Collection of Lung Fluid and Tissue Samples for Research

This research protocol involves one or more of the following procedures in healthy volunteers
and patients with known or suspected predisposition to respiratory infection who are enrolled
in National Institutes of Health (NIH) protocols: 1) Adults only: bronchoscopy with sampling
of bronchoalveolar lavage fluid and epithelial cells in healthy adult volunteers and
patients; 2) Adults and Children: sputum induction for collection of sputum specimens; 3)
Adults and Children: nasal mucosal biopsies and brushings for sampling of epithelial cells;
4) Adults and Children: measurement of nasal nitric oxide production; 5) Adults and children:
collection of exhaled breath condensate; 6) Adults and children: measurement of nasal
potential difference. The cellular and acellular samples will be separated, and stored or
transferred to the appropriate laboratories investigating these diseases.

Alveolar macrophages are the predominant (greater than 95%) cell type present in the lavage
of normal subjects. Alveolar macrophages play a central role in the initiation and
propagation of lung inflammation by releasing cytokines (i.e., interleukin-1, tumor necrosis
factor) and chemokines (i.e., interleukin-8, monocyte chemotactic protein, macrophage
inflammatory protein) that activate other resident cells and recruit inflammatory cells to a
local nidus of inflammation. Airway epithelial cells are known to release a variety of
mediators as well. Thus, the interaction of cells with mediators generated by alveolar cells
and bronchial epithelial cells during acute inflammation is a key element in the initiation
of pulmonary inflammatory responses.

Bronchoalveolar lavage (BAL), bronchial brushings, and mucosal biopsies are standard
diagnostic techniques done through the bronchoscope to obtain samples of alveolar and
bronchial specimens for diagnosis of infection, malignancy, or non-infectious inflammation.
Nasal mucosal scrape biopsy is a minimally invasive method of obtaining airway epithelial
cells to diagnose disorders of airway clearance associated with abnormal cilia (hair-like
structures on airway lining cells). Sputum induction is a routinely performed procedure to
facilitate the collection of respiratory secretions (mucus) through stimulation of cough with
inhalation of an aerosolized concentrated salt-water solution. Exhaled breath condensate is
simply collected by breathing normally through a plastic tube inserted into a chilled
cylinder. Nasal potential difference is performed by placing a small needle under the skin of
the forearm that is connected to a salt solution bridge and resting a small catheter on the
surface of the nose through which various salt solutions are dripped.

The objective of this protocol is to analyze bronchoalveolar lavage fluid, airway epithelial
cells, sputum, and exhaled breath specimens and bedside physiologic measurements from healthy
volunteers and from patients who acquire respiratory infections to look for differences in
immune function and to discover new pathways of infectious disease susceptibility. We
hypothesize that studying cellular responses to infection and inflammatory markers released
from these cells will further our understanding of human susceptibility to respiratory tract
infections.

Five hundred and fifty subjects (250 healthy volunteers and 300 patients) will undergo one or
more of the following: 1) bronchoscopy with bronchoalveolar lavage, bronchial brushings,
endobronchial biopsies; 2) nasal mucosal scrape and/or brush biopsies; 3) sputum inductions
4) exhaled breath condensate to obtain specimens for in vitro investigations and comparisons
of both the cellular and acellular components. Bedside measurements 5) nasal nitric oxide
production and 6) nasal potential difference may be done to assess epithelial cell functions
in real-time.

- HEALTHY VOLUNTEER INCLUSION CRITERIA FOR BRONCHOSCOPY AND BRONCHOSCOPIC PROCEDURES:

- 18 to 75 years of age

- Enrolled without regard to gender, race, or ethnicity

- NIH employees or non-employees eligible

- Able to provide proof of identity to the satisfaction of the study clinician
completing the enrollment process

- Able and willing to complete the informed consent process

- Able and willing to arrange to have another person drive them home after the procedure

- Able and willing not to eat or drink anything for 6 hours prior and 2 hours after the
procedure

- Willing to donate blood and respiratory tract samples for storage to be used for
future research

- In good general health without clinically significant medical history

- Physical examination without clinically significant findings

- Screening laboratory tests without clinically significant abnormalities:

1. Complete blood count with differential

2. Serum chemistries including creatinine, blood urea nitrogen, glucose, liver
enzymes and function tests, electrolytes

3. HIV test and hepatitis serologies (HBsAg; HCV) if status is unknown

4. Prothrombin time, partial thromboplastin time

5. Urinalysis

6. Female subjects must have negative urine pregnancy test within 1 week of
participation and continue birth control practices prior to participation

7. Chest radiograph (CXR) (if the subject has not had a CXR or computerized
tomography [CT] scan of the chest within the prior7 days)

8. Pulse oximetry

9. Electrocardiogram (ECG)

10. Treadmill exercise stress test (as indicated for history of angina or
abnormalities on ECG)

HEALTHY VOLUNTEER EXCLUSION CRITERIA FOR BRONCHOSCOPY AND BRONCHOSCOPIC PROCEDURES:

- Less than 18 or greater than 75 years old

- A smoking history of 10 pack-years or more, a current smoker, or tobacco free for less
than a year.

- Positive HIV status. Subjects must have a negative FDA-approved HIV blood test. [Note:
Results of HIV enzyme-linked immunosorbent assay (ELISA) will be documented, but a
negative HIV polymerase chain reaction (PCR) test result will be sufficient for
eligibility screening of subjects with positive HIV ELISA that is due to prior
participation in an HIV vaccine study]

- Acute or chronic hepatitis based on viral hepatitis serologies

- Pregnancy or breastfeeding

- Any active medical problems especially bleeding disorders, significant bruising or
bleeding difficulties with intramuscular (IM) injections or blood draws, use of
anticoagulants, or pulmonary disorders including asthma

- History of allergic reaction to lidocaine, sedative medications like Valium Trademark
or Versed Trademark, or narcotic medications like morphine or fentanyl

- Immunosuppressive medications, cytotoxic medications, inhaled corticosteroids, or
long-acting beta-agonists within the past three months. (Note that use of
corticosteroid nasal spray for allergic rhinitis, topical corticosteroids for an acute
uncomplicated dermatitis, or short-acting beta-agonists in controlled asthmatics is
not excluded).

- Use of platelet inhibitors including aspirin and nonsteroidal anti-inflammatory drugs
(NSAIDs) within 7 days of procedure

- Any medical, psychiatric, social condition, occupational reason or other
responsibility that, in the judgment of the investigator, is a contraindication to
protocol participation or impairs a volunteer s ability to give informed consent

PATIENT INCLUSION CRITERIA FOR BRONCHOSCOPY AND BRONCHOSCOPIC PROCEDURES

1. 18 to 75 years of age inclusive

2. Known or suspected respiratory infections or infection susceptibility

3. Enrolled without regard to gender, race, or ethnicity

4. Must be enrolled in a concurrent NIH protocol and under the care of a primary
physician outside of the NIH

5. Able and willing to complete informed consent process

6. Able and willing to arrange to have another person drive them home after the procedure

7. Able and willing not to eat or drink anything for 6 hours prior and 2 hours after the
procedure

8. Willing to donate blood and respiratory tract samples for storage to be used for
future research

PATIENT EXCLUSION CRITERIA FOR BRONCHOSCOPY AND BRONCHOSCOPIC PROCEDURES

1. Less than 18 or greater than 75 years old

2. History of recent/acute clinically significant pulmonary compromise. This will be
defined by the following criteria:

1. New lung infection or change in status of chronic lung infection or significant
new findings on chest x-ray or CT scan

2. Asthma that is unstable or required emergent care, urgent care, hospitalization,
or intubation during the past two years, or that required the use of oral or
parenteral corticosteroids during the past two years

3. Clinically significant reactive airway disease that does not respond to
bronchodilators

4. Unstable chronic lung disease such as Chronic Obstructive Pulmonary Disease
(COPD) or pulmonary fibrosis

5. History of pulmonary hypertension

6. Requirement of supplemental oxygen at rest

3. Unstable angina or uncontrolled heart failure or rhythm disturbance

4. Significant kidney or liver disease

5. Significant anemia with a hemoglobin of less than 7.5 grams/dl.

6. Bleeding disorder diagnosed by a doctor (e.g., factor deficiency, coagulopathy, or
platelet disorder requiring special precautions), significant bruising or bleeding
difficulties with IM injections or blood draws, or use of anticoagulant medications

7. Use of platelet inhibitors including aspirin and NSAIDs within 7 days of procedure or
clopidogrel (Plavix TM) within 14 days of procedure or the inability to safely stop
platelet inhibitors for 7-14 days prior to procedures

8. History of allergic reaction to lidocaine, sedative medications like Valium TM or
Versed TM, or narcotic medications like morphine or fentanyl

9. Pregnancy or breastfeeding

10. Any medical, psychiatric, social condition, occupational reason or other
responsibility that, in the judgment of the investigator, is a contraindication to
protocol participation or impairs a volunteer's ability to give informed consent

HEALTHY VOLUNTEER INCLUSION CRITERIA FOR NASAL MUCOSAL BIOPSY:

- Greater than or equal to 10 years old

- Enrolled without regard to gender, race, or ethnicity

- NIH employees or non-employees eligible

- Able to provide proof of identity to the satisfaction of the study clinician
completing the enrollment process

- Able and willing to complete the informed consent process

- Willing to donate blood and respiratory tract samples for storage to be used for
future research

- Stable vital signs

HEALTHY VOLUNTEER EXCLUSION CRITERIA FOR NASAL MUCOSAL BIOPSY , Nasal Nitric Oxide
Measurement, and Nasal Potential Difference Measurement:

- Less than 10 years old

- History of frequent colds or significant uncontrolled hay fever symptoms, recent or
active upper respiratory tract infection, such as a cold or sinusitis, or chronic
sinus infection or congestion

- History of turbinectomy or significant nasal pathology that would preclude obtaining
mucosal scrape biopsies or other measures

- Bleeding disorder diagnosed by a doctor (e.g., factor deficiency, coagulopathy, or
platelet disorder requiring special precautions), significant bruising or bleeding
difficulties with IM injections or blood draws, or use of anticoagulant medications

- The use of nasal steroids in the past 6 weeks is an exclusion to protocol
participation.

- Any medical, psychiatric, social condition, occupational reason, or other
responsibility that, in the judgment of the investigator, is a contraindication to
protocol participation or impairs a volunteer s ability to give informed consent

PATIENT INCLUSION CRITERIA FOR NASAL MUCOSAL BIOPSY, Nasal Nitric Oxide Measurement, and
Nasal Potential Difference Measurement

- Greater than or equal to 10 years old

- Known or suspected infections or infection susceptibility

- Enrolled without regard to gender, race, or ethnicity

- Must be enrolled in a concurrent NIH protocol and under the care of a primary
physician outside of the NIH

- Able and willing to complete informed consent process

- Willing to donate blood and respiratory tract samples for storage to be used for
future research

PATIENT EXCLUSION CRITERIA FOR NASAL MUCOSAL BIOPSY, Nasal Nitric Oxide Measurement, and
Nasal Potential Difference Measurement:

- Less than 10 years old

- Significant uncontrolled hay fever symptoms or recent or active upper respiratory
tract infection, such as a cold or sinusitis

- History of turbinectomy or significant nasal pathology that would preclude obtaining
mucosal scrape biopsies or other measures

- Bleeding disorder diagnosed by a doctor (e.g., factor deficiency, coagulopathy, or
platelet disorder requiring special precautions), significant bruising or bleeding
difficulties with IM injections or blood draws, or use of anticoagulant medications

- Any medical, psychiatric, social condition, occupational reason, or other
responsibility that, in the judgment of the investigator, is a contraindication to
protocol participation or impairs a volunteer's ability to give informed consent.

Healthy Volunteer Inclusion Criteria for Sputum Induction and Exhaled Breath Condensate
Collection

1. greater than or equal to 10 years old

2. Enrolled without regard to gender, race, or ethnicity

3. NIH employees or non-employees eligible

4. Able to provide proof of identity to the satisfaction of the study clinician
completing the enrollment process

5. Able and willing to complete the informed consent process

6. Willing to donate blood and respiratory tract samples for storage to be used for
future research

7. Stable vital signs

Healthy Volunteer Exclusion Criteria for Sputum Induction and Exhaled Breath Condensate
Collection

1. < 10 years old

2. History of asthma or reactive airways disease

3. Any medical, psychiatric, social condition, occupational reason, or other
responsibility that, in the judgment of the investigator, is a contraindication to
protocol participation or impairs a volunteer s ability to give informed consent

PATIENT INCLUSION CRITERIA FOR SPUTUM INDUCTION and Exhaled Breath Condensate Collection:

1. greater than or equal to 10 years old

2. Known or suspected infections or infection susceptibility

3. Enrolled without regard to gender, race, or ethnicity

4. Must be enrolled in a concurrent NIH protocol and under the care of a primary
physician outside of the NIH

5. Able and willing to complete informed consent process

6. Willing to donate blood and respiratory tract samples for storage to be used for
future research

PATIENT EXCLUSION CRITERIA FOR SPUTUM and Exhaled Breath Condensate Collection:

1. <10 years old

2. Significant uncontrolled asthma or reactive airways disease

3. Any medical, psychiatric, social condition, occupational reason, or other
responsibility that, in the judgment of the investigator, is a contraindication to
protocol participation or impairs a volunteer s ability to give informed consent.