaffolds) to create a more physiological milieu by providing an alveolar extracellular matrix. Released mediators were analyzed and further evaluated for effects on epithelial cell migration. Results: Tryptase increased IL-6, VEGF and HGF release whereas co-culture with mast cells increased IL-6 in healthy lung fibroblasts. VEGF-C release was significantly increased in IPF fibroblasts and further induced by mast cells compared to healthy fibroblasts. Tryptase induced fibroblast migration but mast cells did not promote a myofibroblast phenotype such as altered αSMA levels. Culture in lung scaffolds increased the release of HGF and VEGF compared to culture on plastic plates. Migration of A549 epithelial cells was significantly reduced by IL-6, while HGF and conditioned media from scaffold cultures with mast cells and fibroblasts promoted migration. Conclusions: Mast cells and tryptase increased fibroblast release of mediators that influenced epithelial migration. These data indicate a role of mast cells in the interplay between fibroblasts, epithelial cells and the alveolar extracellular matrix in the pathogenesis of lung diseases.

Background: CAT scores can be used to assess the effects of COPD on patient health status. Within a study cohort, higher CAT scores are associated with more frequent exacerbations (Kelly JF, et al. Respiration 2012;84:193–9) and predict exacerbations in patients at risk (Lee SD, et al. Respir Med 2014;108:600–8). Aim: To compare individual CAT item scores in cohorts with differing risk of exacerbation from two COPD trials. Methods: Data from the EMAX and IMPACT trials were used as baseline differences between these trials in total CAT score were small, but differences in exacerbation rates were large (Figure 1). The analysis was post hoc without statistical comparisons. Results: Compared with IMPACT, EMAX patients had less severe airflow limitation and a greater proportion were current smokers (Figure 1); however, individual CAT item scores were similar between the trials (Figure 2). Conclusion: Despite differences in exacerbation history of the two cohorts, mean individual CAT item scores were similar. Method: GSK (201749, NCT03034915; 116855, NCT02164513)

Background: Eosinophilic asthma and COPD endotypes have been associated with increased exacerbation risk and symptom burden. We aimed to study the difference between airway and systemic eosinophilia in terms of clinical outcomes for both asthma and COPD. Methods: BREATHE is a real-life study assessing biomarkers and disease mechanisms in asthma and COPD patients. Symptoms were assessed using ACQ-5 and CAT scores. Blood eosinophilia was defined as >0.3x109 cells/L, sputum eosinophilia as ≥3%, and blood+sputum eosinophilia as both. Results: In asthma patients, ACQ-5 and CAT scores were higher in patients with elevated blood and sputum (2.47 and 14.24) and elevated sputum (1.84 and 13.19) eosinophils compared to blood (1.37 and 10.30) eosinophils (p For asthma and COPD patients, exacerbations during the previous year were more frequent in patients with elevated sputum and blood+sputum eosinophils (asthma: p=0.001; COPD: p=0.015). Conclusion: Asthma, but not COPD, patients with sputum eosinophilia (regardless of co-expression of blood eosinophilia) have more symptoms than those with blood eosinophilia alone. Eosinophilia in sputum may be a stronger predicter for exacerbations than blood eosinophilia in both COPD and asthma patients.

Use of cardiopulmonary exercise testing (CPET) at a submaximal level (Endurance test) is limited, in monitoring disease status and treatment effect in COPD, both in clinical practise and clinical trials, due to large interindividual variability. The present study targeted the heterogeneity in the duration of Endurance test intending to modify both the intensity and the method of applying workload, in order to accomplish shorter (between 180s-480s) and less variable endurance time,according to recommendations of ERS. 21 COPD patients were included in a cycle CPET double-blind,randomised cross-over study (LABA/LAMA vs placebo) comparing: 1) Standard Endurance Test (SET),with a 1-minute loadless pedalling warm-up period followed by a constant load at 75% of Wmax (maximum workload), 2) New Endurance Test (NET), with a 4-min warm-up (1-min loadless pedalling followed by 3-min at 30% of Wmax), followed by an instant increase at 70% of Wmax and thereafter a linear increase of 1% of Wmax per min up to 90% of Wmax. We argue that a submaximal incremental test with a warm-up period at 30% of Wmax, followed by a linear increase of workload can significantly reduce endurance time variation compared to a submaximal constant workload exercise test .Whether such an incremental test could detect differences after intervention remains to be seen.

Introduction: Idiopathic pulmonary fibrosis (IPF) involves extensive remodeling of the extracellular matrix (ECM), primarily in the periphery of the lung. This leads to altered mechanical properties, which in turn results in altered mechanical stimulation of the cells. In stiffer and less elastic ECM found in IPF, fibroblasts are thus exposed to altered strain compared to a healthy ECM. Our aim is to investigate the impact of mechanical stimulation on fibroblasts activity in IPF. Methods: IPF and healthy distal lung tissue were decellularized in slices (350 mm) to produce acellular lung scaffolds. The scaffolds were attached to a custom-made device for cyclic stretch built in polydimethylsiloxane and repopulated with healthy primary distal lung fibroblasts. The scaffolds were either exposed to cyclic stretch (0.2 Hz, 10% strain) or cultured under static conditions upto 3 days and analyzed for cell viability, histology, RNA expression, and released mediators. Results: Compared to healthy scaffolds, fibroblasts on IPF scaffolds showed increased metabolic activity, both at static and cyclic stretch condition. Scaffolds under cyclic stretch showed preserved tissue morphology with dispersed elongated fibroblasts shown with H&E staining. Interestingly, we see a shift in released mediators linked to angiogenesis in cyclic stretch cultures, mostly pronounced in IPF scaffolds. Discussion: We demonstrate that we have developed a physiological more relevant ex vivo model to study cellular responses in lung tissue. Our data indicate that there is a change in cellular activity in IPF tissue under cyclic stretch. This allows us to study the effect of alterations in mechanical and matrisome properties in chronic lung disease.

Targeted therapies for severe T2-high asthma emphasize the need to investigate the expression of different T2 markers in real-life patients. We aimed to assess the co-expression of T2 markers in patients with asthma, COPD and asthma+COPD. BREATHE is a large real-life study assessing biomarkers and disease mechanisms in a real-life population of asthma and COPD patients. Eosinophilia was defined as blood eosinophils >0.3x109 cells/L and/or sputum eosinophils ≥3%, elevated FeNO as ≥25 ppb, and elevated IgE as ≥100 IU/ml. 63% of asthma patients had ≥1 increased T2 biomarker: 25% had increased IgE, 33% had elevated FeNO and 42% had eosinophilia. Among COPD patients, 53% had ≥1 increased T2 marker: 19% had increased IgE, 15% had elevated FeNO and 36% had eosinophilia. In asthma+COPD patients, 63% had ≥1 increased T2 biomarker: 22% had increased IgE, 23% had elevated FeNO and 47% had eosinophilia. Blood and sputum eosinophilia were co-expressed in 19.6% of asthma, 13.3% of COPD and 20.3% of asthma+COPD patients. COPD and asthma+COPD patients were more likely to have isolated eosinophilia (42% and 41%) compared to asthma patients (25%) (figure 1a-c). The prevalence of at least one elevated T2 marker was comparable between asthma, COPD and asthma+COPD, with isolated eosinophilia being most common in COPD and asthma+COPD. This supports the existence of different subtypes of T2 asthma, COPD and asthma+COPD.

Introduction: Pulmonary disease after very preterm birth may cause permanent lung damage and as a consequence, lung function impairment in long-term survivors, bronchopulmonary dysplasia being one of the earliest manifestation. Aims: The aim of this study was to assess lung function in children 12 years of age, born very preterm and compare with children born at term. In addition we determined the impact of BPD and prematurity during childhood. Methods: Spirometry, impulse oscillometry, body plethysmograhy and diffusing capacity was performed at 12 years of age in 98 children, born at gestational age of 22-31 weeks (median 27 weeks and birth weight 950g). Age-matched children born at term were included as controls (n=17). BPD was defined as need for supplemental oxygen at 36 weeks postmenstrual age. Results: Prematurity was associated with lower forced expiratory flow (FEF25-75), p=0.05, higher total (R5) and peripheral (R5-20) resistance, p=0.01 resp p Prematurity was also associated with lower diffusion capacity, p=0.01 and higher residual volume, p=0.02. Preterm children with BPD showed no significant lung function impairment at the age of 12 compared to preterm children without BPD. Conclusion: Preterm birth is associated with an increased risk of significant obstructive airway disease and lung function impairment at the age of 12, regardless of BPD diagnosis. Children born preterm would benefit from regular assessment of lung function to give an insight regarding long-term sequele and respiratory health throughout adolescence and adulthood.

Background: Symptom benefits of dual bronchodilation vs monotherapy in corticosteroid-free patients at low exacerbation risk have not been established using the Evaluating Respiratory Symptoms–COPD (E‑RS) scale. Aims: This pre-specified secondary analysis of the Early MAXimization of bronchodilation for improving COPD stability (EMAX) trial compared daily symptoms using E-RS in patients receiving umeclidinium/vilanterol (UMEC/VI), UMEC, or salmeterol (SAL). Methods: This double-blind, parallel-group trial randomised patients 1:1:1 to 24 weeks of UMEC/VI 62.5/25 μg once-daily, UMEC 62.5 μg once-daily or SAL 50 μg twice-daily. Change from baseline and proportion of responders over 24 weeks were analysed by 4-week periods for E-RS total score and Breathlessness, Cough & Sputum and Chest symptoms subscales. Results: At Weeks 21–24, mean symptom scores statistically significantly favoured UMEC/VI for 3 of 4 and all 4 symptom outcomes vs UMEC and SAL, respectively. Responder rates favoured UMEC/VI for all 4 outcomes vs UMEC and SAL (Figure). Treatment differences consistently favoured UMEC/VI vs UMEC and SAL from the first to last 4-week period. Differences between UMEC and SAL were not significant. Conclusion: UMEC/VI provided early and sustained improvement in a range of daily COPD symptoms vs UMEC or SAL in corticosteroid‑free low-risk symptomatic patients with COPD. Funding: GSK (201749; NCT03034915)

Background: Oral corticosteroids (OCS) may be used for treatment of severe asthma to achieve disease control. Nordic guidelines recommend low doses and short courses of treatment due to limited long-term efficacy and risk of adverse effects. Knowledge of OCS usage patterns in asthma is limited. Aims and Objectives: Describe OCS use across ages in Swedish and Finnish severe asthma patients. Methods: The NORdic Dataset for aSThmA Research (NORDSTAR) is a population-based, observational dataset of asthma patients based on Nordic registries. Severe asthma was based on ERS/ATS definitions. Patients were grouped annually into OCS burst ( 64 years old. Results: In 2015, 7,568 (62% female) and 5,167 (67% female) patients were identified as OCS users in Sweden and Finland, respectively. Of these, more patients received OCS bursts in Sweden (54%) than Finland (15%) while more Finnish than Swedish patients received COU (96% vs 69%), chronic COU (49% vs 39%), and chronic intermittent COU (25% vs 14%). In Sweden but not Finland there were fewer COU patients aged 6-17 (57% of 362) compared to those >17 (70% of 7,206). Conclusions: OCS dispensing is consistent across age groups. High levels of OCS use in severe patients, likely already receiving maximal OCS treatment, suggest poor asthma control. The associated burden should be further investigated.

Chronic Obstructive Pulmonary Disease (COPD) is often caused by cigarette smoke, which is shown to cause oxidative stress in the lungs. This study aims to investigate the expression and location of protective proteins in lung fibroblasts from COPD patients and healthy subjects after stimulation with cigarette smoke extract (CsE) in increasing concentrations. mRNAs that translate into several intracellular stress pathway proteins were quantified. Lactate dehydrogenase (LDH) was measured in cell medium to investigate the degree of apoptosis. Lung fibroblasts were also subjected to immunofluorescence, after stimulation, to investigate the intracellular localization of the protective proteins. At higher CsE concentrations (20-40%), we found, through mRNA quantification, upregulation of several stress response factors in healthy smokers but not COPD patients: endoplasmic reticulum stress factors (IRE1, PERK, and ATF6), a proteasome subunit (PSMA1), an oxidative stress response factor (OXR1), and a cell death regulator (Bcl2). However, the endoplasmic reticulum stress factor Nrf2 was increased in both groups. An increase in LDH release was found in COPD patients. Immunofluorescent stainings showed that PERK and ATF6 co-localized with the endoplasmic reticulum as expected. The proteins of interest were found in their expected locations, and there seems to be a general upregulation of protective genes. Patients with COPD are more sensitive to stress with an increase in apoptosis. Overall, the stress protective pathways seem to respond better in healthy subjects, which may explain why some smokers do not develop COPD while others do.

Decellularized tissues offer an excellent approach to study cell-ECM interaction in health and disease. We have used peripheral lung tissue from healthy individuals and idiopathic pulmonary fibrosis (IPF) patients. IPF is characterized by excessive matrix production and stiffening of the tissue. The aim was to examine temporal changes in the original ECM in healthy and IPF scaffolds and how these affect protein production of repopulating fibroblasts. Tissue slices (350µm) were decellularized using CHAPS to generate biological scaffolds, characterized by density, biomechanical properties, histology, and mass spectrometry (MS). Scaffolds were mounted on custom-made holders, to mimic the native setting, seeded with human primary fibroblasts derived from a healthy donor, and cultured using medium supplemented with isotope-labeled Arg and Lys. Repopulated scaffolds were examined as described above to study differences in ECM. Heavy isotope labelling of cultured cells allowed us to follow up- and downregulation of newly synthesized proteins compared to original scaffold due to a mass shift detectable in MS. Interestingly, fibroblasts cultured on IPF scaffolds had a protein production profile overlapping with the profile of the original scaffold. Our biological system allowed us to study temporal differences in protein production in healthy and diseased scaffolds. By culturing under static stretch we created a 3D environment similar to the native situation, strongly influencing the cellular response. This opens up for in depth identification of proteins involved in lung disease and tissue regeneration. Our goal is to identify a combination of factors that can locally trigger a healthy lung regeneration.

Background: Forced oscillometry technique (FOT) measures resistance, R, and reactance, X in the respiratory system. Resmon Pro, a new FOT technique, provides analysis of inspiratory and expiratory resistance (Rin and Rexp) and reactance (Xin and Xexp) separately. This provides simple assessment of peripheral and central airway resistance and reactance, and adding a measure of air trapping. Aim: To investigate the difference in inspiratory and expiratory resistance and reactance in obstructive diseases as a measure of air trapping. A secondary aim was to investigate airtrapping assessment in comparison to baseline measurements by Resmon Pro and the more established method impulse oscillometry (IOS). Methods: A total of 61 subjects (20 healthy, 9 Rhinitis, 16 asthma, 16 COPD) performed spirometry and measurements with Resmon Pro followed by IOS. Results: The difference in expiratory and inspiratory parameters obtained by Resmon Pro showed that subjects with COPD had more difference (p Conclusion: The increased difference in expiratory versus inspiratory resistance and reactance in subjects with COPD suggest increased dynamic air trapping and loss of elasticity. This air trapping correlated most prominent to parameters measuring peripheral resistance and reactance.

Background: The risk of short-term deterioration, assessed by the CID composite measure, is reduced with dual vs mono bronchodilators in inhaled corticosteroid (ICS)-free symptomatic patients with COPD. It is unclear if this protection alters with baseline severity of COPD. Aims: This pre-specified secondary analysis of the Early MAXimization of bronchodilation for improving COPD stability (EMAX) trial compared CID risk in the ITT population and in severity subgroups with a baseline GOLD spirometric grade 3 (FEV1 30–50% predicted) or COPD Assessment Test (CAT) score ≥20. Methods: This 24-week, double-blind, parallel-group trial randomised patients to umeclidinium/vilanterol (UMEC/VI) 62.5/25 µg QD, UMEC 62.5 µg QD, or salmeterol (SAL) 50 µg BID. Risk of a first CID was assessed using 3 definitions of CID (Figure). Results: In the ITT population and subgroups, CID risk was lower with UMEC/VI vs UMEC or SAL for all CID definitions, except in one instance (Figure). This protection was numerically higher in the GOLD 3 subgroup regardless of CID definition, but not in the CAT ≥20 subgroup. Conclusions: In symptomatic ICS-free patients at low exacerbation risk, UMEC/VI reduced CID risk vs UMEC and SAL. Compared with the ITT population, this protection was greater in patients with more severe airflow limitation but not with more symptoms. Funding: GSK (study 201749; NCT03034915)

Introduction: Measuring symptom improvement over time can inform the appropriate timing of follow-up assessments to monitor response to COPD treatment. Aims: This post-hoc analysis of the Early MAXimization of bronchodilation for improving COPD stability (EMAX) trial compared early symptom improvement in response to umeclidinium/vilanterol (UMEC/VI), UMEC, or salmeterol (SAL) in inhaled corticosteroid-free symptomatic patients with COPD at low exacerbation risk. Methods: This 24-week double-blind, parallel-group trial randomised patients 1:1:1 to UMEC/VI 62.5/25 μg once-daily, UMEC 62.5 μg once-daily, or SAL 50 μg twice-daily. Symptom improvements were evaluated at the population level by least squares mean change from baseline in Evaluation of Respiratory Symptoms (E-RS) score and percentage of rescue-free days weekly from Week 1 to 8 (post hoc) and at Weeks 21–24. Results: Adjusted mean weekly E-RS total score and rescue medication use improved rapidly and consistently from Week 1 to 8 with all treatments (Figure). Statistically significant treatment differences favouring UMEC/VI were maintained throughout treatment, with similar between-treatment differences at Weeks 4, 8 and 21–24. Conclusion: The added symptomatic benefits of UMEC/VI versus UMEC or SAL were apparent at Week 1, fully established by Week 4, and sustained over 24 weeks. Funding: GSK (201749; NCT03034915)

Asthma exacerbations are severe conditions lacking efficient treatment options. We aimed to study the role of IL-1s in asthma exacerbation as a potential pharmacological target using primary human bronchial epithelial cells (HBEC) as well as our translational mouse model of asthma exacerbation, using IL-1s deficient (IL-1s-/-) mice. Methods: HBECs (from healthy donors and asthma patients) were infected with rhinovirus (RV) and IL-1s was quantified by RTqPCR, 24 h post RV-infection. Wild type (WT) and IL-1s-/- mice were challenged with HDM to establish allergic airway inflammation followed by dsRNA stimulation for 3 consecutive days to mimic viral-induced asthma exacerbation. Immune cells, proteins and gene expression were analysed in BAL fluid, lung histology or lung homogenates. Results: HBECs from asthmatic patients had higher levels of IL-1s at baseline (p Conclusion: Our data suggest that IL-1s signalling plays an important role at RV-induced asthma exacerbation by enhancement of cytokine production and immune lung cell infiltration suggesting that IL-1s could be a potential pharmacological target for management of acute asthma exacerbations.

Background: Increased mast cell (MC) densities in the airway epithelium is a hallmark of asthma. However, little is known regarding the role and effect of MC mediators on epithelium damaged by respiratory viruses. Aim: To investigate the density of MCs in biopsies in patients with different asthma phenotypes and the effect of MC mediator tryptase on wound-healing in bronchial epithelial cells. Methods: Intraepithelial MCs (IEMCs) were stained for tryptase (MCT) and tryptase/chymase (MCTC) in bronchial biopsies. In a BEAS-2B cell line, the effect of tryptase and the TLR3 agonist polyI:C on wound healing was studied using live cell imaging (Phase Holographic Imaging). Results: MCT, but not MCTC, were increased in the epithelium in ICS-naive mild asthma and ICS-responsive asymptomatic moderate and severe asthma when compared to ICS-unresponsive symptomatic moderate and severe asthmatics (p=0.03). Within the asthma groups, patients with atopy had the highest numbers of IEMCs compared to non-atopic asthmatics and controls (p=0.002). Stimulation of BEAS-2B with polyI:C resulted in impaired wound gap closure compared to untreated cells (p=0.05). However, MC tryptase enhanced cell proliferation and wound healing responses when compared to cells stimulated with polyI:C (p Conclusion: We showed that asymptomatic patients with different severities of asthma had a higher density of IEMCs regardless of treatment with ICS. Further, the MC mediator tryptase promoted epithelial proliferation and wound healing responses. Hence, IEMCs may have beneficial roles and MC localization may be an important determinant in asthma pathology.

Oxidative stress is linked to the inflammation observed in asthma and COPD and might be involved in exacerbations. Both COPD and asthma exacerbations often involve rhinovirus (RV) infection. Impaired anti-viral signaling and attenuated viral clearance in the bronchial epithelium has been hypothesized for these diseases. However, it is not known whether oxidative stress affects the anti-viral signaling capacity. Bronchial epithelial cells from asthma and COPD donors were infected with RV or treated with the oxidative stressor H2O2 followed by exposure to the synthetic RV replication intermediate poly(I:C). Gene and protein levels of antioxidants and anti-viral responses were measured 3h and 24h post poly(I:C) exposure. RV infection and poly(I:C) stimulation induced protein levels of the antioxidants SOD1 and SOD2. poly(I:C) was used to ascertain a constant infection-like burden in the interaction experiments. Upon pre-treatment with increasing doses of H2O2 the antioxidant response to dsRNA was dose-dependently decreased. This data suggests exaggerated H2O2-induced oxidative stress. Further, poly(I:C)-induced IFNs gene expression was reduced after pre-treatment with H2O2. This was associated with a reduced expression of the pattern recognition receptors RIG-I, MDA5 and TLR3 both on gene and protein level. Knockdown of TLR3 but not RIG-I/MDA5 abrogated impairment of poly(I:C)-induced IFNs gene expression by H2O2. Oxidative stress impairs anti-viral signaling in asthma and COPD bronchial epithelium, likely by reducing RV-responsiveness of TLR3. These findings shed light on molecular mechanisms potentially causing reduced IFNs at exacerbation.

Viral infections predispose to the development of childhood asthma, a disease associated with increased lung mast cells (MCs). This study investigated whether viral lower respiratory tract infections (LRTIs) can already evoke a MC response during childhood. Lung tissue from young children who died following LRTIs were processed for immunohistochemical identification of MCs. Children who died from nonrespiratory causes served as controls. MCs were examined in relation to sensitisation in infant mice exposed to allergen during influenza A infection. Increased numbers of MCs were observed in the alveolar parenchyma of children infected with LRTIs (median (range) 12.5 (0–78) MCs per mm2) compared to controls (0.63 (0–4) MCs per mm2, p=0.0005). The alveolar MC expansion was associated with a higher proportion of CD34+ tryptase+ progenitors (controls: 0% (0–1%); LRTIs: 0.9% (0–3%) CD34+ MCs (p=0.01)) and an increased expression of the vascular cell adhesion molecule (VCAM)-1 (controls: 0.2 (0.07–0.3); LRTIs: 0.3 (0.02–2) VCAM-1 per mm2 (p=0.04)). Similarly, infant mice infected with H1N1 alone or together with house dust mite (HDM) developed an increase in alveolar MCs (saline: 0.4 (0.3–0.5); HDM: 0.6 (0.4–0.9); H1N1: 1.4 (0.4–2.0); HDM+H1N1: 2.2 (1.2–4.4) MCs per mm2 (p, Viral infections in children evokes a rapid recruitment and accumulation of mast cells in the alveolar parenchyma http://ow.ly/i9eN30meNM7

Background: The Resmon Pro system uses the forced oscillation technique (FOT) with sound waves at 5, 11 and 19 Hz, to avoid self-resonating waves. It separates inspiratory and expiratory resistance (Rinsp, Rexp) and reactance (Xinsp, Xexp), aiming to reflect obstruction, since expiration is affected by airway closure. Impulse oscillometry (IOS) use waves at 5-35 Hz, and does not separate the inspiratory phase from the expiratory. Aim: To validate the Resmon Pro system against IOS by Jaeger, and to define the uses of inspiratory and expiratory measurements in obstructive diseases. Methods: A total of 31 subjects (16 healthy, 9 COPD, 5 asthma) were included and performed FOT (Resmon Pro), IOS and spirometry in the given order. Results: Total resistance (R5) and central resistance (R20 or R19) correlated between IOS and FOT. FOT could detect increased total resistance in COPD, while IOS could not. The use of separating Rinsp from Rexp was most prominent in COPD, where R5exp was higher than R5insp. Peripheral resistance (R5-R20 or R5-R19) showed correlation between IOS and FOT, and only IOS detected differences between healthy and COPD. The elastic properties of the lungs (reactance; X5) also correlated between IOS and FOT, and both methods detected differences between healthy and COPD patients. When separated into insp and exp, Xinsp showed a smaller Confidence Interval, but did not detect any differences between COPD and healthy. Conclusion: Both systems showed similar results, but with different abilities to detect airway obstruction. Although less variation, the use of inspiratory resistance and reactance needs to be further investigated.

Background: A cross-border research collaboration was recently initiated across the Nordic countries. These countries maintain population-based registers containing a variety of patient-level healt ...

Background: Increased mast cell (MC) densities in the airway epithelium is an important hallmark of asthma. Within the epithelium, MCs are ideally situated to react on harmful substances and to exert immunological responses. However, little is known regarding the direct effect of MC mediators on the epithelium. Objective: To investigate the density and phenotype of MCs in bronchial biopsies in patients with asthma and the effect of MC mediator tryptase on bronchial epithelial cells (BECs). Methods: Intraepithelial MCs were characterised in bronchial biopsies from patients with asthma and controls using immunohistochemistry for tryptase (MCT) and tryptase/chymase (MCTC). To study the effect of MC mediator tryptase on BECs, BEAS-2B and 16HBE cell lines were treated with tryptase (0.1 to 1nM) for 1, 3, 6 and 24h. Culture supernatants and cell lysates were evaluated for alarmin and inflammatory cytokine release and expression of tight-junction proteins. Results: Tryptase-positive MCTs, but not MCTCs, were increased in the bronchial epithelium in patients with difficult-to-control asthma compared to healthy controls. Furthermore, our data showed that tryptase induced release of the alarmin ATP from BECs after 1h stimulation. Also, tryptase induced inflammatory cytokine CXCL8 gene and protein release from BECs at 6 and 24h, respectively. Additionally, tryptase induced a downregulation of the tight junction proteins ZO-1 and E-cadherin mRNA. Conclusion: Our results suggest that tryptase released from MCs may play a direct role in inducing an inflammatory response and a damaged barrier function in BECs which may have an important role in the progression of asthma pathology.

Introduction: The FLAME study demonstrated that indacaterol/glycopyrronium (IND/GLY) is superior to salmeterol/fluticasone (SFC) in reducing the rate and risk of exacerbations 1 . Here, we determined the NNT for IND/GLY to prevent 1 COPD exacerbation, to prevent 1 case of repeat exacerbation, and to prevent a patient from having an exacerbation during 1 year vs SFC. Methods: FLAME was a 52-week multicentre, randomised (1:1), double-blind, double-dummy, parallel-group study which compared IND/GLY 110/50 µg o.d. and SFC 50/500 µg b.i.d. Annualised and Kaplan-Meier (KM) event rates of exacerbation during the 52-week treatment period from the FLAME study were used to estimate the NNT for IND/GLY vs SFC. Results: Based on the annualised exacerbation event rates, the NNT for IND/GLY vs SFC was 4.76 to prevent 1 moderate or severe exacerbation. The NNT with IND/GLY vs SFC was 50 to prevent 1 severe exacerbation requiring hospitalisation. To prevent 1 incidence of repeat exacerbations (≥ 3 exacerbations of any severity: mild, moderate or severe) for 1 year, NNT with IND/GLY was estimated to be 31.58 vs SFC. Furthermore, the NNT with IND/GLY vs SFC was 15 to maintain a patient free from moderate or severe exacerbation for 1 year, as calculated from KM event rates. Conclusion: NNT calculations confirm the clear efficacy advantage of IND/GLY compared with SFC in preventing COPD exacerbations in patients with moderate-to-very severe airflow limitation. Reference: 1. Wedzicha JA et al. N Engl J Med 2016; 374:2222-2234.

Background: Today, when assessing chronic obstructive pulmonary disease (COPD), we use symptoms and exacerbation frequency to identify patients that are at risk for more rapid progression. A better measure is needed to identify patients in need for increased monitoring. Aim: To identify predictors of disease progression such as lung function measures and reversibility. Methods: 81 smokers/former smokers with/without COPD previously performed body plethysmography, spirometry and impulse oscillometry before and after inhalation of salbutamol and ipratropium. After at least 6 months, 41 patients returned for a second visit. Lung function decline was analyzed by dividing the FEV 1 (L) with the follow up time. Results: The median follow up time was 435 days (287-560) and the median decline in FEV 1 was -20mL (-130-80). After correction for age, gender, smoking status, pack years and disease severity, linear regression identified a relationship between FEV 1 decline and FEV 1 (L) reversibility at visit 1. The more reversible the patient was, the less loss of lung function (p=0.015, r=0.475). High reversibility of peripheral resistance (R5-R20) at visit 1 showed a relationship, although not significant (p=0.059, r=0.319) with the decline in FEV 1 . Less reversibility in resonance frequency (F res ) could equally predict increases in F res over time (p=0.2, r=0.364). Symptoms (CCQ), FEV 1 %p and small airway measures (R5-R20, F res ) post bronchodilators at visit 1 did not show any correlation to the FEV 1 decline. Conclusion: FEV 1 reversibility and small airway reversibility (R5-R20, F res ) might be useful in identifying patients that are of greater risk to have a more rapid lung function decline, thereby improve disease monitoring.

Background: Reslizumab (RES) is a humanized anti-interleukin-5 monoclonal antibody approved by the European Medicines Agency (EMA) as an add-on therapy for adult patients (pts) with inadequately controlled severe eosinophilic asthma. Aims/Objectives: To evaluate the impact of RES on pt-reported measures and lung function in pts who experienced ≥3 exacerbations in the previous year despite using high-dose inhaled corticosteroids (ICS). Methods: A post-hoc, subgroup analysis of adult pts from two duplicate placebo (PBO)-controlled 52-wk phase 3 RES trials reported by Castro et al (Lancet Resp Med 2015;3:355–366) was performed in those with inadequately controlled (despite having used high-dose ICS plus another agent), severe eosinophilic asthma who experienced ≥3 exacerbations in the 12 months before study enrollment. Changes from baseline in FEV1, ACQ-7, AQLQ, and ASUI are reported. Results: Of the 953 randomized pts, 86 (RES 36, PBO 50) were included in this subgroup analysis. Compared with PBO, RES treatment improved FEV1 (difference 304 mL [95% CI: 117, 490], p=0.0018), ACQ-7 (difference -0.535 [-0.939, -0.130], p=0.0103), AQLQ (difference 0.681 [0.246, 1.116], p=0.0026) and ASUI (difference 0.101 [0.033, 0.169], p=0.0043). The observed improvements in this subgroup were both statistically significant and clinically meaningful (exceeding the minimally important differences). Conclusions: RES was clinically effective in improving lung function, asthma control, quality of life, and symptoms in this subset of pts with inadequately controlled, severe eosinophilic asthma who reported ≥3 exacerbations in the previous year.

Pulmonary vascular remodelling is a characteristic sign in different lung disorders. Vascular endothelial growth factor (VEGF) is a key mediator in vascular remodelling. The objective was to study the role of VEGF on fibroblast activity, such as extracellular matrix (ECM) synthesis, migration and proliferative capacity and to study if VEGF is affected in different lung disorders. Studies were performed in human lung fibroblasts (HFL-1) and primary distal fibroblasts cultures from control subjects, patients with COPD (GOLD IV) and patients with bronchiolitis obliterans syndrome (BOS). Lung fibroblasts were stimulated with TGF-b1. VEGF165 synthesis was measured in the cell culture medium. Changes in synthesis of the ECM proteins proteoglycans and procollagen I, proliferation rate and migration were analysed after stimulations with VEGF165 (1-10000 pg/ml). TGF-β1 significantly enhanced VEGF synthesis in all cell types. There were no differences in VEGF synthesis between fibroblasts from control subjects and COPD patients, whereas patients with BOS had a higher VEGF synthesis (p In conclusion, VEGF is promoting specific ECM synthesis and fibroblast activation. VEGF may have a crucial role in the interplay between fibroblasts and other cells in vascular remodelling processes in the distal lung.

Background: Chronic obstructive pulmonary disease (COPD) begins with inhomogeneous peripheral lung pathology for which the cheapest and simplest method of recognition is volumetric capnography. Aim: To evaluate the capnographic Lung Inhomogeneity index (LINHI) for diagnostics of COPD. Method: Volumetric capnography for a single breath at rest was analysed over a volume segment starting at appearance of CO2 and covering a volume of 15 % of predicted TLC. LINHI was defind as the grey area above the curve of the healthy subject divided by the area of the rectangle, i.e. 5x15 (Fig. 1A). Material: 12 non-smokers and 54 subjects with COPD GOLD 1-4 performed volumetric capnography, body plethysmography/spirometry, impulse oscillometry, DLCO test and N2 washout (ventilation heterogenity in the acinar airways). Results: LINHI continuously increased from healthy subjects to COPD of increasing severity. (Figure 1B). It correlated to N2 washout (0.72***), FEV1%predicted (-0.74***), DLCO%predicted (-0.75***) and FEV1/FVC (-0.55***). Conclusion: LINHI reflects inefectiveness of CO2 elimination caused by inhomogeniety of lung function and could identify COPD patients with increasing stages. LINHI offers an easy, effortless and cost valuable complement and in some situations, as it is easy to perform, even a good alternative to spirometry.