An Update on Bronchodilator Treatment of Chronic Obstructive Pulmonary Disease (COPD)

REVIEW ARTICLE


Walter Vincken

Affiliation: University Hospital Brussels (UZ Brussel), University of Brussels (Vrije Universiteit Brussel), Belgium

ABSTRACT

Although the main characteristic of chronic obstructive pulmonary disease (COPD) is relentlessly worsening airflow limitation, many patients show some degree of reversibility and, more importantly, clinically relevant improvements in dyspnea, exercise capacity, and health status following the administration of a bronchodilator. The mechanism through which bronchodilators effect these improvements appears to be a reduction in hyperinflation both at rest and during exercise. Bronchodilators also consistently reduce exacerbations. As a result, bronchodilators have become the recommended cornerstone of maintenance treatment of COPD.

Three classes of bronchodilators are currently available: the oral methylxanthine theophylline, both short-acting (SA) and long-acting (LA) inhaled ß2-adrenergic receptor agonists (BA), and anticholinergics (AC) or muscarinic receptor antagonists (MA). The SA inhaled bronchodilators are still used for rescue treatment, but should, for maintenance treatment, be replaced by their LA counterparts for reasons of both efficacy and convenience. Evidence also advocates the introduction of LA inhaled bronchodilators early in the disease process. Among the available LA inhaled bronchodilators, the once daily LAMA tiotropium appears a safe, effective, and convenient choice to initiate maintenance treatment with, but the advent of equally effective and convenient once daily LABAs and LAMAs may offer clinicians a valid alternative. Furthering the debate as to which bronchodilator to start maintenance treatment with is somewhat superfluous, as the constant finding that a combination of bronchodilators acting through different mechanisms has at numerous times been shown to be superior and perhaps safer than treatments with a single bronchodilator class. Once-daily combinations of LAMA and LABA formulated into one single device are now under way and probably will become the preferred maintenance treatment for COPD patients. Finally, another important step forward in the treatment of COPD will be the development of inhalation devices delivering aerosols with optimal pulmonary deposition and equipped with features that facilitate their correct handling by the COPD patient.

Keywords: COPD, treatment, bronchodilators, inhalation

Correspondence: Walter Vincken, Respiratory Division, University Hospital Brussels (UZ Brussel), 101 Laarbeeklaan, 1090 Brussels, Belgium. Tel: +32 (0)2 4776841; Fax: +32 (0)2 4776840; E-mail: walter.vincken@uzbrussel.be