#mucus hypersecretion

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New Post has been published on Asthma Inhalers (Ventolin & Flovent)

Canadian Health&Care Mall Articles about Ventolin Inhaler for Treatment Asthma

The subjects demographic and lung function data are shown in Table 2. There were no differences in age among the groups (ANOVA). However, as expected, AMH had poorer mean lung function compared with those who had mild/moderate asthma and healthy subjects (73 ± 13%, 94 ± 9%, and 95 ± 7% co...

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New Post has been published on Preventive measures in Asthma

New Post has been published on http://the-asthma.com/asthmatic-subjects-treated-by-ventolin-inhalers.html

Asthmatic Subjects Treated by Ventolin Inhalers

In this study, we found elevated MMP-9 activity and TIMP-1 expression in asthmatic patients who had a history of AMH that was confirmed at bronchoscopy or severe asthma, compared to healthy subjects and patients who had mild/moderate asthma. There were no differences in MMP-9/TIMP-1 ratios among groups. The clinical parameters of the AMH group were similar to those of the severe asthma group with the presence of frequent symptoms, comparable lung function, and high inhaled corticosteroid requirements. Thus, this subgroup of asthmatic patients that has evidence of AMH, with copious amounts of mucus present in the large airways seen bronchoscopically, may represent part of the spectrum of severe asthma.

Chronic mucus hypersecretion is a well-recognized pathology in patients who have COPD, in whom it has been found to be associated with exacerbations. In asthma patients, mucus hypersecretion is well-recognized as an important component of the pathogenesis of acute attacks, during which it is thought to cause further narrowing by causing physical obstruction of airways that are already inflamed and narrowed by bronchoconstriction. An increase in the number of goblet cells has also been found in postmortem studies of asthmatic subjects. Lange et al reported that AMH, defined by self-reported production of phlegm during at least 3 months per year for at least two consecutive years, was present in 63% of men and 54% of women who had asthma. More importantly, it has also been associated with a greater decline in lung function in asthmatic patients, regardless of smoking history and initial FEV1 values.

The association between mucus hypersecretion and faster decline in lung function in asthma suggests that there might be more airway inflammation and remodeling. Hence, there may also be greater MMP-9 activity given its association with eosinophilic and neutrophilic inflammation, and its potential role in tissue remodeling by degrading elastin, collagen, and proteoglycan. In two published studies of bronchial biopsies, immunohistochemical staining for MMP-9 was colocalized with neutro-phils and eosinophils, although there were no differences between asthmatic subjects, either treated with steroids or untreated, compared with healthy subjects. The activity of MMP-9 in the airway secretions of patients who have AMH has not been reported previously. The best opportunity to give up asthma is ventolin inhalers which may be bought using the link – buy-asthma-inhalers-online.

We defined mucus hypersecretion as the clear-cut presence of increased mucus in the airways causing airway obstruction, independently of asthma severity and of a history of chronic cough productive of phlegm. This was based on the “bronchitis index,” which was validated as a way of describing the severity of bronchitis seen during bronchoscopy. It is a four-component index that includes the presence of mucus in the airways, with airway occlusion being classified as the highest grade. Although we cannot be completely sure that mucous plugging was chronic, we think it is highly likely since we ensured that all patients were clinically stable (ie, they did not have symptoms of a recent respiratory tract infection), and seven of the eight patients reported having chronic cough and sputum production. If we had defined AMH by both history and bronchoscopic appearance, one patient would be reclassified as having mild/moderate asthma; however, this only increased the differences between the AMH and severe asthma groups, compared with the mild asthma group. We also found a high proportion of subjects who had severe asthma and also had a history of chronic productive cough but no mucous plugging seen at bronchoscopy. This may have been due to selection bias, with patients having chronic cough being more likely to respond to recruiting advertisements and more likely to agree to undergo bronchoscopy. These patients could have had intermittent mucous plugging.

The asthmatic subjects who had mucus hypersecretion had copious amount of sputum in the airways at bronchoscopy. Although it is not possible to determine how much this abnormal mucus secretion contributed to the spirometric abnormality, it was likely that it played a significant role not only by causing physical blockage, but also by increasing surface tension, thereby favoring airway closure during forced expiratory maneuvers. Furthermore, the presence of increased amounts of mucus in the bronchial tree may also impede the deposition of inhaled drugs to the inflamed airways, suggesting that better clearance of secretions might help to improve asthma treatment. AMH might represent a variation of the disease, and, although its causes are unclear, it might include the up-regulation of the T-helper type 2 cytokines interleukin (IL)-4, IL-5, IL-9, and IL-13, which have been implicated in increasing mucus secretion.

Our findings that MMP-9 activity and TIMP-1 expression are increased in the BALF of subjects who had severe asthma compared to healthy subjects and patients with mild/moderate asthma are in accordance with the findings of previous stud-ies.’’ Lemjabbar and colleagues found a 10-fold to 160-fold increase in MMP-9 activity in BALF in patients receiving mechanical ventilation for the treatment of acute severe asthma over that of nonasthmatic subjects. Mattos et al also demonstrated increased MMP-9 activity in the induced sputum of patients who had severe asthma compared with patients who had mild asthma and healthy subjects, although levels of MMP-9 in BALF was not different. Patients who had nocturnal asthma had a fourfold circadian increase in levels of MMP-9 in BALF compared with healthy subjects and asthmatic patients who did not have nocturnal asthma. Interestingly, the investigators observed that these differences in MMP-9 expression disappeared when MMP-9 activity was determined in the afternoon. This observation would indicate that the amount of MMP-9 found in the BALF of asthma patients correlates with the infiltration of inflammatory cells in the lung and therefore most probably is produced by such cell types rather than by resident lung cells.

In regard to the possible source of MMP-9 activity in the BALF of patients who have severe asthma or AMH, we found an increase in the percentage of neutrophils in these subjects, who also had high levels of MMP-9 activity despite receiving high doses of inhaled corticosteroids. This suggests that severe asthma is associated with a persistent airway neutrophilia that is poorly responsive to ventolin inhalers treatment. This then provides an ongoing source of MMP-9 and is consistent with previous findings of the poor response of MMP-9 activity to steroid treatment in patients with severe asthma. Neutrophils therefore could play a significant role in severe asthma and also in the inflammation associated with AMH. Thus, neutrophils might be important in asthmatic remodeling given the known presence of MMP-9 in neutrophils and our findings of an association between MMP-9 and the percentage of neutrophils. Interestingly, Corbel at al, in a murine model of asthma, also found that MMP-9 activity measured in BALF increased as the duration of repeated ovalbumin challenges progressed and that this was also correlated with the number of neutrophils in the BALF. This is analogous to chronic allergen exposure, which has also been shown to increase MMP-9 activity in the BALF of asthmatic subjects.

Our severity score was based on our national guidelines, which, like the Global Strategy for Asthma Management and Prevention guidelines, do not include the dose of inhaled steroids being administered. This explains why the doses of inhaled steroids were comparable between the different asthma groups, which perhaps suggests the limitations of such “clinical severity” scores such that they could be considered more appropriately to be measures of asthma control rather than severity.

As metalloproteinase inhibitors are now available for clinical trials in the treatment of diseases like osteoarthritis and rheumatoid arthritis, MMPs may be a target for novel therapy in asthma patients, Mechanical obstruction may play a role in AMH by decreasing mucociliary clearance, by trapping the inflammatory mediators with resulting persistent inflammation, and possibly by preventing the penetration of antiinflammatory medications.

We did not observe any differences among groups in our study in regard to the serum levels of MMP-9 or TIMP-1, suggesting that the increases in MMP-9 activity and TIMP-1 expression are restricted to the inflamed area of the lung. However, other groups have reported’ increased serum levels of MMP-9 in patients presenting with asthma exacerbations, although there are no published data of any increase in MMP-9 level in the blood of subjects who have severe but clinically stable asthma.

In conclusion, our study shows that MMP-9 levels are high in the BALF of patients who have AMH or severe asthma. However, MMP-9 levels are similarly low in the airways of patients with mild/moderate asthma and in control subjects. No correlation in the levels of MMP-9 or TIMP-1 between serum and BALF was noted. Further studies are needed to assess whether the removal of the mucus can improve inflammation and remodeling in patients with AMH.

[maddison555brooksild]

New Post has been published on All about Asthma

New Post has been published on http://no-asthma.com/preparation-for-asthma-treatment-ventolin-inhalers.html

Preparation for Asthma Treatment: Ventolin Inhalers

Asthma has many well-known clinical manifestations, one of which is an accelerated decline in spirometric function. This occurs particularly in patients who have severe, longstanding, or adult-onset asthma ultimately leading to chronic, fixed airflow limitation of varying degree. This is thought to be secondary to structural changes in the airway, collectively referred to as remodeling, which involves changes in extracellular matrix, collagen, elastin, and airway smooth muscle. Accelerated decline in spirometric function also occurs in asthmatic subjects who report chronic cough and sputum production due to asthmatic mucus hypersecretion (AMH), but who do not have bronchiectasis, allergic bronchopulmonary aspergillosis, or a history of heavy smoking.

Matrix metalloproteinases (MMPs) play a role in tissue remodeling in diseases such as asthma, bronchiectasis, rheumatoid arthritis, and mesothelioma, and in wound healing. MMP-9 is a 92-kd collagenase that cleaves type IV collagen, which makes up a substantial portion of the basement membrane of airways and is regulated by the tissue inhibitor of metalloproteinase (TIMP)-1, which binds to MMPs in a 1:1 ratio. Its activity is increased in the bronchial biopsy specimens, blood, induced sputum, and BAL fluid (BALF) of patients who have severe or uncontrolled asthma. Ventolin Inhalers are worked out to stop the asthma attack, they are convenient in usage and may be ordered via buy-asthma-inhalers-online.

Because of the association of decline in lung function with AMH, severe asthma, and persistent airway inflammation, we hypothesized that MMP-9 activity would be increased in the blood and airway secretions in asthmatic patients who had severe disease and/or AMH (diagnosed at bronchoscopy), and that it would correlate with airway inflammation. Our aim was to compare MMP-9 activity and TIMP-1 expression in the serum and BALF in healthy subjects, patients with mild/moderate asthma, patients with severe asthma, and patients with AMH. In addition, we compared MMP-9 activity in serum and BALF.

Asthmatic and nonasthmatic subjects underwent clinical testing in the lung function laboratory and then underwent bronchoscopy within 2 weeks of laboratory testing. Asthmatic subjects were classified as having mucus hypersecretion if they had mucus causing occlusion of the subsegmental or larger airways visualized during bronchoscopy, as described by Thompson et al (bron-choscopists, G.G.K. and K.Y.). The study was approved by the Ethics Review Committee of the Central Sydney Area Health Service (reference X99-0217). Written informed consent was obtained from all subjects.

Subjects

Seven nonasthmatic subjects and 22 asthmatic subjects were recruited from among patients and students at the Asthma Centre, Royal Prince Alfred Hospital, and from the University of Sydney. The diagnosis of asthma was based on the World Health Organization/National Heart, Lung, and Blood Institute guide-lines. Asthmatic subjects had clinically stable asthma, as defined by stable symptoms and medication usage over the previous 3 months, and had no symptoms of respiratory tract infection in the previous 6 weeks. None of the subjects were current smokers, ex-smokers of > 20 pack-years, or pregnant, or had coexistent chronic cardiac or pulmonary disease.

Clinical Assessment of Asthma

We administered a respiratory questionnaire- that included questions on the frequency and nature of asthma symptoms, medication use- and the presence of chronic cough that was productive of phlegm. The dose of inhaled corticosteroids was converted to equivalent doses of beclomethasone dipropionate, ventolin inhalers according to the following equation: 100 μg of beclomethasone dipropionate = 80 μg of budesonide = 50 μg of fluticasone. Skin prick tests were performed with a panel of 14 common aeroal-lergens applied to the forearm. Skin wheal sizes were considered to be positive if they were > 4 mm in mean diameter, and atopy was defined as the presence of one or more positive reactions.

Lung Function Tests

Spirometry was measured in all subjects in accordance with American Thoracic Society criteria (VMAX; SensorMedics; Yorba Linda, CA), and the normal reference values used were those of Morris et al. Nonasthmatic subjects underwent methacholine challenge with doses ranging from 3 to 199 μmol using a nebulizer (model No. 646; DeVilbiss HealthCare; Somerset, PA) and a dosimeter (Rosenthal French; Baltimore, MD). Asthmatic subjects underwent methacholine challenge by the rapid method and received doses from 0.03 to 7.8 μmol administered with a hand-held nebulizer (model No. 45; DeVilbiss). The challenge was stopped in all subjects either after their FEV1 had decreased by > 20% of baseline values or after the final dose had been administered. Results were expressed as the log dose-response ratio (DRR).

BAL

Fiberoptic bronchoscopy (Olympus; Tokyo, Japan) was performed under IV sedation after premedication with IV atropine and local anesthesia of the upper airways half an hour before the procedure. BAL was performed in a subsegmental bronchus of the left lower lobe by infusing 50 mL of sterile 0.9% saline solution. BALF was separated into acellular and cellular components by centrifugation (400g for 10 min at4°C). The supernatant was further centrifuged (5,000g for 20 min at 4°C) to remove any debris and was stored at — 20°C in 1-mL aliquots for zymography.

The cell pellet was resuspended in phosphate-buffered saline (PBS) solution to its original BALF volume, filtered through nylon gauze (pore size, 60 |xm), then diluted 1:1 with 20 μL of Trypan blue for cell counting and viability assessment using a hemocytometer. To standardize cell numbers, after centrifugation (200g for 10 min at 20°C), PBS solution was added to the pellet to yield approximately 1 X 106 cells/mL. Seventy microliters of the cell suspension was added to a cytospin slide, spun at 5,000 revolutions per minute for 5 min and then stained (Diff Quick solution; Lab Aids; Sydney, NSW, Australia) for differential cell counting. At least 400 inflammatory cells were counted in each slide by two investigators (F.W.S.K. and C.D.) who were blinded to the clinical details of the subjects, and the average was used. The protein concentration of BALF was measured by calorimetric assay (DC protein Assay; Bio-Rad; Hercules, CA), with the spectrophotometer set at a wavelength of 655 nm (microplate reader model 450; Bio-Rad).

Zymography for MMP Activity

Gelatin zymography was used to assess the activity of MMP-9 in BALF as previously described. The supernatant was diluted two times with nonreducing loading buffer (400 mmol/L Tris-HCL, 5% sodium dodecyl sulfate, 20% glycerol, 0.006% bromo-phenol blue). Fifteen microliters of equal amounts of the sample (15 μL) were mixed with the loading buffer, and proteins were separated by polyacrylamide gel electrophoresis (0.75 mm; constant current 20 mA) consisting of an 8% sodium dodecyl sulfate solution with 1% gelatin (Bio-Rad). The gels were incubated in a renaturing buffer (2.5% Triton X-100 buffer) for 30 min to remove the sodium dodecyl sulfate. After rinsing, the gels were incubated (37°C for 20 h) in an enzyme activation buffer (50 mmol/L Tris-HCL [pH 7.3], 200 mmol/L NaCl, and 0.02% Tween 20). The gels were then stained with Coomassie brilliant blue R250 stain and destained (5% methanol, 7% acetic acid in PBS solution), and the gelatinolytic activity was detected as clear bands. The molecular weight of the gelatinolytic bands was estimated relative to the prestained molecular-weight markers (see BluePlus2 Prestained Standard; Invitrogen, Carlsbad, CA), and an MMP-9 standard (Quantikine; R&D Systems; Minneapolis, MN) was run in each gel as a positive control.

Zymogram Image Analyses

Zymograms were digitized (Kodak Digital Science Image Station 440; NEN Life Science Products, Inc; Boston, MA), and gelatinolytic activity (Fig 1) was measured using freeware (Image J, release p 4.0.2; Scion Corporation, Frederick, MD). The gelatinolytic activity was measured as the product of mean optical density multiplied by the area of digestion of the band inside a region of interest that was drawn around the clearly visible digested band (Fig 1). The mean of three measurements was used. Variations in Coomassie brilliant blue staining between different zymograms was standardized by using a single biological standard that had a high level of gelatinolytic activity and that was not from one of the study subjects (Fig 2). A 1:64 dilution of this sample was used in all zymographic assays as the common standard to adjust for small differences by reference to the standard curve in Figure 2 (closed circle).

Enzyme-Linked Immunosorbent Assay

Total MMP-9 and TIMP-1 were measured in BALF and serum by enzyme-linked immunosorbent assay (ELISA) [human MMP-9 and human TIMP-1; Quantikine; R&D Systems) according to the instructions of the manufacturer. The minimum detectable amounts of MMP-9 and TIMP-1 were 0.156 and 0.08 ng/mL, respectively.

Data Analysis

Asthmatic patients were classified by an asthma severity score based on the National Asthma Council Guidelines (Table 1). For analyses, subjects were classified into the following four groups: AMH (defined by bronchoscopic appearance, regardless of asthma severity); severe asthma (severity score, 3); mild/moderate asthma (severity score, 1 to 2); or nonasthmatic. Zymographic data and BAL cell counts were reported as the median (interquartile range). The MMP-9 activity data were nonnormally distributed (Shapiro-Wilk coefficient, 0.68; p < 0.0001) due to the zero values; therefore, differences between clinical groupings were examined by Kruskal-Wallis test, and any significant differences were further analyzed by pair-wise comparisons using Mann-Whitney tests. The relationships between MMP activity and inflammatory cell counts, FEV1, and DRR were examined using the Spearman rank correlation test. All other data were presented as the mean (95% confidence intervals) with differences between groups examined using analysis of variance (ANOVA).

Figure 1. Zymograms showing gelatin digestion by pro-MMP-9 (92 kd) and active MMP-9 (85 kd). Lane 1, internal standard; lane 2, MMP-9; lane 3, normal; lane 4, mild asthma; lane 5, severe asthma; lane 6, AMH.

Figure 2. Standard curve for the standardization of image analyses between zymograms. The undiluted standard sample was assigned an arbitrary concentration of 100 U, and the percentage concentration was derived from the dilution (eg, 1:2 dilution = 50%). • = relative concentration used in all zymograms as the internal standard.

Table 1—Asthma Severity Score

Severity Score Symptoms Bronchodilator Use FEVj,% predicted Taking Oral Corticosteroids 1 < Once/mo < Once/mo > 80% No 2 a Once/mo but < daily > Once/mo but < 3 Times/d 60-80% No 3 Daily or nocturnal symptoms > once/wk a 3 Times/d < 60% Yes