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Background: Dupilumab, a fully human monoclonal antibody that blocks the shared receptor component for interleukin-4 and interleukin-13, reduced exacerbations and improved lung function in patients with chronic obstructive pulmonary disease (COPD) and type 2 inflammation in the phase 3 BOREAS trial., Objective: To assess clinical outcomes in patients from BOREAS by emphysema status., Methods: Patients with COPD and type 2 inflammation (screening blood eosinophils ≥300 cells/μL) on maximal inhaled therapy were randomized to add-on dupilumab 300 mg or placebo every 2 weeks for 52 weeks. We assessed the annualized moderate/severe COPD exacerbation rates over 52 weeks and change from baseline to Week 12 in prebronchodilator forced expiratory volume in 1 second (FEV 1 ) in patients with and without investigator-reported emphysema., Results: Investigator-reported emphysema was present in 306/939 patients (32.6%) at baseline. Dupilumab reduced exacerbation rates vs placebo by 29% (relative risk [RR] 0.71 [95% CI 0.53-0.95]) and 31% (RR 0.69 [95% CI 0.53-0.89]) in patients with and without emphysema, respectively. Prebronchodilator FEV 1 least squares mean difference from baseline to Week 12 for dupilumab vs placebo was 0.07 L ([95% CI 0.002-0.14]) and 0.09 L ([95% CI 0.04-0.14]) in patients with and without emphysema, respectively. No treatment by emphysema interaction effect was observed for the annualized rate of exacerbations (P value for interaction = 0.8296) or change in prebronchodilator FEV 1 (P value for interaction = 0.6438)., Conclusion: Dupilumab efficacy was similar in patients with COPD and type 2 inflammation, with or without investigator-reported emphysema., Competing Interests: Declaration of Competing Interest Bhatt SP: Apreo, Boehringer Ingelheim, Chiesi, Genentech, Medscape, Sanofi, Verona Pharma – consultant; Genentech, Nuvaira, Sanofi – grants (to institution); GSK, Regeneron Pharmaceuticals Inc. – advisory board; Horizon CME, Integrity CME – honoraria. Rabe KF: AstraZeneca, Chiesi Farmaceutici, CSL Behring, Sanofi – consultant; AstraZeneca, Boehringer Ingelheim – travel fees; Boehringer Ingelheim, Sanofi, Novartis – grants. Hanania NA: Amgen, AstraZeneca, Boehringer Ingelheim, Genentech USA, GSK – consultant; AstraZeneca, Genentech, GSK, Sanofi, Teva Pharmaceuticals – grants (to institution); Sanofi, Teva Pharmaceuticals – advisory board; Elsevier Publishing – Editor in Chief, Respiratory Medicine. Vogelmeier CF: AstraZeneca, Boehringer Ingelheim, Chiesi Farmaceutici, CSL Behring, GSK, Grifols, Insmed, Novartis, Roche, Sanofi – advisory board and speaking engagements; AstraZeneca – data and safety monitoring board. Bafadhel M: AstraZeneca, Roche – grant funding to institution; AstraZeneca, Chiesi, GSK – consultancy and speaker honoraria; Albus Health, ProAxsis – scientific advisor. Christenson SA: Amgen, Apogee Therapeutics, Atheneum Consulting, Axon Advisors, Genentech, Verona Pharma – consultant; AstraZeneca, GSK, Regeneron Pharmaceuticals Inc., Sanofi – advisory boards/non-branded medical teaching; BMJ Publishing Group – Associate Editor for Thorax; CME Consultants, Horizon CME, Medscape, MJH Life Sciences – non-branded medical teaching; Glenmark Pharmaceuticals – advisory boards; UpToDate – compensation for authorship. Papi A: AstraZeneca, Avillion, Chiesi Farmaceutici, Edmond Pharma, GSK, Mundipharma, Roche, Sanofi – consultant/advisory boards; IQVIA – advisory board; Mundipharma – speaker; Sandoz, Zambon – lecture fees. Singh D: Aerogen, AstraZeneca, BIAL, Boehringer Ingelheim, Chiesi Farmaceutici, Cipla USA, CSL Behring, EpiEndo, Glenmark, GSK, Kinaset, Menarini, Novartis Pharma, Orion Corporation, Pulmatrix, Sanofi, Therevance, Verona Pharma – consultant; NIHR Manchester Biomedical Research Centre – research grants (to institution). Laws E, Lu X, Bauer D, Robinson LB: Sanofi – employees, may hold stock and/or stock options in the company. Dakin P, Maloney J, Bansal A: Regeneron Pharmaceuticals Inc. – employees and shareholders. Abdulai RM: Sanofi – former employee, (Copyright © 2024. Published by Elsevier Ltd.)

Background: Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of cardiovascular disease (CVD). The extent to which the excess CVD risk is captured by risk factors in QRISK, a widely used CVD risk scoring tool, is not well studied., Methods: We created an incidence cohort of diagnosed COPD patients from the United Kingdom (UK) Clinical Practice Research Datalink GOLD database (January 1998-July 2018). The outcome was a composite of fatal or non-fatal CVD events. Sex-specific age-standardised incidence ratios (SIR) were compared with values for the UK primary-care population. The observed 10-year CVD risk was derived using the Kaplan-Meier estimator and was compared with predicted 10-year risk from the QRISK3 tool., Results: 13 208 patients (mean age 64.9 years, 45% women) were included. CVD incidence was 3.53 events per 100 person-years. The SIR of CVD was 1.71 (95% CI 1.61 to 1.75) in women and 1.62 (95%CI 1.54-1.64) in men. SIR was particularly high among patients younger than 65 years (women=2.13 (95% CI 1.94 to 2.19); men=1.86 (95% CI 1.74 to 1.90)). On average, the observed 10-year risk was 52% higher than QRISK predicted score (33.5% vs 22.1%). The difference was higher in patients younger than 65 years (observed risk 82% higher than predicted)., Conclusion: People living with COPD are at a significantly heightened risk of CVD over and beyond their predicted risk. This is particularly the case for younger people whose 10-year CVD risk can be >80% higher than predicted. Risk scoring tools must be validated and revised to provide accurate CVD predictions in patients with COPD., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Immunological dysregulation plays a fundamental role in the inflammatory aspects of endometriosis. Circulating blood leukocytes, one of the most abundant immune cell populations in the human body, have been shown diagnostic significance in some diseases. Nevertheless, the association between peripheral blood leukocyte counts and endometriosis remains unexplored to date. We analysed two targeted study cohorts: a tertiary centre cohort (Endometriosis at Oxford University [ENDOX] study, 325 cases/177 controls) and a large-scale population study (UK Biobank [UKBB], 1537 cases/6331 controls). In both datasets, peripheral venous blood sample results were retrieved and counts of leukocyte subpopulations, including neutrophils, lymphocytes, monocytes, eosinophils and basophils analysed. Logistic regression models were used to investigate the association of leukocyte subtype alterations with endometriosis status, adjusting for confounding factors. We demonstrate that higher blood basophil level is associated with increased odds of endometriosis. This association was first discovered in the ENDOX cohort (basophils >0.04 x10^9/L: OR 1.65 [95%CI:1.06-2.57], P trend = 0.025) and replicated in the UKBB dataset (basophils >0.04 x10^9/L: OR 1.26 [95%CI:1.09-1.45], P trend = 0.001). Notably, women with basophil counts in the upper tercile had significantly increased odds of having stage III/IV endometriosis (ENDOX study: OR = 2.30, 95% CI [1.25 to 4.22], P trend = 0.007; UKBB study (OR = 1.40, 95% CI [1.07 to 1.85], P trend = 0.015). None of the other leukocyte subtypes showed an association. Our findings suggest an association between inflammatory responses and the pathogenesis of endometriosis; future studies are warranted to investigate whether the association is causal.

Background: Dupilumab, a fully human monoclonal antibody that blocks the shared receptor component for interleukin-4 and interleukin-13, key and central drivers of type 2 inflammation, has shown efficacy and safety in a phase 3 trial involving patients with chronic obstructive pulmonary disease (COPD) and type 2 inflammation and an elevated risk of exacerbation. Whether the findings would be confirmed in a second phase 3 trial was unclear., Methods: In a phase 3, double-blind, randomized trial, we assigned patients with COPD who had a blood eosinophil count of 300 cells per microliter or higher to receive subcutaneous dupilumab (300 mg) or placebo every 2 weeks. The primary end point was the annualized rate of moderate or severe exacerbations. Key secondary end points, analyzed in a hierarchical manner to adjust for multiplicity, included the changes from baseline in the prebronchodilator forced expiratory volume in 1 second (FEV 1 ) at weeks 12 and 52 and in the St. George's Respiratory Questionnaire (SGRQ; scores range from 0 to 100, with lower scores indicating better quality of life) total score at week 52., Results: A total of 935 patients underwent randomization: 470 were assigned to the dupilumab group and 465 to the placebo group. As prespecified, the primary analysis was performed after a positive interim analysis and included all available data for the 935 participants, 721 of whom were included in the analysis at week 52. The annualized rate of moderate or severe exacerbations was 0.86 (95% confidence interval [CI], 0.70 to 1.06) with dupilumab and 1.30 (95% CI, 1.05 to 1.60) with placebo; the rate ratio as compared with placebo was 0.66 (95% CI, 0.54 to 0.82; P<0.001). The prebronchodilator FEV 1 increased from baseline to week 12 with dupilumab (least-squares mean change, 139 ml [95% CI, 105 to 173]) as compared with placebo (least-squares mean change, 57 ml [95% CI, 23 to 91]), with a significant least-squares mean difference at week 12 of 82 ml (P<0.001) and at week 52 of 62 ml (P = 0.02). No significant between-group difference was observed in the change in SGRQ scores from baseline to 52 weeks. The incidence of adverse events was similar in the two groups and consistent with the established profile of dupilumab., Conclusions: In patients with COPD and type 2 inflammation as indicated by elevated blood eosinophil counts, dupilumab was associated with fewer exacerbations and better lung function than placebo. (Funded by Sanofi and Regeneron Pharmaceuticals; NOTUS ClinicalTrials.gov number, NCT04456673.)., (Copyright © 2024 Massachusetts Medical Society.)

Introduction: Understanding the interplay of immune mediators in relation to clinical outcomes during acute infection has the potential to highlight immune networks critical to symptom recovery. The objective of the present study was to elucidate the immune networks critical to early symptom resolution following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection., Methods: In a community-based randomised clinical trial comparing inhaled budesonide against usual care in 139 participants with early onset SARS-CoV-2 (the STOIC study; clinicaltrials.gov identifier NCT04416399), significant clinical deterioration (reported need for urgent care, emergency department visit, hospitalisation: the primary outcome), self-reported symptom severity (Influenza Patient-Reported Outcome questionnaire) and immune mediator networks were assessed. Immune mediator networks were determined using pre-defined mathematical modelling of immune mediators, determined by the Meso Scale Discovery U-Plex platform, within the first 7 days of SARS-CoV-2 infection compared to 22 healthy controls., Results: Interferon- and chemokine-dominant networks were associated with high viral burden. Elevated levels of the mucosal network (chemokine (C-C motif) ligand (CCL)13, CCL17, interleukin (IL)-33, IL-5, IL-4, CCL26, IL-2, IL-12 and granulocyte-macrophage colony-stimulating factor) was associated with a mean 3.7-day quicker recovery time, with no primary outcome events, irrespective of treatment arm. This mucosal network was associated with initial nasal and throat symptoms at day 0., Conclusion: A nasal immune network is critical to accelerated recovery and improved patient outcomes in community-acquired viral infections. Overall, early prognostication and treatments aimed at inducing epithelial responses may prove clinically beneficial in enhancing early host response to virus., Competing Interests: Conflict of interest: S.P. Cass is an early career editor of this journal. S. Ramakrishnan, L.E. Donnelly and M. Bafadhel report grants from AstraZeneca during the conduct of this study paid to the institute., (Copyright ©The authors 2024.)

QRISK algorithms use data from millions of people to help clinicians identify individuals at high risk of cardiovascular disease (CVD). Here, we derive and externally validate a new algorithm, which we have named QR4, that incorporates novel risk factors to estimate 10-year CVD risk separately for men and women. Health data from 9.98 million and 6.79 million adults from the United Kingdom were used for derivation and validation of the algorithm, respectively. Cause-specific Cox models were used to develop models to predict CVD risk, and the performance of QR4 was compared with version 3 of QRISK, Systematic Coronary Risk Evaluation 2 (SCORE2) and atherosclerotic cardiovascular disease (ASCVD) risk scores. We identified seven novel risk factors in models for both men and women (brain cancer, lung cancer, Down syndrome, blood cancer, chronic obstructive pulmonary disease, oral cancer and learning disability) and two additional novel risk factors in women (pre-eclampsia and postnatal depression). On external validation, QR4 had a higher C statistic than QRISK3 in both women (0.835 (95% confidence interval (CI), 0.833-0.837) and 0.831 (95% CI, 0.829-0.832) for QR4 and QRISK3, respectively) and men (0.814 (95% CI, 0.812-0.816) and 0.812 (95% CI, 0.810-0.814) for QR4 and QRISK3, respectively). QR4 was also more accurate than the ASCVD and SCORE2 risk scores in both men and women. The QR4 risk score identifies new risk groups and provides superior CVD risk prediction in the United Kingdom compared with other international scoring systems for CVD risk., (© 2024. The Author(s).)

Background: Asthma attacks are a common problem for people with asthma and are responsible for significant healthcare costs. There is interest in a precision medicine approach to treatment. However, the choice of trial outcome measures for asthma attack treatment is hampered by the absence of a consensus on suitability. We carried out a systematic review to understand the characteristics of outcome measures used in randomised controlled trials of asthma attack treatment. Have randomised controlled trials of asthma attack treatment measured outcomes that are useful to patients and healthcare providers?, Methods: The protocol was registered on PROSPERO (CRD42022311479). We searched for randomised controlled trials comparing treatments for adults with asthma attacks, published in English between 1972 and 2022 on MEDLINE, Embase and Cochrane Library databases. We recorded the outcome measures and study characteristics., Results: We identified 208 eligible randomised controlled trials from 35 countries. Trials ranged from 12 to 1109 participants, with a median of 60. The most common settings were the emergency department (n=165) and hospital admission (n=33). Only 128 studies had primary and secondary outcomes defined clearly. In those that did, 73% of primary outcomes measured change in lung function or other physiological parameters over a short period (usually <24 h). Patient-reported and healthcare utilisation outcomes were the primary outcome in 27%., Conclusions: Outcomes in randomised controlled trials of asthma attack treatment focus on short-term changes in lung function and may not capture patient-centred and economically important longer-term measures. More work is needed to investigate patient and other stakeholder preferences on core outcome sets., Competing Interests: Conflicts of interest: I. Howell reports conference travel support from GSK. Conflicts of interest: A. Howell reports conference travel support from GSK. Conflicts of interest: S. Ramakrishnan reports research funding from the National Institute of Health and Care Research and the Australian Government Research Training Program; S. Ramakrishnan’s institution has received unrestricted grant funding from AstraZeneca which was used to fund a research project; and S. Ramakrishnan has received personal speaker fees and conference travel support from AstraZeneca. Conflicts of interest: M. Bafadhel reports grants from AstraZeneca, and personal fees from AstraZeneca, Chiesi, GSK, Albus Health and ProAxsis. Conflicts of interest: I. Pavord reports having, over the last 5 years, received speaker’s honoraria for speaking at sponsored meetings from AstraZeneca, Boehringer Ingelheim, Aerocrine, Almirall, Novartis, Teva, Chiesi, Sanofi/Regeneron, Menarini and GSK, as well as payments for organising educational events from AstraZeneca, GSK, Sanofi/Regeneron and Teva; and has received honoraria for attending advisory panels with Genentech, Sanofi/Regeneron, AstraZeneca, Boehringer Ingelheim, GSK, Novartis, Teva, Merck, Circassia, Chiesi and Knopp, as well as payments to support US Food and Drug Aministration approval meetings from GSK; receiving sponsorship to attend international scientific meetings from Boehringer Ingelheim, GSK, AstraZeneca, Teva and Chiesi; and has received a grant from Chiesi to support a phase 2 clinical trial in Oxford., (Copyright ©The authors 2024.)

Objectives: To compare mean pulmonary T2* values and pulmonary volumes in fetuses that subsequently spontaneously delivered before 32 weeks with a control cohort with comparable gestational ages and to assess the value of mean pulmonary T2* as a predictor of preterm birth < 32 weeks' gestation., Methods: MRI datasets scanned at similar gestational ages were selected from fetuses who spontaneously delivered < 32 weeks of gestation and a control group who subsequently delivered at term with no complications. All women underwent a fetal MRI on a 3 T MRI imaging system. Sequences included T2-weighted single shot fast spin echo and T2* sequences, using gradient echo single shot echo planar sequencing of the fetal thorax. Motion correction was performed using slice-to-volume reconstruction and T2* maps generated using in-house pipelines. Lungs were manually segmented and volumes and mean T2* values calculated for both lungs combined and left and right lung separately. Linear regression was used to compare values between the preterm and control cohorts accounting for the effects of gestation. Receiver operating curves were generated for mean T2* values and pulmonary volume as predictors of preterm birth < 32 weeks' gestation., Results: Datasets from twenty-eight preterm and 74 control fetuses were suitable for analysis. MRI images were taken at similar fetal gestational ages (preterm cohort (mean ± SD) 24.9 ± 3.3 and control cohort (mean ± SD) 26.5 ± 3.0). Mean gestational age at delivery was 26.4 ± 3.3 for the preterm group and 39.9 ± 1.3 for the control group. Mean pulmonary T2* values remained constant with increasing gestational age while pulmonary volumes increased. Both T2* and pulmonary volumes were lower in the preterm group than in the control group for all parameters (both combined, left, and right lung (p < 0.001 in all cases). Adjusted for gestational age, pulmonary volumes and mean T2* values were good predictors of premature delivery in fetuses < 32 weeks (area under the curve of 0.828 and 0.754 respectively)., Conclusion: These findings indicate that mean pulmonary T2* values and volumes were lower in fetuses that subsequently delivered very preterm. This may suggest potentially altered oxygenation and indicate that pulmonary morbidity associated with prematurity has an antenatal antecedent. Future work should explore these results correlating antenatal findings with long term pulmonary outcomes., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2023 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Systemic glucocorticoids are recommended for use in chronic obstructive pulmonary disease (COPD) exacerbations; however, there is increased harm associated with their use. We hypothesised that the use of eosinophil biomarker-directed oral prednisolone therapy at the time of an exacerbation of COPD was effective at reducing prednisolone use without affecting adverse outcomes., Methods: The studying acute exacerbations and response (STARR2) study was a multicentre, randomised, double-blind, placebo-controlled trial conducted in 14 primary care practices in the UK. We included adults (aged ≥40 years), who were current or former smokers (with at least a 10 pack year smoking history) with a diagnosis of COPD, defined as a post-bronchodilator FEV 1 /forced vital capacity ratio of less than 0·7 previously recorded by the primary care physician, and a history of at least one exacerbation in the previous 12 months requiring systemic corticosteroids with or without antibiotics. All study staff and participants were masked to study group allocation and to treatment allocation. Participants were randomly assigned (1:1) to blood eosinophil-directed treatment (BET; to receive oral prednisolone 30 mg once daily if eosinophil count was high [≥2%] or placebo if eosinophil count was low [<2%]) or to standard care treatment (ST; to receive prednisolone 30 mg once daily irrespective of the point-of-care eosinophil result). Treatment was prescribed for 14 days and all patients also received antibiotics. The primary outcome was the rate of treatment failure, defined as any need for re-treatment with antibiotics or steroids, hospitalisation for any cause, or death, assessed at 30 days after exacerbation in the modified intention-to-treat population. Participants were eligible for re-randomisation at further exacerbations (with a maximum of four exacerbations per participant). A safety analysis was conducted on all randomly assigned participants. Although designed as a superiority trial, after identification of an error in the randomisation code before data lock the study converted to show non-inferiority. An upper margin of 1·105 for the 95% CI was defined as the non-inferiority margin. This study was registered with EudraCT, 2017-001586-24, and is complete., Findings: Between Nov 6, 2017, and April 30, 2020, 308 participants were recruited from 14 general practices. 144 exacerbations (73 in the BET group and 71 in the ST group) from 93 participants (mean age 70 years [range 46-84] and mean percent predicted FEV 1 60·9% [SD 19·4]; 52 [56%] male and 41 [44%] female; ethnicity data was not collected]) were included in the modified intention-to-treat analysis. There were 14 (19%) treatment failures at 30 days post-exacerbation in the BET group and 23 (32%) in the ST group; we found a large non-significant estimated effect between BET and ST (RR 0·60 [95% CI 0·33-1·04]; p=0·070) in reducing treatment failures after a COPD exacerbation. The non-inferiority analysis supported that BET was non-inferior to ST. Frequency of adverse events were similar between the study groups; glycosuria (2/102 [2%] in BET group and 1/101 [1%] in the ST group) and hospital admission for COPD exacerbation (2/102 [2%] in BET group and 1/101 [1%] in the ST group) were the two most common adverse events in both groups. No deaths occurred in the study., Interpretation: Blood eosinophil-directed prednisolone therapy at the time of an acute exacerbation of COPD is non-inferior to standard care and can be used to safely reduce systemic glucocorticoid use in clinical practice., Funding: National Institute for Health and Care Research., Competing Interests: Declaration of interests SR reports personal salary support from the National Institute for Health and Care Research, an unrestricted research grant from AstraZeneca to his institution, and speaker fees and conference travel support from AstraZeneca, all outside of the submitted work. MB reports salary support and direct funding for the study from the National Institute for Health and Care Research through a named fellowship. Outside of the submitted work, MB reports research grant funding paid to her institution from AstraZeneca, Roche, the European Respiratory Society, and Asthma + Lung UK. Outside of the submitted work, she also reports consulting fees from AstraZeneca, Sanofi, GSK, and Areteia, paid to her and her institution. She has received conference travel support from Chiesi. She has a leadership and board roles at the British Thoracic Society, AlbusHealth, and ProAxsis. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Oral corticosteroids (OCS) are often prescribed for chronic obstructive pulmonary disease (COPD) exacerbations., Methods: This observational, individually matched historical cohort study used electronic medical records (1987-2019) from the UK Clinical Practice Research Datalink linked to English Hospital Episode Statistics (HES) to evaluate adverse outcomes in patients with COPD who used OCS (OCS cohort) and those not exposed to OCS (non-OCS cohort). Risk of 17 adverse outcomes was estimated using proportional hazard regression., Results: Of 323,722 patients, 106,775 (33.0%) had COPD-related OCS prescriptions. Of the 106,775 patients in the overall cohort, 58,955 had HES linkage and were eligible for inclusion in the OCS cohort. The individual matching process identified 53,299 pairs of patients to form the OCS and non-OCS cohorts. Median follow-up post-index was 6.9 years (OCS cohort) and 5.4 years (non-OCS cohort). Adjusted risk of multiple adverse outcomes was higher for the OCS cohort versus the non-OCS cohort, including osteoporosis with/without fractures (adjusted hazard ratio [aHR] 1.80; 95% confidence interval [CI] 1.70-1.92), type 2 diabetes mellitus (aHR 1.44; 95% CI 1.37-1.51), cardiovascular/cerebrovascular disease (aHR 1.26; 95% CI 1.21-1.30), and all-cause mortality (aHR 1.04; 95% CI 1.02-1.07). In the OCS cohort, risk of most adverse outcomes increased with increasing categorized cumulative OCS dose. For example, risk of cardiovascular/cerebrovascular disease was 34% higher in the 1.0-<2.5 g group versus the <0.5 g group (HR 1.34; 95% CI 1.26-1.42)., Conclusion: Any OCS use was associated with higher risk of adverse outcomes in patients with COPD, with risk generally increasing with greater cumulative OCS dose., Competing Interests: GT and CA are former employees of the Observational and Pragmatic Research Institute (OPRI), which was funded by AstraZeneca to conduct this study. VC, JZ, and DS are employees of OPRI, which was funded by AstraZeneca to conduct this study. BE, XX, and HM are employees of AstraZeneca and hold stock and/or stock options in the company. MB has received research grants to her institution from AstraZeneca; honoraria to her institution from AstraZeneca, Chiesi, and GlaxoSmithKline; and is an advisory board member for Albus Health and ProAxsis. AP has received scientific grants to his institution from Agenzia Italiana del Farmaco (AIFA), AstraZeneca, Chiesi, GlaxoSmithKline, and Sanofi; has received consulting fees from AstraZeneca, Avillion, Chiesi, ELPEN Pharmaceuticals, GlaxoSmithKline, Novartis, and Sanofi; has received payment or honoraria for lectures, presentations, speaker bureaus, or educational events from AstraZeneca, Avillion, Chiesi, Edmond Pharma, ELPEN Pharmaceuticals, Moderna, GlaxoSmithKline, IQVIA, Menarini, Mundipharma, Novartis, Sanofi, and Zambon; and is an advisory board member for AstraZeneca, Avillion, Chiesi, ELPEN Pharmaceuticals, GlaxoSmithKline, IQVIA, MSD, Novartis, and Sanofi. DP is an employee of OPRI, which was funded by AstraZeneca to conduct this study; has advisory board membership with AstraZeneca, Boehringer Ingelheim, Chiesi, Mylan, Novartis, Regeneron Pharmaceuticals, Sanofi Genzyme, and Thermo Fisher; has consultancy agreements with Airway Vista Secretariat, AstraZeneca, Boehringer Ingelheim, Chiesi, EPG Communication Holdings Ltd, FIECON, Fieldwork International, GlaxoSmithKline, Mundipharma, Mylan, Novartis, OM Pharma SA, PeerVoice, Phadia AB, Spirosure Inc, Strategic North Limited, Synapse Research Management Partners S.L., Talos Health Solutions, Theravance, and WebMD Global LLC; has received grants and unrestricted funding for investigator-initiated studies (conducted through OPRI) from AstraZeneca, Boehringer Ingelheim, Chiesi, Mylan, Novartis, Regeneron Pharmaceuticals, Respiratory Effectiveness Group, Sanofi Genzyme, Theravance, and UK National Health Service; has received payment for lectures/speaking engagements from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, Kyorin, Mundipharma, Mylan, Novartis, Regeneron Pharmaceuticals, and Sanofi Genzyme; has received payment for travel/accommodation/meeting expenses from AstraZeneca, Boehringer Ingelheim, Mundipharma, Mylan, Novartis, and Thermo Fisher; has stock/stock options from AKL Research and Development Ltd, which produces phytopharmaceuticals; owns 74% of the social enterprise Optimum Patient Care Ltd (Australia and UK) and 92.61% of OPRI (Singapore); has a 5% shareholding in Timestamp, which develops adherence monitoring technology; is peer reviewer for grant committees of the UK Efficacy and Mechanism Evaluation Programme and Health Technology Assessment; and has been an expert witness for GlaxoSmithKline. The authors report no other conflicts of interest in this work., (© 2023 Tse et al.)

Chronic obstructive pulmonary disease is a major health problem with a high prevalence, a rising incidence, and substantial morbidity and mortality. Its course is punctuated by acute episodes of increased respiratory symptoms, termed exacerbations of chronic obstructive pulmonary disease (ECOPD). ECOPD are important events in the natural history of the disease, as they are associated with lung function decline and prolonged negative effects on quality of life. The present-day therapy for ECOPD with short courses of antibiotics and steroids and escalation of bronchodilators has resulted in only modest improvements in outcomes. Recent data indicate that ECOPD are heterogeneous, raising the need to identify distinct etioendophenotypes, incorporating traits of the acute event and of patients who experience recurrent events, to develop novel and targeted therapies. These characterizations can provide a complete clinical picture, the severity of which will dictate acute pharmacological treatment, and may also indicate whether a change in maintenance therapy is needed to reduce the risk of future exacerbations. In this review we discuss the latest knowledge of ECOPD types on the basis of clinical presentation, etiology, natural history, frequency, severity, and biomarkers in an attempt to characterize these events.

Chronic obstructive pulmonary disease (COPD) is a complex, heterogeneous, progressive inflammatory airway disease associated with a significant impact on patients' lives, including morbidity and mortality, and significant healthcare costs. Current pharmacologic strategies, including first- and second-line therapies such as long-acting β 2 -agonists, long-acting muscarinic antagonists, inhaled corticosteroids, phosphodiesterase-4 inhibitors, and macrolides, provide relief to patients with COPD. However, many patients remain symptomatic, with persistent symptoms and/or acute exacerbations and progressive lung function loss. Although neutrophilic inflammation is the most common type of inflammation in COPD, 20-40% of patients with COPD exhibit type 2 inflammation, with roles for CD4 + (cluster of differentiation 4) T-helper cell type 1 cells, type 2 innate lymphoid cells, eosinophils, and alternatively activated macrophages. On the basis of the current limitations of available therapies, a significant unmet need exists in COPD management, including the need for targeted therapies to address the underlying pathophysiology leading to disease progression, such as type 2 inflammation, as well as biomarkers to help select the patients who would most benefit from the new therapies. Significant progress is being made, with evolving understanding of the pathobiology of COPD leading to novel therapeutic targets including epithelial alarmins. In this review, we describe the current therapeutic landscape in COPD, discuss unmet treatment needs, review the current knowledge of type 2 inflammation and epithelial alarmins in COPD, explore potential biomarkers of type 2 inflammation in COPD, and finally provide a rationale for incorporating therapies targeting type 2 inflammation and epithelial alarmins in COPD. Video Abstract available online at www.atsjournals.org.

Exacerbations in chronic obstructive pulmonary disease (COPD), which tend to occur in clusters and increase with disease severity, come with high societal and economic burdens. Prevention and delay of recurrent exacerbations is an unmet and significant therapeutic need for patients with COPD. GALATHEA (NCT02138916) and TERRANOVA (NCT02155660) were trials assessing efficacy of benralizumab in patients with frequent COPD exacerbations despite treatment. Although these studies found that benralizumab given as an add-on treatment did not significantly reduce annual rates of COPD exacerbations after 56 weeks of treatment, in the following exploratory post hoc analysis of the GALATHEA and TERRANOVA trials we identified a potential responder population in which treatment with benralizumab prevents recurrent COPD exacerbations during 30- and 90-day periods following an initial exacerbation, a vulnerable period for an exacerbation to occur. This responder population was characterized by high blood eosinophil counts and frequent previous exacerbations despite optimized triple therapy. These results highlight the importance of targeted therapies for high-risk populations and merit further research into the benefits of biologic therapies for COPD exacerbations., Competing Interests: DS has received personal fees from Aerogen, AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, CSL Behring, Epiendo, Genentech, GlaxoSmithKline, Glenmark, Gossamerbio, Kinaset, Menarini, Novartis, Orion, Pulmatrix, Sanofi, Synairgen, Teva, Theravance, and Verona. GJC has received grants from NIH-NHLBI, PA-DOH, GSK, Boehringer Ingelheim, Novartis, AstraZeneca, Respironics, MedImmune, Novartis, Pearl, PneumRx, Pulmonx, Broncus, Spiration, Olympus, Fisher-Paykel Healthcare, Chiesi, Gilead, Pfizer, Corvus, Lilly, Regeneron, Genentech, and Roche and is a consultant for Almirall, AstraZeneca, Nuvaira, GSK, CSA Medical, PneumRx, BTG, Mereo, Broncus, Pulmonx, and EOLO. AA has received grants and private fees from AstraZeneca, Chiesi, GlaxoSmithKline, and Menarini and is a member of the GOLD Science Committee and Board of Directors. MB has received fees from AstraZeneca, Boehringer Ingelheim, Chiesi, and GlaxoSmithKline, and grants from AstraZeneca, Roche, and other support from Asthma & Lung UK, Albus Health and ProAxsis to the institution, outside the submitted work. JS, GLS, YS, MJ, UJM, and IP are or were employees of AstraZeneca at the time these analyses were conducted and may own stock/stock options in AstraZeneca. IL was a contractor for AstraZeneca at the time these analyses were conducted and affiliated with Cytel Inc. The authors report no other conflicts of interest in this work., (© 2023 Singh et al.)

Background: In some patients with chronic obstructive pulmonary disease (COPD), type 2 inflammation may increase exacerbation risk and may be indicated by elevated blood eosinophil counts. Dupilumab, a fully human monoclonal antibody, blocks the shared receptor component for interleukin-4 and interleukin-13, key drivers of type 2 inflammation., Methods: In a phase 3, double-blind, randomized trial, we assigned patients with COPD who had a blood eosinophil count of at least 300 per microliter and an elevated exacerbation risk despite the use of standard triple therapy to receive dupilumab (300 mg) or placebo subcutaneously once every 2 weeks. The primary end point was the annualized rate of moderate or severe exacerbations of COPD. Key secondary and other end points that were corrected for multiplicity were the change in the prebronchodilator forced expiratory volume in 1 second (FEV 1 ) and in the scores on the St. George's Respiratory Questionnaire (SGRQ; range, 0 to 100, with lower scores indicating a better quality of life) and the Evaluating Respiratory Symptoms in COPD (E-RS-COPD; range, 0 to 40, with lower scores indicating less severe symptoms)., Results: A total of 939 patients underwent randomization: 468 to the dupilumab group and 471 to the placebo group. The annualized rate of moderate or severe exacerbations was 0.78 (95% confidence interval [CI], 0.64 to 0.93) with dupilumab and 1.10 (95% CI, 0.93 to 1.30) with placebo (rate ratio, 0.70; 95% CI, 0.58 to 0.86; P<0.001). The prebronchodilator FEV 1 increased from baseline to week 12 by a least-squares (LS) mean of 160 ml (95% CI, 126 to 195) with dupilumab and 77 ml (95% CI, 42 to 112) with placebo (LS mean difference, 83 ml; 95% CI, 42 to 125; P<0.001), a difference that was sustained through week 52. At week 52, the SGRQ score had improved by an LS mean of -9.7 (95% CI, -11.3 to -8.1) with dupilumab and -6.4 (95% CI, -8.0 to -4.8) with placebo (LS mean difference, -3.4; 95% CI, -5.5 to -1.3; P = 0.002). The E-RS-COPD score at week 52 had improved by an LS mean of -2.7 (95% CI, -3.2 to -2.2) with dupilumab and -1.6 (95% CI, -2.1 to -1.1) with placebo (LS mean difference, -1.1; 95% CI, -1.8 to -0.4; P = 0.001). The numbers of patients with adverse events that led to discontinuation of dupilumab or placebo, serious adverse events, and adverse events that led to death were balanced in the two groups., Conclusions: Among patients with COPD who had type 2 inflammation as indicated by elevated blood eosinophil counts, those who received dupilumab had fewer exacerbations, better lung function and quality of life, and less severe respiratory symptoms than those who received placebo. (Funded by Sanofi and Regeneron Pharmaceuticals; BOREAS ClinicalTrials.gov number, NCT03930732.)., (Copyright © 2023 Massachusetts Medical Society.)

Background: The lack of standardised outcome assessments during hospitalisation and follow-up for acute COPD exacerbations has hampered scientific progress and clinical proficiency. The objective of the present study was to evaluate patients' acceptance of selected outcome and experience measurements during hospitalisations for COPD exacerbations and follow-up., Methods: An online survey was held amongst COPD patients in France, Belgium, The Netherlands, Germany and the UK. The European Lung Foundation COPD Patient Advisory Group was involved in the conceptualisation, development and dissemination of the survey. The survey was complementary to a previously obtained expert consensus. We assessed patients' views and acceptance of selected patient-reported outcomes or experiences and corresponding measurement instruments (for dyspnoea, frequent productive cough, health status and hospitalisation experience), and of selected clinical investigations (blood draw, pulmonary function test, 6-min walk test, chest computed tomography, echocardiography)., Findings: 200 patients completed the survey. All selected outcomes and experiences were deemed important, and acceptance of their methods of assessment was high. The modified Medical Research Council scale and a numerical rating scale to address dyspnoea, the COPD Assessment Test for quality of life and frequent productive cough, and the Hospital Consumer Assessment of Healthcare Providers and Systems for hospital experiences were the instruments preferred by patients. Consensus on importance of blood draw and spirometry was higher compared with the other investigations., Interpretation: The survey results endorse the use of the selected outcome and experience measurements during hospitalisations for COPD exacerbations. They can be used to optimise standardised and patient-centred care and facilitate multicentric data collection., Competing Interests: Conflicts of interest: An ICMJE Conflict of Interest form has been collected from all authors. I. Gyselinck reports grants from Research Foundation Flanders (FWO). S. Ramakrishnan reports grants from the National Institute of Health Research UK and AstraZeneca paid to his institution; and honoraria for speaker's fees from AstraZeneca. C. Coleman reports funding from the CICERO CRC budget for coordinating patient involvement in the project paid to the ERS; and is an employee of the European Lung Foundation. T. Greulich reports grants from Grifols paid to his institution; consulting fees from AstraZeneca, Berlin-Chemie, Boehringer Ingelheim, Chiesi, CSL-Behring, Grifols, GSK, Mundipharma, Novartis and Takeda; honoraria for speaker's fees from AstraZeneca, Berlin-Chemie, Boehringer Ingelheim, Chiesi, CSL-Behring, Grifols, GSK, Mundipharma and Takeda; travel support from AstraZeneca, Berlin-Chemie, Chiesi, CSL-Behring, Grifols, GSK and Takeda; DSMB and/or advisory board participation for AstraZeneca, Berlin-Chemie, Boehringer-Ingelheim, Chiesi, CSL-Behring, Grifols, GSK, Mundipharma, Novartis, Takeda; and membership of Alpha-1-Deutschland. F. Franssen reports grants from AstraZeneca; consulting fees from MSD; honoraria for speaker's fees from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Chiesi and Novartis; and travel support from Chiesi. P.R. Burgel reports grants from GSK and Vertex paid to his institution; consulting fees from AstraZeneca, Chiesi, Insmed, Viatris, Vertex, Zambon and Boehringer Ingelheim; travel support from Chiesi and Zambon. M. Bafadhel reports grants from AstraZeneca and Roche paid to her institution; honoraria for speaker's fees from AstraZeneca, Chiesi, Cipla, GlaxoSmithKline and Boehringer Ingelheim, paid to her institution; travel support from Boehringer Ingelheim; DSMB and/or advisory board participation for AstraZeneca, Sanofi/Regeneron, GlaxoSmithKline, Albus Health and ProAxsis; unpaid leadership roles in the BTS research and scientific faculty and NIHR TRC. W. Janssens reports grants from FWO, AstraZeneca and Chiesi, paid to the institution; honoraria for speaker's fees from AstraZeneca, Chiesi and GlaxoSmithKline; and nonfinancial support from ArtiQ. K. Vermeersch, A. Halner, H. Pott, F. Dobbels, P. Collis and H. Watz report no conflicts of interest., (Copyright ©The authors 2023.)

Background: Asthma attacks are a common and important problem. Someone experiences an asthma attack in the United Kingdom every 10 seconds. Asthma attacks cause coughing, wheezing, breathlessness, and chest tightness and are highly stressful for patients. They result in reduced quality of life, with days lost from work or school. Asthma attacks are treated with oral corticosteroids (OCSs), but these have many short- and long-term side effects. Asthma monoclonal antibodies (mAbs) have revolutionized the treatment of severe asthma by reducing asthma attacks and OCS burden by over 50%, but some people still experience attacks while on mAbs. The MEX study showed that residual asthma attacks are broadly eosinophilic (high fractional exhaled nitric oxide [FeNO]) or noneosinophilic (low FeNO), but it did not measure response to OCS treatment. There is an evidence gap in understanding the clinical and inflammatory responses that occur when using OCSs to treat residual asthma attacks in patients taking asthma mAbs., Objective: The primary objective is to compare the clinical recovery between high-FeNO and low-FeNO attacks after acute treatment with oral prednisolone among people established on long-term asthma mAb treatment. The exploratory objective is to compare the inflammatory response to acute treatment with oral prednisolone between high-FeNO and low-FeNO attacks., Methods: BOOST (Breakthrough Asthma Attacks Treated With Oral Steroids) is a single-center, prospective observational study of 60 adults established on long-term asthma mAb treatment who receive acute treatment with oral prednisolone (usual care) for an asthma attack. The primary outcome will be the proportion of treatment failure (the need to start oral prednisolone or antibiotics or an unscheduled health care visit for asthma, following an attack) at day 28. The secondary outcomes will be the change in forced expiratory volume in 1 second and the change in visual analogue scale symptom score between the stable state, attack, day 7, and day 28 visits. The exploratory outcomes include the changes in sputum, nasal, and blood inflammometry between the stable state, attack, day 7, and day 28 visits., Results: The last asthma attack visit is anticipated to occur in December 2023. Data analysis and publication will take place in 2024., Conclusions: We will test the hypothesis that there is a difference in the rate of recovery of clinical and inflammatory measures between high-FeNO and low-FeNO asthma attacks that occur in patients on mAb therapy. The study data will help power a future randomized placebo-controlled trial of prednisolone treatment for nonsevere attacks in patients treated with asthma mAbs and will provide important information on whether corticosteroid treatment should be FeNO-directed., International Registered Report Identifier (irrid): DERR1-10.2196/46741., (©Imran Howell, Mahdi Mahdi, Mona Bafadhel, Timothy S C Hinks, Sanjay Ramakrishnan, James Melhorn, Maisha Jabeen, Ian D Pavord. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 23.06.2023.)

Background: The ever-growing size, breadth, and availability of patient data allows for a wide variety of clinical features to serve as inputs for phenotype discovery using cluster analysis. Data of mixed types in particular are not straightforward to combine into a single feature vector, and techniques used to address this can be biased towards certain data types in ways that are not immediately obvious or intended. In this context, the process of constructing clinically meaningful patient representations from complex datasets has not been systematically evaluated., Aims: Our aim was to a) outline and b) implement an analytical framework to evaluate distinct methods of constructing patient representations from routine electronic health record data for the purpose of measuring patient similarity. We applied the analysis on a patient cohort diagnosed with chronic obstructive pulmonary disease., Methods: Using data from the CALIBER data resource, we extracted clinically relevant features for a cohort of patients diagnosed with chronic obstructive pulmonary disease. We used four different data processing pipelines to construct lower dimensional patient representations from which we calculated patient similarity scores. We described the resulting representations, ranked the influence of each individual feature on patient similarity and evaluated the effect of different pipelines on clustering outcomes. Experts evaluated the resulting representations by rating the clinical relevance of similar patient suggestions with regard to a reference patient., Results: Each of the four pipelines resulted in similarity scores primarily driven by a unique set of features. It was demonstrated that data transformations according to each pipeline prior to clustering can result in a variation of clustering results of over 40%. The most appropriate pipeline was selected on the basis of feature ranking and clinical expertise. There was moderate agreement between clinicians as measured by Cohen's kappa coefficient., Conclusions: Data transformation has downstream and unforeseen consequences in cluster analysis. Rather than viewing this process as a black box, we have shown ways to quantitatively and qualitatively evaluate and select the appropriate preprocessing pipeline., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Mona Bafadhel has received grants from AstraZeneca, Roche (to institution). Has received honoraria from AstraZeneca, Chiesi, Cipla, GlaxoSmithKline, Sanofi (to institution) and is Scientific advisor to AlbusHealth® and ProAxsis®. The rest of authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright: © 2023 Pikoula et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Previous trials have demonstrated the effects of fluvoxamine alone and inhaled budesonide alone for prevention of disease progression among outpatients with COVID-19., Objective: To determine whether the combination of fluvoxamine and inhaled budesonide would increase treatment effects in a highly vaccinated population., Design: Randomized, placebo-controlled, adaptive platform trial. (ClinicalTrials.gov: NCT04727424)., Setting: 12 clinical sites in Brazil., Participants: Symptomatic adults with confirmed SARS-CoV-2 infection and a known risk factor for progression to severe disease., Intervention: Patients were randomly assigned to either fluvoxamine (100 mg twice daily for 10 days) plus inhaled budesonide (800 mcg twice daily for 10 days) or matching placebos., Measurements: The primary outcome was a composite of emergency setting retention for COVID-19 for more than 6 hours, hospitalization, and/or suspected complications due to clinical progression of COVID-19 within 28 days of randomization. Secondary outcomes included health care attendance (defined as hospitalization for any cause or emergency department visit lasting >6 hours), time to hospitalization, mortality, patient-reported outcomes, and adverse drug reactions., Results: Randomization occurred from 15 January to 6 July 2022. A total of 738 participants were allocated to oral fluvoxamine plus inhaled budesonide, and 738 received placebo. The proportion of patients observed in an emergency setting for COVID-19 for more than 6 hours or hospitalized due to COVID-19 was lower in the treatment group than the placebo group (1.8% [95% credible interval {CrI}, 1.1% to 3.0%] vs. 3.7% [95% CrI, 2.5% to 5.3%]; relative risk, 0.50 [95% CrI, 0.25 to 0.92]), with a probability of superiority of 98.7%. No relative effects were found between groups for any of the secondary outcomes. More adverse events occurred in the intervention group than the placebo group, but no important differences between the groups were detected., Limitation: Low event rate overall, consistent with contemporary trials in vaccinated populations., Conclusion: Treatment with oral fluvoxamine plus inhaled budesonide among high-risk outpatients with early COVID-19 reduced the incidence of severe disease requiring advanced care., Primary Funding Source: Latona Foundation, FastGrants, and Rainwater Charitable Foundation., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-3305.

Background: This study compared management of high-risk COPD patients in the UK to national and international management recommendations and quality standards, including the COllaboratioN on QUality improvement initiative for achieving Excellence in STandards of COPD care (CONQUEST). The primary comparison was in 2019, but trends from 2000 to 2019 were also examined., Methods: Patients identified in the Optimum Patient Care Research Database were categorised as newly diagnosed (≤12 months after diagnosis), already diagnosed, and potential COPD (smokers having exacerbation-like events). High-risk patients had a history of ≥2 moderate or ≥1 severe exacerbations in the previous 12 months., Findings: For diagnosed patients, the median time between diagnosis and first meeting the high-risk criteria was 617 days (Q1-Q3: 3246). The use of spirometry for diagnosis increased dramatically after 2004 before plateauing and falling in recent years. In 2019, 41% (95% CI 39-44%; n = 550/1343) of newly diagnosed patients had no record of spirometry in the previous year, and 45% (95% CI 43-48%; n = 352/783) had no record of a COPD medication review within 6 months of treatment initiation or change. In 2019, 39% (n = 6893/17,858) of already diagnosed patients had no consideration of exacerbation rates, 46% (95% CI 45-47%; n = 4942/10,725) were not offered or referred for pulmonary rehabilitation, and 41% (95% CI 40-42%; n = 3026/7361) had not had a COPD review within 6 weeks of respiratory hospitalization., Interpretation: Opportunities for early diagnosis of COPD patients at high risk of exacerbations are being missed. Newly and already diagnosed patients at high-risk are not being assessed or treated promptly. There is substantial scope to improve the assessment and treatment optimisation of these patients., Funding: This study is conducted by the Observational & Pragmatic Research International Ltd and was co-funded by Optimum Patient Care and AstraZeneca. No funding was received by the Observational & Pragmatic Research Institute Pte Ltd (OPRI) for its contribution., Competing Interests: David MG Halpin has received sponsorship to attend international meetings, and honoraria for lecturing, attending advisory boards and preparing educational materials from AstraZeneca, Boehringer Ingelheim, Chiesi, GSK, Novartis and Pfizer. Andrew P. Dickens, Rachel Pullen, and Amy Couper, are employees of the Observational and Pragmatic Research Institute, which is a research collaborator of the CONQUEST initiative with Optimum Patient Care and AstraZeneca. Alexander Evans, Victoria Carter, Derek Skinner and Ruth Murray are employees of Optimum Patient Care, UK, which is a research collaborator of the CONQUEST initiative with Optimum Patient Care and AstraZeneca. Mukesh Singh reports personal fees from AstraZeneca, Boehringer Ingelheim, Cheisi, GlaxoSmithKline, Napp/Mundipharma, Pfizer, Teva. Tamsin Morris, Shruti Menon and Hana Muellerova are employees of AstraZeneca and hold stock and/or stock options in the company. AstraZeneca is a co-funder of the CONQUEST initiative. Mona Bafadhel reports grants from AstraZeneca and personal fees and non-financial support from AstraZeneca, Chiesi, GSK and others from AlbusHealth, outside the submitted work. James Chalmers has received research grants or consultancy fees from AstraZeneca, Boehringer Ingelheim, Gilead Sciences, GlaxoSmithKline, Grifols, Insmed and Zambon. Katherine Hickman, Graham Devereux, Martin Gibson, Jennifer Quint, and Marije van Melle report no conflicts of interest. John Hurst has received personal payment and payment to his institution (UCL), including research grants, reimbursement for advisory work and educational activities, and support to attend meetings from pharmaceutical companies that make medicines to treat COPD, which includes AstraZeneca, Boehringer Ingelheim, Chiesi, and Novartis. Rupert C. Jones declares grants from AstraZeneca, GlaxoSmithKline, Novartis, and Teva, and personal fees for consultancy, speakers’ fees or travel support from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, Novartis, and Observational & Pragmatic Research Institute Pte Ltd (OPRI). Konstantinos Kostikas has received honoraria for presentations and consultancy fees from AstraZeneca, Boehringer Ingelheim, CSL Behring, Chiesi, ELPEN, GILEAD, GSK, Menarini, Novartis, Sanofi, Specialty Therapeutics; WebMD (paid to the University of Ioannina); his department has received funding and grants from AstraZeneca, Boehringer Ingelheim, Chiesi, Innovis, ELPEN, GSK, Menarini, Novartis and NuvoAir (paid to the University of Ioannina); KK is a member of the GOLD Assembly. Dave Singh has received personal fees from GSK, Cipla, Genentech and Peptinnovate, and personal fees and grant support from AstraZeneca, Boehringer Ingelheim, Chiesi, Glenmark, Gossamerbio, Menarini, Mundipharma, Novartis, Pfizer, Pulmatrix, Theravance, and Verona. Tom Wilkinson is the co-founder, shareholder and director of Mymhealth Limited; he has received grants or consultancy fees from GSK, AstraZeneca, Janssen, Bergenbio, UCB, Olam, Valneva, Synairgen, Novavax, Teva, BI. David Price has advisory board membership with AstraZeneca, Boehringer Ingelheim, Chiesi, Mylan, Novartis, Regeneron Pharmaceuticals, Sanofi Genzyme, Thermofisher; consultancy agreements with Airway Vista Secretariat, AstraZeneca, Boehringer Ingelheim, Chiesi, EPG Communication Holdings Ltd, FIECON Ltd, Fieldwork International, GlaxoSmithKline, Mylan, Mundipharma, Novartis, OM Pharma SA, PeerVoice, Phadia AB, Spirosure Inc, Strategic North Limited, Synapse Research Management Partners S.L., Talos Health Solutions, Theravance and WebMD Global LLC; grants and unrestricted funding for investigator-initiated studies (conducted through Observational and Pragmatic Research Institute Pte Ltd) from AstraZeneca, Boehringer Ingelheim, Chiesi, Mylan, Novartis, Regeneron Pharmaceuticals, Respiratory Effectiveness Group, Sanofi Genzyme, Theravance and UK National Health Service; payment for lectures/speaking engagements from AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, GlaxoSmithKline, Kyorin, Mylan, Mundipharma, Novartis, Regeneron Pharmaceuticals and Sanofi Genzyme; payment for travel/accommodation/meeting expenses from AstraZeneca, Boehringer Ingelheim, Mundipharma, Mylan, Novartis, Thermofisher; stock/stock options from AKL Research and Development Ltd which produces phytopharmaceuticals; owns 74% of the social enterprise Optimum Patient Care Ltd (Australia and UK) and 92.61% of Observational and Pragmatic Research Institute Pte Ltd (Singapore); 5% shareholding in Timestamp which develops adherence monitoring technology; is peer reviewer for grant committees of the UK Efficacy and Mechanism Evaluation programme, and Health Technology Assessment; and was an expert witness for GlaxoSmithKline., (© 2023 The Author(s).)

Purpose: Blood eosinophil (EOS) count can guide treatment decisions for chronic obstructive pulmonary disease (COPD). In the 52-week ETHOS study (NCT02465567), budesonide/glycopyrronium/formoterol fumarate dihydrate (BGF) triple therapy at two inhaled corticosteroid doses reduced moderate/severe exacerbation rates and improved lung function, symptoms, and disease-related quality of life (QoL) versus dual therapy with glycopyrronium/formoterol fumarate dihydrate (GFF) or budesonide/formoterol fumarate dihydrate (BFF) in patients with moderate-to-very severe COPD. This subgroup analysis evaluated treatment benefits in ETHOS by baseline EOS count., Methods: Patients (40-80 years) with a COPD history were randomly assigned 1:1:1:1 to receive BGF 320/14.4/10 µg, BGF 160/14.4/10 µg, GFF 14.4/10 µg, or BFF 320/10 µg via a metered-dose inhaler. This post-hoc analysis assessed endpoints by baseline EOS count using Global Initiative for Obstructive Lung Disease thresholds (<100, ≥100, ≥100-<300, ≥300 cells/mm 3 ), and investigated continuous relationships between treatment effects and EOS count on exacerbations, symptoms, disease-related QoL, lung function, and safety., Results: In the modified intention-to-treat population (n=8509), 82.6% had EOS counts ≥100 cells/mm 3 . BGF 320 reduced moderate/severe exacerbation rates versus GFF in the ≥100, ≥100-<300, and ≥300 subgroups; treatment differences increased with EOS count. BGF 320 improved rescue medication use and lung-function outcomes across all subgroups, and St George's Respiratory Questionnaire total score, Transition Dyspnea Index focal score, and Exacerbations of Chronic Pulmonary Disease Tool total score in all except the <100 subgroup versus GFF. Benefits of BGF 320 versus BFF were generally consistent across subgroups. Safety data were comparable across subgroups., Conclusion: Benefits of BGF versus GFF were observed across EOS counts, particularly at ≥100 cells/mm³; versus BFF, benefits were largely independent of EOS. These findings confirm that benefits of ICS-containing triple therapy are not restricted to EOS counts ≥300 cells/mm³, supporting recommendations to consider triple therapy in patients with an exacerbation history and EOS counts ≥100 cells/mm³., Competing Interests: MB reports grants from AstraZeneca, and honoraria from AstraZeneca, Chiesi, and GlaxoSmithKline; and is on the scientific advisory board for Albus Health and ProAxsis. KFR reports grants and personal fees from AstraZeneca and Boehringer Ingelheim; and personal fees from Berlin Chemie, Chiesi Pharmaceuticals, GlaxoSmithKline, Novartis, Regeneron, Roche, and Sanofi, outside the submitted work. FJM reports grants, personal fees, and non-financial support from AstraZeneca during the conduct of the study; grants, personal fees, and non-financial support from AstraZeneca, Boehringer Ingelheim, Bioscale/Proterrix Bio, Chiesi, CSL Behring, Gala, GlaxoSmithKline, Metronic, Novartis, Polarean, Pulmatrix, Pulmonx, Sanofi/Regeneron, Sunovion, Teva, Theravance/Viatris, and Verona; grants and personal fees from AstraZeneca, Chiesi, GlaxoSmithKline, and Sanofi/Regeneron. He is also a COPD teleconsultant for Bayer. DS reports personal fees from AstraZeneca during the conduct of the study; and personal fees from Aerogen, AstraZeneca, Boehringer Ingelheim, Chiesi, Cipla, CSL Behring, Epiendo, Genentech, GlaxoSmithKline, Glenmark, Gossamerbio, Kinaset, Menarini, Mundipharma, Novartis, Peptinnovate, Pfizer, Pulmatrix, Sanofi, Synairgen, Teva, Theravance, and Verona, outside the submitted work. PDa, MJ, MA, and MP are employees of AstraZeneca and hold stock and/or stock options in the company. PDo is a former employee of AstraZeneca and previously held stock and/or stock options in the company. The authors report no other conflicts of interest in this work., (© 2022 Bafadhel et al.)

Introduction: Objective cough frequency is a key clinical end-point but existing wearable monitors are limited to 24-h recordings. Albus Home uses contactless motion, acoustic and environmental sensors to monitor multiple metrics, including respiratory rate and cough without encroaching on patient lifestyle. The aim of this study was to evaluate measurement characteristics of nocturnal cough monitoring by Albus Home compared to manual counts., Methods: Adults with respiratory conditions underwent overnight monitoring using Albus Home in their usual bedroom environments. Participants set-up the plug-and-play device themselves. For reference counts, each audio recording was counted by two annotators, and cough defined as explosive phases audio-visually labelled by both. In parallel, recordings were processed by a proprietary Albus system, comprising a deep-learning algorithm with a human screening step for verifying or excluding occasional events that mimic cough. Performance of the Albus system in detecting individual cough events and reporting hourly cough counts was compared against reference counts., Results: 30 nights from 10 subjects comprised 375 hours of recording. Mean±sd coughs per night were 90±76. Coughs per hour ranged from 0 to 129. Albus counts were accurate across hours with high and low cough frequencies, with median sensitivity, specificity, positive predictive value and negative predictive values of 94.8, 100.0, 99.1 and 100.0%, respectively. Agreement between Albus and reference was strong (intra-class correlation coefficient (ICC) 0.99; 95% CI 0.99-0.99; p<0.001) and equivalent to agreement between observers and reference counts (ICC 0.98 and 0.99, respectively)., Conclusions: Albus Home provides a unique, contactless and accurate system for cough monitoring, enabling collection of high-quality and potentially clinically relevant longitudinal data., Competing Interests: Conflict of interest: W. Do is a co-founding shareholder and director of Albus Health. R. Russell is a scientific advisor and minority shareholder of Albus Health; and reports grants from AstraZeneca, and personal fees from Boehringer Ingelheim, Chiesi UK and GlaxoSmithKline, outside the submitted work. C. Wheeler, H. Javed, C. Dogan, G. Cunningham and V. Khanna were employees of Albus Health during the conduct of the study. M. De Vos reports consulting fees and minority shareholding from Albus Health; and reports grants from J&J/Janssen and public government outside the submitted work. I. Satia reports grants from Merck, GSK, Bellus and Bayer, personal speaker and consulting fees from GSK, AstraZeneca, Merck, Genentech and Respiplus outside the submitted work, and is an associate editor of this journal. M. Bafadhel is a scientific advisor and minority shareholder of Albus Health, reports grants from AstraZeneca, personal fees from AstraZeneca, Chiesi, and GlaxoSmithKline, and is a scientific advisor of ProAxsis, outside of submitted work. I. Pavord has received speaker's honoraria for speaking at sponsored meetings from AstraZeneca, Boehringer Ingelheim, Aerocrine AB, Almirall, Novartis, Teva, Chiesi, Sanofi/Regeneron, Menarini and GSK, and payments for organising educational events from AstraZeneca, GSK, Sanofi/Regeneron, and Teva; has received honoraria for attending advisory panels with Genentech, Sanofi/Regeneron, AstraZeneca, Boehringer Ingelheim, GSK, Novartis, Teva, Merck, Circassia, Chiesi and Knopp, and payments to support FDA approval meetings from GSK; has received sponsorship to attend international scientific meetings from Boehringer Ingelheim, GSK, AstraZeneca, Teva and Chiesi; has received grants from Chiesi and Sanofi Genzyme; and is co-patent holder of the rights to the Leicester Cough Questionnaire and has received payments for its use in clinical trials from Merck, Bayer and Insmed, outside the submitted work., (Copyright ©The authors or their employers 2022.)

Competing Interests: SPC, APC, and DVN Jr declare no competing interests. REKR discloses consultancy or speaker fees paid to their institution from AstraZeneca, Chiesi, and GlaxoSmithKline, is a scientific advisor to GlaxoSmithKline, and discloses support for attending meetings from Boehringer Ingelheim. MB discloses grants paid to their institution from AstraZeneca, Roche, and Asthma & Lung UK, has received consultancy or speaker fees paid to their institution from AstraZeneca, Chiesi, GlaxoSmithKline, and Sanofi, and is a scientific advisor to ProAxsis and AlbusHealth.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has caused severe illness and mortality for millions worldwide. Despite the development, approval and rollout of vaccination programmes globally to prevent infection by SARS-CoV-2 and the development of coronavirus disease 2019 (COVID-19), treatments are still urgently needed to improve outcomes. Early in the pandemic it was observed that patients with pre-existing asthma or COPD were underrepresented among those with COVID-19. Evidence from clinical studies indicates that the inhaled corticosteroids (ICS) routinely taken for asthma and COPD could have had a protective role in preventing severe COVID-19 and, therefore, may be a promising treatment for COVID-19. This review summarises the evidence supporting the beneficial effects of ICS on outcomes in patients with COVID-19 and explores the potential protective mechanisms., Competing Interests: Conflict of interest: M. Bafadhel has unrestricted research grants from AstraZeneca and Roche, and has received honoraria to her institution for speaker's fees from AstraZeneca, Chiesi, Cipla and GlaxoSmithKline. She is a scientific adviser to Albus Health and ProAxsis. Conflict of interest: R. Faner has received research funding, advisory board fees and lecture fees from AstraZeneca, Chiesi, GlaxoSmithKline and Menarini. Conflict of interest: C. Taillé has received grants to her institution, advisory board fees and lecture fees from AstraZeneca, Chiesi, GlaxoSmithKline, Novartis and Sanofi. Conflict of interest: R.E.K. Russell has received advisory board fees and lecture fees from AstraZeneca, Chiesi, Cipla and GlaxoSmithKline. Conflict of interest: T. Welte has received lecture fees from AstraZeneca, Basilea, Bayer, Berlin Chemie, Biotest, Boehringer Ingelheim, GlaxoSmithKline, MSD, Novartis, Pfizer, Roche and Sanofi-Aventis, and advisory board fees from AstraZeneca, Basilea, Bayer, Biotest, Boehringer Ingelheim, Gilead, GlaxoSmithKline, Janssen, Novartis, Pfizer and Roche. Conflict of interest: P.J. Barnes has received research funding from AstraZeneca and Boehringer Ingelheim, and funding for consultancy, scientific advisory boards and talks from AstraZeneca, Boehringer Ingelheim, Covis, Epi-Endo, Novartis, Pieris and Teva. Conflict of interest: A. Agustí has unrestricted research grants from AstraZeneca and GlaxoSmithKline, and has received honoraria for speaker's fees from AstraZeneca, Chiesi, GlaxoSmithKline, Menarini, Orion Pharma and Zambon., (Copyright ©The authors 2022.)

Respiratory rate (RR) is a clinically important predictor of cardio-respiratory deteriorations. The mainstay of clinical measurement comprises the manual counting of chest movements, which is variable between clinicians and limited to sporadic readings. Emerging solutions are limited by poor adherence and acceptability or are not clinically validated. Albus Home TM is a contactless and automated bedside system for nocturnal respiratory monitoring that overcomes these limitations. This study aimed to validate the accuracy of Albus Home compared to gold standards in real-world sleeping environments. Participants undertook overnight monitoring simultaneously using Albus Home and gold-standard polygraphy with thoraco-abdominal respiratory effort belts (SomnomedicsEU). Reference RR readings were obtained by clinician-count of polygraphy data. For both the Albus system and reference, RRs were measured in 30-s segments, reported as breaths/minute, and compared. Accuracy was defined as the percentage of RRs from the Albus system within ±2 breaths/minute of reference counts. Across a diverse validation set of 32 participants, the mean accuracy exceeded 98% and was maintained across different participant characteristics. In a Bland-Altman analysis, Albus RRs had strong agreement with reference mean differences and the limits of agreement of -0.4 and ±1.2 breaths/minute, respectively. Albus Home is a contactless yet accurate system for automated respiratory monitoring. Validated against gold -standard methods, it enables long-term, reliable nocturnal monitoring without patient burden.

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity, mortality, and health-care use worldwide. COPD is caused by exposure to inhaled noxious particles, notably tobacco smoke and pollutants. However, the broad range of factors that increase the risk of development and progression of COPD throughout the life course are increasingly being recognised. Innovations in omics and imaging techniques have provided greater insight into disease pathobiology, which might result in advances in COPD prevention, diagnosis, and treatment. Although few novel treatments have been approved for COPD in the past 5 years, advances have been made in targeting existing therapies to specific subpopulations using new biomarker-based strategies. Additionally, COVID-19 has undeniably affected individuals with COPD, who are not only at higher risk for severe disease manifestations than healthy individuals but also negatively affected by interruptions in health-care delivery and social isolation. This Seminar reviews COPD with an emphasis on recent advances in epidemiology, pathophysiology, imaging, diagnosis, and treatment., Competing Interests: Declaration of interests SAC reports grant funding paid to her institution from the National Institutes of Health (NIH) and Merck; consulting fees paid from AstraZeneca, GlaxoSmithKline, and Glenmark Pharmaceuticals; payment and honoraria paid from AstraZeneca, Sanofi/Regeneron, Genentech, and Sunovion; and participation in advisory boards or Data and Safety Monitoring Boards (DSMBs) for AstraZeneca, GlaxoSmithKline, Sanofi/Regeneron, and Glenmark Pharmaceuticals. BMS reports grants paid to their institution from NIH, Canadian Institutes of Health Research, Canadian Lung Association, Quebec Respiratory Health Research Network, and McGill University Health Centre Foundation, and leadership as director for the Centre for Outcomes and Research Evaluation of the McGill University Health Centre Research Institute. MB reports grants paid to their institution from AstraZeneca and Roche; consulting fees paid to their institution from AstraZeneca and GlaxoSmithKline; honoraria paid to their institution from AstraZeneca, Boehringer Ingelheim, and GlaxoSmithKline; and participation in advisory boards or DSMBs with fees paid to their institution from AstraZeneca and GlaxoSmithKline. NP reports research funding paid to their institution from NIH and CSL Behring, and participation in advisory boards for CSL Behring and Pharmacosmos., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Community-based clinical trials of the inhaled corticosteroid budesonide in early COVID-19 have shown improved patient outcomes. We aimed to understand the inflammatory mechanism of budesonide in the treatment of early COVID-19., Methods: The STOIC trial was a randomised, open label, parallel group, phase 2 clinical intervention trial where patients were randomly assigned (1:1) to receive usual care (as needed antipyretics were only available treatment) or inhaled budesonide at a dose of 800 μg twice a day plus usual care. For this experimental analysis, we investigated the nasal mucosal inflammatory response in patients recruited to the STOIC trial and in a cohort of SARS-CoV-2-negative healthy controls, recruited from a long-term observational data collection study at the University of Oxford. In patients with SARS-CoV-2 who entered the STOIC study, nasal epithelial lining fluid was sampled at day of randomisation (day 0) and at day 14 following randomisation, blood samples were also collected at day 28 after randomisation. Nasal epithelial lining fluid and blood samples were collected from the SARS-CoV-2 negative control cohort. Inflammatory mediators in the nasal epithelial lining fluid and blood were assessed for a range of viral response proteins, and innate and adaptive response markers using Meso Scale Discovery enzyme linked immunoassay panels. These samples were used to investigate the evolution of inflammation in the early COVID-19 disease course and assess the effect of budesonide on inflammation., Findings: 146 participants were recruited in the STOIC trial (n=73 in the usual care group; n=73 in the budesonide group). 140 nasal mucosal samples were available at day 0 (randomisation) and 122 samples at day 14. At day 28, whole blood was collected from 123 participants (62 in the budesonide group and 61 in the usual care group). 20 blood or nasal samples were collected from healthy controls. In early COVID-19 disease, there was an enhanced inflammatory airway response with the induction of an anti-viral and T-helper 1 and 2 (Th1/2) inflammatory response compared with healthy individuals. Individuals with COVID-19 who clinically deteriorated (ie, who met the primary outcome) showed an early blunted respiratory interferon response and pronounced and persistent Th2 inflammation, mediated by CC chemokine ligand (CCL)-24, compared with those with COVID-19 who did not clinically deteriorate. Over time, the natural course of COVID-19 showed persistently high respiratory interferon concentrations and elevated concentrations of the eosinophil chemokine, CCL-11, despite clinical symptom improvement. There was persistent systemic inflammation after 28 days following COVID-19, including elevated concentrations of interleukin (IL)-6, tumour necrosis factor-α, and CCL-11. Budesonide treatment modulated inflammation in the nose and blood and was shown to decrease IL-33 and increase CCL17. The STOIC trial was registered with ClinicalTrials.gov, NCT04416399., Interpretation: An initial blunted interferon response and heightened T-helper 2 inflammatory response in the respiratory tract following SARS-CoV-2 infection could be a biomarker for predicting the development of severe COVID-19 disease. The clinical benefit of inhaled budesonide in early COVID-19 is likely to be as a consequence of its inflammatory modulatory effect, suggesting efficacy by reducing epithelial damage and an improved T-cell response., Funding: Oxford National Institute of Health Research Biomedical Research Centre and AstraZeneca., Competing Interests: Declaration of interests SR reports grants and non-financial support from Oxford Respiratory National Institute for Health Research (NIHR) Biomedical Research Centre (BRC), during the conduct of the study; and non-financial support from AstraZeneca and personal fees from Australian Government Research Training Program, outside of the submitted work. LED reports grants from AstraZeneca and Boehringer-Ingelheim, outside of the submitted work. PJB reports grants and personal fees from AstraZeneca and Boehringer Ingelheim, and personal fees from Teva and Covis, during the conduct of the study. REKR reports grants from AstraZeneca, and personal fees from Boehringer Ingelheim, Chiesi UK, and GlaxoSmithKline, during the conduct of the study. MB reports grants from AstraZeneca; personal fees from AstraZeneca, Chiesi, and GlaxoSmithKline; and is a scientific advisor for Albus Health and ProAxsis, outside of the submitted work. JRB, SPC, MM, DVN, and JSL declare no competing interests., (Copyright © 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)