Lung function is essential for good health and compromises in this capacity have a large and broad effect on the ability to lead a full and satisfying life. The NHLBI Lung Division convened a workshop in September 2013, at which pulmonary experts provided state-of-the-art status of prevention for several specific lung diseases, identified key questions, and considered approaches to facilitate prevention. The results of the workshop have been published in a special issue of the Annals of the American Thoracic Society.
Workshop participants distinguished two major concepts as uniquely important to primary prevention of lung disease: the promotion of lung health and the prevention of lung disease. The lung continues to develop in postnatal, early childhood, and young adult life, after which time lung function declines with aging. This offers intriguing opportunities, not only for promotion of healthy lungs, but also for interventions for development of healthier lungs by accelerating growth and/or slowing decline. Likewise, successful prevention of lung diseases requires clear demarcation of the pre-disease state from the onset of disease. In this context, a major barrier to health promotion and disease prevention is the current lack of biomarkers or proxy measures of lung health or disease. There was consensus that to achieve prevention, it is essential to more fully and comprehensively define what is lung health across the life course. This topic became the cornerstone of discussions and framed the approaches for metrics of prevention outcomes. The life course approaches take into consideration exposures, (i.e. biological, behavioral, and psychosocial) that operate across an individual’s life as well as across generations.
In addition to lung health, specific diseases under review and discussion included: asthma, bronchopulmonary dysplasia, chronic obstructive lung disease, cystic fibrosis, interstitial lung disease, and pulmonary hypertension. Generally, the recommendations from the workshop describe an approach to identify both the at-risk patient and the response that marks a shift from health to disease, as well as providing general strategies to begin to implement primary prevention interventions. A number of key points emerged during the workshop, which were common across disease areas, and had broad directive influence to establish programs of prevention.
- Standardization: There is a need for standardization across definitions, methodologies, and technologies such that data can be compared and/or integrated across studies.
- Lung health and disease: These are dynamic states and need to be defined using biologic phenomena as a foundation. Health is not merely the absence of disease. Symptoms, clinical outcomes and/or response to treatments may provide context to refine phenotypes and/or endotypes but should not be used as the basis for definition.
- Metrics of health: Population measures of lung physiology and defense across the life stages should be developed that identify relevant, specific markers for comparison to early disease.
- Existing cohorts: Data from existing studies should be leveraged to increase sample size and identify commonalities to aid description of new phenotypes and endotypes.
- Biomarkers: Biomarkers need to be identified and validated to distinguish health and the pre-disease state. These measures will be used to predict health status and risk, and should be quantifiable and modifiable.
- Prematurity: To the extent possible, sampling and longitudinal assessment of premature infants needs to be performed to determine trajectory of pulmonary and immune system development and abnormalities.
- Concomitant studies: A dual approach is needed to mechanistic and interventional studies in order to test approaches with preventive potential, within reasonable timeframes, while continuing to understand pulmonary and immune development and homeostasis.
- Novel technologies: Technologies need to be developed that can identify regional perturbations of lung biology and identify “at risk” individuals.
- Environmental modifications: Broad, low risk interventions (e.g. nutrition, smoking cessation, pre-natal care) need to be implemented at the population level to promote lung health and reduce risk.
These broad recommendations, along with the specific recommendations in the workshop summaries provide actionable next steps, which include identification of health, pre-disease, and disease phenotypes and endotypes, development of proxy measures such as genomic and proteomic biomarkers and imaging, determination of risk factors for disease in the general and high-risk populations, and strategies for development of clinical trials that will provide the basis for a paradigm changing approach to promote and enhance lung health and prevent chronic lung disease. We have already begun to see significant benefits of early identification of at-risk individuals with cystic fibrosis. The overall goal is to detect at-risk individuals using quantitative modifiable biomarkers that will allow effective prevention of a wide-variety of lung diseases and ensure optimal lung health over the entire life of an individual. A workshop executive summary of this workshop was published in the Annals of the American Thoracic Society (Vol. 11, No. Supplement 3 (2014), pp. S123-S124).
- William Busse, M.D., University of Wisconsin School of Medicine and Public Health
- Serpil Erzurum, MD, Cleveland Clinic
- John V. Fahy, M.D., M.Sc. , University of California at San Francisco
- Tina V. Hartert, MD, MPH, Vanderbilt University School of Medicine
- Daniel J. Jackson, M.D., University of Wisconsin, Madison
- Fernando Martinez, M.D., University of Arizona
- Scott T. Weiss, MD, MS, Brigham and Women's Hospital
Bronchopulmonary Dysplasia (BPD)
- Judy L. Aschner, MD, Albert Einstein College of Medicine
- Eduardo Bancalari MD, University of Miami
- Lucky Jain, MD, Emory University School of Medicine
- Cindy McEvoy, MD, MCR, Oregon Health & Science University
- Barbara Schmidt, MD, Children’s Hospital of Philadelphia
Chronic Obstructive Pulmonary Disease (COPD)
- Stephen I. Rennard, MD, University of Nebraska Medical Center
- Sonia Buist, M.D., Oregon Health and Science University
- James D. Crapo, MD, National Jewish Health and University of Colorado Denver
- M. Brad Drummond, MD, MHS , Johns Hopkins University School of Medicine
- Robert A. Wise, MD, Johns Hopkins University
Cystic Fibrosis (CF)
- Richard C. Boucher, M.D., The University of North Carolina at Chapel Hill
- Garry R. Cutting, MD, Johns Hopkins University School of Medicine
- Stephanie Davis, MD, Indiana University
- Thomas W. Ferkol, Jr., MD, Washington University in St. Louis
- Jessica Pittman, MD, MPH, University of North Carolina at Chapel Hill
Interstitial Lung Disease (ILD)
- Fernando Jose Martinez, MD, MS, University of Michigan Health System
- David J. Lederer, MD, MS, Columbia University Medical Center
- Ivan O. Rosas, MD, Brigham and Women's Hospital
- Lisa R. Young, MD, Vanderbilt University School of Medicine
- Paul F. Dellaripa, MD, Brigham and Women's Hospital
- Dinesh Khanna, MD, University of Michigan Health System
- Steven H. Abman, MD, University of Colorado School of Medicine and Children's Hospital Colorado
- Eric Austin, MD, MSCI , Vanderbilt University Medical Center
- Mark T. Gladwin, MD, University of Pittsburgh Medical Center
- Steve Kawut, MD, University of Pennsylvania School of Medicine
Lung Health Promotion
- Carlos A. Camargo, Jr., MD, DrPH, Harvard Medical School, Massachusetts General Hospital
- Gregory R. “Scott” Budinger, MD, Northwestern University
- Gabriel J. Escobar, MD, Kaiser Permanente Division of Research
- Nadia N. Hansel, MD, MPH, Johns Hopkins University
- Corrine K. (Corri) Hanson, PhD, RD, University of Nebraska Medical Center
- Gary B. Huffnagle, PhD, University of Michigan Medical Center
- Veronica Gunn, MD, MPH, FAAP, Children's Hospital of Wisconsin
- Daniel Levy, MD, Leader, Framingham Heart Study, NHLBI
- Jeffrey R. Galvin, MD, University of Maryland School of Medicine
- Teri J. Franks, MD, The Joint Pathology Center
- Tim Le Cras, PhD, Cincinnati Children's Hospital Medical Center
- Robert F. Lemanske, Jr., M.D., University of Wisconsin
- Lisa A. Miller, Ph.D., UC Davis School of Veterinary Medicine California National Primate Research Center
Michael A. O'Reilly, Ph.D. , The University of Rochester
- Lawrence S. (Lance) Prince, MD, PhD, University of California, San Diego
- Gary H. Gibbons, MD
- James Kiley, PhD- DLD
- Patricia Noel, PhD- DLD
- Carol Blaisdell, MD- DLD
- Virginia Taggart, MPH- DLD
- Antonello Punturieri, MD, PhD- DLD
- Susan Banks-Schlegel, PhD- DLD
- Jerry Eu, MD- DLD
- Tim Moore, MD PhD- DLD
- Michelle M. Freemer, M.D.- DLD