Week 40 – TORCH

“Salmeterol and Fluticasone Propionate and Survival in Chronic Obstructive Pulmonary Disease”

by the Towards a Revolution in COPD Health (TORCH) investigators

N Engl J Med. 2007 Feb 22;356(8):775-89. [free full text]

When the TORCH study was published in 2007, no prospective study to date had demonstrated a mortality benefit of inhaled corticosteroids (ICS) in COPD. Pulmonary inflammation occurs in COPD, and it had been hypothesized that ICS would improve COPD in multiple measures. Previously, ICS had been shown to reduce the frequency of COPD exacerbations, and retrospective data suggested that ICS reduced mortality, particularly when used in combination with a long-acting beta-agonist (LABA). TORCH was designed to evaluate prospectively the potential mortality benefit of combined ICS/LABA vs. ICS vs. LABA vs. placebo.

Population: COPD patients age 40-80, current or former smokers with ≥ 10-pack-year smoking hx, FEV1 < 60% predicted value and increase in FEV1 < 10% with albuterol administration, and prebronchodilator FEV1/FVC ratio of ≤ 70%

Intervention: combination salmeterol 50 µg and fluticasone propionate 500 µg BID


  1. placebo BID
  2. salmeterol 50 µg BID
  3. fluticasone 500 µg BID

Note: all patients underwent a two-week run-in period during which the use of all corticosteroids and long-acting bronchodilators was stopped. Other classes COPD medications were allowed throughout the study.

Primary – time to all-cause mortality by 3 years, per log-rank test


  • time to all-cause mortality, per Cox proportional hazards model
  • time to all-cause mortality, per log-rank test stratified by smoking status and country of residency
  • frequency of COPD exacerbations
  • quality of life per the St. George’s Respiratory Questionnaire
  • lung function, per postbronchodilator spirometry
  • incidence of pneumonia


6184 patients were randomized, but only 6112 were included in the final analyses (several sites excluded for not adhering to quality standards). The four groups were similar in all baseline characteristics (see Table 1).

All-cause mortality at 3 years was 12.6% in the combination-therapy group, 15.2% in the placebo group, 13.5% in the salmeterol group, and 16.0% in the fluticasone group. The hazard ratio for the comparison between combination-therapy and placebo was 0.825 (95% CI 0.681–1.002, p = 0.052, per log-rank test). See Figure 2B. This comparison was repeated in a pre-specified secondary analysis, using the Cox proportional hazards model, which yielded a HR of 0.811 (95% CI 0.670-0.982, p = 0.03), and in another pre-specified secondary analysis, using the log-rank test stratified according to smoking status and country of residency, which yielded a HR of 0.815 (95% CI 0.673-0.987, p = 0.04). In the primary analysis, the mortality risk did not differ among the salmeterol or fluticasone groups relative to the placebo group (see Table 2). Mortality risk in the combination-therapy group was less than that of the fluticasone group (HR 0.774, 95% CI 0.641-0.934, p = 0.007).

COPD exacerbations occurred at an annual rate of 0.85 in the combination therapy group and 1.13 in the placebo group, thus the rate ratio for exacerbations was 0.75 (95% CI 0.69-0.81, p < 0.001, NNT = 4). Exacerbation rates were also lower in the salmeterol and fluticasone groups (see Table 2).

The adjusted mean quality of life score per the St. George’s Respiratory Questionnaire improved in the combination-therapy, salmeterol, and fluticasone groups, and worsened slightly in the placebo group (see Table 3). All groups initially demonstrated an improvement in quality of life. In pairwise comparisons, combination therapy was superior to placebo, salmeterol, and fluticasone (p ranging from < 0.001 to 0.02).

Mean postbronchodilator FEV1 averaged over 3 years improved in the combination therapy group and decreased in the other groups. In all groups, the overall trend was a decrease in FEV1 following an initial improvement (see Figure 2E). In pairwise comparisons, combination therapy was superior to the other groups with respect to change in FEV1 (see Table 3).

The incidence of pneumonia was increased in groups receiving an ICS. The probability of developing pneumonia within the 3 year period was 19.6% in the combination-therapy group, 12.3% in the placebo group, 13.3% in the salmeterol group, and 18.3% in the fluticasone group (p < 0.001 for comparison between both combination-therapy versus placebo and fluticasone versus placebo).

44% of patients in the placebo group withdrew from the study. Only 34% of the combination-therapy group withdrew.

In this large, international, double-blind, placebo-controlled, randomized, parallel-group trial of patients with COPD, combination therapy with ICS/LABA did not improve mortality when compared to a placebo. However, combination therapy improved the frequency of COPD exacerbations, improved quality of life, and slowed the decline in FEV1 relative to placebo.

It is notable that, according to this study’s pre-specified secondary analyses of mortality per Cox proportional hazards and log-rank test stratified by smoking status and location, there was a mortality benefit of combination therapy.

The authors suspect that there is indeed a mortality benefit, but that the trial was underpowered to detect it. Furthermore, the higher rate of treatment-group withdrawal among placebo patients may have biased the study toward a null result, given the intention-to-treat analysis.

In the years since TORCH, meta-analyses that included TORCH have concluded that ICS therapy in COPD slows the rate of decline in FEV1 and decreases the rate of COPD exacerbations when compared with placebo, but it does not reduce mortality.

Today, inhaled corticosteroids remain an integral component of our management of moderate to very severe COPD. See the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Pocket Guide to COPD Diagnosis, Management, and Prevention (2017) pages 14-16.

Further Reading/References
1. Wiki Journal Club
2. 2 Minute Medicine
3. UpToDate “Role of inhaled glucocorticoid therapy in stable COPD”
4. “Inhaled corticosteroids for stable chronic obstructive pulmonary disease.” Cochrane Database Syst Rev (2012).
5. Global Initiative for Chronic Obstructive Lung Disease (GOLD) Pocket Guide to COPD Diagnosis, Management, and Prevention (2017)

Summary by Duncan F. Moore, MD

Week 27 – UPLIFT

“A 4-Year Trial of Tiotropium in Chronic Obstructive Pulmonary Disease”

by the Understanding Potential Impacts on Function with Tiotropium (UPLIFT) investigators

N Engl J Med. 2008 October 9; 359(15):1543-1554 [free full text]

The 2008 UPLIFT trial was a four-year, randomized, double-blind, prospective study investigating whether or not tiotropium could reduce the rate of decline of FEV1 (a common metric for COPD progression).  A previous retrospective study had shown a reduced rate of FEV1 decline at one year with daily tiotropium. However, this finding had not been shown in any prospective study. As of 2008, smoking cessation was the only intervention demonstrated prospectively to decrease the rate of decline in FEV1.

Population:  Patients were selected from 490 investigational centers in 37 countries

Inclusion: COPD, age ≥ 40, ≥ 10 pack-year smoking history, post-bronchodilator FEV1 ≤70% of predicted value, and FEV1/FVC ≤70%

Exclusion: history of asthma, COPD exacerbation or respiratory infection within the past 4 weeks, history of pulmonary resection, or use of supplemental O2 for more than 12 hours per day

Intervention: daily tiotropium 18mcg + usual respiratory medications

Control: daily placebo + usual respiratory medications

(Of note, in both arms, the usual respiratory medications could not include an anticholinergic.)



  • Rate of decline in mean FEV1 before bronchodilation
  • Rate of decline in mean FEV1 after bronchodilation


  • Rate of decline in FVC
  • Quality of life as measured by St. George’s Respiratory Questionnaire (SGRQ, ranges 0-100 with lower scores indicating improved quality)
  • Rate of COPD exacerbations
  • All-cause mortality

2987 patients were assigned to receive tiotropium, and 3006 were assigned to receive placebo. Baseline characteristics were similar between the two groups. 44.6% of placebo and 36.2% of tiotropium patients did not complete at least 45 months of treatment.

The primary outcomes of decline in mean FEV1 either before or after bronchodilation were not significantly different between the two groups. Before bronchodilation, the difference in mean decline was 0 ml/year (p=0.95). After bronchodilation, the mean decline with tiotropium was 2 ml/year less than with placebo (p=0.21)

Regarding secondary outcomes:
There was no significant difference in rate of decline of FVC. The SGRQ was significantly lower (better) at all time points in the tiotropium group and, on average, was 2.7 points lower than in the placebo group (95% CI 2.0-3.3, p<0.001). The number of COPD exacerbations per year in the tiotropium group was 0.73 vs. 0.85 in the placebo group (RR 0.86, 95% CI 0.81-0.91; p<0.001), and the median time to first exacerbation was longer in the tiotropium group (16.7 months vs. 12.5 months, 95% CI 11.5-13.8,). All-cause mortality was not significantly different among the two groups (14.9% vs. 16.5%, HR 0.89; 95% CI 0.79-1.02; p=0.09). Respiratory failure developed in 88 patients in the tiotropium group vs. 120 in the placebo group (RR 0.67, 95% CI 0.51 to 0.89).

The UPLIFT study demonstrated no significant change in rate of decline in FEV1 with tiotropium therapy compared to placebo. However, tiotropium therapy improved quality of life and reduced the frequency of COPD exacerbations and respiratory failure. Overall, this study is an excellent example how a well-designed prospective study can overturn the results of prior retrospective analyses.

The authors offered three potential reasons for the lack of difference in rate of FEV1 decline among the groups. First, tiotropium may not actually alter the decline of lung function in COPD. Second, since both groups were permitted any respiratory medications other than another anticholinergic, there may have been a “ceiling effect” reached by the alternative medications, and thus no additional benefit offered by tiotropium therapy. Third, the authors noted the placebo group dropouts tended to be have more severe COPD, and so the remaining “healthy survivor” patients may have biased the group differences toward a null result.

Limitations of this study include a high dropout rate in both groups as well as a large male predominance (~75%) that limits generalizability. Finally, the limited clinical benefits of daily tiotropium use are not likely to be cost-effective. In 2010, researchers applied the treatment effects demonstrated in UPLIFT to an observational dataset of 56,321 tiotropium users in Belgium and estimated an average cost of 1.2 million euros per quality-adjusted life year (QALY) gained.

Further Reading/References:
1. Wiki Journal Club
2. 2 Minute Medicine
3. Neyt et al., “Tiotropium’s cost-effectiveness for the treatment of COPD: a cost-utility analysis under real-world conditions” (2010)

Summary by Gordon Pelegrin, MD

Week 17 – PROSEVA

“Prone Positioning in Severe Acute Respiratory Distress Syndrome”

by the PROSEVA Study Group

N Engl J Med. 2013 June 6; 368(23):2159-2168 [free full text]

Prone positioning had been used for many years in ICU patients with ARDS in order to improve oxygenation. Per Dr. Sonti’s Georgetown Critical Care Top 40, the physiologic basis for benefit with proning lies in the idea that atelectatic regions of lung typically occur in the most dependent portion of an ARDS patient, with hyperinflation affecting the remaining lung. Periodic reversal of these regions via moving the patient from supine to prone and vice versa ensures no one region of the lung will have extended exposure to either atelectasis or overdistention. Although the oxygenation benefits have been long noted, the PROSEVA trial established mortality benefit.

Population:  Patients were selected from 26 ICUs in France and 1 in Spain which had daily practice with prone positioning for at least 5 years.

Inclusion: ARDS patients intubated and ventilated <36hr with severe ARDS (defined as PaO2:FiO2 ratio <150, PEEP>5, and TV of about 6ml/kg of predicted body weight)

(NB: by the Berlin definition for ARDS, severe ARDS is defined as PaO2:FiO2 ratio <100)

Intervention: Proning patients within 36 hours of mechanical ventilation for at least 16 consecutive hours (N=237)

Control: Leaving patients in a semirecumbent (supine) position (N=229)


Primary: mortality at day 28

Secondary: mortality at day 90, rate of successful (no reintubation or use of noninvasive ventilation x48hr) extubation, time to successful extubation, length of stay in the ICU, complications, use of noninvasive ventilation, tracheotomy rate, number of days free from organ dysfunction, ventilator settings, measurements of ABG, and respiratory system mechanics during the first week after randomization

At the time of randomization in the study, the majority of characteristics were similar between the two groups, although the authors noted differences in the SOFA score and the use of neuromuscular blockers and vasopressors. The supine group at baseline had a higher SOFA score indicating more severe organ failure, and also had higher rate of vasopressor usage. The prone group had a higher rate of usage of neuromuscular blockade.

The primary outcome of 28 day mortality was significantly lower in the prone group than in the supine group, at 16.0% vs 32.8% (P<0.001, NNT = 6.0). This mortality decrease was still statistically significant when adjusted for the SOFA score.

Secondary outcomes were notable for a significantly higher rate of successful extubation in the prone group (hazard ratio 0.45; 95% CI 0.29-0.7, P<0.001). Additionally, the PaO2:FiO2 ratio was significantly higher in the supine group, whereas the PEEP and FiO2 were significantly lower. The remainder of secondary outcomes were statistically similar.

PROSEVA showed a significant mortality benefit with early use of prone positioning in severe ARDS. This mortality benefit was considerably larger than seen in past meta-analyses, which was likely due to this study selecting specifically for patients with severe disease as well as specifying longer prone-positioning sessions than employed in prior studies. Critics have noted the unexpected difference in baseline characteristics between the two arms of the study. While these critiques are reasonable, the authors mitigate at least some of these complaints by adjusting the mortality for the statistically significant differences. With such a radical mortality benefit it might be surprising that more patients are not proned at our institution. One reason is that relatively few of our patients have severe ARDS. Additionally, proning places a high demand on resources and requires a coordinated effort of multiple staff. All treatment centers in this study had specially-trained staff that had been performing proning on a daily basis for at least 5 years, and thus were very familiar with the process. With this in mind, we consider the use of proning in patients meeting criteria for severe ARDS.

References and further reading:
1. 2 Minute Medicine
2. Wiki Journal Club
3. Georgetown Critical Care Top 40, pages 8-9
4. Life in the Fastlane, Critical Care Compendium, “Prone Position and Mechanical Ventilation”
5. PulmCCM.org, “ICU Physiology in 1000 Words: The Hemodynamics of Prone”

Summary by Gordon Pelegrin, MD

Week 14 – ARDSNet aka ARMA

“Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome”

by the Acute Respiratory Distress Syndrome Network (ARDSNet)

N Engl J Med. 2000 May 4;342(18):1301-8. [free full text]

Acute respiratory distress syndrome (ARDS) is an inflammatory and highly morbid lung injury found in many critically ill patients. In the 1990s, it was hypothesized that overdistention of aerated lung volumes and elevated airway pressures might contribute to the severity of ARDS, and indeed some work in animal models supported this theory. Prior to the ARDSNet study, four randomized trials had been conducted investigating the possible protective effect of ventilation with lower tidal volumes, but their results were conflicting.

Population: patients with ARDS diagnosed within < 36 hrs
Intervention: initial tidal volume 6 ml/kg predicted body weight, downtitrated as necessary to maintain plateau pressure ≤ 30 cm of water
Comparison: initial tidal volume 12 ml/kg predicted body weight, downtitrated as necessary to maintain plateau pressure ≤ 50 cm of water


1) in-hospital mortality
2) ventilator-free days within the first 28 days

1) number of days without organ failure
2) occurrence of barotrauma
3) reduction in IL-6 concentration from day 0 to day 3


861 patients were randomized before the trial was stopped early due to the increased mortality in the control arm noted during interim analysis. In-hospital mortality was 31.0% in the lower tidal volume group and 39.8% in the traditional tidal volume group (p = 0.007, NNT = 11.4). Ventilator free days were 12±11 in the lower tidal volume group vs. 10±11 in the traditional group (n = 0.007). The lower tidal volume group had more days without organ failure (15±11 vs. 12±11, p = 0.006). There was no difference in rates of barotrauma among the two groups. IL-6 concentration decrease between days 0 and 3 was greater in the low tidal volume group (p < 0.001), and IL-6 concentration at day 3 was lower in the low tidal volume group (p = 0.002).

Low tidal volume ventilation decreases mortality in ARDS relative to “traditional” tidal volumes.

The authors felt that this study confirmed the results of prior animal models and conclusively answered the question of whether or not low tidal volume ventilation provided a mortality benefit. In fact, in the years following, low tidal volume ventilation became the standard of care, and a robust body of literature followed this study to further delineate a “lung protective strategy.”

Critics of the study noted that at the time of the study the standard of care/“traditional” tidal volume in ARDS was less than the 12 ml/kg used in the comparison arm. (Non-enrolled patients at the participating centers were receiving a mean tidal volume of 10.3 ml/kg.) Thus not only was the trial making a comparison to a faulty control, but it was also potentially harming patients in the control arm. Here is an excellent summary of the ethical issues and debate regarding this specific issue and regarding control arms of RCTs in general.

Corresponding practice point from Dr. Sonti and Dr. Vinayak and their Georgetown Critical Care Top 40: “Low tidal volume ventilation is the standard of care in patients with ARDS (P/F < 300). Use ≤ 6 ml/kg predicted body weight, follow plateau pressures, and be cautious of mixed modes in which you set a tidal volume but the ventilator can adjust and choose a larger one.”

PulmCCM is an excellent blog, and they have a nice page reviewing this topic and summarizing some of the research and guidelines that have followed.

Further Reading/References:
1. Wiki Journal Club
2. 2 Minute Medicine
3. PulmCCM “Mechanical Ventilation in ARDS: Research Update”
4. Georgetown Critical Care Top 40, page 6

Summary by Duncan F. Moore, MD