What are the recommended inhaler choices for patients with chronic bronchitis?

Inhaler Choices in Chronic Bronchitis

For patients with chronic bronchitis, a long-acting muscarinic antagonist (LAMA) such as ipratropium bromide should be the first-line inhaler choice, as it provides superior cough reduction and symptom control compared to other bronchodilator options. 1, 2

First-Line Treatment Options

• Ipratropium bromide is recommended with a grade A recommendation for improving cough in stable patients with chronic bronchitis, as it reduces cough frequency, cough severity, and volume of sputum expectorated 1, 2
• The standard dosing is ipratropium bromide 36 μg (2 inhalations) four times daily 1, 3
• Short-acting β-agonists (SABAs) can be used as needed to control bronchospasm and relieve dyspnea; in some patients, they may also reduce chronic cough 1, 3

Treatment Algorithm Based on GOLD Classification

Group A (Low Symptom Burden, Low Exacerbation Risk)

• Start with a bronchodilator (either short-acting or long-acting) to reduce breathlessness 4
• Continue treatment if symptomatic benefit is noted 4
• If inadequate response, try alternative class of bronchodilator 4

Group B (High Symptom Burden, Low Exacerbation Risk)

• Initial therapy should be a long-acting bronchodilator (LAMA or LABA) 4
• For persistent breathlessness on monotherapy, use two bronchodilators (LABA/LAMA) 4
• For severe breathlessness, initial therapy with two bronchodilators may be considered 4

Group C (Low Symptom Burden, High Exacerbation Risk)

• Start with a LAMA as it is superior to LABA for exacerbation prevention 4
• If exacerbations persist, consider:
  • LABA/LAMA combination, or
  • LABA/ICS combination 4
• Consider roflumilast if FEV1 < 50% predicted and patient has chronic bronchitis 4

Group D (High Symptom Burden, High Exacerbation Risk)

• Initiate LABA/LAMA combination as first choice 4
• LABA/LAMA combinations show superior results compared with single bronchodilators for symptom control 4
• LABA/LAMA combinations are superior to LABA/ICS combinations in preventing exacerbations in Group D patients 4
• If exacerbations persist on LABA/LAMA therapy, consider:
  • Escalation to LABA/LAMA/ICS triple therapy, or
  • Switch to LABA/ICS (especially with features of asthma-COPD overlap or high blood eosinophil counts) 4

Advanced Therapy Options

• For patients with inadequate response to ipratropium bromide after 2 weeks, consider adding a SABA for additional bronchodilation and potential cough relief 1, 2
• For patients with severe airflow obstruction or frequent exacerbations, consider adding an inhaled corticosteroid (ICS) with a LABA 1, 3
• If patients on LABA/LAMA/ICS still have exacerbations, consider:
  • Adding roflumilast in patients with FEV1 < 50% predicted and chronic bronchitis, particularly if they experienced hospitalization for exacerbation in the previous year 4
  • Adding a macrolide in former smokers (consider risk of developing resistant organisms) 4

Specific Inhaler Options

• LAMAs: Tiotropium bromide, glycopyrronium bromide, and umeclidinium bromide (once daily); aclidinium bromide (twice daily) 5
• LABAs: Indacaterol (once daily); salmeterol and formoterol (twice daily) 6, 5
• LABA/LAMA fixed-dose combinations: Indacaterol/glycopyrronium, umeclidinium/vilanterol, and olodaterol/tiotropium 7, 8

Common Pitfalls and Caveats

• Long-term monotherapy with ICSs is not recommended for chronic bronchitis 4
• Group D patients are at higher risk for pneumonia when receiving ICS treatment 4
• Long-term therapy with oral corticosteroids is not recommended 4
• Long-term prophylactic therapy with antibiotics is not recommended for stable patients with chronic bronchitis due to concerns about antibiotic resistance 1
• ICS should be reserved for patients with a history of exacerbations despite appropriate treatment with long-acting bronchodilators 4
• When using combination therapy, consider the trade-off between improved efficacy and increased risk of side effects 7

Special Considerations for Acute Exacerbations

• During acute exacerbations, both short-acting β-agonists and anticholinergic bronchodilators should be administered 1, 3
• Add the other agent at maximal dose if prompt response is not observed 1, 3
• The American College of Chest Physicians recommends antibiotics for acute exacerbations of chronic bronchitis, particularly for patients with severe exacerbations and those with more severe airflow obstruction at baseline 1