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Rogliani P, Radovanovic D, Ora J, Starc N, Verri S, Pistocchini E, Calzetta L. Assessing the relationship between cardiovascular and small airway disease and acute events in COPD: The ARCADIA study protocol. Pulm Pharmacol Ther 2023; 82:102231. [PMID: 37414133 DOI: 10.1016/j.pupt.2023.102231] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 06/26/2023] [Accepted: 07/03/2023] [Indexed: 07/08/2023]
Abstract
The initial alterations of chronic obstructive pulmonary disease (COPD) involve the small airways. Small airway disease (SAD) is related to lung hyperinflation and air trapping. Several lung function tests may detect the presence of SAD, namely forced mid-expiratory flows, residual volume (RV), RV/total lung capacity (TLC) ratio, functional residual capacity, airway resistances obtained with body-plethysmography and oscillometry, and the single-breath nitrogen washout test. Additionally, high-resolution computed tomography can detect SAD. In addition to SAD, COPD is related to cardiovascular disease (CVD) such as heart failure, peripheral vascular disease, and ischemic heart disease. No studies have assessed the relationship between CVD, COPD, and SAD. Therefore, the main objective of the Assessing the Relationship between Cardiovascular and small Airway Disease and Acute events in COPD (ARCADIA) study is to assess the risk of CVD in COPD patients according to SAD in a real-life setting. The correlation between CVD, mortality, and acute exacerbation of COPD (AECOPD) is also evaluated. ARCADIA is a 52-week prospective, multicentre, pilot, observational, cohort study conducted in ≥22 pulmonary centres in Italy and that enrols ≥500 COPD patients, regardless of disease severity (protocol registration: ISRCTN49392136). SAD is evaluated at baseline, after that CVD, mortality, and AECOPD are recorded at 6 and 12 months. Bayesian inference is used to quantify the risk and correlation of the investigated outcomes in COPD patients according to SAD. The ARCADIA study provides relevant findings in the daily clinical management of COPD patients.
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Affiliation(s)
- Paola Rogliani
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy.
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milano, Italy
| | - Josuel Ora
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Nadia Starc
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Stefano Verri
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Elena Pistocchini
- Department of Experimental Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, University of Parma, Parma, Italy
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Santus P, Radovanovic D, Saad M, Zilianti C, Coppola S, Chiumello DA, Pecchiari M. Acute dyspnea in the emergency department: a clinical review. Intern Emerg Med 2023; 18:1491-1507. [PMID: 37266791 PMCID: PMC10235852 DOI: 10.1007/s11739-023-03322-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The differential diagnosis of dyspnea is complex due to the lack of specificity and the loose association between its intensity and the severity of the underlying pathological condition. The initial assessment of dyspnea calls for prompt diagnostic evaluation and identification of optimal monitoring strategy and provides information useful to allocate the patient to the most appropriate setting of care. In recent years, accumulating evidence indicated that lung ultrasound, along with echocardiography, represents the first rapid and non-invasive line of assessment that accurately differentiates heart, lung or extra-pulmonary involvement in patients with dyspnea. Moreover, non-invasive respiratory support modalities such as high-flow nasal oxygen and continuous positive airway pressure have aroused major clinical interest, in light of their efficacy and practicality to treat patients with dyspnea requiring ventilatory support, without using invasive mechanical ventilation. This clinical review is focused on the pathophysiology of acute dyspnea, on its clinical presentation and evaluation, including ultrasound-based diagnostic workup, and on available non-invasive modalities of respiratory support that may be required in patients with acute dyspnea secondary or associated with respiratory failure.
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Affiliation(s)
- Pierachille Santus
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy.
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy.
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milan, Italy
| | - Marina Saad
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Via G.B. Grassi 74, 20157, Milan, Italy
| | - Camilla Zilianti
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
| | - Davide Alberto Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo E Carlo, Ospedale Universitario San Paolo, Milan, Italy
- Department of Health Sciences, Università Degli Studi Di Milano, Milan, Italy
- Coordinated Research Center On Respiratory Failure, Università Degli Studi Di Milano, Milan, Italy
| | - Matteo Pecchiari
- Department of Pathophysiology and Transplantation, Università Degli Studi Di Milano, Milan, Italy
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3
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An identifiable model of lung mechanics to diagnose and monitor COPD. Comput Biol Med 2023; 152:106430. [PMID: 36543001 DOI: 10.1016/j.compbiomed.2022.106430] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/23/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Current methods to diagnose and monitor COPD employ spirometry as the gold standard to identify lung function reduction with reduced forced expiratory volume (FEV1)/vital capacity (VC) ratio. Current methods utilise linear assumptions regarding airway resistance, where nonlinear resistance modelling may provide rapid insight into patient specific condition and disease progression. This study examines model-based expiratory resistance in healthy lungs and those with progressively more severe COPD. METHODS Healthy and COPD pressure (P)[cmH2O] and flow (Q)[L/s] data is obtained from the literature, and 5 intermediate levels of COPD and responses are created to simulate COPD progression and assess model-based metric resolution. Linear and nonlinear single compartment models are used to identify changes in inspiratory (R1,insp) and linear (R1,exp)/nonlinear (R2Φ) expiratory resistance with disease severity and over the course of expiration. RESULTS R1,insp increases from 2.1 to 7.3 cmH2O/L/s, R1,exp increases from 2.4 to 10.0 cmH2O/L/s with COPD severity. Nonlinear R2Φ increases (mean R2Φ: 2.5 cmH2O/L/s (healthy) to 24.4 cmH2O/L/s (COPD)), with increasing end-expiratory nonlinearity as COPD severity increases. CONCLUSION Expiratory resistance is increasingly highly nonlinear with COPD severity. These results show a simple, nonlinear model can capture fundamental COPD dynamics and progression from regular breathing data, and such an approach may be useful for patient-specific diagnosis and monitoring.
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Danzo F, Radovanovic D, Gatti M, Saad M, Perotto L, Franceschi E, Santus P. A reappraisal of inspiratory capacity in chronic obstructive pulmonary disease: clinical correlates and role of long-acting muscarinic antagonists and long-acting β2 agonists. Expert Rev Respir Med 2022; 16:623-635. [PMID: 35722753 DOI: 10.1080/17476348.2022.2090343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION In patients with chronic obstructive pulmonary disease (COPD), static and dynamic hyperinflation, together with expiratory flow limitation and gas exchange abnormalities, is one of the major causes of dyspnea, decreased exercise performance and ventilatory failure. An increase in functional residual capacity (FRC) is accompanied by a decrease in inspiratory capacity (IC), which is a volume readily available, repeatable, and simple to measure with any spirometer. Changes in IC and FRC after bronchodilation, contrary to changes in FEV1, have been closely associated with improvements in dyspnea and exercise performance. We systematically searched PubMed and Embase databases for clinical trials that assessed the effects of dual bronchodilation on inspiratory capacity in patients with COPD. AREAS COVERED Despite their pivotal role in COPD, IC and static volumes have rarely been considered as primary outcomes in randomized clinical trials assessing the efficacy of bronchodilators. Available studies on dual bronchodilation have shown a significant and persistent positive impact on IC focusing mainly on patients with moderate-to-severe COPD, whereas dynamic hyperinflation is also present at milder disease stages. EXPERT OPINION This narrative review discusses the pathophysiological and clinical importance of measuring IC in patients with COPD and how IC can be modified by maximizing bronchodilation combining long-acting muscarinic antagonists and long-acting β2 agonists.
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Affiliation(s)
- Fiammetta Danzo
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy
| | - Marina Gatti
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
| | - Marina Saad
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
| | - Luca Perotto
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
| | - Elisa Franceschi
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
| | - Pierachille Santus
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milano, Italy.,Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi Di Milano, Milano, Italy
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Diagnostic Insights from Plethysmographic Alveolar Pressure Assessed during Spontaneous Breathing in COPD Patients. Diagnostics (Basel) 2021; 11:diagnostics11060918. [PMID: 34063762 PMCID: PMC8223795 DOI: 10.3390/diagnostics11060918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 11/25/2022] Open
Abstract
Since its introduction in the clinical practice, body plethysmography has assisted pneumologists in the diagnosis of respiratory diseases and patients’ follow-up, by providing easy assessment of absolute lung volumes and airway resistance. In the last decade, emerging evidence suggested that estimation of alveolar pressure by electronically-compensated plethysmographs may contain information concerning the mechanics of the respiratory system which goes beyond those provided by the simple value of airway resistance or conductance. Indeed, the systematic study of expiratory alveolar pressure-flow loops produced during spontaneous breathing at rest has shown that the marked expansion of expiratory loops in chronic obstructive pulmonary disease patients mainly reflects the presence of tidal expiratory flow-limitation. The presence of this phenomenon can be accurately predicted on the basis of loop-derived parameters. Finally, we present results suggesting that plethysmographic alveolar pressure may be used to estimate non-invasively intrinsic positive end-expiratory pressure (PEEPi) in spontaneously breathing patients, a task which previously could be only accomplished by introducing a balloon-tipped catheter in the esophagus.
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Contoli M, Morandi L, Di Marco F, Carone M. A perspective for chronic obstructive pulmonary disease (COPD) management: six key clinical questions to improve disease treatment. Expert Opin Pharmacother 2020; 22:427-437. [PMID: 33021128 DOI: 10.1080/14656566.2020.1828352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION In 2011, the GOLD recommendations for the treatment of Chronic Obstructive Pulmonary Disease (COPD) introduced new clinical elements to classify the severity of the disease and to guide pharmacological choice. For the first time in the GOLD documents, treatment decision was no longer guided only by pulmonary function, but by a more complex combination of pulmonary function and clinical aspects. The recent versions of the GOLD recommendations introduce new aspects for the clinicians and pose new question for the management of the disease. In addition, inflammatory biomarkers and blood eosinophil levels, have been considered to guide treatment selection. AREA COVERED The evolution of disease management proposed by the GOLD document opens several areas of debate. A series of roundtable discussions among respiratory physicians took place in Italy to address key clinical questions. Particularly, the role of lung function and the use of biomarkers, the adherence to international guidelines and the possibility to personalize the pharmacological approach in COPD patients have been discussed, summarized and analyzed. EXPERT OPINION The authors believe that the development of a precision medicine approach tailoring the specific treatment for each patient is the goal of COPD management and may be achieved by considering the phenotypic classification of COPD patients.
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Affiliation(s)
- Marco Contoli
- Department of Morphology, Surgery and Experimental Medicine, Università Di Ferrara, Ferrara, Italy
| | - Luca Morandi
- Department of Morphology, Surgery and Experimental Medicine, Università Di Ferrara, Ferrara, Italy
| | - Fabiano Di Marco
- Department of Health Science, Università degli studi di Milano, Respiratory Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Mauro Carone
- Division of Pneumology, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
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Santus P, Franceschi E, Radovanovic D. Sublobar resection: functional evaluation and pathophysiological considerations. J Thorac Dis 2020; 12:3363-3368. [PMID: 32642261 PMCID: PMC7330776 DOI: 10.21037/jtd.2019.12.35] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
To date, pulmonary function tests (PFTs) are part of consolidated standard operating procedures in thoracic surgery. PFTs are usually used to assess the pre-operative risk, post-operative outcomes and complications after pulmonary resections. The only functional parameter used in common practice is the forced expiratory volume in one second (FEV1). However, the FEV1 alone poorly reflects lung pathophysiology, especially in patients with pre-operative emphysema and airflow obstruction; moreover, the predictive power of spirometric parameters in guiding the surgical approach in terms of the extension of the excision is currently unknown. In the present critical overview, we report and discuss the results of four studies that compared pre and post-surgery FEV1 and forced vital capacity (FVC) in patients undergoing lobectomy or segmentectomy, highlighting the critical aspects of spirometry in lung surgery and suggesting new approaches for the interpretation of pulmonary mechanics in patients undergoing major or minor parenchymal resections. Overall, the literature on the topic is limited to spirometric parameters, and post-surgical function loss and the consequent recovery are often analysed in inhomogeneous study samples, with varying respiratory comorbidities and functional phenotypes. We underline the role of static lung volumes in the patients’ initial assessment. In fact, they tend to decrease in patients with emphysema that undergo a lobectomy, followed by a decrease in lung compliance; some of these patients experience also an increase in closing volume, a condition that worsens the stresses implicated in lung ventilation and promotes the damage to the remaining airways. Spirometric data should be therefore always associated to body-plethysmography and indexes of ventilation distribution, to improve the evaluation of the functional characteristics in patients undergoing lung surgery. Prospective studies are needed to establish the relationship and long-term consequences of different surgical approaches in terms of lung mechanics and functional loss.
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Affiliation(s)
- Pierachille Santus
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Elisa Franceschi
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Dejan Radovanovic
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
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Pecchiari M, Radovanovic D, Zilianti C, Saderi L, Sotgiu G, D'Angelo E, Santus P. Tidal expiratory flow limitation induces expiratory looping of the alveolar pressure-flow relation in COPD patients. J Appl Physiol (1985) 2020; 129:75-83. [PMID: 32501776 DOI: 10.1152/japplphysiol.00664.2019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
During spontaneous breathing at rest, the alveolar pressure (Palv)-flow (V̇) relation exhibits a prominent expiratory loop in many chronic obstructive pulmonary disease (COPD) patients. Among the possible determinants of the loop, tidal expiratory flow limitation (tEFL) may be the main responsible. To compare the characteristics of the expiratory loop in COPD patients with flow limitation (FL) and without flow limitation (NFL), tEFL was assessed with the negative expiratory pressure technique in stable mild to very severe COPD patients undergoing body plethysmography before and after bronchodilation (BD), an intervention that is able to reduce mechanical heterogeneity, recruitment/derecruitment, and gas trapping but rarely abolishes tEFL. The magnitude of the expiratory loop was indexed by the integral of Palv on V̇ during expiration (Aexp). Before BD, Aexp was 360% greater in FL (n = 35) than in NFL (n = 25) patients (P < 0.001). After BD, Aexp was unchanged in NFL patients (ΔAexp 0%, P = 0.882) and slightly decreased in FL patients who remained FL (n = 32, ΔAexp -17%, P = 0.064). Three FL patients became NFL after BD, and their Aexp decreased markedly (ΔAexp -61%), reaching values similar to those observed in NFL patients at baseline. In conclusion, the greater Aexp measured in FL relative to NFL COPD patients, its relative invariance after BD when flow limitation persists, and its fall when flow limitation is abolished indicate that tEFL is a major determinant of the magnitude of the expiratory loop. Furthermore, Aexp can be used as a predictor of the presence of tEFL.NEW & NOTEWORTHY In stable chronic obstructive pulmonary disease (COPD) patients spontaneously breathing at rest, tidal expiratory flow limitation is the major determinant of the occurrence of expiratory looping in the plethysmographic flow-alveolar pressure diagram. In these patients the magnitude and the characteristics of the loop can be used as predictors of the presence of tidal expiratory flow limitation.
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Affiliation(s)
- Matteo Pecchiari
- Dipartimento di Fisiopatologia e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Dejan Radovanovic
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Camilla Zilianti
- Dipartimento di Fisiopatologia e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Laura Saderi
- Dipartimento di Medicina Clinica e Sperimentale Scienze Mediche Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Dipartimento di Medicina Clinica e Sperimentale Scienze Mediche Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italy
| | - Edgardo D'Angelo
- Dipartimento di Fisiopatologia e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
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Braghiroli A, Braido F, Piraino A, Rogliani P, Santus P, Scichilone N. Day and Night Control of COPD and Role of Pharmacotherapy: A Review. Int J Chron Obstruct Pulmon Dis 2020; 15:1269-1285. [PMID: 32606638 PMCID: PMC7283230 DOI: 10.2147/copd.s240033] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/03/2020] [Indexed: 12/30/2022] Open
Abstract
The topic of 24-hour management of COPD is related to day-to-night symptoms management, specific follow-up and patients' adherence to therapy. COPD symptoms strongly vary during day and night, being worse in the night and early morning. This variability is not always adequately considered in the trials. Night-time symptoms are predictive of higher mortality and more frequent exacerbations; therefore, they should be a target of therapy. During night-time, in COPD patients the supine position is responsible for a different thoracic physiology; moreover, during some sleep phases the vagal stimulation determines increased bronchial secretions, increased blood flow in the bronchial circulation (enhancing inflammation) and increased airway resistance (broncho-motor tone). Moreover, in COPD patients the circadian rhythm may be impaired. The role of pharmacotherapy in this regard is still poorly investigated. Symptoms can be grossly differentiated according to the different phenotypes of the disease: wheezing recalls asthma, while dyspnea is strongly related to emphysema (dynamic hyperinflation) or obstructive bronchiolitis (secretions). Those symptoms may be different targets of therapy. In this regard, GOLD recommendations for the first time introduced the concept of phenotype distinction suggesting the use of inhaled corticosteroids (ICS) particularly when an asthmatic pattern or eosiophilic inflammations are present, and hypothesized different approaches to target symptoms (ie, dyspnea) or exacerbations. Pharmacotherapy should be evaluated and possibly directed on the basis of circadian variations, for instance, supporting the use of twice-daily rapid-action bronchodilators and evening dose of ICS. Recommendations on day and night symptoms monitoring strategies and choice of the specific drug according to patient's profile are still not systematically investigated or established. This review is the summary of an advisory board on the topic "24-hour control of COPD and role of pharmacotherapy", held by five pulmonologists, experts in respiratory pathophysiology, pharmacology and sleep medicine.
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Affiliation(s)
- Alberto Braghiroli
- Department of Pulmonary Rehabilitation, Sleep Laboratory, Istituti Clinici Scientifici Maugeri, IRCCS, Veruno, NO, Italy
| | - Fulvio Braido
- Department of Internal Medicine, Respiratory Diseases and Allergy Clinic, University of Genoa, Azienda Policlinico IRCCS San Martino, Genoa, Italy
| | - Alessio Piraino
- Respiratory Area, Medical Affairs Chiesi Italia, Parma, Italy
| | - Paola Rogliani
- Respiratory Unit, Department of Experimental Medicine, University of Rome “Tor Vergata”, Rome, Italy
| | - Pierachille Santus
- Pierachille Santus, Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Milan, Italy
| | - Nicola Scichilone
- Department of Biomedicine and Internal and Specialistic Medicine (DIBIMIS), University of Palermo, Palermo, Italy
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Radovanovic D, Contoli M, Marco FD, Sotgiu G, Pelaia G, Braido F, Corsico AG, Micheletto C, Rogliani P, Scichilone N, Saderi L, Santus P, Solidoro P. Clinical and Functional Characteristics of COPD Patients Across GOLD Classifications: Results of a Multicenter Observational Study. COPD 2019; 16:215-226. [PMID: 31500459 DOI: 10.1080/15412555.2019.1659760] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a heterogeneous disease. The severity grading systems proposed by the Global initiative for Chronic Obstructive Lung Disease (GOLD) have changed over time. The aim of the study was to evaluate if the different GOLD classifications can capture the complexity of the disease by investigating the distribution of lung function and clinical parameters across the GOLD classification systems. This was an observational, retrospective, multicentre study. COPD patients were stratified according to the GOLD severity grading proposed in the 2007, and to the ABCD assessment tool present in the 2011, and 2017 versions of the initiative. Data from body plethysmography, DLCO, comorbidities, exacerbation history, pharmacological therapy and eosinophil counts were collected. A total of 1360 patients (73.4% males) were included in the analysis. Overall, 37% of the patients were severe-very severe according to GOLD 2007. Compared with GOLD 2011, applying the GOLD 2017 criteria, the proportion of the at risk categories (C and D) was reduced by ∼23%. Impairment in inspiratory capacity, DLCO and the prevalence of emphysema paralleled the GOLD 2007 classification only. The proportion of patients with ≥ 200 eosinophils/µL was higher in GOLD 2007 stages 3-4 compared with stages 1-2 (P = 0.008). Eosinophil levels were similar across risk classes in GOLD 2011 and 2017. Overall, 41.8% and 52.4% of the patients in the low risk groups according to GOLD 2011 and 2017 were exposed to inhaled corticosteroids. The GOLD 2011 and 2017 classifications, despite exploring symptoms and exacerbations, might miss other relevant patients' clinical characteristics such as lung function and phenotypes, which have a significant impact on outcomes and disease severity.
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Affiliation(s)
- Dejan Radovanovic
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi di Milano, Division of Pulmonary Diseases, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco , Milan , Italy
| | - Marco Contoli
- Section of Internal and Cardiorespiratory Medicine, Department of Medical Sciences, University of Ferrara , Ferrara , Italy
| | - Fabiano Di Marco
- Department of Health Sciences, Università Degli Studi di Milano, Respiratory Unit, ASST, Ospedale Papa Giovanni XXIII , Bergamo , Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Medicine, University of Sassari , Sassari , Italy
| | - Girolamo Pelaia
- Department of Medical and Surgical Sciences, Section of Respiratory Diseases, Magna Graecia University of Catanzaro , Catanzaro , Italy
| | - Fulvio Braido
- Respiratory Disease and Allergy Clinic, Department of Internal Medicine, Ospedale Policlinico IRCCS San Martino di Genova , Italy
| | - Angelo Guido Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation, Department of Internal Medicine and Therapeutics, University of Pavia , Pavia , Italy
| | - Claudio Micheletto
- UOC Pneumologia, Azienda Ospedaliera Universitaria Integrata , Verona , Italy
| | - Paola Rogliani
- Department of Experimental Medicine and Surgery, School of Respiratory Medicine, University of Rome Tor Vergata , Rome , Italy.,Department of Experimental Medicine and Surgery, University of Rome Tor Vergata , Rome , Italy
| | - Nicola Scichilone
- Department of Biomedicine and Internal and Specialistic Medicine, University of Palermo , Palermo , Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medical, Surgical and Experimental Medicine, University of Sassari , Sassari , Italy
| | - Pierachille Santus
- Department of Biomedical and Clinical Sciences (DIBIC), Università Degli Studi di Milano, Division of Pulmonary Diseases, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco , Milan , Italy
| | - Paolo Solidoro
- Cardiovascular and Thoracic Department, SC Pneumologia U, Città Della Salute e Della Scienza (Molinette) University Hospital , Turin , Italy
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The Airways' Mechanical Stress in Lung Disease: Implications for COPD Pathophysiology and Treatment Evaluation. Can Respir J 2019; 2019:3546056. [PMID: 31583033 PMCID: PMC6748188 DOI: 10.1155/2019/3546056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 08/14/2019] [Indexed: 11/17/2022] Open
Abstract
The airway epithelium stretches and relaxes during the normal respiratory cycle, and hyperventilation exaggerates this effect, resulting in changes in lung physiology. In fact, stretching of the airways influences lung function and the secretion of airway mediators, which in turn may cause a potentially injurious inflammatory response. This aim of the present narrative review was to illustrate the current evidence on the importance of mechanical stress in the pathophysiology of lung diseases with a particular focus on chronic obstructive pulmonary disease (COPD) and to discuss how this may influence pharmacological treatment strategies. Overall, treatment selection should be tailored to counterpart the effects of mechanical stress, which influences inflammation both in asthma and COPD. The most suitable treatment approach between a long-acting β2-agonists/long-acting antimuscarinic-agonist (LABA/LAMA) alone or with the addition of inhaled corticosteroids should be determined based on the underlying mechanism of inflammation. Noteworthy, the anti-inflammatory effects of the glycopyrronium/indacaterol combination on hyperinflation and mucociliary clearance may decrease the rate of COPD exacerbations, and it may synergistically improve bronchodilation with a double action on both the cyclic adenosine monophosphate (cAMP) and the acetylcholine pathways.
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Bake B, Larsson P, Ljungkvist G, Ljungström E, Olin AC. Exhaled particles and small airways. Respir Res 2019; 20:8. [PMID: 30634967 PMCID: PMC6330423 DOI: 10.1186/s12931-019-0970-9] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 01/01/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Originally, studies on exhaled droplets explored properties of airborne transmission of infectious diseases. More recently, the interest focuses on properties of exhaled droplets as biomarkers, enabled by the development of technical equipment and methods for chemical analysis. Because exhaled droplets contain nonvolatile substances, particles is the physical designation. This review aims to outline the development in the area of exhaled particles, particularly regarding biomarkers and the connection with small airways, i e airways with an internal diameter < 2 mm. MAIN BODY Generation mechanisms, sites of origin, number concentrations of exhaled particles and the content of nonvolatile substances are studied. Exhaled particles range in diameter from 0.01 and 1000 μm depending on generation mechanism and site of origin. Airway reopening is one scientifically substantiated particle generation mechanism. During deep expirations, small airways close and the reopening process produces minute particles. When exhaled, these particles have a diameter of < 4 μm. A size discriminating sampling of particles < 4 μm and determination of the size distribution, allows exhaled particle mass to be estimated. The median mass is represented by particles in the size range of 0.7 to 1.0 μm. Half an hour of repeated deep expirations result in samples in the order of nanogram to microgram. The source of these samples is the respiratory tract ling fluid of small airways and consists of lipids and proteins, similarly to surfactant. Early clinical studies of e g chronic obstructive pulmonary disease and asthma, reported altered particle formation and particle composition. CONCLUSION The physical properties and content of exhaled particles generated by the airway reopening mechanism offers an exciting noninvasive way to obtain samples from the respiratory tract lining fluid of small airways. The biomarker potential is only at the beginning to be explored.
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Affiliation(s)
- B. Bake
- Unit of Respiratory Medicine and Allergy, Department of Internal Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - P. Larsson
- Unit of Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - G. Ljungkvist
- Unit of Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - E. Ljungström
- Atmospheric Science, Department of Chemistry and Molecular Biology, University of Gothenburg, Gothenburg, Sweden
| | - A-C Olin
- Unit of Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Harrison EM, Kim V. Long-acting maintenance pharmacotherapy in chronic obstructive pulmonary disease. RESPIRATORY MEDICINE: X 2019. [DOI: 10.1016/j.yrmex.2019.100009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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A comprehensive approach to lung function in bronchiectasis. Respir Med 2018; 145:120-129. [PMID: 30509700 DOI: 10.1016/j.rmed.2018.10.031] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 08/14/2018] [Accepted: 10/30/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND International guidelines recommend simple spirometry for bronchiectasis patients. However, pulmonary pathophysiology of bronchiectasis is very complex and still poorly understood. Our objective was to characterize lung function in bronchiectasis and identify specific functional sub-groups. METHODS This was a multicenter, prospective, observational study enrolling consecutive adults with bronchiectasis during stable sate. Patients underwent body-plethysmography before and after acute bronchodilation testing, diffusing lung capacity (DLCO) with a 3-year follow up. Air trapping and hyperinflation were a residual volume (RV) > 120%predicted and a total lung capacity>120%predicted. Acute reversibility was: ΔFEV1 ≥12% and 200 mL from baseline (FEV1rev) and ΔRV ≥10% reduction from baseline (RVrev). Sensitivity analyses included different reversibility cutoffs and excluded patients with concomitant asthma or chronic obstructive pulmonary disease. RESULTS 187 patients were enrolled (median age: 68 years; 29.4% males). Pathophysiological abnormalities often overlapped and were distributed as follows: air trapping (70.2%), impaired DLCO (55.7%), airflow obstruction (41.1%), hyperinflation (15.7%) and restriction (8.0%). 9.7% of patients had normal lung function. RVrev (17.6%) was more frequent than FEV1rev (4.3%). Similar proportions were found after multiple sensitivity analyses. Compared with non-reversible patients, patients with RVrev had more severe obstruction (mean(SD) FEV1%pred: 83.0% (24.4) vs 68.9% (26.2); P = 0.02) and air trapping (RV%pred, 151.9% (26.6) vs 166.2% (39.9); P = 0.028). CONCLUSIONS Spirometry alone does not encompass the variety of pathophysiological characteristics in bronchiectasis. Air trapping and diffusion impairment, not airflow obstruction, represent the most common functional abnormalities. RVrev is related to worse lung function and might be considered in bronchiectasis' workup and for patients' functional stratification.
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Pirina P, Foschino Barbaro MP, Paleari D, Spanevello A. Small airway inflammation and extrafine inhaled corticosteroids plus long-acting beta 2-agonists formulations in chronic obstructive pulmonary disease. Respir Med 2018; 143:74-81. [PMID: 30261996 DOI: 10.1016/j.rmed.2018.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 07/10/2018] [Accepted: 08/27/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To summarize the evidence of small airways involvement in chronic obstructive pulmonary disease (COPD) pathophysiology, and to evaluate the efficacy of extrafine formulations of inhaled corticosteroids (ICS) in combination with long-acting beta2-agonists (LABAs) in the treatment of COPD. DATA SOURCE A search of the PubMed database was conducted using the keywords "COPD", "small airways", "inflammation" and "extrafine formulation." The search was limited to entries published in English before August 2016. Only studies conducted in humans were considered. STUDY SELECTION Publications were included on the basis of relevance. RESULTS COPD is a common preventable and treatable disease, characterized by persistent and progressive airflow limitation. With improved understanding of COPD pathophysiology, small airways (internal diameter <2 mm), a well-known major site of COPD-associated inflammation and remodeling, have emerged as a potential target for COPD pharmacologic therapies. The ability of extrafine formulations of ICS in combination with LABAs to achieve central and peripheral lung deposition, and the implications of the enhanced efficacy that this may bring, are discussed by examining findings from the development trials plan of the extrafine formulation of beclometasone dipropionate/formoterol fumarate (Foster®, Chiesi Farmaceutici, Italy) in patients with COPD. CONCLUSION There is an urgent need for improved and reliable techniques for small airways assessment in order to detect early damage, disease progression and response to treatment. Evidence from randomized clinical trials supports the benefits of extrafine ICS/LABA formulations in COPD, real world studies are necessary to confirm this.
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Affiliation(s)
- Pietro Pirina
- Lung Disease Unit, Department of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy.
| | - Maria Pia Foschino Barbaro
- Institute of Respiratory Disease, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Davide Paleari
- Medical Department, Chiesi Farmaceutici SpA, Parma, Italy
| | - Antonio Spanevello
- Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italy; University of Insubria, Varese, Italy
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Santus P, Radovanovic D, Mascetti S, Pauletti A, Valenti V, Mantero M, Papi A, Contoli M. Effects of bronchodilation on biomarkers of peripheral airway inflammation in COPD. Pharmacol Res 2018; 133:160-169. [PMID: 29775687 DOI: 10.1016/j.phrs.2018.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 04/07/2018] [Accepted: 05/14/2018] [Indexed: 11/26/2022]
Abstract
Peripheral airway inflammation and dysfunction are key elements in the pathogenesis of COPD. The exhaled alveolar fraction of nitric oxide (CANO) is an indirect biomarker of lung peripheral inflammation. We tested whether inhaled long-acting bronchodilators (LABA) can affect CANO and we evaluated correlations with lung mechanics in patients with COPD. Two-centre, randomised, double blind, crossover study including COPD patients with moderate-to-severe airflow obstruction. Following a pharmacological washout, multi-flow exhaled fraction of NO (FENO), plethysmography, lung diffusion (DLCO), single breath nitrogen washout test and dyspnoea were measured in a crossover manner at baseline and 30, 60 and 180 min following administration of salmeterol (Sal) or formoterol fumarate (FF). (ClinicalTrials.gov, number NCT01853787). Fort-five patients were enrolled (median age: 71.8 years; 84.4% males). At baseline, CANO correlated with airway resistances (r = 0.422), residual volume/total lung capacity (RV/TLC; r = 0.375), transfer factor (r= -0.463) and forced expiratory volume in 1 s (FEV1; r= -0.375, all P < 0.01). After LABA administration, we found a significant reduction of FENO that reached statistical significance at 180'; no difference was found between FF and S. Consistently, a significant reduction of CANO was documented at 60' and 180' compared to baseline for both FF and S (P < 0.01 and P < 0.05, respectively). Changes in CANO were correlated with changes in vital capacity (r=-44; P < 0.001) and RV/TLC (r = 0.56; P < 0.001), but not FEV1. In COPD, direct correlations were found between the levels of CANO and the magnitude of peripheral airway dysfunction. LABA reduced CANO levels. The reduction was associated with improvement in functional parameters reflecting air trapping.
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Affiliation(s)
- Pierachille Santus
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Pulmonary Unit, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco, Milan, Italy.
| | - Dejan Radovanovic
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Pulmonary Unit, Ospedale L. Sacco, ASST Fatebenfratelli-Sacco, Milan, Italy
| | - Susanna Mascetti
- Research Centre on Asthma and COPD, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Alessia Pauletti
- Research Centre on Asthma and COPD, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Vincenzo Valenti
- Department of Health Bioscience, University of Milan - Respiratory Unit, Policlinico di San Donato, IRCCS - San Donato Milanese, Milan, Italy
| | - Marco Mantero
- Department of Pathophysiology and Transplantation, University of Milan, Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, Milan, 20122, Italy
| | - Alberto Papi
- Research Centre on Asthma and COPD, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Marco Contoli
- Research Centre on Asthma and COPD, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
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Radovanovic D, Pecchiari M, Pirracchio F, Zilianti C, D’Angelo E, Santus P. Plethysmographic Loops: A Window on the Lung Pathophysiology of COPD Patients. Front Physiol 2018; 9:484. [PMID: 29765337 PMCID: PMC5938386 DOI: 10.3389/fphys.2018.00484] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/16/2018] [Indexed: 01/12/2023] Open
Abstract
Plethysmographic alveolar pressure-flow (Palv-F) loops contain potentially relevant information about the pathophysiology of chronic obstructive pulmonary disease (COPD), but no quantitative analysis of these loops during spontaneous breathing has ever been performed. The area of the loop's inspiratory (Ains) and expiratory portion (Aexp), and the difference between the end-expiratory and end-inspiratory alveolar pressure (ΔPalv) were measured in 20 young, 20 elderly healthy subjects, and 130 stable COPD patients. Ains and ΔPalv increased by 55 and 78% from young to elderly subjects, and by 107 and 122% from elderly subjects to COPD patients, reflecting changes in mechanical heterogeneity, lung-units recruitment/derecruitment, and possibly air trapping occurring with aging and/or obstructive disease. Aexp increased by 38% from young to elderly subjects, and by 198% from elderly subjects to COPD patients, consistent with the additional contribution of tidal expiratory flow-limitation, which occurs only in COPD patients and affects Aexp only. In COPD patients, Aexp and ΔPalv showed a significant negative correlation with VC, FEV1, IC, and a significant positive correlation with RV/TLC. The results suggest that the analysis of plethysmographic Palv-F loops provides an insight of the pathophysiological factors, especially tidal expiratory flow-limitation, that affect lung function in COPD patients.
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Affiliation(s)
- Dejan Radovanovic
- Dipartimento di Scienze Biomediche e Cliniche Luigi Sacco, Università degli Studi di Milano, Milan, Italy
| | - Matteo Pecchiari
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Fabio Pirracchio
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Camilla Zilianti
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Edgardo D’Angelo
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Pierachille Santus
- Dipartimento di Scienze Biomediche e Cliniche Luigi Sacco, Università degli Studi di Milano, Milan, Italy
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Santus P, Radovanovic D, Cristiano A, Valenti V, Rizzi M. Role of nebulized glycopyrrolate in the treatment of chronic obstructive pulmonary disease. Drug Des Devel Ther 2017; 11:3257-3271. [PMID: 29180850 PMCID: PMC5695264 DOI: 10.2147/dddt.s135377] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
In the upcoming years, the proportion of elderly patients with chronic obstructive pulmonary disease (COPD) will increase, according to the progressively aging population and the increased efficacy of the pharmacological treatments, especially considering the management of chronic comorbidities. The issue to prescribe an appropriate inhalation therapy to COPD patients with significant handling or coordination difficulties represents a common clinical experience; in the latter case, the choice of an inadequate inhalation device may jeopardize the adherence to the treatment and eventually lead to its ineffectiveness. Treatment options that do not require particular timing for coordination between activation and/or inhalation or require high flow thresholds to be activated should represent the best treatment option for these patients. Nebulized bronchodilators, usually used only in acute conditions such as COPD exacerbations, could fulfill this gap, enabling an adequate drug administration during tidal breathing and without the need for patients' cooperation. However, so far, only short-acting muscarinic antagonists have been available for nebulization. Recently, a nebulized formulation of the inhaled long-acting muscarinic antagonist glycopyrrolate, delivered by means of a novel proprietary vibrating mesh nebulizer closed system (SUN-101/eFlow®), has progressed to Phase III trials and is currently in late-stage development as an option for maintenance treatment in COPD. The present critical review describes the current knowledge about the novel nebulizer technology, the efficacy, safety, and critical role of nebulized glycopyrrolate in patients with COPD. To this end, PubMed, ClinicalTrials.gov, Embase, and Cochrane Library have been searched for relevant papers. According to the available results, the efficacy and tolerability profile of nebulized glycopyrrolate may represent a valuable and dynamic treatment option for the chronic pharmacological management of patients with COPD.
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Affiliation(s)
- Pierachille Santus
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Division of Respiratory Diseases, “L. Sacco” Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Dejan Radovanovic
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Division of Respiratory Diseases, “L. Sacco” Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Andrea Cristiano
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Division of Respiratory Diseases, “L. Sacco” Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | - Vincenzo Valenti
- Department of Health Bioscience, University of Milan – Respiratory Unit, Policlinico di San Donato, IRCCS – San Donato Milanese, Milan, Italy
| | - Maurizio Rizzi
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Division of Respiratory Diseases, “L. Sacco” Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
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Pecchiari M, Santus P, Radovanovic D, DʼAngelo E. Acute effects of long-acting bronchodilators on small airways detected in COPD patients by single-breath N 2 test and lung P-V curve. J Appl Physiol (1985) 2017; 123:1266-1275. [PMID: 28775071 DOI: 10.1152/japplphysiol.00493.2017] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/06/2017] [Accepted: 07/31/2017] [Indexed: 11/22/2022] Open
Abstract
Small airways represent the key factor of chronic obstructive pulmonary disease (COPD) pathophysiology. The effect of different classes of bronchodilators on small airways is still poorly understood and difficult to assess. Hence the acute effects of tiotropium (18 µg) and indacaterol (150 µg) on closing volume (CV) and ventilation inhomogeneity were investigated and compared in 51 stable patients (aged 70 ± 7 yr, mean ± SD; 82% men) with moderate to very severe COPD. Patients underwent body plethysmography, arterial blood gas analysis, tidal expiratory flow limitation (EFL), dyspnea assessment, and simultaneous recording of single-breath N2 test and transpulmonary pressure-volume curve (PL-V), before and 1 h after drug administration. The effects produced by indacaterol on each variable did not differ from those caused by tiotropium, independent of the severity of disease, assessed according to the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) scale and the presence of EFL. Bronchodilators significantly decreased the slope of phase III and CV (-5 ± 4 and -2.5 ± 2.1%, respectively, both P < 0.001), with an increase in both slope and height of phase IV and of the anatomical dead space. Arterial oxygen pressure and saturation significantly improved (3 ± 3 mmHg and 2 ± 2%, respectively, both P < 0.001); their changes negatively correlated with those of phase III slope (r = -0.659 and r = -0.454, respectively, both P < 0.01). The vital capacity (VC) increased substantially, but the PL-V/VC curve above CV was unaffected. In conclusion, bronchodilators reduce the heterogeneity of peripheral airway mechanical properties and the extent of their closure, with minor effects on critical closing pressure. This should lessen the risk of small-airway damage and positively affect gas exchange.NEW & NOTEWORTHY This is the first study investigating in stable chronic obstructive pulmonary disease patients the acute effects of two long-acting bronchodilators, a β-agonist and a muscarinic antagonist, on peripheral airways using simultaneous lung pressure-volume curve and single-breath N2 test. By lessening airway mechanical property heterogeneity, both drugs similarly reduced ventilation inhomogeneity and extent of small-airway closure, as indicated by the decrease of phase III slope, increased oxygen saturation, and fall of closing volume, often below expiratory reserve volume.
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Affiliation(s)
- Matteo Pecchiari
- Dipartimento di Fisiopatologia e dei Trapianti, Università degli Studi di Milano, Milan, Italy; and
| | - Pierachille Santus
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano, Division of Respiratory Diseases, "L. Sacco" Hospital, Azienda Socio-Sanitaria Territoriale Fatebenefratelli Sacco, Milan, Italy
| | - Dejan Radovanovic
- Dipartimento di Scienze Biomediche e Cliniche, Università degli Studi di Milano, Division of Respiratory Diseases, "L. Sacco" Hospital, Azienda Socio-Sanitaria Territoriale Fatebenefratelli Sacco, Milan, Italy
| | - Edgardo DʼAngelo
- Dipartimento di Fisiopatologia e dei Trapianti, Università degli Studi di Milano, Milan, Italy; and
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Affiliation(s)
- Antonio Anzueto
- Pulmonology Section, University of Texas Health Science Center, San Antonio, TX, USA
- South Texas Veterans Health Care System, Department of Medicine, Pulmonary Section, San Antonio, TX, USA
| | - Marc Miravitlles
- Pneumonology Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain
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