The Characteristics Of Inflammation In Asthma And The Association Of It With Cold-phlegm And Heat-phelgm Syndrome In Traditional Chinese Medicine

Objective:To study the characteristics of airway inflammation in eosinophilic asthma(EA) and non-eosinophilic asthma(NEA) and explore the pathogenesis of it.To examine the association of cold-phlegm and heat-phlegm syndrome with inflammatory markers of asthma and explore the intrinsic quality of the cold-phlegm and heat-phlegm syndrome in asthma.Methods:Ninety patients aged between 18 and 70 with persistent symptomatic and acute asthma were included.One group was cold-phlegm syndrome and the others were heat-phlegm syndrome group,neither heat nor cold syndrome group and healthy control group(each group was 30 subjects).We excluded subjects with other pulmonary diseases and symptoms of respiratory tract infection in the previous two weeks or with systemic manifestations of atopy.Sputum induction with hypertonic saline(5%) was performed and the sputum was processed to determine the percentage of neutrophils and eosinophils(PMN%,EOS%).The recognition of EA(EOS%≥2%) and NEA relied upon the EOS%in sputum.EOS%and PMN%in serum and sputum were examed;The concentrations of interleukin(IL)-8,IL-5,IL-4,IL-6,IL-10,Leukotriene(LT)B4, eosinophil cationic protein(ECP),C-reactive protein(CRP) and interferon(IFN)-γwere determined in sputum supernatant and serum by enzyme-linked immunosorbent assay;FEV1%predicted and FEV1/FVC%were also recorded.Results:First:General informationThere were 90 asthma subjects in our study,there were 27 subjects in cold-phlegm syndrome group,32 subjects in heat-phlegm syndrome and 31 subjects in neither cold nor heat syndrome group.Sputum induction was successful in 83 patients.The number of people whose EOS%in sputum increased was 33,and the number of NEA patients was 60%.Second:Markers in EA,NEA and healthy control groups1.Sputum and serum PMN%and EOS%in EA,NEA and healthy control groups:Sputum and serum PMN%were similar to healthy control group in EA and NEA groups(P＞0.05 );Sputum and serum EOS%were significantly higher in EA group when compared to healthy control group(P＜0.01);serum and sputum PMN% decreased and sputum EOS%significantly increased in EA group compared to NEA group(P＜0.05). 2.Inflammatory markers in EA,NEA and healthy control groups:Sputum IL-8, IL-4 and IL-5 levels and the ratio of IL-10/IL-6 as well as IFN-γ/IL-4 in EA group were similar to healthy control group(P＞0.05),and the concentrations of sputum ECP,LTB4,IL-6,IL-10 and IFN-γwere higher in EA group when compared to healthy control group(P＜0.05);Sputum IL-8,IL-6 and IL-5 levels in NEA group were similar to healthy control group(P＞0.05),and the concentrations of sputum ECP,LTB4,IL-10 and IFN-γand the ratio of IL-10/IL-6 as well as IFN-γ/IL-4 were higher and sputum IL-4 levels was lower in NEA group when compared to healthy control group(P＜0.05).The level of IL-5 and IL-6 in sputum were higher in EA group compared with NEA group(P＜0.05),and the level of IL-8,ECP,IL-4,IL-10,IFN-γand LTB4 and the ratio of IL-10/IL-6 as well as IFN-γ/IL-4 in EA group were similar to NEA group(P＞0.05).Serum LTB4 and CRP levels in EA group were increased significantly compared with healthy control group(P＜0.01),and the level of IL-5,IL-8,IL-4,ECP,IL-6,IL-10 and IFN-γand the ratio of IL-10/IL-6 as well as IFN-γ/IL-4 were similar to healthy control group(P＞0.05).Serum LTB4,IL-5 and CRP levels in NEA group increased compared with healthy control group(P＜0.05) and the level of IL-8,IL-4,ECP,IL-6,IL-10,IFN-γand the ratio of IL-10/IL-6 as well as IFN-γ/IL-4 were similar to healthy control group (P＞0.05).Serum markers investigated in EA group were all similar to NEA group(P＞0.05).3.Pulmonary functions in EA and NEA groups:Subjects with NEA had significantly higher FEV1(%predicted) and FEV1/FVC%compared with healthy controls(P＜0.01).Third:Markers in cold-phlegm syndrome,heat-phlegm syndrome,neither cold nor heat syndrome and healthy control groups1.PMN%and EOS%in Sputum and serum in every groups:Sputum PMN%was higher in heat-phlegm syndrome group than in healthy control and neither heat nor cold groups(P＜0.05),but sputum EOS%and EOS%as well as PMN%in serum were similar to the healthy control and neither heat nor cold groups(P＞0.05);Serum and sputum EOS%in cold-phlegm syndrome group were higher than in heat-phlegm syndrome group and the healthy control group(P＜0.01),but PMN%in serum and sputum were similar to the other two groups(P＞0.05);Serum and sputum EOS%and PMN%in the neither heat nor cold group were similar to the other two groups(P＞0.05). 2.Inflammatory markers in serum and sputum in four groups:Subjects with heat-phlegm syndrome had increased sputum IL-10 levels and the ratio of IL-10/IL-6 compared with healthy control group(P＜0.05),but the level of IL-8,IL-5,ECP,IL-4,IL-6,IFN-γ,LTB4 and the ratio of IFN-γ/IL-4 were similar to the healthy control group(P＞0.05).Subjects with cold-phlegm syndrome had increased sputum ECP,LTB4 and IFN-γlevels compared with healthy control group(P＜0.05),but levels of IL-8,IL-5,IL-4,IL-6,IL-10,IFN-γand the ratio of IFN-γ/IL-4 as well as IL-10/IL-6 were similar to the healthy control group(P＞0.05).Subjects with neither heat nor cold syndrome had increased sputum ECP,IL-6,IL-10,IFN-γlevels and the ratio of IL-10/IL-6 compared with healthy control group(P＜0.05),but levels of IL-8,IL-5,IL-4,and the ratio of IL-10/IL-6 were similar to the healthy control group(P＞0.05).Sputum markers investigated in neither heat nor cold syndrome subjects were similar to the cold-phlegm and heat-phlegm subjects.The ratio of IL-10/IL-6 in sputum was higher in cold-phlegm syndrome than in heat-phlegm syndrome,and the levels of the other markers in cold-phlegm syndrome group were similar to the levels in heat-phlegm syndrome group(P＞0.05).Subjects with heat-phlegm syndrome had increased serum IL-5,CRP and LTB4 levels compared with healthy control group(P＜0.05),and the level of IL-8,IL-6,IL-10,IFN-γ,ECP,IL-4 and the ratio of IL-10/IL-6 as well as IFN-γ/IL-4 were similar to the healthy control group(P＞0.05).Subjects with cold-phlegm syndrome had increased serum IL-4,IL-5,CRP and LTB4 levels and decreased levels of ECP and the ratio of IFN-γ/IL-4 when compared with healthy control group(P＜0.05),and the level of IL-8,IL-6,IL-10,IFN-γand the ratio of IL-10/IL-6 were similar to the healthy control group(P＞0.05).Subjects with neither cold nor heat syndrome had increased serum IL-5,CRP and LTB4 levels the ratio of IFN-γ/IL-4 when compared with healthy control group(P＜0.05),and the level of ECP,IL-8,IL-6,IL-4,IL-10,IFN-γand the ratio of IL-10/IL-6 were similar to the healthy control group(P＞0.05).Subjects with cold -phelgm syndrome had increased serum IL-4 levels and the ratio of IFN-γ/IL-4 decreased compared with neither cold nor heat syndrome(P＜0.05),but the level of ECP,IL-8,IL-5,ECP,CRP,IL-6,IL-10,IFN-γand the ratio of IL-10/IL-6 were similar to the neither cold nor heat syndrome group(P＞0.05).Subjects with heat-phelgm syndrome had decreased serum IFN-γlevels and the ratio of IFN-γ/IL-4 decreased compared with neither cold nor heat syndrome(P＜0.05),but the level of ECP,IL-8,IL-5,ECP,CRP,IL-6,IL-10,and the ratio of IL-10/IL-6 were similar to the neither cold nor heat syndrome group(P＞0.05 ).The levels of all markers investigated in cold-phlegm syndrome group were similar to the levels in heat-phlegm syndrome group(P＞0.05).3.Pulmonary functions in asthma groups:FEV(%predicted) in cold-phlegm sputum was lower than in heat-phlegm syndrome and neither heat nor cold syndrome groups(P＜0.05),and FEV1/FVC%was lower than in heat-phlegm syndrome group (P＜0.05),but the the percentage of FEV1/FVC was similar to neither heat nor cold syndrome group(P＞0.05);FEV1(%predicted) and FEV1/FVC%were all similar to neither heat nor cold syndrome group(P＞0.05).Fourth:The correlation between serum and sputum markersEOS%in serum had close correlation to that of in sputum(r=0.585,p=0.000). PMN%and the level of IL-8,IL-5,ECP,IL-4,IL-6,IL-10,IFN-γand LTB4 in sputum had no correlation to that of in serum(P＞0.05).EOS in sputum had positive correlation to that of IL-6 and IL-5 levels in sputum;LTB4 and CRP levels in serum(r= 0.224 p=0.032;r=0.227 p=0.036;r=0.258 p=0.016) had negative correlation to FEV1(%predicted)(r= -0.234 p=0.035).EOS in sputum had no correlation to IFN-γ,ECP,IL-8,IL-10,IL-4 and LTB4 levels in sputum and IL-4,IL-5,IL-6,IL-10,IFN-γ,IL-8 as well as ECP levels in serum,and FEV1/FVC%as well(P＞0.05).PMN in sputum had positive correlation to the level of IL-6 and IL-8(r=0.221p=0.035;r=0.214p=0.034) in sputum but had no correlation to the level of IFN-γ,ECP,IL-10,IL-5,LTB4 and IL-4 in sputum as well as all the markers investigated in serum,and also FEV1(%predicted) and FEV1/FVC%as well(P＞0.05).Blood EOS had positive correlation to that of IL-5 levels in sputum(r= 0.344 p= 0.001) and had negative correlation to that of FEV1(%predicted) and FEV1/FVC%(r=-0.471 p=0.000;r=-0.255 p=0.023 );EOS in blood had no correlation to the level of sputum IFN-γ,ECP,IL-10,LTB4,IL-4,IL-6 and IL-8,and also had no correlation to that of all markers investigated in serum(P＞0.05).PMN in blood had no correlation to that of the other markers(P＞0.05).Conclusion:1.There about 60 percent of asthma were NEA patients in clinic in our study;PMN% and IL-8 levels in NEA group not increased in this study and we thought that the infiltration of PMN could not represent the principal characteristics of inflammation in NEA patients,and it may be the severe NEA patients'.EOS and IL-5 levels were the important markers in EA.The primary marker of inflammation in NEA had to be investigated farther.2.The predominant of TH2 cells could not represent the pathogenisis of asthma,and it was confirmed that EA had close relationship with the predominant of TH2 cells.We speculated that NEA had TH1 predominance.We thougt that the ventilatory function of EA subjects was weaker and the chronic airway inflammation was more severe compared with that of in NEA subjects,which might result from the defect function of endogenous action of anti-inflammation,and the action of endogenous anti-inflammation in NEA subjects was more stronger.So the therapy of EA should emphasize the endogenous action of anti-inflammation.3.It existed not only airway inflammation but also systemic inflammation in asthma.We found that the percentage of EOS in serum had positive correlation to that of in sputum,and there was no similar correlation between the sputum and serum on other inflammatory markers in our study.The characteristics of systemic inflammation and airway inflammation in asthma are not all consistent,and we thought that sputum was better than serum in representing the characteristic of inflammation in asthma.4.We thought that the intrinsic quality of the traditional Chinese "phlegm" was inflammation,and the therapy of "eliminating phlegm" was anti-inflammation.The number of EOS cells was elevated in cold-phlegm syndrome asthma and the number of PMN cells in the local airway was elevated in heat-phlegm syndrome.Sputum EOS%and PMN%were important markers in microcosmic syndrome differentiation in asthmatic cold-phlegm and heat-phlegm syndrome.The characteristics of airway inflammation in cold-phlegm syndrome asthma may be similar to the modern medicine of eosinophilic asthmas,and it existed predominant of Th2 Type Cytokines in cold-phlegm syndrome asthma. We thought that the intrinsic quality of cold-phlegm syndrome was similar to eosinophilic asthma,but the intrinsic quality of heat-phlegm syndrome had relationship to the infectious inflammatiom.We emphasized that the therapy of acute asthma in traditional Chinese medicine should not olny pointed to lung but also the kidney.So the therapy of cold-phlegm syndrome in traditional Chinese medicine was not only warming lung for eliminating phlegm but also tonifying yang and invigorating kidney.The marker of EOS could be investigated to know the changes of airway inflammation in cold-phlegm syndrome.Our investigation provided a important Theoretical basis for the therapy of cold-phlegm syndrome.