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Miguel Ángel Martínez-García, MD
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From Pneumology Service, La Fe University Hospital.

Correspondence to: Miguel Ángel Martínez-García, MD, Pneumology Service, La Fe University Hospital, Bulevar Sur, 46006, Valencia, Spain; e-mail: miangel@comv.es


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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


© 2012 American College of Chest Physicians


Chest. 2012;141(3):825-826. doi:10.1378/chest.11-2218
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To the Editor:

I would like to thank Dr Stirling for his interest in and comments on our recent article in CHEST1 on the efficacy and safety of budesonide-formoterol in the management of non-cystic fibrosis bronchiectasis. In my opinion, the scenario we are currently facing in non-cystic fibrosis bronchiectasis is one of an inflammatory disease of the airways of growing epidemiologic importance with an inflammatory profile similar to that observed in COPD, albeit with a more substantial presence of bronchial infection, but also one in which only minimal scientific evidence is available. This means that in many cases, patients with bronchiectasis and chronic airflow obstruction are treated as patients with COPD or asthma and, therefore, receive therapies such as long-action β2 adrenergic plus inhaled corticosteroids (ICs), although there are no studies to support (or rule out) this clinical practice.2

The limited literature to date suggests a small improvement in some clinical parameters with the use of ICs in some patients with bronchiectasis but, as Dr Stirling comments this is effectively accompanied by an increase in the number of local side effects because the relative resistance of neutrophilic inflammation to corticosteroids makes it necessary to use high doses.3,4 With the limited evidence available, however, it is not possible to confirm any significant increase in serious adverse effects such as pneumonia or exacerbations in patients with bronchiectasis. In any case, we completely agree with Dr Stirling that primary therapy in bronchiectasis should be addressed to treating chronic bronchial infection, although it is true that, even after intensive antibiotic treatment, many patients continue to present symptomatic airway obstruction and need antiinflammatory and bronchodilator therapy and, in such cases, combined inhaled therapy may be effective. Therefore, the study, which can only be considered a pilot study, as noted in the “Discussion” section in the article, aimed to increase the scientific evidence in the literature for a common therapeutic practice in patients with bronchiectasis, while assessing, to my knowledge for the first time in the literature, whether long-action β2 adrenergic therapy can reduce the high IC doses customarily used and, thus, reduce their adverse effects. I agree with Dr Stirling that in patients with bronchiectasis in which bronchial infection is a cornerstone, treatment with high doses of ICs could be harmful, and individualized treatment with close monitoring for adverse affects should be applied.

Really, however, this study1 sought not only to assess the efficacy of this treatment but also to make the scientific community aware of the current imbalance between the growing importance of bronchiectasis and the limited scientific evidence available. I hope that similar studies increase the scientific and commercial interest in this disease and trigger the multicenter clinical trials that Dr Stirling have called for in order to respond to the basic questions we face every day regarding patients with bronchiectasis. Until this happens, bronchiectasis, although no longer neglected as an epidemiologic disease, will remain on the dark side of science.

Martínez-García MA, Soler-Cataluña JJ, Catalán-Serra P, Román-Sánchez P, Perpiñá-Tordera M. Clinical efficacy and safety of budesonide-formoterol in non-cystic fibrosis bronchiectasis. Chest. 2012;1412:461-468. [PubMed] [CrossRef]
 
Pasteur MC, Bilton D, Hill AT. British Thoracic Society Bronchiectasis non-CF Guideline Group British Thoracic Society Bronchiectasis non-CF Guideline Group British Thoracic Society guideline for non-CF bronchiectasis. Thorax. 2010;65suppl 1:i1-i58. [PubMed]
 
Tsang KW, Tan KC, Ho PL, et al. Inhaled fluticasone in bronchiectasis: a 12 month study. Thorax. 2005;603:239-243. [PubMed]
 
Martínez-García MA, Perpiñá-Tordera M, Román-Sánchez P, Soler-Cataluña JJ. Inhaled steroids improve quality of life in patients with steady-state bronchiectasis. Respir Med. 2006;1009:1623-1632. [PubMed]
 

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References

Martínez-García MA, Soler-Cataluña JJ, Catalán-Serra P, Román-Sánchez P, Perpiñá-Tordera M. Clinical efficacy and safety of budesonide-formoterol in non-cystic fibrosis bronchiectasis. Chest. 2012;1412:461-468. [PubMed] [CrossRef]
 
Pasteur MC, Bilton D, Hill AT. British Thoracic Society Bronchiectasis non-CF Guideline Group British Thoracic Society Bronchiectasis non-CF Guideline Group British Thoracic Society guideline for non-CF bronchiectasis. Thorax. 2010;65suppl 1:i1-i58. [PubMed]
 
Tsang KW, Tan KC, Ho PL, et al. Inhaled fluticasone in bronchiectasis: a 12 month study. Thorax. 2005;603:239-243. [PubMed]
 
Martínez-García MA, Perpiñá-Tordera M, Román-Sánchez P, Soler-Cataluña JJ. Inhaled steroids improve quality of life in patients with steady-state bronchiectasis. Respir Med. 2006;1009:1623-1632. [PubMed]
 
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