Escolar Documentos
Profissional Documentos
Cultura Documentos
E VtIh
EmWa
S
Chronic obstructive Asthma and chronic obstructive pulmonary disease of the disease, the lung parenchyma is not affected. By
pulmonary disease (COPD) are both very common and their incidence contrast, COPD predominantly affects the small airways
(COPD). A group of diseases is increasing globally, placing an increasing burden and the lung parenchyma, although similar inflamma-
characterized by the on health services in industrialized and developing tory changes can also be found in larger airways6,7. These
pathological limitation of
airflow in the airway, including
countries13. Both diseases are characterized by airway differences in disease distribution may partly reflect the
chronic obstructive bronchitis obstruction, which is variable and reversible in asthma distribution of inhaled inciting agents, such as allergens
and emphysema. It is most but is progressive and largely irreversible in COPD. in asthma and tobacco smoke in COPD. In both dis-
often caused by tobacco In both diseases, there is chronic inflammation of the eases, there are different clinical phenotypes recognized.
smoking, but can also be
respiratory tract, which is mediated by the increased Most patients with asthma are atopic (extrinsic asthma),
caused by other airborne
irritants, such as coal dust, and expression of multiple inflammatory proteins, including but a few patients are non-atopic (intrinsic asthma), and
occasionally by genetic cytokines, chemokines, adhesion molecules, inflamma- these patients often have a more severe form of the dis-
abnormalities, such as tory enzymes and receptors. In both diseases there are ease8. There is a range of asthma severity, which tends
1-antitrypsin deficiency. acute episodes or exacerbations, when the intensity of to be maintained throughout life9. Approximately 5%
Atopic (extrinsic) asthma
this inflammation increases. The similarity between of patients have severe asthma that is difficult to con-
The commonest form of these airway diseases prompted the suggestion in the trol with maximal inhaler therapy and for whom new
asthma in which the patients 1960s that asthma and COPD are different forms of therapeutic approaches are needed. The main types of
are atopic (as indicated by a a common disease (chronic obstructive lung disease), COPD are the development of small-airway obstruction
positive skin-prick test and the
and this came to be known as the Dutch hypothesis. and emphysema, which can occur alone or together, but
presence of IgE to common
inhalant allergens, such as This was countered by the British hypothesis, which which both involve progressive airflow limitation and
house-dust mites) and have maintained that these diseases were separate entities; are usually caused by tobacco smoke.
allergic inflammation of the the debate continues today, with evidence both for and The differences in inflammation between asthma
airways. against these two views4,5. and COPD are linked to differences in the immuno-
Despite the similarity of some clinical features of logical mechanisms that underlie these two diseases
Airway Disease Section,
asthma and COPD, there are marked differences in the (FIGS1,2). There have been several recent important
National Heart and Lung
Institute, Imperial College pattern of inflammation that occurs in the respiratory advances in our understanding of the immunopathol-
London, Dovehouse Street, tract, with different inflammatory cells recruited, dif- ogy of asthma and COPD, and these are discussed in
London SW3 6LY, UK. ferent mediators produced, distinct consequences of this Review. Tcells have a crucial role in both asthma
e-mail: inflammation and differing responses to therapy. In and COPD and it is now recognized that different sub-
p.j.barnes@imperial.ac.uk
doi:10.1038/nri2254
addition, the inflammation seen in asthma is mainly sets are involved in orchestrating inflammation in these
Published online located in the larger conducting airways, and although two diseases, resulting in different inflammatory and
15 February 2008 small airways can also be affected in more severe forms structural consequences. Bcells also have an important
Inhaled allergens at the airway surface and activated Tcells. There are
characteristic structural changes, with collagen deposi-
tion under the epithelium that is sometimes described
as basement-membrane thickening and is found in
Epithelial cells all patients with asthma, and thickening of the airway
CCL11 smooth-muscle cell layer as a result of hyperplasia and
hypertrophy, which is more commonly seen in patients
SCF
with severe asthma14. Epithelial cells are often shed from
Mast cell
asthmatic patient biopsies compared to normal control
TSLP biopsies, as they are friable and more easily detach from
the basement membrane during the biopsy procedure.
Histamine, cysteinyl Dendritic
leukotrienes and
CCL17 and
cell In addition, there is an increase in the number of blood
IL-9 CCL22
prostaglandin D2 vessels (angiogenesis) in response to increased secre-
CCR4 tion of vascular-endothelial growth factor (VEGF)15.
Smooth-muscle Mucus hyperplasia is commonly seen in biopsies from
cell IgE asthmatic patients, with an increase in the number of
mucus-secreting goblet cells in the epithelium and an
TH2 cell TReg cells?
Bronchoconstriction increase in the size of submucosal glands16.
IL-13
Antibody IL-5 In biopsies of the bronchial airways, small airways and
production IL-4
lung parenchyma from patients with COPD, there is no
CCR3 evidence for mast-cell activation, but there is an infiltra-
Eosinophil tion of Tcells and increased numbers of neutrophils,
particularly in the airway lumen17. Subepithelial fibrosis
B cell Eosinophilic inflammation is not apparent, but fibrosis does occur around small air-
Figure 1 | Inflammatory and immune cells involved in asthma. Inhaled allergens ways and is thought to be a main factor that contributes
activate sensitized mast cells by crosslinking surface-bound IgE molecules to the irreversible airway narrowing that is characteristic
Nature Reviewsto| Immunology
release
several bronchoconstrictor mediators, including cysteinyl leukotrienes and of this disease18. The airway smooth-muscle cell layer is
prostaglandin D2. Epithelial cells release stem-cell factor (SCF), which is important for not usually increased in COPD patients compared with
maintaining mucosal mast cells at the airway surface. Allergens are processed by myeloid normal airways, and airway epithelial cells may show
dendritic cells, which are conditioned by thymic stromal lymphopoietin (TSLP) secreted pseudostratification as a result of chronic irritation from
by epithelial cells and mast cells to release the chemokines CCchemokine ligand 17 inhaled cigarette smoke or other irritants and the release
(CCL17) and CCL22, which act on CCchemokine receptor 4 (CCR4) to attract T helper 2
of epithelial-cell growth factors. As in biopsies from
(TH2) cells. TH2 cells have a central role in orchestrating the inflammatory response in
allergy through the release of interleukin4 (IL4) and IL13 (which stimulate Bcells to
asthma patients, there is mucus hyperplasia and increased
synthesize IgE), IL5 (which is necessary for eosinophilic inflammation) and IL9 (which expression of mucin genes in biopsies from patients
stimulates mast-cell proliferation). Epithelial cells release CCL11, which recruits with COPD19. A marked difference between COPD and
eosinophils via CCR3. Patients with asthma may have a defect in regulatory T(TReg) cells, asthma is the destruction of alveolar walls (emphysema)
which may favour further TH2-cell proliferation. that occurs in COPD as a result of protease-mediated
degradation of connective tissue elements, particularly
elastin, and apoptosis of typeI pneumocytes and pos-
role, although this remains poorly understood in COPD. sibly endothelial cells20,21. In addition, the production
The appreciation that similar immune mechanisms are of elastolytic enzymes, such as neutrophil elastase and
involved in both asthma and COPD has important particularly several matrix metalloproteinases (MMPs),
implications for the development of new therapies for is increased in the lungs of COPD patients22, and there
these troublesome diseases. may be a reduction in the levels of antiproteinases, such
as 1-antitrypsin, as seen in a rare form of emphysema
Non-atopic (intrinsic)
asthma Inflammatory cells and mediators caused by a congenital deficiency of 1-antitrypsin23.
An uncommon form of asthma There are many differences between mild asthma and
that is more likely to be severe COPD in the type of inflammation that occurs in the lungs, Mast cells. Mast cells have a key role in asthma through
and characterized by negative with a different range of inflammatory cells and mediators the release of several bronchoconstrictors, including
skin-prick tests. The airway
inflammation is similar to that
being implicated10,11. However, many of the cytokines and histamine, which is preformed and stored in granules,
of atopic asthma and may be chemokines that are secreted in both asthma and COPD and the lipid mediators leukotriene C4, leukotriene D4,
mediated by local rather than are regulated by the transcription factor nuclear factor-B leukotriene E4 and prostaglandin D2, which are synthe-
systemic IgE production. (NF-B), which is activated in airway epithelial cells and sized following mast-cell activation. The release of these
macrophages in both diseases, and may have an important mediators may account for the variable bronchocon-
Emphysema
Destruction of the alveolar role in amplifying airway inflammation12,13. striction seen in asthma, as these mediators are released
walls, resulting in decreased by various environmental triggers, such as allergens, and
gas exchange and contributing Histopathology. The histological appearance of airways an increase in plasma osmolality as a result of increased
to airflow limitation by loss of from asthmatic individuals is very different from the ventilation during exercise. Mucosal mast cells are
alveolar attachments to the
small airways that serve to
changes that are observed in patients with COPD (FIG.3). recruited to the surface of the airways by stem-cell factor
keep the airways open during Bronchial biopsies from asthmatic subjects reveal an (SCF; also known as KIT ligand) released from epithelial
expiration. infiltration of eosinophils, activated mucosal mast cells cells, which acts on KIT receptors expressed by the
Pseudostratification mast cells24. Mast cells also release cytokines that are eosinophils in asthma is not clear and the evidence that
Increased proliferation of linked to allergic inflammation, including interleukin4 links their presence to airway hyper-responsiveness has
airway epithelial cells in chronic (IL4), IL5 and IL13 (Ref.25). The presence of mast been questioned by the finding that the administration of
obstructive pulmonary disease, cells in the airway smooth muscle has been linked to IL5-specific blocking antibodies that markedly reduce
as a result of the release of
airway hyper-responsiveness in asthma26, as patients with the number of eosinophils in the blood and sputum
epithelial-cell growth factors,
which lead to increased eosinophilic bronchitis have a similar degree of eosino does not reduce airway hyper-responsiveness or asthma
thickness of the epithelial-cell philic inflammation to that found in asthmatics and symptoms27,28. As discussed above, eosinophilic bronchi-
layer. also have subepithelial fibrosis, but they do not show tis is not associated with airway hyper-responsiveness,
airway hyper-responsiveness, which is the physiological but subepithelial fibrosis does occur, which suggests a
TypeI pneumocytes
Flat alveolar cells that make up
hallmark of asthma. By contrast, mast cells do not seem role for eosinophils in airway fibrosis. Interestingly, the
most of the epithelial-cell layer to have a role in COPD, which may explain the lack of presence of eosinophils seems to be a good marker of
of the alveolar wall and that are variable bronchoconstriction in this disease. steroid responsiveness29.
responsible for gas exchange in Neutrophils are increased in the sputum of patients
the alveoli.
Granulocytes. The inflammation that occurs in asthma is with COPD and this correlates with disease severity30.
Bronchoconstrictor often described as eosinophilic, whereas that occurring The increase in neutrophils is related to an increase
An agent that induces in COPD is described as neutrophilic. These differences in the production of CXC-chemokines, such as CXC-
contraction of airway smooth reflect the secretion of different chemotactic factors in chemokine ligand 1 (CXCL1; also known as GRO) and
muscle and thereby narrows
these diseases. In asthma, eosinophil chemotactic factors, CXCL8 (also known as IL8), which act on CXCR2 that
the airways, thus reducing the
flow of air.
such as CCchemokine ligand 11 (CCL11; also known is expressed predominantly by neutrophils.
as eotaxin1) and related CCchemokines, are mainly
secreted by airway epithelial cells. The functional role of Macrophages. Macrophage numbers are increased in the
lungs of patients with asthma and COPD, but their num-
bers are far greater in COPD than in asthma. These mac-
Cigarette smoke
(and other irritants) rophages are derived from circulating monocytes, which
migrate to the lungs in response to chemoattractants such
as CCL2 (also known as MCP1) acting on CCR2, and
CXCL1 acting on CXCR2 (Ref.31). There is increasing
evidence that lung macrophages orchestrate the inflam-
Epithelial cells CXCL9, CXCL10 Macrophage mation of COPD through the release of chemokines that
and CXCL11 attract neutrophils, monocytes and Tcells and the release
CCL2
CXCL1 of proteases, particularly MMP9 (Ref.32).
TGF and CXCL8 The pattern of inflammatory cells found in the res-
CXCR2 CCR2 piratory tract therefore differs in patients with asthma
CXCR3
and those with COPD and some of these contrasts
may be explained by differences in the immunological
Fibroblast TH1 cell TC1 cell Neutrophil Monocyte mechanisms that drive these two diseases.
Asthma COPD
Inflammation
Basement membrane
Fibrosis
Alveolar disruption
TH2 cells51, making the distinction between the THcell eosinophilic inflammation67. The production of CCL5
patterns in these two diseases less clear. (also known as RANTES), which attracts CD4+ and CD8+
Other subtypes of CD4+ Tcells that may have an Tcells via CCR5, is also increased in the sputum of COPD
important role in airway diseases are regulatory Tcells, patients compared with controls and may also be involved
Regulatory Tcells
A specialized type of CD4+
which have a suppressive effect on other CD4+ Tcells in Tcell recruitment49. TC1 cells release granzyme B and
Tcells that can suppress the and may have a role in regulating TH2-cell function perforins, which are also present at higher levels in the
responses of other Tcells. in asthma33,52. There is evidence that the numbers of sputum of COPD patients than normal control subjects
These cells provide a crucial CD4+CD25+ regulatory Tcells that express the tran- who also smoke68, and may induce apoptosis of type1
mechanism for the
scription factor forkhead box P3 (FOXP3) are reduced pneumocytes, thereby contributing to the development of
maintenance of peripheral self-
tolerance and a subset of these in individuals with allergic rhinitis (hay fever) compared emphysema20. TC1- and TH1-cell-driven inflammation is
cells is characterized by with non-atopic individuals, and this may be important likely to be self-perpetuating as IFN stimulates the release
expression of CD25 and the in enabling high numbers of TH2 cells to develop in aller- of CXCR3 ligands, which then attract more TH1 and TC1
transcription factor forkhead gic disease53. However, by contrast, asthmatic patients cells into the lungs (FIG.6). TC2 cells, which secrete IL4,
box P3 (FOXP3).
seem to have an increase in FOXP3-expressing regula- have also been described in COPD50. In asthma, CD8+
Allergic rhinitis tory Tcells compared with patients with mild asthma, Tcells are present in patients with more severe disease
Allergic inflammation that is at least among circulating cells54. Analysis of sputum and irreversible airflow obstruction69 and these cells may
caused by the pollen of specific from COPD patients suggests that the numbers of be of either the TC1 or TC2 type70.
seasonal plants, such as
CD4+CD25+FOXP3+ regulatory Tcells are reduced, but
grasses (causing hay fever), and
house dust (causing perennial similar changes are also seen in people who smoke but do Bcells. Bcells have an important role in allergic diseases,
rhinitis) in people who are not have airflow obstruction55. So, the role of regulatory including asthma, through the release of allergen-specific
allergic to these substances. It Tcells in asthma and COPD remains unclear and fur- IgE which binds to high-affinity Fc receptors for IgE
is characterized by sneezing, ther research is therefore needed, particularly in defining (FcRI) expressed by mast cells and basophils, and to
and a runny and blocked nose.
the role of different types of regulatory Tcells56. low-affinity Fc receptors for IgE (FcRII) expressed by
TH17 cells Another subset of CD4+ Tcells, known as TH17 cells, other inflammatory cells, including Bcells, macrophages
(T helper 17 cells). A subset of has recently been described and shown to have an and possibly eosinophils71. The TH2-type cytokines IL4
CD4+ T helper cells that important role in inflammatory and autoimmune dis- and IL13 induce Bcells to undergo immunoglobulin class
produce interleukin17 (IL17)
eases57,58. Little is known about the role of TH17 cells in switching to produce IgE. Blocking IgE with the mono-
and that are thought to be
important in inflammatory and asthma or COPD, but increased concentrations of IL17 clonal antibody omalizumab reduces the response to
autoimmune diseases. Their (the predominant product of T H17 cells) have been allergens, airway inflammation and asthma exacerba-
generation involves IL23 and reported in the sputum of asthma patients59. IL17 and tions, indicating that IgE drives allergic inflammation in
IL21, as well as the the closely related cytokine IL17F have been linked to asthma72. In both atopic asthma and non-atopic asthma,
transcription factors RORt
(retinoic-acid-receptor-related
neutrophilic inflammation by inducing the release of IgE may be produced locally by Bcells in the airways73.
orphan receptor-t) and STAT3 CXCL1 and CXCL8 from airway epithelial cells60 (FIG.5). Interestingly, IgE secretion is not observed in patients
(signal transducer and activator As well as IL17, TH17 cells also produce IL21, which with COPD, but in the peripheral airways of patients
of transcription 3). is important for the differentiation of these cells and with more severe disease there is a marked increase in
thus acts as a positive autoregulatory mechanism, but the number of Bcells, which are organized into lym-
Invariant natural killer T
(iNKT)cells it also inhibits FOXP3 expression and regulatory Tcell phoid follicles that are surrounded by Tcells18. The
Lymphocytes that express development61,62. Another cytokine IL22 is also released class of immunoglobulin they secrete and how they
a particular variable gene by these cells and stimulates the production of IL10 and
segment, V14 (in mice) and acute-phase proteins63. However, more work is needed
V24 (in humans), precisely IL-27 IL-12 IL-4 IL-33
rearranged to a particular J
to understand the role and regulation of TH17 cells in
(joining) gene segment to yield asthma and COPD, as they may represent important
STAT1 STAT4 STAT6
Tcell receptor -chains with an new targets for future therapies.
invariant sequence. Typically, A subset of CD4+ Tcells termed invariant natural killer T
these cells co-express cell-
(iNKT) cells, which secrete IL4 and IL13, has been shown TH1 cells T-bet GATA3 TH2 cells
surface markers that are
encoded by the natural killer to account for 60% of all CD4+ Tcells in bronchial biop-
(NK) locus, and they are sies from asthmatic patients64, but this has been disputed TH1-type cytokines TH2-type cytokines
activated by recognition of in another study that failed to show any increase in iNKT- (IL-2 and IFN) (IL-4, IL-5, IL-9 and IL-13)
CD1d, particularly when cell numbers in bronchial biopsies, bronchoalveolar lavage
galactosylceramide is bound Allergic inflammation
in the groove of CD1d.
or sputum of either asthma or COPD patients65. The role
of iNKTcells in asthma is currently uncertain as there Figure 4 | Interactions between TH1 and TH2 cells in
Type 1 cytotoxic T (TC1) and appears to be a discrepancy between the data from murine asthma. The transcription factor GATA3 (GATA-binding
Nature Reviews
protein 3) is regulated by interleukin4 | Immunology
(IL4) via STAT6
TC2 cells models of asthma and humans with the disease33.
A designation that is used to
CD8+ Tcells predominate over CD4+ Tcells in the (signal transducer and activator of transcription 6) and
describe subsets of CD8+ regulates the expression of IL4, IL5, IL9 and IL13 from
cytotoxic Tcells. TC1 cells airways and lung parenchyma of patients with COPD66,
Thelper 2 (TH2) cells and also inhibits the expression of
typically secrete interferon but their role in disease pathogenesis is not yet certain. Tbet via inhibition of STAT4. IL33 enhances the actions of
and granulocyte/macrophage Type1 cytotoxic T (TC1) cells, which secrete IFN, predomi- GATA3. Tbet regulates T helper 1 (TH1)-cell secretion of IL2
colony-stimulating factor, and nate and express CXCR3, suggesting that they are attracted
have strong cytotoxic capacity,
and interferon (IFN) and also has an inhibitory action on
whereas TC2 cells secrete
to the lungs by CXCR3-binding chemokines47,49. These GATA3. Tbet is regulated by IL12 via STAT4 and by IL27
interleukin4 (IL4) and IL10 CXCR3 ligands suppress signalling through CCR3, the via STAT1. This demonstrates the complex interplay of
and are less effective killers. receptor for CCL11, suggesting that they might suppress cytokines and transcription factors in asthma.
IL-6
IL-23
TGF
of myeloid DCs and the recruitment of TH2 cells to the
airways by inducing the release of CCL17 (also known as
?
TARC) and CCL22 (also known as MDC), which bind to
CCR4 that is selectively expressed by TH2 cells80.
ROR t Cigarette smoking is associated with an expansion
TH17 cell IL-21
STAT3 of the DC population and with a marked increase in
the number of mature DCs in the airways and alveolar
TNF walls of people who smoke81. However, the role of DCs
in COPD is currently unclear as there are no obvious
IL-22
IL-17 and antigenic stimulants, apart from glycoprotein, which
IL-6 IL-17F is isolated from tobacco and known to have a powerful
immunostimulatory effect82. However, a recent electron
CD8+ T cell
microscopy study has demonstrated a decrease in DCs
CXCL1 and IL-10 in the airways of patients with COPD who smoke com-
CXCL8 Epithelial cells Acute-phase pared to smokers without airway obstruction, suggesting
Neutrophils proteins that they do not have a key role in COPD83.
Figure 5 | TH17 cells and airway inflammation. T helper17
(TH17) cells are a newly described subset of CD4+ Tcells Similarities between asthma and COPD
that may have a role in chronic obstructive pulmonary
Nature Reviews | Immunology Although the inflammatory and immune mechanisms of
disease (COPD) and severe asthma. These cells release asthma and COPD described above are markedly differ-
interleukin17 (IL17) and IL17F, which act on airway ent, there are several situations where they become more
epithelial cells to release CXC-chemokine ligand 1 (CXCL1) similar and the distinction between asthma and COPD
and CXCL8, which attract neutrophils, and IL6, which
becomes blurred (TABLE1).
enhances the activation of TH17 cells. TH17 cells also release
IL21, which promotes TH17-cell differentiation via a
positive autoregulatory loop involving the transcription Severe asthma. Although only about 5% of the asthmatic
factor STAT3 (signal transducer and activator of population develop severe disease, such cases account for
transcription 3) and IL22, which induces the release of more than half of the healthcare spending in asthma and
IL10 and acute-phase proteins. The regulation of TH17 cells they are poorly controlled by currently available thera-
is predominantly via IL23 through the activation of the pies84. The inflammatory pattern that occurs in cases of
transcription factor retinoic-acid-receptor-related orphan severe asthma, contrary to mild asthma, is more similar
receptor-t (RORt), whereas transforming growth factor to that which occurs in COPD, with increased numbers
(TGF) may have an inhibitory effect in human cells. of neutrophils in the sputum and increased amounts of
TNF, tumour-necrosis factor.
CXCL8 and tumour-necrosis factor85, increased oxidative
stress and a poor response to corticosteroids as is observed
are regulated is currently unknown, but they might be in patients with COPD (TABLE1). Moreover, whereas in
activated by bacterial or viral antigens as a consequence mild asthma TH2 cells predominate, in more severe
of the chronic bacterial colonization or latent viral infec- asthmatic disease there is a mixture of TH1 and TH2
tion in the airways of these patients. Alternatively, it has cells present in bronchial biopsies, as well as more CD8+
been suggested that COPD might have an autoimmune Tcells and this more closely resembles the immune-cell
component characterized by the development of new infiltration seen in COPD51,69,70. The neutrophilic inflam-
Immunoglobulin class
switching
antigenic epitopes as a result of the tissue damage induced mation seen in cases of severe asthma may be induced by
The somatic-recombination by cigarette smoking, oxidative stress or chronic bacte- IL17 production by TH17 cells, which induces the release
process by which the class of rial infection21,74. CD4+ Tcells isolated from the lungs of of the neutrophilic chemokine CXCL8 from airway epi-
immunoglobulin expressed by patients with severe emphysema are oligoclonal, which is thelial cells59,60. A neutrophilic pattern of inflammation,
activated Bcells is switched
consistent with antigenic stimulation by infective organ- with high levels of CXCL8, is also found in the sputum
from IgM to IgG, IgA or IgE.
isms or autoimmunity75. Indeed, in a mouse model of of asthmatic individuals who smoke86. Similar to patients
Corticosteroids emphysema induced by tobacco smoke, an autoimmune with severe disease or COPD, these individuals also have
Anti-inflammatory drugs that mechanism has been proposed with a role for antibodies a poor response to corticosteroids, even if given orally at
are derived from cortisol specific for neutrophil elastase76. high doses.
secreted by the adrenal cortex
and that are effective in
suppressing inflammation Dendritic cells. Dendritic cells (DCs) have an impor- Reversible COPD.Approximately 10% of patients with
in asthma but not in chronic tant role in asthma as regulators of T H2 cells and in COPD have a reversibility of bronchoconstriction, show-
obstructive pulmonary disease. the presentation of processed peptides from inhaled ing greater than 12% improvement in lung function as
allergens to TH2 cells77. They are not only involved in assessed by forced expiratory volume in 1 second (FEV1),
FEV1
(Forced expiratory volume in the initial sensitization to allergens, but also in driving and therefore behave more like asthmatics. Furthermore,
1 second). The amount of air the chronic inflammatory response in the lungs, and compared with most patients with COPD, these patients
that can be forcibly exhaled in therefore provide a link between allergen exposure and more frequently have eosinophils in their sputum, an
1 second, measured in litres. allergic inflammation in asthma. The cytokine thymic increase in exhaled nitric oxide and respond better to
It is used as a measurement of
airway obstruction in asthma
stromal lymphopoietin (TSLP), which is secreted in large corticosteroid treatment, all of which are characteristic
and chronic obstructive amounts by epithelial cells and mast cells of asthmatic features of asthma87,88. It therefore seems likely that these
pulmonary disease. patients78,79, might have a critical role in the maturation patients have concomitant asthma and COPD.
Given the role of Bcells in both asthma and COPD, this could be achieved by blocking STAT4 activity, but
non-selective Bcell inhibitors, such as the CD20- no such drugs have so far been developed.
specific monoclonal antibody rituximab (Rituxan; Given that chemokines are crucial mediators in
Genentech, Inc. and Biogen Idec) might be beneficial, the recruitment of inflammatory cells to the lungs of
as it is in rheumatoid arthritis and other autoimmune patients with asthma and COPD, antagonism of spe-
diseases103. However, there are concerns about the safety cific chemokine receptors would be a logical approach
of using rituximab, particularly in COPD patients who for treating these diseases108,109. In asthma, chemokine
are susceptible to recurrent bacterial infections, as the receptors on eosinophils (CCR3) and TH2 cells (CCR4,
airways of patients with more severe disease are often CCR8 and CXCR4) are the main targets, whereas in
colonized by bacteria. COPD, receptors on neutrophils (CXCR2), monocytes
(CXCR2 and CCR2), TH1 cells (CXCR3) and TC1 cells
Other novel therapeutic approaches. Several novel (CXCR3) are the major foci of drug development. Small
therapeutic approaches are currently in development molecule inhibitors for all of these receptors are now
for treating inflammation in asthma and COPD104,105, in development.
for example, one type of therapy involves targeting spe-
cific transcription factors that are known to be active in Conclusions and future perspectives
these diseases106. In both airway diseases, NFB acti- Although both COPD and asthma involve chronic
vation appears to be important for activating multiple inflammation of the respiratory tract, the pattern of
but different inflammatory genes, so inhibition of this inflammation is markedly different between these two
transcription factor using small molecule inhibitors of diseases. Mild asthma is characterized by eosinophilic
IKK2 (inhibitor of NFB kinase 2) would be a logical inflammation driven by TH2 cells and DCs, and is asso-
approach. For the treatment of asthma, inhibition of ciated with mast-cell sensitization by IgE, and by the
GATA3 function and therefore TH2-type cytokine pro- release of multiple bronchoconstrictors. By contrast,
duction may be a more specific approach and this might COPD is characterized by neutrophilic inflammation
be possible using inhibitors of the GATA3-activating that can be driven by a marked increase in the number
kinase p38 MAPK39. Indeed, downregulation of p38 of lung-resident macrophages, which also attract CD4+
MAPK expression using an antisense oligonucleotide and CD8+ Tcells to the lungs. This lymphocytic infil-
has proved to be effective in inhibiting TH2-type cytokine tration can also be driven by chronic stimulation by
production in a mouse model of asthma107. For the treat- viral and bacterial antigens or by autoantigens released
ment of COPD, inhibition of the TH1-cell-inducing tran- following lung injury. Mast cells and DCs, which have
scription factor Tbet would be more appropriate and such a key role in asthma, have little or no known
involvement in COPD. However, these distinctions New therapeutic approaches may also stem from a
between asthma and COPD may not be as clear as greater understanding and appreciation of the similarities
previously believed, as in patients with severe asthma between asthma and COPD. Although there are highly
and in asthmatic individuals who smoke there is a effective treatments for mild asthma, severe asthma and
neutrophilic pattern of inflammation, and acute exac- asthma in people who smoke are poorly treated with cur-
erbations of asthma and of COPD have similar inflam- rent therapies and because of the similarities with COPD,
matory features. The role of TH17 cells in severe asthma it is likely that new anti-inflammatory treatments that
and COPD as a driving mechanism of neutrophilic are effective in COPD may also be effective in refractory
inflammation is not yet fully understood and deserves asthma. Whether therapies based on the immune mecha-
more research; understanding these mechanisms may nisms will be safe and effective in treating airway diseases
lead to new therapeutic approaches. also deserves further research.
1. Barnes, P.J. Chronic obstructive pulmonary disease: 19. Caramori, G. etal. Mucin expression in peripheral 34. Kay, A.B. The role of T lymphocytes in asthma.
a growing but neglected epidemic. PLoS Med. 4, e112 airways of patients with chronic obstructive pulmonary Chem. Immunol. Allergy. 91, 5975 (2006).
(2007). disease. Histopathology 45, 477484 (2004). 35. Ho, I.C. & Pai, S.Y. GATA3 not just for Th2 cells
2. Mannino, D.M. & Buist, A.S. Global burden of 20. Majo, J., Ghezzo, H. & Cosio, M.G. Lymphocyte anymore. Cell Mol. Immunol. 4, 1529 (2007).
COPD: risk factors, prevalence, and future trends. population and apoptosis in the lungs of smokers and 36. Barnes, P.J. Role of GATA3 in allergic diseases.
Lancet 370, 765773 (2007). their relation to emphysema. Eur. Respir. J. 17, Curr. Mol. Med. (in the press) (2008).
A comprehensive recent review of the various risk 946953 (2001). 37. Caramori, G. etal. Expression of GATA family of
factors involved in COPD and the current global A demonstration of increased numbers of CD8+ transcription factors in Tcells, monocytes and bronchial
prevalence of the disease. Tcells in the lung parenchyma of patients with biopsies. Eur. Respir. J. 18, 466473 (2001).
3. Pearce, N. etal. Worldwide trends in the prevalence of COPD and their relationship to apoptosis of typeI 38. Nakamura, Y. etal. Gene expression of the GATA3
asthma symptoms: phaseIII of the International Study pneumocytes. transcription factor is increased in atopic asthma.
of Asthma and Allergies in Childhood (ISAAC). Thorax 21. Taraseviciene-Stewart, L. etal. Is alveolar destruction J. Allergy Clin. Immunol. 103, 215222 (1999).
62, 758766 (2007). and emphysema in chronic obstructive pulmonary 39. Maneechotesuwan, K. etal. Regulation of Th2 cytokine
This paper provides the most recent data showing disease an immune disease? Proc. Am. Thorac. Soc. genes by p38 MAPK-mediated phosphorylation of
the worldwide prevalence of asthma. 3, 687690 (2006). GATA3..J. Immunol. 178, 24912498 (2007).
4. Kraft, M. Asthma and chronic obstructive pulmonary 22. Ohnishi, K., Takagi, M., Kurokawa, Y., Satomi, S. & This study shows that in human Tcells GATA3
disease exhibit common origins in any country! Konttinen, Y.T. Matrix metalloproteinase-mediated translocates to the nucleus after phosphorylation
Am. J. Respir. Crit. Care Med. 174, 238240 extracellular matrix protein degradation in human by p38 MAPK, which is activated by TCR and co-
(2006). pulmonary emphysema. Lab. Invest. 78, 10771087 receptor activation.
5. Barnes, P.J. Against the Dutch hypothesis: asthma (1998). 40. Finotto, S. etal. Development of spontaneous airway
and chronic obstructive pulmonary disease are 23. Tuder, R.M., Yoshida, T., Arap, W., Pasqualini, R. & changes consistent with human asthma in mice
distinct diseases. Am. J. Respir. Crit. Care. Med. 174, Petrache, I. State of the art. Cellular and molecular lacking Tbet. Science 295, 336338 (2002).
240243 (2006). mechanisms of alveolar destruction in emphysema: This paper shows that the lack of Tbet results in
6. Barnes, P.J. Mechanisms in COPD: differences from an evolutionary perspective. Proc. Am. Thorac. Soc. 3, eosinophilic inflammation in mouse lungs and a
asthma. Chest 117, 10S14S (2000). 503510 (2006). reduction in Tcells expressing Tbet in the airways
7. Jeffery, P.K. Comparison of the structural and 24. Reber, L., Da Silva, C.A. & Frossard, N. Stem cell of asthmatic patients.
inflammatory features of COPD and asthma. Chest factor and its receptor cKit as targets for 41. Hwang, E.S., Szabo, S.J., Schwartzberg, P.L. &
117, 251S260S (2000). inflammatory diseases. Eur. J. Pharmacol. 533, Glimcher, L.H. T helper cell fate specified by kinase-
8. Wenzel, S.E. Asthma: defining of the persistent adult 327340 (2006). mediated interaction of Tbet with GATA3. Science
phenotypes. Lancet 368, 804813 (2006). 25. Galli, S.J. etal. Mast cells as tunable effector and 307, 430433 (2005).
This paper provides a discussion of the different immunoregulatory cells: recent advances. Annu. Rev. 42. Yoshimoto, T., Yoshimoto, T., Yasuda, K., Mizuguchi, J.
phenotypes of asthma that are discussed in this Immunol. 23, 749786 (2005). & Nakanishi, K. IL27 suppresses Th2 cell
Review. 26. Brightling, C.E. etal. Mast-cell infiltration of airway development and Th2 cytokines production from
9. Phelan, P.D., Robertson, C.F. & Olinsky, A. The smooth muscle in asthma. N. Engl. J. Med. 346, polarized Th2 cells: a novel therapeutic way for
Melbourne Asthma Study: 19641999. J. Allergy 16991705 (2002). Th2-mediated allergic inflammation. J. Immunol. 179,
Clin. Immunol. 109, 189194 (2002). This paper shows that mast-cell numbers are 44154423 (2007).
10. Barnes, P.J., Chung, K.F. & Page, C.P. Inflammatory present in the airway smooth muscle of asthmatic 43. Usui, T. etal. Tbet regulates Th1 responses through
mediators of asthma: an update. Pharmacol. Rev. 50, patients, whereas this is not seen in non-asthmatic essential effects on GATA3 function rather than on
515596 (1998). subjects or patients with eosinophilic bronchitis IFNG gene acetylation and transcription. J. Exp. Med.
11. Barnes, P.J. Mediators of chronic obstructive who do not have asthma. 203, 755766 (2006).
pulmonary disease. Pharm. Rev. 56, 515548 (2004). 27. Leckie, M.J. etal. Effects of an interleukin5 blocking 44. Avni, O. etal. TH cell differentiation is accompanied by
12. Hart, L.A., Krishnan, V.L., Adcock, I.M., Barnes, P.J. monoclonal antibody on eosinophils, airway dynamic changes in histone acetylation of cytokine
& Chung, K.F. Activation and localization of hyperresponsiveness and the late asthmatic response. genes. Nature Immunol. 3, 643651 (2002).
transcription factor, nuclear factor-B, in asthma. Lancet 356, 21442148 (2000). 45. Carriere, V. etal. IL33, the IL1like cytokine ligand
Am. J. Respir. Crit. Care Med. 158, 15851592 This study reports a surprising finding that for ST2 receptor, is a chromatin-associated nuclear
(1998). blocking IL5 in asthmatic patients does not reduce factor invivo. Proc. Natl Acad. Sci. USA 104,
13. Caramori, G. etal. Nuclear localisation of p65 in the response to allergen or airway hyper- 282287 (2007).
sputum macrophages but not in sputum neutrophils responsiveness despite a profound reduction in 46. Komai-Koma, M. etal. IL33 is a chemoattractant for
during COPD exacerbations. Thorax 58, 348351 circulating and sputum eosinophils. human Th2 cells. Eur. J. Immunol. 37, 27792786
(2003). 28. Flood-Page, P. etal. A study to evaluate safety and (2007).
14. Benayoun, L., Druilhe, A., Dombret, M.C., Aubier, M. efficacy of mepolizumab in patients with moderate 47. Grumelli, S. etal. An immune basis for lung
& Pretolani, M. Airway structural alterations persistent asthma. Am. J. Respir. Crit. Care Med. parenchymal destruction in chronic obstructive
selectively associated with severe asthma. Am. J. 176, 10621071 (2007). pulmonary disease and emphysema. PLoS Med. 1,
Respir. Crit. Care Med. 167, 13601368 (2003). 29. Green, R.H. etal. Analysis of induced sputum in 7583 (2004).
This study quantifies the changes in airway smooth adults with asthma: identification of subgroup with This study shows that the numbers of TH1 and TC1
muscle that occur in asthmatic patients. isolated sputum neutrophilia and poor response to cells, both of which express CXCR3, are increased
15. Siddiqui, S. etal. Vascular remodeling is a feature of inhaled corticosteroids. Thorax 57, 875879 in the lung parenchyma of patients with COPD.
asthma and nonasthmatic eosinophilic bronchitis. (2002). 48. Saetta, M. etal. Increased expression of the
J. Allergy Clin. Immunol. 120, 813819 (2007). 30. Keatings, V.M., Collins, P.D., Scott, D.M. & chemokine receptor CXCR3 and its ligand CXCL10 in
16. Ordonez, C.L. etal. Mild and moderate asthma is Barnes, P.J. Differences in interleukin8 and tumor peripheral airways of smokers with chronic obstructive
associated with airway goblet cell hyperplasia and necrosis factor in induced sputum from patients with pulmonary disease. Am. J. Respir. Crit. Care Med.
abnormalities in mucin gene expression. Am. J. chronic obstructive pulmonary disease or asthma. 165, 14041409 (2002).
Respir. Crit. Care Med. 163, 517523 (2001). Am. J. Respir. Crit. Care Med. 153, 530534 (1996). 49. Costa, C. etal. CXCR3 and CCR5 chemokines in the
17. Hogg, J.C. Pathophysiology of airflow limitation in 31. Traves, S.L., Smith, S.J., Barnes, P.J. & Donnelly, L.E. induced sputum from patients with COPD. Chest 133,
chronic obstructive pulmonary disease. Lancet 364, Specific CXC but not CC chemokines cause elevated 2633 (2008).
709721 (2004). monocyte migration in COPD: a role for CXCR2. 50. Barczyk, A. etal. Cytokine production by
18. Hogg, J.C. etal. The nature of small-airway J. Leukoc. Biol. 76, 441450 (2004). bronchoalveolar lavage T lymphocytes in chronic
obstruction in chronic obstructive pulmonary disease. 32. Barnes, P.J. Macrophages as orchestrators of COPD. obstructive pulmonary disease. J. Allergy Clin.
N. Engl. J. Med. 350, 26452653 (2004). COPD 1, 5970 (2004). Immunol. 117, 14841492 (2006).
An important study quantifying the inflammation in 33. Meyer, E.H., DeKruyff, R.H. & Umetsu, D.T. 51. Kurashima, K. etal. Asthma severity is associated
small airways in patients with differing severity of T cells and NKTcells in the pathogenesis of asthma. with an increase in both blood CXCR3+ and CCR4+
COPD. Annu. Rev. Med. 59, 281292 (2008). Tcells. Respirology 11, 152157 (2006).
52. Larche, M. Regulatory Tcells in allergy and asthma. 77. Hammad, H. & Lambrecht, B.N. Recent progress 99. Finegold, I. Allergen immunotherapy: present and
Chest 132, 10071014 (2007). in the biology of airway dendritic cells and implications future. Allergy Asthma Proc. 28, 4449 (2007).
53. Ling, E.M. etal. Relation of CD4+CD25+ regulatory for understanding the regulation of asthmatic 100. Alexander, A., Barnes, N.C. & Kay, A.B. CyclosporinA
Tcell suppression of allergen-driven Tcell activation inflammation. J. Allergy Clin. Immunol. 118, 331336 in chronic severe asthma: a double-blind placebo-
to atopic status and expression of allergic disease. (2006). controlled trial. Am. Rev. Respir. Dis. 143, A633
Lancet 363, 608615 (2004). 78. Ying, S. etal. Thymic stromal lymphopoietin (1991).
54. Lee, J.H. etal. The levels of CD4+CD25+ regulatory expression is increased in asthmatic airways and 101. Evans, D.J., Cullinan, P. & Geddes, D.M. Cyclosporin
Tcells in paediatric patients with allergic rhinitis and correlates with expression of Th2-attracting as an oral corticosteroid sparing agent in stable
bronchial asthma. Clin. Exp. Immunol. 148, 5363 chemokines and disease severity. J. Immunol. 174, asthma. Cochrane Database Syst. Rev. 2, CD002993
(2007). 81838190 (2005). (2001).
55. Smyth, L.J., Starkey, C., Vestbo, J. & Singh, D. 79. Allakhverdi, Z. etal. Thymic stromal lymphopoietin 102. Tamaoki, J. etal. Effect of suplatast tosilate, a Th2
CD4-regulatory cells in COPD patients. Chest 132, is released by human epithelial cells in response to cytokine inhibitor, on steroid-dependent asthma: a
156163 (2007). microbes, trauma, or inflammation and potently double-blind randomised study. Lancet 356,
56. Wan, Y.Y. & Flavell, R.A. Regulatory Tcells, activates mast cells. J. Exp. Med. 204, 253258 273278 (2000).
transforming growth factor-, and immune (2007). 103. Edwards, J.C. & Cambridge, G. Bcell targeting in
suppression. Proc. Am. Thorac. Soc. 4, 271276 This study highlights an important role for TSLP rheumatoid arthritis and other autoimmune diseases.
(2007). released from airway epithelial cells in the Nature Rev. Immunol. 6, 394403 (2006).
57. Stockinger, B. & Veldhoen, M. Differentiation and activation of mast cells, providing a link between 104. Barnes, P.J. New therapies for asthma. Trends Mol.
function of Th17 Tcells. Curr. Opin. Immunol. 19, environmental factors and mast-cell activation in Med. 12, 515520 (2006).
281286 (2007). asthma. 105. Barnes, P.J. & Hansel, T.T. Prospects for new drugs
58. Weaver, C.T., Harrington, L.E., Mangan, P.R., 80. Liu, Y.J. Thymic stromal lymphopoietin: master switch for chronic obstructive pulmonary disease. Lancet
Gavrieli, M. & Murphy, K.M. Th17: an effector CD4 for allergic inflammation. J. Exp. Med. 203, 269273 364, 985996 (2004).
Tcell lineage with regulatory Tcell ties. Immunity 24, (2006). 106. Barnes, P.J. Transcription factors in airway diseases.
677688 (2006). 81. Soler, P., Moreau, A., Basset, F. & Hance, A.J. Lab. Invest. 86, 867872 (2006).
59. Bullens, D.M. etal. IL17 mRNA in sputum of Cigarette smoking-induced changes in the number 107. Duan, W. etal. Inhaled p38 mitogen-activated
asthmatic patients: linking Tcell driven inflammation and differentiated state of pulmonary dendritic cells/ protein kinase antisense oligonucleotide attenuates
and granulocytic influx? Respir. Res. 7, 135 (2006). Langerhans cells. Am. Rev. Respir. Dis. 139, asthma in mice. Am. J. Respir. Crit. Care Med. 171,
60. Laan, M., Lotvall, J., Chung, K.F. & Linden, A. 11121117 (1989). 571578 (2005).
IL17induced cytokine release in human bronchial 82. Francus, T., Klein, R.F., Staiano-Coico, L., Becker, C.G. 108. Smit, J.J. & Lukacs, N.W. A closer look at
epithelial cells invitro: role of mitogen-activated & Siskind, G.W. Effects of tobacco glycoprotein (TGP) chemokines and their role in asthmatic responses.
protein (MAP) kinases. Br. J. Pharmacol. 133, on the immune system. II. TGP stimulates the Eur. J. Pharmacol. 533, 277288 (2006).
200206 (2001). proliferation of human Tcells and the differentiation 109. Donnelly, L.E. & Barnes, P.J. Chemokine receptors as
61. Nurieva, R. etal. Essential autocrine regulation by of human Bcells into Ig secreting cells. J. Immunol. therapeutic targets in chronic obstructive pulmonary
IL21 in the generation of inflammatory Tcells. Nature 140, 18231829 (1988). disease. Trends Pharmacol. Sci. 27, 546553
448, 480483 (2007). 83. Rogers, A.V., Adelroth, E., Hattotuwa, K., Dewar, A. & (2006).
62. Spolski, R. & Leonard, W.J. Interleukin21: basic Jeffery, P.K. Bronchial mucosal dendritic cells in 110. Saetta, M. etal. Airway eosinophilia and expression of
biology and implications for cancer and autoimmunity. smokers and ex-smokers with COPD: an electron interleukin5 protein in asthma and in exacerbations
Annu. Rev. Immunol. 8 November 2007 (doi:10.1146/ microscopic study. Thorax 63,108114 (2008). of chronic bronchitis. Clin. Exp. Allergy 26, 766774
annurev.immunol.26.021607.090316). 84. Wenzel, S.E. & Busse, W.W. Severe asthma: lessons (1996).
63. Wolk, K. & Sabat, R. Interleukin22: a novel T and from the Severe Asthma Research Program. J. Allergy. 111. Zhu, J. etal. Exacerbations of bronchitis: bronchial
NKcell derived cytokine that regulates the biology Clin. Immunol. 119, 1421 (2007). eosinophilia and gene expression for interleukin4,
of tissue cells. Cytokine Growth Factor Rev. 17, 85. Jatakanon, A. etal. Neutrophilic inflammation in interleukin5, and eosinophil chemoattractants.
367380 (2006). severe persistent asthma. Am. J. Respir. Crit. Care Am. J. Respir. Crit. Care Med. 164, 109116 (2001).
64. Akbari, O. etal. CD4+ invariant Tcellreceptor+ Med. 160, 15321539 (1999). 112. Gamble, E. etal. Airway mucosal inflammation in
natural killer Tcells in bronchial asthma. N. Engl. 86. Thomson, N.C., Chaudhuri, R. & Livingston, E. COPD is similar in smokers and ex-smokers: a pooled
J. Med. 354, 11171129 (2006). Asthma and cigarette smoking. Eur. Respir. J. 24, analysis. Eur. Respir. J. 30, 467471 (2007).
65. Vijayanand, P. etal. Invariant natural killer Tcells in 822833 (2004). 113. Retamales, I. etal. Amplification of inflammation in
asthma and chronic obstructive pulmonary disease. 87. Papi, A. etal. Partial reversibility of airflow limitation emphysema and its association with latent adenoviral
N. Engl. J. Med. 356, 14101422 (2007). and increased exhaled NO and sputum eosinophilia in infection. Am. J. Respir. Crit. Care Med. 164,
A careful study showing that there is no increase chronic obstructive pulmonary disease. Am. J. Respir. 469473 (2001).
in iNKTcells in asthma or COPD in contrast to Crit. Care Med. 162, 17731777 (2000). 114. Humbert, M. etal. The immunopathology of extrinsic
reference 64. 88. Brightling, C.E. etal. Sputum eosinophilia and the (atopic) and intrinsic (non-atopic) asthma: more
66. Saetta, M. etal. CD8+ Tlymphocytes in peripheral short term response to inhaled mometasone in similarities than differences. Immunol. Today 20,
airways of smokers with chronic obstructive chronic obstructive pulmonary disease. Thorax 60, 528533 (1999).
pulmonary disease. Am. J. Respir. Crit. Care Med. 193198 (2005). 115. Jahnsen, F.L. etal. Rapid dendritic cell recruitment to
157, 822826 (1998). 89. Wark, P.A. & Gibson, P.G. Asthma exacerbations. 3: the bronchial mucosa of patients with atopic asthma
67. Xanthou, G., Duchesnes, C.E., Williams, T.J. & pathogenesis. Thorax 61, 909915 (2006). in response to local allergen challenge. Thorax 56,
Pease, J.E. CCR3 functional responses are regulated 90. Celli, B.R. & Barnes, P.J. Exacerbations of chronic 823826 (2001).
by both CXCR3 and its ligands CXCL9, CXCL10 and obstructive pulmonary disease. Eur. Respir. J. 29, 116. Lukacs, N.W., Hogaboam, C.M. & Kunkel, S.L.
CXCL11. Eur. J. Immunol. 33, 22412250 (2003). 12241238 (2007). Chemokines and their receptors in chronic pulmonary
68. Chrysofakis, G. etal. Perforin expression and cytotoxic 91. Papi, A., Luppi, F., Franco, F. & Fabbri, L.M. disease. Curr. Drug Targets Inflamm. Allergy 4,
activity of sputum CD8+ lymphocytes in patients with Pathophysiology of exacerbations of chronic 313317 (2005).
COPD. Chest 125, 7176 (2004). obstructive pulmonary disease. Proc. Am. Thorac. Soc. 117. Chung, K.F. & Barnes, P.J. Cytokines in asthma.
69. van Rensen, E.L. etal. Bronchial CD8 cell infiltrate 3, 245251 (2006). Thorax 54, 825857 (1999).
and lung function decline in asthma. Am. J. Respir. 92. Barnes, P.J. How corticosteroids control inflammation. 118. Chung, K.F. Cytokines in chronic obstructive pulmonary
Crit. Care Med. 172, 837841 (2005). Br. J. Pharmacol. 148, 245254 (2006). disease. Eur. Respir. J. 34, 50S59S (2001).
70. Cho, S.H., Stanciu, L.A., Holgate, S.T. & Johnston, S.L. A review of the molecular mechanisms involved in 119. Montuschi, P. etal. Increased 8Isoprostane, a marker
Increased interleukin4, interleukin5, and interferon- in the anti-inflammatory actions of corticosteroids of oxidative stress, in exhaled condensates of
airway CD4+ and CD8+ Tcells in atopic asthma. and a discussion of the mechanisms of asthmatic patients. Am. J. Respir. Crit. Care Med.
Am. J. Respir. Crit. Care Med. 171, 224230 (2005). corticosteroid resistance in airway diseases. 160, 216220 (1999).
71. Gould, H.J., Beavil, R.L. & Vercelli, D. IgE isotype 93. Ito, K. etal. Decreased histone deacetylase activity 120. Paredi, P., Kharitonov, S.A. & Barnes, P.J. Elevation
determination: epsilon-germline gene transcription, in chronic obstructive pulmonary disease. N. Engl. of exhaled ethane concentration in asthma. Am. J.
DNA recombination and Bcell differentiation. J. Med. 352, 19671976 (2005). Respir. Crit. Care Med. 162, 14501454 (2000).
Br. Med. Bull. 56, 908924 (2000). This paper shows that HDAC2 activity and 121. Montuschi, P. etal. Exhaled 8isoprostane as an
72. Avila, P.C. Does anti-IgE therapy help in asthma? expression are reduced in peripheral lungs, airways invivo biomarker of lung oxidative stress in patients
Efficacy and controversies. Annu. Rev. Med. 58, and alveolar macrophages of COPD patients, and with COPD and healthy smokers. Am. J. Respir. Crit.
185203 (2007). that this is associated with an increase in Care Med. 162, 11751177 (2000).
73. Takhar, P. etal. Class switch recombination to IgE in inflammatory gene expression. 122. Rahman, I., Biswas, S.K. & Kode, A. Oxidant and
the bronchial mucosa of atopic and nonatopic patients 94. Barnes, P.J. Reduced histone deacetylase in COPD: antioxidant balance in the airways and airway
with asthma. J. Allergy Clin. Immunol. 119, 213218 clinical implications. Chest 129, 151155 (2006). diseases. Eur. J. Pharmacol. 533, 222239 (2006).
(2007). 95. Barnes, P.J., Ito, K. & Adcock, I.M. A mechanism of
An important study demonstrating that IgE is corticosteroid resistance in COPD: inactivation of
produced locally in the airways of patients with histone deacetylase. Lancet 363, 731733 (2004). DATABASES
non-atopic (intrinsic) asthma. 96. Cosio, B.G. etal. Histone acetylase and deacetylase Entrez Gene: http://www.ncbi.nlm.nih.gov/entrez/query.
74. Agusti, A., Macnee, W., Donaldson, K. & Cosio, M. activity in alveolar macrophages and blood monocytes fcgi?db=gene
Hypothesis: does COPD have an autoimmune in asthma. Am. J. Respir. Crit. Care Med. 170, CCR2 | CCR3 | CCR4 | CXCR2 | CXCR3 | CXCR4 | GATA3 |
component? Thorax 58, 832834 (2003). 141147 (2004). IFN| IL4 | IL5 | IL-6 | IL-9 | IL13 | IL17 | IL33 | p38 | TSLP
75. Sullivan, A.K. etal. Oligoclonal CD4+ Tcells in the 97. Hew, M. etal. Relative corticosteroid insensitivity of
lungs of patients with severe emphysema. Am. J. peripheral blood mononuclear cells in severe asthma. FURTHER INFORMATION
Respir. Crit. Care Med. 172, 590596 (2005). Am. J. Respir. Crit. Care Med. 174, 134141 (2006). Peter Barness homepage: http://www1.imperial.ac.uk/
76. Lee, S.H. etal. Antielastin autoimmunity in tobacco 98. Barnes, P.J. Theophylline: new perspectives on an old medicine/people/p.j.barnes.html
smoking-induced emphysema. Nature Med. 13, drug. Am. J. Respir. Crit. Care Med. 167, 813818 All links are active in the online pdf
567569 (2007). (2003).