Pharmacological management—inhaled treatment

doi:10.1136/bmj.332.7555.1439

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Graeme P Currie, specialist registrar1,
Brian J Lipworth, professor2

¹ Respiratory Unit, Aberdeen Royal Infirmary, Aberdeen
² Asthma and Allergy Research Group, Division of Medicine and Therapeutics, Ninewells Hospital and Medical School, Dundee

Chronic obstructive airways disease (COPD) is a heterogeneous condition, and all patients should be viewed as individuals—not only in terms of presentation, history, symptoms, and disability, but also in response to treatment. Acceptability to the patient, possible adverse effects, and efficacy of treatment are important factors to consider when prescribing inhaled drugs. The titration of drug treatment in COPD is usually based on the degree of airflow obstruction, severity of symptoms, exercise tolerance, and frequency of exacerbations.

All patients with established COPD should be prescribed a short acting inhaled bronchodilator for use as required

Short acting bronchodilators

For all patients with established COPD, prescribe a short acting inhaled bronchodilator (β₂ agonist or anticholinergic, or both in combination).

Patients with COPD have pulmonary hyperinflation, with increased functional residual capacity (red) and decreased inspiratory capacity (white). This increases the volume at which tidal breathing (oscillating line) occurs and places the respiratory muscles at mechanical disadvantage. Hyperinflation worsens with exercise and reduces exercise tolerance (dynamic hyperinflation). Inhaled bronchodilators improve dynamic hyperinflation and hyperinflation at rest, reducing the work of breathing and increasing exercise tolerance

Short acting β₂ agonists such as salbutamol reduce breathlessness and improve lung function, and are effective when used “as required.” They act directly on bronchial smooth muscle and cause the airways to dilate for up to six hours.

Short acting anticholinergics such as ipratropium reduce breathlessness, improve lung function, improve health related quality of life, and reduce the need for rescue medication. They offset high resting bronchomotor tone and improve airway calibre for up to six hours.

Both drugs in combination (salbutamol plus ipratropium delivered via a metered dose inhaler) have been shown to confer greater improvement in lung function than either drug given alone.