Abstract
Background
Symptoms of bronchiectasis include chronic productive cough, wheeze, breathlessness and recurrent infections of the lower respiratory tract. Long‐acting bronchodilators are being used more frequently in the management of people with this condition.
Objectives
To determine the effectiveness of long‐acting bronchodilators in the management of bronchiectasis that is not due to cystic fibrosis.
Search methods
We searched the Cochrane Airways Group Specialised Register of bronchiectasis trials. The latest searches were carried out in August 2010.
Selection criteria
Randomised controlled trials, with or without masking.
Data collection and analysis
The results of searches were reviewed against pre‐specified criteria.
Main results
We were unable to identify any randomised controlled trials investigating the effectiveness of long‐acting bronchodilator therapy in the management of bronchiectasis. An update search in August 2010 did not identify any new studies.
Authors' conclusions
Further research is needed to establish if long‐acting bronchodilators have a role in the management of people with bronchiectasis.
Plain language summary
Long‐acting beta2‐agonists for bronchiectasis
Long‐acting bronchodilators are used in asthma, so may also benefit people with bronchiectasis. However, there is no good evidence for this at present.
Background
Bronchiectasis is a condition characterised by chronic pathological dilation of one or more bronchi. The condition, in the main, affects medium‐large bronchi, either in a focal or diffuse pattern. Bronchiectasis may be caused by a wide variety of disease processes, which include congenital disorders, mechanical obstruction of the bronchi, respiratory infections, immunodeficiencies, and idiopathic (unknown) causes. Many of these conditions lead to impaired tracheobronchial clearance, resulting in recurrent lower respiratory tract infection and inflammation, leading to a cycle of infection, scarring and bronchial damage.
Symptoms of bronchiectasis include chronic productive cough, wheeze, and dyspnoea. Infective exacerbations of bronchiectasis are associated with worsening of these symptoms, possible development of respiratory failure, and features suggestive of systemic infection. The natural history of the condition is usually a slow but progressive deterioration in lung function over time, although some people may remain clinically stable for many years.
Medical treatment includes physiotherapy, antibiotics, bronchodilators and occasionally mucolytic drugs. Surgery is rarely performed and is reserved for localised disease. Airflow obstruction is common in this disease, so bronchodilators are widely used. In this review, we aimed to critically appraise evidence for the use of long‐acting beta2‐agonists in bronchiectasis.
Objectives
To determine whether long‐acting beta2‐agonists:
Are of symptomatic benefit in patients with bronchiectasis
Improve lung function in patients with bronchiectasis
Alter the long‐term prognosis in patients with bronchiectasis
Methods
Criteria for considering studies for this review
Types of studies
Randomised controlled trials, with or without masking. The control group may have been treated with no treatment, placebo or drug/physical interventions.
Types of participants
Children or adults diagnosed with bronchiectasis by plain‐film chest radiograph, bronchography or high resolution computerised tomography. We stipulated that studies involving subjects with cystic fibrosis be excluded.
Types of interventions
Any type of long‐acting beta2‐agonist administered either orally or by inhalation.
Types of outcome measures
The optimal outcome measures in bronchiectasis have yet to be determined: We intended to consider both subjective and objective outcome measures that included:
Respiratory symptom scores
Objective measures of lung function, such as forced expiratory volume in one second (FEV1), peak expiratory flow (PEF), and forced vital capacity (FVC)
Rates of hospital admission and length of stay
School/work absences
Frequency and duration of exacerbations of bronchiectasis
Health status/quality of life measures
Adverse events and side effects
Number of dropouts
Mortality
Exhaled nitric oxide and other inflammatory markers, as these may represent a surrogate for long‐term impairment and decline in lung function
Search methods for identification of studies
We searched the Cochrane Airways Group Specialised Register of trials which is derived from systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and CINAHL, and handsearching of respiratory journals and meeting abstracts. The following search terms were used on all records coded as 'bronchiectasis':
(beta* and agonist*) or ventolin or salmeterol or serevent or formoterol or foradil or bambuterol
There were no restrictions used with respect to the language of publication. The most recent search was conducted in August 2010.
Data collection and analysis
The abstracts of papers identified from the search were read by the trials search co‐ordinator of the Airways Group (Karen Blackhall) and by one reviewer (AS). All trials that appeared to satisfy the criteria for inclusion were identified for full review. It was our intention that two reviewers should independently select trials for inclusion in the review and also independently assess the methodological quality of the included trials with particular emphasis on allocation concealment, which will be ranked using the Cochrane approach. We planned to only include trials graded A or B in this review. Two sub‐group analysis were planned:
Children versus adults
Severity (using FEV1 or exacerbation frequency criteria)
Results
Description of studies
The searches yielded two papers, neither of which satisfied the inclusion criteria for this review. An update search in August 2010 did not yield any additional references.
Risk of bias in included studies
Not applicable.
Effects of interventions
Despite an exhaustive search of the literature, two studies were identified but both were excluded (see Excluded studies). We were unable to identify any randomised controlled trials examining the efficacy or effectiveness of beta2‐agonists in the management of bronchiectasis. An update search conducted in August 2008 did not identify any new studies.
Discussion
Long acting bronchodilators have an established role in the management of airflow obstruction in asthma where they allow a reduction of inhaled steroid dose and reduce the frequency of exacerbations. By extension, they are also commonly used in the management of bronchiectasis where airflow obstruction is present, although there appears to be no high‐quality evidence to support their use in this condition. Long‐acting beta2‐agonist treatment may have a role in the management of patients with co‐existent asthma and bronchiectasis or where the bronchiectasis has caused or coexists with COPD (chronic obstructive pulmonary disease) but there is at present no clinical trial data to support this strategy beyond the evidence that exists independently for asthma and COPD.
Authors' conclusions
Implications for practice.
In the absence of identifying any experimental evidence, we are unable to either support or refute the continued use of bronchodilators for people with bronchiectasis. It is important that the conclusion of no evidence of effect is not confused with the conclusion that there is evidence of no effect.
Implications for research.
There is a need for pragmatic randomised controlled trials to establish the role, if any, for bronchodilators in the management of bronchiectasis.
What's new
| Date | Event | Description |
|---|---|---|
| 6 August 2010 | New search has been performed | New literature search. No studies found. |
History
Protocol first published: Issue 1, 2000 Review first published: Issue 3, 2001
| Date | Event | Description |
|---|---|---|
| 23 October 2009 | Amended | Contact details for Aziz Sheikh amended. |
| 8 August 2008 | New search has been performed | Search re‐run in August 2008; no new studies found. |
| 1 August 2008 | Amended | Converted to new review format. |
| 3 August 2006 | New search has been performed | Literature search re‐run; no new studies found. |
| 10 July 2001 | New citation required and conclusions have changed | Substantive amendment |
Acknowledgements
We thank the Cochrane Airways Group for their invaluable support in the preparation of this review.
Characteristics of studies
Characteristics of excluded studies [ordered by study ID]
| Study | Reason for exclusion |
|---|---|
| De Lunca 1999 | Not randomised |
| Weiss 1982 | Not randomised |
Contributions of authors
DN and AS conceived the review with all three authors contributing to the writing of the protocol. AS completed the review. MG was the assigned editor and offered input in the interpretation of the literature assembled in the review.
Sources of support
Internal sources
Department of General Practice and Primary Care, GKT, London, UK.
Cochrane Airways Group, St Georges Hospital, London, UK.
Department of General Practice and Primary Health Care, Imperial College School of Medicine, UK.
External sources
Garfield Weston Foundation, UK.
Declarations of interest
None known.
New search for studies and content updated (no change to conclusions)
References
References to studies excluded from this review
De Lunca 1999 {published data only}
- Lunca N, Capuzi P, D'Angeli AL, D'Antoni L, Pavone P, Santis M, et al. High resolution computed tomography assessment of beta 2‐agonist induced bronchodilation in chronic obstructive pulmonary disease patients. European Review for Medical and Pharmocological Sciences 1999;3(2):83‐7. [PubMed] [Google Scholar]
Weiss 1982 {published data only}
- Weiss JW, McFadden ER, Ingram RH. Bronchodilatation, lung recoil, and density dependence of maximal expiratory flow. Journal of Applied Physiology 1982;52(4):874‐8. [DOI] [PubMed] [Google Scholar]