Over the past decade different effective treatment options for use in pulmonary arterial hypertension (PAH) have been developed. Due to multiple pathophysiological pathways in PAH and unsatisfactory overall results with the use of monotherapy in a substantial number of PAH patients, there is a pharmacological rationale for combination therapy. The currently approved substances target the prostacyclin, the endothelin and the NO (nitric oxide) -pathways.

Those agents have shown a varying degree of improvement in different categories of PAH associated limitations like hemodynamics, exercise capacity, functional class, and quality of life. However, clinical worsening over time is still significant in most patients irrespective of the treatment utilized. The recently published ESC-ERS (European Society of Cardiology and European Respiratory Society) guidelines on pulmonary hypertension suggest the use of combination therapy in patients who do not respond adequately to monotheapy.

This article reviews and critically discusses the available data on combination therapy in PAH.

In COPD, inhaler choice should be based on the likelihood that the patient will be able to use the device correctly in order to favour adherence and compliance, and therefore treatment efficacy.

SATE OF THE ART: Performances of usual inhalers are limited by the necessity of a good coordination of patient inspiration and inhaler activation (pressurized metered dose inhalers), or a sufficient inspiratory flow (dry powder inhalers).

Respimat®, the first "Soft Mist™ inhaler" (SMI), releases the drug solution as a low and sustained soft mist, so that lung deposition is both improved and reproducible.

Comorbidities of chronic obstructive pulmonary disease (COPD) have been recognized as an important issue in COPD management. We have reported that patients with liver diseases show a higher prevalence of COPD, but the number of patients with liver diseases was small and the details of liver diseases were not clearly investigated.

In this study, we investigated the prevalence of COPD in patients with liver diseases by recruiting a large number of patients, and also investigated was the effect of hepatitis virus infection on COPD prevalence.

Mechanical ventilation is a lifesaving treatment delivered to patients with a wide spectrum of medical and surgical diseases. However, significant limitations of the clinical application of mechanical ventilation in current practice have emerged, prompting the definition of novel therapeutic perspectives, especially concerning the prevention and treatment of acute respiratory failure.

In the past few decades, there has been a consistent scientific and technologic effort to develop alternative strategies to avoid the need for mechanical ventilation. In particular, several studies have explored the feasibility and efficacy of extracorporeal oxygenation and carbon dioxide removal. Furthermore, promising results on the prevention of the occurrence of severe acute respiratory failure have been provided by clinical studies on the noninvasive application of continuous positive airway pressure as well as by experimental investigations in basic science.

Therefore, further development in this direction will occur only with a permanent integration and exchange of knowledge among industry, clinicians, and scientific investigators.