Additive efficacy of short-acting bronchodilators on dynamic hyperinflation and exercise tolerance in stable COPD patients treated with long-acting bronchodilators

The efficacy and safety of additional treatment with short-acting muscarinic antagonist combined with long-acting beta-2 agonist in stable patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis

BACKGROUND

The rationale for additional treatment with short-acting bronchodilators combined with long-acting bronchodilators for patients with chronic obstructive pulmonary disease (COPD) is not adequately studied.

METHODS

We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of a short-acting muscarinic antagonist (SAMA) therapy combined with a long-acting beta-2 agonist (LABA) in patients with stable COPD. Pulmonary function, dyspnea, health-related quality of life, exercise tolerance, physical activity, exacerbations of COPD, and adverse events during regular use were set as outcomes of interest.

RESULTS

We included five controlled trials including two sets of publicly available online data without article publications for the meta-analysis. Additional use of SAMA plus LABA showed a significant improvement in the peak response in FEV₁ (mean difference (MD) 98.70 mL, p < .00001), transitional dyspnea index score (MD .85, p = .02), and St George's Respiratory Questionnaire score (MD -2.00, p = .008) compared to LABA treatment. There was no significant difference in the risk of exacerbation of COPD (p = .20) and only a slight trend of increased severe adverse events (OR: 2.16, p = .08) and cardiovascular events (OR: 2.38, p = .06).

CONCLUSION

Additional treatment with SAMA combined with LABA could be a feasible choice due to its efficacy and safety.

Effects of high flow nasal cannula on exercise endurance in patients with chronic obstructive pulmonary disease

BACKGROUND

Ventilation limitation has a significant adverse effects on cardiovascular function and tissue oxygenation during exercise in patients with chronic obstructive pulmonary disease (COPD). High flow nasal cannula (HFNC) improve ventilation by washing out the anatomical dead space and providing oxygen at constant concentration. This study aimed to examine the effects of HFNC on the exercise performance and hemodynamic status in COPD patients.

METHODS

Fifteen patients with COPD performed two constant load exercise tests (CLET) at the 70% of maximum workload achieved at a previous incremental exercise test on arm ergometer. The CLET were performed with HFNC and with nasal cannula (NC) in random order. The hemodynamics parameters of subjects during exercises were measured by a bioelectrical impedance device. The tissue oxygenation status (oxygenated hemoglobin, deoxygenated hemoglobin (hHb), total hemoglobin) was measured by a near infrared spectrophotometer.

RESULTS

The exercise duration was longer for HFNC test than NC test (962.9 ± 281.7 s, vs 823.9 ± 184.9 s, p < 0.05). At the end of CLET, the PetCO2 was lower for HFNC than NC (29.3 ± 5.1 mmHg vs 32.1 ± 5.5 mmHg, p < 0.05). There was no difference in cardiac output (NC: 7.5 ± 1.8 vs HFNC: 7.4 ± 3.0 L,p > 0.05), stroke volume (NC:73.5 ± 21.0 vs HFNC 67.5 ± 16.3 ml, p > 0.05). The changes of hHb in muscle tissues was significantly lower in HFNC test than that in NC test (p < 0.05).

CONCLUSION

HFNC resulted in a significant decrease in CO2 production and increase in exercise duration. The application of HFNC may improve the efficiency of exercise training by allowing patients to sustain exercise for longer time.

Association between chronic obstructive pulmonary disease and ventricular arrhythmia: a nationwide population-based cohort study

The ventricular arrhythmia (VA)-chronic obstructive pulmonary disease (COPD) association and related risk factors remain unclear. Using 2001-2012 data from National Health Insurance Research Database, we retrospectively reviewed 71,838 patients diagnosed as having COPD and 71,838 age- and sex-matched controls. After adjustments for comorbidities, medication, urbanization level, and monthly income, patients with COPD had higher incidence rates of VA than did the controls (adjusted hazard ratio [aHR] [95% confidence interval (CI)]: 1.45 [1.25-1.68]). More hospitalization or emergency visits because of acute COPD exacerbation (aHRs [95% CIs] for first, second, and third visits: 1.28 [1.08-1.50], 1.75 [1.32-2.32], and 1.88 [1.46-2.41], respectively) and asthma-COPD overlap (aHR [95% CI]: 1.49 [1.25-1.79]) were associated with high VA risk in patients with COPD. In the multivariate analysis, heart failure (aHR [95% CI]: 2.37 [1.79-3.14]), diabetes (aHR [95% CI]:1.64 [1.29-2.08]), age ≥75 (aHR [95% CI]: 2.48 [1.68-3.67]), male (aHR [95% CI]: 1.69[1.34-2.12]), and class III antiarrhythmic drug use (aHR [95% CI]: 2.49 [1.88-3.28]) are the most significant risk factors of new onset of VA in patients with COPD.

Redundant medication use during acute exacerbation of chronic obstructive pulmonary disease in hospitalized patients

Background Few clinical studies have evaluated redundant therapy during an exacerbation of chronic obstructive pulmonary disease in hospitalized patients, but clinical practice guidelines endorse this practice. Objective The aim of this study is to measure the frequency of redundant therapy and explore its association with clinical outcomes, adverse effects, and cost among adults hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Setting Six hospitals within an academic health system in the United States. Method A retrospective cohort study of adults with a principal diagnosis of acute exacerbation of chronic obstructive pulmonary disease between January 1, 2016 and March 31, 2016 was performed. Main outcome measure The primary outcome was the proportion of patients who received redundant therapy during inpatient management of acute exacerbation of chronic obstructive pulmonary disease. Results Overall, 137 patients were included and 99 (72.7%) received redundant medication therapy. Redundant therapy was not associated with significant differences in clinical outcomes such as median hospital length of stay, 30-day readmission, tachycardia, thrush, psychiatric symptoms or urinary retention in the univariate or multivariate analyses. The median medication acquisition cost per patient was nearly 11-fold higher among those receiving redundant medication therapy [$135.14 (49.21) vs 12.50 (17.02); p < 0.001]. After controlling for confounding variables using multivariate linear regression, the cost of redundant medication therapy was $50.20 higher on average (p < 0.001). Conclusion Redundant inhaled therapy for acute exacerbation of chronic obstructive pulmonary disease in the hospital setting was not associated with improved clinical outcomes or more adverse effects but did significantly increase medication cost. The findings of this study should be considered exploratory.

Effect of pulmonary rehabilitation with assistive use of short-acting β2 agonist in COPD patients using long-acting bronchodilators

Background: Assistive use of short-acting β2 agonists (SABAs) reportedly improves exercise tolerance, activities of daily living, and health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD). However, the effect of SABA on physical activity (PA) is unclear.Objective: This study aimed to determine whether assistive use of SABA increases PA and whether additional pulmonary rehabilitation (PR) can aid further improvement.Methods: Twelve outpatients with COPD and dyspnea during daily activities despite regular use of long-acting bronchodilators were enrolled. This study comprised a 2-week pre-intervention investigation, a 12-week investigation of SABA effects, and an 8-week investigation of the additional effects of PR. Assistive use of SABA was allowed up to 4 times per day after the pre-intervention period. PA was measured for 14 consecutive days using an accelerometer sensor. Dyspnea, exercise tolerance, and HRQOL were evaluated at entry, at 4 and 12 weeks after initiating SABA use, and after completing PR.Results: Assistive use of SABA improved breathlessness during daily activities and increased PA (p < .001). PA and HRQOL were also improved following PR (p < .001 and p = .013, respectively).Conclusions: Combined therapy of SABA and PR can increase PA and HRQOL in COPD patients.

Effect of high-flow nasal therapy during exercise training in COPD patients with chronic respiratory failure: study protocol for a randomised controlled trial

Background

The benefit of pulmonary rehabilitation (PR) in symptomatic chronic obstructive pulmonary disease (COPD) is well known. However, advanced patients with chronic respiratory failure (CRF), a category excluded from most studies, are frequently unable to sustain a work-load sufficiently high to obtain the full benefit of PR on exercise tolerance. Recent studies involving heated and humidified high flow oxygen therapy (HFOT) showed positive effects on breathing pattern and ventilatory efficiency during effort. We thus plan to compare, in COPD patients with CRF undergoing a high-intensity exercise programme, the effect of using HFOT versus standard oxygen delivery via Venturi Mask (V-mask), at the same inspiratory oxygen fraction, on improving exercise endurance.

Methods/Design

This is a multicentre randomised controlled trial that will involve 156 COPD inpatients with CRF recruited from seven PR hospitals. Patients will be randomised to one of two groups – V-mask versus HFOT. All patients will undergo the same high-intensity exercise programme using either of the oxygen delivery devices as per their group allocation. Training will consist of 20 sessions, over 1 month (5 sessions per week) within the hospitalisation period. Anthropometric and clinical data, including body mass index, diagnosis, spirometry and comorbidities (Cumulative Rating Scale) will be collected at baseline. At baseline and at the end of the exercise programme (primary assessment time) evaluation will include exercise tolerance (Constant Work Rate Exercise Test) (primary outcome), functional capacity (6-min walk test), maximal inspiratory pressure/maximal expiratory pressure, peripheral muscle strength (biceps and quadriceps) by manual dynamometer, respiratory exchanges (blood gases analysis), disability (Barthel Index and Barthel Dyspnoea Index), impact of disease (COPD Assessment test), and quality of life (Maugeri Respiratory Failure Scale-26). At the end of the training period, patient satisfaction will be evaluated.

Discussion

This study will add knowledge about the exercise response in advanced COPD with CRF and verify if an alternative tool, namely HFOT, can increase the benefit obtained from PR.

Trial registration

ClinicalTrials.gov ID NET03322787

Registered: 6 November 2017

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3440-2) contains supplementary material, which is available to authorized users.

Respiratory system reactance reflects communicating lung volume in chronic obstructive pulmonary disease

Respiratory system reactance (Xrs) measured by the forced oscillation technique (FOT) is theoretically and experimentally related to lung volume. In chronic obstructive pulmonary disease (COPD), the absolute volume measured by body plethysmography includes a proportion that is inaccessible to pressure oscillations applied via the mouth, that is, a "noncommunicating" lung volume. We hypothesized that in COPD the presence of noncommunicating lung would disrupt the expected Xrs-volume relationship compared with plethysmographic functional residual capacity (FRC_pleth). Instead, Xrs would relate to estimates of communicating volume, namely, expiratory reserve volume (ERV) and single-breath alveolar volume (Va_SB). We examined FOT and lung function data from people with COPD (n = 51) and from healthy volunteers (n = 40). In healthy volunteers, we observed an expected inverse relationship between reactance at 5 Hz (X5) and FRC_pleth. In contrast, there was no such relationship between X5 and FRC_pleth in COPD subjects. However, there was an inverse relationship between X5 and both ERV and Va_SB. Hence the theoretical Xrs-volume relationship is present in COPD but only when considering the communicating volume rather than the absolute lung volume. These findings confirm the role of reduced communicating lung volume as an important determinant of Xrs and therefore advance our understanding and interpretation of FOT measurements in COPD. NEW & NOTEWORTHY To investigate the determinants of respiratory system reactance (Xrs) measured by the forced oscillation technique (FOT) in chronic obstructive pulmonary disease (COPD), we examine the relationship between Xrs and lung volume. We show that Xrs does not relate to absolute lung volume (functional residual capacity) in COPD but instead relates only to the volume of lung in communication with the airway opening. This communicating volume may therefore be fundamental to our interpretation of FOT measurements in COPD and other pulmonary diseases.

Combination of assist use of short-acting beta-2 agonists inhalation and guidance based on patient-specific restrictions in daily behavior: Impact on physical activity of Japanese patients with chronic obstructive pulmonary disease

BACKGROUND

Assist use of inhaled short-acting beta 2 agonists (SABAs) is reportedly effective for preventing shortness of breath on exertion in chronic obstructive pulmonary disease (COPD) patients. However, it is unclear what strategy would be useful for improving physical activity in such patients. The aim is to investigate the effects of assisted use of SABA (procaterol) on physical activity in Japanese COPD patients targeting patient-specific restrictions in daily behavior.

METHODS

Fourteen patients with stable COPD (age: 72.1±1.5, %FEV₁: 55.6±4.5%) were asked to inhale 20 μg of procaterol 15 minutes before patient-specific daily physical activity that had been identified as limited by a questionnaire and document their usage in a diary. Physical activity was measured using a triaxial accelerometer and the results were collected every month for 2 months. In the first month, a clinician assessed whether inhalation of SABA was appropriate based on a usage diary and coached patients to conduct adequate assist use of SABA for limited physical activity.

RESULTS

The strategy significantly improved the physical activity level, assessed using the values of the metabolic equivalents (METs) multiplied by physical activity endurance, at ≥3.0 METs (p<0.05), and physical activity endurance at ≥2.5 and ≥3.0 METs, (p<0.05, p<0.05, respectively). The degree of improvement of physical activity level was significantly positively correlated with the baseline %FVC and %FEV₁ (p<0.05, p<0.05, respectively).

CONCLUSIONS

Assist use of SABA targeting patient-specific restrictions, particularly when better lung function is still preserved, could be a useful approach for improving physical activity in patients with COPD.

Usefulness of a Newly Developed Spirometer to Measure Dynamic Lung Hyperinflation following Incremental Hyperventilation in Patients with Chronic Obstructive Pulmonary Disease

Objective This study was performed to determine the usefulness of a newly developed spirometer for the quantitative assessment of dynamic lung hyperinflation (DLH) following incremental hyperventilation in chronic obstructive pulmonary disease (COPD). Methods The subjects were 54 patients with COPD and 25 healthy volunteers. Each subject was asked to hyperventilate for 30 seconds with stepwise increments starting at the resting respiration rate and increasing to respiratory rates of 20, 30, and finally 40 breaths/min while using a newly developed spirometer. The relationship between the observed inspiratory capacity (IC) reduction following incremental hyperventilation as an index of DLH and spirometry or the 6-minute walking distance was examined. Results The IC did not decrease significantly from the resting IC, even when the respiratory rate was increased, in the healthy volunteer group. However, in the COPD patient group, the IC decreased with increases in the respiratory rate. Significant correlations were found between all IC parameters and the severity of COPD. A significant negative correlation was also found between the decreased IC and the 6-minute walking distance. Conclusion These findings suggest that the quantitative assessment of DLH following incremental hyperventilation using the newly developed spirometer may be useful for the assessment of pathophysiological impairment in patients with COPD.

Bronchodilator Responses in Respiratory Impedance, Hyperinflation and Gas Trapping in COPD

Hyperinflation, gas trapping and their responses to long-acting bronchodilator are clinically important in COPD. The forced oscillation technique (FOT) measures of respiratory system resistance and reactance are sensitive markers of bronchodilator response in COPD. The relationships between changes in resistance and reactance, and changes in hyperinflation and gas trapping, following long-acting bronchodilator (LA-BD) have not been studied. 15 subjects with mild-moderate COPD underwent FOT, spirometry then body plethysmography, before and 2 hours after a single 150 microg dose of the LA-BD indacaterol. Hyperinflation was quantified as the inspiratory capacity to total lung capacity ratio (IC/TLC), and gas trapping as residual volume to TLC ratio (RV/TLC). At baseline, FOT parameters were moderately correlated with IC/TLC (|r| 0.53-0.73, p < 0.05). At 2 hours post-LA-BD, there were moderate correlations between change in FOT and change in RV/TLC (|r| 0.60-0.82, p < 0.05). Baseline FOT parameters also correlated with the subsequent post-LA-BD change in both IC/TLC (|r| 0.54-0.62, p < 0.05) and RV/TLC (|r| 0.57-0.76, p < 0.05). FOT impedance reflects hyperinflation and gas trapping in COPD, and the potential for long-acting bronchodilator responsiveness. These results provide us with further insight into the physiological mechanisms of action of long-acting bronchodilator treatment, and may be clinically useful for predicting treatment responses.

Efficacy of tiotropium and indacaterol monotherapy and their combination on dynamic lung hyperinflation in COPD: a random open-label crossover study

BACKGROUND AND OBJECTIVE

The difference in efficacy of long-acting muscarinic antagonists (LAMAs) and long-acting β2-agonists (LABAs) for dynamic lung hyperinflation (DLH) in COPD is unclear. The purpose of this study was to elucidate the difference in efficacy of LAMA and LABA alone and the combination thereof for DLH.

SUBJECTS AND METHODS

Thirty stable patients were enrolled and randomly divided into two groups following baseline measurements. One group was treated with 5 μg tiotropium (Respimat inhaler) for 4 weeks following a 4-week treatment with 150 μg indacaterol, while the other group was treated with indacaterol for 4 weeks following a 4-week treatment with tiotropium. For both groups, these treatments were followed by a combination of the two drugs for 4 weeks. Pulmonary function tests, including DLH evaluated by metronome-paced incremental hyperventilation and exercise tolerance evaluated by the shuttle-walk test, were performed at the end of each treatment period.

RESULTS

In total, 23 patients completed this study. Both tiotropium and indacaterol alone significantly increased forced expiratory volume in 1 second, exercise tolerance, and improved health status. Tiotropium significantly improved DLH, but indacaterol did not. The combination therapy resulted in further improvements in lung function and exercise tolerance, but not in DLH.

CONCLUSION

The efficacy of tiotropium in inhibiting DLH following metronome-paced incremental hyperventilation may be superior to that of 150 μg indacaterol, although the effects on airflow obstruction were the same, and the combination therapy showed further improvement in airflow obstruction, but not in DLH.