Translation Evaluation of Aging, Inflammation and HIV in Lung Function (TEAL)
Translation Evaluation of Aging, Inflammation and HIV in Lung Function (TEAL)
Hypothesis;Aging modifies the risk of pulmonary dysfunction in HIV+ individuals.

 The study is a multicenter, prospective observational study of aging and pulmonary function
 in HIV. The investigator will determine the prevalence and risk factors for lung dysfunction
 as quantified by pulmonary function testing in both younger (<50 years) and older (≥50 years)
 HIV+ and HIV-uninfected controls. The investigator will build on existing cohorts and enrich
 enrollment for individuals over the age of 50 while adjusting for important co-variates such
 as ART, smoking history, co-infections, and illicit drug use. Evaluations will be scheduled
 at baseline, 18 months, and 36 months. Study visits will consist of blood draw,
 questionnaires, and pulmonary function testing.
All clinical procedures will be performed by a registered nurse. Bronchoscopy procedures will
 be performed by physician.

 Subjects will be instructed to avoid smoking, alcoholic beverages and caffeine or medications
 containing caffeine for eight hours, prior to the visit. In addition, the subject will be
 asked to hold all medications that are bronchodilators prior to the test being administered
 and to eat a light meal 2-4 hours prior to testing.

 Part I

 Respiratory questionnaires:

 Translation Evaluation of Aging, Inflammation and HIV in Lung Function questionnaire, MMRC
 and the ST. George's Questionnaire will be administered. These are paper and pencil
 questionnaires that inquire about respiratory symptoms, quality of life, smoking history and
 other health issures. This will take approximately 30 minutes to complete.

 Blood Sample collection:

 The subject will be asked to provide a blood sample by venipuncture of approximately 40mls (8
 teaspoons) at this study visit. The purpose of this collection is to have blood processed for
 serum, plasma, and PBMCS, and a protion stored in RNAlater to be used for future use. A
 hemoglobin and Carboxyhemoglobin will be done in order to calculate the DLCO. The
 de-identified samples will be processed and stored at -80C.

 Personal genetic information will not be provided to individual research subjects as Dr.
 Morris's laboratory is not CLIA certified and because the blood samples will be
 de-identified.

 Lung function testing:

 The routine lung function endpoints of FVC, FEV1, FEV1/FVC, and FEF25-75% will be measured
 with the flow-volume loop recorder on a NDD EasyOne Pro testing system before and after
 bronchodilator administration. The system is calibrated for body temperature and pressure of
 saturated gas and volumes, per American Thoracic Society (ATS) standards . The best of three
 reproducible forced expiratory attempts is used in analysis. Percent predicted spirometric
 values are based on age, height, gender, and ethnicity. DLco will be measured using the
 automated single-breath procedure of the integrated testing system, which conforms with ATS
 standards. All testing will be reviewed by (PI). If any concerns or abnormal results are
 discovered during this testing, a member of the research team will notify the subject or the
 subject's primary care physician, who will assess the need to provide additional evaluation.

 Subjects will have these tests done at baseline, 18 months and 36 months. Each visit will
 last 3 to 4 hours. The visits will take place in the MUH 6th floor CTRC

 6 minute walk test; Particiapant will rest for 10 minutes prior to beginning the test. BP and
 pulse ox are checked prior to the test. The six-minute walk tests are performed in a 100-foot
 segment of straight hallway marked at 1-foot intervals. In addition to the usual ATS
 protocol, the patient is monitored with wireless pulse oximetry and the time and distance
 recorded at which they desaturate to <88% or at 6 minutes. The test is also terminated if the
 saturation falls below 80%. Dyspnea and perceived exertion are rated using the Borg scale at
 the end of test. BP is checked post test. For this study the test will be performed off of
 supplemental oxygen if possible. O2 can be used on subjects who use O2 regularly to keep
 O2Sat > 88%

 Oral specimen collection. The investigator will collect a 10ml oral wash, a tongue scraping
 and a 1 to 5ml saliva collection. This is a one time collection at any visit.

 Part II Bronchoscopy visit (Selected subjects only) Subjects will be called back depending on
 the outcome of the PFT's and medical history. Subjects selected for bronchoscopy may have
 lung testing repeated depending on the time lapse between PFT and bronchoscopy. This will be
 decided at the discreation of the PI There will be two visits for the bronchoscopy
 participants. Both visits will take place in MUH 6th floor CTRC

 Visit One: Apprx. 3 hours Screening procedures Oral Wash Tongue scraping Sputum induction
 Blood collection (Repeat breathing test will be completed at the discretion of the principal
 investigator)

 Oral Wash The participant will gargle with .9% saline for 1 minute and then spit into a
 container to provide a sample of approximately 10mls (2 teaspoons) at this study visit.

 Tongue Scraping A tongue blade or similar object will be used to scrape the tongue. This
 procedure should only take minutes.

 Sputum Induction The subject will breathe in and out mists of saline (3%-5% saline) with a
 mouthpiece for 20 minutes. During this time, they will actively cough and spit out saliva and
 sputum into two separate cups every 4 minutes. We will frequently measure lung function
 during the procedure (every 4 min) using a peak flow meter.

 Blood The investigator will take a blood sample of approximately 60mls (10 teaspoons) at this
 study visit for research blood. (serum, plasma, and PBMCS ) In addition, part of this blood
 will be used to perform routine clinical blood tests to assure that it is safe to proceed
 with the bronchoscopy test. (CBC/DIFF/PLT, LYTS, BUN, Creatinine, Glucose, PT/PTT)

 Visit Two: Approx. 6 hours Oral wash Tongue scraping with rinse Bronchoscopy Monitoring
 (Blood draw- if visit two is more than 24 hours from visit one to repeat clinical labs)

 Oral wash and Tongue Scraping will be repeated, and then the subject will rinse with 10cc's
 of Listerine. to assure that there are no bacteria left behind in the mouth prior to the
 bronchoscopy.

 Bronchoscopy: Fiberoptic bronchoscopy will be performed using the ATS recommendation and
 institutional protocols for conscious sedation. The testing will be performed by a physician
 certified in pulmonary medicine and proficient in the procedure and certified by UPMC.
 Subjects will be instructed to fast overnight and withhold aspirin and anti-inflammatory
 analgesics for 48 hours prior to the procedure. Subjects will have undergone a pre-
 bronchoscopy spirometry and only clinically stable subjects (FEV1>30% predicted after
 albuterol) will undergo the procedure. Subjects will also recieve Proventil HFA Inhaler 2
 puffs, after 5 minutes will recieve a second dose of Proventil 2 puffs prior to sending
 patient to the Bronchoscopy suite. Subjects will recieve an intramuscular injection of a mild
 sedative and a drug to dry secretions Demerol 50mg IV and Atropine 0.6mg.

 Subjects will receive a local anesthetic to the upper and lower airways and an intravenous
 sedative and/or analgesic (midazolam; fentanyl). The midazolam dose will not exceed 10mg
 and/or the fentanyl dose will not exceed 200 micrograms. Lidocaine will not exceed a dose of
 9 mg/kg (0.9 cc of 1%/kg) or a maximum dose of 600 mg (60 cc 1%) during the procedure.
 Subject monitoring will follow the local protocol for conscious/deep sedation. If needed,
 subjects will receive additional short acting beta agonist. After transoral insertion of the
 bronchoscope a general inspection of the airways will be performed followed by the
 bronchoalveolar lavage. Blood pressure, heart rate, and oxygen saturation will be monitored
 throughout the procedure.

 Bronchoalveolar lavage:

 BAL will be performed with room temperature normal saline. After wedging the bronchoscope in
 a (sub)segmental bronchus, approximately 50cc of saline will be instilled with each washing
 and withdrawn by syringe aspiration. This will be repeated up to 4 times per segment as
 needed. Amount of wash and selection of segments will be at the discretion of the physician.
 Many clinical bronchoscopies are within this range of volume, and research bronchoscopies
 have been found to be safe with volumes ranging from 100 to 300 cc even in subjects with
 severe asthma (Wenzel S et al. Bronchoscopic evaluation of severe asthma. American Journal of
 Respiratory and Critical Care Medicine 1997;156:737-43; Summary and recommendations of a
 workshop on the investigative use of fiberoptic bronchoscopy and bronchoalveolar lavage in
 asthmatic patients. Chest 1985;88:136-38). We will stop the lavage at any point where we do
 not feel that it would be clinically tolerated by the patient.

 The volume collected after each withdrawal will be recorded.

 Bronchial brushing:

 Cytology bronchial brushing involves positioning the bronchoscope at the right middle or
 lower lobe, passing a cytology brush through the bronchoscope and gently brushing the lining
 of the airways. This may be repeated at least eight more times per segment to ensure an
 adequate sample collection. If any sample collected is not acceptable or adequate for
 analysis, another sample may be collected so long as the physician performnig the
 bronchoscopy procedure decides that no significant risk is present with the additional
 collection.

 1. Participant will be monitored at UPMC Montefiore until the sedation has worn off. After
 the bronchoscopy is completed, the subject will wait in the bronchoscopy recovery area
 or the clinical research CTRC to make sure thier breathing has not been affected by the
 procedure and to be sure that the anesthesia has worn off. Pulse oximetry montioring
 will continue throughout recovery period. If the subject is not able to breathe as well
 as they could before the bronchoscopy, we will give additional albuterol and check the
 breathing again.Participant will not be allowed to leave the recovery area until their
 breathing is back to their normal level. If a participants breathing does not return to
 baseline they will be required to be admitted overnight

 2. Participant will not be allowed to drive themselves home after the bronchoscopy.

 Broncoscopy pre and post sedation care will be conducted in the MUH CTRC. Staff are trained
 research registered nurses and familiar with post bronchoscopy monitoring. Pulse oximetry
 will be closely monitored and the subect will not be discharged until anethseia has worn off
 and the subject's breathing is back to normal.

 The bronchoscopy procedure will take about 45 minutes, the participant will not be discharged
 until anesthesia has worn off and their breathing is back to normal.

 All bronchoscopies will be done in the pulmonary division bronchoscopy suite. Resuscitative
 equipment and personnel are present in the room to minimize risk. In addition, all research
 bronchoscopies will have an RN present, as well as the physician in charge of the procedure.
 The physician will be a faculty member of UPMC with brochoscopy privileges.

 Bronchoscopy will only be offered once.
Inclusion Criteria:

 -  Pregnancy or breast-feeding.

 -  Contraindication to pulmonary function testing (i.e. abdominal or cataract surgery
 within 3 months, recent myocardial infarction, etc.).

 -  Increasing respiratory symptoms or febrile (temperature >100.40F [380C]) within 4
 weeks of study entry.

 -  Hospitalization within 4 weeks prior to study entry.

 -  Uncontrolled hypertension at screening visit (systolic > 160 mm Hg or diastolic > 100
 mm Hg) from an average of two or more readings. Subject may return for screening after
 blood pressure is controlled.

 -  Active cancer requiring systemic chemotherapy or radiation.

 -  Active infection of lungs, brain, or abdomen.

 -  Intravenous drug use or alcohol use that will impair ability to complete study
 investigations in the opinion of the investigator.

 Exclusion Criteria:

 HIV+ young:

 -  HIV-1 infection, documented in medical record at any time prior to study entry.

 -  Men and women age 45 years and below.

 -  Ability and willingness to complete all tests.

 -  Participant in MACS, Women's Interagency Health Study and secondarily clinics and the
 community

 HIV+ old:

 -  HIV-1 infection, documented in medical record at any time prior to study entry.

 -  Men and women age 50 years and above.

 -  Ability and willingness to complete all tests.

 -  Participant in MACS, Women's Interagency Health Study and secondarily clinics and the
 community

 HIV- young:

 -  HIV-uninfected, documented at most recent MACS or WIHS visit.

 -  Men and women age 45 years and below.

 -  Ability and willingness to complete all tests.

 -  Participant in MACS, Women's Interagency Health Study and secondarily clinics and the
 community

 HIV- old:

 -  HIV-uninfected, documented at most recent MACS or WIHS visit.

 -  Men and women age 50 years and above.

 -  Ability and willingness to complete all tests.

 -  Participant in MACS, Women's Interagency Health Study and secondarily clinics and the
 community