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Wachtel H, Emerson-Stadler R, Langguth P, Hohlfeld JM, Ohar J. Aerosol Plumes of Inhalers Used in COPD. Pulm Ther 2024; 10:109-122. [PMID: 38194194 PMCID: PMC10881950 DOI: 10.1007/s41030-023-00249-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/21/2023] [Indexed: 01/10/2024] Open
Abstract
INTRODUCTION The selection of inhaler device is of critical importance in chronic obstructive pulmonary disease (COPD) as the interaction between a patient's inhalation profile and the aerosol characteristics of an inhaler can affect drug delivery and lung deposition. This study assessed the in vitro aerosol characteristics of inhaler devices approved for the treatment of COPD, including a soft mist inhaler (SMI), pressurized metered-dose inhalers (pMDIs), and dry powder inhalers (DPIs). METHODS High-speed video recording was used to visualize and measure aerosol velocity and spray duration for nine different inhalers (one SMI, three pMDIs, and five DPIs), each containing dual or triple fixed-dose combinations of long-acting muscarinic receptor antagonists and long-acting β2-agonists, with or without an inhaled corticosteroid. Measurements were taken in triplicate at experimental flow rates of 30, 60, and 90 l/min. Optimal flow rates were defined based on pharmacopoeial testing requirements: 30 l/min for pMDIs and SMIs, and the rate achieving a 4-kPa pressure drop against internal inhaler resistance for DPIs. Comparison of aerosol plumes was based on the experimental flow rates closest to the optimal flow rates. RESULTS The Respimat SMI had the slowest plume velocity (0.99 m/s) and longest spray duration (1447 ms) compared with pMDIs (velocity: 3.65-5.09 m/s; duration: 227-270 ms) and DPIs (velocity: 1.43-4.60 m/s; duration: 60-757 ms). With increasing flow rates, SMI aerosol duration was unaffected, but velocity increased (maximum 2.63 m/s), pMDI aerosol velocity and duration were unaffected, and DPI aerosol velocity tended to increase, with a more variable impact on duration. CONCLUSIONS Aerosol characteristics (velocity and duration of aerosol plume) vary by inhaler type. Plume velocity was lower and spray duration longer for the SMI compared with pMDIs and DPIs. Increasing experimental flow rate was associated with faster plume velocity for DPIs and the SMI, with no or variable impact on plume duration, whereas pMDI aerosol velocity and duration were unaffected by increasing flow rate.
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Affiliation(s)
- Herbert Wachtel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Strasse 173, 55216, Ingelheim am Rhein, Germany.
| | - Rachel Emerson-Stadler
- Boehringer Ingelheim Pharma GmbH & Co. KG, Binger Strasse 173, 55216, Ingelheim am Rhein, Germany
| | - Peter Langguth
- Institute for Pharmaceutical and Biomedical Sciences (IPBW), University of Mainz, Mainz, Germany
| | - Jens M Hohlfeld
- Fraunhofer Institute for Toxicology and Experimental Medicine ITEM, Hannover, Germany
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Jill Ohar
- Department of Internal Medicine, Section on Pulmonary Medicine, Critical Care, Allergy and Immunologic Diseases, Atrium Health Wake Forest Baptist, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
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Usmani O, Li G, De Backer J, Sadafi H, Wu L, Marshall J. Modeled small airways lung deposition of two fixed-dose triple therapy combinations assessed with in silico functional respiratory imaging. Respir Res 2023; 24:226. [PMID: 37742015 PMCID: PMC10517457 DOI: 10.1186/s12931-023-02534-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 09/08/2023] [Indexed: 09/25/2023] Open
Abstract
BACKGROUND Small airways disease plays a key role in the pathogenesis of chronic obstructive pulmonary disease (COPD) and is a major cause of obstruction; therefore, it is a critical pharmacotherapy target. This study evaluated lung deposition of two inhaled corticosteroid (ICS)/long-acting β2-agonist/long-acting muscarinic antagonist single-inhaler triple therapies using in silico functional respiratory imaging (FRI). Deposition was assessed using real-world inhalation profiles simulating everyday use where optimal inhalation may be compromised. METHODS Three-dimensional airway models were produced from 20 patients with moderate-to-very severe COPD. Total, central, and regional small airways deposition as a percentage of delivered dose of budesonide/glycopyrronium/formoterol fumarate dihydrate (BGF) 160/7.2/5 µg per actuation and fluticasone furoate/umeclidinium/vilanterol (FF/UM/VI) 100/62.5/25 µg were evaluated using in silico FRI based on in vitro aerodynamic particle size distributions of each device. Simulations were performed using multiple inhalation profiles of varying durations and flow rates representing patterns suited for a pressurized metered-dose inhaler or dry-powder inhaler (four for BGF, two for FF/UM/VI, with one common profile). For the common profile, deposition for BGF versus FF/UM/VI was compared post-hoc using paired t-tests. RESULTS Across inhalation profiles, mean total lung deposition was consistently higher with BGF (47.0-54.1%) versus FF/UM/VI (20.8-22.7%) and for each treatment component, with greater deposition for BGF also seen in the central large airways. Mean regional small airways deposition was also greater across inhalation profiles with BGF (16.9-23.6%) versus FF/UM/VI (6.8-8.7%) and for each treatment component. For the common profile, total, central, and regional small airways deposition were significantly greater for BGF versus FF/UM/VI (nominal p < 0.001), overall and for treatment components; notably, regional small airways deposition of the ICS components was approximately five-fold greater with budesonide versus fluticasone furoate (16.1% vs. 3.3%). CONCLUSIONS BGF was associated with greater total, central, and small airways deposition for all components versus FF/UM/VI. Importantly, using an identical inhalation profile, there was an approximately five-fold difference in small airways deposition for the ICS components, with only a small percentage of the ICS from FF/UM/VI reaching the small airways. Further research is needed to understand if the enhanced delivery of BGF translates to clinical benefits.
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Affiliation(s)
- Omar Usmani
- Imperial College London and Royal Brompton Hospital, London, UK
| | - Grace Li
- AstraZeneca, South San Francisco, CA, USA
| | | | | | - Libo Wu
- AstraZeneca, Durham, NC, USA
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Chetta A, Facciolongo N, Franco C, Franzini L, Piraino A, Rossi C. Impulse Oscillometry, Small Airways Disease, and Extra-Fine Formulations in Asthma and Chronic Obstructive Pulmonary Disease: Windows for New Opportunities. Ther Clin Risk Manag 2022; 18:965-979. [PMID: 36212050 PMCID: PMC9533783 DOI: 10.2147/tcrm.s369876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 09/01/2022] [Indexed: 11/23/2022] Open
Abstract
In recent years, the perspective of management of respiratory disease has been gradually changing in light of the increasing evidence of small airways as the major site of airflow obstruction contributing to the development of both COPD and asthma already in early stages of disease. First and foremost, the evidence is redefining disease severity, identifying small airways disease phenotypes and early signs of disease, and revising prevalence and overall epidemiological data as well. Much effort has been put toward the instrumental assessment of small airways’ involvement and early detection. Several clinical trials have evaluated the advantage of extra-fine formulations which can best target the small airways in uncontrolled asthma and severe COPD. Here, we briefly present a practical overview of the role of the small airways in disease, the most appropriate diagnostic methods for quantifying their impairment, and provide some insight into the costs of respiratory management in Italy, especially in sub-optimally controlled disease.
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Affiliation(s)
- Alfredo Chetta
- Clinica Pneumologica, Università di Parma, Parma, Italy
- Correspondence: Alfredo Chetta, Tel +39 0521.703478, Email
| | | | - Cosimo Franco
- UOC Pneumologia, Ospedale Guglielmo da Saliceto, Piacenza, Italy
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Schwarz C, Procaccianti C, Costa L, Brini R, Friend R, Caivano G, Sadafi H, Mussche C, Schwenck N, Hahn M, Murgia X, Bianco F. Differential Performance and Lung Deposition of Levofloxacin with Different Nebulisers Used in Cystic Fibrosis. Int J Mol Sci 2022; 23:ijms23179597. [PMID: 36076992 PMCID: PMC9455972 DOI: 10.3390/ijms23179597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/15/2022] [Accepted: 08/19/2022] [Indexed: 11/16/2022] Open
Abstract
We compared the performance and levofloxacin (Quinsair) lung deposition of three nebulisers commonly used in CF (I-Neb Advance, eFlow rapid, and LC Plus) with the approved nebuliser Zirela. The delivered dose, delivery rate, and aerosol particle size distribution (APSD) for each device were determined using the methods described in the Pharmacopeia. High-resolution computed tomography scans obtained from seven adult patients with mild CF were used to generate computer-aided, three-dimensional models of their airway tree to assess lung deposition using functional respiratory imaging (FRI). The eFlow rapid and the LC Plus showed poor delivery efficiencies due to their high residual volumes. The I-Neb, which only delivers aerosols during the inspiratory phase, achieved the highest aerosol delivery efficiency. However, the I-Neb showed the largest particle size and lowest delivery rate (2.9 mg/min), which were respectively associated with a high extrathoracic deposition and extremely long nebulisation times (>20 min). Zirela showed the best performance considering delivery efficiency (159.6 mg out of a nominal dose of 240 mg), delivery rate (43.5 mg/min), and lung deposition (20% of the nominal dose), requiring less than 5 min to deliver a full dose of levofloxacin. The present study supports the use of drug-specific nebulisers and discourages the off-label use of general-purpose devices with the present levofloxacin formulation since subtherapeutic lung doses and long nebulisation times may compromise treatment efficacy and adherence.
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Affiliation(s)
- Carsten Schwarz
- Division Cystic Fibrosis, CF Center Westbrandenburg, Campus Potsdam, Clinic Westbrandenburg, 14467 Potsdam, Germany
| | | | - Laura Costa
- Global Medical Affairs, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy
| | - Riccardo Brini
- Global Technical Development, Chiesi Ltd., Chippenham SN14 0AB, UK
| | - Richard Friend
- Global Technical Development, Chiesi Ltd., Chippenham SN14 0AB, UK
| | - Grazia Caivano
- Global Technical Development, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy
| | | | | | | | | | | | - Federico Bianco
- Global Medical Affairs, Chiesi Farmaceutici S.p.A., 43122 Parma, Italy
- Correspondence:
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Usmani OS, Baldi S, Warren S, Panni I, Girardello L, Rony F, Taylor G, DeBacker W, Georges G. Lung Deposition of Inhaled Extrafine Beclomethasone Dipropionate/Formoterol Fumarate/Glycopyrronium Bromide in Healthy Volunteers and Asthma: The STORM Study. J Aerosol Med Pulm Drug Deliv 2022; 35:179-185. [PMID: 35128939 PMCID: PMC9416540 DOI: 10.1089/jamp.2021.0046] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: An extrafine formulation triple therapy combination of beclomethasone dipropionate (BDP), formoterol fumarate (FF), and glycopyrronium bromide (GB) has been developed for the maintenance treatment of asthma and chronic obstructive pulmonary disease. This study used gamma scintigraphy to evaluate the intrapulmonary and extrapulmonary in vivo deposition of BDP/FF/GB, and the intrapulmonary regional distribution of the deposited formulation. Methods: This open-label uncontrolled nonrandomized single-dose study recruited 10 healthy volunteers and 9 patients with asthma. After a krypton-81m (81mKr) ventilation scan was conducted, subjects inhaled study drug (four inhalations of BDP/FF/GB 100/6/12.5 μg radiolabeled using technetium-99 m [99mTc]) through pressurized metered-dose inhaler, and a series of scintigraphic images were taken. The primary objective was to evaluate intrapulmonary drug deposition of BDP/FF/GB, determined as the percentage of nominal (i.e., metered) dose. Secondary endpoints included central/peripheral deposition ratio (C/P), and the standardized central/peripheral ratio (sC/P; 99mTc aerosol C/P/81mKr gas C/P). Results: All participants completed the study, with all scintigraphy procedures performed at one site. In patients with asthma, mean ± standard deviation intrapulmonary deposition was 25.50% ± 6.81%, not significantly different to that in healthy volunteers (22.74% ± 9.19%; p = 0.4715). Approximately half of the lung dose was deposited in the peripheral region of the lung (fraction deposited 0.52 ± 0.07 and 0.49 ± 0.06 in healthy volunteers and patients with asthma, respectively), resulting in C/P ratios of 0.94 ± 0.25 and 1.06 ± 0.25, respectively, with sC/P ratios of 1.80 ± 0.40 and 1.94 ± 0.38. Deposition patterns were similar in the two populations. BDP/FF/GB was well tolerated. Conclusions: This study confirmed that the extrafine particles delivered by BDP/FF/GB penetrate the peripheral areas of the lungs, with a similar proportion of particles deposited in the central and peripheral regions. Importantly, the deposition patterns were similar in healthy volunteers and patients with asthma, suggesting that disease characteristics are unlikely to impact drug deposition. Clinical Trial Registration number: NCT03795350.
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Affiliation(s)
- Omar S Usmani
- NHLI Imperial College London, London, United Kingdom
| | | | - Simon Warren
- Cardiff Scintigraphics Ltd., Cardiff, United Kingdom
| | | | | | | | - Glyn Taylor
- Cardiff Scintigraphics Ltd., Cardiff, United Kingdom
| | - Wilfried DeBacker
- Department of Respiratory Medicine, University of Antwerp, Antwerpen, Belgium
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Price DB, Henley W, Cançado JED, Fabbri LM, Kerstjens HAM, Papi A, Roche N, Şen E, Singh D, Vogelmeier CF, Barille S, Nudo E, Carter V, Skinner D, Vella R, Georges G. Interclass Difference in Pneumonia Risk in COPD Patients Initiating Fixed Dose Inhaled Treatment Containing Extrafine Particle Beclometasone versus Fine Particle Fluticasone. Int J Chron Obstruct Pulmon Dis 2022; 17:355-370. [PMID: 35210765 PMCID: PMC8858000 DOI: 10.2147/copd.s342357] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/24/2022] [Indexed: 12/13/2022] Open
Abstract
Background Inhaled corticosteroids (ICS) afford therapeutic benefits in some COPD patients, but their widespread use is cautioned due to an increased risk of developing pneumonia. Subclass variations exist, and the risk profile differs for individual ICS. Formulation particle size has been identified as a potential effect modifier. The present study compared the risk of pneumonia among new COPD users of fixed-dose combination inhalers containing fine-particle fluticasone (fp-FDC-F) versus extrafine particle beclometasone (ef-FDC-BDP). Methods A propensity matched historical cohort study was conducted using data from the Optimum Patient Care Research Database. COPD patients aged ≥40 years with ≥1 year of continuous medical data who initiated fp-FDC-F or ef-FDC-BDP were compared. The primary outcome was time to pneumonia event, as treated, using either sensitive (physician diagnosed) or specific (physician diagnosed and x-ray or hospital admission confirmed) definitions. Results A total of 13,316 patients were matched. Initiation of fp-FDC-F (mean dosage furoate 99 µg; propionate 710 µg) was associated with an increased risk of pneumonia versus ef-FDC-BDP (mean beclometasone dose 395 µg), irrespective of definition (sensitive HR 1.38 95% CI 1.14–1.68; specific HR 1.31 95% CI 1.05–1.62). Conclusion In the current investigation, we found that in comparison to extrafine beclomethasone, commencing a formulation containing fluticasone is associated with an increased risk of developing pneumonia. These observations support the idea that not all ICS are equal in their adverse effects and subclass variations exist and should be carefully considered in the treatment choice.
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Affiliation(s)
- David B Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Correspondence: David B Price, Observational and Pragmatic Research Institute, 22 Sin Ming Lane, #06-76, Midview City, 573969, Singapore, Email
| | - William Henley
- Observational and Pragmatic Research Institute, Singapore
- Health Statistics Group, Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | | | - Leonardo M Fabbri
- Respiratory Medicine, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Huib A M Kerstjens
- Department of Pulmonary Diseases, University of Groningen and University Medical Centre Groningen, and Groningen Research Institute for Asthma and COPD (GRIAC), Groningen, Netherlands
| | - Alberto Papi
- Respiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Nicolas Roche
- Department of Respiratory Medicine, APHP-Centre University of Paris, Cochin Institute, Paris, France
| | - Elif Şen
- Department of Pulmonary Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Dave Singh
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - Claus F Vogelmeier
- Department of Internal Medicine, Pulmonary and Critical Care Medicine, University of Marburg, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | - Sara Barille
- Global Medical Affairs, Chiesi Farmaceutici, S.p.A., Parma, Italy
| | - Elena Nudo
- Global Medical Affairs, Chiesi Farmaceutici, S.p.A., Parma, Italy
| | | | - Derek Skinner
- Observational and Pragmatic Research Institute, Singapore
| | - Rebecca Vella
- Observational and Pragmatic Research Institute, Singapore
| | - George Georges
- Global Clinical Development, Chiesi Farmaceutici, S.p.A., Parma, Italy
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Li Y, Li XY, Yuan LR, Wang HL, Pang M. Evaluation of small airway function and its application in patients with chronic obstructive pulmonary disease (Review). Exp Ther Med 2021; 22:1386. [PMID: 34650634 DOI: 10.3892/etm.2021.10822] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 08/26/2021] [Indexed: 12/13/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a chronic airway inflammatory disease characterized by incomplete reversible airflow limitation. The diagnosis of COPD is mainly based on pulmonary function examination. In recent years, it has been indicated that small airway dysfunction occurs in patients with all stages of COPD, even in high-risk smoking groups who have not yet met the diagnostic criteria for COPD. Early recognition of small airway dysfunction and early initiation of small airway targeted therapy have become foci of research. In the present review, the methods of evaluating small airway function were summarized and their merits and shortcomings were discussed. Furthermore, the potential of targeted treatment of small airways in patients with COPD was outlined.
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Affiliation(s)
- Yan Li
- Department of Pulmonary and Critical Care Medicine, The First Hospital, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Xin-Yang Li
- Department of Medical Parasitology, School of Basic Medicine, Basic Medical Science Center, Shanxi Medical University, Jinzhong, Shanxi 030600, P.R. China
| | - Li-Rong Yuan
- Department of Pulmonary and Critical Care Medicine, The First Hospital, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Hai-Long Wang
- Department of Medical Parasitology, School of Basic Medicine, Basic Medical Science Center, Shanxi Medical University, Jinzhong, Shanxi 030600, P.R. China
| | - Min Pang
- Department of Pulmonary and Critical Care Medicine, The First Hospital, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
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Cazzola M, Calzetta L, Matera MG. Long-acting muscarinic antagonists and small airways in asthma: Which link? Allergy 2021; 76:1990-2001. [PMID: 33559139 DOI: 10.1111/all.14766] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/29/2021] [Accepted: 02/03/2021] [Indexed: 12/14/2022]
Abstract
Involvement of small airways, those of <2 mm in internal diameter, is present in all stages of asthma and contributes substantially to its pathophysiologic expression. Therefore, small airways are a potential target to achieve optimal asthma control. Airway tone, which is increased in asthma, is mainly controlled by the vagus nerve that releases acetylcholine (ACh) and activates muscarinic ACh receptors (mAChRs) post-synaptically on airway smooth muscle (ASM). In small airways, M3 mAChRs are expressed, but there is no vagal innervation. Non-neuronal ACh released from the epithelial cells that may express choline acetyltransferase in response to inflammatory stimuli, as well as from other structural cells in the airways, including fibroblasts and mast cells, can activate mAChRs. By antagonizing M3 mAChR, the contraction of the ASM is prevented and, potentially, local inflammation can be reduced and the progression of remodeling may be averted. In fact, ACh also contributes to inflammation and remodeling of the airways and regulates the growth of ASM. Several experimental studies have demonstrated the potential benefit derived from the use of mAChR antagonists, mainly long-acting mAChR antagonists (LAMAs), on small airways in asthma. However, there are several confounding factors that may cause a wrong estimation of the relationship between LAMAs and small airways in asthma. Further studies are needed to differentiate broncholytic and anti-inflammatory effects of LAMAs and to better understand the interaction between LAMAs and corticosteroids, also in the context of a triple therapy that includes a β2 -AR agonist, at different levels of the bronchial tree.
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Affiliation(s)
- Mario Cazzola
- Department of Experimental Medicine University of Rome “Tor Vergata” Rome Italy
| | - Luigino Calzetta
- Respiratory Disease and Lung Function Unit Department of Medicine and Surgery University of Parma Parma Italy
| | - Maria Gabriella Matera
- Department of Experimental Medicine University of Campania “Luigi Vanvitelli” Naples Italy
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