ETIOPATHOGENESIS OF ASTHMA

Asthma usually occurs as a consequence of genetic factors interacting with environment and

lifestyle of an individual.

Etiology: The exact etiology for asthma has not been clearly defines but occurs due to

interaction between environmental exposures and inherent biological and genetic

vulnerabilities.1.

Genetics and epigenetics: It has been recognised for long, that genetics contributes to the

development of asthma, based on the observation that asthma tends to cluster in families.

Familial aggregation studies have compared disease occurrence in families and concluded

that asthma is common not only in siblings but also in parent and child. This could be due to

shared genes or shared environment. Increased aggregation between spouses suggests that

environment also plays a role.

Monozygotic twins have a higher concordance rate (19.8%) when compared to dizygotic

twins (4.8%) pairs which suggests that genetic factors contribute to asthma. 2 (Middleton

textbook 8th edition)

Asthma does not follow simple Mendelian inheritance characteristics. Identification of

genetic variants that contribute to asthma susceptibility has been done by genome-wide

association analysis (GWAS). It identified genetic variants at chromosome which regulates

ORMDL3 expression as a risk factor for childhood asthma.3

The first asthma-susceptibility locus to be identified by a GWAS was on chromosome 17q12-

21. This locus encompasses the ORMDL3 and GSDMB genes. Several single nuclear

polymorphisms (SNP) on this locus are associated with childhood and adult asthma

particularly in those who were exposed to environmental tobacco smoke in early life. 4
The genes involved in the development of asthma are classified as: 2

1.Genes involved in Th2 inflammation (IL-13, GATA3, TBX21, IL-4, STAT6, IRAK3,

PHF11, IL-33 etc.)

2.Genes involved in modulating response to environment (CD14 TLR4, GST gene)

3.Genes which play a role in maintaining epithelial barrier (PCDH1, IL-33, IL-6R, NPSR 1

4.Genes that are involved in tissue response to inflammation. (ADAM 33, PDE4D, SMAD3,

CDHR3)

5. Genes involved in pharmacogenetics (ADRB2, ALOX5, CRHR1)

Importance of knowing genetics in asthma:

1. Identifying susceptible individuals through screening and planning early intervention

in them.

2. Predicting therapeutic responses and tailoring treatment accordingly.

3. Understanding the genes involved in pathogenesis help to innovate new therapies. In

future, gene therapy hold potential to prevent or cure asthma in genetically

susceptible individuals.

Pitfalls:

These genes are not proven to be sensitive or specific predictor of asthma. There is no direct

relation between the genetic differences and clinical markers like IgE. Hence genetics is one of the

predisposing factors for asthma along with host and environmental factors. So, considering genetics

in isolation may not have much clinical relevance in all patients.

Epigenetics:

Epigenetics describes mechanisms of (heritable) regulation of gene expression that occur

without changes in DNA sequence. They occur in response to the environment, aging and

disease. Epigenetic processes are cell-type and tissue specific and modifiable. In recent

years, there has been an emerging role of epigenetic mechanisms, as transducers of signals

provided by pre- and/or perinatal exposures that influence the trajectory of childhood asthma

and modify risk for this disease.

Epigenetic mechanisms which contribute to childhood asthma are:5

1. DNA methylation:

2. Histone modification

3. Regulation of noncoding RNAs.

Prenatal exposures & DNA methylation: Exposures to the following in the antenatal period

modulate DNA methylation: 6,7,8

1. Maternal smoking

2. Maternal asthma

3. Maternal stress

4. Maternal obesity

5. Maternal diet during pregnancy

6. Exposure to particulate air pollution more specifically diesel exhaust particles (DEPs)

Role of histone modifications in asthma: Histone deacetylases (HDACs) is an enzyme that

regulates the development and functions of T lymphocytes. Animal studies have

demonstrated increase in Th2 cytokines and eosinophil recruitment into the lung, mucus

hypersecretion, parenchymal lung inflammation and increased airway resistance, suggesting

airway inflammation due to deletion of HDAC1 in T-cell lineage. Thus HDACs contribute to

development of asthma.

Environmental exposures & histone modifications:

Exposure to farm environment in prenatal period can cause histone modification and DNA

methylation in genes encoding the Th1 cytokine (IFN-γ) and Th2 cytokines (i.e., IL-4, IL-5

and IL-13), reducing risk of asthma.7

Micro RNA (miRNA):9 miRNAs are small single stranded RNAs which causes supress gene

expression. They play a role in immune development and differentiation, airway inflammation

airway hyper responsiveness.

AntagomiRs (anti mi-R):9 These are chemically engineered nucleotides that can antagonise

the actions of miRNAs. They may be useful in the treatment of asthma in future.

miR-21:10,11 This mRNA is found to be upregulated in many animal models which had

airway eosinophilia. It is one of the most over expressed mi RNA in inflamed lung tissue,

macrophages and dendritic cells. The role of miRNAs studied in human asthmatic subjects

and their effects in etiopathogenesis in asthma is given in Table I

Table 1: Role of miRNA in animal studies

miRNA Expression Target Effect
let7 Reduced Il- 13 (increases TH2 Increased IL-13 Increased TH2
response) response

miR-21 Increased IL-12 which helps in TH1 Decreased IL-12 & increased TH2
response response
miR-133a Downregulated IL-13 (airway smooth Increased IL-13 and airway
muscle specific) hyperreactivity
miR-106a Upregulated IL-10 Increased IL-10 &TH2 response
Airway hyperreactivity
 miR-145 Upregulated Increases eosinophil infiltration,
mucus production, Th2 cytokines
& airway hyperactivity

Table 2: Role of miRNA in humans

miRNA Expression Target Effect

miR-221 Upregulation SPRED2- protein Increased airway
miR146a &miR146b which decreases inflammation
airway inflammation
miR 146 a & b Downregulation CD4 & CD8 cells Increased
inflammation
miR28-5p Downregulation CD8 cells Increased
inflammation
miR-let7 Upregulated Associated with mid
miR-486 expiratory flow in
miR-1260 asthmatics (ME75)

Environmental exposures & miRNAs: 1. Exposure to diesel exhaust particles (DEP) can

lead to significant upregulation of miR-513a-5p, miR-494 and miR-923, and downregulation

of miR-96 in normal human bronchial epithelial cells and initiate asthma pathogenesis.12

Role of mi RNA in asthma:

1. They can polarise the adaptive immune response to TH1/ TH2 pathway.

2. They can be used as biomarkers for disease diagnosis and prognosis.

3. They can reverse an established phenotype.

4. Regulate epigenetic mechanisms.

5. Potential targets for asthma treatment in future

RISK FACTORS FOR ASTHMA:
The foetal onset of adult disorders hypothesis proposes that during critical periods of early

life, nutritional and environmental exposures can induce permanent long-term changes in

metabolic and immune physiology of the host leading to susceptibility to chronic diseases.

Hence, the trajectory of asthma begins from the in-utero period itself. Ref needed

I. PERINATAL FACTORS: In the perinatal period, the presence of the following factors can

influence the development of asthma.

A) Maternal factors:

1.Tobacco smoking- both active and passive during pregnancy, has been postulated to cause

asthma in children. 14 The association of 17q21 variants with asthma is enhanced in children

who have respiratory infections before 2 years of age, particularly in those also exposed to

tobacco smoke. 15

2.Maternal diet and nutrition: Increased risk for asthma: Diet high in sugar, sweetened

beverages were associated with 50-70% increased risk of asthma in offspring.16

3.Maternal obesity: Obesity during pregnancy is a significant risk factor for the

development of asthma in the offspring.17

4.Maternal intake of paracetamol: It is associated with a high risk of asthma in the child. 18

B) Fetal and newborn factors: Prematurity, low birth weight, low weight gain (growth) of

fetus in the first and second trimester of intrauterine period and LSCS delivery have

increased likelihood of asthma.19,20,21

II. EARLY CHILDHOOD:

1. Sex: Boys have smaller airways and lung size as compared to girls and therefore

prevalence of asthma is higher in young boys compared to girls. However, this

changes in adolescence with the prevalence being 20% higher in women compared to

men probably due to the switch in puberty. 22

2. Childhood diet and nutrition: Diet of a child has an impact on the development of

allergic disorders like asthma. Introduction of infant formula before 14 weeks of life

is known to increase the risk of non-atopic asthma in later childhood. 23

3. Rapid weight gain in infancy and obesity in childhood are also risk factors for

development of asthma. 24, 25

Obesity is a strong preventable risk factor for asthma, however overweight is only a

moderate risk factor. The risk of asthma increased from 8% to 17% in overweight

children whereas in obese children it increased from 26% to 38%. 26 Obese children

have increased asthma severity and a poor disease control because of decreased

response to asthma medications.25 This could be possibly because of the common

genetic background, changes in the lung function, changes in the physical activity and

diet, increased insulin resistance and systemic inflammation. 26

4. Atopy: The tendency to inappropriately produce IgE antibody in response to an

allergen defines atopy.

 Figure 2: Atopic march

Atopic march: Atopic march is the typical sequence of progression of different

atopic conditions. Atopic dermatitis (AD) is the first condition which manifests in

infancy, followed by food allergy, asthma, and allergic rhinitis.27 Atopy in childhood

has a strong impact on persistence of asthma.28

Children with AD and allergic sensitization have 7 times higher risk of asthma at age

3 years.29 Family history of atopy in infantile AD also increases the risk of allergic

disorders and asthma later in life which suggests that genetics has a role to play in

atopic march .29

5.Infections: Viral infections are documented in 90% of children who have wheeze

associated lower respiratory tract infection in infancy.28 Early viral infections, immune

responses of the host and interactions with allergic sensitization, altogether have a role to

play in the development of asthma.30

Reasons for viral infections causing asthma:30

a) The infections which occur in early infancy affect the lung during its crucial period of

development resulting in long lasting damage of the airways.

b) Polymorphisms related to genes, which are related to immune regulation.

c) Decreased expression of interferon IFN- ģ

Around 90% of the children with RV-induced wheezing in the third year of life have

asthma by the age of 6 years.30,31

The reason for this is:30

a) Genetic variation at the 17q21 locus

b) Stimulation of IL-25 and IL-33 and induction of Type 2 inflammation.

c) Disruption of the airway epithelial barrier leading to easy access and absorption of

aeroallergens

d) Repeated HRV infections cause Vascular Endothelial Growth Factor (VEGF) and

TGF-β mediated airway remodeling.

➢ Respiratory Syncytial Virus (RSV): A Finish Study reported that children who are

hospitalized for RSV bronchiolitis before 2 years of age have an increased risk of

asthma at 15–18 years of age .The severity of RSV bronchiolitis is proportional to the

risk of future asthma.30

➢ Helminth infections:18 Modulation of host immune responses towards TH1

inflammatory response due to helminthic infections in childhood can protect against

asthma in later life. This is the basis of hygiene hypothesis. This hypothesis is also

supported by microflora hypothesis and biodiversity hypothesis, which state that

interaction with microbes may prevent asthma. Exposure of children to farm

environment and consumption of raw farm milk lowers the risk of asthma in children.
 6.Antibiotic use: Antibiotic exposure during pregnancy or infancy elevates the risk of

childhood asthma. This could be probably due to alteration in gut flora and increasing

TH2 responses.32

III. ENVIRONMENTAL RISK FACTORS

a) Outdoor pollutants: Particulate matter, volatile organic compounds, nitrous oxide,

nitric oxide, carbon monoxide, ozone, sulfur dioxide are the major air pollutants from

automobile exhausts, power plant emissions, open burning of solid waste and

construction related activities. Exposure to outdoor air pollutants has proven to

influence the development of asthma and asthma exacerbations.33 These pollutants

increase systemic inflammation, decrease lung function and increase bronchial

hyperresponsiveness. Young children are particularly susceptible, while atopy, stress

and obesity modify the susceptibility to air pollution.

Diesel exhaust particles (DEPs): DEPs constitute more than 90% of particulate

matters (PM) generated from traffic sources in European and American cities. The

size of particles is more than one micrometer (um) in diameter in 90% of DEPmass

and can get easily deposited in the lung inducing inflammatory pathways.34,35

According to the latest GINA guidelines, around 13% of cases of asthma globally are

due to traffic related air pollution (TRAP).18 An Indian study also showed that asthma

was more prevalent in children living close to areas with traffic congestion compared

to those living in areas with less traffic.36

Particulate matter 2.5 (PM2.5): This size of PM constitutes a large proportion of

atmospheric particulate matter. Exposure to this can result in oxidative stress and

inflammation, thereby predisposing children and adults to develop asthma and

increase the severity in those who have asthma.

 Aeroallergens: Aeroallergens (house dust mite (HDM), animal dander, molds,

cockroach, grass, pollens) also play an important role in the development of asthma.

The early sensitization to aeroallergens is a strong risk factor for development and

persistence of asthma.28

b) Indoor pollutants: Children can be exposed to indoor pollution right from the in-

utero period and in the early years of life. This includes combustion-source emissions

from cooking stoves and ovens, space heaters fueled by gas or kerosene, wood-

burning stoves or fireplaces and tobacco smoking; volatile and semi-volatile organic

compounds released from household products, furnishings, and other sources; and

allergens from insects, molds, mites, rodents, and pets. Since the respiratory system is

rapidly developing, they are more prone to inflammation due to these pollutants. 37

Low lung function in early life is an independent risk factor for persistent asthma. 28

Environmental tobacco smoke (ETS): This includes sidestream smoke from the

burning end of the cigarette and exhaled mainstream smoke from the smoker.

ETS exposure, particularly in early life, is a major risk factor for asthma

development. A systematic review identified that exposure to maternal (prenatal and

postnatal), paternal, and household sources of cigarette smoke was associated with an

increased likelihood of children wheezing up to the age of 18 years. Even electronic

nicotinic delivery devices are not safe. 38

Mold exposure: Exposure to mold is an independent risk factor for asthma. 39

IV. OTHER FACTORS:

 Socioeconomic factors: Children belonging to families of lower socioeconomic

status have a higher risk of wheezing in early life and development of asthma later in

life. 40

Psychosocial factors: Mothers who experience stress in antenatal period and during

the early years of their child’s life have increased risk of asthma in their children. 18

PROTECTIVE FACTORS:

A) Maternal:

1.Vitamin D: Vitamin D Antenatal Asthma Reduction Trial (VDAART) trial has concluded

that, in mothers who have a baseline vitamin D concentration >30 ng/ml, supplementing

high-dose vitamin D (4400 IU/day) is beneficial towards reducing the risk of wheezing and

asthma in the offspring compared to supplementation of low-dose vitamin D ( 400IU/day)

in mothers with baseline vitamin D concentration of less than 20 ng/mL .41 Hence, the

guidelines advocate maintaining sufficient levels of Vitamin D levels is important in early

pregnancy to prevent asthma in children.18

2. Selenium: The role of selenium in the diet of pregnant has been proven in reducing the

risk of asthma in the offspring.

B) CHILDHOOD FACTORS:

1. Breast-feeding: Human milk contains substances that promote innate and adaptive

immunity in a child. Infants who are breast-fed have reduced incidence of wheezing

in infancy and have lesser probability of developing asthma at 3 years of age as per a

Canadian study.42 The protective effect of breast milk reduced when infant formula

was supplemented whereas supplementing solid foods did not have a similar effect.

Direct breast-feeding provided more protection to wheezing as compared to breast

 milk fed using a bottle.43 The process of feeding on breast serves as a good

stimulation for lung growth and provides exposure to protective maternal skin

microbiota. Thus, feeding mode is important to consider in breastfeeding.

2. Early introduction of fish (<43 weeks) reduced the risk of asthma.44

3. A diet rich in fruits and vegetables like the Mediterranean diet has been found

protective against the development of asthma compared to the Western diet, possibly

due to rich content of vitamins, minerals, fibre and antioxidants.45

4. Vitamin D: Vitamin D plays an important role in lung development and

immunological functions.

5. Physical Activity: Physical activity has shown to reduce the risk of asthma in

adulthood. 48
PATHOGENESIS OF ASTHMA

The pulmonary epithelium is an immunologically active structure which acts as a barrier to

prevent entry of allergens and pathogens. When a host is susceptible to allergic disorders, the

barrier and immune function gets altered resulting in a “leaky” airway. This permits the entry

of antigens and allergens through the epithelium. This results in allergic sensitization, key

component of asthma in children. Immunologic and inflammatory mechanisms play a

major role in asthma etiology and natural history.

Innate Immune system: Allergic sensitization, inflammation, and asthma may originate

during aberrant innate immune development.

Mast cell is a cardinal cell of the innate immune system. It contributes towards maintenance

of tissue homeostasis, wound repair, and protective responses to bacterial infection. Allergic

symptoms manifest in a host when there is “misguided” activation of mast cells by allergens.

These cells maintain a sustained release of numerous pro-inflammatory mediators, proteases,

and cytokines within specific tissue structures when there is an ongoing tissue insult. This

contributes to the pathophysiology of various chronic inflammatory diseases like asthma.

They recognize antigens and give immediate and direct innate immune responses. They

express Toll- like receptors (TLR1, TLR2, TLR4, and TLR6) and complement receptors for

C3a and C5a88.

Activation of mast cells: A high-affinity IgE receptor FcεRI is present on the mast cells.

The structure of this receptor stabilizes by the binding of IgE resulting in activation of mast

cells.

Expression of class II MHC antigens on mast cells helps in presenting soluble antigens to T

cells resulting in T cell proliferation. Through the release of IL-4, they help Th2 cell

proliferation. This could occur in the absence of IgE, because a number of diverse allergens

including bee venom phospholipase (PLA2) and house dust mite antigen Der p I induce the

release of histamine and IL-4 from mast cells in the absence of cell-bound IgE.49

Histamine released by mast cells helps in maturation of dendritic cells. It also increases IL-10

and decreases IL-12 production by mature dendritic cells (DC), resulting in naïve T cells

becoming polarized toward a Th2 phenotype. TNF-α released by the mast cell is important for

dendritic cell migration during immune responses.

Table 3: Role of these mediators produced by mast cells

Mediator Effect

Histamine Bronchoconstriction, ↑ mucus secretion, ↑ vascular

permeability & tissue edema, ↑ fibroblast proliferation &
collagen synthesis, maturation & activation of DC

Tryptase (stored) Degrades respiratory allergens, activatesTGF-β generates C3a,

↑ fibroblast proliferation and collagen synthesis

Heparin (stored) Sequesters growth factors and fibroblast activation

Chymase (stored) ↑ mucus secretion, activates IL-1β, degrades IL-4

Extracellular matrix degradation, type I procollagen
processing; ↓ T cell adhesion to airway smooth muscle;

Prostaglandins Bronchoconstriction; tissue edema; ↑ mucus secretion; DC

PGD2 (synthesized) activation; chemotaxis of eosinophils, basophils &Th2 cells

Leukotrienes Bronchoconstriction; tissue edema; ↑ mucus secretion

Releases: - IL-13 (helps airway smooth muscle proliferation)
LTC4/LTD4(synthesized)
DC maturation and recruitment; IL-4 secretion; mast cell IL-5,
IL-8, and TNF-α secretion; tissue fibrosis

DC= Dendritic cell

Role in acute asthma: The mediators released from mast cells cause bronchoconstriction,

mucosal oedema and mucus secretion in a sensitised individual leading to an acute attack of

asthma.

Role in chronic allergic asthma: Mast cells are in an activated state and degranulate

continuously in the airway epithelium and smooth muscles of chronic allergic asthmatics.
This is evident by the study of bronchoalveolar lavage (BAL) fluid in chronic asthma which

has shown increased numbers of mast cells and elevated levels of histamine and tryptase.50

Adaptive immunity:

Adaptive immunity has the ability to distinguish innocuous foreign antigens (allergens) from

the self-antigens. Allergy develops when an immune response is generated to a

nonpathogenic antigen and is repeatedly elicited throughout the life of the individual.

The response in adaptive immunity is amplified with repeated exposures.

ROLE OF LYMPHOCYTES:

T LYMPHOCYTES: The naïve T cells (TH0) remain in the thymus gland. On binding of

antigen presenting cells (APC) to resting T cells, they get transformed to activated T cells in

the presence of several interleukins like IL-1, IL-4, IL-6) and TNF-α.

There are two major T lymphocyte subtypes known as the Helper T cells (CD4+ cells) and

the cytotoxic T cells (CD8 +cells). Less than 10% of mature T cells emerge from the thymus

which are CD4−/CD8−

Helper T cells or CD4 cells: They are further classified as Th1 and Th2 cells. IL-4 helps in

the differentiation of Th0 cells into Th2 cells. In asthma, the Th2 cytokines are often elevated.

The dysregulation of Th2/ Th1 lymphocytes remains a common hypothesis in pathogenesis of

asthma.51

Th2 cells are the most important cells needed to induce and maintain allergy and

inflammation. They release cytokines like IL-4, IL-5 and IL-13. Th2 cells exert their effect

on immunologic responses to parasites with augmentation of inflammation from Ig E

production and eosinophilic infiltration.

Type 2 innate lymphoid cells (ILC2s): These lymphocytes are a part of innate immunity

and generate cytokines IL-5 and IL-13. This induces airway hyper-reactivity (AHR), mucus

secretion, and eosinophilic aggregation. ILC2 can play a role in acquired immunity as well by

promoting B lymphocytes to produce IgE. Research has shown that subcutaneous

immunotherapy (SCIT) aims at reducing the ILC2 cells.

Regulatory T cells (Treg cells): Treg cells downregulate Th2 cells and their inflammatory

actions by secreting TGF-β. Thus, Treg cells have an important role to play in the

pathogenesis of asthma. Impaired functions of Treg cells have been demonstrated in patients

with asthma.52

There are two types of Treg cells:2 (1) Natural Treg cells and (2) Inducible or adaptive Treg

cells.

Natural Treg cells constitute about 1% to 5% of the CD4+ cells in the blood. They are

CD4+CD25+. They originate in the thymus and proliferate in the periphery on exposure to an

antigen.

Antigen-specific adaptive Treg cells: They are induced by immunization with antigen or by

natural exposure to antigen in the environment. Adaptive Treg cells have exhibited cytokine

mediated (IL-10 and TGF B) suppression of Th2 inflammation.

Th17 cells: Th17 cells induce neutrophilic inflammation and provide protection against

extracellular microbes. The activity of Th17 cells is upregulated in asthma. The severity and

symptom control of asthma is mediated by the imbalance of Th17/Treg cells.

B LYMPHOCYTES:

Isotype switching to produce IgE involves further rearrangement of Ig heavy-chain genes and

DNA splicing and this process is under T cell control mediated by IL-4.

Allergic sensitization: The phenomenon of release of Ig E into the circulation and

pulmonary tissue to prepare the host to mount a response when there is re exposure to an

allergen.

Secondary immune response: In sensitized individuals, when there is a repeat exposure to

these antigens, the memory B cells encounter this known antigen. Plasma cells are formed

just like the primary response but it is faster and intense compared to the primary one.

The IgE antibody, which is formed, recognizes the antigen and it binds to the mast cells

resulting in degranulation of the mast cells to release histamine, tryptase, leukotrienes, and

prostaglandins. This Type 1 Hypersensitivity reaction results in airway edema, smooth

muscle and mucus gland hypertrophy and mucus hypersecretion resulting in

bronchoconstriction and limitation of airflow.

IgE: The predisposition to inappropriately produce IgE antibody against an allergen defines

atopy. IgE also plays a key role in responses to parasitic infections. The cytokines IL-4 and

IL-13 alongwith some synergism provided by IL-9 help induce the production of IgE. IFN-γ

and IL-21 are important inhibitors of IgE isotype switch.

Table 4: Role of inflammatory cytokines 2,53

Cytokine Cell of origin Action Role in asthma

IL-1 Mono Activation of CD4cells,
Augments B cell
proliferation & Ig synthesis.

IL-2 TH1 cells, Eos Clonal proliferation of T- Increased

cells, Activation of B cell,
macro & CD8 cells
IL-3 TH1 &TH2 cells, Eos activation and survival Increased
Eos, Mono/ Macro, Baso proliferation
Baso, Fib
IL-4 TH2 cells, Eos, MC, Promotes TH2 proliferation Increased
Baso Induces lympho aggregation
Promotes humoral response
IL-5 TH2, Eos, MC, Baso Proliferation of Eos Increased
Prolongs Eos survival
chemotaxis, baso
differentiation
IL -6 TH1 &TH2 cells, Production of Ig by B cells, Increased
Mono & Macro IL-4 production, TH17 cells
formation
IL-9 TH2 cells (Main Promotes MC actions & Increased
source) IgE production, Acute Allergic
MC Favors Eos maturation& response,
activation mucus secretion

IL-10 T cells, Treg Favors B cell production of Decreased

Macro IgG 4
Suppress inflammation
 IL-12 Macro & B cells Favors TH1 response Decreased
Inhibits IgE

IL-13 TH2 cells, Eos, MC, Airway remodelling, mucus Increased

Baso secretion

GM-CSF TH1 &TH2 cells Activation and Increased

differentiation of Eos, Neu,
MC, increases airway
inflammation
TNF-a Mac, NK cells, T Endothelial and epithelial Increased
cells cell activation

TGF-β Eos, MC, Baso, T Suppresses TH1/TH2 Increased

cells, Mono, Mac function, favours Treg
induction, fibrosis inhibits
IgE synthesis
Treg- T-cell regulatory cell; Eos, eosinophil; Neu, neutrophil; Baso, basophil; MC= mast

cell; Mac, macrophage; Mono, monocyte; Fib, fibroblast; TGF, transforming growth factor.

Anti-inflammatory cytokines:

IFN r TH1 cells Formation of Mac Increased in viral

NK cells for phagocytosis
SuppressTH2 infections and

inflammation exacerbations

TGF-β: Eos, Tcells, Fib Promotes fibrosis & Increased

airway remodelling,
Decreases
lymphocyte & MC
activity

Role of Eosinophils:2,
Eosinophils are a hallmark feature of allergic inflammation. They are recruited by cytokines

and chemokines like IL-5, RANTES (Regulated upon Activation, Normal Tcell Expressed

and Secreted) and eotaxin to the airway of asthmatic children.

Table 5: Mediators produced by eosinophils

Class Mediators

Granule EMBP, ECP, EDN, EP, sPLA2, acid phosphatase, Epithelial injury
arylsulfatase, β-Glucuronidase, BPI
proteins Charcot-Leyden crystal (CLC)

Lipid Leukotriene C4, Platelet-activating factor (PAF), Acute

Mediators Prostaglandin E1 and E2, Thromboxane B2 inflammation

Cytokines IL-1α, IL-2, IL-3, IL-4, IL-5, IL-6, IL-9, IL-10, IL-11, Eosinophil
recruitment
IL-12, IL-13, IL-16, IFN-γ, TNF-α, GM-CSF &survival

Chemokines CCL2,CCL3,CCL5(RANTES)CCL7,CCL11(eotaxin), Same as above

CCL13, CXCL8, (MIP-1α),

Growth NGF, PDGF, SCF, TGF-α, TGF-β

Factors
 Enzymes Collagenase, Metalloproteinase-9 Tissue damage
& remodelling

Oxidative Superoxide radical anion (OH−), Hydrogen peroxide Cytotoxic to

tissues &
products (H2O2) microbes

EBMP= eosinophil major basic protein, ECP= eosinophil cationic protein, EDN= eosinophil-derived

neurotoxin, EP=Eosinophil peroxidase, sPLA2=Protein Secretory phospholipase A2, BPI=Bactericidal

inducing protein, NGF= Nerve growth factor, PDGF= SCF Platelet-derived growth factor, SCF=Stem cell

factor, TGF= Transforming growth factor, RANTES = Regulated upon Activation, Normal Tcell

Expressed and Secreted

Major Basic Protein: It acts as a M2 receptor antagonist leading to increased acetylcholine

(Ach) because of loss of M2 receptor inhibitory feedback on Ach. This causes

bronchoconstriction.

EDN – activates dendritic cells, increases TH2 responses and is a chemoattractant .

Enzymes: They release highly inflammatory granules and associated substances which injure

the airways and cause persistent inflammation, increase airway hyperresponsiveness (AHR)

and cause degranulation of mast cells and basophils s acids

Lipid mediators:
The main substrate for these mediators is arachidonic acid (AA), which is specifically

liberated from membrane phospholipids. Lipid bodies in eosinophils also serve as sites for

storage of esterified AA. Arachidonic acid undergoes metabolism by Lipoxygenase pathway

to produce leukotrienes (LTA4, LTB4, LTC4, LTD4, LTE4) and 5-hydroxyeicosatetraenoic

acid (5-HETE) and by cyclooxygenase pathway to produce prostaglandins, thromboxane and

prostacyclin. LTC4 and 5-HETE are the main leukotriene mediators produced in eosinophils.

IL-5 primes eosinophils for production of cysteinyl leukotrienes. Eosinophils can generate

relatively large amounts of LTC4 but only negligible amounts of LTB4. LTB4 is one of the

most potent chemoattractant and its role in asthma is due to its actions on high affinity BLT1

receptor which is expressed mainly on leucocytes (granulocytes, macrophages, monocytes,

DCs, and eosinophils) which are involved in asthma pathogenesis. Activation of BLT1

receptors causes chemotaxis of these immune cells and inflammation. Children with asthma

have a higher proportion of cells which express BLT1 receptors compared to those without

the disease.

Cysteinyl leukotrienes (Cys LTs)- LTC4, LTD4 & LTE4 activate CysLT1 and CysLT2

receptors. CysLT1 receptor is present on smooth muscles of the bronchi whereas CysLT2 is

expressed on vascular endothelial cells. Eosinophils, mast cells and macrophages produce

these mediators in response to a variety of stimuli. Their action is bronchoconstriction,

recruitment of eosinophils, increased vascular permeability and chronic inflammation.

Thus, inhibiting the action of leukotrienes has a beneficial effect in patients with asthma.

Two classes of drugs which act as leukotriene modifiers are used in asthma:53

Leukotriene synthesis inhibitor: Zileuton and Leukotriene Receptor Antagonists (LTRA):

Montelukast, Zafirlukast
Fig 6: Interaction of Eosinophils with the autonomic nervous system 56

The sensory nerve is the vagus nerve and the efferent nerves are the parasympathetic nerves.

Both innervate the airways and help to maintain airway tone and provoke

bronchoconstriction. They communicate through a central pathway known as a neuronal

reflex. Sensory nerves, through this pathway stimulate the parasympathetic nerves to release

acetylcholine ACh which binds M3 muscarinic receptors airway smooth muscle and induces

reflex bronchoconstriction. Simultaneously, ACh also exerts auto inhibition by activating the

prejunctional inhibitory M2 muscarinic receptors that reduce its release and limit

bronchoconstriction.

A variety of stimuli like cold air, exercise , allergens , methacholine and histamine induce

reflex bronchoconstriction.
Role of Eosinophil Major Basic Protein (EMBP): Eosinophils densely surround the airways

of asthmatic children. They release EMBP which functions as a M2 receptor antagonist,

thereby not limiting the release of Ach from parasympathetic nerves leading to

bronchoconstriction. Hence, in asthma M2 receptor tiotropium reverse bronchoconstriction.

. Autonomic dysfunction has been observed in children with asthma when compared to

healthy children. Asthma severity is directly proportional to the vagal activity even when an

asthmatic child is stable. However, contradictory to the hypothesis of vagal hyperactivity

during flare ups, it ha been observe that there is sympathetic activation during this period.

Role in inflammation: Neural mechanisms also play a role in regulating inflammation in

asthma. The activation of the vagus nerve leads to inhibition of the activation of

macrophages and the synthesis of TNFα as well as the activation of the reticuloendothelial

system for the release of acetylcholine.57

CHRONIC ASTHMA: Chronic asthma is characterised by increased Th2 inflammatory

response in the airway.

Airflow limitation: Reversible and variable airflow limitations are key features of asthma.

Airway hyper responsiveness: Airways of asthmatic patients are hyper-responsive. These

airways react to a lower dose of, and are more responsive to, a bronchoconstrictor than the

airways of normal individuals.Airway wall thickening, which reduces the airway intraluminal

diameter, were thought to result in hyperresponsiveness.

Airway epithelial damage: In asthma, there is sustained Type 2 inflammation with persistent

epithelial damage. The stressed and damaged epithelium is not only a source of increased

expression of pro-inflammatory cytokines but also of pro-fibrogenic and fibro-proliferative

cytokines that can modulate the activity of the underlying myofibroblasts leading to airway

remodelling.
Airway remodelling: Airway remodelling occurs early in children. It is due to the following

factors:

Increase in pro-fibrotic factors: Increased synthesis of types I and III collagen mediated by

IL-11, IL-17 and TGF- β causes sub-epithelial fibrosis. TGF-β is produced by the

eosinophils and serves as an important contributor to airway remodelling in asthma 52

TH2 lymphocytes and cytokines IL-5 and IL-13 also promote airway remodelling in chronic

asthma. 52

Actions of TGF-β in chronic asthma:

1. It activates fibroblasts for production of extracellular matrix proteins (collagen,

fibronectin).

2. Reduces production of collagenase, an enzyme that degrades extracellular matrix.

3. Increases the production of (tissue inhibitor of metalloprotease) which inhibits

enzymes that degrade the extracellular matrix.

4. Proliferation of smooth muscle of the airways

Histopathological changes in chronic asthma:

- Epithelial damage and ciliary dysfunction

- Goblet cell hyperplasia

- Sub-basement membrane thickening

- Blood vessel proliferation and dilation causing increased vascularity

- Increased myofibroblasts and fibrocytes leading to sub-epithelial fibrosis

-
Increase in airway smooth muscle mass – this is the strongest predictor of airway

limitation. 22

- Airway hyper-responsiveness, or twitchy airways, occurs secondary to

inflammation and airway remodelling.