title: COPD: maximization of bronchodilation.
abstract: The most recent guidelines define COPD in a multidimensional way, nevertheless the diagnosis is still linked to the limitation of airflow, usually measured by the reduction in the FEV1/FVC ratio below 70%. However, the severity of obstruction is not directly correlated to symptoms or to invalidity determined by COPD. Thus, besides respiratory function, COPD should be evaluated based on symptoms, frequency and severity of exacerbations, patient's functional status and health related quality of life (HRQoL). Therapy is mainly aimed at increasing exercise tolerance and reducing dyspnea, with improvement of daily activities and HRQoL. This can be accomplished by a drug-induced reduction of pulmonary hyperinflation and exacerbations frequency and severity. All guidelines recommend bronchodilators as baseline therapy for all stages of COPD, and long-acting inhaled bronchodilators, both beta-2 agonist (LABA) and antimuscarinic (LAMA) drugs, are the most effective in regular treatment in the clinically stable phase. The effectiveness of bronchodilators should be evaluated in terms of functional (relief of bronchial obstruction and pulmonary hyperinflation), symptomatic (exercise tolerance and HRQoL), and clinical improvement (reduction in number or severity of exacerbations), while the absence of a spirometric response is not a reason for interrupting treatment, if there is subjective improvement in symptoms. Because LABA and LAMA act via different mechanisms of action, when administered in combination they can exert additional effects, thus optimizing (i.e. maximizing) sustained bronchodilation in COPD patients with severe airflow limitation, who cannot benefit (or can get only partial benefit) by therapy with a single bronchodilator. Recently, a fixed combination of ultra LABA/LAMA (indacaterol/glycopyrronium) has shown that it is possible to get a stable and persistent bronchodilation, which can help in avoiding undesirable fluctuations of bronchial calibre.
authors.affiliation: Pulmonary and TB Unit, Vittorio Veneto General Hospital, Vittorio Veneto, TV Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Nardini
authors.affiliation: Department of Experimental and Clinical Medicine, Section of Respiratory Medicine, AOU Careggi, Florence, Italy.
authors.forename: Gianna
authors.initials: G
authors.lastname: Camiciottoli
authors.affiliation: Pneumotisiology, NiguardaCa'Granda Hospital, Milan, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Locicero
authors.affiliation: Department of Medical and Surgical Sciences, Section of Respiratory Diseases, University "Magna Graecia" of Catanzaro, Catanzaro, Italy.
authors.forename: Rosario
authors.initials: R
authors.lastname: Maselli
authors.affiliation: Pneumology Rehabilitation, Villa delle Querce Hospital, Nemi, Rome, Italy.
authors.forename: Franco
authors.initials: F
authors.lastname: Pasqua
authors.affiliation: Department of Internal Medicine and Medical Specialities, Respiratory Diseases and Allergology, Università degli Studi di Genova, Genoa, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Passalacqua
authors.affiliation: Pneumology Unit, C. e G. Mazzoni Hospital, Ascoli Piceno, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Pela
authors.affiliation: Department of Pneumology, San Gerardo Hospital Monza (Mi), Monza, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Pesci
authors.affiliation: Pneumology Unit, AO S.Camillo-Forlanini, Rome, Italy.
authors.forename: Alfredo
authors.initials: A
authors.lastname: Sebastiani
authors.affiliation: Department of Medicine and Surgery, University of Salerno, Salerno, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Vatrella
keywords: Bronchodilation; COPD; Dyspnea; Exercise tolerance; Fixed combination indacaterol/glycopyrronium; HRQoL; Hyperinflation; LABA; LAMA