Bronchodilator Reversibility in COPD

doi:10.1378/chest.10-2974

Chest

Volume 140, Issue 4, October 2011, Pages 1055-1063

https://doi.org/10.1378/chest.10-2974 Get rights and content

COPD is a preventable and treatable disease characterized by airflow limitation that is not fully reversible. The diagnosis of COPD is based on spirometric evidence of airways obstruction following bronchodilator administration. Although it used to be commonly believed that patients with COPD have largely irreversible airflow obstruction, evidence now suggests that a considerable proportion of patients exhibit clinically significant bronchodilator reversibility. The complexity and inherent variability of a patient's acute response to a bronchodilator and the lack of a standardized procedure for assessing bronchodilator reversibility have led to significant confusion surrounding this concept. Although bronchodilator reversibility commonly is defined based on thresholds for improvement in FEV₁, lung volume-based measures of pulmonary function may be of particular importance in patients with severe COPD. The usefulness of acute reversibility to short-acting bronchodilators in predicting a patient's long-term response to bronchodilator maintenance therapy is also unclear, although most studies suggest that a lack of acute response to short-acting bronchodilators does not preclude a beneficial long-term response to maintenance bronchodilator treatment. This review outlines recent findings about the prevalence and usefulness of bronchodilator reversibility in patients with COPD based on the available literature and proposes areas of future research.

Section snippets

Determination of Bronchodilator Reversibility

Although no standard definition of acute bronchodilator reversibility exists, available definitions are based on the absolute or percentage improvements in FEV₁, FVC, or both from baseline following bronchodilator administration (Table 1).2, 6, 7, 8, 9 In addition, the definitions for a clinically meaningful improvement in FEV₁ after long-term treatment may differ from the criteria used to determine acute bronchodilator reversibility. Although a minimal clinically important difference (MCID)

Within-Subject Variability in Bronchodilator Reversibility

The interpretation of acute reversibility findings is also complicated by the inherent variability in patient-level factors. Considerable variation exists in bronchodilator response over time.²¹ In a study by Calverley et al,¹⁹ reversibility status changed with subsequent study visits in 52% and 38% of patients based on the ATS threshold and the ERS criterion, respectively. Anthonisen and Wright²¹ reported within- and between-subject variability in the annual percentage change in FEV₁ of 11.1%

FEV1

It is believed that patients with COPD have considerably less reversible airflow obstruction than patients with asthma, and this concept was, for a long time, inappropriately used to differentiate one disease from the other.⁵ Evidence now suggests that patients with COPD indeed can also show significant reversibility following acute bronchodilator administration13, 14, 15, 18, 24 and that reversibility testing may not be sensitive or specific enough to differentiate asthma from COPD.²⁵ In a

Therapeutic Implications of Bronchodilator Reversibility

Another misconception about the usefulness of the acute bronchodilator reversibility is that patients with COPD who exhibit poor or no acute bronchodilator reversibility are not good candidates for long-term treatment with bronchodilators. This has been shown repeatedly to be inaccurate, although patients who exhibit acute reversibility to study medication or short-acting bronchodilators at baseline usually exhibit greater long-term improvements in pulmonary function than those classified as

Summary

Patients with COPD were traditionally believed to have largely irreversible airway obstruction, and the acute reversibility status was often used to differentiate between COPD and asthma. However, recent studies demonstrate that many patients with COPD do indeed exhibit bronchodilator reversibility13, 14, 15, 18, 24 and that reversibility testing is not a reliable measure to differentiate between asthma and COPD.2, 25 Several factors may influence bronchodilator reversibility, including disease

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Hanania has received research grant support from Boehringer Ingelheim, AstraZeneca, GlaxoSmithKline, Novartis, and Pfizer and has served as a consultant for GlaxoSmithKline, Novartis, and Pfizer and on the Speakers Bureaus of GlaxoSmithKline, Boehringer Ingelheim, and AstraZeneca. Dr Celli has served as a consultant or on the advisory boards for AstraZeneca, Boehringer Ingelheim, and

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Funding/Support: This work was funded by AstraZeneca LP.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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Chest

Special FeaturesBronchodilator Reversibility in COPD

Section snippets

Determination of Bronchodilator Reversibility

Within-Subject Variability in Bronchodilator Reversibility

FEV1

Therapeutic Implications of Bronchodilator Reversibility

Summary

Acknowledgments

Chest

Pulm Pharmacol Ther

Chest

Chest

Pulm Pharmacol Ther

J Allergy Clin Immunol

Chest

Chest

Chest

Chest

Chest

Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper

Eur Respir J

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease

Comparison of spirometry criteria for the diagnosis of COPD: results from the BOLD study

Eur Respir J

Reversibility testing in patients with asthma and COPD

Nurs Stand

Lung function testing: selection of reference values and interpretative strategies

Am Rev Respir Dis

Optimal assessment and management of chronic obstructive pulmonary disease (COPD)

Eur Respir J

Criteria for the assessment of reversibility in airways obstruction

Chest

Interpretative strategies for lung function tests

Eur Respir J

Special Features
Bronchodilator Reversibility in COPD