[Show abstract][Hide abstract] ABSTRACT: Background
Asthma and chronic obstructive pulmonary disease (COPD) are heterogeneous diseases.
We sought to determine, in terms of their sputum cellular and mediator profiles, the extent to which they represent distinct or overlapping conditions supporting either the “British” or “Dutch” hypotheses of airway disease pathogenesis.
We compared the clinical and physiological characteristics and sputum mediators between 86 subjects with severe asthma and 75 with moderate-to-severe COPD. Biological subgroups were determined using factor and cluster analyses on 18 sputum cytokines. The subgroups were validated on independent severe asthma (n = 166) and COPD (n = 58) cohorts. Two techniques were used to assign the validation subjects to subgroups: linear discriminant analysis, or the best identified discriminator (single cytokine) in combination with subject disease status (asthma or COPD).
Discriminant analysis distinguished severe asthma from COPD completely using a combination of clinical and biological variables. Factor and cluster analyses of the sputum cytokine profiles revealed 3 biological clusters: cluster 1: asthma predominant, eosinophilic, high TH2 cytokines; cluster 2: asthma and COPD overlap, neutrophilic; cluster 3: COPD predominant, mixed eosinophilic and neutrophilic. Validation subjects were classified into 3 subgroups using discriminant analysis, or disease status with a binary assessment of sputum IL-1β expression. Sputum cellular and cytokine profiles of the validation subgroups were similar to the subgroups from the test study.
Sputum cytokine profiling can determine distinct and overlapping groups of subjects with asthma and COPD, supporting both the British and Dutch hypotheses. These findings may contribute to improved patient classification to enable stratified medicine.
The Journal of allergy and clinical immunology 08/2014; · 12.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Asthma is characterized by variable airflow obstruction, airway inflammation, airway hyper-responsiveness and airway remodelling. Airway smooth muscle (ASM) hyperplasia is a feature of airway remodelling and contributes to bronchial wall thickening. We sought to investigate the expression levels of chemokines in primary cultures of ASM cells from asthmatics vs healthy controls and to assess whether differentially expressed chemokines (i) promote fibrocyte (FC) migration towards ASM and (ii) are increased in blood from subjects with asthma and in sputum samples from those asthmatics with bronchial wall thickening.
[Show abstract][Hide abstract] ABSTRACT: The role of small airway obstruction in the clinical expression of asthma is incompletely understood.
We tested the hypotheses that markers of small airway obstruction are associated with (i) increased asthma severity, (ii) impaired asthma control and quality of life, and (iii) frequent exacerbations.
Seventy-four adults with asthma and 18 healthy control subjects underwent impulse oscillometry (IOS), multiple breath inert gas washout (MBW), body plethysmography, single-breath determination of carbon monoxide uptake and spirometry. Patients completed the six-point Asthma Control Questionnaire (ACQ-6) and standardised Asthma Quality of Life Questionnaire (AQLQ(S)). Asthma severity was classified according to the Global Initiative for Asthma (GINA) treatment steps.
The putative small airway obstruction markers Sacin , resistance at 5Hz minus resistance at 20 Hz (R5-R20) and reactance area (AX) were not independently associated with asthma severity, control, quality of life or exacerbations. In contrast, markers of total (R5) and mean airway resistance of large and small airways (R20) were significantly higher in the severe asthma group compared to the mild-moderate group (0.47 vs 0.37, p < 0.05 for R5; 0.39 vs 0.31, p < 0.01 for R20). The strongest independent contributors to ACQ-6 score were R20 and forced expiratory volume in one second (% pred.), and the strongest independent contributors to AQLQ(S) score were R20 and forced vital capacity (% pred.). A history of one or more exacerbations within the previous year was independently associated with R20.
Previously reported markers of small airway obstruction do not appear to be independently associated with asthma disease expression. In contrast, the IOS parameter R20, a marker of mean airway resistance of both large and small airways, appears to have independent clinical significance. These observations require confirmation in prospective longitudinal studies. This article is protected by copyright. All rights reserved.
[Show abstract][Hide abstract] ABSTRACT: IgE sensitization to Aspergillus fumigatus and a positive sputum fungal culture result are common in patients with refractory asthma. It is not clear whether these patients would benefit from antifungal treatment.
We sought to determine whether a 3-month course of voriconazole improved asthma-related outcomes in patients with asthma who are IgE sensitized to A fumigatus.
Asthmatic patients who were IgE sensitized to A fumigatus with a history of at least 2 severe exacerbations in the previous 12 months were treated for 3 months with 200 mg of voriconazole twice daily, followed by observation for 9 months, in a double-blind, placebo-controlled, randomized design. Primary outcomes were improvement in quality of life at the end of the treatment period and a reduction in the number of severe exacerbations over the 12 months of the study.
Sixty-five patients were randomized. Fifty-nine patients started treatment (32 receiving voriconazole and 27 receiving placebo) and were included in an intention-to-treat analysis. Fifty-six patients took the full 3 months of medication. Between the voriconazole and placebo groups, there were no significant differences in the number of severe exacerbations (1.16 vs 1.41 per patient per year, respectively; mean difference, 0.25; 95% CI, 0.19-0.31), quality of life (change in Asthma Quality of Life Questionnaire score, 0.68 vs 0.88; mean difference between groups, 0.2; 95% CI, -0.05 to -0.11), or any of our secondary outcome measures.
We were unable to show a beneficial effect of 3 months of treatment with voriconazole in patients with moderate-to-severe asthma who were IgE sensitized to A fumigatus on either the rate of severe exacerbations, quality of life, or other markers of asthma control.
The Journal of allergy and clinical immunology 11/2013; · 12.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Bacteria are often isolated in stable chronic obstructive pulmonary disease (COPD). Whether fungi are also commonly present and associated with clinical and pathological features of disease is uncertain. We investigated the frequency of filamentous fungal culture and IgE sensitization to Aspergillus fumigatus and the relationship to clinical outcomes in COPD subjects.COPD subjects were recruited to enter a 1 year observational study. Assessments of lung function, allergen testing and sputum analysis for inflammation, bacteria and fungus were undertaken in COPD subjects and healthy smoking and non-smoking controls.Filamentous fungi were cultured at baseline in 49% (63/128) of COPD subjects of which 75% (47/63) were A. fumigatus. Fungus was cultured in 3/22 controls (2 were A. fumigatus). The total sputum cell count and inhaled corticosteroid dosage were significantly increased in COPD patients with a positive filamentous fungal culture at baseline (p<0.05). Sensitization to A. fumigatus was present in 13% of COPD subjects and was associated with worse lung function (FEV1 % predicted 39% versus 51%; p=0.01), but not related to filamentous fungal culture.A. fumigatus sensitization is related to poor lung function. Positive filamentous fungal culture is a common feature of COPD. The clinical significance of this remains uncertain.
European Respiratory Journal 04/2013; · 7.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Rationale: The relationship between airway inflammation and obesity in severe asthma is poorly understood. Objectives: We sought to determine the relationship between sputum mediator profiles, the distribution of eosinophilic inflammation and obesity in severe asthmatics. Methods: Clinical parameters and 8 mediators in sputum were assessed in 131 severe asthmatic subjects from a single centre categorised into lean, overweight and obese groups defined by their body mass index. In an independent group of severe asthmatics (n=45) and healthy controls (n=19) eosinophilic inflammation was enumerated in bronchial submucosa, blood and sputum and related to their body mass index. Measurements and Main Results: Sputum interleukin (IL)-5 geometric mean [95% confidence interval] (pg/ml) was elevated in the obese (1.5 [1.0-2.3]) compared to overweight (0.9 [0.7-1.1]; p=0.02) and lean (0.7 [0.5-1.0]; p=0.01) asthmatics and was correlated with the body mass index (r=0.29, p<0.001). There was no relationship between body mass index, the sputum cell count or other sputum mediators. In the bronchoscopy group the submucosal eosinophil number in the asthmatic subjects was correlated with body mass index (Spearman's rank correlation rs=0.38, p=0.013) and the median (interquartile range) number of submucosal eosinophils was increased in obese (19.4 [11.8-31.2]) cells/mm2 versus lean subjects (8.2 [5.4-14.6]) (p=0.006). There was no significant association between sputum or peripheral blood eosinophil counts and body mass index. Conclusion: Sputum IL-5 and submucosal eosinophils, but not sputum eosinophils are elevated in obese severe asthmatics. Whether specific anti-eosinophilic therapy is beneficial, or improved diet and lifestyle in obese asthma has anti-inflammatory effects beyond weight reduction, requires further study.
American Journal of Respiratory and Critical Care Medicine 04/2013; · 11.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: Severe asthma is a heterogeneous disease and the relationship between airway inflammation and airway remodelling is poorly understood. We sought to define sputum mediator profiles in severe asthmatics categorised by CT-determined airway geometry and sputum differential cell counts. METHODS: In a single centre cross-sectional observational study we recruited 59 subjects with severe asthma that underwent sputum induction and thoracic CT. Quantitative CT analysis of the apical segment of the right upper lobe (RB1) was performed. Forty-one mediators in sputum samples were measured of which 21 mediators that were assessable in >50% of samples were included in the analyses. RESULTS: Independent of airway geometry, sputum MMP9 and IL-1beta were elevated in those groups with a high sputum neutrophil count while sputum ICAM was elevated in those subjects with a low sputum neutrophil count. In contrast, sputum CCL11, IL-1alpha and fibrinogen were different in groups stratified by both sputum neutrophil count and airway geometry. Sputum CCL11 concentration was elevated in subjects with a low sputum neutrophil count and high luminal and total RB1 area, whereas sputum IL1alpha was increased in subjects with a high sputum neutrophil count and low total RB1 area. Sputum fibrinogen was elevated in those subjects with RB1 luminal narrowing and in those subjects with neutrophilic inflammation without luminal narrowing. CONCLUSIONS: We have demonstrated that sputum mediator profiling reveals a number of associations with airway geometry. Whether these findings reflect important biological phenotypes that might inform stratified medicine approaches requires further investigation.
Respiratory research 02/2013; 14(1):17. · 3.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Fungal sensitization is common in severe asthma, but the clinical relevance of this and the relationship with airway colonization by fungi remain unclear. The range of fungi that may colonize the airways in asthma is unknown.
To provide a comprehensive analysis on the range of filamentous fungi isolated in sputum from people with asthma and report the relationship with their clinico-immunological features of their disease.
We recruited 126 subjects with a diagnosis of asthma, 94% with moderate-severe disease, and 18 healthy volunteers. At a single stable visit, subjects underwent spirometry; sputum fungal culture and a sputum cell differential count; skin prick testing to both common aeroallergens and an extended fungal panel; specific IgE to Aspergillus fumigatus. Fungi were identified by morphology and species identity was confirmed by sequencing. Four patients had allergic bronchopulmonary aspergillosis.
Forty-eight percent of asthma subjects were IgE-sensitized to one fungal allergen and 22% to ≥ 2. Twenty-seven different taxa of filamentous fungi were isolated from 54% of their sputa, more than one species being detected in 17%. This compared with 3 (17%) healthy controls culturing any fungus (P < 0.01). Aspergillus species were most frequently cultured in isolation followed by Penicillium species. Post-bronchodilator FEV (1) (% predicted) in the subjects with asthma was 71(± 25) in those with a positive fungal culture vs. 83 (± 25) in those culture-negative, (P < 0.01).
Numerous thermotolerant fungi other than A. fumigatus can be cultured from sputum of people with moderate-to-severe asthma; a positive culture is associated with an impaired post-bronchodilator FEV (1) , which might be partly responsible for the development of fixed airflow obstruction in asthma. Sensitization to these fungi is also common.
[Show abstract][Hide abstract] ABSTRACT: Variability of peak flow measurements has been related to clinical outcomes in asthma. We hypothesized that the entropy, or information content, of airway impedance over short time scales may predict asthma exacerbation frequency.Sixty-six patients with severe asthma and thirty healthy control subjects underwent impulse oscillometry at baseline, following a deep exhalation manoeuvre, and following bronchodilator administration. On each occasion, airway impedance parameters were measured at 0.2 second intervals for 150 seconds, yielding a time series, which was then subjected to Sample Entropy analysis.Airway impedance, and Sample Entropy of impedance, was increased in asthmatic patients compared to healthy controls. In a logistic regression model, Sample Entropy of R5-R20, a marker of the fluctuation of the heterogeneity of airway constriction over time, was the variable most strongly associated with the frequent exacerbation phenotype (odds ratio of 3.23 for every 0.1 increase in Sample Entropy).Increased airway impedance and Sample Entropy of impedance is associated with the frequent exacerbation phenotype. Prospective studies are required to assess their predictive value.
European Respiratory Journal 03/2012; · 7.13 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Asthma is increasing in prevalence worldwide. It is characterized by typical symptoms and variable airway obstruction punctuated with episodes of worsening symptoms known as exacerbations. Underlying this clinical expression of disease is airway inflammation and remodeling. Cytokines and their networks are implicated in the innate and adaptive immune responses driving airway inflammation in asthma and are modulated by host-environment interactions. Asthma is a complex heterogeneous disease, and the paradigm of Th2 cytokine-mediated eosinophilic inflammation as a consequence of allergic sensitization has been challenged and probably represents a subgroup of asthma. Indeed, as attention has switched to the importance of severe asthma, which represents the highest burden both to the patient and health care provider, there is an increasing recognition of inflammatory subphenotypes that are likely to be driven by different cytokine networks. Interestingly, these networks may be specific to aspects of clinical expression as well as inflammatory cell profiles and therefore present novel phenotype-specific therapeutic strategies. Here, we review the breadth of cytokines implicated in the pathogenesis of asthma and focus upon the outcomes of early clinical trials conducted using cytokines or cytokine-blocking therapies.
Advances in clinical chemistry 01/2012; 57:57-97. · 4.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Asthma is a complex inflammatory disease and current therapy remains inadequate in many sufferers. There is phenotypic heterogeneity in its clinical expression as a consequence of gene-environment interactions and heterogeneity in response to therapy. This review summarizes the current state of knowledge on phenotype-driven treatment of asthma.
Evidence is accumulating that even standard therapies such as inhaled corticosteroids benefit some groups of asthmatic patients more than others. Macrolide antibiotics and antifungal agents are examples of drugs that have established indications outside the field of airways disease but which may benefit a subset of patients with asthma. Finally, new and expensive biological therapies for asthma are emerging that may be highly efficacious, but only for a selected group of patients.
The emergence of novel therapies, in particular highly specific treatments, bring the promise of improving healthcare in asthma but present the challenge of choosing the right therapy for the right patient. Phenotype-driven treatment of asthma is emerging as a potential reality and will pave the way for personalized healthcare.
Current Opinion in Allergy and Clinical Immunology 06/2011; 11(4):381-5. · 3.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Corresponding author's email: firstname.lastname@example.org Understanding the phenotypic heterogeneity of asthma is likely to shed light upon its immunopathogenesis. Introduction: To examine patterns of cytokine expression in different clinical phenotypes of severe asthma. Rationale: We performed k-means clustering on demographic, lung function, allergen testing and sputum induction data of 164 patients Methods: attending our Difficult Asthma Clinic. Sputum supernatant was analysed for 23 mediators using Meso Scale Discovery platform. The data obtained was reduced using principal component analysis. Factorial patterns of mediator expression were compared across clinical phenotypes. Using unbiased data reduction tools we were able to identify severe asthma clinical sub-phenotypes. Cluster analysis identified 4 Results: clinical phenotypes: A. Discordant high symptoms/non-eosinophilic, obese, normal FEV ‚; B. Late onset, concordant 1 symptoms/eosinophilia, normal FEV ‚; C. Early onset, discordant low symptoms/eosinophilia, low FEV ; D. Early onset, concordant 1 1 symptoms/eosinophilia, normal FEV ‚. The individual mediators did not differ significantly across clusters. Four cytokine factors were 1 identified 1. IL6R, IL8, TNFRI; 2. CXCL11, IL6, CCL5; 3. CCL26, IL13, IL5 and; 4. IL10, IL17, IL4. The factors loaded onto the clusters as shown in the figure below where data are shown as the mean factor loading ± SEM. Graph showing cytokine factor loading across clinical clusters Clinical phenotypes of severe asthma differ in their patterns of mediator expression. The biological basis of clinical disease Conclusion: expression requires further study. Clinical clustering is proving a useful tool at identifying underlying biology. This abstract is funded by: None
American Journal of Respiratory and Critical Care Medicine 05/2011; 183:A3179. · 11.99 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The importance of Aspergillus fumigatus sensitization and colonization of the airways in patients with asthma is unclear. Objectives: To define the relationship between the clinical and laboratory features of A. fumigatus-associated asthma.
We studied 79 patients with asthma (89% classed as GINA 4 or 5) classified into 3 groups according to A. fumigatus sensitization: (1) IgE-sensitized (immediate cutaneous reactivity > 3 mm and/or IgE > 0.35 kU/L); (2) IgG-only-sensitized (IgG > 40 mg/L); and (3) nonsensitized. These were compared with 14 healthy control subjects. Sputum culture was focused toward detection of A. fumigatus and compared with clinical assessment data.
A. fumigatus was cultured from 63% of IgE-sensitized patients with asthma (n = 40), 39% of IgG-only-sensitized patients with asthma (n = 13), 31% of nonsensitized patients with asthma (n = 26) and 7% of healthy control subjects (n = 14). Patients sensitized to A. fumigatus compared with nonsensitized patients with asthma had lower lung function (postbronchodilator FEV₁ % predicted, mean [SEM]: 68 [±5]% versus 88 [±5]%; P < 0.05), more bronchiectasis (68% versus 35%; P < 0.05), and more sputum neutrophils (median [interquartile range]: 80.9 [50.1-94.1]% versus 49.5 [21.2-71.4]%; P < 0.01). In a multilinear regression model, A. fumigatus-IgE sensitization and sputum neutrophil differential cell count were important predictors of lung function (P = 0.016), supported by culture of A. fumigatus (P = 0.046) and eosinophil differential cell count (P = 0.024).
A. fumigatus detection in sputum is associated with A. fumigatus-IgE sensitization, neutrophilic airway inflammation, and reduced lung function. This supports the concept that development of fixed airflow obstruction in asthma is consequent upon the damaging effects of airway colonization with A. fumigatus.
American Journal of Respiratory and Critical Care Medicine 12/2010; 182(11):1362-8. · 11.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A small minority of patients with asthma have severe disease that is refractory or poorly responsive and remain persistently symptomatic despite maximal inhaled therapy. These patients represent an important unmet clinical need as they suffer considerable morbidity and mortality and consume a disproportionately large amount of health care resource. Tumour necrosis factor- alpha (TNF-α) is a pro-inflammatory cytokine that has been implicated in many aspects of the airway pathology in asthma. Evidence is emerging to suggest that it may play an important role in severe, refractory disease. The development of novel TNF-α antagonist has allowed us to test the role of this cytokine in vivo. Early studies demonstrated an improvement in asthma quality-of-life, lung function, airway hyperresponsiveness (AHR) and a reduction in exacerbation frequency, in patients treated with anti-TNF-α therapy. However, there is marked heterogeneity in response suggesting that benefit is likely to be reserved to a small sub-group. This view is supported by the lack of efficacy in later large clinical trials, although subgroups of responders were identified. Importantly, concerns have been raised about the safety of anti-TNF-α therapies in severe asthma. Therefore, current evidence suggests that the risk of anti- TNF-α therapies outweighs benefit in severe asthma. In this review, we will discuss the role of TNF-α biology and its role in severe asthma, the clinical trials conducted so far and summarize the patents related to TNF-α and the antagonist drug therapies.
Recent Patents on Inflammation & Allergy Drug Discovery 11/2010; 4(3):193-200.
[Show abstract][Hide abstract] ABSTRACT: asthma exacerbations occur unpredictably, are a cause of morbidity and mortality, and contribute significantly to increased healthcare costs. Inhaled corticosteroids reduce exacerbations and improve quality of life.
the aetiopathology of asthma exacerbations is heterogeneous. Attempts to phenotype the heterogeneity of the pattern of airway inflammation by noninvasive monitoring of airway inflammation has identified a subgroup of patients with eosinophilic inflammation who are most likely to respond to steroid therapy. Strategies directed to normalize eosinophilic airway inflammation with corticosteroids have consistently led to a marked reduction in exacerbations. In contrast, their role in modulating the natural history of disease is less certain.
in the near future, improvements in our understanding of the mechanisms of exacerbations may identify therapeutic targets. While we await these developments, inhaled corticosteroids remain the first choice anti-inflammatory therapy for asthma.
Current opinion in pulmonary medicine 11/2010; 17(1):16-22. · 2.96 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Asthma and COPD are characterized by airway dysfunction and inflammation. Neutrophilic airway inflammation is a common feature of COPD and is recognized in asthma, particularly in severe disease. The T helper (Th) 17 cytokines IL-17A and IL-17F have been implicated in the development of neutrophilic airway inflammation, but their expression in asthma and COPD is uncertain.
We assessed IL-17A and IL-17F expression in the bronchial submucosa from 30 subjects with asthma, 10 ex-smokers with mild to moderate COPD, and 27 nonsmoking and 14 smoking control subjects. Sputum IL-17 concentration was measured in 165 subjects with asthma and 27 with COPD.
The median (interquartile range) IL-17A cells/mm² submucosa was increased in mild to moderate asthma (2.1 [2.4]) compared with healthy control subjects (0.4 [2.8]) but not in severe asthma (P = .04). In COPD, IL-17A(+) cells/mm² submucosa were increased (0.5 [3.7]) compared with nonsmoking control subjects (0 ) but not compared with smoking control subjects (P = .046). IL-17F(+) cells/mm² submucosa were increased in severe asthma (2.7 [3.6]) and mild to moderate asthma (1.6 [1.0]) compared with healthy controls subjects (0.7 [1.4]) (P = .001) but was not increased in subjects with COPD. IL-17A and IL-17F were not associated with increased neutrophilic inflammation, but IL-17F was correlated with the submucosal eosinophil count (rs = 0.5, P = .005). The sputum IL-17 concentration in COPD was increased compared with asthma (2 [0-7] pg/mL vs 0 [0-2] pg/mL, P < .0001) and was correlated with post-bronchodilator FEV₁% predicted (r = -0.5, P = .008) and FEV(1)/FVC (r = -0.4, P = .04).
Our findings support a potential role for the Th17 cytokines IL-17A and IL-17F in asthma and COPD, but do not demonstrate a relationship with neutrophilic inflammation.
[Show abstract][Hide abstract] ABSTRACT: Introduction: the increased exacerbation frequency and persistent airflow obstruction that characterise this subgroup. Attempts to identify the phenotypic heterogeneity that exists in this group will help characterization of the disease. Patients attending a tertiary centre Difficult Asthma Clinic over a 24 month period were characterized with the respect to Methods: demographics, presence of atopy, airway inflammation and lung function. The data was used to determine factors associated with a) frequent exacerbations (defined as ≥3 severe exacerbations requiring oral prednisolone in the past 12 months) and b) fixed airflow obstruction [FAO] defined as Post bronchodilator [PBD] FEV /FVC ratio<70% 1 predicted and FEV % predicted<80). 1 There were 203 subjects (124F) with a mean (sem) age of 49 (1) years, smoking history of 4 (1) pack years and atopy 42%. Lung Results: function showed PBD FEV /FVC ratio %predicted 71 (1), PBD FEV % predicted 78 (2). Sputum differential analysis revealed Neutrophils 61 1 1 (2) %, Eosinophils [geometric mean (95% CI)] 2.6 (2.0–3.4) % and severe exacerbations in past year 3.5 (0.3). There was no association with exacerbation frequency. For lung function univariate analysis revealed: (1) Sputum eosinophilia (Eos >3%) was associated with poorer FEV % predicted and higher 1 serum IgE levels; (2) Male asthmatics were older and had worse FAO Multivariate analysis using logistic and standard multiple regression revealed: (1) Males emerged as an important predictor of FAO (p=0.003, odds ratio (OR)=3.4), neutrophilic airway inflammation best predicted FAO among males (p=0.02, OR=1.04); (2)In females eosinophilic airway inflammation was associated with poorer lung function (R =0.16,p=0.003) (3) post BD FEV /FVC ratio was predicted by 2 1
American Journal of Respiratory and Critical Care Medicine 05/2010; 181:A3128. · 11.04 Impact Factor