Bronchodilator therapy represents a potentially valuable therapeutic option to increase exercise tolerance and enhance lung function in mild-to-moderate chronic obstructive pulmonary disease (COPD).
Objectives: To determine effects of tiotropium on pulmonary hyperinflation and exercise tolerance in symptomatic Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1 and 2 COPD patients who experienced inspiratory capacity decrease ≥100 mL during incremental and constant work rate treadmill exercise.
Methods: 22-week, randomized, double-blind, two-period cross-over study evaluated efficacy of once-daily tiotropium bromide (18 µg) versus placebo in GOLD 1 and 2 COPD patients. Primary endpoint was between-group (tiotropium vs. placebo) difference in inspiratory capacity at isotime (i.e. at the time the shortest test ended) during constant work rate treadmill exercise from baseline to the end of a 6-week treatment period. Key secondary endpoints included differences in exercise duration and exertional dyspnea. Safety was assessed by recording adverse events.
Measurements and Main Results: Study population comprised 48 GOLD 1 and 78 GOLD 2 patients. Resting inspiratory capacity significantly improved with tiotropium versus placebo in the overall (P<0.0001), GOLD 1 (P=0.0183), and GOLD 2 (P<0.0001) groups. Isotime inspiratory capacity was significantly enhanced during exercise in the overall (P=0.0087) and GOLD 2 (P=0.0494) groups following tiotropium versus placebo. Tiotropium versus placebo significantly enhanced exercise duration in the GOLD 2 group (P=0.0070) but not in the GOLD 1 or overall patient groups. In the overall group, increase in exercise duration seen with tiotropium was well correlated with the increase in isotime inspiratory capacity (r=0.463, P<0.0001).
Conclusions: Resting and exercise hyperinflation was ameliorated by bronchodilator therapy with tiotropium in the overall GOLD 1 plus 2 COPD group. Exercise tolerance was enhanced in GOLD 2, but not GOLD 1 COPD.
Umeclidinium (UMEC) is a long-acting inhaled antagonist of muscarinic cholinergic receptors. The FDA approved UMEC for maintenance treatment of chronic obstructive pulmonary disease (COPD) in 2013 and it became available for commercial use as a single agent in 2014. After tiotropium, this is the only other once daily LAMA available for COPD patients.
Areas covered: In this article, we have comprehensively reviewed the pharmacokinetic properties and analyzed the currently available randomized controlled trials on the efficacy and safety profile of UMEC. We have discussed the current clinical application of UMEC and its future implication.
Expert opinion: UMEC is the newer long-acting antimuscarinic agent (LAMA) that has demonstrated significant improvement in lung function and improved the quality of life in moderate-to-severe COPD patients. It is suitable for once daily dosing, has low anticholinergic side effects and is well tolerated. Overall, it is a safe, effective and convenient LAMA for maintenance therapy in COPD patients.
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Lung emphysema is a chronic, progressive and irreversible destruction of the lung tissue. Besides non-medical therapies and the well established medical treatment there are surgical and minimally invasive methods for lung volume reduction (LVR) to treat severe emphysema.
This report deals with the effectiveness and cost-effectiveness of minimally invasive methods compared to other treatments for LVR in patients with lung emphysema. Furthermore, legal and ethical aspects are discussed. No clear benefit of minimally invasive methods compared to surgical methods can be demonstrated based on the identified and included evidence. In order to assess the different methods for LVR regarding their relative effectiveness and safety in patients with lung emphysema direct comparative studies are necessary.
Rationale: The demographic, physiologic, and computed tomography (CT) features associated with pneumothorax in smokers with and without chronic obstructive pulmonary disease (COPD) are not clearly defined.
Objectives: We evaluated the hypothesis that pneumothorax in smokers is associated with male gender, tall and thin stature, airflow obstruction, and increased total and sub-pleural emphysema.
Methods: The study included smokers with and without COPD from the COPDGene study, with quantitative chest CT analysis. Pleural-based emphysema was assessed using local histogram measures of emphysema. Pneumothorax history was defined by subject self-report.
Measurements and Main Results: Pneumothorax was reported in 286 (3.2%) of 9,062 participants. In all participants, risk of prior pneumothorax was significantly higher in men (OR 1.55, 95% CI 1.08 - 2.22) and non-Hispanic whites (OR 1.90, 95% CI 1.34 - 2.69). Risk of prior pneumothorax was associated with increased percent CT emphysema in all participants and participants with COPD (OR 1.04 for each 1% increase in emphysema, 95% CI 1.03 - 1.06). Increased pleural-based emphysema was independently associated with risk of past pneumothorax in all participants (OR 1.05 for each 1% increase, 95% CI 1.01 - 1.10). In smokers with normal spirometry, risk of past pneumothorax was associated with non-Hispanic white race and lifetime smoking intensity (OR 1.20 for every 10 pack-years, 95% CI 1.09 - 1.33).
Conclusions: Among smokers, pneumothorax is associated with male gender, non-Hispanic white race, and increased percentage of total and sub-pleural CT emphysema. Pneumothorax was not independently associated with height or lung function, even in participants with COPD. ClinicalTrials.gov Identifier: NCT00608764.