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3rd October 2024
The rapidly developing area of technology and artificial intelligence (AI) within respiratory medicine and science was under the spotlight at this year’s European Respiratory Society (ERS) Congress, including the use of large language models (LLMs) such as ChatGPT to assess complex respiratory disease in children.
The LLM ChatGPT performed better than trainee doctors in assessing complex paediatric cases of respiratory disease, a study found, suggesting LLMs could be used to support patient triage.
UK researchers compared the performance of three LLMs (ChatGPT, Microsoft Bing and Google’s Bard) against early-career trainee doctors in providing responses to six paediatric respiratory clinical scenarios. Each scenario had obvious diagnosis and no published evidence, guidelines or expert consensus that pointed to a specific diagnosis or plan.
The 10 trainee doctors were given an hour with internet access, excluding access to LLMs, to solve each scenario with a 200- to 400-word answer.
Responses were randomised and scored by six experts overall and on specific criteria: correctness, comprehensiveness, utility, plausibility, coherence and humanness.
ChatGPT (median overall score 7) outperformed Bard (median 6), Bing (median 4) and the trainee doctors (median 4) in all domains.
Bard scored better than the trainee doctors in coherence, with Bing and the trainee doctors scoring similarly.
The six experts were able to identify Bing and Bard’s responses as non-human, but not ChatGPT’s responses.
Dr Manjith Narayanan, lead author and consultant in paediatric pulmonology at the Royal Hospital for Children and Young People, Edinburgh, and honorary senior clinical lecturer at the University of Edinburgh, UK, said they did not find any obvious instances of ‘hallucinations’ – the term for false information provided by LLMs – in the responses.
‘Even though… we did not see any instance of hallucination… we need to be aware of this possibility and build mitigations against this,’ he said.
The research team plan to test LLMs against more senior doctors and investigate newer and more advanced versions of the technology.
Commenting on the findings, Professor Hilary Pinnock, ERS Education Council chair and professor of primary care respiratory medicine at the University of Edinburgh, said the study pointed to a ‘brave new world of AI-supported care’.
She added: ‘As the researchers have demonstrated, AI holds out the promise of a new way of working, but we need extensive testing of clinical accuracy and safety, pragmatic assessment of organisational efficiency, and exploration of the societal implications before we embed this technology in routine care.’
ERS Congress co-chair Professor Judith Löffler-Ragg said the research presented at this year’s event under the theme of ‘Humans and machines: getting the balance right’ was pioneering and should guide future developments.
‘It is extremely important that we view developments in technology, and specifically AI, with an open mind but also a critical eye,’ she said.
‘Our vision is to advance personalised medicine through the responsible use of AI, continuously improving respiratory medicine.’
2nd October 2024
The rapidly developing area of technology and artificial intelligence (AI) within respiratory medicine and science was under the spotlight at this year’s European Respiratory Society (ERS) Congress, including the use of voice recording technology in identifying chronic obstructive pulmonary disease (COPD) exacerbations.
A trial showing vocal changes recorded on a smartphone can signal the start of a COPD exacerbation was among the research presented under the Congress’s humans and machines theme.
In the prospective cohort study, patients with COPD were asked to record their voices via a smartphone app every day for 12 weeks and also complete a daily report on any COPD symptoms.
Using the app, patients recorded themselves saying ‘aah’ for as long as they could manage in one breath and then either read a short paragraph of a story or answer a question.
A total of 11 COPD patients completed the daily report and voice tasks, equating to 1,691 voice recordings in total.
During the 12-week study, there were 16 occasions when a patient experienced a COPD exacerbation, six of which were treated.
Analysis found specific speech features were significantly different at the onset and peak of a COPD exacerbation. Patients’ voices became higher pitched when an exacerbation was imminent, and voices also become more breathy or hoarse when an exacerbation was beginning.
Lead author Loes van Bemmel, a researcher in the department of respiratory medicine at Maastricht University Medical Centre in the Netherlands, said these preliminary results needed to be validated in larger numbers of patients with COPD.
‘If we are able to do this, it would pave the way for early detection and diagnosis of exacerbations in the home environment. This would enable patients to manage these events themselves at home,’ she said.
‘While every disease is different, speech analysis could potentially help in other respiratory diseases as well. We suspect there are speech biomarkers for many respiratory diseases.’
ERS Congress co-chair Professor Judith Löffler-Ragg said the research presented at this year’s event under the theme of ‘Humans and machines: getting the balance right’, including this COPD study, was pioneering and should guide future developments.
‘It is extremely important that we view developments in technology, and specifically AI, with an open mind but also a critical eye,’ she said.
‘Our vision is to advance personalised medicine through the responsible use of AI, continuously improving respiratory medicine.’
16th September 2024
The European Respiratory Society convened a multidisciplinary respiratory task force group in 2024 to create a clinical practice guideline including recommendations for symptomatic treatment of advanced respiratory diseases. Ravijyot Saggu, co-author of the guideline, summarises the findings and details how holistic, patient-centred care is required.
A 2019 report highlighted that chronic respiratory diseases were the third leading cause of death and had a high prevalence of 454.6 million cases globally.1 What’s more, the burden of chronic respiratory disease can be significant for patients and carers, adversely impacting health-related quality of life (HRQoL).
The symptoms of respiratory disease are not exhaustive. Exacerbations aside, they often include anxiety and depression, but fatigue and breathlessness are prominent features in more advanced disease.
Many patients with advanced lung disease suffer from breathlessness, which can be limiting.
Breathlessness can be frightening and debilitating and lead to both psychological and functional decline,2 propagating inactivity and deconditioning, which further increases risks of falls and mortality.3 It is also associated with high healthcare utilisation. In England, for example, it accounts for 5% of presentations to emergency departments and approximately 4% of general practitioner consultations, as well as being reported by patients in 12% of medical admissions.4
A combination of pharmacological and non-pharmacological approaches to management is often beneficial. Breathlessness is not always due to hypoxia, which can sometimes be misunderstood by patients. Education is important to manage expectations and concerns.
There is often a lack of large randomised controlled trials in advanced symptom management of lung disease. Any available evidence for interventions, which may include palliation, is mixed, of varying quality or conflicting.
To address this need, the European Respiratory Society (ERS) convened a multiprofessional respiratory task force group to undertake a review, create a clinical practice guideline and set out recommendations for the symptomatic treatment of advanced respiratory illness. The group also included patients affected by severe respiratory illness and informal carers. The resulting clinical practice guideline was published in the European Respiratory Journal in May 2024.5
The task force defined ‘serious respiratory illness’ as a respiratory condition that carries a high risk of mortality; negatively impacts quality of life and daily function; and/or is burdensome in symptoms, treatments, or caregiver stress.5,6
The task force adopted a rigorous approach, following ERS methodology and setting out Population, Intervention, Comparison, Outcome (PICO) questions for six interventions and one narrative question. Systematic reviews were undertaken, and as expected, there were some limitations on the included populations, the methods and the quality of evidence available.
The patient population in the trials reviewed included mixed lung diseases but chronic obstructive pulmonary disease (COPD) and interstitial lung disease were mainly represented. Patients in these studies had moderate to severe lung disease.
The ERS guideline reviewed six interventions, which were intended as ‘add-ons’ to complement the usual standard of care for the respective lung conditions: multicomponent services, graded exercise therapy, hand-held fans, breathing techniques, opioid use and supplemental oxygen.
Question 1: Should a multicomponent service be used to reduce symptoms in people with serious respiratory illness?
Question 2: Should GET be used to reduce fatigue in people with serious respiratory illness?
Question 3: Should increased airflow be used to reduce breathlessness in people with serious respiratory illness?
Question 4: Should supplemental oxygen be used to reduce symptoms in people with serious respiratory illness?
Question 5: Should opioids be used to reduce symptoms in people with serious respiratory illness?
Question 6: Should breathing techniques be used to reduce symptoms in people with serious respiratory illness?
Evidence was reviewed using ‘grading of recommendation, assessment, development and evaluation’ (GRADE) – a systematic approach for rating the certainty of evidence.
Recommendations were made based on the available included evidence, as well as noting the strength and certainty of these and the fact that the relevance of interventions may vary over time along a patient’s disease trajectory.
A multicomponent model of care offers more than one intervention and includes at least one non-pharmacological intervention. Pulmonary rehabilitation (PR) was outside the scope of the review. Patients are enrolled in multicomponent services due to their symptoms, not diagnoses.
As a lower-risk and lower-cost intervention, the multicomponent model of care addresses a gap in healthcare, however, such services may not be widespread across all countries.
Graded exercise therapy (GET)is part of PR programmes, supervised over 12 weeks in an outpatient setting. It may include aerobic or water-based exercise and usually does not require specific equipment but usually needs staff supervision. It can also be delivered remotely.
Patients may have to wait a long time to access PR programmes or may be ineligible to be referred to PR if their lung disease is too advanced. They may also have a personal lack of confidence and reservations about participating in PR. The guideline serves as a lever to promote physical activity in patients and increase the availability and access of GET across countries.
A hand-held fan to ease the feeling of breathlessness is already established as part of COPD care in parallel to the use of usual inhaled treatments and breathing techniques.
Usually held six inches from the face, a fan generating cool air reduces the sensation and modulates the perception of, and patient response to, breathlessness.7 Use of a hand-held fan requires little patient training and is portable with virtually no associated adverse effects. However, there may be variations in the frequency, positioning and timing of patients’ use.
The guideline reaffirms its benefits and will hopefully promote greater uptake of this relatively inexpensive and accessible intervention.
People with lung disease may hyperventilate or have shallower or mouth breathing. Anxiety can also contribute to a dysfunctional breathing pattern, which can be further compounded by the side effects of beta-agonist medication use and overuse in lung disease.
Breathing techniques essentially slow breathing, enabling deeper breathing and increased mindfulness of respiration. This can be useful when a person undertakes an activity to help expel air and pace themselves. Breathing exercises also help manage panic attacks and are an established part of COPD care.
Opioids are commonly prescribed for pain but sometimes for a non-analgesic effect in lung disease. To look at this in more detail, the ERS task force reviewed studies which mainly included patients with COPD (and none that were at end of life) comparing opioids to placebo for the treatment of breathlessness or cough when used for >4 days.
Based on the evidence included in the review, the guideline recommends against opioid use for breathlessness or improving HRQoL, which is contrary to current practice in some countries.
The review found that regular use of opioids also had no significant effect on cough scores. Opioids have a range of adverse effects associated with their use; these may be heightened in people with advanced lung disease who may be more sensitive to their effects, for example, due to older age or if there is renal or liver dysfunction.
Before the guideline, patients with more advanced lung disease might have been prescribed low-dose morphine (such as 1.25–2.5 mg orally) for breathlessness, which is an unlicensed use of opioids; however, the evidence of benefit is variable.
This practice may be harder to change but publication of the guideline offers an opportunity to deprescribe and reduce unnecessary medication burden, or equally prevent the prescribing in the first place where it may not be beneficial.
This is also in line with national patient safety concerns related to opioid use in the UK. There may be a role for morphine in the palliation of refractory breathlessness in advanced or terminal illnesses.8
The ERS practice guidance reviewed supplemental oxygen use at rest or exertion. It points out that there is little reliable evidence that oxygen positively affects HRQoL or breathlessness scores in daily life. Hence, oxygen should not be routinely prescribed for breathlessness.
It has utility in an emergency setting or for longer-term use, such as in respiratory failure or palliative care, but also has risks relating to the oxygen itself but also equipment, which include local side effects, trip hazards and burns. Therefore, it should be prescribed as per national guidelines to ensure safe and clinically appropriate use.
Although the guidance suggests not using oxygen, there may be individuals who may derive small benefit and these patients should be reviewed on a case-by-case basis. For selected patients with severe breathlessness and exertional desaturation, and who will be able to use it safely, a trial of oxygen can be instituted. If so, the lowest concentration and flow rate to ease symptoms should be trialled.
Positive recommendation:
Conditional recommendations, very low certainty of evidence:
Negative recommendations:
The task force wanted to maintain rigour and a robust review process and acknowledge that the certainty of the available evidence for review was often low or very low. Certainty of evidence was impacted by various factors in the studies, including the risk of bias, imprecision and reporting bias.
Sometimes, a variety of scales for measuring a clinical difference were used, and sometimes multiple measures within a study were used at inconsistent times. Scores did not always correlate with an improved perception of symptoms or have a positive impact on other non-study-specified outcomes.
Acute improvements and reductions in breathlessness may be more clinically meaningful than a change over time.
HRQoL is impacted by various factors, including when it is measured and by breathlessness, which were, in some cases, measured separately and by the same and different scales, making results challenging to interpret. This reiterates that the studies reviewed had heterogeneity and that patients’ symptoms and the relevance of interventions change over time.
Additionally, the task force noted ‘the low certainty of evidence, modest impact of interventions on patient-centred outcomes, and absence of effective strategies to ameliorate cough highlight the need for new approaches to reduce symptoms and enhance wellbeing for individuals who live with serious respiratory illness.’5
The guideline highlights several research priorities and priorities for future work.
It is intended to complement the usual good practice management of respiratory diseases in line with national and international guidelines. The standard fundamentals of care should be applied, including, where relevant, optimising medicines, inhaler technique and adherence to therapy; ensuring uptake of vaccinations such as pneumococcal and influenza; and the optimal management of co-morbidities.
Smoking cessation is a key intervention at any stage, and patients should be supported to achieve this. In some countries, smoking status may impact eligibility for oxygen therapy.
Considerations of different payers and how healthcare is accessed in different countries are also important in influencing the uptake of care and interventions, recognising that this may widen health inequalities and poor health outcomes if people cannot afford to pay for treatments.
The guideline highlights the need for shared decision-making conversations with patients and a balance of benefit versus risk and adverse events on an individual basis alongside regular review and monitoring, including trialling and stopping interventions if they are not beneficial. This is important to manage patient expectations and personalise care and may be included in advanced care planning conversations.
Additionally, equity of access to interventions, such as oxygen, may be variable depending on the set-up of healthcare in different countries and an individual’s ability to pay for and access care, but, equally, the availability of services and treatments. It is also influenced by geographical location – be that coastal, rural or urban. The guidance hopefully levels this inequity by dissuading the use of oxygen, although it can be difficult to change historical practices.
There is also the opportunity and consideration to employ different models of care for multidisciplinary review and interventions going forward. This is useful in re-imagining pathways of service provision and when considering our respiratory workforce, including growing this for the future; capacity plans; and working in more integrated ways.
Studies of multicomponent services reviewed have been respiratory- or palliative-based and not in primary care. Therefore, the feasibility of implementation in expanded settings must be considered in line with local infrastructure and scope for expansion.
Many of the interventions reviewed are relatively inexpensive and can be implemented with little or no training. Pharmacological interventions, including oxygen, have their own associated potential adverse events and this guideline offers an evidence-based approach to support clinicians with patient discussions as to how and when these interventions may be utilised.
Ultimately, we need to provide holistic, patient-centred care, offering both pharmacological and non-pharmacological interventions which take account of individual needs, balancing risk and benefit to ease symptoms in advanced lung disease.
Ravijyot Saggu
Respiratory pharmacist, London, UK, and chair of the UK Clinical Pharmacy Association Respiratory Committee
9th February 2024
There is insufficient evidence to recommend the use of novel nicotine and tobacco products as a ‘harm reduction’ strategy to reduce smoking and aid quitting.
This is according to an updated position statement from the European Respiratory Society (ERS), which states that such harm reduction claims are ‘simply exploited by the tobacco industry for financial gain’.
Since its previous statement on this topic was issued in 2019, evidence has increasingly shown legitimate concern around the long-term health risks of novel products such as electronic cigarettes, heated tobacco products and nicotine pouches, the ERS said.
‘ERS maintains a firm position that all nicotine and tobacco products are highly addictive and harmful, and that quitting smoking entirely is still the best option,’ it added.
Across eight position statements, the ERS details this increasing evidence and suggests that novel tobacco and nicotine products do not help existing smokers to quit, are harmful to public health and constitute gateways towards nicotine addiction and the initiation of smoking among youth.
This can lead to much greater negative effect on a population level, it said.
And it encouraged the use of evidence-based interventions, such as nicotine replacement therapy or tobacco cessation medications when cessation aids are required.
‘Reducing tobacco use and protecting youth from addiction to emerging products that may normalise tobacco use should be a top priority,’ the ERS concluded.
Referring to the EU’s priority of a tobacco-free generation by 2040, the ERS added that it ‘does not recommend any lung-damaging products and cannot recommend harm reduction as a population-based strategy to reduce smoking and aid quitting’.
Commenting on the revised position statement, Dr Filippos Filippidis, chair of the ERS Tobacco Control Committee, said: ‘The argument that novel tobacco products contribute to “harm reduction” lacks sufficient independent evidence. Their potential lung damaging effects, and uptake amongst young people, means that ERS cannot support novel tobacco products and “harm reduction” as a population-based strategy.’
This updated ERS position statement on novel tobacco and nicotine products comes as the UK Government announced disposable vapes and alternatives such as nicotine pouches are to be banned.
The planned measures follow a consultation on smoking and vaping launched in October 2023, and are designed to ‘tackle the rise in youth vaping and protect children’s health’.
As part of the package announced by Prime Minister Rishi Sunak, new powers will be introduced to restrict flavours specifically marketed at children and to ensure that manufacturers produce plain and less visually appealing packaging.
These powers will also allow the Government to change how vapes are displayed in shops, moving them out of sight of children and away from products that appeal to them, such as sweets.
Furthermore, the crackdown on underage sales will see the introduction of a new set of fines to shops in England and Wales selling vapes illegally to children, and trading standards officers will be empowered to act ‘on the spot’ to tackle underage sales.
The number of children using vapes in the UK in the past three years has tripled. Use among younger children is also rising, according to the figures, with 9% of 11- to 15-year-olds now using vapes.
Commenting that ‘marketing vapes to children is not acceptable‘, Mr Sunak said: ‘Alongside our commitment to stop children who turn 15 this year or younger from ever legally being sold cigarettes, these changes will leave a lasting legacy by protecting our children’s health for the long term.’
6th February 2024
There will be more than 327,600 premature deaths across Europe if there is a delay in fully aligning the EU’s Ambient Air Quality Directive (AAQD) with World Health Organization (WHO) Air Quality Guidelines (AQG) 2021, according to a new report.
Writing in the International Journal of Public Health, doctors and experts from European Respiratory Society (ERS) and other health groups called for immediate action on European air pollution to ensure alignment with the AQG by 2030.
They warned that not doing so will result in poorer health for millions of people and widen the health inequality gap between western and eastern Europe.
Research from Europe indicates a strong link between air pollution and millions of new cases of asthma, COPD, acute respiratory infections, lung cancer and other serious illnesses each year.
The report stated: ‘This is a historic opportunity towards clean air in Europe for all that could prevent hundreds of thousands of premature deaths and millions of new cases of non-communicable diseases every year, as well as improve health of all European citizens.
‘Full alignment with WHO AQG would enhance children health in Europe by improving lung function and reducing asthma and respiratory infections burden. Achieving the WHO AQG would also reduce healthcare costs, social, environmental and health inequalities, boost economic growth, and help mitigate the adverse effects of climate change.’
This urgent call for action against air pollution comes as trilogue discussions between the EU Commission, Parliament and Council continue, with a deal to be reached soon regarding revisions to the EU’s AAQD.
The current proposals, the report said, leave out full alignment with WHO AQGs and allow delays in achieving air pollution limit values up to the 2040 for countries whose gross domestic product per capita is below EU average.
The report highlighted that ‘using poverty as an excuse to fail to act is the opposite of what countries in Europe need’.
It concludes: ‘We strongly urge the EU environment ministers to put European health and environmental justice at the core of their political aspirations.
‘This is a unique public health opportunity for EU Member States to follow the scientific evidence and listen to the concerns of citizens.’
Commenting on the report, Professor Zorana J. Andersen, ERS Environment and Health Committee chair, said: ‘Allowing additional delays in reaching new EU air quality standards, differentiated based on GDP, is completely unacceptable to the ERS community. A delay would widen existing inequalities in air pollution levels and health burden between east and west.
‘Children and adults in eastern European countries have already been breathing the most polluted air in Europe and suffering from related lung diseases for far too long. We need fair, ambitious new EU air quality legislation that values the health of all Europeans equally.
‘A new Air Quality Directive must provide clear vision and support to speed up, and not delay, much needed air pollution reductions in eastern Europe, in order to improve health and wellbeing, and achieve clean air for all in Europe, as soon as possible.’
In September 2023, the ERS issued a consensus statement on climate change and respiratory health, including guidance on how global warming can be addressed in clinical practice.
And in November 2023, the WHO published a new operational framework for building climate-resilient, low-carbon and sustainable health systems and address climate-related health risks to safeguard health.
18th September 2023
Three studies presented at the recent European Respiratory Society (ERS) International Congress in Milan, Italy, highlight the various damaging effects of air pollution in early childhood, including on birthweight and the incidence of respiratory infections.
According to a recent consensus statement from the European Respiratory Society on climate change, there is likely to be a disproportionately greater negative impact from global warming on individuals living with respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD).
One of the most important and detrimental consequences of climate change is the resulting increased levels of air pollution, which is already known to damage the lungs and have other negative consequences such as mental health issues in dementia.
Now, three related studies presented at the ERS International Congress have shed further light on the deleterious effect of air pollution. The studies reveal how pollution not only reduces the birthweight of newborns, but also increases the incidence of respiratory infections experienced by young children.
In the first study (abstract PA311), researchers sought to investigate the association of maternal exposure to air pollution based on what they described as the level of environmental ‘greenness’ during pregnancy, and whether this affected birthweight.
They devised a measure of greenness termed the ‘normalised difference vegetation index‘ (NDVI), which was based on the density of vegetation seen on satellite images. In addition, the team modelled exposure to five known pollutants: nitrogen dioxide (NO2), ozone, black carbon (BC), and two types of particulate matter (PM2.5 and PM10). The levels of these pollutants were estimated for mothers based on their residential address during pregnancy.
The researchers analysed data on 5,434 children from 2,742 mothers. The median NDVI300m was 0.3 (interquartile range, IQR, 0.2 – 0.4). Increases in the level of greenness were positively associated with birthweight. For example, each IQR increase in NDVI300m was associated with an increase in birthweight of 29g, a 23% lower odds of a low birthweight (Odds ratio, OR = 0.77, 95% CI 0.64 – 0.94), as well as a 14% increased odds of a high birthweight (> 4000g) (OR = 1.14, 95% CI 1.02 – 1.26).
Commenting on the findings, lead author, Robin Mzati Sinsamala, a researcher in the department of global public health and primary care at the University of Bergen (UiB), Norway said: ‘The time when babies are growing in the womb is critical for lung development. We know that babies with lower birthweight are susceptible to chest infections, and this can lead on to problems like asthma and COPD later on.
‘Our results suggest that pregnant women exposed to air pollution, even at relatively low levels, give birth to smaller babies. They also suggest that living in a greener area could help counteract this effect. It could be that green areas tend to have lower traffic or that plants help to clear the air of pollution, or green areas may mean it’s easier for pregnant women to be physically active.’
In the second study (abstract PA311), which was published in the journal Pediatric Pulmonology, a UK team from Sussex Medical School and University Hospitals Sussex NHS Foundation Trust sought to evaluate the effect of environmental factors on respiratory infections and symptoms in early childhood.
Researchers turned to data from the GO-CHILD prospective birth cohort study, which explored the role of environment and gene variation on infection and atopy-related outcomes. As part of the study, pregnant women were recruited and their children followed up for infection and respiratory symptoms and outcomes after 12 and 24 months via postal questionnaires.
Information was available for 1,344 children, and the researchers identified how several environmental factors and settings were significantly associated with respiratory infections. For example, use of daycare facilities was associated with a more than two-fold increased risk of pneumonia (odds ratio, OR = 2.39), wheeze (OR = 2.16) and a dry cough (OR = 2.01). There was also a higher risk of developing bronchiolitis (OR = 1.40).
The presence of visible damp in the home increased the risk of wheeze (OR = 1.85) and led to a two-fold increased risk of being prescribed an inhaled corticosteroid (Relative risk, RR = 2.61).
Air pollution also contributed to the risk of respiratory problems. The presence of dense traffic around the child’s home, increased the risk of bronchiolitis (OR = 1.32). However, it was found that the harmful effects of environmental pollution could be mitigated to some extent by measures such as breastfeeding. In fact, continuing to breastfeed beyond six months was associated with a significantly reduced odds of bronchiolitis (OR = 0.55).
Commenting on this study, lead author, Dr Tom Ruffles from the Sussex Medical School, said: ‘This research provides some important evidence about how we can help reduce chest infections in babies and toddlers. The benefits of breastfeeding are well-established, and we should continue to support mothers who want to breastfeed their babies. We should also be making every effort to reduce exposure to infections in daycare, keep homes free of damp and mould, reduce tobacco smoking and cut air pollution.’
Finally, researchers in the third study (abstract PA2721), who were part of the Copenhagen Prospective Studies on Asthma in Childhood (COPSAC) based at Gentofte Hospital and the University of Copenhagen in Denmark, looked at the level of respiratory infections seen in children who had been born in either a rural or urban location.
Using the COPSAC2010 mother-child cohort, researchers followed the participants from pregnancy until three years of age and recorded whether the children were growing up in urban or rural areas and how many respiratory infections they developed. The researchers also performed an analysis of the airway immune profile in the children at age four weeks and undertook both maternal and child metabolomic profiling during week 24 of their pregnancy and two to three days after birth.
Among 663 children, the team found there was a mean of 16.3 infections, which were mainly respiratory in nature. Among children living in an urban area, there was a 15% higher risk of infections compared to those living in rural areas (adjusted incidence rate ratio = 1.15, 95% CI 1.05 – 1.26, p = 0.002).
Urbanisation resulted in a different airway immune profile and it was this change that increased the risk of infections, they concluded. Furthermore, urbanisation resulted in different maternal and child metabolomic profiles, which significantly increased the risk of infections.
Lead author for the study and COPSAC researcher and physician, Dr Nicklas Brustad, said: ‘Our findings suggest that urban living is an independent risk factor for developing infections in early life when taking account of several related factors such as exposure to air pollution and starting day care. Interestingly, changes in the blood of pregnant mothers and newborn babies, as well as changes in the newborn immune system, seem to partly explain this relationship.
‘Our results suggest that the environment children live in can have an effect on their developing immune system before they are exposed to coughs and colds. We continue to investigate why some otherwise healthy children are more prone to infections than others and what the implications are for later health.
‘We have several other studies planned that will look for risk factors and try to explain the underlying mechanisms using our large amount of data.’
14th September 2023
Using lung progenitor cell transplantation in patients with chronic obstructive pulmonary disease (COPD) appears to improve symptoms and could lead to a cure, according to a study presented at the recent European Respiratory Society (ERS) International Congress 2023 in Milan, Italy.
It has been previously shown that P63+ progenitor cells, which are used by the body to repair and replace damaged tissue, are able to induce lung epithelium regeneration in animal models.
Consequently, in this first-in-human phase 1 clinical trial (abstract OA4297), researchers set out to investigate the efficacy and safety of taking autologous P63+ progenitor cells transplanted into the lungs of patients with COPD.
They demonstrated that the use of P63+ progenitor cells in those with COPD enabled patients to breathe better, walk further and have improved quality of life. This is the first time researchers have shown it‘s possible to repair damaged lung tissue in patients with COPD using their own lung cells.
The trial included 17 COPD patients with a diffusing capacity of the lungs (DLCO) of less than 80% of the predicted value and three control patients. Individuals were autologously transplanted with the P63+ progenitor cells through bronchoscopy, followed by subsequent assessment for both safety and efficacy within 24 weeks.
The cell treatment was well tolerated by all patients and following transplantation, the median DLCO of treated patients increased from a baseline value of 30.00% to 39.70% after 12 weeks and still further to 40.30% after 24 weeks.
When it came to quality of life, the average St George’s Respiratory Questionnaire score of those receiving cell therapy group decreased from 51.3% at baseline to 44.2% after treatment. The median six-minute-walk distance increased from 410m to 447m at 24 weeks.
In addition, two patients with mild emphysema showed resolution of the lesions at 24 weeks by CT imaging.
Professor Wei Zuo, chief scientist of the study and professor in the school of medicine at Tongji University, Shanghai, China, told the congress: ‘P63+ progenitor cells are known for their ability to regenerate the tissues of the airways, and previously we and other scientists have shown in animal experiments that they can repair the damaged epithelial tissue in the alveoli.‘
He added: ‘We found that P63+ progenitor cell transplantation, not only improved the lung
function of patients with COPD, but also relieved their symptoms, such as shortness of breath, loss
of exercise ability and persistent coughing. This means that the patients could live a better life, and
usually with longer life expectancy.
‘If emphysema progresses, it increases the risk of death. In this trial, we found that P63+ progenitor cell transplantation could repair mild emphysema, making the lung damage disappear. However, we
cannot repair severe emphysema yet.‘
Commenting on the ‘encouraging‘ results, Professor Omar Usmani, head of the European Respiratory Society group on airway disease and professor of respiratory medicine at Imperial College London, UK, added: ‘COPD is in desperate need of new and more effective treatments, so if these results can be confirmed in subsequent clinical trials it will be very exciting. It is also very encouraging that two patients with emphysema responded so well.
‘A limitation of this study is that the uptake of the progenitor cells when they were transplanted back into the patients is uncontrolled. So we do not know whether the lungs of some patients responded better to the transplantation than other. We hope this information may become apparent in future studies.‘
The researchers are planning a phase II trial of the treatment, which will evaluate its efficacy in a
larger group of patients.
11th September 2023
Guidance on how global warming can be addressed in clinical practice has been outlined by the European Respiratory Society (ERS) in its latest consensus statement on climate change and respiratory health.
Published in the European Respiratory Journal, the statement describes climate change as ‘an unfolding major planetary and health crisis’, and a major threat to those with common lung conditions.
This, it says, is linked to the frequent and extreme weather events, prolonged aeroallergen seasons and poorer air quality associated with climate change, which can lead directly to a worsening of health and an increased risk of death.
Traditionally, clinicians have been involved in climate change adaptation strategies such as identifying vulnerable groups and providing advice on how they can protect themselves during heatwaves, for example.
However, the ERS says this clinical role has now expanded to focus on both human and planetary health, which includes contributing to the reduction in greenhouse gas emissions.
According to the ERS, subsequent changes to clinical practice could therefore include promoting green prescriptions such as inhalers; focusing efforts on smoking eradication; and encouraging patients, where appropriate, to engage with nature, take active modes of transport and make more sustainable food choices.
Professor Zorana Jovanovic Andersen, chair of the ERS Environment and Health Committee and professor of environmental epidemiology at the University of Copenhagen, who was one of the authors, said: ‘As respiratory doctors and nurses, we need to be aware of these new risks and do all we can to help alleviate patients’ suffering. We also need to explain the risks to our patients so they can protect themselves from adverse effects of climate change.‘
The consensus statement also highlights that climate change will have a disproportionately greater adverse effect on individuals living with respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD).
It outlines some of the health risks of climate change such as a decline in lung function, increases in allergic responses and/or new cases of chronic (asthma, COPD, lung cancer) or infectious (pneumonia, influenza, tuberculosis, Covid-19) respiratory diseases.
It also identifies a higher risk of exacerbations for existing respiratory diseases, increased use of medication, emergency department visits, hospitalisations and death.
The fact that children are more susceptible to the impact of climate change on lung health is also highlighted, including the fact that the prevention of chronic respiratory disease should start as early as possible as many chronic lung diseases in adults have childhood origins.
Several previous reviews have provided extensive summaries of the different mechanisms by which climate change affects respiratory health, as well as outlining adaptation strategies. The latest statement provides an overview of all major pathways linking climate change with lung health.
While it summarises all of the available evidence, the authors also recognise some gaps in current knowledge. For instance, there is the need for further research to fully map the burden of climate change on respiratory diseases under different global warming scenarios and to understand underlying biological mechanisms, as well as identifying pathways of adaptation that can be translated into public health policies.
Professor Jovanovic Andersen, added: ‘Climate change affects everyone’s health, but arguably, respiratory patients are among the most vulnerable. These are people who already experience breathing difficulties and they are far more sensitive to our changing climate. Their symptoms will become worse, and for some this will be fatal.
‘Air pollution is already damaging our lungs. Now the effects of climate change are becoming a major threat to respiratory patients.’
Indeed, the deleterious respiratory effects of the particulate matter contained within air pollution, are already known to provide a mechanism through which lung cancer can develop among individuals who have never smoked.
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