Treatment of COPD: from pharmacological to instrumental therapies

The two main goals of the current management of chronic obstructive pulmonary disease (COPD) are: 1) to reduce the impact of the disease on daily activities; and 2) to reduce the risk of future events (exacerbations, lung function decline and death) [1]. The first measure is obviously smoking cessation; however, we will not discuss this. Treatment guidelines are mainly based on randomised clinical trials that include a small and highly selected fraction of the COPD population [2]. Therefore, it is questionable as to whether these evidence-based guidelines can be extrapolated to the overall COPD population in the everyday practice. Indeed, less than one in five or 10 patients with COPD could fit into inclusion or exclusion criteria commonly used in clinical trials evaluating efficacy of pharmacological treatments [2, 3]. In addition, COPD is a heterogeneous disease and patients with similar forced expiratory volume in 1 s (FEV1) may show very different functional status, underlying lung pathology and comorbidities. For most treatments, differences in the responsiveness of COPD subgroups are not yet established and large, long clinical trials, along with high-quality meta-analyses, remain the basis of the current treatment guidelines and the evaluation of the benefit/risk ratio of the main therapeutic classes used in COPD management. However, even the large therapeutic trials may suffer from methodological limitations in the design or analysis [4]. The most important outcomes in clinical trials are patient-centred outcomes. Exacerbations, health-related quality of life and mortality are logical major outcomes in COPD trials [4]. In addition, exercise performance and lung function decline are other important targets for therapeutic intervention in COPD [5]. Lung function and biological markers reliably predicting individual response to treatments would be useful. ### Bronchodilators Bronchodilators are the mainstay of the current pharmacological …