Bronchodilator Responsiveness in Obliterative Bronchiolitis

Conditions

Obliterative Bronchiolitis

Keywords

Obliterative bronchiolitis, Bronchodilator responsiveness, Partial forced expiratory flow, Lung volumes

Brief summary

This study has been designed to provide a substantial evidence of acute bronchodilator responsiveness to two sequentially inhaled drugs, a beta2-agonist (i.e., albuterol) and an anticholinergic (i.e., tiotropium bromide), in a group of patients who developed obliterative bronchiolitis after hematopoietic stem cell transplantation.

Detailed description

Obliterative bronchiolitis is a life-threatening non-infectious pulmonary complication of allogeneic hematopoietic stem cell transplantation (HSCT). It is characterized by the development of an obstructive abnormality which has been considered to be insensitive to bronchodilator treatments. However, this knowledge stems from measurements of forced expiratory volume in 1 s (FEV1) which is relatively insensitive to changes in small airway caliber. Moreover, it is known from studies in chronic obstructive pulmonary disease that symptoms improve after bronchodilator treatment even when FEV1 is minimally increased and correlate with the reduction of lung hyperinflation, which is the major consequence of severe expiratory airflow limitation. Therefore, measurements of airway caliber by parameters not affected by volume history and absolute lung volumes are preferable for assessing the effect of bronchodilator interventions. In the current study, the bronchodilators responsiveness will be assessed by using not only spirometry but also measurements of absolute lung volumes and the forced expiratory flow of a partial maneuver (V'part) started from submaximal lung inflation, thus free of volume history effects.

Barisione G, Bacigalupo A, Crimi E, Brusasco V.

2010-08-1919 citations

10.1378/chest.10-1442

Interventions

DRUGalbuterol plus tiotropium

Four separate doses of 100 μg of albuterol and 18 μg of tiotropium bromide. Albuterol will be given by a metered-dose inhaler connected to a valved-holding chamber and tiotropium by a dry-powder device.

Study design

Allocation

NA

Intervention model

SINGLE_GROUP

Primary purpose

DIAGNOSTIC

Masking

NONE

Eligibility

Sex/Gender

ALL

Healthy volunteers

No

Inclusion criteria

* Obliterative bronchiolitis (OB) following allogeneic HSCT * FEV1 to slow inspiratory vital capacity (VC) ratio (FEV1/VC)\<5th percentile * FEV1 \<75% predicted or absolute FEV1 fall \>10% of pre-HSCT value * evidence of OB by computed tomography scanning * negative microbiological yields in bronchoalveolar lavage fluid * chronic graft-versus-host disease score \>0 * negative history for bronchial asthma, chronic obstructive pulmonary disease or other significant respiratory disease.

Exclusion criteria

* inability to perform lung function maneuvers * pre-existent chronic lung disease other than OB

Design outcomes

Primary

Measure	Time frame	Description
Per Cent Change of Forced Expiratory Volume in 1 Second (FEV1) After Bronchodilators	Baseline and 90 min after bronchodilators	Following albuterol plus tiotropium inhalation, FEV1 increments ≥12 per cent as compared to baseline, in an individual subject, were considered as evidence of response to bronchodilators, according to the American Thoracic Society-European Respiratory Society standard criteria \[Pellegrino et al. Eur Respir J 2005; 26: 948-968\]. They were calculated as follows: \[FEV1, expressed in liters (L), after bronchodilators - FEV1 (L) before bronchodilators/FEV1 (L) before bronchodilators x 100\].
Absolute Change of Forced Expiratory Volume in 1 Second (FEV1) After Bronchodilators	Baseline and 90 min after bronchodilators	Following albuterol plus tiotropium inhalation, FEV1 increments ≥0.20 liters (L) as compared to baseline, in an individual subject, were considered as evidence of response to bronchodilators, according to the American Thoracic Society-European Respiratory Society standard criteria \[Pellegrino et al. Eur Respir J 2005; 26: 948-968\]. They were calculated as follows: \[FEV1 (L) after bronchodilators - FEV1 (L) before bronchodilators\].
Per Cent Change of Forced Vital Capacity (FVC) After Bronchodilators	Baseline and 90 min after bronchodilators	Following albuterol plus tiotropium inhalation, FVC increments ≥12 per cent as compared to baseline, in an individual subject, were considered as evidence of response to bronchodilators, according to the American Thoracic Society-European Respiratory Society standard criteria \[Pellegrino et al. Eur Respir J 2005; 26: 948-968\]. They were calculated as follows: \[FVC, expressed in liters (L), after bronchodilators - FVC (L) before bronchodilators/FVC (L) before bronchodilators x 100\].
Absolute Change of Forced Vital Capacity (FVC) After Bronchodilators	Baseline and 90 min after bronchodilators	Following albuterol plus tiotropium inhalation, FVC increments ≥0.20 liters (L) compared with baseline, in an individual subject, were considered as evidence of response to bronchodilators, according to the American Thoracic Society-European Respiratory Society standard criteria \[Pellegrino et al. Eur Respir J 2005; 26: 948-968\]. They were calculated as follows: \[FVC (L) after bronchodilators - FVC (L) before bronchodilators\].
Per Cent Change of Instantaneous Maximal Forced Expiratory Flow (V'Max) After Bronchodilators	Baseline and 90 min after bronchodilators	Following albuterol plus tiotropium inhalation, V'max increments ≥40 per cent as compared to baseline, in an individual subject, were considered as evidence of response to bronchodilators, according to Pellegrino et al. \[Chest 1998; 114:1607-1612\]. They were calculated as follows: \[V'max, expressed in liters.second-1 (L.s-1), after bronchodilators - V'max (L.s-1) before bronchodilators/V'max (L.s-1) before bronchodilators x 100\].
Per Cent Change of Partial Forced Expiratory Flow (V'Part) After Bronchodilators	Baseline and 90 min after bronchodilators	Following albuterol plus tiotropium inhalation, V'part increments ≥40 per cent as compared to baseline, in an individual subject, were considered as evidence of response to bronchodilators, according to Pellegrino et al. \[Chest 1998; 114:1607-1612\]. They were calculated as follows: \[V'part, expressed in liters.second-1 (L.s-1), after bronchodilators - V'part (L.s-1) before bronchodilators/V'part (L.s-1) before bronchodilators x 100\].
Per Cent Change of Residual Volume (RV) After Bronchodilators	Baseline and 90 min after bronchodilators	Following albuterol plus tiotropium inhalation, RV decrements ≥10 per cent as compared to baseline, in an individual subject, were considered as evidence of response to bronchodilators, according to O'Donnell et al. \[Eur Respir J 2001; 18: 914-920\]. They were calculated as follows: \[RV, expressed in liters (L), before bronchodilators - RV (L) after bronchodilators/RV (L) after bronchodilators x 100\].
Absolute Change of Residual Volume (RV) After Bronchodilators	Baseline and 90 min after bronchodilators	Following albuterol plus tiotropium inhalation, RV decrements ≥0.30 liters (L) as compared to baseline, in an individual subject, were considered as evidence of response to bronchodilators, according to O'Donnell et al. \[Eur Respir J 2001; 18: 914-920\]. They were calculated as follows: \[RV (L), before bronchodilators - RV (L) after bronchodilators\].
Per Cent Change of Functional Residual Capacity (FRC) After Bronchodilators	Baseline and 90 min after bronchodilators	Following albuterol plus tiotropium inhalation, FRC decrements ≥10 per cent as compared to baseline, in an individual subject, were considered as evidence of response to bronchodilators, according to O'Donnell et al. \[Eur Respir J 2001; 18: 914-920\]. They were calculated as follows: \[FRC, expressed in liters (L), before bronchodilators - FRC (L) after bronchodilators/FRC (L) after bronchodilators x 100\].
Absolute Change of Functional Residual Capacity (FRC) After Bronchodilators	Baseline and 90 min after bronchodilators	Following albuterol plus tiotropium inhalation, FRC decrements ≥0.30 liters (L) as compared to baseline, in an individual subject, were considered as evidence of response to bronchodilators, according to O'Donnell et al. \[Eur Respir J 2001; 18: 914-920\]. They were calculated as follows: \[FRC (L), before bronchodilators - FRC (L) after bronchodilators\].

Countries

Italy

Participant flow

Recruitment details

Between April 2010 and May 2010, seventeen consecutive bronchiolitis obliterans (BOS) patients following hematopoietic stem cell transplantation (HSCT) were studied.

Pre-assignment details

In all patients, airflow obstruction was found at spirometry between 14 and 72 months (median, 41 months) after HSCT. The diagnosis of BOS was confirmed by fulfilment of currently updated criteria \[Filipovich AH et al. Biol Blood Marrow Transplant 2005; 11:945-956\]\[Chien JW et al. Biol Blood Marrow Transplant 2010; 16:S106-S114\].

Participants by arm

Arm	Count
Albuterol Plus Tiotropium At visit 1, lung function measurements will be performed in triplicate before and 90 min after inhaling four separate doses of 100 μg of albuterol (Ventolin®) and soon after 18 μg of tiotropium bromide \[Spiriva®\] to ensure maximal or near-maximal bronchodilation. Albuterol will be given by a metered-dose inhaler connected to a valved-holding chamber (Volumatic®) and tiotropium by a dry-powder device (Handihaler®).	17
Total	17

Arm

Count

Albuterol Plus Tiotropium

At visit 1, lung function measurements will be performed in triplicate before and 90 min after inhaling four separate doses of 100 μg of albuterol (Ventolin®) and soon after 18 μg of tiotropium bromide \[Spiriva®\] to ensure maximal or near-maximal bronchodilation. Albuterol will be given by a metered-dose inhaler connected to a valved-holding chamber (Volumatic®) and tiotropium by a dry-powder device (Handihaler®).

17

Total

17

Baseline characteristics

Characteristic	Albuterol Plus Tiotropium
Age, Categorical <=18 years	0 Participants
Age, Categorical >=65 years	0 Participants
Age, Categorical Between 18 and 65 years	17 Participants
Age Continuous	48 years STANDARD_DEVIATION 12
Region of Enrollment Italy	17 participants
Sex: Female, Male Female	5 Participants
Sex: Female, Male Male	12 Participants

Adverse events

Event type	EG000 affected / at risk
deaths Total, all-cause mortality	— / —
other Total, other adverse events	0 / 17
serious Total, serious adverse events	0 / 17

Outcome results

Primary

Absolute Change of Forced Expiratory Volume in 1 Second (FEV1) After Bronchodilators

Following albuterol plus tiotropium inhalation, FEV1 increments ≥0.20 liters (L) as compared to baseline, in an individual subject, were considered as evidence of response to bronchodilators, according to the American Thoracic Society-European Respiratory Society standard criteria \[Pellegrino et al. Eur Respir J 2005; 26: 948-968\]. They were calculated as follows: \[FEV1 (L) after bronchodilators - FEV1 (L) before bronchodilators\].