A Randomized, Crossover, Placebo Controlled, Double-blind Trial of the Effect of STIOLTO™ RESPIMAT® on Central and Peripheral Components of Fatigue During Exercise in Chronic Obstructive Pulmonary Disease
Phase: PHASE4
Conditions: Chronic Obstructive Pulmonary Disease
Sponsor: Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center

Study Protocol and Statistical Analysis Plan 
 
Title: 
The Effect of STIOLTO™ RESPIMAT® on Fatigue in Chronic Obstructive Pulmonary 
Disease 
 
NCT Number: 
NCT02845752 
 
Document Date: 
November 13, 2015 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 1 of 31 
 
1) Protocol Title 
A randomized, crossover, placebo controlled, double-blind phase IV trial of the effect 
of STIOLTO™ RESPIMAT® on central and peripheral components of fatigue during 
exercise in chronic obstructive pulmonary disease 
 
2) HSC Review History 
Not applicable 
 
3) Investigators 
Richard Casaburi, Ph.D., M.D. Principal Investigator 
Harry B. Rossiter, Ph.D. Co-Investigator 
 
4) Objectives* 
Patients with chronic obstructive pulmonary disease (COPD) have reduced exercise 
tolerance. One mechanism for this is thought to be due to dynamic hyperinflation 
during exercise (an increase in the end-expiratory lung volume) that contributes to the 
sensation of breathlessness. Whether this also contributes to inhibiting motor 
recruitment, and reduces the available power output (termed performance fatigue; 
PF), is not well understood. Preliminary data from our lab suggests that many COPD 
patients, unlike healthy subjects, stop exercise with a ‘skeletal muscle power reserve’ 
i.e. the ability to acutely increase muscle power output, suggesting that they are 
limited by mechanisms other than acute intramuscular limitations to power 
production. Exercise tolerance is increased by treatment with the fixed-dose 
combination bronchodilator, STIOLTO™ RESPIMAT®.  We hypothesize that 
increased exercise tolerance with STIOLTO™ RESPIMAT® (reduced performance 
fatigue; PF) will be mediated by a combination of: 1) reduced inhibition of muscle 
activation (termed activation fatigue; AF) allowing patients to drive their leg muscles 
harder, and thus; 2) increased muscle fatigue (MF). 
 
Primary objective: To determine the magnitude of performance fatigue (PF), 
activation fatigue (AF), and muscle fatigue (MF) during and after exercise in COPD 
patients with STIOLTO™ RESPIMAT® treatment versus placebo. 
 
Secondary objective: To determine the association of dynamic hyperinflation with 
performance fatigue (PF), activation fatigue (AF), and muscle fatigue (MF) during 
and after constant power exercise to the limit of tolerance in COPD patients 
 
5) Background* 
Chronic obstructive pulmonary disease (COPD) is a major worldwide cause of 
disability and death, with an estimated prevalence of 210 million and with more than 
80 million of these being severe disease (World Health Organization). Recent data 
suggest that COPD is now the third leading cause of death in the USA (Miniño et al., 
2010). In addition, COPD is among the top five causes of adult disability, of which 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 2 of 31 
 
exercise intolerance consequent to dynamic hyperinflation is the main feature (Eisner 
et al., 2011; Casaburi & ZuWallack 2009).  
 
Twenty to forty percent of these patients will manifest muscle abnormality, which is 
strongly related to mortality (Schols et al., 2005). As such, skeletal muscle function in 
COPD is increasingly recognized as a contributing factor to exercise limitation, 
impaired health-related quality of life and as a major contributor to mortality in 
COPD (ATS/ERS 1999; Marquis et al., 2002). Peripheral muscle dysfunction in 
COPD is consequent to a wide range of structural and functional changes including a 
dramatic loss of lower limb muscle mass (25-30%), and a switch towards more 
fatigable, less aerobic, muscle fibers (opposite to that seen with healthy aging) 
(Schols et al., 1993; Augusti et al., 2001; Engelen et al., 2002; Marquis et al., 2002; 
Richardson et al., 2004; Seymor et al., 2009). These detrimental skeletal muscle 
adaptations in COPD are accompanied by reduced performance of activities of daily 
living, increased sense of fatigue, and loss of autonomy. Physical inactivity itself is 
directly causal to chronic diseases such as obesity, hypertension, and diabetes. 
Therefore, ameliorating these deficits is key to the maintenance of quality of life in 
COPD. 
 
The unknown causes of the decline in performance with exertion during whole-body 
activity - defined as performance fatigue (PF) - are a major barrier to developing 
effective strategies to overcome exercise limitations in COPD. PF is a highly 
regulated strategy conserving cellular integrity, function, and survival (McKenna & 
Hargreaves, 2008). Effective performance requires excitatory input to the motor 
cortex and motor neuron excitability, neuromuscular excitability and excitation-
contraction coupling, a functioning contractile mechanism, and appropriate responses 
in other physiological systems to support energy supply (Bainbridge, 1919; Bigland-
Richie, 1981). PF may, therefore, be conceptually divided into two components: one 
‘central’ arising entirely within the central nervous system (activation fatigue, AF: 
inhibition of voluntary muscle activation with exertion); and another ‘peripheral’ in 
which fatigue occurs in the muscles themselves (muscle fatigue, MF: the reduction in 
power production for a given muscle activation). 
 
In COPD patients, exertional dyspnea causes the avoidance of physical activity 
resulting in extreme deconditioning of the locomotor muscles; which is a major 
contributor to morbidity and mortality (Casaburi et al., 1999). Hence COPD patients 
show both increased MF (possibly from impaired gas exchange, muscle metabolism, 
and muscle oxygenation; Mador et al., 2000; Meyer et al., 2013), and increased AF 
(possibly from dynamic hyperinflation, dyspnea, cerebral deoxygenation, and/or 
respiratory muscle or pulmonary afferent signaling; Gagnon et al., 2012; Goodall et 
al., 2012). Differences in the magnitude of these effects may underlie the varied 
responsiveness to bronchodilation therapy in COPD (Saey et al., 2003). The degree to 
which these mechanisms influence independently the ‘central’ (AF) and ‘peripheral’ 
(MF) components of fatigue in during exercise in COPD is unknown. The answer is 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 3 of 31 
 
crucial for effective targeting of therapeutic strategies to ameliorate exercise 
intolerance in COPD. 
 
The purpose of the proposed study is to use a novel exercise testing protocol, 
designed and validated in our laboratories (Coelho et al., 2015), to determine the 
magnitude of PF, and its components (AF and MF) during and following whole body 
exercise in COPD. Bronchodilator treatment with the FDA-approved once-daily 
STIOLTO™ RESPIMAT® (tiotropium bromide and olodaterol hydrochloride) versus 
placebo will provide an intervention designed to acutely improve pulmonary function 
in COPD and reduce dynamic hyperinflation in the absence of changes to peripheral 
muscle metabolism and fatigue processes contributing to MF. Combined 
measurements of dynamic hyperinflation and muscle oxygenation dynamics will 
allow us to relate changes in PF, AF and MF following STIOLTO™ RESPIMAT® 
treatment to their putative physiological determinants. STIOLTO™ RESPIMAT® is 
a combination long-acting anticholinergic and beta2-adrenergic agonist that produces 
greater increases in forced expiratory flow in 1 second (FEV1) compared the two 
drugs individually in GOLD stage 2-4 COPD patients (Ferguson et al., 2015).  
 
This will be the first time that fatigue is measured during exercise in COPD with and 
without bronchodilator therapy. Previous studies have measured MF approximately 
10 minutes after exercise cessation (Saey et al., 2003). However, preliminary data 
from our lab in COPD (unpublished; LA BioMed Protocol 30044-01) show that PF 
and MF are recovered by 90% or more after 2 minutes of recovery from exercise; 
meaning that the important exercise-limiting signals need to be measured during the 
exercise task itself. These preliminary data (n=13) show that MF is a minor 
contributor to exercise in COPD (20%), and the predominant cause of fatigue in 
COPD is AF (80%) (unlike in healthy young subjects). This suggestion supports the 
hypothesis that exercise limitation in COPD may be related to dynamic hyperinflation 
rather than to intramuscular limitations of muscle power production (MF). 
 
Assessment of performance fatigue, activation fatigue and muscle fatigue  
Muscle force and power production are dependent on muscle contractile velocity. 
Therefore assessment of fatigue (the magnitude of reduction in muscle power during 
contractions) requires power to be measured at a known rate of muscle shortening i.e. 
isometric (constant length, no shortening) or isokinetic (constant velocity) 
contractions (e.g. Sargeant & Dolan, 1987).  
 
Shortening movements that produce power are highly relevant to the actions of daily 
living (Newham et al., 1991; Beelen & Sargeant, 1991). Standard isokinetic 
dynamometry, however, uses complex bulky machinery, complicating its application 
during whole-body activities such as treadmill walking or cycle ergometry. 
 
Isometric assessment of muscle force, such as by potentiated twitch force 
measurement using magnetic stimulation (Mador et al., 2000; Saey et al., 2003), 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 4 of 31 
 
allows changes in MF to be measured accurately and reliably. Twitch force 
measurements, however, can only be determined ~10 min after a whole-body exercise 
task (Mador et al., 2000). In healthy subjects, skeletal muscle recovers from fatigue 
with a half-time close to that of phosphocreatine resynthesis (about 30 s; Sargeant & 
Dolan, 1987; Elmer et al., 2013), whole-body exercise tolerance recovery half-time is 
about 4 min (Ferguson et al., 2010), and the half-time of recovery from supraspinal 
fatigue is about 5 min in young subjects, and prolonged in the elderly (Yoon et al., 
2012). Therefore, by 10 min post-exercise, many of the varied physiological 
processes that integrate to cause task failure during whole-body exercise have 
recovered (Mador et al., 2003; McKenna & Hargreaves, 2008). This questions the 
validity of using twitch force measurements after exercise cessation in COPD 
patients, to draw conclusions on muscle function and fatigue at the point of 
intolerance that occurred ~10 minutes earlier. 
 
We have provided a solution to this complexity, by instantaneously interleaving 
voluntary isokinetic torque measurements during standard, cadence-independent, 
cycle ergometry (Excalibur Sport PFM, Lode). We can establish peak isokinetic 
power (PISO) at any point in time before, during, or after cycle ergometry to 
intolerance to quantify PF (Cannon et al., 2011). Coupling this with measurement of 
muscle activity by surface electromyography (EMG) during interleaved maximal 
voluntary efforts, the dynamics of AF and MF can be determined (Ferguson et al., 
2013; Coelho et al., 2015; LA BioMed Protocol 30044-01). 
 
6) Setting of the Human Research 
Patient recruitment and testing will take place at the Rehabilitation Clinical Trials 
Center (RCTC; consisting of 4 principal investigators, and 11 research staff, 
postdoctoral researchers, study coordinators). The RCTC is housed within the 
Chronic Disease Clinical Research Center (CDCRC). The RCTC occupies 5 new 
laboratory spaces in the CDCRC, which encompass an exercise-training and 
functional testing laboratory, an exercise physiology laboratory, a fatigue laboratory, 
a special pulmonary function testing facility, and a near-infrared spectroscopy 
laboratory (totaling 1,000 sqft). We also have 2 examination rooms that are dedicated 
to the RCTC, and access to an additional shared examination rooms.  
 
7) Resources Available to Conduct the Human Research 
This study is financially supported by Boehringer-Ingelheim Pharmaceuticals Inc. as 
part of their Investigator Initiated Studies program. 
 
The Rehabilitation Clinical Trials Center at LA BioMed has a >15-year history in 
recruiting large numbers of COPD patients and healthy controls for multiple NIH and 
industry sponsored clinical trials and exercise studies. The RCTC commonly 
conducts large-scale COPD-related clinical trials, and as such there is potential access 
to several hundred subjects per year. Twenty-one COPD patient volunteers are 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 5 of 31 
 
needed for this study over an approximate 1-year period, which is a small fraction of 
this pool. Therefore we do not anticipate any problems with patient recruitment. 
Several investigators and staff will contribute to the study. All have extensive 
experience in working with COPD patients in physiologic exercise studies. The 
methods used in this study were developed at LA BioMed and the PI and Co-Is are 
world leaders in the field, and contribute to setting the guidelines for exercise testing 
in patient populations. All the equipment required for the study is in standard use in 
our lab. The Co-I (Rossiter) will devote 10% FTE to the study, with PI (Casaburi) 
contributing 2% FTE. Co-I (Porszasz) will contribute 5% FTE. There will also be 4 
participating physicians (Stringer, Chavoshan, Hsia, Kim). All investigators have MD 
and/or PhD degrees. Recruitment and regulatory compliance will be supported by 
contributions from study coordinators (Walker, Diaz). Physiological testing will be 
supported by post-doctoral scientists (Khamoui, Adami), and a clinical research 
associate in the RCTC lab (Cao). Staff members have been involved in a previous 
study using the same measurements (LA BioMed protocol 30044-01) and are well 
trained in their application. Our laboratory has routine staff meetings where the 
experimental protocols are continually reviewed and the roles of staff members 
clarified. 
 
No adverse events are anticipated. However, in the event of an adverse event, our lab 
is equipped with a crash cart and a licensed physician will be available during all 
initial exercise tests. In case of emergency the lab is located in the CDCRC Building 
on the Harbor-UCLA Medical Center (HUMC) campus, with excellent access to the 
emergency facilities. HUMC is a level 1 trauma center. Four of the investigators are 
HUMC physicians with full and unrestricted California medical licenses.  
 
8) Study Design 
a) Recruitment Methods 
Potential subjects for the study will be drawn from people known to Rehabilitation 
Clinical Trials Center who have previously participated in studies in our laboratory, 
attended clinics of Harbor-UCLA Medical Center or local patient support groups, and 
through a network of area pulmonologists.  Subjects will be contacted by phone to 
determine their initial interest and invited to the study site for a complete explanation 
of the protocol and consent. 
 
Subjects are reimbursed for their time and inconvenience in participating in this 
study. They will be informed of the following:  
“For your time and inconvenience related to your taking part in this study, you 
will be paid a total of $450 if you complete this study. If you do not complete the 
study, for any reason, you will be paid for the study visits you do complete 
according to the following schedule: $50 for visit 1; and $100 each for visits 2, 3, 
4, and 5.” 
 
 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 6 of 31 
 
b) Inclusion and Exclusion Criteria* 
 
 
Inclusion criteria 
1) All patients must have a diagnosis of chronic obstructive pulmonary disease and 
must meet the following criteria: (a) Patients must be in a stable state of their 
disease with no exacerbation within the previous 4 weeks; and (b) At visit 1 
spirometric must demonstrate a post-bronchodilator FEV1 <50% of predicted 
normal and a post-bronchodilator FEV1/FVC <70%. 
2) At visit 1, patients will demonstrate appreciable reversibility, defined as a 12% 
increase in FEV1 in response to albuterol administration. 
3) Baseline dyspnea index focal score ≤ 9. 
4) Male or female patients, between 45 and 90 years (inclusive) of age.  
5) Patients must be current or ex-smokers with a smoking history of more than 10 
pack-years  
6) Patients must be able to perform technically acceptable pulmonary function tests 
must be able to complete multiple symptom-limited cycle ergometry tests.  
7) Patients must be able to inhale medication in a competent manner from the 
inhalers used in the study.  
 
 
Exclusion criteria 
1) Patients with a significant disease other than COPD; a significant disease is 
defined as a disease which, in the opinion of the investigator, may (i) put the 
patient at risk because of participation in the study, (ii) influence the results of the 
study, or (iii) cause concern regarding the patient’s ability to participate in the 
study. 
2) Patients with a documented history of asthma. For patients with allergic rhinitis or 
atopy, medical records will be required to verify that the patient does not have 
asthma. 
3) Patients with any of the following conditions: 
a) A history of myocardial infarction within 1 year of screening visit. 
b) Unstable or life-threatening cardiac arrhythmia. 
c) Hospitalized for heart failure within the past year.  
d) Known active tuberculosis. 
e) A malignancy for which patient has undergone resection, radiation therapy or 
chemotherapy within last two years (patients with treated basal cell carcinoma 
are allowed). 
f) A history of life-threatening pulmonary obstruction within the past two years. 
g) A history of cystic fibrosis. 
h) Clinically evident bronchiectasis.  
i) A history of significant alcohol or drug abuse within the past two years. 
j) Any contraindications for exercise testing as outlined below (see 
contraindications to exercise). 
k) Patients who have undergone thoracotomy with pulmonary resection. 
4) Patients being treated with oral corticosteroid medication at unstable doses (i.e., 
less than six weeks on a stable dose) or at doses in excess of the equivalent of 10 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 7 of 31 
 
mg of prednisone per day or 20 mg every other day. 
5) Patients who regularly use daytime oxygen therapy for more than one hour per 
day and in the investigator’s opinion will be unable to abstain from the use of 
oxygen therapy during clinic visits. 
6) Patients who desaturate to SpO2 <85% on screening incremental exercise testing. 
7) Patients who have completed a pulmonary rehabilitation program in the six weeks 
prior to the screening visit or patients who are currently in a pulmonary 
rehabilitation program. 
8) Patients who have a limitation of exercise performance as a result of factors other 
than fatigue or exertional dyspnea, such as arthritis in the leg, angina pectoris or 
claudication or morbid obesity. 
9) Patients with a constant power cycle ergometry endurance time less than 4 or 
greater than 10 minutes after work rate adjustment procedures (described below).  
10) Patients who have taken an investigational drug within one month or six half-lives 
(whichever is greater) prior to screening visit (Visit 1). 
11) Pregnant or nursing women. 
12) Women of childbearing who have the potential not to be using a highly effective 
method of birth control. Female patients will be considered to be of childbearing 
potential unless surgically sterilized by hysterectomy or bilateral tubal ligation, or 
post-menopausal for at least two years.  
13) Patients who are currently participating in another interventional study.  
14) Patients who are unable to comply with pulmonary medication restrictions prior 
to randomization. 
 
All subjects will be screened for eligibility during visits 1 and 2.  Eligibility will be 
determined by medical history, physical examination, spirometry (visit 1) and 
exercise testing (visit 2).  Women with the potential for pregnancy will be tested 
using a urine-based testing kit. Eligibility will be determined according to the study 
inclusion and exclusion criteria 
 
c) Local Number of Subjects 
Twenty one patients are required to complete the research procedures. LA 
BioMed is the only study site. 
 
Based on experience we anticipate an approximate 15% screen failure rate from 
spirometry and a 15% screen failure rate following the screening exercise test. 
Therefore we anticipate screening approximately 28 patients to complete the 
research in 21 subjects. 
 
d) Study-Wide Number of Subjects* 
Not applicable. 
 
 
 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 8 of 31 
 
e) Study Timelines* 
Each patient will be enrolled for approximately 9 weeks. This is a randomized, 
crossover, placebo controlled, double-blind study that includes 5 laboratory visits 
and three periods of 2-week washout from drug or placebo. The timeline for each 
patient visit is shown in Figure 1. Visit 1 will be approximately 1 hour duration. 
Visit 2 will be approximately 4 hours duration. Visits 3, 4, and 5 will each be 
approximately 2 hours duration. 
 
Complete enrollment (n=21) is anticipated to take 12 months. We anticipate that 
the first-patient first-visit will be in January 2016, and completion of study visits 
by January 2017. Completion of primary analysis is anticipated by April 2017. 
 
 
 
Figure 1. Study Timeline. Post-consent study timeline, including study drug administration, 
crossover, and washout periods. Drug A or B refers to STIOLTO™ RESPIMAT® or 
placebo. The administration of these drugs will be double-blinded. *The study drug A or B that 
resulted in a longer endurance time will be given in the week prior to Visit 5. 
 
 
f) Study Endpoints* 
The study endpoint is completion of Visit 5. Patient safety will be monitored 
throughout, and the procedures stopped if a problem arises. There are no clinical 
or therapeutic endpoints. 
 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 9 of 31 
 
Safety endpoints include the ability to complete an exercise test safely, as judged 
by the investigator. Exercise tests will be stopped if clinically significant changes 
in the ECG occur, such as ST-segment depression, or a dangerous arrhythmia. 
 
Adverse events (AE) and serious adverse events (SAE) are safety endpoints of the 
study. An AE is defined as any untoward medical occurrence, including an 
exacerbation of a pre-existing condition, in a patient who received a 
pharmaceutical product. The event does not necessarily have to have a causal 
relationship with this treatment. An SAE is defined as any AE which results in 
death, is immediately life-threatening, results in persistent or significant disability 
/ incapacity, requires or prolongs patient hospitalization, or is to be deemed 
serious for any other reason if it is an important medical event when based upon 
appropriate medical judgment which may jeopardize the patient and may require 
medical or surgical intervention to prevent one of the other outcomes listed in the 
above definitions. Medical judgment will be used to determine the relationship 
between study drug or procedures and an (S)AE, considering all relevant factors, 
including pattern of reaction, temporal relationship, de-challenge or re-challenge, 
confounding factors such as concomitant medication, concomitant diseases and 
relevant history. 
 
Changes in vital signs, ECG, physical examination and laboratory test results will 
be recorded as an (S)AE, if they are judged clinically relevant by the investigator. 
Vital signs, ECG, and physiological test results are recorded as part of 
cardiopulmonary exercise testing at each visit. These may cause exclusion of the 
patient from the study at any time, should they meet the exclusion criteria listed. 
 
g) Procedures Involved in the Human Research* 
All study procedures are done solely for the purposes of research. 
 
Study design 
This will be a randomized, placebo controlled, double-blind study investigating 
the effects of STIOLTO™ RESPIMAT® on the mechanisms of exercise 
intolerance in COPD patients. The study is a crossover, within-patients, design 
comparing the effect STIOLTO™ RESPIMAT® to placebo on dynamic 
hyperinflation, performance fatigue (PF), activation fatigue (AF), and muscle 
fatigue (MF) during and after constant power exercise to intolerance. Twenty-one 
patients with moderate to very severe disease will be recruited into this study.  
 
Initially pulmonary function and cardiopulmonary exercise variables will be used 
to characterize recruited patients. Subsequently, constant power exercise tests 
(calculated from the initial incremental exercise test to bring the patient to 
intolerance in approx. 6 min) will be used to characterize the components of 
performance fatigue, ventilation, dynamic hyperinflation, skeletal muscle 
oxygenation, and accessory respiratory muscle activity. Patients will perform two 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 10 of 31 
 
tests, each to the limit of tolerance, with prior STIOLTO™ RESPIMAT® 
bronchodilator and placebo. An independent statistician will randomize the order 
of these two tests, and both patients and investigators blinded to the condition. A 
pharmacist, who will otherwise not participate in the study, will facilitate drug 
administration. Unblinding information will be kept in sealed envelopes by the 
pharmacist in case of (S)AE.  
 
A third constant power exercise test will be performed with the treatment that 
resulted in the longer endurance time. In this test the components of performance 
fatigue and dynamic hyperinflation will be measured at the duration at which the 
patient reached intolerance in the alternative treatment trial (i.e. isotime 
measurement). This will allow comparisons of PF, AF, and MF and their 
associations with ventilation, dynamic hyperinflation, skeletal muscle 
oxygenation, and accessory respiratory muscle activity, between STIOLTO™ 
RESPIMAT® and placebo at during and following exercise to intolerance and at 
isotime.  
 
Visit schedule 
Written informed consent will be administered in the study center. Consenting 
subjects will discontinue long-acting bronchodilators for the entire duration of the 
study. All subjects will receive albuterol (either alone, or as a combination 
therapy; see below for details) to be taken as needed (prn) for the duration of the 
study. For those subjects prescribed long-acting antimuscarinic therapy at study 
entry, during the three washout periods of the protocol subject’s therapy shall 
consist of combination albuterol and ipratropium (Combivent) prn. Patients taking 
a combination long-acting beta agonist and inhaled corticosteroid therapy 
(LABA+ICS) at study entry will be transitioned to ICS monotherapy for the 
duration of the study. The study drug (STIOLTO™ RESPIMAT® or placebo) 
will be administered daily during three 1-week periods during the protocol. Each 
time, the study drug will be taken for one week before testing is performed. The 
study timeline is shown in Figure 1. The study will require a total 5 visits by each 
patient for pulmonary function and exercise tests. 
 
Visit 1: Baseline pulmonary function test. Visit 1 will occur after consent and will 
include full pulmonary function assessment including pre- and post-
bronchodilator spirometry, resting ECG, and muscle NIRS test. 
 
Visit 2: Baseline cardiopulmonary exercise tests. Visit 2 will include spirometry, 
an incremental exercise test, and a constant power exercise test on a cycle 
ergometer. This testing day will be preceded by a 14-day washout of all long 
acting bronchodilators, and an overnight washout of short-acting albuterol. COPD 
questionnaires will be completed. 
 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 11 of 31 
 
Visits 3-5: Constant power exercise and fatigue tests. Visits 3-5 will each include 
spirometry, an exercise test (constant power exercise), and measurement of 
activation and muscle fatigue, dynamic hyperinflation, ventilation and gas 
exchange, accessory respiratory muscle activation, and leg muscle deoxygenation. 
The condition (active drug vs placebo) of visits 3 and 4 will be randomized and 
each test will be continued to the limit of tolerance. Visit 5 will be an ‘isotime’ 
test, in which the patient is stopped at the tolerable duration of the shorter test, 
using the condition that resulted in the longer duration. Visits 3-5 will be preceded 
by a 14-day washout period and 7 days using once-daily STIOLTO™ 
RESPIMAT® bronchodilator treatment or placebo, with the condition blinded to 
the patient and investigators. Subjects will take their daily dose of the study 
medication 90 minutes before undergoing spirometry and constant work rate 
testing. 
 
Fatigue measurements (particularly AF, and MF) are technically challenging to 
make, and sometimes a repeat visit is required to secure robust measurements. 
This occurred in about 15% of visits in our previous study (LA BioMed protocol 
30044-01); typically repeated measurements are needed at visit 2 where the 
patient is initially introduced to the requirement to make a 5-second maximal 
effort to measure fatigue. Should a repeated visit be necessary, the patient will be 
continued in the study phase i.e. taking no drug (baseline, visit 2), or taking active 
drug or placebo (visit 3, 4 or 5). They will be recalled within approximately 1 
week for re-testing. On completion of the repeat the subject will then be advanced 
to the next phase of the study (crossover or isotime). 
 
Medications 
STIOLTO™ RESPIMAT®: Two actuations of STIOLTO™ RESPIMAT®, taken 
once daily, provides 6.2 micrograms of tiotropium bromide monohydrate and 5.5 
micrograms olodaterol hydrochloride, which is equivalent to 5.0 micrograms of 
tiotropium and 5.0 micrograms of olodaterol. 
 
Tiotropium bromide is a non-chiral, long-acting, inhaled anticholinergic 
bronchodilator initially developed for the long-term, once-daily, maintenance 
treatment of bronchospasm and dyspnea associated with chronic obstructive 
pulmonary disease (COPD), including chronic bronchitis and emphysema. It has 
had FDA approval for use in COPD for over 10 years and is used in COPD more 
than any other bronchodilator medication.  
 
Olodaterol hydrochloride is a long-acting beta2-adrenergic agonist bronchodilator 
indicated for the long-term, once-daily maintenance bronchodilator treatment of 
airflow obstruction in patients with chronic obstructive pulmonary disease 
(COPD), including chronic bronchitis and/or emphysema.  It has had FDA 
approval for use in COPD for about 2 years. 
 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 12 of 31 
 
The drug product, STIOLTO™ RESPIMAT®  is composed of a sterile aqueous 
solution of tiotropium bromide and olodaterol hydrochloride filled into a 4.5 mL 
plastic container crimped into an aluminum cylinder (StioltoTM cartridge) for use 
with the StioltoTM  Respimat® inhaler. 
 
The drug package insert is attached to this application. 
 
Placebo Respimat®: The placebo Respimat® inhaler will be prepared by the 
manufacturer and contains no active therapeutic agent. 
 
Albuterol: Albuterol is an FDA approved medication for pulmonary function 
testing. It may be used in this study as a short-acting medication during washout 
periods. The drug package insert is attached to this application. 
 
Combivent: Combivent contains ipratropium bromide and albuterol. Ipratropium 
bromide is a marketed drug approved for use in the United States. It is a 
bronchodilator for maintenance treatment of bronchospasm (tightening of the 
airways) associated with COPD, including chronic bronchitis and emphysema. It 
may be used in this study as a maintenance therapy during washout periods. The 
drug package insert is attached to this application. 
 
Inhaled corticosteroids (ICS): Some COPD patients take combination therapies 
that contain an inhaled corticosteroid and a long-acting bronchodilator in one 
dose. In these cases, patients will be transitioned to inhaled corticosteroid 
monotherapy for the duration of the study. ICS monotherapy may be used in this 
study as a maintenance therapy. The drug package insert is attached to this 
application. 
 
Procedures 
An assessment schedule for the procedures in the study is shown in Table 1. 
 
Pulmonary function: Visit 1 will include spirometry, lung volume by body 
plethysmography, and single-breath carbon monoxide diffusing capacity tests. 
Each will be made according to ATS/ERS guidelines, at least 10 min after 200 µg 
of albuterol (Millar et al., 2005). Visits 2-5 will include spirometry prior to each 
exercise test. 
 
Resting ECG: Visit 1 will include a resting 12 lead ECG to determine a normal 
electrocardiogram prior to any exercise testing.  
 
Medical history and questionnaires: During visit 1 a medical history will be 
collected, including respiratory and heart history, smoking history, and 
medication history. Patients will also complete the St. George’s Respiratory 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 13 of 31 
 
Questionnaire (SGRQ) and the COPD Assessment Tool (CAT) to assess COPD 
symptoms. 
 
Table 1. Assessment Schedule 
 
 
 
Non-invasive assessment of oxidative capacity by NIRS: Visit 1 will include 
measurement of quadriceps muscle oxygenation by near-infrared spectroscopy 
(NIRS; Hamamatsu Photonics KK) during a supine protocol using intermittent 
venous and arterial occlusion (Ryan et al., 2012). The FDA deems use of NIRS in 
humans as a ‘non-significant risk’. The recovery dynamics of muscle O2 
consumption after brief, light muscle contractions is directly determined by 
mitochondrial oxidative capacity in vivo (McCully et al., 1993). We will use this 
for non-invasive assessment of vastus lateralis oxidative capacity by NIRS, 
together with an assessment of muscle vasoreactivity (Ryan et al., 2012). Briefly, 
the protocol consists of five key phases: 1) resting muscle oxygenation (2 
minutes); 2) Ten intermittent venous occlusions (~50 mmHg cuff pressure, for 20 
seconds each) to determine resting muscle blood flow; 3) Three arterial 
occlusions (~250 mmHg cuff pressure, for 30 seconds each) to measure resting 
muscle oxygen consumption; 4) a sustained arterial occlusion (maximum 5 
minutes) and recovery for physiologic calibration and to characterize 
vasoreactivity during cuff release; 5) Ten seconds of low-intensity rhythmic knee-
extension followed immediately by high-frequency intermittent arterial occlusions 
(~250 mmHg cuff pressure) to estimate recovery O2 consumption dynamics for 
~5 minutes; 6) a repeat of item 5 to improve signal-to-noise. The assessment takes 
approximately 30-35 min in total. 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 14 of 31 
 
 
Incremental exercise test: All patients will perform a ramp-incremental cycle 
exercise on an electromagnetically-braked cycle ergometer (Excalibur Sport PFM, 
Lode NL) to the limit of tolerance after an overnight washout of short-acting 
bronchodilator (visit 2). Patients will breathe through a mouthpiece with nose clip 
in place for measurement of respired gases and volumes for breath-by-breath gas 
exchange and ventilatory measurements (Vmax Spectra, CareFusion USA). Tests 
will be administered with 3 minutes of rest and at least 3 minutes of unloaded 
cycling (until a steady-state is achieved), followed by an increase in power output 
at 5 W/min (for patients with FEV1 ≤ 1 L) or 10 W/min (for patients with FEV1 > 
1 L) and continued to the limit of tolerance. The limit of tolerance will be 
determined as the point at which the patient experiences intolerable dyspnea or is 
unable to maintain pedaling rate above 50 rpm despite verbal encouragement. At 
the limit of tolerance and every 1 minute during recovery an isokinetic power test 
will be performed (described below). At specified times during the exercise test, 
inspiratory capacity (IC) measurements will be made using a maximum 
inhalation. These will be made at rest, every 2 min during exercise, at end-
exercise, and every 1 minute during recovery 
 
Constant work rate (CWR) exercise tests: From an unloaded pedaling baseline 
(~3 min), the power output will be abruptly increased to approximately 75% 
WRpeak (this is the peak work rate achieved during the incremental exercise test). 
The specific work rate chosen will be chosen to elicit intolerance in ~6 min in the 
placebo condition (van der Vaart et al., 2013). The patient will be instructed and 
encouraged to maintain the power output for as long as they can manage (except 
in the isotime test, as noted below). Patients will breathe through a mouthpiece 
with nose clip in place for measurement of respired gases and volumes for breath-
by-breath gas exchange and ventilatory measurements (Vmax Spectra, 
CareFusion USA). A familiarization CWR test will be performed at visit 2, at 
least 1 hour after the incremental test. At specified times during the exercise test, 
inspiratory capacity (IC) measurements will be made using a maximum 
inhalation. These will be made at rest, every 2 min during exercise, at end-
exercise, and every 1 minute during recovery 
 
The constant power test will be repeated on at least 4 occasions. The initial 
constant power test will be made at least 2 hours after the incremental test and 
will be used to identify the ~6 min endurance time in untreated conditions (visit 
2). If the endurance time is not ~6 min (in the range 4-10 minutes), then an 
additional visit (visit 2a) will be made to identify required power output. After 
this, two constant power tests will be performed to intolerance with either 
STIOLTO™ RESPIMAT® or placebo (visits 3 and 4). An additional, third 
constant power test will be performed using the treatment condition that resulted 
in the longest endurance time (visit 5). For this test the isokinetic measurements 
will be made at a time when the shorter of the two treatment tests ended, 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 15 of 31 
 
providing isotime assessment. The condition (active drug vs placebo) of visits 3-5 
will remain blinded to the participants and the experimenters until the end of the 
study. At the limit of tolerance and every 1 minute during recovery an isokinetic 
power test will be performed (described below). 
 
Isokinetic power tests (baseline and fatigue): Patients will be familiarized with 
the maximal isokinetic cycling task at visit 2. Initially patients will be oriented to 
the cycle ergometer and optimal seat height will be determined. Following this, 
isokinetic ergometry tests will be performed at baseline, at the limit of tolerance, 
and in recovery during visits 2 (incremental exercise) and 3-5 (constant work rate 
tests). 
 
At baseline subjects will cycle at a comfortable cadence with zero load for ~3 
min, after which they will be asked to perform 5 pedal strokes (~4 seconds) 
isokinetic cycling at each of ~25%, ~50%, ~75% and 100% maximal effort. The 
strain of the task is minimal and only a few seconds (~30 s) recovery is necessary 
between each effort, but subjects will be given as long as they feel is necessary to 
recover. During these efforts the flywheel braking of the cycle ergometer is 
controlled to result in predetermined velocities equating to a constant pedal 
cadence of 70 rpm. Patients will complete this test twice at baseline (unfatigued 
condition) prior to each exercise test to ensure reproducibility. If the two repeats 
do not cohere to within 10%, then the procedure is repeated a third time following 
a short (~10 min) rest. The patient will then be given 30 minutes to recover before 
the incremental or CWR exercise test is performed. 
 
During each exercise test, isokinetic fatigue tests will be made at the point of 
limitation (or at isotime) and during recovery. For this the cycle ergometer will be 
switched to isokinetic mode and five pedal strokes will be completed at maximal 
effort (~4 seconds) to determine PF, AF and MF. In order to track fatigue during 
recovery, 5-pedal-stroke maximal isokinetic efforts will also be made every 
minute during recovery until the fatigue has recovered to 90% of the baseline 
value (up to a maximum of 6 minutes; 3-4 minutes is typical). 
 
Exercise NIRS: Tissue oxygenation during exercise will be assessed by NIRS (as 
described above in Non-invasive assessment of oxidative capacity by NIRS). NIRS 
probes will be attached by adhesive tape to the skin of the quadriceps (for muscle 
oxygenation) and the forehead (for cerebral oxygenation), and a bandage will be 
placed over the probe to help ensure its stability during exercise. 
 
Measurements 
Ventilation, gas exchange, heart rate, and perceived exertion during exercise: 
During incremental and CWR exercise, patients will breathe through a 
mouthpiece for breath-by-breath pulmonary gas exchange and ventilation 
measurement (Vmax Encore, CareFusion USA). Heart rate, arterial oxygen 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 16 of 31 
 
saturation, and transcutaneous CO2 partial pressure will also be measured. 
Patients will be asked to rate their perceived exertion (“rate your leg fatigue” and 
“rate your difficulty of breathing”) every 2 minutes during exercise and recovery. 
All methods are well established in our lab. From these measurements the 
following variables will be determined in the incremental test:  Peak oxygen 
uptake, lactate threshold (LT), ventilatory equivalent for CO2 at LT as an index of 
ventilatory efficiency, peak ventilation (also expressed relative to maximum 
voluntary ventilation calculated from pulmonary function tests).  
 
Tissue oxygenation: Tissue oxygenation dynamics [(oxygenated hemoglobin and 
myoglobin) / (total heme-chrompohor concentration)] will be measured in the 
quadriceps using spatially-resolved near-infrared spectroscopy (NIRO200, 
Hamamatsu; as previously described in our laboratories; Bowen et al., 2012). 
Kinetic modeling of deoxygenation response dynamics will be made by non-
linear least squares fitting procedures to determine the association between tissue 
oxygenation and fatigue characteristics. 
 
Dynamic hyperinflation (DH): DH will be evaluated from inspiratory capacity 
(IC) measurements at rest, every 2 min during exercise, and at end-exercise and 
during recovery (Somfay et al., 2001) immediately prior to the AF and MF 
measurement. This reproducible method allows dynamic changes in the 
operational lung volume to be determined.  
 
Isokinetic power and leg muscle activity: Wireless surface electromyography 
(EMG) sensors (Trigno, Delsys) are fitted using adhesive patch on the quadriceps, 
hamstrings, and gastrocnemius. Pedal torque is measured at the crank every 2° of 
rotation and mean isokinetic power is determined over each complete revolution. 
Using these measurements a relationship between the average root mean square 
EMG activity (RMS EMG) and power output can be generated (Coelho et al., 
2015). The baseline (unfatigued) relationship between RMS EMG and power 
becomes the reference value. The fatigue point is then placed in the context of the 
reference value (see Fig 2). Performance fatigue (PF) is the decline in power 
output at maximal effort between baseline and the measurement during fatigue. 
The activation fatigue (AF) is the power-equivalent of the reduction in RMS 
EMG activity between the maximal effort at baseline and during fatigue. The 
muscle fatigue (MF) is the difference in power output between that expected (at 
baseline) at the achieved RMS EMG and the measured power (see Fig 2). 
 
 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 17 of 31 
 
 
Figure 2. Relationship between isokinetic power and muscle activity (EMG). The baseline 
(unfatigued) relationship is shown in grey and dashed-line. At the limit of tolerance in incremental 
exercise fatigue is assessed from a single 5-pedal maximal effort (open circle). Recovery of 
fatigue is shown at 1 (horizontal bar), 2 (vertical bar), and 3(plus sign) minutes after intolerance. A 
graphical depiction of the method to qualify performance fatigue (PF), activation fatigue (AF), and 
muscle fatigue (MF) is shown in red. Note that in this example, performance fatigue at end-
exercise is approximately 30% activation fatigue and 70% muscle fatigue. Recovery of muscle 
fatigue is essentially complete 3 minutes after end-exercise. 
 
Accessory muscle activation: Wireless electrodes will be placed over the 
accessory muscle of breathing e.g. sternocleidomastoid, scalene muscles, to 
record electromyographic activity (Trigno, Delsys).  
 
 
 
h) Data and Specimen Banking* 
Data will be stored for at least 3 years required by the USDHSS, in password-
protected PCs and secure filing cabinets in the CDCRC Building. Data will be 
stored indefinitely.  
 
In order to minimize the risk of inappropriate use of medical information, no data 
will be labeled in a way that they can be readily identified to an individual. 
Participants will de-identified using a number code system and the key will be 
kept in a separate locked cabinet in the PI’s office or records room.  
PF 
AF 
MF 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 18 of 31 
 
 
Electronic documents will be stored on password-protected PCs in the CDCRC 
Building. Source documents will be stored in secure filing cabinets in a locked 
records room in the CDCRC Building. The PI and co-investigators will have 
access to the data. 
 
Protected health information linking the data and samples to subject identity will 
be kept for 25 years after the consent is executed. 
 
The LA BioMed training requirement (Study Volunteer Protection, HIPAA 
Compliance, and Good Clinical Practices) will be satisfied before any investigator 
handles data. 
 
i) Data Management * 
Power calculation 
Formal power analyses for these measurements are difficult to compose due to the 
novelty of the approach. Unpublished work from our lab (LA BioMed protocol 
30044-01) were able to detect an average 22% (PF = 24 Watt; p = 0.02) decrease 
in paired measures of isokinetic performance fatigue at isotime in 13 COPD 
patients with a inhaled oxygen as the intervention. This reduction in fatigue 
(increase in power) was due to significant reduction in activation fatigue (AF = 33 
Watt reduction; p=0.03) and a non-significant increase in muscle fatigue (MF = 9 
W increase; p=0.26). However, the expected difference in PF and AF following 
bronchodilator therapy are less than for inhaled oxygen. Saey et al., (2003) found 
a significant 10% difference in post-exercise quadriceps twitch force using a 
bronchodilator intervention vs placebo in 18 COPD patients.  
 
Data from our laboratories, and from others where muscle fatigue was measured 
from change in stimulated twitch force in COPD patients, suggest that the 
variance within groups will be 20 times the variance explained by the main effect 
(that is, a σ ratio 20:1), giving an effect size for AF and MF of f=0.23. For an α of 
0.05 and strong correlation between repeated measures (r=0.80; unpublished 
data), the actual power is 0.95 with n=21 patients (G*Power 3.1.5).  
 
 
Analysis Plan 
It is hypothesized that STIOLTO™ RESPIMAT® will uncover a skeletal muscle 
power reserve, allowing an increased MF to be elicited at the point of exercise 
limitation following bronchodilator therapy (Saey et al., 2003). We hypothesize 
that AF at the limit of tolerance will not differ between STIOLTO™ 
RESPIMAT® and placebo, but that AF will be lower at isotime following 
STIOLTO™ RESPIMAT® treatment in COPD. Differences in AF between 
isotime in the STIOLTO™ RESPIMAT® condition and intolerance in the 
placebo condition will be assessed by paired t-test. A lower AF in STIOLTO™ 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 19 of 31 
 
RESPIMAT® would suggest that the mechanism of exercise tolerance benefit of 
STIOLTO™ RESPIMAT® treatment is related to a reduced inhibition of muscle 
activation during exercise (primary objective). We also hypothesize that MF will 
be greater at the limit of tolerance in the STIOLTO™ RESPIMAT® condition. 
Differences in MF between isotime in the STIOLTO™ RESPIMAT® condition 
and intolerance in the placebo condition will be assessed by paired t-test. A 
similar MF between STIOLTO™ RESPIMAT® and placebo would be in 
accordance with the hypothesis. Differences in MF between isotime and 
intolerance within the STIOLTO™ RESPIMAT® condition will be assessed by 
paired t-test. A lower MF at isotime would suggest that the mechanism of exercise 
tolerance benefit by STIOLTO™ RESPIMAT® treatment is related to better 
maintenance of muscle activity resulting in increased muscle fatigue during 
exercise (primary objective). The rate of recovery of PF, AF, and MF will be 
assessed by repeated measures ANOVA among the baseline (pre-exercise, 
unfatigued) condition and fatigue measurements at intolerance and every minute 
during recovery from exercise (up to 6 minutes). It is hypothesized that PF will 
recover to baseline within 3 minutes following exercise intolerance. 
 
To investigate the physiological mechanisms underlying fatigue, we will 
determine the associations among physiological measurements and PF, AF or MF.  
Firstly we hypothesize that the dynamics of AF will be associated with those of 
dynamic hyperinflation. By reducing dynamic hyperinflation using STIOLTO™ 
RESPIMAT® we hypothesize that dyspneagenesis will be reduced (e.g. reducing 
respiratory muscle work during exercise by reducing end-expiratory lung volume, 
and/or from reducing pulmonary mechanoreceptor activity during hyperinflation). 
We will measure dynamic hyperinflation with inspiratory capacity measurements 
during and following exercise and determine the association between dynamic 
hyperinflation and AF (secondary objective). Secondly, we hypothesize that MF 
at the limit of tolerance will be associated with increased muscle deoxygenation – 
the greater the MF the lower the muscle oxygenation consistent with a limitation 
to oxidative metabolism (secondary objective). These secondary objectives will 
be assessed using linear regression to determine the proportion of AF and MF that 
can be “explained” by e.g. dynamic hyperinflation, or leg muscle deoxygenation 
at isotime, end-exercise and during recovery. 
 
j) Confidentiality 
Data will be de-identified and stored on password-protected PCs and in locked 
cabinets. The PI and co-investigators will have access to the data. Data will be 
stored for at least three years, with the aim of indefinite storage. Data will be 
stored locally. 
 
k) Provisions to Monitor the Data to Ensure the Safety of Subjects* 
The data will be handled as source documents. These will include all data with 
patient demographics, history, questionnaires, pulmonary function, muscle 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 20 of 31 
 
oxidative capacity and exercise testing results. The documents will be filed in the 
subject’s source document binder. This binder will also contain the properly 
executed consent form, the HIPAA (PHI) form as well as demographic data. The 
patient identifiers will be kept in this folder, but under a separate section from the 
study source data. This section will be marked as ‘confidential’ and the binders 
will be kept in a locked cabinet in a locked room. Access to the patient identifiers 
will be permitted only for the study coordinator and the person(s) with direct 
contact with the patient. 
 
The PI will be responsible for reporting any adverse events to the local IRB 
utilizing the adverse event reporting policy established by the local IRB. All 
serious adverse events and non-serious adverse events which are relevant for a 
reported serious adverse event and Adverse Events of Special Interest (AESI) 
shall be reported to Boehringer Ingelheim Pharmaceuticals, Inc. Data monitoring 
will made on a per-procedure basis by the PI or co-investigators.  
 
Per its policy, periodic data monitoring will be undertaken by a member of the 
Compliance Office at Los Angeles Biomedical Research Institute at Harbor-
UCLA Medical Center. 
 
l) Withdrawal of Subjects* 
Participants will be free to withdraw at any time. Participants may choose to stop 
study treatment or leave the study at any time without it affecting their future 
care. Subjects are asked to discuss this decision with the study doctor. Subjects 
will be asked to return to the clinic for a follow-up visit and to return any unused 
study medication, but do not have to do this.  
 
Participants are told that the study doctor may decide to withdraw them from this 
study at any time even without their consent. Participants will be withdrawn for 
any of the following reasons:   
 Consent is withdrawn 
 The subject is unwilling or unable to follow the rules of the protocol 
 The subject becomes pregnant 
 The subject experiences a medical emergency that makes it necessary to 
stop taking study treatment or that requires treatment assignment to be 
revealed to the study doctor and/or staff 
 At the decision of the PI of one of the participating physicians 
 
9) Risks to Subjects* 
Identification of risk and protections to minimize risk 
Our primary concern is the safety of the participant during exercise testing. 
Participants will perform high-intensity exercise that may lead to physical 
discomforts (e.g. fatigue, delayed onset muscle soreness), but especially dyspnea in 
this patient population. The risks associated with participating in this study may 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 21 of 31 
 
include, although unlikely, muscle cramps, muscle strain and/or joint injury, delayed 
muscle soreness, dyspnea, syncope, and fatigue.  They may feel delayed muscle 
soreness (24-48 hr) after exercise. There is a risk of a cardiac event, such as a cardiac 
ischemia, cardiac arrest, dangerous arrhythmia, or acute cardiac collapse. This risk is 
approximately 1-2 occurrences in 10,000 tests of ‘high risk’ subjects with 
cardiovascular disease (American College of Sports Medicine). Similarly, an 
assessment of risk during high-intensity interval exercise testing and training of 
patients with coronary heart disease revealed approximately 1 event in over 23,000 hr 
of exercise, such as arrhythmia or myocardial infarction (Rognmo et al., 2012). 
 
A person trained in CPR will be present during testing and a defibrillator is located 
within the laboratory in case of a cardiac event. A licensed physician will be available 
within the CDCRC for all study visits and will be in the room during each subject’s 
initial incremental test. Participants will be coached to identify to the experimenters 
any unexpected symptoms and the exercise stopped immediately to mitigate risk 
during exercise testing. All tests are done with a 12-lead ECG and the test is stopped 
immediately should arrhythmic or ischemic patterns develop. All tests are done with 
pulse oximetry and the exercise is stopped should oxygen saturation fall below 85%. 
 
All medications have the potential to cause side effects.  The drugs involved in this 
study may involve risks that are already known, as well as risks that are currently 
unknown. Serious allergic reactions that can be life threatening may occur with any 
medication. However, we will take precautions to reduce these risks. Patients will be 
instructed to immediately report any allergic reactions to the PI, such as: 
 a rash  
 having a hard time breathing 
 wheezing 
 sudden dizziness, especially when standing 
 swelling around the mouth, throat, or eyes 
 fast pulse 
 sweating 
 
Placebo Respimat® 
There are no known risks associated with using the placebo Respimat®. 
 
STIOLTO™ RESPIMAT® 
Combination treatment with tiotropium plus olodaterol (STIOLTO™ RESPIMAT®) 
has been studied in 6 completed clinical trials. The following side effects occurred in 
more than 3% of subjects: 
 nasopharyngitis  
 cough 
 back pain  
 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 22 of 31 
 
Other side effects that occurred in less than 3% of patients are: 
 dehydration 
 dizziness, insomnia 
 glaucoma, intraocular pressure increased, vision blurred 
 atrial fibrillation, palpitations, supraventricular tachycardia, tachycardia, 
hypertension 
 epistaxis, pharyngitis, dysphonia, bronchospasm, laryngitis, sinusitis 
 dry mouth, constipation, oropharyngeal candidiasis, dysphagia, gastroesophageal 
reflux disease, gingivitis, glossitis, stomatitis, intestinal obstruction including 
ileus paralytic 
 rash, pruritus, angioneurotic edema, urticaria, skin infection, and skin ulcer, dry 
skin, hypersensitivity (including immediate reactions) 
 arthralgia, joint swelling 
 urinary retention, dysuria, and urinary tract infection 
 
Use of short acting bronchodilators 
The study is a crossover design. Prior to beginning each new condition a 2 week 
washout from the study drug or placebo is required. This means that the COPD 
patients in the study will not be able to take long-acting anticholinergic or long-acting 
beta-agonist bronchodilators for several 2 week periods during the study. During this 
time they will be provided with a short-acting brochodilator replacement medication 
(albuterol, or in some cases, Combivent) and be given instructions how to use it. In 
addition, any patients on combination therapies that include a long-acting 
bronchodilator will be required to discontinue its use prior to the study. This may 
include combination inhaled corticosteroid medications. These patients will be 
transitioned to a short-acting bronchodilator (albuterol, or in some cases, Combivent), 
and an inhaled corticosteroid monotherapy as appropriate. 
 
Albuterol 
Four puffs of albuterol will be given at visit 1 during the lung function tests, and will 
be provided as a short-acting bronchodilator medication. Albuterol is an FDA 
approved bronchodilator with mild side effects. Reported risks include:        
 Very common (greater than 10%): Pharyngitis (sore throat). 
 Common (3% - 7%): Headache, rapid heart rate, muscle and joint pain, dizziness, 
stuffy and runny nose, and unpleasant awareness of palpitations (strong heart 
beat).   
 Uncommon (less than 3%): Chest pain, infection, diarrhea, inflammation of the 
tongue, accidental injury, anxiety, shortness of breath, ear disorder, ear pain and 
urinary tract infection. 
 
Combivent 
Combivent is an FDA approved short-acting bronchodilator containing albuterol and 
ipratropium bromide.  

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 23 of 31 
 
 Common side effects (greater than 2%) associated with Combivent include: 
Cough, shortness of breath, headache, bronchitis, sore throat, respiratory infection 
 Uncommon side effects (less than 2%) include: High blood pressure, dizziness, 
tremor, muscle spasms or muscle pain, diarrhea, nausea, dry mouth, constipation, 
vomiting, weakness, flu-like illness, chest discomfort, eye pain, low blood 
potassium, palpitations (strong heat beat), fast heartbeat, skin itching or rash, pain 
in nose or throat, wheezing 
 
Patients taking an inhaled corticosteroid in a combined therapy will transition to an 
FDA approved monotherapy at the beginning of the study. Risks of corticosteroids 
include:  
 Common side effects (greater than 3%) associated with inhaled corticosteroids 
include: upper respiratory infections, throat irritation, upper respiratory 
inflammation, sinus infection, hoarseness, mouth or throat infection, cough, 
bronchitis, headache 
 Uncommon side effects (less than 3%) include: runny nose or post-nasal drip, 
nasal sinus disorders, laryngitis, diarrhea, viral gastrointestinal infections, 
dyspeptic symptoms, gastrointestinal discomfort and pain, dry mouth, joint pain, 
muscle pain, muscle stiffness/tightness/rigidity, dizziness, migraines, fever, viral 
infections, pain, chest symptoms, viral skin infections, muscle injuries, soft tissue 
injuries, urinary infections 
 
Pulmonary function tests represent minimal risk and are done routinely. In the past 
ten years there has been no adverse event precipitated by pulmonary function tests in 
our laboratory. Some people find the breathing tests tiring and occasionally patients 
experience a sense of dizziness, headache or shortness of breath that usually resolves 
quickly (common, mild seriousness). A few may experience a feeling of 
claustrophobia while in the body-plethysmograph. This usually passes as soon as the 
door is opened (uncommon, mild seriousness). The carbon monoxide content of the 
gas mixture used to measure lung diffusion capacity is low (0.3%) and the duplicate 
tests are done five minutes apart; therefore this test does not increase significantly 
carboxy-hemoglobin concentration. 
 
Risks of adhesive tape allergy or discomfort from EMG and NIRS probes will be 
minimized using pinned-bandages in participants with adhesive allergies or those 
expressing adverse discomfort. The attachment and removal of the NIRS probe and 
EMG electrodes with adhesive may present a minimal, though brief, discomfort. Mild 
discomfort is common with the occlusion of extremity blood flow with the inflation 
of the blood pressure cuff during the resting NIRS measurement of oxidative 
capacity. 
 
The risks associated with reading and filling out questionnaires are some 
psychological discomfort and anxiety. 
 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 24 of 31 
 
Only personal information essential to the research will be recorded, including age, 
anthropometric data such as height and weight, and physiologic data gathered during 
the experiments. These variables are important to define the patients enrolled for 
future publications. Personal health information is protected by conducting all data 
collection, storage, or transfer according to HIPAA Privacy regulations. Identifiable 
data will be securely stored and access is limited to the principal investigator and 
authorized assistants. Data will be coded as early in the research as possible and the 
code linking the data is stored in a locked cabinet. None of the data are considered to 
be sensitive or place the subject at legal risk. Personally identifiable data will not be 
disclosed to anyone other than the research team without the written consent of the 
subjects or their legal representative. 
 
10) Potential Benefits to Subjects* 
There are no direct benefits to the subjects from their participation in the study. 
 
11) Provisions to Protect the Privacy Interests of Subjects 
The collection of data will be within the confines of the local research laboratories in 
the CDCRC Building within areas that insure subject privacy away from other 
ongoing activities and personnel. Only investigators and the necessary support staff 
will interact with the subjects during historical and experimental data collection. 
 
The investigators and the support personnel involved are highly experienced with 
appropriate interaction with research subjects. This expertise and the physical means 
of providing privacy (see above) are the main methods in place in order to maximize 
the subjects’ sense of ease during the study-related activities.  
 
The patients’ historical and experimental data will be secured. Only the investigators 
and the necessary support personnel with a need to know will have access to the files. 
 
Subjects are informed in the consent form: 
“We will do our best to make sure that the personal information in your medical 
record is kept private.  However, we cannot guarantee total privacy. We may have 
to give out your personal information if required by law.  If information from this 
study is published or presented at scientific meetings, we will not use your name 
or other personal information that can identify you. 
 
Organizations that may look at and/or copy your medical records for research, 
quality assurance, and data analysis include: 
 The 
maker 
of 
the 
study 
medication, 
Boehringer-Ingelheim 
Pharmaceuticals Inc., and its representatives 
 The Office of Human Research Protection and other government agencies, 
like the Food and Drug Administration (FDA), involved in keeping 
research safe for people 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 25 of 31 
 
 The Institutional Review Board at the Los Angeles Biomedical Research 
Institute or its staff 
The ways your study doctor will use your study-related health information and the 
people who may receive it are identified in a separate form entitled 
“Authorization For Release of Protected Health Information (PHI).” ” 
 
12) Compensation for Research-Related Injury 
Participants are informed: 
“If you are injured because of your taking part in this research study medical care 
will be available. This care will not necessarily be free of charge. If you are 
injured as a direct result of taking the drugs used in this study or as a result of a 
procedure that would not have been performed on you if you were not in the 
study, you will be provided with appropriate medical care including treatment and 
hospitalization if necessary. The care will not necessarily be free of charge. 
Financial compensation for any injury from this research is not available. The 
study sponsor Los Angeles Biomedical Research Institute will not pay for the 
normal progress of your disease, or any injury or complication due to the medical 
condition you already have. Financial compensation for such things as lost wages, 
disability or discomfort due to an injury is not available.” 
 
13) Economic Burden to Subjects 
Participants are informed: 
“You do not have to pay for study drugs, study visits, supplemental medications 
or tests that are part of the study. 
 
We will conduct all tests and procedures required for this study at no cost to you. 
You (and/or your health care payer) will continue to be responsible for the costs 
of your regular medical care and any medications you take for any condition that 
is not part of this study. 
 
Boehringer-Ingelheim Pharmaceuticals Inc. will supply the study medication at no 
charge while you take part in this study. The costs of the cost of getting the 
medications ready and giving it to you are also provided by the sponsor, Los 
Angeles Biomedical Research Institute. Even though it probably won’t happen, it 
is possible that the sponsor may not be able to continue to provide the medications 
for some reason. If this would happen, the study may have to close. Your study 
doctor will talk with you about this, if it happens.   
 
For your time and inconvenience related to your taking part in this study, you will 
be paid a total of $450 if you complete this study. If you do not complete the 
study, for any reason, you will be paid for the study visits you do complete 
according to the following schedule: $50 for visit 1; and $100 each for visits 2, 3, 
4, and 5. If you are asked to repeat a visit, you will also be paid at the same rate 
that visit.”  

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 26 of 31 
 
 
 
14) Consent Process 
The consent will be obtained at the CDCRC Building before any study-related 
procedures are performed. Subjects will be told that they have as much time as they 
need to consider consenting and will be given the opportunity to discuss the study 
with friends, family and their health care provider. At each visit subjects will be 
reminded that participation in the study is voluntary and their questions, if any, will 
be answered. We will follow the SOP: Informed Consent Process for Research (HRP-
090). 
 
Non-English Speaking Subjects 
Since our area has a significant Spanish-speaking population, this ethno-linguistic 
population will also be considered for recruitment. An IRB-approved Spanish 
Language Consent form will be officially produced if needed. Several of the study 
associates are natively fluent in Spanish and will assist with communication during 
the actual experiments.  
 
Waiver or Alteration of the Consent Process (consent will not be obtained, required 
information will not be disclosed, or the research involves deception) 
Not Applicable. 
 
Subjects who are not yet adults (infants, children, teenagers) 
Subjects who are not yet adults are excluded from this research. 
 
Cognitively Impaired Adults  
Subjects who are cognitively impaired are excluded from this research. 
 
Adults Unable to Consent 
Adults who are unable to consent are excluded from this research. 
 
15) Process to Document Consent in Writing 
We will follow the standard operating procedure (Written Documentation of Consent; 
HRP-091) for written documentation of consent. 
 
16) Vulnerable Populations 
Vulnerable populations such as, pregnant women, adults unable to give consent, 
individuals who are not yet adults and prisoners are excluded from this research. 
 
17) Drugs or Devices 
The study drug, STIOLTO™ RESPIMAT® and matching placebo, will be prepared 
by the manufacturer who is experienced in placebo controlled trials. Medication will 
be packaged with a coded label and shipped to each study site. The LA BioMed 
Research Pharmacy will prepare blinded study medication, utilizing randomization 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 27 of 31 
 
codes supplied by an independent statistician who is otherwise not involved in the 
study.  Blinded drug supply for each patient will be kept in temperature and humidity 
controlled cabinets in the Research Pharmacy. 
 
The study drug and matching placebo will be provided by Boehringer-Ingelheim 
Pharmaceuticals Inc. Supplemental medication (albuterol, Combivent, and ICS) will 
be obtained commercially by the research team. These drugs will be stored in a 
locked cabinet in the Drug Supply Room in the CDCRC and supplied to study 
participants as needed in unblinded containers. 
 
18) Multi-Site Human Research* 
Not applicable. 
 
19) Community-Based Participatory Research 
Not applicable. 
 
20) Sharing of Results with Subjects 
The results of this study will not be shared directly with the participants. As part of 
the consent process it will be explained to the participants that they can contact the 
Principal Investigator should they wish to find out about the results of the study, or 
for any other information about the study.  
 
The results of the pulmonary function tests and cardiopulmonary exercise tests may 
be shared with the patient on request. Patients are likely to have performed this test 
previously, and the results of this test may provide information on the progression of 
their disease. Patients will be provided with a copy of their incremental exercise test 
results on request. Information on pulmonary function or clinical exercise testing will 
be provided by the PI or participating physician. Other results will be explained on 
request by the PI or his staff, but these are experimental procedures and have no 
specific diagnostic or clinical benefit to the individual patient. 
 
 
References 
American Thoracic Society/European Respiratory Society. Skeletal muscle dysfunction 
in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 159:S1–S40, 1999. 
(PMID 10194189) 
 
Agusti AG, Sauleda J, Miralles C, Gomez C, Togores B, Sala E, Batle S, Busquets X. 
Skeletal muscle apoptosis and weight loss in chronic obstructive pulmonary disease. Am 
J Respir Crit Care Med 166:485–489, 2001. (PMID 12186825) 
 
Bainbridge FA. Physiology of muscular exercise. London: Longmans, 1919. 
 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 28 of 31 
 
Beelen A, Sargeant AJ. Effect of fatigue on maximal power output at different 
contraction velocities in humans. J Appl Physiol 71:2332-2337, 1991. (PMID 1778931) 
 
Bigland-Ritchie B. EMG and fatigue of human voluntary and stimulated contractions. In: 
Human Muscle Fatigue: Physiological Mechanisms. Eds Porter R, Whelan J. London: 
Pitman Medical, pp 130–156, 1981. 
 
Bowen TS, Cannon DT, Murgatroyd SR, Birch KM, Witte KK, Rossiter HB. The 
intramuscular contribution to the slow oxygen uptake kinetics during exercise in chronic 
heart failure is related to the severity of the condition. J Appl Physiol 112:378-387, 2012. 
(PMID 22033530) 
 
Cannon DT, White AC, Andriano MF, Kolkhorst FW, Rossiter HB. Skeletal muscle 
fatigue precedes the slow component of oxygen uptake kinetics during exercise in 
humans. J Physiol 589:727-739, 2011. (PMID 21135050) 
 
Casaburi R, Gosselink R, Decramer M, Dekhuijzen PN, Fournier M, Lewis MI, Maltais 
F, Oelberg D, Reid MB, Roca J, Schols AM, Sieck GC, Systrom D, Wagner PD, 
Williams TJ, Wouters EF. Skeletal muscle dysfunction in obstructive pulmonary disease. 
A Statement of the American Thoracic Society and European Respiratory Society.  Am J 
Respir Crit Care Med 159:S1-S40, 1999. (PMID 10194189) 
 
Casaburi R, ZuWallack R. Pulmonary rehabilitation for management of chronic 
obstructive pulmonary disease. N Engl J Med. 360:1329-1335, 2009. (PMID 19321869) 
 
Coelho AC, Cannon DT, Cao R, Porszasz J, Casaburi R, Knorst MM, Rossiter HB. 
Instantaneous quantification of skeletal muscle activation, power production, and fatigue 
during cycle ergometry. Journal of Applied Physiology 118:646-654, 2015.  (PMID 
25539940). 
 
Eisner MD, Iribarren C, Blanc PD, Yelin EH, Ackerson L, Byl N, Omachi TA, Sidney S, 
Katz PP. Development of disability in chronic obstructive pulmonary disease: beyond 
lung function. Thorax 66:108-114, 2011. (PMID 21047868) 
 
Elmer SJ, Amann M, McDaniel J, Martin DT, Martin JC. Fatigue is specific to working 
muscles: no cross-over with single-leg cycling in trained cyclists. Eur J Appl Physiol 
113:479-488, 2013. (PMID 22806085) 
 
Engelen MP, Schols AM, Does JD, Wouters EF. Skeletal muscle weakness is associated 
with wasting of extremity fatfree mass but not with airﬂow obstruction in patients with 
chronic obstructive pulmonary disease. Am J Clin Nutr 71:733–738, 2002. (PMID 
10702166) 
 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 29 of 31 
 
Ferguson C, Rossiter HB, Whipp BJ, Cathcart AJ, Murgatroyd SR, Ward SA. Effect of 
recovery duration from prior exhaustive exercise on the parameters of the power-duration 
relationship. J Appl Physiol 108:866-874, 2010. (PMID 20093659) 
 
Ferguson C, Wylde LA, Cannon DT, Benson AP, Rossiter HB. No reserve in maximal 
voluntary cycling power at the limit of tolerance using isokinetic ergometry. Med Sci 
Sports Exerc [abstract], in press, 2013. 
 
Ferguson GT, Fležar M, Korn S, Korducki L, Grönke L, Abrahams R, Buhl R. Efficacy 
of Tiotropium + Olodaterol in Patients with Chronic Obstructive Pulmonary Disease by 
Initial Disease Severity and Treatment Intensity: A Post Hoc Analysis. Adv Ther. 32:523-
536, 2015. (PMID 26112656) 
 
Gagnon P, Bussières JS, Ribeiro F, Gagnon SL, Saey D, Gagné N, Provencher S, Maltais 
F. Influences of spinal anaesthesia on exercise tolerance in patients with chronic 
obstructive pulmonary disease. Am J Respir Crit Care Med 186:606-615, 2012. (PMID 
22822019) 
 
Goodall S, Gonzalez-Alonso J, Ali L, Ross EZ, Romer LM. Supraspinal fatigue after 
normoxic and hypoxic exercise in humans. J Physiol 590:2767-2782, 2012. (PMID 
22473785) 
 
Mador MJ, Bozkanat E, Kufel TJ. Quadriceps fatigue after cycle exercise in patients with 
COPD compared to healthy control subjects. Chest 123:1104-1111, 2003. (PMID 
12684300) 
 
Mador MJ, Kufel TJ, Pineda L. Quadriceps fatigue after cycle exercise in patients with 
chronic obstructive pulmonary disease. Am J Respir Crit Care Med 161:447-453, 2000. 
(PMID 11282768) 
 
Marquis K, Debigaré R, Lacasse Y, LeBlanc P, Jobin J, Carrier G, Maltais F. Midthigh 
muscle cross-sectional area is a better predictor of mortality than body mass index in 
patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 
166:809–813, 2002. (PMID 12231489) 
 
McKenna MJ, Hargreaves M. Resolving fatigue mechanisms determining exercise 
performance: integrative physiology at its finest! J Appl Physiol 104:286-287, 2008. 
(PMID 17962568) 
 
Meyer A, Zoll J, Charles AL, Charloux A, de Blay F, Diemunsch P, Sibilia J, Piquard F, 
Geny B. Skeletal muscle mitochondrial dysfunction during chronic obstructive 
pulmonary disease: Central actor and therapeutic target. Exp Physiol (in press), 2013. 
(PMID 23377494) 
 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 30 of 31 
 
Miller MR, Crapo R, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, Enright 
P, van der Grinten CPM, Gustafsson P, Jensen R, Johnson DC, MacIntyre N, McKay R, 
Navajas D, Pedersen OF, Pellegrino R, Viegi G, Wanger J. General considerations for 
lung function testing. Eur Respir J 26:153–161, 2005. (PMID 15994402) 
 
Miniño AM, Murphy SL, Xu JQ, Kochanek KD. Deaths: Final data for 2008. Natl Vital 
Stat Rep. 59:1-126, 2011. (PMID 22808755) 
 
Newham DJ, McCarthy T, Turner J. Voluntary activation of human quadriceps during 
and after isokinetic exercise. J Appl Physiol 71:2122-2126, 1991. (PMID 1778901) 
 
Richardson RS, Leek BT, Gavin TP, Haseler LJ, Mudaliar SR, Henry R, Mathieu-
Costello O, Wagner PD. Reduced mechanical efficiency in chronic obstructive 
pulmonary disease but normal peak VO2 with small muscle mass exercise. Am J Respir 
Crit Care Med 69:89-96, 2004. (PMID 14500263) 
 
Saey D, Debigare R, LeBlanc P, Mador MJ, Côté CH, Jobin J, Maltais F. Contractile leg 
fatigue after cycle exercise: a factor limiting exercise in patients with chronic obstructive 
pulmonary disease. Am J Respir Crit Care Med 168:425-430, 2003. (PMID 12714348) 
 
Sargeant AJ, Dolan P. Effect of prior exercise on maximal short-term power output in 
humans. J Appl Physiol 63:1475-1480, 1987. (PMID 3693183) 
 
Schols AM, Broekhuizen R, Weling-Scheepers CA, Wouters EF. Body composition and 
mortality in chronic obstructive pulmonary disease. Am J Clin Nutr 82:53–59, 2005. 
(PMID 16002800) 
 
Schols AM, Soeters PB, Dingemans AM, Mostert R, Frantzen PJ, Wouters EF. 
Prevalence and characteristics of nutritional depletion in patients with stable COPD 
eligible for pulmonary rehabilitation. Am Rev Respir Dis 147:1151–1156, 1993. (PMID 
8484624) 
 
Seymour JM, Ward K, Sidhu PS, Puthucheary Z, Steier J, Jolley CJ, Rafferty G, Polkey 
MI, Moxham J. Ultrasound measurement of rectus femoris crosssectional area and the 
relationship with quadriceps strength in COPD. Thorax 64:418–423, 2009. (PMID 
19158125) 
 
Somfay A, Porszasz J, Lee SM, Casaburi R. Dose-response effect of oxygen on 
hyperinflation and exercise endurance in nonhypoxaemic COPD patients. Eur Respir J 
18:77-84, 2001. (PMID 11510809) 
 
van der Vaart H, Murgatroyd SR, Rossiter HB, Chen C, Casaburi R, Porszasz J. (2013). 
Using the power-duration curve to select constant work rates for endurance testing in 
COPD. Proc American Thoracic Society annual conference. [abstract], in press. 

PROTOCOL TITLE: A randomized, crossover, placebo controlled, double-blind phase 
IV trial of the effect of on STIOLTO™ RESPIMAT® on central and peripheral 
components of fatigue during exercise in chronic obstructive pulmonary disease 
Revised: November 13, 2015 
 
 
Page 31 of 31 
 
 
Weir JP, Wagner LL, Housh TJ. Linearity and reliability of the iEMG v torque 
relationship for the forearm flexors and leg extensors. Am J Phys Med and Rehabil 
71:283-287, 1992. (PMID 1388975) 
 
Whipp BJ, Rossiter HB. The kinetics of oxygen uptake: Physiological inferences from 
the parameters. In: Oxygen uptake kinetics in sport, exercise and medicine. Eds. Jones 
AM, Poole DC. Routeledge, London. Ch 3. 2005 
 
Yoon T, Schlinder-Delap B, Keller ML, Hunter SK. Supraspinal fatigue impedes 
recovery from a low-intensity sustained contraction in old adults. J Appl Physiol 
112:849-858, 2012. (PMID 22174405)