INTRODUCTION:COPD is a progressive respiratory condition marked by persistent airflow limitation and chronic inflammation, mainly caused by cigarette smoking. Although current inhaled therapies improve symptoms and reduce exacerbations, they do not substantially modify disease progression, emphasizing the need for novel therapeutic approaches. AREAS COVERED:This review provides a comprehensive overview of the effectiveness and mechanisms of biologic therapies in the management of COPD. We discuss the mechanistic rationale, clinical efficacy, and limitations of currently approved and emerging biologics, highlighting their relevance to distinct inflammatory endotypes of COPD. The role of small-airway disease in COPD is highlighted, together with advances in drug formulation and inhaled delivery technologies. Challenges related to drug delivery, particularly the influence of particle size on distal airway deposition, are examined, along with recent innovations in nanotechnology and comparative considerations of systemic versus inhaled therapeutic approaches. Relevant literature was identified through searches of PubMed (MEDLINE), Embase, Web of Science, and Google Scholar. Studies available in print or online up to June 2025 were considered. EXPERT OPINION:Biologic therapies offer promise for selected COPD phenotypes; however, their long-term impact will depend on precision medicine, optimized airway-targeted delivery, and integration with established inhaled treatments to achieve meaningful disease modification.

Rationale Biofilms on endotracheal tubes (ETT) of mechanically ventilated patients have been associated with ventilator associated pneumonia (VAP). Pseudomonas aeruginosa (PA) is a problematic biofilm-producing pathogen with increasing resistance in mucoid strains. We evaluated the effect of BromAc® (clinical stage mucolytic) and BromAc®-antibiotic combinations on PA biofilms and bacterial growth ex-vivo and in-vitro. Methods ETTs collected from ICU-patients ventilated >24 hours were connected to a ventilator. Using an Aerogen® vibrating mesh nebulizer, 5ml of BromAc® (250ug/20mg/ml) or 0.9% saline was nebulized followed by 30 minutes of ventilation. In vitro, biofilms from mucoidal (PA-183, PA-297, PA-298) and non-mucoidal (PA-201) strains were grown on ETTs in a 48-well plate for 48 hours and exposed to BromAc® 6.25-50ug/5mg/ml +/- antibiotic (Colistin, Tobramycin, Amikacin, Gentamicin at 0.72-64ug/ml) for 24 hours (triplicate). Planktonic growth inhibition was assessed by exposure to BromAc® 3.125-50ug/ml/5mg/ml +/- antibiotic (0.18-64 ug/ml) for 24 hours.Biofilms were stained with crystal-violet. The effect on biofilm ex-vivo was assessed using time-lapse imaging and stain intensity quantification. In-vitro biofilm and bacterial density were measured by spectrophotometry. Results BromAc® removed biofilm from patient-derived ETTs compared to saline control in a time-dependent manner, with 40-50% reduction in biofilm staining intensity within 5 minutes of nebulization, and >90% clearance after 30-minutes. In-vitro, BromAc® alone removed PA-201 biofilm up to 66%, and up to 90% when combined with lower concentrations of Colistin, Gentamicin and Amikacin (antibiotic alone 10%, 26%, 39% respectively). In PA-298, BromAc® improved biofilm removal up to 90% with Colistin, Tobramycin, Gentamicin and Amikacin (antibiotic alone 52%, 16%, 9%, 8% respectively). For PA-297, BromAc® increased biofilm removal up to 58% in PA-297 with Tobramycin, Colistin and Amikacin (antibiotic alone 10%, 20%, 33% respectively) and up to 50% in PA-183 (antibiotic alone 2%, 27%, 15% respectively). The effect was additive for PA-201 and PA-183 and synergistic for PA-297 and PA-298, with 2+ fold increase in biofilm removal. BromAc® inhibited planktonic growth by 28%, up to 89% when combined with Gentamicin, Colistin or Amikacin, and 96% when combined with Tobramycin. A plateau in the effect on biofilm and bacteria in BromAc®-combination was observed with antibiotic concentrations >4ug/ml. Conclusions Nebulized BromAc® rapidly and effectively removed biofilm from ETTs. In-vitro, BromAc® alone and in combination with antibiotic removed biofilms and reduced bacterial load of Pseudomonas Aeroginosa. The ability of BromAc® to remove biofilm, especially when caused by Pseudomonas Aeroginosa, holds potential to reduce the burden of VAP in mechanically ventilated patients.

The recent pandemic represented one of the biggest challenges of modern civilization. SARS-CoV-2 remains an imminent public health threat and currently, there is no effective and greatly affordable treatment for severe COVID-19. Although standard management with dexamethasone, and physical management including physiotherapy, prone positioning and mechanical ventilation are used, severe disease patients may still succumb to infection. In this regard, BromAc® is a combination therapy of a refined protein derived from Bromelain and acetylcysteine, that shows significant mucolytic and anti-inflammatory properties. In the present study, we performed in vitro, and ex vivo analyses to assess the effect of BromAc® in inhibiting Omicron variant of SARS-CoV-2 at different levels. Here, we provide evidence of the in vitro virucidal activity of BromAc® in Vero-ACE2/TMPRSS2 cell line infected with the Omicron variant. BromAc® can also abrogate SARS-CoV-2 RNA genomic copies in tracheal aspirate (TA) samples from critically ill COVID-19 patients after long term exposure. These results were confirmed by lower spike expression observed in EpCAM+PanCKneg epithelial cells from tracheal aspirate samples after BromAc® treatment. Furthermore, atomized BromAc® promoted cleavage of the S1 Spike subunit in TA samples, demonstrating the mechanism of the antiviral activity displayed by BromAc® in human samples. These results bring novel evidence of antiviral activity in cell lines in vitro as well as in tracheal aspirate samples from critically ill COVID-19 patients, which support its potential use as an adjunct to COVID-19 management in future waves of Omicron subvariants.

Introduction:Asthma and chronic obstructive pulmonary disease (COPD) overlap (ACO) is a term used to describe a patient with coexisting clinical features of asthma and COPD. We have previously reported that epithelial to mesenchymal transition (EMT) is active in the lungs of patients with COPD however, EMT in ACO remains an unexplored area. We hypothesize that EMT is an active process in ACO. Methods:In this cross-sectional study, large airway endobronchial biopsy (EBB) tissues from patients with asthma (14), COPD (22), current (CS) and ex-smokers (ES), and ACO (12) were immunohistochemically stained for EMT markers (E and N cadherin, vimentin, S100A4, and Collagen IV) and compared with 12 current smokers with normal lung function (NLFS) and 10 non-smoking healthy control (HC) subjects. In addition, air-liquid interface (ALI) cell cultures were performed and cells from patients with ACO and HC were treated with TGF-β, IL-13 and cigarette smoke extract (CSE). Later cells from ALI cultures were lysed for Immunoblotting. Immunostained tissues were enumerated for percent expression of E and N-Cadherin in the epithelium, vimentin and S100A4 positive cells both in the epithelium and reticular basement membrane (RBM). Additionally, the degree of RBM fragmentation was evaluated, a key tissue structural marker of EMT. Results:Compared to healthy controls and asthmatics, ACO had the greatest fragmentation of RBM (P < 0.01). ACO also had substantially decreased percentage expression of E-cadherin (P <0.01), increase percentage of N-cadherin expression, and higher vimentin and S100A4 positive basal cells, in comparison to healthy controls. In the RBM of ACO, S100A4 positive cells (P <0.05) and Vimentin-positive cells were markedly higher in comparison to HC. Similar changes were observed with western blots in response to Th-2 cytokine IL-13, CSE and EMT activator TGF-β. Conclusions:These data are suggestive of active EMT in ACO. Additionally, 50% of the patients with ACO were on 800 mcg/day inhaled corticosteroid (ICS) treatment which may have abrogated some EMT activity; however, it suggests protective effects of ICS as we previously reported in COPD. Studies with larger cohorts are needed to further confirm ICS effects in ACO.

Background: Idiopathic pulmonary fibrosis (IPF) is an irreversible lung fibrotic disorder of unknown cause. It has been reported that bacterial and viral co-infections exacerbate disease pathogenesis. These pathogens use adhesion molecules such as platelet activating factor receptor (PAFR) and intercellular adhesion molecule-1 (ICAM–1) to gain cellular entry, causing infections. Methods: Immunohistochemical staining was carried out for lung resections from IPF patients (n = 11) and normal controls (n = 12). The quantification of PAFR and ICAM–1 expression is presented as a percentage in the small airway epithelium. Also, type 2 pneumocytes and alveolar macrophages were counted as cells per mm2 of the parenchymal area and presented as a percentage. All image analysis was done using Image Pro Plus 7.0 software. Results: PAFR expression significantly increased in the small airway epithelium (p < 0.0001), type 2 pneumocytes (p < 0.0001) and alveolar macrophages (p < 0.0001) compared to normal controls. Similar trend was observed for ICAM–1 expression in the small airway epithelium (p < 0.0001), type 2 pneumocytes (p < 0.0001) and alveolar macrophages (p < 0.0001) compared to normal controls. Furthermore, the proportion of positively expressed type 2 pneumocytes and alveolar macrophages was higher in IPF than in normal control. Conclusions: This is the first study to show PAFR and ICAM–1 expression in small airway epithelium, type 2 pneumocytes and alveolar macrophages in IPF. These findings could help intervene microbial impact and facilitate management of disease pathogenesis.

We previously reported pulmonary arterial remodelling and active endothelial-to-mesenchymal transition (EndMT) in smokers and patients with early chronic obstructive pulmonary disease (COPD). In the present study, we aimed to evaluate the role of different drivers of EndMT. Immunohistochemical staining for EndMT drivers, TGF-β1, pSMAD-2/3, SMAD-7, and β-catenin, was performed on lung resections from 46 subjects. Twelve were non-smoker-controls (NC), six normal lung function smokers (NLFS), nine patients with small-airway diseases (SAD), nine mild-moderate COPD-current smokers (COPD-CS) and ten COPD-ex-smokers (COPD-ES). Histopathological measurements were done using Image ProPlus softwarev7.0. We observed lower levels of total TGF-β1 (P<0.05) in all smoking groups than in the non-smoking control (NC). Across arterial sizes, smoking groups exhibited significantly higher (P<0.05) total and individual layer pSMAD-2/3 and SMAD-7 than in the NC group. The ratio of SAMD-7 to pSMAD-2/3 was higher in COPD patients compared with NC. Total β-catenin expression was significantly higher in smoking groups across arterial sizes (P<0.05), except for COPD-ES and NLFS groups in small and medium arteries, respectively. Increased total β-catenin was positively correlated with total S100A4 in small and medium arteries (r = 0.35, 0.50; P=0.02, 0.01, respectively), with Vimentin in medium arteries (r = 0.42, P=0.07), and with arterial thickness of medium and large arteries (r = 0.34, 0.41, P=0.02, 0.01, respectively). This is the first study uncovering active endothelial SMAD pathway independent of TGF-β1 in smokers, SAD, and COPD patients. Increased expression of β-catenin indicates its potential interaction with SMAD pathway, warranting further research to identify the deviation of this classical pathway.

Large airway wall lamina propria in patients with asthma-COPD overlap is hypovascular with an increase in reticular basement membrane neoangiogenesis, reflecting smoking-related COPD-like pathology and potential epithelial-to-mesenchymal transition https://bit.ly/49DeoFX.

Background:COPD patients suffer from dysregulated and suppressed immune functionality, determined by their loss of degranulating capacity. Here we provide crucial information on the presence of degranulated mast cells (MCs) in COPD airways and demonstrate their relationship to lung physiology and airway remodelling. Methods:Small airway lung resections from non-smoking controls (NC), normal lung function smokers (NLFS), small airway disease (SAD), and mild-to-moderate COPD current smokers (COPD-CS) and ex-smokers (COPD-ES) were dual immuno-stained with MC tryptase and degranulation marker lysosome-associated membrane protein (LAMP)-1. Total MCs, degranulating MCs and non-MCs were enumerated in small airway epithelium and subepithelium, and in alveolar septa. Results:In the small airway wall subepithelial areas, COPD-CS and COPD-ES patients had significantly lower MCs than the NC group (p<0.05), although the numbers were considerably higher in the small airway epithelium (p<0.01). Degranulating non-MCs were higher in SAD (p<0.05) than in COPD in the small airway subepithelium. In contrast, there were significant increases in total MCs (degranulated and non-degranulated) and degranulated non-MCs in the alveolar septum of COPD patients compared with the NC group (p<001). The lower numbers of MCs in the subepithelium correlated with lower forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) and forced expiratory flow at 25-75% of FVC (FEF25-75%), higher smoking rates in COPD patients, and increased small airway wall thickness and extracellular matrix. The increase in MCs in the alveolar septum negatively correlated with FEF25-75%. Conclusions:This study is the first to assess the differential pattern of MC, degranulating MC and non-MC populations in the small airways and alveoli of COPD patients. The spatial positioning of the MCs within the airways showed variable correlations with lung function.

Mucus plugging of the respiratory tract occurs in airway diseases, including asthma, chronic obstructive pulmonary disease and cystic fibrosis. It can cause blockage of airways, leading to breathlessness and lung failure. Here, we demonstrate the effect of BromAc® in dissolving mucus plugs in an novel ex-vivo ovine obstructive lung model using a ventilatory setup. Mucus simulant was filled into the trachea of freshly slaughtered ovine lungs and ventilated via an endotracheal tube (ETT) using Continuous Mandatory Ventilation. Predetermined single or repeated doses of Bromelain, Acetylcysteine (Ac), BromAc® and saline control were administered via an Aerogen® vibrating nebuliser and ventilated for 30 or 60 minutes. Ventilatory recording of resistance, compliance, tidal volume was conducted and rheology pre and post treatment were measured. A significant decline in airway resistance (p<0.0001) compared to saline control was observed when treated with Bromelain, Ac and BromAc®, with the latter showing a stronger mucolytic effect than single agents. The decline in resistance was also effective in shorter timepoint (p<0.05) at lower doses of the drugs. Changes in compliance, peak pressure and tidal volume was not observed post-administration of the drugs. Rheology measurements revealed that BromAc®™ significantly reduced the viscosity of the mucin at the end of 30-minute and 60-minute time points (p<0.001) compared to the saline control. BromAc® showed complete dissolution of the respiratory mucus simulant and improved ventilatory airflow parameters in the ex-vivo ovine model.

Background: We have previously reported that endothelial-to-mesenchymal transition (EndMT) is an active process in patients with idiopathic pulmonary fibrosis (IPF) contributing to arterial remodelling. Here, we aim to quantify drivers of EndMT in IPF patients compared to normal controls (NCs). Methods: Lung resections from thirteen IPF patients and eleven NCs were immunohistochemically stained for EndMT drivers, including TGF-β1, pSmad-2/3, Smad-7, and β-catenin. Intima, media, and adventitia were analysed for expression of each EndMT driver in pulmonary arteries. Computer- and microscope-assisted Image ProPlus7.0 image analysis software was used for quantifications. Results: Significant TGF-β1, pSmad-2/3, Smad-7, and β-catenin expression was apparent across all arterial sizes in IPF (p < 0.05). Intimal TGF-β1, pSmad-2/3, Smad-7, and β-catenin were augmented in the arterial range of 100–1000 μm (p < 0.001) compared to NC. Intimal TGF-β1 and β-catenin percentage expression showed a strong correlation with the percentage expression of intimal vimentin (r′ = 0.54, p = 0.05 and r′ = 0.61, p = 0.02, respectively) and intimal N-cadherin (r′ = 0.62, p = 0.03 and r′ = 0.70, p = 0.001, respectively). Intimal TGF-β1 and β-catenin expression were significantly correlated with increased intimal thickness as well (r′ = 0.52, p = 0.04; r′ = 0.052, p = 0.04, respectively). Moreover, intimal TGF-β1 expression was also significantly associated with increased intimal elastin deposition (r′ = 0.79, p = 0.002). Furthermore, total TGF-β1 expression significantly impacted the percentage of DLCO (r′ = −0.61, p = 0.03). Conclusions: This is the first study to illustrate the involvement of active TGF-β/Smad-2/3-dependent and β-catenin-dependent Wnt signalling pathways in driving EndMT and resultant pulmonary arterial remodelling in patients with IPF. EndMT is a potential therapeutic target for vascular remodelling and fibrosis in general in patients with IPF.

Mucus plugging of the respiratory tract occurs in airway diseases, including asthma, chronic obstructive pulmonary disease, and cystic fibrosis. It can cause blockage of the airways, leading to breathlessness and lung failure. Here, we used a ventilatory setup to demonstrate the effect of BromAc® in dissolving mucus plugs in a novel ex vivo ovine obstructive lung model. Mucus simulant was filled into the trachea of freshly slaughtered ovine lungs and ventilated via an endotracheal tube (ETT) using Continuous Mandatory Ventilation. Predetermined single or repeated doses of Bromelain, Acetylcysteine (Ac), BromAc®, and saline control were administered via an Aerogen® vibrating nebulizer and ventilated for 30 or 60 min. Ventilatory recording of resistance, compliance, and tidal volume was conducted, and rheology pre- and post-treatment were measured. A significant decline in airway resistance (p < 0.0001) compared to the saline control was observed when treated with Bromelain, Ac, and BromAc®, with the latter showing a stronger mucolytic effect than single agents. The decline in resistance was also effective in shorter time points (p < 0.05) at lower doses of the drugs. Changes in compliance, peak pressure, and tidal volume were not observed after administration of the drugs. Rheology measurements revealed that BromAc®TM significantly reduced the viscosity of the mucin at the end of 30 min and 60 min time points (p < 0.001) compared to the saline control. BromAc® showed complete dissolution of the respiratory mucus simulant and improved ventilatory airflow parameters in the ex vivo ovine model.

Introduction: Our previous studies have shown active EMT in smokers and COPD patients, which is central to lung cancer development in these patients. Aim: We aim to evaluate EMT changes in extensive patient groups who were diagnosed with NSCLC (adenocarcinoma and squamous cell carcinoma) compared to normal controls (NC). Method: Resected lung tissue from NSCLC patients (n=35), sub-grouped as COPD current and ex-smokers, patients with small airway (SA) disease and normal lung function smokers compared to NC (n=11), were immuno-stained for EMT biomarkers: E-cadherin, N-cadherin, S100A4, Vimentin, and epidermal growth factor receptor (EGFR). Biomarkers were analysed in the SA epithelium and sub-epithelial layers. Tissue analysis was done with microscope-assisted Image-ProPlus 7.0 software. Results: Compared to NC, in all pathological groups, SA wall thickness was significantly increased (p<0.05); SA epithelial E-cadherin expression markedly decreased (p<0.01), whereas N-cadherin, Vimentin, S100A4, and EGFR expression were notably increased (p<0.01). Vimentin expression in sub-epithelium showed a similar trend to epithelium across all pathological groups (p<0.05). However, such changes were only seen in Rbm for S100A4 (p<0.05). EGFR and N-cadherin expressions in both cancer phenotypes were markedly higher than Vimentin and S100A4 (p<0.0001). EMT markers expression positively correlated to smoking history. Conclusion: EMT is a crucial and active process in NSCLC patients with COPD, resulting in SA remodelling and cancer development. This is the first study to show such changes in broadly phenotyped individuals, suggesting EMT as a key mechanism and novel therapeutic target.