There is now compelling evidence that proteinases and oxidative stress play pathogenetic roles in the following pathologies in chronic obstructive pulmonary disease: airspace enlargement; chronic inflammation in the airways, lung interstitium, and alveolar space; and mucus hypersecretion in the large airways. Proteinases and oxidants may also contribute to remodeling processes in the small airways. In addition, data are emerging that show interactions between classes of proteinases and between proteinases and oxidants, which amplify lung inflammation and injury in chronic obstructive pulmonary disease. This review discusses the biologic roles of proteinases and oxidants, their roles in the pathogenesis of chronic obstructive pulmonary disease, and their potential as targets for therapy.Keywords: antiinflammatory drugs; antioxidants; oxidative stress; proteinase inhibition; proteinases
PROTEINASES AND OXIDANTS IN THE PATHOGENESIS OF COPDThe proteinase-antiproteinase hypothesis for the pathogenesis of chronic obstructive pulmonary disease (COPD) was formulated almost 40 yr ago in response to two key observations. First, genetic deficiency of ␣ 1 -antitrypsin (AAT, the major inhibitor of neutrophil elastase [NE] in the lower respiratory tract) is associated with early onset, severe panlobular emphysema (1). Second, instillation of papain (an enzyme with elastase activity) into rat lungs results in progressive airspace enlargement (2). Since then, other elastolytic proteinases have been shown to cause airspace enlargement when instilled into rodent lungs. Consequently, it was thought that an imbalance between proteinases (especially elastases derived from polymorphonuclear neutrophils [PMNs]) and their inhibitors causes pulmonary emphysema. Although excessive activity of PMN-derived elastases is likely to be important in the panlobular pulmonary emphysema associated with AAT deficiency, this is probably an oversimplification of mechanisms underlying common, "garden variety" COPD in cigarette smokers. Other factors have now been implicated in airspace enlargement in COPD, including other classes of proteinases (matrix metalloproteinases [MMPs] and cysteine proteinases), oxidative stress, and apoptosis of lung structural cells. In addition, COPD is clinically and pathologically a heterogeneous disease and includes chronic inflammation in the airways, lung interstitium, and the alveolar space; mucus hypersecretion; and subepithelial fibrosis in the small airways. There is evidence