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      Clinical issues of mucus accumulation in COPD

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          Abstract

          Dear editor We wish to thank Ramos et al for presenting a succinct and up-to-date synthesis of the evidence relating to the important issue of mucus hypersecretion in COPD.1 The authors highlight the association of mucus hypersecretion with poor outcomes, including increased risk of exacerbations, hospitalization and mortality. These associations have led to interest in the potential benefits of mucus clearance techniques in COPD. As Ramos et al1 point out, although the physiological rationale for airway clearance techniques (ACTs) in COPD is strong, clinical efficacy has historically been difficult to establish, perhaps due to the variety of techniques and outcomes that have been employed in small studies. We have recently synthesized this body of evidence in a Cochrane systematic review of ACTs for individuals with COPD. The review demonstrated ACTs are safe and meta-analysis showed they confer small beneficial effects on a limited range of important clinical outcomes, such as the need for and duration of ventilatory assistance during an acute exacerbation of COPD (AECOPD).2 We agree with Ramos et al1 that ACTs based upon positive expiratory pressure (or PEP) appear to be physiologically suited to addressing the underlying pathophysiology and mechanics of the lungs in individuals affected by COPD. This is supported by non-significant trends of improved efficacy of PEP-based ACTs over other types of ACTs,2 and was the premise of our multicentre, randomized controlled trial (n=92) investigating the effect of PEP compared to usual care consisting of no ACTs in patients with AECOPD.3 However, this study demonstrated a clear lack of benefit in a range of important clinical outcomes, including self-reported symptom severity, both in the short-term and long-term. The lack of impact of ACTs on significant outcomes in COPD is now emerging consistently in the literature, such as the important investigation by Cross et al4 of manual chest physical therapy (percussions and vibrations) in 526 inpatients with AECOPD. A theme of these new investigations is the importance of outcome choice. Much of the existing literature in the area of ACTs in COPD is founded on outcomes such as forced expiratory volume or measures of sputum clearance. These may be intuitively useful and relatively simple to obtain, however measures of lung function correlate poorly with more relevant patient-centered outcomes5 and measures of sputum clearance are fraught with limitations regarding their interpretation. Both are no longer considered useful indicators of ACT success.6 Future investigations in this area should address whether ACTs can modify the important adverse outcomes associated with mucus hypersecretion, as outlined in the review of Ramos et al.1 We would like to add our voice to the growing call for high quality research into the clinically challenging dilemma of diagnosing and managing coexistent COPD (or chronic bronchitis) with bronchiectasis. Although radiological evidence of bronchiectasis is present in a significant proportion of people with COPD, defining the dominant condition in cases of established or severe co-existing disease poses a challenge, as does determination of the ideal pharmacological and non-pharmacological management for this “combined” phenotype.

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          Clinical issues of mucus accumulation in COPD

          Airway mucus is part of the lung’s native immune function that traps particulates and microorganisms, enabling their clearance from the lung by ciliary transport and cough. Mucus hypersecretion and chronic productive cough are the features of the chronic bronchitis and chronic obstructive pulmonary disease (COPD). Overproduction and hypersecretion by goblet cells and the decreased elimination of mucus are the primary mechanisms responsible for excessive mucus in chronic bronchitis. Mucus accumulation in COPD patients affects several important outcomes such as lung function, health-related quality of life, COPD exacerbations, hospitalizations, and mortality. Nonpharmacologic options for the treatment of mucus accumulation in COPD are smoking cessation and physical measures used to promote mucus clearance. Pharmacologic therapies include expectorants, mucolytics, methylxanthines, beta-adrenergic receptor agonists, anticholinergics, glucocorticoids, phosphodiesterase-4 inhibitors, antioxidants, and antibiotics.
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            Airway clearance techniques for chronic obstructive pulmonary disease.

            Cough and sputum production are common in chronic obstructive pulmonary disease (COPD) and are associated with adverse clinical outcomes. Airway clearance techniques (ACTs) aim to remove sputum from the lungs, however evidence of their efficacy during acute exacerbations of COPD (AECOPD) or stable disease is unclear.
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              The effect of positive expiratory pressure (PEP) therapy on symptoms, quality of life and incidence of re-exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease: a multicentre, randomised controlled trial.

              Positive expiratory pressure (PEP) is a technique used to enhance sputum clearance during acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The impact of PEP therapy during acute exacerbations on clinically important outcomes is not clear. This study sought to determine the effect of PEP therapy on symptoms, quality of life and future exacerbations in patients with AECOPD.
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                Author and article information

                Journal
                Int J Chron Obstruct Pulmon Dis
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                1176-9106
                1178-2005
                2014
                25 March 2014
                : 9
                : 301-302
                Affiliations
                [1 ]Department of Physiotherapy, Monash University, Melbourne, VIC, Australia
                [2 ]Institute for Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
                [3 ]Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, VIC, Australia
                [4 ]Department of Physiotherapy, La Trobe University, Melbourne, VIC, Australia
                [5 ]Department of Physiotherapy, Alfred Health, Melbourne, VIC, Australia
                Author notes
                Correspondence: Christian R Osadnik, Department of Physiotherapy, Monash University, Peninsula Campus, McMahons Road, Frankston, Victoria 3199, Australia
                Article
                copd-9-301
                10.2147/COPD.S61797
                3970915
                24741301
                © 2014 Osadnik et al. This work is published by Dove Medical Press Ltd, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License

                The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Ltd, provided the work is properly attributed.

                Categories
                Letter

                Respiratory medicine

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