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Association between metabolic syndrome and chronic obstructive pulmonary disease development in young individuals: a nationwide cohort study

Respiratory Research volume 25, Article number: 414 (2024) Cite this article

Abstract

Background

The association between metabolic syndrome (MetS) and chronic obstructive pulmonary disease (COPD) has not been studied well, particularly in young individuals. We investigated the risk of COPD development in young individuals based on MetS and its components.

Methods

We used the Korean National Health Information Database to identify 6,891,400 individuals aged 20–39 years who participated in the national health check-up service between 2009 and 2012. Then, we identified individuals with MetS and investigated COPD development based on health insurance claims. Cox proportional hazard regression models were used to calculate the adjusted hazard ratio (aHR) for the risk of COPD development.

Results

During a mean follow-up period of 8.35 years, 13,784 individuals were newly diagnosed with COPD. MetS was associated with an increased risk of COPD (aHR, 1.18; 95% confidence interval [CI], 1.11–1.24). Among the MetS components, except for hyperglycemia, abdominal obesity (aHR, 1.27; 95% CI, 1.19–1.34), hypertension (aHR, 1.05; 95% CI, 1.01–1.10), hypertriglyceridemia (aHR, 1.11; 95% CI, 1.07–1.16), and low high-density lipoprotein cholesterol levels (aHR, 1.16; 95% CI, 1.11–1.22) were significantly associated with COPD development. A higher number of MetS components correlated with an increased risk of COPD development, with the highest risk observed when all five MetS components were present (aHR, 1.55; 95% CI, 1.28–1.87).

Conclusion

MetS was associated with COPD development in young individuals. The risk of COPD development increased along with the increasing number of MetS components. These findings suggest that careful monitoring for COPD development is necessary in young individuals with MetS, especially those with multiple components of MetS.

Introduction

Chronic obstructive pulmonary disease (COPD) is a heterogeneous lung condition characterized by chronic respiratory symptoms due to abnormalities of the airways and/or alveoli that cause persistent, often progressive, airflow obstruction [1]. Although cigarette smoking has been recognized as a major risk factor for COPD, other factors such as age, a previous history of asthma, genetic predisposition, early respiratory infections, occupational exposures, and exposure to biomass smoke may contribute to COPD development [1, 2]. The current knowledge of the risk factors for COPD is generally based on data obtained from the older adult population [2]. Although COPD is more frequent in older adults, it can also occur in younger individuals [3]. Considering the demographic characteristics, the effect of major risk factors, such as smoking and age, can be relatively smaller in younger individuals, making other risk factors more prominent contributors to COPD development. As only a few studies have been conducted regarding this issue [1, 4, 5], the risk factors for COPD development in younger individuals are currently not adequately understood.

Metabolic syndrome (MetS) is a common metabolic disorder defined as a complex of interrelated cardiovascular risk factors (abdominal obesity, hyperglycemia, hypertension, and dyslipidemia) [6]. MetS is twice more common in patients with COPD than in the general population [7]. Several studies have reported that the prevalence of MetS among patients with COPD ranges from 21 to 62% [6, 8,9,10,11,12,13,14]. However, only a few studies have examined the reverse relationship, i.e., the incidence risk of COPD in individuals with MetS. A few cross-sectional population-based or small studies have explored the association between MetS and lung function impairment [15,16,17,18]. However, except for a population-based study including participants with a mean age of 37.1 years [15], most of the studies have focused on middle-aged to older adult populations with a mean age over 40 years [16,17,18]. A cross-sectional population-based study in a French population showed that abdominal obesity, one of MetS components, was independently related to obstructive ventilatory pattern [18]. This finding indirectly supports the potential impact of MetS on the development of COPD.

Nevertheless, the association between MetS and COPD has not been studied well, particularly in younger individuals. Furthermore, little is known regarding whether each metabolic factor has been independently associated with COPD development and the extent of their impact. To address these gaps, we investigated the risk of COPD development with the presence of MetS and each of its components in young individuals.

Methods

Data source

The National Health Insurance Service (NHIS) is a mandatory health insurance system, covering approximately 97% of the South Korean population [19]. The NHIS established the National Health Information Database (NHID), which is a public database including information on socio-demographic variables, healthcare utilization, health screening, and mortality for the entire South Korean population [20]. The NHIS provides regular health check-up services every 1 or 2 years to insured adults over the age of 40 years and all employees over the age of 20 years [21]. The national health screening database was obtained through these checkups, and it provides information on health behaviors and bioclinical variables [22]. This retrospective nationwide cohort study was conducted using this database. The study protocol was approved by the Asan Medical Center Institutional Review Board (IRB No. 2022 − 1593), which waived the requirement for informed consent owing to the retrospective nature of the analysis.

Study population

Our search identified 6,891,400 young individuals, aged 20–39 years, who participated in the national health check-up service between 2009 and 2012. After excluding individuals with missing data (N = 577,714), those with pre-existing International Classification of Diseases 10th Revision (ICD-10) codes for COPD or emphysema (N = 5,265), and those with newly assigned ICD-10 codes for COPD or emphysema within a lag period of one year from the index year when each individual had their first health examination (N = 3,652) were selected. The study participants had been under observation from the time of their first recorded annual check-up after they reached the age of 20. The medical claim data of the remaining individuals were analyzed until December 2019 (Fig. 1).

Fig. 1
figure 1

Flow chart of the patient selection process. Abbreviations: ICD-10, International Classification of Diseases 10th Revision; COPD, chronic obstructive pulmonary disease; MetS, metabolic syndrome

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Assessment of MetS and its components

We identified individuals with MetS fulfilling the diagnostic criteria, defined as the presence of any three of the following five characteristics: abdominal obesity (waist circumference ≥ 90 cm in men or ≥ 85 cm in women), hyperglycemia (fasting plasma glucose ≥ 100 mg/dL or drug treatment for elevated blood glucose), hypertension (systolic/diastolic blood pressure ≥ 130/85 mmHg or drug treatment for elevated blood pressure), hypertriglyceridemia (triglyceride ≥ 150 mg/dL or drug treatment for elevated triglycerides), and low high-density lipoprotein (HDL) cholesterol levels (HDL cholesterol < 40 mg/dL in men and < 50 mg/dL in women or drug treatment for low HDL cholesterol) [23,24,25]. The MetS components were recorded based on the results from the initial health examination, and the presence or absence of MetS was determined accordingly.

Study outcome

We investigated the risk of COPD development based on MetS and its components. Incident cases of COPD were defined as fulfilling all of the following: (1) ICD-10 codes for COPD (J44.x) or emphysema (J43.x), except for unilateral pulmonary emphysema, Macleod’s syndrome (J43.0); (2) medical insurance claims for the aforementioned codes made more than three times per year; (3) medical insurance claims for the aforementioned codes for at least two years [1, 26, 27]. We followed up the study population beginning one year after the index year to minimize the potential impact of reverse causality. The incident time was defined as the date when all criteria were met.

Covariates

In the NHID, anthropometric examinations (height, body weight, waist circumference, and blood pressure), laboratory tests (fasting glucose and lipid profile), and questionnaires on sociodemographic factors (income and region), and health behaviors (smoking status, alcohol consumption, and exercise) were included [20, 21]. Most variables related to sociodemographic factors and health behaviors were obtained from self-reports in nationwide health screenings. The household income level was categorized into quartiles (Q1 = the lowest, Q4 = the highest) based on payers’ annual national health insurance premium. Regions were divided into two groups: urban and rural, with urban areas defined as metropolitan cities such as Seoul, Busan, Daegu, Incheon, Gwangju, Daejeon, and Ulsan. Smoking status was classified into never-, ex-, or current smoker. Alcohol consumption was classified as never, mild to moderate (< 30 g of alcohol per day), and heavy drinkers (≥ 30 g of alcohol per day). Regular exercise was defined as ≥ 30 min of moderate physical activity ≥ 5 times per week, or ≥ 20 min of vigorous physical activity ≥ 3 times per week [28, 29]. Body mass index (BMI) was calculated as weight in kilograms divided by square of height in meters and categorized into five groups as recommended for Asians: (1) < 18.5 kg/m2 (underweight); (2) 18.5–22.9 kg/m2 (normal weight); (3) 23.0–24.9 kg/m2 (overweight); (4) 25.0–29.9 kg/m2 (obese I); (5) ≥ 30.0 kg/m2 (obese II) [30]. Asthma was defined as having ICD-10 codes for asthma (J45.x) or status asthmaticus (J46) with medical insurance claims for the aforementioned codes more than three times per year before their health examination [31].

Statistical analysis

All data are presented as mean ± standard deviation or geometric mean (95% confidence interval [CI]) for continuous variables and numbers (%) for categorical variables. Data categorized according to the presence of MetS were compared using the Student’s t-test for continuous variables and the χ2 test for categorical variables. Incidence rates of COPD were calculated by dividing the number of events by 1000 person-years of follow-up for each group. Cox proportional hazard regression models were used to calculate the hazard ratio (HR) and 95% CI for the risk of COPD development. We fitted the following statistical models with sequentially greater adjustments. Model 1 was unadjusted; Model 2 was adjusted for age and sex; Model 3 was additionally adjusted for income, region, smoking status, alcohol consumption, regular exercise, and BMI; Model 4 was additionally adjusted for asthma; Model 5 was further adjusted for abdominal obesity. We then performed a stratified analysis by sex, dividing participants into two groups (men and women) to evaluate the association between MetS and COPD development in each group. Additionally, we conducted an interaction test to determine whether the effect of MetS on COPD development differed by sex. The Kaplan-Meier method was used to estimate the cumulative incidences of COPD based on the number of MetS components. All significance tests were two-sided and P values < 0.05 were considered to indicate statistical significance. Statistical analyses were performed using SAS, version 9.4 (SAS Institute Inc., Cary, NC, United States).

Results

Characteristics of study population

We identified 649,198 individuals with MetS and 5,655,571 individuals without MetS through eligibility screening. The mean age of the study population was 30.8 ± 5.0 years, including 59.2% male individuals. Table 1 presents the clinical characteristics of the study population based on the presence of MetS. Compared with individuals without MetS, those with MetS were considerably older and included higher proportions of males (87.3% vs. 56.0%), ex- and current-smokers (68.3% vs. 42.1%), heavy drinkers (16.3% vs. 7.9%), those who exercise regularly (13.2% vs. 12.8%), those with obesity (BMI ≥ 25.0 kg/m2) (77.7% vs. 20.5%), and those with asthma (3.0% vs. 2.9%). Conversely, there was a lower proportion of individuals with MetS in the lowest 25% income bracket (17.4% vs. 22.2%) and those living in urban areas (46.1% vs. 48.5%). Metabolic parameters such as waist circumference, fasting plasma glucose, systolic/diastolic blood pressure, and total cholesterol, triglyceride, and LDL cholesterol levels were higher in individuals with MetS than in those without MetS.

Table 1 Clinical characteristics of the study population based on the presence of metabolic syndrome
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Risk of COPD development based on MetS and its components

The median duration of follow-up was 9.0 years (interquartile range [IQR], 7.7–9.2 years) for individuals with MetS and 8.6 years (IQR, 7.5–9.2 years) for those without MetS. In total, 1,842 (0.28%) individuals with MetS were newly diagnosed with COPD during the follow-up period, and 11,942 (0.21%) individuals without MetS were diagnosed with COPD. Individuals with MetS exhibited a significantly higher incidence rate (0.34/1000 person-years) of COPD than that of individuals without MetS (0.25/1000 person-years). Compared to the non-MetS group, the MetS group exhibited a higher risk of COPD in the unadjusted model (HR, 1.33; 95% CI, 1.27–1.40). After adjusting for age, sex, income, region, smoking status, alcohol consumption, regular exercise, BMI, and asthma (Model 4), MetS remained associated with COPD development (adjusted HR [aHR], 1.18; 95% CI, 1.11–1.24). Among each component of MetS, except for hyperglycemia (aHR, 0.97; 95% CI, 0.93–1.01), abdominal obesity (aHR, 1.27; 95% CI, 1.19–1.34), hypertension (aHR, 1.05; 95% CI, 1.01–1.10), hypertriglyceridemia (aHR, 1.11; 95% CI, 1.07–1.16), and low HDL cholesterol levels (aHR, 1.16; 95% CI, 1.11–1.22) were significantly associated with COPD development (Table 2).

Table 2 Risk of chronic obstructive pulmonary disease development based on metabolic syndrome and its components
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In the stratified analysis by sex, aHR for COPD development associated with MetS was higher in women than in men (aHR, 1.55; 95% CI, 1.37–1.76 vs. aHR, 1.12; 95% CI, 1.06–1.19). Among the MetS components, neither hypertension nor hyperglycemia were significantly associated with COPD development in men (Table 3).

Table 3 Sex-stratified analysis of the risk of chronic obstructive pulmonary disease development based on metabolic syndrome and its components
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Risk of COPD development based on the number of MetS components

We investigated the risk of COPD development based on the number of MetS components. Table 4 illustrates a trend toward increasing risk of COPD development with an increasing number of MetS components. The risk of COPD development was greatest when all five MetS components were present (unadjusted HR, 1.82; 95% CI, 1.51–2.17; aHR, 1.55; 95% CI, 1.28–1.87). Kaplan-Meier plots depicting the incidence of COPD based on the number of MetS components are presented in Fig. 2.

Table 4 Risk of chronic obstructive pulmonary disease development based on the number of metabolic syndrome components
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Fig. 2
figure 2

Kaplan-Meier plots of the incidence of chronic obstructive pulmonary disease based on the number of metabolic syndrome components. Time 0 represents the time point one year after the first health examination (index year), with a one-year lag period applied

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When stratified by sex, a higher number of MetS components correlated with an increased risk of COPD development in women. However, this trend was not observed in men (Table 3).

Discussion

To our knowledge, this is the first study to investigate the risk of COPD development based on MetS and its components in young individuals. The key finding of our study is that MetS and its components, except hyperglycemia, were associated with COPD development in the younger population and the risk of COPD development increased with the increasing number of MetS components.

Previous studies have reported an association between MetS and lung function impairment [15,16,17,18]. Although most studies reported that MetS is associated with a restrictive ventilatory pattern [15,16,17], a large-scale study including a French population indicated that abdominal obesity, one of MetS components, is independently associated with restrictive and obstructive ventilatory patterns [18]. Despite addressing lung function impairment, this study had limitations in establishing a direct association between abdominal obesity and COPD. The present study revealed that MetS and its components, other than abdominal obesity, were also associated with an increased risk of COPD. Similarly, a recent large-scale prospective cohort study from the UK Biobank Study found that MetS was associated with a 24% increased risk of subsequent developed COPD [32]. However, our study population consisted of younger adults with a mean age of 30.8 years, whereas Li et al.’s participants had a mean age of 55.5 years [32]. Additionally, among the MetS components studied by Li et al., elevated fasting glucose, elevated waist circumference, and reduced HDL cholesterol were associated with higher risks of COPD [32], which differed from those identified in our study.

In the sex-stratified analysis, the HR for COPD development associated with MetS was higher in women than in men, indicating that women with MetS are at greater risk of developing COPD. Furthermore, a higher number of MetS components correlated with an increased risk of COPD development in women, suggesting potential differences in COPD development between sexes related to MetS. Women may be more susceptible to external factors such as smoking and household air pollutants, which could explain these differences between the sexes [33]. Additionally, hormonal changes such as fluctuating estrogen levels, which help suppress lung inflammation and reduce oxidative stress, may be another contributing factor [34]. Further studies are needed to investigate these sex-related differences regarding the risk of MetS-associated COPD development.

A previous study indicated that the risk for incident COPD events increased with increasing quartiles of the triglyceride-glucose (TyG) index in women [34]. TyG index is calculated using triglyceride and fasting blood glucose, both of which are MetS components, and it is known as one of the insulin resistance biomarkers [35]. Zaigham et al. suggested that a raised TyG index score serves as a risk marker for future incidence of COPD events in women [34]. Similarly, in our study, the risk of COPD development increased along with an increasing number of MetS components. When stratified by sex, a higher number of MetS components correlated with an increased risk of COPD development in women. Compared with the TyG index, the number of MetS components is directly related to the definition of MetS and serves as a more intuitive index [36, 37]. The number of MetS components can be considered as a potential risk marker for COPD development, particularly for women.

Several mechanisms have been proposed to explain the association between MetS and COPD. First, adipose tissue may act as a source of systemic inflammation [18]. COPD is a chronic inflammatory disorder with systemic manifestation [38]. Adipokines, such as leptin and adiponectin, produced by adipose tissue may exert metabolic effects on the lung. These may modulate the immune reaction in the airways by inciting a pro-inflammatory response [39]. Second, advanced glycation end-products are formed in response to hyperglycemia, and their binding to receptors in the lung may increase inflammatory response, contributing to the development of COPD [34]. Third, fatty acid-induced inflammation provides another potential mechanism. In MetS, adipose tissue cannot efficiently regulate fat storage, leading to excess triglycerides and free fatty acids circulating in the bloodstream. Free fatty acids activate innate immune responses, which can be implicated in COPD development [39].

In this study, hyperglycemia was not associated with COPD development, and this finding was inconsistent with those of previous observational studies [40,41,42]. A cross-sectional study including 53,146 adults from the C8 Health Project in the United States demonstrated that participants with diabetes were more likely to have COPD than those without diabetes [40]. A population-based cohort study using Taiwan’s National Health Insurance claim data demonstrated a modest association between type 2 diabetes and the risk of developing COPD [41]. A prospective analysis involving 452,680 UK participants suggested that individuals with prediabetes or diabetes were associated with a higher risk of COPD than that of individuals without diabetes [42]. In contrast, a retrospective case-control study using a long-established English general practice network database (N = 894,646) demonstrated that individuals with type 2 diabetes had a reduced risk of COPD than that of matched controls [43]. Rayner et al. suggested that this discrepancy may be due to positive lifestyle changes, such as smoking cessation, in those with type 2 diabetes [43].

COPD is a considerable problem for younger individuals. Although cigarette smoking increases the risk of developing COPD in this demographic [1, 4], the average rate of tobacco use among young people aged 15–44 years has declined globally [44]. This study implies that MetS and its components may be other important modifiable risk factors for COPD in the young population. Further studies are needed to elucidate whether interventions aimed at improving MetS and its components will contribute to reducing the risk of COPD development and whether watchful screening of pulmonary function in the presence of MetS may lead to decreased disease burden and mortality due to COPD.

Our study had several limitations. First, due to the use of an established public database, lung function could not be evaluated, and the diagnosis of COPD relied on health insurance claims. To overcome this limitation, COPD was strictly defined based on medical insurance claims of more than three times per year over two years. Although this definition has not been formally validated against a gold standard, such criteria combining ICD codes and medical insurance claims have been widely used for identifying COPD in many studies [1, 45, 46]. As COPD is usually suspected in individuals over 40 years of age, the incidence of COPD in younger individuals might be underestimated. Despite the strict definition and possible underestimation of COPD, the observed HR remained significant. Second, our study is observational, and causal association may not have been conclusively established. However, we minimized the potential impact of reverse causality by following up on the study population, beginning one year after the index year. Additionally, to investigate possible reverse causation caused by undiagnosed COPD, we conducted a sensitivity analysis excluding individuals with ICD-10 codes for COPD or emphysema within three years from the index year. Even after excluding these individuals, the conclusions remained similar (Supplementary Material 1), suggesting that MetS is associated with COPD development. Third, potential confounders that were not available in our data, such as a family history of respiratory diseases, respiratory infections in childhood, and occupational or environmental exposures, may exist. Finally, our analyses were conducted based on a single country database, and the generalizability of the results of this study to other races or populations is uncertain. Additionally, this study was only performed on employed individuals aged 20–39 years. Therefore, the findings may not be generalizable to the general population in that age range.

Conclusions

In conclusion, our study demonstrated that MetS and its components, except hyperglycemia, were associated with COPD development in the younger population. Furthermore, the risk of COPD development increased along with the increasing number of MetS components. These findings underscore the importance of careful monitoring for COPD development in young individuals with MetS, especially those with multiple components of MetS.

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

aHR:

Adjusted hazard ratio

BMI:

Body mass index

CI:

Confidence interval

COPD:

Chronic obstructive pulmonary disease

HDL:

High-density lipoprotein

HR:

Hazard ratio

ICD:

International Classification of Diseases

MetS:

Metabolic syndrome

NHID:

National Health Information Database

NHIS:

National Health Insurance Service

TyG:

Triglyceride-glucose

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Acknowledgements

Not applicable.

Funding

This study was supported by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (No. 2023R1A2C2006688 and RS-2023-00222687, SWL), the Bio & Medical Technology Development Program of the National Research Foundation (NRF) funded by the Korean government (MSIT) (No. 2022M3A9G8017220), and the National Institute of Health research project (2024ER080600).

Author information

Author notes

  1. Dong Wook Shin, Sei Won Lee these authors contributed equally to this work and share last authorship.

Authors and Affiliations

  1. Division of Pulmonology and Allergy, Department of Internal Medicine, Chungnam National University, Chungnam National University Sejong Hospital, Sejong, Republic of Korea

    Ock-Hwa Kim

  2. Department of Biomedicine and Health Science, The Catholic University of Korea, Seoul, Republic of Korea

    Kyu Na Lee

  3. Department of Statistics and Actuarial Science, Soongsil University, Seoul, Republic of Korea

    Kyungdo Han

  4. Department of Family Medicine & Supportive Care Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea

    In Young Cho & Dong Wook Shin

  5. Department of Clinical Research Design and Evaluation, Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Sungkyunkwan University, 81 Irwon-Ro, Gangnam-gu, Seoul, 06351, South Korea

    Dong Wook Shin

  6. Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88, Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea

    Sei Won Lee

Authors
  1. Ock-Hwa Kim
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  2. Kyu Na Lee
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  3. Kyungdo Han
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  4. In Young Cho
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  5. Dong Wook Shin
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Contributions

Study conception and design: DWS, SWL; data acquisition and analysis: KNL, KDH; data interpretation and manuscript writing: OHK, IYC; critical revision and final approval of the manuscript: KDH, DWS, SWL.

Corresponding authors

Correspondence to Dong Wook Shin or Sei Won Lee.

Ethics declarations

Ethics approval and consent to participate

This study was performed in line with the principles of the Declaration of Helsinki. The study protocol was approved by the Asan Medical Center Institutional Review Board (IRB No. 2022 − 1593), which waived the requirement for informed consent owing to the retrospective nature of the analysis.

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Not applicable.

Competing interests

The authors declare no competing interests.

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Kim, OH., Lee, K.N., Han, K. et al. Association between metabolic syndrome and chronic obstructive pulmonary disease development in young individuals: a nationwide cohort study. Respir Res 25, 414 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12931-024-03038-z

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12931-024-03038-z

Keywords

Respiratory Research

ISSN: 1465-993X

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