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The Effects of Inhaled Fluticasone on Airway Inflammation in Chronic Obstructive Pulmonary Disease

A Double-Blind, Placebo-controlled Biopsy Study

Lung Pathology Unit, Imperial College School of Medicine at the Royal Brompton Hospital; and London Chest Hospital, London, United Kingdom

Correspondence and requests for reprints should be addressed to Dr. Neil C. Barnes, Department of Thoracic Medicine, London Chest Hospital, Bonner Road, London E2 9JX, UK. E-mail: neil.barnes{at}bartsandthelondon.nhs.uk

	ABSTRACT

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Inhaled corticosteroids (ICS) are effective in the treatment of asthma and markedly reduce the numbers of inflammatory cells in bronchial biopsies. However, the effect of ICS on the inflammatory profile of biopsies in smokers with chronic obstructive pulmonary disease (COPD) is unknown. We have performed a double-blind, placebo-controlled, randomized study to compare fluticasone propionate (FP) 500 µg twice daily via a dry powder inhaler and placebo (P) over a 3-month period in subjects with COPD. Fiberoptic bronchoscopy and bronchial biopsy was carried out at baseline and after the 3 months of treatment. Thirty-one subjects completed the trial and 30 paired biopsies were available for analysis. Compared with P (n = 14), subjects on inhaled FP (n = 16) had no significant reductions in the primary endpoints: CD8+, CD68+ cells, or neutrophils, considered to be of importance in COPD. However, there was a reduction in the CD8:CD4 ratio in the epithelium and of the numbers of subepithelial mast cells in the FP group. CD4+ cells were significantly raised in the P group in both subepithelium and epithelium. Symptoms significantly improved, and there were significantly fewer exacerbations in subjects on FP, compared to subjects on P. The data indicate that inhaled fluticasone does affect selected aspects of airway inflammation in COPD, and this may explain, in part, the decrease in exacerbations seen in long-term studies with fluticasone propionate.

Key Words: COPD • fluticasone propionate • inhaled steroid • placebo • randomized • bronchial biopsy • airway inflammation

	INTRODUCTION

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Chronic obstructive pulmonary disease (COPD) is a common condition with high morbidity and mortality. It is a heterogeneous disorder, usually distinguished clinically from asthma by failure to respond to either bronchodilators or steroids. There are at least three contributing factors: (1) chronic bronchitis, defined clinically on the basis of recurrent cough productive of sputum on most days of the month for at least three months of the year during the last two years, due to mucous hyper secretion, with enlargement of tracheobronchial submucosal glands and hyperplasia of surface mucosal cells; (2) peripheral airways disease, which is difficult to detect clinically and characterized by inflammation of bronchioli, mucous metaplasia, increased luminal mucus, fibrosis, and increase of wall muscle; and (3) emphysema diagnosed pathologically by destructive enlargement of the airspaces beyond the terminal bronchiole (1–4). In addition, some patients may have a component of late-onset asthma.

The clinical efficacy of inhaled corticosteroids (ICS) in asthma as an antiinflammatory agent and their beneficial effect on bronchial epithelial histology and remodeling are well established (5–7). Studies of bronchial biopsies and bronchoalveolar lavage (BAL) in patients with asthma have demonstrated that the characteristic asthmatic inflammation of excessive activation and increased numbers of CD4+ T lymphocytes, eosinophils, and mast cells is substantially reduced by ICS. Studies have also shown improvements in airway epithelium and possibly a reduction in basement membrane thickening (8).

The clinical effects of ICS in COPD are less clear. Oral corticosteroids (OCS) improve pulmonary function in about 10% of patients (9). In those COPD patients without a clear-cut improvement in lung function there is some evidence of benefit with respect to decreased exacerbation frequency (10, 11). However, the scale of the clinical benefit of ICS in COPD is far less marked than in asthma. There are indicators that COPD is a heterogeneous group, some with asthma-like features that respond to oral steroids, and others that do not (8). The recent long-term (3-year) trials of fluticasone propionate (FP) in moderate to severe COPD show an initial improvement in the FEV₁ during the first 3 months of treatment; after this the decline in FEV₁ in the FP group did not differ significantly from the placebo group (11).

In asthma the inflammation in mild or moderate untreated asthma is predominantly of CD4+ T lymphocytes and eosinophils, with few neutrophils. We and others have shown the pattern of inflammation in COPD: the predominant cells appear to be CD8+ T lymphocytes, mononuclear cells, neutrophils, macrophages, and scanty eosinophils (12–25). Unlike asthma, there is little knowledge of the effect of inhaled steroids on the airway inflammation in COPD (26–33).

We have conducted a 3-month-long placebo-controlled trial of ICS in subjects with COPD to investigate the effects of a potent inhaled corticosteroid, FP, on bronchial inflammation and pathology. We have tried to study a group similar in severity to the ISOLDE (Inhaled Steroids in Chronic Obstructive Lung Disease in Europe) study by having similar inclusion and exclusion criteria (11). Our primary end point was to see if the inflammatory cellular profile, principally CD8+ cells and macrophages, would decrease after 3 months of treatment with inhaled fluticasone. Secondary end points were lung function, symptom scores, and exacerbation rates.

	METHODS

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Trial Design
After recruitment, subjects had a run-in period of 8 weeks to ensure they were stable before the first bronchoscopy. Fiberoptic bronchoscopy and endobronchial biopsies were performed and within 2 weeks the subjects were randomized to receive either placebo or 500 µg of fluticasone twice daily via a multidose dry powder inhaler (Accuhaler^TM; Glaxo-Wellcome, Middlesex, UK). Subjects were required to keep a diary of peak flows twice daily as well as symptom scores. At each monthly visit they underwent spirometry and assessment of symptoms. After 3 months of treatment they underwent a second biopsy. These subjects were then reviewed in clinic and followed up for a further month to ensure no clinical deterioration occurred after stopping the inhaled treatment. After this they received 30 mg of oral prednisolone for 2 weeks as a steroid trial and lung function was measured.

Subjects
Subjects were recruited from chest clinics at the London Chest Hospital and by advertisement. Ethics approval was obtained from the East London City Health Authority (ELCHA) and subjects gave written informed consent. Eligible subjects were male or female, 40–75 years of age, current or ex-smokers with greater than 20 pack-years of smoking, nonatopic, and with an FEV₁ 25–80% of predicted which improved by less than 15% over baseline and 200 ml after 200 µg inhaled salbutamol. Subjects with severe concurrent medical problems, psychological impairment, on immunosuppresive treatment, or with a chest infection within 8 weeks were excluded. Subjects who were already on inhaled steroids had the drug withdrawn and had to be stable for at least 8 weeks before the first biopsy. All reliever medications (inhaled ß₂ agonist, anticholinergics, and theophylline) were continued as before. All subjects underwent a full physical examination, baseline pulmonary function testing (spirometry, flow volume loop, and transfer factor), full blood count, electrolytes, liver function tests, total IgE, RAST test, and skin prick tests (ALK Soluprick, Denmark) to house dust mite, mixed feathers, grass pollen, and cat and dog fur. After the first bronchoscopy, subjects were randomized to FP or P in a double-blind manner using a random number table. Subjects maintained daily peak flow charts, recorded any symptoms, and at each monthly follow up underwent spirometry, at which time exhaled carbon monoxide and symptom scores were recorded. If symptoms were felt to have improved since the subject's previous visit while on placebo or fluticasone they were scored as +1, if no change 0, and if symptoms were felt to have got worse –1. Three visits before the second bronchoscopy, i.e., 3 months treatment were assessed. At the end of the trial, symptom scores were added, the best possible score being +3 and the worst being –3.

Bronchoscopy
Subjects underwent bronchoscopy as a day case using the standards set by the American Thoracic Society (34, 35). After an overnight fast they were admitted the following morning to the day case unit and had baseline observations checked. All subjects then received 2.5 mg of nebulized salbutamol and 600 µg atropine intramuscularly as premedication. At bronchoscopy they were monitored by pulse oximetry and received oxygen at 2 L/minute as required. All subjects received lignocaine spray to the oropharynx and 2.5–5 mg midazolam given intravenously. 4% lignocaine was installed via the bronchoscope to the vocal cords and further 2% lignocaine was used in the tracheobronchial tree. Bronchial biopsies were obtained from the carinae of the second order bronchi of the right, middle, and lower lobes using a Pentax FB19 TX bronchoscope and Pentax x1718A cup forceps (Pentax, Tokyo, Japan). After bronchoscopy, subjects were observed and then discharged home with follow-up in 2 weeks.

Biopsy Processing
Four samples were immediately placed in 2% Formaldehyde and transferred to 15% sucrose in phosphate-buffered saline after 2 hours and stored at 4°C for immunohistology. After 72 hours, the sample was embedded in OCT medium, snap-frozen in isopentane precooled in liquid nitrogen, and stored at –80°C. Five-micron-thick sections were cut and stored at –80°C until stained. Microscope slides were retrieved from cold storage and stained by the alkaline phosphatase, anti-alkaline phosphatase method (APAAP) (36–38).

Snap-frozen sections were stained with monoclonal antibodies directed against the following markers: leukocytes (CD45; DAKO M0701); lymphocytes (CD3, CD4, CD8, and CD45-Ro; Nova NCLCD 3–9196–0, Nova NCLCD4, DAKO M0707, DAKO M0742); eosinophils (EG2; Pharmacia 10–9196–0); neutrophils (anti-elastase; DAKO M0752); macrophages (CD68; DAKO M0876); and mast cells (anti-tryptase; DAKO M7052).

Biopsy Counts
Epithelial integrity, subepithelial reticular collagen thickness, and inflammatory cell number were assessed by light microscopy using 5-µm-thick hematoxylin and eosin-stained sections. Epithelial integrity was measured using a calibrated Apple MAC image analysis system (Image 1.55; Improvision Ltd., Lexington, MA). The coefficient of variability (CV) of such repeat measurement has been determined at 6.5%. Areas of intact epithelium were counted using a graticule and expressed as number of cells per 100 microns². Subepithelial areas were counted using the same graticule up to 100 microns deep to the reticular basement membrane and expressed as number of cells per mm basement membrane length.

Statistical Analysis
Statistical analyses were performed by means of data processed by SPSS. Nonparametric unpaired data were analyzed by means of the Kruskall-Wallis tests. Nonparametric paired data were analyzed by means of the Wilcoxon Signed Ranks test. Values are reported as mean (± SE). A p value < 0.05 was considered to be statistically significant. Power calculation was difficult, as there were no data from a previous study. They were initially performed on an expectation of reducing GM-CSF levels by 25% on a population of 30 subjects giving a power of 80% (29). Unfortunately GM-CSF showed strong nonspecific binding signal and this made quantification impossible. Statistical guidelines were obtained as described by Bland (39) and Altman and colleagues (40).

	RESULTS

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Patient Characteristics
Thirty-seven subjects were initially enrolled into the study. Of the 37 subjects who joined the study, 31 completed the study. One patient withdrew for personal reasons (FP group) and another one was withdrawn due to a myocardial infarction for safety reasons (P group). One patient died during the study and postmortem gave the cause of death as severe emphysema and pulmonary hypertension (P group), and three withdrew due to exacerbations of COPD (all P group). A total of 10 exacerbations were experienced in the P group compared with three in the FP group; this figure was statistically significant (p = 0.02). An exacerbation was defined by criteria used by Anthonisen and coworkers (41). Three exacerbators in the P group were severe enough to require oral steroids in addition to antibiotics and were withdrawn from the study and the others were treated with antibiotics and increased bronchodilator therapy. The withdrawal rate was higher in the placebo group but not statistically significant (p = 0.09). Six of the 13 exacerbations reported were in patients who had their inhaled steroids withdrawn for recruitment into this study and this was not significantly different from those on no inhaled steroid. The three patients in the FP group continued with the study and required antibiotics and increased bronchodilator therapy. There was insufficient biopsy material to analyze in one patient's second biopsy and this subject's data was excluded from the analyses.

Subjects were well matched for age, smoking history, and lung function (Table 1).

Immunohistochemistry
Adequate tissue was obtained from 30 subjects who completed the study. Most biopsies demonstrated intact epithelium and a reticular basement membrane of normal thickness that was not altered by FP or P treatment (Table 2). In general, CD8+ cells outnumbered CD4+ cells by 2:1 at baseline (Figure 1) . For the epithelium. there was no significant change in CD3+, CD8+, CD45, CD45Ro+ cells, neutrophils, macrophages, mast cells, and eosinophils between the baseline and end of treatment in either the P or FP groups. However, there was a significant reduction of the ratio of CD8:CD4 in the epithelium in the FP group (p = 0.03) and a trend to a reduction of the CD45+ phenotype (p = 0.06). In the epithelium and subepithelium, CD4+ cells were significantly raised in the P group (p < 0.05 for both). Apart from mast cells, there were no significant alterations of any cell type in the subepithelium of either group. In comparison to P, mast cells showed a 25% decrease in number in the subepithelium after FP (p = 0.04). The within-group comparison also showed that there was a significant reduction for mast cells after FP (p = 0.003). When the two oral steroid responders were excluded from the analysis, the decrease in mast cells in the FP group was still significant statistically. A Bonferroni correction for multiple comparisons resulted in a loss of the statistically significant differences shown above, albeit the mast cell reduction in the FP-treated group was still apparent statistically (p = 0.06).

View larger version (10K): [in this window] [in a new window]   Figure 1. Cumulative baseline CD4 and CD8 counts.

	DISCUSSION

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To our knowledge, this is the first double-blinded, placebo-controlled study to investigate the effect of ICS on the immunopathology of bronchial biopsies in COPD. The study included subjects with well-defined COPD with no reversibility to bronchodilator therapy. We included subjects with COPD, from mild to severe, to assess the effect of ICS throughout the spectrum of subjects with COPD. The strength of the study is that subjects included closely matched the clinical characteristics of patients in the ISOLDE study (11). The FP and P groups were well matched, except that there were higher numbers of current smokers in the placebo group compared with the ICS group. However, our own data (unpublished) and that of Turato and coworkers (43) have shown no difference in airway pathology in COPD between continuing smokers and ex-smokers, especially in those who have symptoms of chronic bronchitis or in whom the severity of airflow obstruction is similar.

We have confirmed our previous studies and those of Saetta and coworkers (44), demonstrating that the pathology of COPD is distinct from asthma and consists of CD8+ T cells, macrophages, and neutrophils. In contrast to its antiinflammatory effects in asthma, FP did not alter the key cells of COPD, albeit there was a decrease in the epithelial CD8:CD4 ratio after FP. However, we do show a decrease in subepithelial mast cells, the effect similar to that of ICS in asthma. A decrease in mast cells of approximately 65% in the FP group has also been demonstrated in our electron microscopic study of bronchial biopsies from these patients (45).

Mast cells are important in asthma and are also found in the subepithelium in chronic bronchitis. Pesci and coworkers compared 25 subjects (10 smokers and 15 ex-smokers) with chronic bronchitis as defined by MRC criteria with 7 nonsmoking normal subjects (46). They found that subjects with chronic bronchitis had higher numbers of mast cells in the epithelium and subepithelium compared with normal subjects. The smokers had higher numbers of mast cells in the epithelium and subepithelium compared with the ex-smokers. There was a significant increase in degranulated mast cells in the bronchial glands of subjects with chronic bronchitis, which they concluded was evidence in support of the role of the mast cell in the involvement of airway hypersecretion.

It is possible that the changes in mast cells and of CD4+ cells in COPD may explain the observations in the ISOLDE study of decreased exacerbation frequency in the FP-treated group. The reduction of exacerbation frequency and severity by steroids was demonstrated in an earlier study by Paggiaro and coworkers (10).

Chanez and colleagues studied a more heterogeneous group and found that the clinical improvement in COPD correlated with the presence of asthma-like features; we have been unable to show such a distinction statistically (8). Unlike the study by Chanez and coworkers, our study did not find that increased thickness of basement membrane or an increase activated eosinophils (EG2) predicted improvement with inhaled steroid. In our study there was no significant improvement in airflow obstruction over the 3 months of the study in either group. Twenty-nine of the original 37 subjects underwent a 2-week oral prednisolone trial of 30 mg/day after the final visit. Two patients responded with an increase in FEV₁ greater than 15% of predicted using criteria established by the ATS (47). These two patients had clinical features of COPD and showed no reversibility to ß agonist at the onset of the study. The remainder either refused oral steroids or had withdrawn from the study. One patient was on the placebo arm of the study and the biopsies did not show any features suggestive of asthma. The other subject was in the steroid group and had higher CD4+ cells than CD8+ cells and a raised eosinophil count in his baseline biopsy, a feature seen in asthma biopsies. This subject reported improvement in symptoms but did not show any improvement in his postbronchodilator FEV₁ after 3 months of FP.

We hypothesize that the rise in the CD4+ cells in the epithelium and subepithelium in the P group may be due to subclinical exacerbations. It is possible that ICS prevents the rise in CD4+ cells in the bronchial mucosa, which would lead to deterioration in symptom control and exacerbations. Our study, therefore, did not reflect the findings by other workers who have shown an improvement in airflow after receiving inhaled steroids (48, 49), which were long-term as well as short-term studies.

Analysis of symptom scores showed no significant improvement in exercise tolerance, breathlessness, or wheeze in both treatment groups. This may be explained by the lack of improvement in airflow obstruction. However, cough and sputum was decreased in volume and purulence, withdrawal from study due to exacerbations, and use of rescue medication was less in the fluticasone-treated group. A total of 13 exacerbations were reported during this study. Three subjects in the fluticasone group reported exacerbations requiring antibiotics, but no steroid was given and they completed the study. There were significantly more exacerbations in the placebo group, and three subjects required oral steroids and were withdrawn from the study. Of interest is an uncontrolled observational study reported of patients during the run in to the ISOLDE study, in which symptoms worsened when ICS were withdrawn (50). Six of the 13 exacerbations reported were in subjects who had their inhaled corticosteroids withdrawn before recruitment to the study and this was not significantly different from those subjects who were not on inhaled corticosteroid before recruitment.

In summary, we have shown that 3 months of treatment with the inhaled corticosteroid fluticasone propionate has no effect on the major inflammatory cell types in COPD, although it reduces the epithelial CD8:CD4 ratio and subepithelial mast cells. We postulate that the changes seen may correlate with the decreases in exacerbations seen in the ISOLDE study. Studies of the effects of oral steroids on the pathology of COPD are now required. Drugs that specifically affect the key inflammatory cells of COPD are needed.

	Acknowledgments

 
Supported by Glaxo-Wellcome and Departmental Funds.

Received in original form May 8, 2001; accepted in final form February 15, 2002

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				S. Siddiqui, F. Hollins, S. Saha, and C. E. Brightling Inflammatory cell microlocalisation and airway dysfunction: cause and effect? Eur. Respir. J., December 1, 2007; 30(6): 1043 - 1056. [Abstract] [Full Text] [PDF]

				D. C Grootendorst, S. A Gauw, R. M Verhoosel, P. J Sterk, J. J Hospers, D. Bredenbroker, T. D Bethke, P. S Hiemstra, and K. F Rabe Reduction in sputum neutrophil and eosinophil numbers by the PDE4 inhibitor roflumilast in patients with COPD Thorax, December 1, 2007; 62(12): 1081 - 1087. [Abstract] [Full Text] [PDF]

				S. J. Tudhope, M. C. Catley, P. S. Fenwick, R. E. K. Russell, W. L. Rumsey, R. Newton, P. J. Barnes, and L. E. Donnelly The Role of I{kappa}B Kinase 2, but Not Activation of NF-{kappa}B, in the Release of CXCR3 Ligands from IFN-{gamma}-Stimulated Human Bronchial Epithelial Cells J. Immunol., November 1, 2007; 179(9): 6237 - 6245. [Abstract] [Full Text] [PDF]

				N. Barnes Reducing inflammation in COPD: the evidence builds Thorax, November 1, 2007; 62(11): 927 - 928. [Full Text] [PDF]

				J. Bourbeau, P. Christodoulopoulos, F. Maltais, Y. Yamauchi, R. Olivenstein, and Q. Hamid Effect of salmeterol/fluticasone propionate on airway inflammation in COPD: a randomised controlled trial Thorax, November 1, 2007; 62(11): 938 - 943. [Abstract] [Full Text] [PDF]

				S. Suissa, R. McGhan, D. Niewoehner, and B. Make Inhaled Corticosteroids in Chronic Obstructive Pulmonary Disease Proceedings of the ATS, October 1, 2007; 4(7): 535 - 542. [Abstract] [Full Text] [PDF]

				E. Gamble, D. C. Grootendorst, K. Hattotuwa, T. O'Shaughnessy, F. S. F. Ram, Y. Qiu, J. Zhu, A. M. Vignola, C. Kroegel, F. Morell, et al. Airway mucosal inflammation in COPD is similar in smokers and ex-smokers: a pooled analysis Eur. Respir. J., September 1, 2007; 30(3): 467 - 471. [Abstract] [Full Text] [PDF]

				D. J. Powrie, T. M. A. Wilkinson, G. C. Donaldson, P. Jones, K. Scrine, K. Viel, S. Kesten, and J. A. Wedzicha Effect of tiotropium on sputum and serum inflammatory markers and exacerbations in COPD Eur. Respir. J., September 1, 2007; 30(3): 472 - 478. [Abstract] [Full Text] [PDF]

				T. Parimon, J. W. Chien, C. L. Bryson, M. B. McDonell, E. M. Udris, and D. H. Au Inhaled Corticosteroids and Risk of Lung Cancer among Patients with Chronic Obstructive Pulmonary Disease Am. J. Respir. Crit. Care Med., April 1, 2007; 175(7): 712 - 719. [Abstract] [Full Text] [PDF]

				J. B. Soriano, D. D. Sin, X. Zhang, P. G. Camp, J. A. Anderson, N. R. Anthonisen, A. S. Buist, P. S. Burge, P. M. Calverley, J. E. Connett, et al. A Pooled Analysis of FEV1 Decline in COPD Patients Randomized to Inhaled Corticosteroids or Placebo Chest, March 1, 2007; 131(3): 682 - 689. [Abstract] [Full Text] [PDF]

				J R Hurst and J A Wedzicha What is (and what is not) a COPD exacerbation: thoughts from the new GOLD guidelines Thorax, March 1, 2007; 62(3): 198 - 199. [Full Text] [PDF]

				V. Soyseth, P. H. Brekke, P. Smith, and T. Omland Statin use is associated with reduced mortality in COPD Eur. Respir. J., February 1, 2007; 29(2): 279 - 283. [Abstract] [Full Text] [PDF]

				P. Kardos, M. Wencker, T. Glaab, and C. Vogelmeier Impact of Salmeterol/Fluticasone Propionate versus Salmeterol on Exacerbations in Severe Chronic Obstructive Pulmonary Disease Am. J. Respir. Crit. Care Med., January 15, 2007; 175(2): 144 - 149. [Abstract] [Full Text] [PDF]

				P. J. Barnes Against the dutch hypothesis: asthma and chronic obstructive pulmonary disease are distinct diseases. Am. J. Respir. Crit. Care Med., August 1, 2006; 174(3): 240 - 243. [Full Text] [PDF]

				P. J. Barnes, B. Chowdhury, S. A. Kharitonov, H. Magnussen, C. P. Page, D. Postma, and M. Saetta Pulmonary Biomarkers in Chronic Obstructive Pulmonary Disease Am. J. Respir. Crit. Care Med., July 1, 2006; 174(1): 6 - 14. [Abstract] [Full Text] [PDF]

				I. M. Balfour-Lynn, B. Lees, P. Hall, G. Phillips, M. Khan, M. Flather, J. S. Elborn, and on behalf of the CF WISE (Withdrawal of Inhaled St Multicenter Randomized Controlled Trial of Withdrawal of Inhaled Corticosteroids in Cystic Fibrosis Am. J. Respir. Crit. Care Med., June 15, 2006; 173(12): 1356 - 1362. [Abstract] [Full Text] [PDF]

				O. Leclerc, V. Lagente, J-M. Planquois, C. Berthelier, M. Artola, T. Eichholtz, C. P. Bertrand, and F. Schmidlin Involvement of MMP-12 and phosphodiesterase type 4 in cigarette smoke-induced inflammation in mice Eur. Respir. J., June 1, 2006; 27(6): 1102 - 1109. [Abstract] [Full Text] [PDF]

				C. Bergeron and L.-P. Boulet Structural changes in airway diseases: characteristics, mechanisms, consequences, and pharmacologic modulation. Chest, April 1, 2006; 129(4): 1068 - 1087. [Abstract] [Full Text] [PDF]

				N. C. Barnes, Y.-S. Qiu, I. D. Pavord, D. Parker, P. A. Davis, J. Zhu, M. Johnson, N. C. Thomson, P. K. Jeffery, and on behalf of the SCO30005 Study Group Antiinflammatory Effects of Salmeterol/Fluticasone Propionate in Chronic Obstructive Lung Disease Am. J. Respir. Crit. Care Med., April 1, 2006; 173(7): 736 - 743. [Abstract] [Full Text] [PDF]

				E. Gamble, Y. Qiu, D. Wang, J. Zhu, A. M. Vignola{dagger}, C. Kroegel, F. Morell, T. T. Hansel, I. D. Pavord, K. F. Rabe, et al. Variability of bronchial inflammation in chronic obstructive pulmonary disease: implications for study design Eur. Respir. J., February 1, 2006; 27(2): 293 - 299. [Abstract] [Full Text] [PDF]

				P. W. Ind COPD disease progression and airway inflammation: uncoupled by smoking cessation Eur. Respir. J., November 1, 2005; 26(5): 764 - 766. [Full Text] [PDF]

				I. M. Adcock and K. Ito Glucocorticoid Pathways in Chronic Obstructive Pulmonary Disease Therapy Proceedings of the ATS, November 1, 2005; 2(4): 313 - 319. [Abstract] [Full Text] [PDF]

				M. Johnson Corticosteroids: Potential {beta}2-Agonist and Anticholinergic Interactions in Chronic Obstructive Pulmonary Disease Proceedings of the ATS, November 1, 2005; 2(4): 320 - 325. [Abstract] [Full Text] [PDF]

				A. R. Pons, J. Sauleda, A. Noguera, J. Pons, B. Barcelo, A. Fuster, and A. G. N. Agusti Decreased macrophage release of TGF-{beta} and TIMP-1 in chronic obstructive pulmonary disease Eur. Respir. J., July 1, 2005; 26(1): 60 - 66. [Abstract] [Full Text] [PDF]

				M. A. Birrell, S. Wong, D. J. Hele, K. McCluskie, E. Hardaker, and M. G. Belvisi Steroid-resistant Inflammation in a Rat Model of Chronic Obstructive Pulmonary Disease Is Associated with a Lack of Nuclear Factor-{kappa}B Pathway Activation Am. J. Respir. Crit. Care Med., July 1, 2005; 172(1): 74 - 84. [Abstract] [Full Text] [PDF]

				P. J. Barnes and R. A. Stockley COPD: current therapeutic interventions and future approaches Eur. Respir. J., June 1, 2005; 25(6): 1084 - 1106. [Abstract] [Full Text] [PDF]

				S. F. P. Man and D. D. Sin Effects of Corticosteroids on Systemic Inflammation in Chronic Obstructive Pulmonary Disease Proceedings of the ATS, April 1, 2005; 2(1): 78 - 82. [Abstract] [Full Text] [PDF]

				C B Cooper and D P Tashkin Recent developments in inhaled therapy in stable chronic obstructive pulmonary disease BMJ, March 19, 2005; 330(7492): 640 - 644. [Full Text] [PDF]

M. Dolovich and R. Labiris Imaging Drug Delivery and Drug Responses in the Lung Proceedings of the ATS, December 1, 2004; 1(4): 329 - 337.