Introduction Chronic obstructive pulmonary disease (COPD) is a heterogeneous condition without effective disease modifying therapies. Identification of novel inflammatory endotype markers such as extracellular vesicles (EVs), which are important intercellular messengers carrying microRNA (miRNA), may enable earlier diagnosis and disease stratification for a targeted treatment approach. Our aim was to identify differentially expressed EV miRNA in the lungs of COPD patients compared with healthy ex-smokers and determine whether they can help define inflammatory COPD endotypes. Methods EV miRNA were isolated and sequenced from ex-smoking COPD patients and healthy ex-smoker bronchoalveolar lavage fluid. Results were validated with RT-qPCR and compared to differential inflammatory cell counts. Results Expression analysis identified five upregulated miRNA in COPD (miR-223-3p, miR-2110, miR-182-5p, miR-200b-5p and miR-625-3p) and three downregulated miRNA (miR-138-5p, miR-338-3p and miR-204-5p), all with a log2 fold change of >1/−1, FDR < 0.05. These miRNAs correlated with disease defining characteristics such as FEF 25–75% (a small airways disease measure) and DLCO% (a surrogate measure of emphysema). Receiver operator curve analysis demonstrated miR-2110, miR-223-3p, and miR-182-5p showed excellent combinatory predictive ability (AUC 0.91, p < 0.0001) in differentiating between health and mild COPD. Furthermore, miR-223-3p and miR-338-3p correlated with airway eosinophilia and were able to distinguish “pure eosinophilic” COPD from other airway inflammatory subtypes (AUC 0.94 and 0.85, respectively). Discussion This is the first study to identify differentially expressed miRNA in COPD bronchoalveolar lavage fluid EVs. These findings suggest specific lung derived EV miRNA are a strong predictor of disease presence even in mild COPD. Furthermore, specific miRNA correlated with inflammatory cell numbers in COPD, and may have a role in defining inflammatory endotypes for future treatment stratification.

COPD remains largely undiagnosed or is diagnosed late in the course of disease. We report findings of a specialist outreach programme to identify undiagnosed COPD in primary care. An electronic case-finding algorithm identified 1602 at-risk patients from 12 practices who were invited to attend the clinic. Three hundred and eighty-three (23.9%) responded and 288 were enrolled into the study. Forty-eight (16.6%) had undiagnosed mild and 28 (9.7%) had moderate airway obstruction, meeting spirometric diagnostic criteria for COPD. However, at 12 months only 8 suspected COPD patients (10.6%) had received a diagnostic label in their primary care record. This constituted 0.38% of the total patient population, as compared with 0.31% of control practices, p = 0.306. However, if all patients with airway obstruction received a coding of COPD, then the diagnosis rate in the intervention group would have risen by 0.84%. Despite the low take-up and diagnostic yield, this programme suggests that integrated case-finding strategies could improve COPD recognition.

Across Europe, COPD affects 23 million people leading to annual health care costs of ~€25.1 billion. This burden is particularly severe during winter months in association with the peak incidence of exacerbation events. Seasonal variation in the health status of patients with COPD places additional and often critical pressure on already strained health care resources. COPD exacerbations are characterized by worsening day-to-day symptoms of an individual and often triggered by respiratory infections, but the process by which this occurs in a seasonal fashion is likely to be multifactorial. In this review, we discuss recent population studies that highlight the impact of seasonality in COPD and review the proposed biological mechanisms underlying this. An appraisal of the role of the host susceptibility and response, environmental triggers and the biology of respiratory pathogens is detailed. The impact of each aspect is considered, and an integrated model of the context for the whole individual and society in general is explored.

Introduction and objectives Viral infections are major drivers of exacerbations and clinical burden in patients with asthma and COPD. IFN-β is essential for controlling the infection and spread of viruses such as influenza. However, in recent clinical trials, treatment with IFN-β failed to prevent asthma exacerbations. We aimed to compare the utility of IFN-β as either a treatment or prophylactic for modulating influenza infection in macrophages from health and COPD, with an aim of generating new insights for the optimal design of future clinical trials. Methods Monocyte-derived macrophages (MDM) and primary alveolar macrophages were isolated from healthy and COPD patients. Cells were then infected with influenza virus either prior to or after IFN-β stimulation. Levels of influenza infection were measured by%NP1 +cells using flow cytometry. Viral RNA shedding and anti-viral gene expression (Including OAS1, MX1 and RIG-I) were measured by qPCR. Concentration of inflammatory cytokines (including GM-CSF, TSLP, IL-33, IL-25, TNF-α, IL-1β, IL-6, CCL17, CCL22 and RANTES) in supernatants was measured using MSD. Results Levels of influenza infection in MDMs was similar for both healthy and COPD patients with a%NP1 of 24.4 and 22.0, respectively (p=0.79). Treatment after infection of MDMs with IFN-β was ineffective at modulating influenza infection rates or viral load but IFN-β prophylaxis effectively reduced%NP1+ cells and shedding by 85% (p<0.001) and, 20 fold (p<0.01), respectively. The effect of IFN-β prophylaxis in modulating influenza infection lasted up to 1 week in MDMs from both health and COPD. This was mirrored by the expression of OAS1, MX1 and RIG-I interferon stimulated genes. Exogenous IFN-β did not induce inflammatory cytokine production by MDMs. Conclusions We modelled IFN-β dynamics in vitro and highlight the potential for intermittent prophylactic doses of exogenous IFN-β to modulate viral infection. This generates novel insights to both understand recent clinical trial results in asthma and to aid the optimal design of future clinical trials in both asthma and COPD.

Rationale: Viral infections are major drivers of exacerbations and clinical burden in patients with asthma and COPD. IFN-s is essential for controlling the infection and spread of viruses such as influenza. Objectives: The dynamics of IFN-s activity were investigated to inform on future clinical indications for this potential anti-viral therapy. Methods: Monocyte-derived macrophages (MDMs), alveolar macrophages and primary bronchial epithelial cells (PBECs) were isolated from healthy controls and COPD patients and infected with influenza virus either prior to or after IFN-s stimulation. Infection levels were measured by %NP1+ cells using flow cytometry. Viral RNA shedding and interferon stimulated gene expression were measured by qPCR. Production of inflammatory cytokines was measured using MSD. Measurements and Main Results: Adding IFN-s to MDMs, alveolar macrophages and PBECs prior to, but not after, infection reduced %NP1+ cells by 85%, 56% and 66%, respectively (p Conclusions: In vitro modelling of IFN-s dynamics highlights the potential for intermittent prophylactic doses of exogenous IFN-s to modulate viral infection. This generates novel insights to aid the future design of clinical trials of IFN-s in asthma and COPD.

Introduction There is evidence that an impaired innate immunity, caused by a defect in IFN&bgr; expression in response to viral infections could be linked with exacerbations in asthmatic and COPD patients. So far the administration of inhaled IFN&bgr; upon patients reporting cold or flu symptoms has failed to prevent exacerbations. This highlights the need to understand the dynamics between viral infection and the IFN system to be able to design effective antiviral therapies. Objective To investigate the dynamics of induction and maintenance of anti-viral responses mediated by exogenous IFN&bgr; in the context of influenza infection, we set up an in-vitro model with PBECs from healthy and COPD. Cells were cultured in media containing IFN&bgr; 50IU/ml either for 16 hour or for 2 hour pre or post infection with H3N2 Influenza A/Wisconsin/67/2005. We also investigated the duration of the IFN&bgr; response by culturing PBECs for up to 1 week prior to infection. Proportion of infected cells (%NP1+) was measured by flow cytometry and qPCR was used to measure viral RNA and anti-viral gene expression. Multiplex ELISA (MSD) was used to measure inflammatory cytokines. Results Administration of IFN&bgr; 16 hour prior to infection reduced%NP1+ PBECs from a median of 27% to 9.2% (p<0.001) and there was 200x less viral RNA in the supernatant of cells conditioned with IFN&bgr; compared to untreated (p<0.05). The IFN&bgr; effect was still evident 24 hour after administration (7.9% NP1+), maintained up to 48 hour (16.7%, p<0.05) and lost at 1 week (26.1%). This effect was mirrored by the upregulation of interferon stimulated genes including MX1, OAS1 and RIG-I. The expression of negative regulatory genes: BLIMP1, SOCS1, SOCS3 and USP18 also followed a similar trend. Furthermore IFN&bgr; did not induce a general production of inflammatory cytokine production but reduced IL-1&bgr; expression after infection with influenza. Conclusions This primary epithelial model demonstrates that IFN&bgr; pre-treatment may be suitable to prevent infection. Moreover these results highlight the need to understand the interactions between the virus and the IFN system to be able to identify optimal time of clinical delivery.