When should bronchodilator therapy be commenced and how often should it be used

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The prescriber should begin bronchodilator therapy when patients with COPD report breathlessness or wheeze. Many patients with COPD are unaware of gradual loss of lung function over several decades. It is common for the first symptoms of breathlessness to occur during chest infections. At this stage, the patient may require bronchodilator therapy only during exacerbations but, as the FEV1 declines over a period of years, the patient is likely to require bronchodilator therapy on many or most days.

Short-acting bronchodilator drugs are usually prescribed for use 'as required' to relieve breathlessness. Bronchodilators are also used to relieve breathlessness or chest tightness during exercise or they may be used before exercise to increase the patient's exercise capacity or to reduce breathlessness during the planned activity.

Bronchodilator drugs may also assist mucus clearance for some patients with COPD (especially in the morning). Mucus clearance is assisted by dilatation of narrowed airways [2]. It is possible that b-agonists may also assist muco-ciliary clearance although this remains controversial. This use of bronchodilator therapy is likely to be of greatest benefit to patients with copious sputum (for example those with coexisting bronchiectasis) or if the sputum is difficult to expectorate. Anticholinergic bronchodilators could theoretically cause some drying of bronchial secretions and could therefore make sputum more viscous in some cases although this would appear to be a rare problem in clinical practice.

Some patients prefer to use bronchodilator drugs on a regular basis to obtain a constant level of symptom relief throughout the day. There is no evidence to suggest that a prescription for regular bronchodilator therapy is better or worse than a prescription for bronchodilator therapy to be used 'as required'. In these circumstances, it is reasonable to let the patient choose whether the drug is to be used on an intermittent or regular basis. In practice, most patients with symptomatic COPD use their bronchodilator inhalers three or more times per day.

Patients requiring frequent short-acting bronchodilator therapy or patients with more severe symptoms should be considered for a trial of a long-acting bronchodilator.

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