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Correction
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Ferguson and Cherniack,
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Before routine diagnostic testing is recommended, there should be some indication of how the results will alter management. Since the risk factors for chronic obstructive pulmonary disease (i.e., smoking or occupational exposure) should in any event be avoided, why perform this test routinely, adding to the cost without providing a comparable increase in benefit?
Robert Matz, M.D.
Mount Sinai Medical Center
New York, NY 10029
References
In 12 patients with asthma, the improvement in the forced expiratory volume in one second after the administration of two puffs of pirbuterol (400 µg) or albuterol (200 µg) was similar3. Double-blind comparisons of inhaled pirbuterol with placebo established that pirbuterol has a median duration of action of more than five hours4. In five crossover studies comparing the functional effects of inhaled albuterol and pirbuterol for four hours after the administration of each drug, 80.8 percent of patients were still responding to pirbuterol after four hours, whereas only 67.3 percent were responding to albuterol. The magnitude of the response at four hours was higher in the patients still responding to pirbuterol than in the patients still responding to albuterol4. These data indicate that pirbuterol has a duration of action that equals or exceeds that of albuterol.
Thierry C. Chinet, M.D.
University of Paris
92104 Boulogne, France
References
David Kinshuck, M.B., B.S., F.C.Ophth.
Tahira Malik, M.B., Ch.B.
Wolverhampton Eye Infirmary
Wolverhampton WV3 9QR, United Kingdom
Norbert K. Mulleneisen, M.D.
Klinikum Leverkusen
51304 Leverkusen, Germany
References
To the Editor: We disagree with Dr. Matz. Clearly, avoidance of risk factors is important, yet many patients do not heed this warning. Early identification of chronic obstructive pulmonary disease with the use of spirometry may provide the added incentive for patients to avoid these risks, especially cigarette smoking. Because of the large reserve capacity of the lung, waiting for pulmonary symptoms delays diagnosis to a point at which serious lung damage is likely to be present. In a manner akin to the management of hypertension, regular spirometry can be used to diagnose acute airflow limitation and, with observation of trends (the rate of decline in the forced expiratory volume in one second), can be used to identify people with increased susceptibility to the disease. This approach should allow earlier diagnosis, lead to early intervention, and alter the long-term course. This is especially true of patients with hereditary predispositions, including alpha1-antitrypsin deficiency, in whom overt risk factors may not be evident and the diagnosis may be missed or delayed without screening spirometry. Furthermore, spirometry adds little to the cost of an evaluation, and plays an essential part in management once the disease is identified and treatment is initiated.
In response to Dr. Chinet, the information provided in Table 2 of our review was gleaned from a literature search and compiled from several reviews of the pharmacotherapy of chronic obstructive pulmonary disease, which typically do not include pirbuterol1; a recent pharmacologic review of pirbuterol2; and an original investigation of the pharmacology of inhaled pirbuterol3. We have tried not to emphasize the use of one beta-agonist over another, but we believe these references support the data in the table.
In response to Drs. Kinshuck and Malik, we agree that pulmonary medications can affect the eye. Although they may be uncommon, it is important to be aware of the potential side effects of any medication.
Finally, Dr. Mulleneisen is correct. In converting microgs to milligrams, we dropped a zero; the correct dose of ipratropium is 18 µg, or 0.018 mg, per puff.
Gary T. Ferguson, M.D.
Reuben M. Cherniack, M.D.
National Jewish Center for Immunology and Respiratory Medicine
Denver, CO 80206
References
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