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 clearance. Steam inhalation (with or without aromatics) may provide symptomatic relief, but there is no evidence that it improves lung function or long-term symptom control.

Several drugs, such as N-acetylcysteine, carbocysteine, bromhexol and ambroxol, reduce mucus viscosity in vitro, but there is little evidence from controlled trials that they improve lung function in patients with COPD, and cannot be recommended as routine therapy. A systematic review of randomized controlled trials has recently shown that mucolytics have a modest bene

Antioxidants

Vitamins C and E N-acetyl cysteine

Antioxidants

Vitamins C and E N-acetyl cysteine

Anti-proteases

Gluthione analogues Nitrones (spin trap)

NF-kB

t Mucus secretion

Isoprostanes

Plasma leak Bronchoconstriction

Anti-proteases

Gluthione analogues Nitrones (spin trap)

NF-kB

t Mucus secretion

Isoprostanes

Plasma leak Bronchoconstriction

Fig. 11.2 Oxidative stress in chronic obstructive pulmonary disease (COPD).

Fig. 11.2 Oxidative stress in chronic obstructive pulmonary disease (COPD).

fit on the frequency and duration of exacerbations in comparison with placebos, although there was a small but significant reduction in lung function [11]. The benefits could not entirely be explained by N-acetylcysteine, which is also an antioxidant.

Expectorants, such as guanifeniesin and potassium iodide, similarly have no proven beneficial effects. Recombinant human DNAase (alfadornase) has beneficial effects in some patients with cystic fibrosis, but its role in COPD is not yet clear. Until there is clear evidence of benefit in COPD, it should not be used, in view of its high cost.

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