3 e-Letters

  • Airway clearance adjuncts in COPD

    We thank the authors for their interest in our paper (1) which was designed, among other things, to be a statement of intent regarding the need to improve the evidence base concerning the use of adjunct devices for sputum clearance in patients with COPD.
    The authors reiterate some limitations of the data that we had outlined in our paper. In particular we are not able, using prescribing data, to capture other pathways through which patients may have obtained devices, including purchasing them from pharmacies. Direct patient surveys would address this as might company or pharmacy data on sales, if available. We did however present data on actual use of devices, reported by survey respondents, who were mostly in hospital practice, in the preceding year (Table 3). This confirms that use of devices for COPD patients was at an extremely low level and does not support the idea that a large amount of in hospital prescribing, not captured by prescription data, has been missed. We agree that some of the huge disparity with the use of mucolytic agents may reflect overuse of those medications. Nevertheless, the central point, that current extremely limited use of these devices in COPD patients seems at odds with the likely prevalence of patient phenotypes which are believed to benefit, stands.
    At present, this subject is largely ignored in clinical guidelines (2,3). Attention will be needed to address the limited evidence base and so feed into clinical guidelines and cli...

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  • Airway clearance technique prescription in COPD: unmet need or unclear data?

    It was interesting to review the findings of the study by Barker and colleagues [1] regarding airway clearance techniques (ACTs) for patients with chronic obstructive pulmonary disease (COPD). The authors suggest there may be a relative ‘under-prescription’ of simple adjunctive therapy options such as oscillatory positive expiratory pressure (OPEP) devices for the care of this patient group and reflect on the ability for ‘actual use’ registry data to inform research questions in this area. The data certainly show OPEP devices to be used less frequently and at significantly lower costs than prescription medications such as Tiotropium and Carbocisteine. This is not surprising, and is a likely accurate reflection of clinical practice.

    Identification of the most important clinical question(s) to arise from this data, however, appears quite challenging owing to significant limitations that may have been under-emphasised. The true incidence of OPEP device use amongst patients with COPD will certainly have been underestimated in the data obtained from the OpenPrescribing.net resource due to the ‘hidden’ market related to private or hospital-based device purchases. While this is acknowledged by the authorship team, we feel this may be more significant than that proposed. Our experience as clinical physiotherapists working in this area suggests a large proportion (if not the majority) of airway clearance therapy is the remit of physiotherapists working in cardiorespiratory...

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  • Cromoglicate at step 4
    Brian J Lipworth

    The excellent review by Slater et al comprehensively covers options for add on therapy to inhaled steroid at step 4 in patients with suboptimal asthma control .However no mention was made of the possible role for inhaled cromoglicate . This is a drug which appears to fallen out of favour and hardly gets a mention in guidelines . This is perhaps surprising given its excellent therapeutic index especially in children1 . We...

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