Early View

Original article

Fatty Airways: Implications for Obstructive

Disease

John G. Elliot, Graham M. Donovan, Kimberley C.W. Wang, Francis H.Y. Green, Alan L. James, Peter
B. Noble

Please cite this article as: Elliot JG, Donovan GM, Wang KCW, et al. Fatty Airways:
Implications for Obstructive Disease. Eur Respir J 2019; in press
(https://doi.org/10.1183/13993003.00857-2019).

This manuscript has recently been accepted for publication in the European Respiratory Journal. It is
published here in its accepted form prior to copyediting and typesetting by our production team. After
these production processes are complete and the authors have approved the resulting proofs, the article
will move to the latest issue of the ERJ online.

Copyright ©ERS 2019

 Fatty Airways: Implications for Obstructive Disease

John G. Elliot,1,2 Graham M. Donovan,3 Kimberley C.W. Wang,2,4 Francis H.Y. Green,5 Alan L.

James,1,6 Peter B. Noble.2

1
West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology and

Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia 6009, Australia;
2
School of Human Sciences, University of Western Australia, Crawley, Western Australia 6008,
3
Australia; Department of Mathematics, University of Auckland, Auckland, New Zealand;
4
Telethon Kids Institute, University of Western Australia, Nedlands, Western Australia 6009,

Australia; 5 Department of Pathology and Laboratory Medicine, University of Calgary, Calgary,

Alta, Canada; 6School of Medicine and Pharmacology, University of Western Australia, Nedlands,

Western Australia 6009, Australia.

Correspondence: John G. Elliot

West Australian Sleep Disorders Research Institute

Department of Pulmonary Physiology and Sleep Medicine

Sir Charles Gairdner Hospital

Queen Elizabeth II Medical Centre

Hospital Avenue

Nedlands

Western Australia 6009

Australia

T: 61 8 6457 3786

F: 61 8 6457 2034

E: [email protected]
Take home message: In individuals with elevated BMI, adipose tissue accumulates within the

airway wall, correlates with greater wall thickness and airway inflammation and represents a new

mechanism for airway pathophysiology in obese asthmatic patients.

ABSTRACT

Epidemiological studies report that overweight or obese asthmatic subjects have more severe

disease than those of a healthy weight. We postulated accumulation of adipose tissue within the

airway wall may occur in overweight patients and contribute to airway pathology. Our aim was to

determine the relationship between adipose tissue within the airway wall and body mass index

(BMI) in individuals with and without asthma.

Transverse airway sections were sampled in a stratified manner from post-mortem lungs of control

subjects (n=15) and cases of nonfatal (NFA, n=21) and fatal (FA, n=16) asthma. The relationship

between airway adipose tissue, remodelling and inflammation was also assessed. The areas of the

airway wall and adipose tissue were estimated by point count and expressed as area per mm of

basement membrane perimeter (Pbm). The number of eosinophils and neutrophils were expressed

as area densities.

BMI ranged from 15-45 (kg/m2) and was greater in NFA (p<0.05). Adipose tissue was identified in

the outer wall of large airways (Pbm >6mm), but was rarely seen in small airways (Pbm <6mm).

Adipose tissue area correlated positively with BMI and airway wall thickness in all groups.

Densities of neutrophils correlated with adipose tissue area in control subjects (Pbm >6mm, p=0.04)

and both neutrophils and eosinophils in FA (Pbm >12mm, p<0.01).

These data show that adipose tissue is present within the airway wall and is related to BMI, wall

thickness and the number of inflammatory cells. The accumulation of airway adipose tissue in

overweight individuals may therefore contribute to airway pathophysiology.

Key words: Adipose tissue; Airway inflammation; Airway remodelling; Asthma; Body mass index
INTRODUCTION

Obesity is recognised as an emerging health problem that is not just confined to high-income

countries (1). It is predicted that by 2025 global obesity frequency will reach 18% in men and 21%

in women (2). A link between obesity and diseases of various biological systems is well established

(3), and includes abnormal respiratory function, particularly asthma. Epidemiological data have

shown a positive association between adiposity and asthma and increased asthma severity (4,5). In

the United States the majority of patients with severe asthma are obese (6).

The mechanism(s) underlying the association between obesity and asthma has yet to be established.

An endocrine role of adipose tissue may contribute to the release of inflammatory mediators in

asthma (7). Alternatively, a direct effect of fat accumulation on the chest and abdomen may reduce

lung volume (8), and in turn, airway inflation, leading to increased airway resistance. Such

inflammatory and mechanical changes at least in part explain the occurrence of an obesity

phenotype in cluster analysis of patients with asthma and asthma symptoms (9,10).

We now propose an additional mechanism that abnormal respiratory function in obesity relates to

accumulation of adipose tissue within the airways. Increased thickness of the airway wall, referred

to as „airway remodelling‟, is a cardinal feature of asthma that is due to increased thickness of the

airway smooth muscle (ASM), oedema and fibrosis (11-13). Accumulation of adipose tissue may

further contribute to increased airway wall thickness and onset of airflow limitation. Geometric

effects of wall thickening have been demonstrated in mathematical models; inward wall movement

that obstructs lumen cross sectional area and outward wall movement that uncouples the airway

from lung forces that normally favour expansion of the airway lumen (14,15), both of which

increase airway resistance.

To the best of our knowledge, this is the first quantitative estimation of adipose tissue within the

airways of human subjects with and without asthma. The present study related adipose tissue area to

body mass index (BMI), airway wall thickness and inflammation. Some of the results of this study

have been previously reported in the form of an abstract (16).

METHODS

Subjects

Subjects were post-mortem cases included in the Prairie Provinces Asthma Study (17,18). Cases

were defined as subjects where the cause of death was: asthma (fatal asthma, FA); non-respiratory

with a history of asthma (nonfatal asthma, NFA); non-respiratory without a history of respiratory

disease (control). After death, the study team contacted the next-of-kin to obtain consent for

autopsy. The next-of-kin were asked to complete a questionnaire that sought information on asthma

severity, age of onset, duration of asthma, asthma medications and smoking history. In addition,

medication history was obtained (with permission) from the asthma subjects health care provider

and then assigned a category for asthma severity (19). This study received ethical approval from

the University of Calgary, University of Edmonton, University of Saskatchewan and University of

Manitoba (17,18).

Tissue sampling

Left lungs were taken at the post-mortem examination and fixed by inflation via the blood vessels

and airways with isotonic glutaraldehyde fixative (2.5% in 0.1M phosphate buffer, pH7.3) at a

pressure of 20cm H2O. A stratified sampling technique was applied as previously described (20).

This sampling procedure was developed to ensure that similar anatomic levels (generations) of

airways were sampled, regardless of lung size. Tissue blocks were embedded in paraffin wax,

sectioned at 5µm, mounted on glass slides and stained with haematoxylin and eosin (H&E).
Morphometry

On airways cut in cross-section, the perimeter of the airway basement membrane (Pbm) was

determined by counting intersections of the Pbm with a square-lattice grid of known dimensions

using a Zeiss-Axioplan light microscope. At a known magnification, a grid was placed at random

over a cross-section of airway and the number of intersections between the grid lines and the

luminal aspect of the epithelial basement membrane were counted and the perimeter then

calculated (21). Airway wall dimensions including total airway wall area and the area of adipose

tissue were measured using point counts on small (Pbm <6mm), medium (Pbm 6-12mm), and large

(Pbm >12mm) airways. The outer boundary of the airway was determined by the border between

the airway wall and the surrounding lung parenchyma for membranous bronchi/bronchioles. For

cartilaginous airways, the outer boundary was set by an imaginary line connecting the outer

perichondrium of the cartilage plates and excluded the adventitia (Figure1A). Adipose tissue was

defined as clusters of cells containing a large lipid droplet, surrounded by a scant cytoplasm and

flattened non-centrally located nuclei. During preparation of the tissue the lipid droplet is dissolved

and the cell appears empty and has a signet ring appearance.

In a subgroup of cases (12 control, 13 NFA and 13 FA cases) where the same airways could be

positively identified from archived tissue blocks, the number of eosinophils and neutrophils within

the submucosa were counted on 5μm sections stained with H&E, based on a staining and

morphology criteria (22). Cell counts were made within the inner airway wall, defined as being

between the basement membrane and the outside of the ASM layer (22, Figure 1B).

Data analysis

Comparisons were undertaken using statistical software SigmaPlot (Version 13.0, Systat Software

GmbH) and graphical analysis by Prism (Version 8.1.2, GraphPad Software). Summary statistics
including means and standard deviations for normally distributed variables, medians and

interquartile ranges for non-normally distributed variables and counts and percentages for

categorical variables were calculated. Subjects were grouped by demographic characteristics,

asthma history and asthma severity and groups were compared using Student‟s t-tests or Chi-

squared tests as appropriate. Separate analysis for airway size groups were undertaken using

analysis of variance and post hoc tests as appropriate. Eosinophil and neutrophil area densities were

log transformed prior to analysis. The relationship between adipose tissue area within the airway

wall and other variables were tested using Pearson‟s correlation and multiple linear regression

models.

RESULTS

Airways were examined from 15 control subjects, 21 NFA and 16 FA cases where weight and

height were available. The BMI ranged from 15 to 45 kg/m2 across groups and was significantly

increased in the NFA cases compared with control subjects and FA cases (p<0.05). Corticosteroid

use (oral and/or inhaled) was increased in the FA cases (92%) compared with NFA cases (53%,

p=0.04). There were no other differences in subject characteristics between the groups (Table 1).

A total of 1373 airways were examined with a mean of 26 ± 1.4 airways per case. Airways were

well matched for size (Pbm, Table 2), however, in airways grouped as >6mm, the Pbm was

modestly greater (p<0.05) in FA (16.12 ± 1.49mm), compared with NFA (14.66 ± 1.89mm). While

adipose tissue was identified in airways from all subject groups, it was limited to the outer airway

wall (Figure 1) and was observed predominantly in large to medium sized airways (>6mm Pbm).

Adipose tissue was seldom observed in the small airways (<6mm Pbm). No differences were seen

in the amount of adipose tissue between the anterior or posterior bronchus of the left lower lobe, or

of the apical bronchus to the left upper lobe.

Adipose tissue area/Pbm was positively correlated with BMI in all case groups and all airway size

groups (Figure 2A, Table 3). In control subjects and NFA cases, adipose tissue area/Pbm (Figure

2B, Table 3) and BMI (Figure 3A, Table 3) were also positively correlated with total airway wall

thickness in all airway sizes. There was however no relationship between total wall thickness and

adipose tissue area/Pbm or BMI in FA cases.

The effect of „asthma‟ diagnosis on adipose tissue within the airway wall was mixed. Adipose tissue

area/Pbm was significantly increased in airways 6-12mm in both NFA and FA cases compared with

the control subjects (p<0.05, Table 2), which could reflect an elevated BMI in the NFA group

(Table 1). Lines of best fit between BMI and adipose tissue area/Pbm (Figure 2A) were the same

between groups suggesting that for a given BMI there was no difference in the deposition of

adipose tissue. Similarly, when the asthma cases were classified as moderate or severe asthma, the

linear relationship between adipose tissue area/Pbm and BMI between subjects with different

asthma severity was the same.

Multiple linear regression analysis (Table 4) showed that BMI and gender were independently

related to the area of airway adipose tissue. In all airway sizes, BMI (p<0.001) and gender (p≤0.01)

were significant in the model. The effect of gender on airway adipose tissue is shown in Figure 3B,

indicating a greater adipose tissue area/Pbm for a given BMI in males compared with females.

When airway wall thickness was used as the dependent variable, models showed BMI and asthma

as the explanatory variables in all airway size groups (p≤0.001). When BMI was replaced in the

model with adipose tissue area/Pbm, the results showed adipose tissue area/Pbm and asthma as the

explanatory variables for airway wall thickness in all airway size groups (p≤0.01).
In a subgroup of cases where the same airways could be positively identified from archived tissue

blocks and compared with the adipose data, adipose tissue area/Pbm positively correlated with the

area densities of eosinophils (r=0.74, p=0.009) and neutrophils (r=0.85, p<0.001) in airways

>12mm in FA, and with the area density of neutrophils in the airways >6mm (r=0.61, p=0.04) in the

controls (Table 5). The area densities of eosinophils and neutrophils were not correlated with BMI.

DISCUSSION

The present study is the first to describe and measure adipose tissue within the airway wall of subjects

who had either died of asthma, had a diagnosis of asthma but died of another cause, or had no history

of respiratory disease. Increased BMI was associated with greater adipose tissue area and both

positively correlated with airway wall thickness. The airway adipose tissue area was consistently

greater in males compared with females at any given BMI. These results support a new mechanism of

increased airway wall thickness associated with increased BMI which may contribute to excessive

airway narrowing and exacerbate symptoms in patients with existing disease.

Explanations for the increased prevalence and severity of asthma in obesity include pro-inflammatory

effects of adipose tissue (7) and reduction in lung volume due to thoracic compression (8). There is

however evidence to suggest that neither inflammation nor reduced lung volume is sufficient to explain

respiratory impairments in obese subjects with asthma. Some asthmatic patients exhibit a reduced

response to anti-inflammatory medications (23), supporting a mechanism that is not simply limited

to increased inflammation. In a recent study examining the effect of BMI on bronchoconstrictor

response (24), it was concluded that reduced lung volume was not the sole contributor to airway

closure. While a direct structural effect of adipose tissue in the airway wall has not been previously

proposed, increased wall thickness has been shown clearly to increase airway resistance, particularly

after bronchial challenge (25, 26). In view of the relationship between airway adipose tissue and wall

thickness, both of which increased with BMI, airway adipose tissue represents a type of “fat-associated
airway remodelling” that may contribute to airflow limitation in a manner not previously proposed. To

exemplify the magnitude of this effect, through extrapolation of the linear relationship between BMI

and wall thickness (Figure 3A), all other factors being equal, a control subject with BMI of 38 kg/m2

would have a comparable wall thickness to a non-fatal asthmatic with a lean BMI of 20 kg/m2. Our

findings are broadly consistent with the study by Higami et al. which showed that increased

epicardial adipose tissue positively correlated with BMI and airway wall thickness on CT scans

(27).

The functional effect of airway adipose tissue on lung function is likely to be dependent on the site of

deposition within the airway wall. Adipose tissue was found in the outer wall of medium to large

airways >6mm Pbm, and seldom in small airways, as defined by a basement membrane perimeter of

<6mm (22). There is ongoing debate as to the anatomical site of lung function impairment in asthma,

with some authors favouring small airways (28) and others large airways (22). What tends to be

overlooked is the interdependence between small and large airways and with surrounding lung

parenchyma such that local changes can impact global lung ventilation. Our mathematical simulations

have shown that thinning of large airways (in the context of bronchial thermoplasty) improved airflow

to the periphery (20). It is therefore more than feasible that increased thickness of the large airway wall

when associated with adipose tissue deposition, will affect lung function, a hypothesis that might be

tested in future studies.

The above considers a direct structural effect of adipose tissue on airway function; there may also be

mechanical implications. Subjects with asthma exhibit greater wall stiffness (29) and reduced

distensibility to lung inflation (30), thereby attenuating beneficial bronchodilator effects of dynamic

stresses accompanying normal breathing (31). Whether adipose tissue increases or decreases wall

stiffness is unclear. Although adipose tissue is a soft connective tissue composed mostly of

adipocytes, due to mechanosensitive and mechanoresponsive properties, cell differentiation and

function are affected by the applied stress and mechanical properties of their environment (32). It

has previously been suggested that a natural variation in airway stiffness and geometry contributes

to symptoms of asthma in obese individuals (33). Our findings demonstrating accumulation of

adipose tissue within the airway wall offer a biological mechanism as to why intrinsic airway

mechanics may be altered in obesity.

The present study does not exclude an effect of adipose tissue-induced inflammation on increased

asthma severity. Desai et al. showed increased submucosal eosinophils in proximal airway biopsies in

obese patients with severe asthma (34), but did not report neutrophils. Scott et al. on the other hand

demonstrated a positive association between sputum neutrophils and obesity (7). In a subset of cases,

we observed a positive association between adipose area and neutrophilic inflammation in airways

from control and fatal asthma cases, and eosinophilic inflammation in fatal cases. There was however

no relationship between inflammatory cells and BMI itself, which may suggest that the direct

association is with adipose tissue and inflammation and that BMI is merely a n indirect marker of

adiposity. It is also clear that increased airway wall thickness cannot be solely due to physical

accumulation of adipose mass, since the increase in wall thickness with BMI is greater than expected

by a simple increase in adipose tissue area (Figure 2B). An inflammatory driven increase in airway

wall thickness due to locally positioned adipose tissue is therefore possible, in addition to direct

structural and mechanical effects of adipose tissue. Our publication on a greater number of subjects

with and without asthma documents a spatial-temporal association between inflammation and inner

and outer wall thickness (22) and from this we speculate that total wall thickness could be increased

due to the pro-inflammatory effects of mural adipocytes. An alternative explanation is that

inflammation present in subjects with asthma could drive the production of adipose tissue. Recently,

eosinophils have been shown to upregulate metabolic homeostasis by promoting adipocyte maturation

(35).
Directs effects of adipokines (e.g., leptin) on ASM also seem likely. Leptin exogenously administered

to ovalbumin-sensitised mice enhanced response to allergen, including serum IgE levels and

methacholine-induced bronchoconstriction (36). In contrast, when leptin was applied to human ASM

in culture, migration and proliferation was inhibited (37). Within the list of known adipokines is TNF-

α, the effects of which have been better studied, and include increased ASM force generation (38). The

effects of adipokines, particularly those produced by airway-associated adipose tissue, represents an

important ongoing area for investigation.

In the present study we found that for any given BMI, the airway adipose tissue was greater in males.

Gender effects on fat deposition are well recognized with increased visceral fat in males compared

with females (39). In epidemiological studies of the relationship between asthma and obesity, it seems

that obese women are more susceptible to asthma (40), and analyses of populations with or without

asthma (10) or of those with severe asthma (41) identify a cluster of obese women with asthma. It is

possible that the effects of obesity on asthma may operate through different mechanisms in males and

females. To the extent that airway adipose tissue contributes to airway disease, our data supports a

greater susceptibility in male subjects, but representing only one of a number of factors contributing to

associations between obesity and asthma.

Several methodological issues in this study require discussion. The stratified sampling technique

adopted was applied to ensure that similar anatomic levels of airways were sampled between

subjects and subject groups, regardless of lung size. When airways were dissected from lung

parenchyma, adipose tissue was noted in the adventitial space, but could not be quantified without

better controlling for dissection margins. A prospective study examining adipose tissue in the

adventitial space is underway, which we predict will allow us to better assess the role of adipose

tissues contribution to uncoupling from lung parenchyma and loss of transmural pressure.
In concluding, it is important to acknowledge that the lung is not the only organ potentially affected

by increased fat infiltration. Infiltration of fatty tissue is associated with non-alcoholic fatty liver

disease or non-alcoholic steatohepatitis (42), fatty infiltration of the right ventricle or

arrhythmogenic right ventricular cardiomyopathy (43), fatty infiltration and inflammatory bowel

disease and pancreatic disease, among others (44). In all of these conditions there is much

discussion and speculation regarding the role of fat in disease pathogenesis and progression. Our

proposal is that airway associated adipose tissue contributes to obstructive disease in obese

individuals, as evidenced by positive correlations with wall thickness and inflammation. We present

plausible structural, mechanical and inflammatory consequences of airway adipose tissue which

will interact with other known mechanisms in obesity to promote increased susceptibility to airflow

limitation in asthma.
Table 1. Subject characteristics

Control Nonfatal asthma Fatal asthma

(n=15) (n=21) (n=16)

Gender, male, n 11 13 11

(%) (73) (62) (69)

Age, years 38 ± 10 36 ± 11 34 ± 14

Body mass index (kg/m2) 27 ± 5 * 32 ± 8 26 ± 6 *

(range) (22 – 38) (16 – 45) (15 – 41)

† Ever smoked, n 8 11 9

(%) (57) (52) (64)

† Age at onset of asthma, - 17 9

years (10 – 26) (3 – 39)

median (IQR)

† Duration of asthma, years - 17 17

median (IQR) (9 – 21) (7 – 22)

† Corticosteroid use - 9 12 *

(oral and/or inhaled), n (53) (92)

(%)

† Severe asthma, n - 8 9

(%) (38) (64)

Mean ± SD; * = p<0.05 v Nonfatal asthma; † = incomplete data set.

Table 2. Airway size and the area of adipose tissue within the airway wall

Control Nonfatal asthma Fatal asthma

(n=15) (n=21) (n=16)

Basement membrane perimeter, mm

>6mm 15.48 ± 1.56 14.66 ± 1.89 16.12 ± 1.49 *

6-12mm 8.53 ± 0.40 8.65 ± 0.41 8.71 ± 0.61

>12mm 20.32 ± 1.71 20.63 ± 2.45 21.87 ± 1.46

Adipose tissue area/Pbm, mm

>6mm 0.017 0.024 0.021

median (IQR) (0.009 - 0.026) (0.015 - 0.035) (0.011 - 0.033)

6-12mm 0.001 0.004 † 0.003 †

median (IQR) (0.000 - 0.004) (0.002 - 0.009) (0.002 - 0.007)

>12mm 0.0288 0.043 0.034

median (IQR) (0.016 - 0.039) (0.029 - 0.061) (0.018 - 0.050)

Mean ± SD. Median (Inter quartile range). *= p<0.05 v Nonfatal asthma. † = p<0.05 v Control.

Abbreviations: IQR = Inter quartile range; Pbm = Basement membrane perimeter.

Table 3. Relationship of BMI with airway adipose tissue and wall thickness

Control Nonfatal asthma Fatal asthma All asthma

(n=15) (n=21) (n=16) (n=37)

BMI v Adipose tissue area/Pbm, mm

>6mm 0.67 / 0.01 0.57 / 0.01 0.60 / 0.01 0.58 / <0.001

>12mm 0.63 / 0.01 0.50 / 0.02 0.62 / 0.01 0.57 / <0.001

6-12mm 0.71 / 0.003 0.57 / 0.01 0.67 / 0.004 0.46 / 0.004

BMI v WA/Pbm, mm

>6mm 0.77 / <0.001 0.48 / 0.03 0.06 / 0.83 0.25 / 0.13

>12mm 0.73 / 0.002 0.48 / 0.03 -0.02 / 0.96 0.34 / 0.04

6-12mm 0.63 / 0.01 0.57 / 0.01 0.26 / 0.32 0.26 / 0.13

Adipose tissue area/Pbm, mm / v WA/Pbm, mm

>6mm 0.57 / 0.03 0.54 / 0.01 0.06 / 0.84 0.30 / 0.07

>12mm 0.58 / 0.02 0.49 / 0.02 0.37 / 0.16 0.33 / 0.05

6-12mm 0.53 / 0.04 0.76 / <0.001 0.24 / 0.37 0.39 / 0.02

r value / p value. Abbreviations: ASM = airway smooth muscle; BMI = Body mass index; Pbm =

Basement membrane perimeter; WA = airway wall area.

Table 4. Multiple linear regression analysis

Coefficient Standard Error p value

Adipose tissue area/Pbm, mm

Airways >6mm

Asthma 0.0023 0.0035 0.52

BMI 0.0013 0.0002 <0.001

Age 0.0001 0.0001 0.46

Gender -0.0134 0.0033 <0.001

WA/Pbm, mm

Airways >6mm

Asthma 0.3710 0.0772 <0.001

BMI 0.0124 0.0050 0.016

Age -0.0019 0.0031 0.540

Gender -0.0357 0.0742 0.632

Adipose tissue area/Pbm, mm

Airways >12mm

Asthma 0.0074 0.0070 0.296

BMI 0.0024 0.0005 <0.001

Age 0.0004 0.0003 0.120

Gender -0.0215 0.0067 0.002

WA/Pbm, mm

Airways >12mm

Asthma 0.5730 0.1210 <0.001

 BMI 0.0208 0.0078 0.010

Age 0.0018 0.0049 0.709

Gender 0.0265 0.1170 0.821

Adipose tissue area/Pbm, mm

Airways 6-12mm

Asthma 0.0021 0.0016 0.201

BMI 0.0005 0.0001 <0.001

Age -0.0001 0.0001 0.343

Gender -0.0039 0.0016 0.016

WA/Pbm, mm

Airways 6-12mm

Asthma 0.2810 0.0607 <0.001

BMI 0.0084 0.0039 0.036

Age -0.0007 0.0025 0.769

Gender 0.0065 0.0583 0.912

Abbreviations: ASM = airway smooth muscle; BMI = Body mass index; Pbm = Basement

membrane perimeter; WA = airway wall area.

Table 5. Relationship of airway adipose tissue with inflammation

Control Nonfatal Fatal asthma All asthma

(n=12) asthma (n=13) (n=26)

(n=13)

Adipose tissue area/Pbm, mm v Eosinophil area density, mm2

>6mm 0.02 / 0.96 0.24 / 0.44 0.002 / 0.99 0.008 / 0.97

>12mm 0.18 / 0.58 0.05 / 0.90 0.74 / 0.009 0.07 / 0.77

6-12mm 0.63 / 0.18 0.36 / 0.30 0.27 / 0.46 0.62 / 0.80

Adipose tissue area/Pbm, mm v Neutrophil area density, mm2

>6mm 0.61 / 0.04 0.41 / 0.17 0.35 / 0.24 0.17 / 0.39

>12mm 0.32 / 0.32 0.46 / 0.18 0.85 / <0.001 0.33 / 0.14

6-12mm 0.42 / 0.41 0.33 / 0.35 0.06 / 0.87 0.11 / 0.66

BMI v Eosinophil area density, mm2

>6mm 0.09 / 0.79 0.09 / 0.76 0.11 / 0.72 0.23 / 0.26

>12mm 0.003 / 0.99 0.54 / 0.11 0.16 / 0.61 0.15 / 0.51

6-12mm 0.15 / 0.77 0.39 / 0.26 0.11 / 0.77 0.37 / 0.11

BMI v Neutrophil area density, mm2

>6mm 0.22 / 0.49 0.10 / 0.74 0.19 / 0.54 0.16 / 0.43

>12mm 0.27 / 0.40 0.12 / 0.75 0.10 / 0.75 0.12 / 0.61

6-12mm 0.50 / 0.31 0.39 / 0.26 0.31 / 0.39 0.31 / 0.18

r value / p value, (n). Abbreviations: ASM = Airway smooth muscle; BMI = Body mass index; Pbm

= Basement membrane perimeter.

Figure 1

Micrographs (x200) of the (A.) outer airway wall, between the airway smooth muscle (ASM) layer

and the airway adventitia (dashed line) showing adipose tissue and mucous glands and (B.) inner

airway wall (submucosa), between the basement membrane and ASM layer (dashed line) in a case

of fatal asthma stained with haematoxylin and eosin. Inflammatory cells were counted within the

inner airway wall.

Figure 2

Scatter plots showing the area of adipose tissue within the airway wall in airways >12mm expressed

as adipose area per mm of the basement membrane perimeter (Adipose tissue area/Pbm, mm)

plotted by (A.) body mass index (BMI = kg/m2) in control subjects (open circles and dashed line,

r=0.63, p=0.01), nonfatal asthma (shaded circles and light line, r=0.50, p=0.02) and fatal asthma

(solid squares and dark line, r=0.62, p=0.01) and (B.) airway wall thickness (wall area/Pbm, mm) in

control subjects (open circles and dashed line, r=0.58, p=0.02), nonfatal asthma (shaded circles and

light line, r=0.49, p=0.02) and fatal asthma (solid squares and dark line, r=0.37, p=0.16).
Figure 3

Scatter plots showing (A.) airway wall thickness (wall area/Pbm, mm) in airways >12mm plotted

by body mass index (BMI = kg/m2) in control subjects (open circles and dashed line, r=0.73,

p=0.002), nonfatal asthma (shaded circles and light line, r=0.48, p=0.03) and fatal asthma (solid

squares, r=-0.02, p=0.96) and (B.) the area of adipose tissue within the outer airway wall in airways

>12mm expressed as adipose area per mm of the basement membrane perimeter (Adipose tissue

area/Pbm, mm) plotted by body mass index (BMI = kg/m2) in female (shaded circles and light line,

r=0.59, p=0.01) and male (solid squares and dark line, r=0.67, p<0.001) in all subjects.
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