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Chest Oct 2011COPD is a preventable and treatable disease characterized by airflow limitation that is not fully reversible. The diagnosis of COPD is based on spirometric evidence of... (Review)
Review
COPD is a preventable and treatable disease characterized by airflow limitation that is not fully reversible. The diagnosis of COPD is based on spirometric evidence of airways obstruction following bronchodilator administration. Although it used to be commonly believed that patients with COPD have largely irreversible airflow obstruction, evidence now suggests that a considerable proportion of patients exhibit clinically significant bronchodilator reversibility. The complexity and inherent variability of a patient's acute response to a bronchodilator and the lack of a standardized procedure for assessing bronchodilator reversibility have led to significant confusion surrounding this concept. Although bronchodilator reversibility commonly is defined based on thresholds for improvement in FEV(1), lung volume-based measures of pulmonary function may be of particular importance in patients with severe COPD. The usefulness of acute reversibility to short-acting bronchodilators in predicting a patient's long-term response to bronchodilator maintenance therapy is also unclear, although most studies suggest that a lack of acute response to short-acting bronchodilators does not preclude a beneficial long-term response to maintenance bronchodilator treatment. This review outlines recent findings about the prevalence and usefulness of bronchodilator reversibility in patients with COPD based on the available literature and proposes areas of future research.
Topics: Administration, Inhalation; Bronchodilator Agents; Forced Expiratory Volume; Humans; Pulmonary Disease, Chronic Obstructive; Spirometry; Treatment Outcome
PubMed: 21972384
DOI: 10.1378/chest.10-2974 -
International Journal of Chronic... 2020Pharmacological medications used for the treatment of COPD patients have increased significantly. Long-acting bronchodilators have been recognized as the mainstay of the... (Review)
Review
Pharmacological medications used for the treatment of COPD patients have increased significantly. Long-acting bronchodilators have been recognized as the mainstay of the treatment of stable COPD, while ICS are usually added in patients with COPD who experience exacerbations, despite bronchodilator treatment. In the latest years, several studies have been published showing the beneficial effect of adding ICS on dual bronchodilation in patients suffering from more severe disease comparing triple therapy with several therapeutic regiments including dual bronchodilation and providing a message that this triple therapy might be more appropriate for COPD patients. However, not all COPD patients have a desirable response to ICS treatment while long-term ICS use in COPD is associated with several side effects. In this report, we aimed to provide a review of the current knowledge on the importance of dual bronchodilation on COPD patients and to compare its use with triple therapy, by covering a wide spectrum of topics. Finally, we propose an algorithm on performing treatment step up from dual bronchodilation to triple therapy and step down from triple to double bronchodilation considering the current evidence.
Topics: Administration, Inhalation; Adrenal Cortex Hormones; Adrenergic beta-2 Receptor Agonists; Bronchodilator Agents; Drug Therapy, Combination; Humans; Pulmonary Disease, Chronic Obstructive
PubMed: 33149567
DOI: 10.2147/COPD.S273987 -
Pulmonary Pharmacology & Therapeutics Dec 2017Experimental studies indicate that airway calibre increases the sensitivity of the afferents involved in the cough reflex but it has proved difficult to demonstrate that... (Review)
Review
Experimental studies indicate that airway calibre increases the sensitivity of the afferents involved in the cough reflex but it has proved difficult to demonstrate that airway calibre increases the sensitivity of the afferents involved in the cough reflex. Therefore, bronchodilators might have a role, although rather minor, in the treatment of cough. However, although bronchodilators represent the standard of care in the treatment of airway obstruction associated with asthma or COPD, controversy persists regarding the mechanism(s) by which these agents alleviate cough. Furthermore, the available evidence indicates that the effects of bronchodilators on cough are rather inconsistent in humans and casts doubt on the appropriateness of the common practice of using bronchodilators in the treatment of patients with cough without any other evidence of airway obstruction. Regrettably, appropriate long-term trials specifically aimed at evaluating the clinical efficacy of bronchodilators in pathologic cough have not yet been performed. Therefore, properly executed clinical studies of bronchodilators in various types of acute and chronic pathologic cough are required.
Topics: Afferent Pathways; Animals; Bronchodilator Agents; Chronic Disease; Clinical Trials as Topic; Cough; Humans; Research Design
PubMed: 28527922
DOI: 10.1016/j.pupt.2017.05.011 -
Respiratory Care Jun 2018Obstructive lung diseases, including asthma and COPD, are characterized by air-flow limitation. Bronchodilator therapy can often decrease symptoms of air-flow... (Review)
Review
Obstructive lung diseases, including asthma and COPD, are characterized by air-flow limitation. Bronchodilator therapy can often decrease symptoms of air-flow obstruction by relaxing airway smooth muscle (bronchodilation), decreasing dyspnea, and improving quality of life. In this review, we discuss the pharmacology of the β agonist and anticholinergic bronchodilators and their use, particularly in asthma and COPD. Expanding knowledge of receptor subtypes and G-protein signaling, agonist and antagonist specificity, and drug delivery have led to the introduction of safer medications with fewer off-target effects, medications with longer duration of action that may improve adherence, and more effective and efficient aerosol delivery devices.
Topics: Administration, Inhalation; Asthma; Bronchodilator Agents; Humans; Pulmonary Disease, Chronic Obstructive
PubMed: 29794201
DOI: 10.4187/respcare.06051 -
Drugs Nov 1982Bronchodilators may be classified into 3 groups: anticholinergics, beta-adrenoceptor agonists and methylxanthines. These drugs act through related biochemical pathways... (Review)
Review
Bronchodilators may be classified into 3 groups: anticholinergics, beta-adrenoceptor agonists and methylxanthines. These drugs act through related biochemical pathways and there are theoretical reasons for expecting beneficial additive or synergistic interactions between them. While there is in vitro evidence of synergistic interactions producing bronchodilatation, in vivo studies indicate that the interactions are additive rather than synergistic but still of therapeutic value. There have been no clinical studies on methylxanthines combined with anticholinergic drugs, but there is an extensive and growing literature on the other combinations. The majority show clear evidence of an additive bronchodilator effect when anticholinergics are combined with beta 2-adrenoceptor agonists, although atropine sulphate is less effective in this regard than atropine methylnitrate or ipratropium bromide. This type of combination has only been tested by inhalation and, because of the slower onset of action of the anticholinergic group, it is preferable that the beta 2-adrenoceptor agonist be inhaled first. There is no evidence for an additive interaction of the side effects of these drugs. In general, bronchitics respond better than asthmatics to anticholinergic drugs. Studies on methylxanthines (usually theophylline) and adrenoceptor agonists may be divided into 2 groups: those using ephedrine and those using more selective beta-adrenoceptor agonists. Ephedrine is a relatively ineffective bronchodilator and often fails to add any useful bronchodilatation to theophylline. Also, there does seem to be a synergistic increase in side effects of the two drugs and this combination is therefore undesirable. Ephedrine has now been superseded by the more selective beta 2-adrenoceptor agonist drugs all of which, whether given orally, intravenously or by inhalation, appear to have an additive effect with the methylxanthines. It is often possible to achieve the same therapeutic effect with half doses of drugs from 2 different groups as with a full dose of 1 drug. This may sometimes, but not always, reduce side effects. There is evidence that giving 2 drugs by different routes is a useful therapeutic procedure; for example, the addition of an inhaled beta 2-adrenoceptor agonist may improve upon the maximal bronchodilatation achieved with intravenous theophylline. When theophylline is administered plasma levels of the drug should be monitored and it is possible that, when used in combination with a beta 2-adrenoceptor agonist, a therapeutic range lower than that normally recommended may apply. There is no longer any place for fixed combination bronchodilators and, in spite of recent suggestions, there is no evidence that bronchodilator combinations are responsible for an increase in asthma mortality. Further studies to clarify some aspects of bronchodilator combinations are needed. The therapeutic use of various combinations is briefly discussed.
Topics: Adrenergic beta-Agonists; Asthma; Bronchodilator Agents; Drug Interactions; Drug Therapy, Combination; Humans; Isoproterenol; Lung Diseases, Obstructive; Parasympatholytics; Xanthines
PubMed: 6129123
DOI: 10.2165/00003495-198224050-00004 -
Pharmacological Reviews Jan 2020Bronchodilators remain the cornerstone of the treatment of airway disorders such as asthma and chronic obstructive pulmonary disease (COPD). There is therefore... (Review)
Review
Bronchodilators remain the cornerstone of the treatment of airway disorders such as asthma and chronic obstructive pulmonary disease (COPD). There is therefore considerable interest in understanding how to optimize the use of our existing classes of bronchodilator and in identifying novel classes of bronchodilator drugs. However, new classes of bronchodilator have proved challenging to develop because many of these have no better efficacy than existing classes of bronchodilator and often have unacceptable safety profiles. Recent research has shown that optimization of bronchodilation occurs when both arms of the autonomic nervous system are affected through antagonism of muscarinic receptors to reduce the influence of parasympathetic innervation of the lung and through stimulation of -adrenoceptors ( -ARs) on airway smooth muscle with -AR-selective agonists to mimic the sympathetic influence on the lung. This is currently achieved by use of fixed-dose combinations of inhaled long-acting -adrenoceptor agonists (LABAs) and long-acting muscarinic acetylcholine receptor antagonists (LAMAs). Due to the distinct mechanisms of action of LAMAs and LABAs, the additive/synergistic effects of using these drug classes together has been extensively investigated. More recently, so-called "triple inhalers" containing fixed-dose combinations of both classes of bronchodilator (dual bronchodilation) and an inhaled corticosteroid in the same inhaler have been developed. Furthermore, a number of so-called "bifunctional drugs" having two different primary pharmacological actions in the same molecule are under development. This review discusses recent advancements in knowledge on bronchodilators and bifunctional drugs for the treatment of asthma and COPD. SIGNIFICANCE STATEMENT: Since our last review in 2012, there has been considerable research to identify novel classes of bronchodilator drugs, to further understand how to optimize the use of the existing classes of bronchodilator, and to better understand the role of bifunctional drugs in the treatment of asthma and chronic obstructive pulmonary disease.
Topics: Adrenergic beta-2 Receptor Agonists; Animals; Asthma; Bronchodilator Agents; Clinical Trials, Phase III as Topic; Humans; Pulmonary Disease, Chronic Obstructive
PubMed: 31848208
DOI: 10.1124/pr.119.018150 -
The American Journal of Medicine Jun 2018The incidence of chronic obstructive pulmonary disease (COPD) is rising in the United States, and the disease represents a significant source of morbidity and mortality.... (Review)
Review
The incidence of chronic obstructive pulmonary disease (COPD) is rising in the United States, and the disease represents a significant source of morbidity and mortality. Primary care providers face many challenges in COPD diagnosis and treatment, as different clinical phenotypes require personalized treatment approaches. Patient adherence and inhaler technique also contribute to treatment outcomes. Around 48% of primary care providers are unaware of guidelines and recommendations for COPD diagnosis and treatment, which may lead to misdiagnosis or undertreatment of COPD symptoms. Inadequately treated COPD can impair patients' quality of life and ability to perform everyday activities. Long-acting bronchodilator therapy is the cornerstone treatment for patients with COPD; combinations of bronchodilators of different pharmacological classes have shown improved efficacy vs monotherapy. We review the rationale behind fixed-dose dual bronchodilator therapy, evidence for the 4 currently Food and Drug Administration-approved long-acting anticholinergic bronchodilators/long-acting β-agonists fixed combinations, patient suitability for the available inhaler devices, and practical guidance to optimize personalized care for patients with COPD.
Topics: Adrenergic beta-2 Receptor Agonists; Bronchodilator Agents; Cholinergic Antagonists; Humans; Muscarinic Antagonists; Pulmonary Disease, Chronic Obstructive
PubMed: 29305841
DOI: 10.1016/j.amjmed.2017.12.018 -
Critical Care (London, England) 2000The delivery of bronchodilators with metered-dose inhaler (MDI) in mechanically ventilated patients has attracted considerable interest in recent years. This is because... (Review)
Review
The delivery of bronchodilators with metered-dose inhaler (MDI) in mechanically ventilated patients has attracted considerable interest in recent years. This is because the use of the MDI has several advantages over the nebulizer, such as reduced cost, ease of administration, less personnel time, reliability of dosing and a lower risk of contamination. A spacer device is fundamental in order to demonstrate the efficacy of the bronchodilatory therapy delivered by MDI. Provided that the technique of administration is appropriate, MDIs are as effective as nebulizers, despite a significantly lower dose of bronchodilator given by the MDI.
Topics: Administration, Inhalation; Bronchodilator Agents; Cost-Benefit Analysis; Drug Monitoring; Equipment Design; Humans; Nebulizers and Vaporizers; Respiration, Artificial
PubMed: 11094505
DOI: 10.1186/cc698 -
Physiological Measurement Oct 2022Viral lower respiratory tract infections (LRTI) are the leading cause for acute admission to the intensive care unit in infants and young children. Nebulized... (Observational Study)
Observational Study
Viral lower respiratory tract infections (LRTI) are the leading cause for acute admission to the intensive care unit in infants and young children. Nebulized bronchodilators are often used when treating the most severe cases. The aim of this study was to investigate the bronchodilator effect on respiratory mechanics during intensive care with electrical impedance tomography (EIT) and to assess the feasibility of EIT in this context.We continuously monitored the children with chest EIT for up to 72 h in an observational study design. The treatment decisions were done by clinical assessment, as the clinicians were blinded to the EIT information during data collection. In a retrospective analysis, clinical parameters and regional expiratory time constants determined by EIT were used to assess the effects of bronchodilator administration, especially regarding airway resistance.We included six children from 11 to 27 months of age requiring intensive care due to viral LRTI and receiving bronchodilator agents. Altogether 131 bronchodilator administrations were identified during EIT monitoring. After validation of the exact timing of events and EIT data quality, 77 administrations were included in the final analysis. Fifty-five bronchodilator events occurred during invasive ventilation and 22 during high-flow nasal cannulae treatment. Only 17% of the bronchodilator administrations resulted in a relevant decrease in calculated expiratory time constants.Continuous monitoring with EIT might help to optimize the treatment of LRTI in pediatric intensive care units. In particular, EIT-based regional expiratory time constants would allow objective assessment of the effects of bronchodilators and other respiratory therapies.
Topics: Infant; Humans; Child; Child, Preschool; Bronchodilator Agents; Tomography; Electric Impedance; Retrospective Studies; Lung; Respiratory Tract Infections
PubMed: 36137548
DOI: 10.1088/1361-6579/ac9450 -
The European Respiratory Journal Mar 1996Metered-dose inhalers (MDIs) provide several advantages over nebulizers, including ease of administration, decreased cost, reliability of dosing, and freedom from... (Review)
Review
Metered-dose inhalers (MDIs) provide several advantages over nebulizers, including ease of administration, decreased cost, reliability of dosing, and freedom from contamination. However, this method of aerosol delivery has been considered ineffective in mechanically-ventilated patients because most of the aerosol deposits in the endotracheal tube and ventilator circuit. A smaller amount of aerosol from a MDI is deposited in the lower respiratory tract of mechanically-ventilated patients than in ambulatory patients, although recent studies show that a significant bronchodilator effect can still be achieved. When employed optimally, significant bronchodilation occurs with as little as 4 puffs of a sympathomimetic aerosol. Multiple factors influence the efficacy of MDIs in mechanically-ventilated patients. The method of connecting the MDI canister to the ventilator circuit has a marked effect on aerosol delivery, and other factors include the timing of MDI actuation, ventilator mode, tidal volume, circuit humidity, and duty cycle. With a proper technique of administration, a MDI serves as an effective, convenient, and safe method for delivering bronchodilator aerosols in mechanically-ventilated patients.
Topics: Administration, Inhalation; Bronchodilator Agents; Combined Modality Therapy; Humans; Lung Diseases; Nebulizers and Vaporizers; Particle Size; Respiration, Artificial; Treatment Outcome
PubMed: 8730023
DOI: 10.1183/09031936.96.09030585