What are the implications of chronic small airway disease?

From the Guidelines

Chronic appearing small airway disease should be managed with a comprehensive approach that includes pharmacological and nonpharmacological treatments, with a focus on alleviating symptoms, improving health status, and preventing exacerbations, as recommended by the 2023 Canadian Thoracic Society guideline on pharmacotherapy in patients with stable COPD 1.

Key Considerations

• The treatment of chronic appearing small airway disease typically involves inhaled corticosteroids (ICS) and long-acting beta-agonists (LABA) to reduce inflammation and bronchospasm in the small airways.
• Smoking cessation is crucial for those who smoke, as tobacco smoking is a major risk factor for COPD, and quitting can slow disease progression and improve symptoms 2.
• Pulmonary rehabilitation, including breathing exercises and physical conditioning, can improve exercise capacity and quality of life for patients with chronic appearing small airway disease.
• Regular follow-up with pulmonary function tests is important to monitor disease progression and treatment response.

Treatment Options

• Inhaled corticosteroids (ICS) such as fluticasone (100-500 mcg twice daily) or budesonide (180-360 mcg twice daily) combined with long-acting beta-agonists (LABA) like salmeterol or formoterol in a single inhaler.
• Short-acting bronchodilators like albuterol (2 puffs every 4-6 hours as needed) for symptom relief.
• A short course of oral prednisone (40mg daily for 5-7 days) may be necessary for acute exacerbations.

Important Considerations

• Patient education on proper inhaler technique and adherence to maximize medication effectiveness is essential.
• A comprehensive approach to management, including nonpharmacological interventions such as self-management education and pulmonary rehabilitation, is recommended to improve symptoms, health status, and prevent exacerbations 1.

From the Research

Chronic Appearing Small Airway Disease

• Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable disease, characterized by persistent and progressive airflow limitation 3
• Small airways (internal diameter <2 mm) are a well-known major site of COPD-associated inflammation and remodeling, and have emerged as a potential target for COPD pharmacologic therapies 3, 4
• The ability of extrafine formulations of inhaled corticosteroids (ICS) in combination with long-acting beta2-agonists (LABAs) to achieve central and peripheral lung deposition has been shown to be effective in the treatment of COPD 3

Treatment Options

• Combination therapy with salmeterol/fluticasone and tiotropium has been shown to lead to better control of symptoms and improved lung function, with no greater risk of side-effects, as compared to salmeterol/fluticasone or tiotropium alone in the treatment of COPD 5, 6
• Tiotropium plus fluticasone-salmeterol has been shown to improve lung function, disease-specific quality of life, and reduce the number of hospitalizations for COPD exacerbation and all-cause hospitalizations compared with tiotropium plus placebo 7
• Long-acting muscarinic antagonists (LAMAs) have been shown to induce an effective bronchorelaxant effect on small airways, and their effectiveness relies on the selected drug, the employed inhalation device, and patient's adherence 4

Efficacy of Combination Therapies

• The combination of salmeterol and fluticasone propionate (SFC) and tiotropium bromide (TIO) has been shown to be more effective than individual components in improving lung function, symptoms, and quality of life in patients with moderate to severe COPD 6
• SFC+TIO triple therapy has been shown to lead to greater improvements in bronchodilation, airway conductance, and lung volumes, as well as patient-related benefits such as improved Transition Dyspnoea Index (TDI) and reduced use of rescue medication 6