Role of longacting bagnoistsdo they act mainly on quality of life rather than on lung function variables

There is increasing evidence that long-acting b2-agonist treatment is effective for patients with COPD. This treatment has been shown to increase FEV1 and peak flow, improve symptom control and improve quality of life compared with 'prn' use of short-acting b-agonist therapy 7,8 . Treatment with a long-acting b-agonist bronchodilator is likely to be of greatest benefit if prescribed for patients with persistent symptoms despite the use of short-acting b-agonists on a 'prn' basis. Some trials...

Does theophylline have a role in COPD management

Theophylline has been used for a long time in the management of COPD, but has not been formally studied in large randomized controlled trials 1 . Theophylline is used as a bronchodilator, with doses that give plasma concentrations of 10-20 mg L. At these doses, theophylline results in reduced symptoms and a small improvement in lung function and exercise capacity 2,3 . In one study, theophylline improved dyspnoea by a reduction in hyperinflation, without significant changes in spirometry 4 ....

Are there any chronic sideeffects from bronchodilator therapy

The short-term side-effects of b-agonists are well known (mostly tremor and palpitations). The main side-effect of anticholinergic therapy is a dry mouth. Some patients find that inhaled medication makes them cough. Theo-phylline treatment carries dangers of theophylline toxicity if high doses are given or if the patient is given other drugs which interact with theophyllines. b-Agonists and anticholinergic treatment have been used for decades without any reports of significant cumulative...

New antiinflammatory treatments

COPD is characterized by inflammation of the airways, with increased numbers of activated macrophages, neutrophils and CD8+ T lymphocytes. Corti-costeroids are largely ineffective at suppressing this inflammatory process, prompting the search for new anti-inflammatory drugs. There are several approaches to inhibiting neutrophilic inflammation (Table 11.1). PDEs break down cyclic nucleotides (cyclic adenosine monophosphate, cAMP and cyclic guanosine monophosphate, cGMP) which regulate cellular...

What is the role of nutritional factors in the susceptibility to COPD

Nutrition may play a role in the development of COPD, especially where oxi-dants and antioxidants are involved. Protective dietary factors concerned include the antioxidant vitamins C and E, magnesium and fish oils. In addition to the endogenous enzymatic antioxidant systems, the antioxidant vitamins C and E may enhance host defences against the oxidative stress of cigarette smoke. Fish oil contains highly polyunsaturated w-3 fatty acids that act as competitive inhibitors of arachidonic acid...

Info

Figure 1.3 outlines the current state of the industry in the United States. We are still surrounded by cigarette advertising. Governments have difficulty in reconciling the huge tax revenues they receive from cigarette sales and the outlay on health care that results from these sales. High-profile sports such as Formula One racing could not exist without cigarette advertising. The World Health Organization recently launched a counter-campaign with large posters...

Is there a role for nebulized bronchodilators in severe but stable COPD

A small minority of COPD patients may derive additional benefit from the very high dose of bronchodilator therapy that can be delivered from a nebulizer 13,14 . Most patients can derive equal benefit from treatment using hand-held inhalers or spacer devices. Nebulized treatment should only be prescribed after a formal trial comparing the response to nebulized treatment with the response to high-dose treatment using hand-held inhalers as recommended in British Thoracic Society and European...

Are bronchodilators cost effective in COPD

Inhaled bronchodilator therapy is relatively inexpensive. For example, eight puffs of salbutamol per day from a metered dose inhaler costs approximately 70 per annum in the UK. This is clearly cost effective if a patient reports significant benefit. Breath-activated inhalers and dry powder inhalers are more expensive than MDIs. Therefore, for patients who can use an MDI effectively, it is the most cost-effective device. However, for patients who cannot use an MDI after careful instruction,...

Is the choice of inhaler device important

Most patients with COPD are best treated with a hand-held device such as a metered dose inhaler or dry powder inhaler. There is not much clinical differ ence between the bronchodilator response achieved by different devices. The most important factor is to choose a device that the patient is able to use. For many COPD patients (especially the elderly), a breath-activated MDI or an MDI with spacer may be the easiest device for the patient to use. Dry powder devices such as Diskhaler, Accuhaler,...

Is there a role for oral bronchodilators in COPD

Oral b-agonists such as salbutamol, terbutaline or bambuterol have been shown to have bronchodilator activity in COPD. However, oral b-agonists tend to cause side-effects such as tremor. Inhaled b-agonists can produce equivalent or superior bronchodilation for most patients with less side-effects. Oral theophylline has been shown to have a modest bronchodilator effect in COPD. However, inhaled b-agonists, especially long-acting b-agonists, achieve greater bronchodilation with less risk of...

Rate of decline in lung function

Typically, FEVj reaches a peak at around age 20-25 and then gradually declines with age by approximately 20-30mL year. Little, however, is known about the lung function of existing individuals with COPD in the decades be fore the disease becomes apparent. It seems logical that patients with COPD may have reached their low FEV1 by one of the following three routes. 1 An accelerated decline in lung function. In their classic paper that followed 800 London office staff with serial measures of FEV1...

When should a second drug be added and does the combination of bagonist and anticholinergic really work better than

There is evidence that combined bronchodilator therapy (b-agonist with anti-cholingeric) produces greater bronchodilation than either drug given alone. This is true whether the agents are given in moderate dose (from hand-held inhalers) or in high doses (from small-volume nebulizers) 5,6 . If patients remains symptomatic despite treatment with a single bron-chodilator agent, it is reasonable to initiate a trial of combined therapy. However, combined therapy should be continued only if the...

Predicted value reference equations

Reference values are derived by measuring lung function in a standardized way in a large group of non-smoking normal individuals. Many such reference ranges exist in the US 11-14 . In Europe, most lung function departments and equipment manufacturers use the European Community for Coal and Steel (ECCS) equation 15 . This was derived from a review of the European literature for lung function in normal Caucasian men and women age 25-70 years, and an overall mean of the reviewed data is...

What are the shortterm effects of pulmonary rehabilitation

A number of randomized controlled trials have shown that rehabilitation leads to short-term effects in patients with COPD 29,30,32,34 . In this chapter, we consider studies with a duration of a maximum of 6 months to be short-term. Important in this respect is to interpret these results in the light of the minimal clinically important difference (MCID). Looking at the MCID, it has been shown that rehabilitation relieves dyspnoea and improves control over COPD 35 . Although most rehabilitation...

Walter McNicholas

Sleep has well-recognized effects on breathing, which in normal individuals have no adverse impact. These effects include a mild degree of hypoventilation with consequent hypoxaemia and hypercapnia, and a diminished responsiveness to respiratory stimuli. However, in patients with chronic lung disease such as chronic obstructive pulmonary disease (COPD), these physiological changes during sleep may have a profound effect on gas exchange, and episodes of profound hypoxaemia may develop,...

Some diagnostic examples

Most books describe the typical features of each condition, and it is often difficult for the clinician to relate the rather dry descriptions to the particular individual in the consulting room. This section describes the diagnostic problems in five real patients as they presented to the author. They are by no means inclusive of all the situations that may arise, but are intended to illustrate the need for objective assessment in order to deliver appropriate therapy for conditions that will...

What is the role of antileukotriene drugs in COPD

There are no published studies on the effects of leukotriene receptor antagonists or 5'-lipoxygenase inhibitors in COPD. There is evidence for increased formation of leukotriene B4 (LTB4) in COPD patients 10 , suggesting that inhibition of LTB4 synthesis by a 5'-lipoxygenase inhibitor or blockage of LTB4-receptors on neutrophils by a receptor antagonist may be of potential benefit. Although a 5'-lipoxygenase inhibitor, zileuton, is available for the treatment of asthma in some countries, its...

Drug delivery in COPD

By analogy with asthma, a disease that affects all airways, it has been presumed that the inhaled route of delivery is preferred for the treatment of patients with COPD. However, the disease process in COPD is predominantly in small airways and in the lung parenchyma, which may not be efficiently targeted by the inhalers designed to treat asthma. This may lead to the development of new inhaler devices with particles that have the optimal distribution for peripheral lung delivery. Furthermore,...

Wisia Wedzicha and Mike Pearson

Why is there a need for a variety of outcome measures in COPD Chronic obstructive pulmonary disease COPD is characterized by a progressive decline in lung function that leads to dyspnoea on exertion and eventually to death. However, there is considerable variability in the rate of decline of forced expiratory volume in 1 second FEVX in different patients. A number of guidelines have been produced for the management of COPD, including those from the European Thoracic Society 1 , American...

Should mucolytics be used routinely

Because mucus hypersecretion is a prominent feature of chronic bronchitis, various mucolytic therapies have been used to increase the ease of mucus expectoration, in the belief that this will improve lung function. Stopping smoking is the most effective way to reduce mucus hypersecretion. Anticholinergics may decrease mucus hypersecretion, although most studies have failed to show an effect of inhaled anticholinergics on mucociliary clearance. b2-agonists and theophylline may improve mucus...

Protease inhibitors

Elastase Half Life Concentration

Emphysema may result from an imbalance between excessive protease activity and deficient endogenous antiproteases Fig. 11.5, Table 11.2 . A logical Fig. 11.5 Imbalance between proteases and antiproteases in chronic obstructive pulmonary disease COPD . Fig. 11.5 Imbalance between proteases and antiproteases in chronic obstructive pulmonary disease COPD . Neutrophil elastase inhibitors ICI 200355, ONO-5046 Cathepsin inhibitors suramin Matrix metalloproteinase inhibitors batimastat, marimastat,...

What are the essential components of pulmonary rehabilitation

A comprehensive rehabilitation programme consists of different components. The literature reports usually include the following elements exercise training, specific limb training, respiratory muscle training, education, nutritional therapy, and psychosocial intervention. While everybody has the feeling that a multidisciplinary treatment is needed in some patients, there is no evidence yet that all components of rehabilitation are equally effective in reducing the level of disability or...

PaO2 between 73 kPa and 8 kPa 55 mmHg and 60mmHg

The range of PaO2 between 7.3 and 8 kPa 55 mmHg and 60 mmHg remains a grey area. From the MRC and NOT Trial, it is not clear whether LTOT has a beneficial effect on prognosis for these patients. This question was addressed by a randomized controlled trial in 135 Polish patients with COPD 4 . These patients had a PaO2 between 7.4kPa 55.5 mmHg and 8.7kPa 65.3 mmHg , with mean PaO2 8 kPa 60 mmHg . LTOT, over at least 3 years, was not associated with a survival benefit, and there was no difference...

Arterial oxygen tension PaO2 less than 73 kPa 55 mmHg

A PaO2 of up to 8kPa 60mmHg was the entry criterion for PaO2 for the MRC study 1 . The main entry criterion for PaO2 for the NOT Trial was a PaO2 below 7.3 kPa 55 mmHg , although patients with a PaO2 of up to 8 kPa 60 mmHg were included if they also had oedema, secondary polycythaemia, or significant pulmonary hypertension 2 . The mean PaO2 of patients entering both studies was 6.8 kPa 51mmHg . The widely used cut-off PaO2 of 7.3 kPa 55 mmHg for the prescription of LTOT in guidelines therefore...