References

Bafadhel M, Peterson S, De Blas M Predictors of exacerbation risk and response to budesonide in patients with chronic obstructive pulmonary disease: a post-hoc analysis of three randomised trials. The Lancet Respiratory Medicine.. 2018; 6:(2)117-126 https://doi.org/10.1016/s2213-2600(18)30006-7

Barnes PJ. Inhaled Corticosteroids. Pharmaceuticals (Basel).. 2010; 3:(3)514-540 https://doi.org/10.3390/ph3030514

Booth A. Devices, drugs and guidelines: prescribing inhaler therapy. Journal of General Practice Nursing.. 2016; 2:(5)13-14

Bourke SJ, Burns GP. Respiratory Medicine Lecture Notes.Oxford: Wiley-Blackwell; 2011

British Thoracic Society/Scottish Intercollegiate Guideline Network. British guideline on the management of asthma. Sign 158. 2019. https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/ (accessed 30 May 2020)

Calverley PM, Boonsawat W, Cseke Z, Zhong N, Peterson S, Olsson H. Maintenance therapy with budesonide and formoterol in chronicobstructive pulmonary disease. European Respiratory Journal.. 2003; 22:(6)912-919 https://doi.org/10.1183/09031936.03.00027003

Calverley PM, Anderson JA, Celli B Salmeterol and fluticasone propionate and survival in chronic obstructive pulmonary disease. New England Journal of Medicine. 2007; 356:775-789

Capstick TGD, Clifton IJ. Inhaler technique and training in people with chronic obstructive pulmonary disease and asthma. Expert Review of Respiratory Medicine.. 2012; 6:(1)91-103 https://doi.org/10.1586/ers.11.89

Capstick T, Khachi H, Murphy A, d'Ancona G, Meynell H, Wilson P. Generic prescribing is not appropriate for inhaled drugs. The Pharmaceutical Journal. 2015; 294

Chalmers JD, Tebboth A, Gayle A, Ternouth A, Ramscar N. Determinants of initial inhaled corticosteroid use in patients with GOLD A/B COPD: a retrospective study of UK general practice. NPJ Prim Care Respir Med.. 2017; 27:(1) https://doi.org/10.1038/s41533-017-0040-z

Chapman KR, Hurst JR, Frent SM Long-Term Triple Therapy De-escalation to Indacaterol/Glycopyrronium in Patients with Chronic Obstructive Pulmonary Disease (SUNSET): A Randomized, Double-Blind, Triple-Dummy Clinical Trial. American Journal of Respiratory Critical Care Medicine.. 2018; 198:(3)329-339 https://doi.org/10.1164/rccm.201803-0405OC

Cheyne L, Irvin-Sellers MJ, White J. Tiotropium versus ipratropium bromide for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2015; https://doi.org/10.1002/14651858.cd009552.pub3

Cole JM, Sheehan AH, Jordan JK. Concomitant use of ipratropium and tiotropium in chronic obstructive pulmonary disease. Ann Pharmacother.. 2012; 46:(12)1717-1721 https://doi.org/10.1345/aph.1R283

Decramer ML, Chapman KR, Dahl R Once-daily indacaterol versus tiotropium for patients with severe chronic obstructive pulmonary disease (INVIGORATE): a randomised, blinded, parallel-group study. Lancet Respir Med.. 2013; 1:(7)524-533 https://doi.org/10.1016/S2213-2600(13)70158-9

Ernst P, Saad N, Suissa S. Inhaled corticosteroids in COPD: the clinical evidence. European Respiratory Journal.. 2014; 45:(2)525-537 https://doi.org/10.1183/09031936.00128914

Fletcher CM. Standardised questionnaire on respiratory symptoms: a statement prepared and approved by the MRC Committee on the Aetiology of Chronic Bronchitis (MRC breathlessness score). BMJ. 1960; 2

Global Initiative For Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Pulmonary Disease. 2020. https://goldcopd.org (accessed 18 August 2020)

Graham B, Steenbruggen I, Miller M Standardization of Spirometry 2019 Update. An Official American Thoracic Society and European Respiratory Society Technical Statement. American Journal of Respiratory Critical Care Medicine.. 2019; 200:(8)e70-e88 https://doi.org/10.1164/rccm.201908-1590st

Haidl P, Heindl S, Siemon K, Bernacka M, Cloes RM. Inhalation device requirements for patients' inhalation maneuvers. Respir Med. 2016; 118:65-75 https://doi.org/10.1016/rmed.2016.07.013

Hogg JC, Chu F, Utokaparch S The nature of small-airway obstruction in chronic obstructive pulmonary disease. N Engl J Med.. 2004; 350:(26)2645-2653 https://doi.org/10.1056/NEJMoa032158

Horita N, Goto A, Shibata Y, Ota E, Nakashima K, Nagai K, Kaneko T. Long-acting muscarinic antagonist (LAMA) plus long-acting beta-agonist (LABA) versus LABA plus inhaled corticosteroid (ICS) for stable chronic obstructive pulmonary disease (COPD). Cochrane Database of Systematic Reviews. 2017; 2 https://doi.org/10.1002/14651858.CD012066.pub2

Jones PW, Harding G, Berry P, Wiklund I, Chen WH, Kline Leidy N. Development and first validation of the COPD Assessment Test. Eur Respir J.. 2009; 34:(3)648-654 https://doi.org/10.1183/09031936.00102509

Kew KM, Mavergames C, Walters JA. Long-acting beta2-agonists for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews. 2013; (10) https://doi.org/10.1002/14651858.cd010177.pub2

Leeds Integrated COPD Service. Leeds COPD prescribing guidance. 2018. http://www.cpwy.org/doc/2704.pdf (accessed 18 August 2020)

Lipson D, Barnhart F, Brealey N Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD. New England Journal of Medicine.. 2018; 378:(18)1671-1680 https://doi.org/10.1056/nejmoa1713901

London Respiratory Network. COPD Value Pyramid. 2014. https://www.networks.nhs.uk/nhs-networks/london-lungs/latest-edition-of-thorax-publication (accessed 23 May 2020)

Marsh S, Travers J, Weatherall M Proportional classifications of COPD phenotypes. Thorax.. 2008; 63:(9)761-767 https://doi.org/10.1136/thx.2007.089193

McGarvey L, Lee A, Roberts J, Gruffydd-Jones K, McKnight E, Haughney J. Characterisation of the frequent exacerbator phenotype in COPD patients in a large UK primary care population. Respiratory Medicine.. 2015; 109:(2)228-237 https://doi.org/10.1016/j.rmed.2014.12.006

ABC of chronic obstructive pulmonary disease. Pathology, pathogenesis, and pathophysiology. 2006. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463976/pdf/bmj33201202.pdf (accessed 23 May 2020)

Medicines.org.uk. Symbicort Turbohaler 400/12, Inhalation powder, Summary of product characteristics. 4.8 Undesirable effects. 2018. https://www.medicines.org.uk/emc/product/6775/smpc#UNDESIRABLE_EFFECTS (accessed 18 August 2020)

Medicines.org.uk. Spiriva 18 microgram inhalation powder, hard capsule, Summary of Product Characteristics, 4.5 Interaction with other medicinal products and other forms of interaction. 2019. https://www.medicines.org.uk/emc/product/1693/smpc#INTERACTIONS (accessed 18 August 2020)

Miravitlles M, Kruesmann F, Haverstock D, Perroncel R, Choudhri S, Arvis P. Sputum colour and bacteria in chronic bronchitis exacerbations: a pooled analysis. European Respiratory Journal.. 2011; 39:(6)1354-1360 https://doi.org/10.1183/09031936.00042111

Morjaria JB, Rigby A, Morice AH. Inhaled Corticosteroid use and the Risk of Pneumonia and COPD Exacerbations in the UPLIFT Study. Lung. 2017; 195:281-288 https://doi.org/10.1007/s00408-017-9990-8

National Institute for Health and Care Excellence. Roflumilast for treating chronic obstructive pulmonary disease. Technology appraisal guidance [TA461]. 2017. https://www.nice.org.uk/guidance/ta461/chapter/1-Recommendations (accessed 18 August 2020)

National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. 2019. http://www.nice.org.uk/guidance/ng115 (accessed 18 August 2020)

Oba Y, Keeney E, Ghatehorde N, Dias S. Dual combination therapy versus long-acting bronchodilators alone for chronic obstructive pulmonary disease (COPD): a systematic review and network meta-analysis. Cochrane Database of Systematic Reviews. 2018; 12 https://doi.org/10.1002/14651858.CD012620.pub2

Primary Care Respiratory Society. All that glitters is not GOLD, nor is it even NICE. Primary Care Respiratory Update. 2019. https://www.pcrs-uk.org/sites/pcrs-uk.org/files/pcru/2019/2019-Spring-Issue-17-GOLD-COPD-PCRS.pdf (accessed 18 August 2020)

Restrepo MI, Mortensen EM, Pugh JA, Anzueto A. COPD is associated with increased mortality in patients with community-acquired pneumonia. Eur Respir J.. 2006; 28:(2)346-351 https://doi.org/10.1183/09031936.06.00131905

Sanders MJ. Guiding Inspiratory Flow: Development of the In-Check DIAL G16, a Tool for Improving Inhaler Technique. Pulmonary Medicine. 2017; 2017:1-7 https://doi.org/10.1155/2017/1495867

Scullion J. Teaching inhaler technique. Journal of Prescribing Practice.. 2020; 2:(5)234-237 https://doi.org/10.12968/jprp.2020.2.5.234

Seberova E, Anderson A. Oxis (formoterol given by Turbuhaler) showed as rapid an onset of action as salbutamol given by a pMDI. Respiratory Medicine.. 2000; 94:(6)607-611 https://doi.org/10.1053/rmed.2000.0788

Singh D, Papi A, Corradi M Single inhaler triple therapy versus inhaled corticosteroid plus long-acting β2-agonist therapy for chronic obstructive pulmonary disease (TRILOGY): a double-blind, parallel group, randomised controlled trial. Lancet.. 2016; 388:(10048)963-973 https://doi.org/10.1016/S0140-6736(16)31354-X

Simonsen T, Aarbakke J, Kay I, Coleman I, Sinnott O, Lyssa R. Illustrated Pharmacology For Nurses.London: Hodder Arnold; 2006

Suissa S, Barnes PJ. Inhaled corticosteroids in COPD: the case against. Eur Respir J.. 2009; 34:(1)13-16 https://doi.org/10.1183/09031936.00190908

UK Inhaler Group. Inhaler Standards and Competency Document. 2019. https://www.ukinhalergroup.co.uk/news-and-activity (accessed 18 August 2020)

Vestbo J, Papi A, Corradi M Single inhaler extrafine triple therapy versus long-acting muscarinic antagonist therapy for chronic obstructive pulmonary disease (TRINITY): a double-blind, parallel group, randomised controlled trial. The Lancet.. 2017; 389:(10082)1919-1929 https://doi.org/10.1016/s0140-6736(17)30188-5

Vogelmeier C, Hederer B, Glaab T Tiotropium versus salmeterol for the prevention of exacerbations of COPD. New England Journal of Medicine.. 2011; 364:(12)1093-1103 https://doi.org/10.1056/NEJMoa1008378

Wedzicha J, Calverley P, Seemungal T The Prevention of Chronic Obstructive Pulmonary Disease Exacerbations by Salmeterol/Fluticasone Propionate or Tiotropium Bromide. American Journal of Respiratory Critical Care Medicine.. 2008; 177:(1)19-26 https://doi.org/10.1164/rccm.200707-973oc

Wedzicha J, Banerji D, Chapman K Indacaterol–Glycopyrronium versus Salmeterol–Fluticasone for COPD. New England Journal of Medicine.. 2016; 374:(23)2222-2234 https://doi.org/10.1056/nejmoa1516385

Wirral University Teaching Hospital. Wirral COPD Guidelines. 2015. https://mm.wirral.nhs.uk/document_uploads/guidelines/COPDguidelinesv2.pdf (accessed 18 August 2020)

Yang IA, Clarke MS, Sim EH, Fong KM. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012; (7) https://doi.org/10.1002/14651858.CD002991.pub3

Respiratory

Inhaled therapy for chronic obstructive pulmonary disease

02 September 2020

Clinical Focus

02 September 2020

Volume 2 · Issue 9

ISSN (print): 2631-8385

ISSN (online): 2631-8393

Abstract

Chronic obstructive pulmonary disease is characterised by progressive symptoms of productive cough, breathlessness, wheeze and exacerbations. Airway obstruction is detected by quality assured spirometry, and is defined as a Forced Expired Volume in one second / Forced Vital Capacity ratio <0.7. Inhaled therapy is the most effective treatment solution, with bronchodilators and inhaled steroids helping to improve symptoms, quality of life and lung function, while reducing risk of exacerbations. Bronchodilators are available as both monotherapy and as dual combination therapy. Inhaled steroids can be added to inhaled long-acting bronchodilators, but are not without significant complications, including pneumonia. Therefore, careful assessment of the phenotype of a patient with chronic obstructive pulmonary disease must be given before commencing any therapy that contains inhaled steroid and other treatments, such as flu vaccination, smoking cessation and pulmonary rehabilitation should be given due consideration.

Airflow obstruction may be caused by bronchoconstriction and an abnormal inflammatory response, often the result of prolonged inhalation of noxious particles, such as through smoking. Overproduction of mucus is seen in chronic bronchitis, and permanent damage to lung tissue can be found in emphysema (McNee, 2006). Symptoms include progressive and persistent shortness of breath that is made worse with activity, a chronic cough that may be intermittent, regular sputum production, and wheezing (National Institute for Health and Care Excellence (NICE), 2019). Respiratory tract infections are common and can lead to exacerbations or attacks that can last days of even weeks, and often result in a decline in lung function (Global Initiative for Chronic Obstructive Lung Disease (GOLD), 2020). The aims of treatment strategies include reduction of disease progression, improving symptoms and quality of life, maintaining lung function, and reducing risk of exacerbation (NICE, 2019; GOLD, 2020).

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chronic obstructive pulmonary disease

COPD

inhaled therapy

bronchodilator

steroid