Effect of the Inhaled Triple Therapies Over the Small Airway in Patients With Chronic Obstructive Pulmonary Disease or Chronic Bronchitis Without Obstruction Secondary to Biomass Exposure: Randomized Controlled Clinical Trial Phase IV
Phase: PHASE4
Conditions: COPD Bronchitis, Pollution Related Respiratory Disorder
Sponsor: National Institute of Respiratory Diseases, Mexico

Effect of inhaled triple therapies on the small airway in patients with Chronic 
Obstructive Pulmonary Disease or chronic bronchitis without obstruction 
exposed to wood smoke: Phase IV randomized controlled clinical trial.  
 
Approved by the Institutional Ethics Committee on November 13th, 2023 under the 
code C74-23.  
 
DEFINITION OF THE PROBLEM  
Domestic pollution secondary to biomass burning is the main risk factor in the field 
of environmental health, according to the World Health Organization (WHO) it 
caused up to 4.3 million deaths in 2012 [1]; It is associated with cooking on open 
stoves with solid fuels such as firewood, charcoal. This activity, common in our 
Mexican population, can cause chronic obstructive pulmonary disease due to 
biomass (firewood smoke) (COPD-B), causing persistent respiratory symptoms and 
a decline in respiratory function [2–4]. However, there is also a proportion of patients 
who present with symptoms of COPD-B but do not meet the established definition 
of obstruction and remain asymptomatic [5]. Patients with COPD-B have a 
predominantly airway phenotype, with small airway dysfunction (SAD) demonstrated 
by oscillometry. Due to the aforementioned, initiating inhaled treatment in patients 
with COPD-B classified as GOLD 0 or pre-COPD or as chronic bronchitis without 
obstruction (BCNO) [6], in an earlier phase, could impact on improving or even 
reversing the peribronchiolar inflammation. Testing triple therapy (TT) long-acting 
muscarinic 
antagonist, 
long-acting 
beta-agonist, 
and 
inhaled 
steroid 
(LAMA/LABA/ICS) is emerging as an alternative to stop the progression of COPD 
[5], improve the quality of life associated with health, integrating patients into their 
work and social environment and even reducing the costs related to health care. 
Currently there are three devices containing umeclidinium, vilanterol, and fluticasone 
in an Ellipta device using dry powder triple therapy (E-PST); glycopyrronium, 
formoterol and extra fine particle beclomethasone in pressurized metered dose 
inhaler (pMDI-EF); glycopyrronium, formoterol, and budesonide also in pMDI (pMDI- 
F), the three therapies being very recently used in COPD due to cigarette smoking 
(COPD-C), and we will also compare the Ellipta device with dry powder dual therapy 
(E-PSD) with umeclidinium/vilanterol) in our social and health context for patients 
with COPD-C, it is very suitable to have a treatment for COPD-C that allows it to be 
more precise and personalized according to their phenotype.  
 
RESEARCH QUESTION  
In patients with COPD-B and BCNO, is there any difference in small airway 
resistance, especially R5-R20 and/or AX, when triple therapies (pMDI-EF, E-PST, 
pMDI-F) are administered for three months? compared to dual therapy (E-PSD)?  
 
BACKGROUND  
Background information must be provided to understand the relevance of this study 
and the purpose and rationale of the study.  
A summary of data from non-clinical studies that are potentially of clinical importance 
and from clinical and epidemiological studies relevant to the present study should be 

included, as well as references to the literature relevant to the study and that provide 
support for the study.  
We know that there are multiple risk factors for the development of COPD, the main 
factor for the burden of COPD is tobacco [7], however, in second place is the burning 
of biomass. The clinical profile of COPD associated with wood smoke (HL) has been 
reported that mainly women are affected and develop COPD associated with 
biomass combustion (COPD-B) [3, 4], they present a decrease in FEV1 slower but 
homogeneous [8], but they present with a deterioration in quality of life and increased 
mortality similar to that of patients with COPD-C[9]. Furthermore, they develop little 
emphysema, but the damage predominates in the VAP, with DVAP manifesting by 
oscillometry [10]. Understanding the progression of COPD offers new opportunities 
for prevention, early diagnosis, and intervention. This has brought about concepts 
such as pre-COPD or GOLD 0, as well as chronic non-obstructive bronchitis (BCNO) 
[11] refers to individuals of any age who have respiratory symptoms with structural 
and/or functional abnormalities, in the absence of respiratory limitation airflow, which 
can have outcomes such as exacerbations or even death. In Mexico, patients 
exposed to wood smoke have been analyzed and 3.5% present obstruction, but if 
exposed women are analyzed, 27% and 16% remain symptomatic (referring to 
cough, phlegm, and dyspnea) [12]. For this group of symptomatic patients without 
obstruction, pharmacological interventions have been performed [13] and there are 
currently some trials for patients with COPD-B [14]. Triple therapy has shown a 
decrease in mortality, which is why it has become one of the standard treatments for 
patients with COPD who present peripheral eosinophils of 300 cells/mcl, and 
frequent exacerbations [13], but as far as we know, they are not included. 
unobstructed symptomatic patients exposed to wood smoke.  
Clinical trials of bronchodilator drugs in COPD often investigate the dose-response 
relationships of different drugs with FEV1, but spirometric measurement of FEV1 is 
usually the main outcome variable, however, it does not reflect damage to VAP; 
Furthermore, bronchodilator drugs can improve lung mechanics in patients with 
COPD despite small changes in FEV1, however, oscillometry seems to be a 
sensitive option to measure these changes [15]. The most sensitive and constant 
parameters to measure changes seem to be R5-R20, AX, R5, being associated with 
quality of life or symptoms [16].  
Thus, comparatively, we propose to carry out a randomized, open clinical trial with 
the different triple therapies U/V/FL, G/F/B and G/F/BD evaluating the response by 
impulse oscillometry, specifically the reduction of resistances in R5, R20, R5-R20, 
and the reactance area (AX). In addition to these interventions, we will secondarily 
investigate the symptoms, and the quality of life evaluated by the Saint George 
questionnaire, in addition to characterizing the VAP condition through respiratory 
function and imaging.  
 
JUSTIFICATION  
We start from the need to treat a group of patients with characteristics different from 
patients with COPD-C, from the mechanisms of pathogenesis, symptoms and  
clinical signs and respiratory function, therefore, even though some patients may not 
develop obstruction [17 , 18] some of them remain with symptoms and with a quality 
of life associated with the affected health [19], since we know that in the pathogenic 

background of the disease the main respiratory condition is directed at the VAP [10], 
demonstrated both histologically as functional [20]. Therefore, hypothetically, 
patients exposed to wood smoke could remain symptomatic and not develop 
obstruction. This is how we propose early therapeutic intervention; This intervention 
will aim to reduce the predominant inflammation in symptomatic women exposed to 
wood smoke with or without obstruction. The evaluation, as mentioned, aims to 
identify the response by oscillometry in those patients with COPD-B and patients 
with BCNO with the 3 different triple therapies in a single device compared to dual 
therapy in a single device.  
 
HYPOTHESIS  
Triple device therapies (pMDI-EF, pMDI-F and E-PST) will show a greater proportion 
of patients with decreased VAP resistance in R5-R20 and/or AX, compared to the E- 
PSD device in patients with COPD-B and BCNO exposed to firewood smoke after 
90 days of treatment.  
 
GENERAL OBJECTIVE  
To evaluate if there is a difference in the response of VAP resistance through iOS in 
R5-R20 and/or AX for triple therapies (pMDI-EF n pMDI-F and E-PST) compared to 
E-PSD in patients with COPD-B and BCNO in a period of 90 days.  
 
SPECIFIC OBJECTIVES  
1. Quantify adherence to treatment according to the inhaler used. [Time frame: 90- 
day 
baseline] 
2. Quantify the proportion of patients with the different triple therapies who present 
a change in peripheral airway resistance using iOS (post-bronchodilator change in 
total resistance, z-score, and percentage change for R5, R20, AX, X5, R5-R20) at 
30 minutes, 2 hours, 4 hours and 24 hours, 30 days and 90 days after administering 
triple therapy or dual treatment.”  
3. The response to bronchodilator will be quantified in FEV1, FVC, FEF 25-26, and 
MEF50, at 30 minutes, 2 hours, 4 hours, and 24 hours, 30 days, and 90 days after 
administering 
triple 
therapy 
or 
dual 
treatment. 
4. Quantify the change in the exhaled fraction of nitric oxide (ppb) before 
administering the triple therapies and the dual bronchodilator at 24 hours, 30 days, 
and 90 days.  
5. Compare peripheral airway resistance using body plethysmography with those 
obtained 
by 
IOS 
[Time 
frame: 
baseline 
and 
90 
days]. 
6. Analyze the proportion of individuals with a significant improvement of 2 units in 
CAT. [Time frame: 90 days].  
7. Analyze the proportion of individuals with a significant improvement of 4 units in 
the Saint George respiratory quality of life questionnaire. [Time frame: 90 days]  
8. Assess the change from baseline in 12-hour minimum inspiratory capacity, FEF25- 
75% 
and 
iso-volume 
FEF25-75% 
(absolute 
value 
and 
% 
predicted) 
9. Describe the biomarkers associated with Th2 and Th17 inflammatory endotypes: 
exhaled fraction of nitric oxide ppm, total peripheral serum eosinophils and 
percentage, serum interleukins 4, 5, 6, 13, 17, 22, 31, 33 and eotaxin.  
10. Evaluate the safety profile of inhaled medications E-PS, pMDI-EF or pMDI-F.  

MATERIAL AND METHODS  
1. Study location. 
National Institute of Respiratory Diseases “Dr. Ismael Cosío Villegas” as directing 
center. It will be a multicenter study where different research centers that care for 
this type of patients will participate, as well as having the place and supplies 
necessary to carry out the procedures, as well as the training of the personnel 
necessary for them. The patients will be those belonging to the COPD Clinic and 
the COPD Patient Cohort of the COPD and Smoking Research Department, as 
well as patients from the participating research centers.  
2. Description of the study population. 
Patients with a diagnosis of COPD-B GOLD I or with chronic non-obstructive 
bronchitis who belong to the COPD-B Clinic Cohort or participating centers.  
3. Inclusion Criteria.  
1. The subject must be able to understand and give informed consent.  
2. Age 35-85 years  
3. Women (not pregnant or using effective contraception).  
4. Diagnosis of COPD-B or BCNO  
i. Patients diagnosed with COPD-B according to the GOLD 2023 guidelines, 
secondary to exposure to wood smoke >100 hours-year, with FEV1 > 70%.  
ii. Patients with BCNO who have at least one exposure to wood smoke for 10 years 
and/or > 100 hours-year, and who also present: 1) history of chronic bronchitis and 
2) post-bronchodilator spirometry with FEV1/FVC >0.7. 
and. 
e. Possibility to attend all study visits. 
f. Cooperative patients with adequate understanding and skill in using inhalers, or 
with caregivers capable of administering medications and filling out a daily 
symptom diary. 
g. Stable patients, with no history of exacerbations in the last 4 weeks before 
inclusion.  
4. Exclusion Criteria. 
a) Documented allergy or intolerance to any of the study medications. 
b) Pregnancy or lactation. 
c) History of clinically significant bronchiectasis, tuberculosis, recent respiratory 
infection (4 weeks), or cardiovascular comorbidity that contraindicates pulmonary 
function tests or that influences their status and functional class.  
d) Patients with suspicion or history of cancer. 
e) Uncontrolled diseases: acute hyperthyroidism, acute uncontrolled DM2, acid- 
peptic disease that causes bleeding, uncontrolled hematological diseases, etc. In 
general, any decompensated disease that, in the opinion of the principal 
investigator, may influence the results of the study.  
5. Elimination criteria. 
a) Side effects that are not tolerated (Adverse effects will be reported immediately 
(<24 hours) to the Institute's Science and Bioethics Committee) 
b) Adherence to treatment < 80% (The devices dispensed will be reviewed at each 
visit to count consumed doses and remaining doses, the inhalation technique will 
be corroborated.) 
c) Do not attend 1 or more visits.  

6. Sample size. 
The sample calculation for mean difference was based on Borrill et al [15] with 
80% power to detect a difference of 0.1 kPa L -1 s in the primary outcome 
assuming a reduction in the basal percentage of AX - 28% and/or R5-R20 -8.5% 
for VAP resistances, expecting an alpha error of 0.05 (two-tailed) with a total of 16 
patients per group for each triple therapy and dual therapy for each group 
(obstructed and non-obstructed by spirometry), with a total of 128 patients.  
Primary 
outcomes: 
•Quantify the change in impulse oscillometry (post-bronchodilator change in total 
resistance measured in percentage change from baseline change R5-R20 and/or 
AX for patients who used E-PS vs pMDI-EF vs pMDI-F at 3 months.  
Secondary 
outcomes: 
• Quantify the change by z-score and percentage change for R5, R20, R15 and Fres. 
• Change in total resistances and reactances in kPaL-s, measured by oscillometry 
in R5-R20, R20,AX, Fres. and total resistances, measured by plethysmography. 
• Change in lung function in FEV1, FVC, FEF25-75%, MMEF(L/s) both in ml and in 
percentage 
change 
from 
predicted. 
• Quantify adherence to treatment according to the type of inhaler. 
• Change in exhaled fraction of nitric oxide measured by parts per million. 
• Change in the level of total peripheral eosinophils and in percentages. 
• Change in quality of life in CAT score according to triple therapy. 
• Change in quality of life in the Saint George respiratory questionnaire score, 
according 
to 
triple 
therapy. 
• Change in dyspnea score measured by mMRC  
Safety 
evaluation: 
Includes the evaluation of adverse events from rare to frequent, which will be 
reported by patients and recorded in a symptom log.  
 
Definition of variables 
 
1. Impulse Oscillometry Measurement: 
to. A Jaeger MasterScreen IOS device will be used, following the technical 
recommendations of the ERS 2020 standard [5]. The patient will be asked to 
position himself in an upright sitting position, a nose clip will be placed and he will 
be asked to place his mouth on the mouthpiece of the device and maintain a tight 
seal at all times, and his hands will be placed on his cheeks to prevent artifacts 
caused by the upper airway and oral cavity. You will be asked to take breaths at 
tidal volume, verify that there are no artifacts (swallowing, glottic closure, cough, 
obstruction of the mouthpiece by the tongue or leaks), and to breathe for about 30 
seconds or until you have adequate measurements without artifacts. 3 acceptable 
and repeatable maneuvers will be performed (with a coefficient of variation less 
than 15% in R5) and the final value of each parameter will be the average of the 3 
maneuvers. 
b. The values or z score will be taken into account to determine if there is an 
obstruction of the VAP, taking into account an increase in resistances in R5-R20 
and in the reactance area (AX) (greater than +1.64z). to that of AX and R5-R20. 
c. To determine the primary outcome, the change in post-bronchodilator 

oscillometry and in PBD oscillometry at the end of the month will be taken into 
account, measuring the percentage change.  
 
2. Slow Spirometry Measurement (inspiratory capacity) 
a) An EasyOne Pro LAB device from ndd Medical Technologies will be used 
following the technical recommendations of the ATS 2019 standard [21]. The 
patient will be asked to position himself in an upright sitting position, a nose clip will 
be placed and he will be asked to place his mouth on the mouthpiece of the device 
and maintain a tight seal at all times, he will be asked to perform tidal breaths, 
Begin the maneuver of relaxed deep inspiration and relaxed deep expiration. At the 
end, a deep inhalation is requested to complete the closed loop circuit.  
 
3. 
Measurement 
of 
simple 
forced 
spirometry 
and 
with 
bronchodilator: 
An EasyOne Pro LAB device from ndd Medical Technologies will be used following 
the technical recommendations of the ATS 2019 standard [21]. The patient will be 
asked to position himself in an upright sitting position, a nose clip will be placed and 
he will be asked to place his mouth on the mouthpiece of the device and maintain a 
tight seal at all times, he will be asked to take a forced inhalation and Subsequently, 
quickly and forcefully exhale until you reach residual volume, thus, without removing 
yourself from the mouthpiece, you will be asked to inhale deeply to complete the 
closed loop circuit of spirometry and the result will be analyzed.  
 
4. 
Exhaled 
fraction 
of 
nitric 
oxide: 
a) Portable equipment with a NIOX-MINO brand electrochemical sensor (Aerocrine, 
Solna) will be used, following the procedure recommended by Cantú et al.  
 
5. Simple Plethysmography Measurement:  
Jaeger MasterScreen Body equipment will be used following the technical 
recommendations of ERS/ATS [22]. Explain the procedure to be performed, 
emphasizing the following instructions to the patient: The patient must remain seated 
inside the cabin, with the chest and neck in a straight position. and with both feet 
supported on the floor. You can move the sensor forward or backward to grasp the 
mouthpiece without flexing or extending your neck. Before starting the 
measurement, place the clamp on your nose. You will need to hold your cheeks with 
both hands (demonstrate). Remember that the mouthpiece should be held with your 
teeth without biting or sticking your tongue in and you should seal your lips around 
it. You should breathe normally through the mouthpiece for 3 to 10 breaths, then the 
mouthpiece will be clogged. Don't be scared, it only lasts a few seconds during which 
you should breathe quickly and shallowly, about one breath per second. When the 
valve opens, inhale deeply until you fill your lungs and then exhale in a relaxed 
manner until it tells you that the measurement is over.  
b. Once the procedure has been explained, close the cabin door and wait one minute 
for 
the 
pressure 
and 
temperature 
inside 
the 
cabin 
to 
stabilize. 
c. Supervise the proper placement of the mouthpiece and nose clip, as well as 
adequate cheek support with the hands.  
d. Ask him to breathe calmly, obtaining 3 to 10 breaths at tidal volume, waiting for 
the volume level to stabilize at the end of each expiration (stable FRC). 

and. Occlude the valve at the end of an expiration when the patient is at the FRC 
level, instruct the patient to breathe at a slow rate of .5 to 1.5 Hz or one breath per 
second (30 to 90 breaths per minute).  
F. When the shutter valve opens, ask the patient to take maximum inspiration and 
then relax expiration until reaching a plateau of at least one second with a volume 
change 
of 
<25 
mL. 
g. In patients with severe dyspnea who cannot complete the VC maneuver 
immediately after the ITGV maneuvers, they can perform a few tidal volume breaths 
and then attempt the VC maneuver.  
h. Verify that the FRCpleth (ITGV) measurement generates almost straight ITGV 
curves that overlap each other, being within the pressure calibration ranges of the 
transducers (± 10 cmH2O or 1.3 kPa) and correct if necessary.  
6. Simple chest tomography, performed on the SOMATOM X equipment, syngo CT 
VA40, Siemens Healthcare Diagnostics, 128 Dual Energy slices; with the following 
acquisition 
parameters: 
Adjustment of Kev and mAs according to weight. A tomographic scan in apnea 
inspiration and maximum expiration.  
Iterative reconstructions: Bf 31 and Bf 45, with lung window for quantitative 
evaluation with Syngovia – Pulmo 3D post-processing software (Siemens). Iterative 
reconstruction: B 70, for morphological evaluation of the lung parenchyma. Iterative 
reconstruction: B 21, for evaluation of the mediastinum and associated findings.  
The tomographic protocol is established in the equipment command for subsequent 
reproducibility with the name “pre-COPD”. On average, each tomography involves a 
radiation dose of 3.9 mSv equivalent to 198.8 plates; compared to a conventional 
tomography where the radiation dose is 5 mSv for a high-resolution tomography and  
7 mSv for a simple tomography, a standardized parameter for the use of effective 
dose. Image post-processing is carried out in Pulmo3D software, syngo via.client 8.6 
(x64) 
Siemens 
2021. 
Tomographic findings will be divided into: Morphological and Quantitative: 
parenchymal and airway.  
 
Procedures:  
Each patient will undergo a clinical evaluation and application of questionnaires; 
Subsequently, baseline spirometry will be performed on both the captive COPD-B 
population and patients with chronic bronchitis exposed to biomass, in whom 
obstruction will be confirmed or ruled out. Subsequently, IOS will be performed for 
EVAP evaluation (R5, R20, AX, R5-R20); in addition to a chest tomography at the 
beginning of the study, which will be evaluated by a radiologist who will determine if 
they have findings compatible with COPD with predominance of emphysema or with 
predominance of air trapping. Assignment to treatment: The assignment to each 
group will be random using a table of random numbers in the Redcap program; Each 
patient will take their assignment on the starting day (visit 0) and the technique and 
dosage will be instructed by the subinvestigators.  
Blinding of the study: It is open, the medication cannot be blinded since the labeling 
on the device indicates what medication the subject who will take it and the doctor 
evaluating the patient is receiving. Although the coordinator or technician who 

applies the questionnaires and respiratory function tests is unaware of the assigned 
medication.  
 
Visits.  
Signing of informed consent (Selection visit day -21 to -1): The diagnosis of COPD- 
HB or BCNO will be verified. The inclusion criteria will be checked and it will be 
verified if there are any exclusion criteria (clinical record will be reviewed if 
necessary). The patient is invited to the study, and will be given detailed information 
about it, and a copy of the informed consent for evaluation. If you agree to participate 
in the study, you will be asked to sign the consent in the indicated space, as well as 
two witnesses. If the patient does not have post-bronchodilator forced spirometry 
and a six-minute walk in the last 3 weeks, these tests will be performed in the COPD 
lung function laboratory. A symptom diary will be dispensed and training will be given 
on how to fill it out. The patient will be instructed to begin the washout time, which 
will be one week for long-acting bronchodilators (LAMA or LABA, or LAMA/LABA 
combination), and 3 weeks for inhaled steroids (or ICS/LABA, ICS/LABA 
combinations). LAMA/LABA). During this period, patients will be able to use their 
rescue bronchodilator (SAMA, SABA, or combination) by schedule. They will be 
instructed in the identification of exacerbations and alarm symptoms and, if 
necessary, communicate with the principal investigator.  
Randomization visit and start of treatment. (Visit 0, day 0): A complete patient history 
will be taken, with main emphasis on the recording of comorbidities and concomitant 
medication. Inclusion and exclusion criteria will be checked. The washout time of 
each bronchodilator will be confirmed, and once confirmed, baseline questionnaires  
will be performed: Measurement of dyspnea (mMRC scale, VAS) and quality of life 
questionnaires (CAT and SGRQ). Symptom diary will be reviewed. The history of 
exacerbations in the last 4 weeks will be verified. If you continue to meet the criteria, 
you will be selected and baseline respiratory function tests will begin: The tests will 
be performed between 7:00 to 8:00 AM in the following order: Exhaled fraction of 
nitric oxide (FeNO), impulse oscillometry, slow spirometry, forced spirometry , and 
simple plethysmography. The selection criteria will be confirmed and if you are a 
candidate, randomization will be carried out through the Redcap program.  
Patients will be assigned one of the four devices contemplated for the study. The first 
group will be assigned the pMDI-EF device containing Beclomethasone/ Formoterol/ 
Glycopyrronium 100/6/12.5 mcg with doses of two inhalations every 12 hours; The 
second 
group 
will 
be 
assigned 
the 
pMDI-F 
device 
containing 
Budesonide/Formoterol/Glycopyrronium 160/4.8/7.2 mcg with doses of two 
inhalations every 12 hours; the third group will be assigned the E-PST device 
containing Fluticasone/ Vilanterol/ Umeclidinium 100/25/62.5 mcg with a dose of one 
inhalation every 24 hours; the fourth group will be assigned the E-PSD device 
containing Vilanterol/Umeclidinium 25/62.5 mcg with a dose of one inhalation every 
24 hours. o Each patient will be given a 100 μg salbutamol device as rescue 
medication.  
Once the study medication is assigned, you will be instructed in technique and 
dosage, and a corresponding dose will be applied. A blood sample will be taken for 
a blood count and IgE test and Th2 and Th17 inflammatory profile cytokines. After 
30 minutes of application of the study medication, impulse oscillometry, slow 

spirometry and forced spirometry will be performed. After 2 hours of application of 
study medication, impulse oscillometry, slow spirometry and forced spirometry will 
be performed. After 4 hours of application of study medication, impulse oscillometry, 
slow spirometry and forced spirometry will be performed. At the end of the respiratory 
function tests, you will be referred to the imaging service for tomography evaluation 
if it is not available with volumetry in the last year. Adverse events will be measured 
at baseline, for the safety outcome. The patient will be instructed in the use of the 
assigned medication, technique, frequency of use, as well as information and 
training on possible side effects. Visit 1 will be scheduled on your card the next day 
without a window period.  
Follow-up visit 1 (Visit 1, Day 1): Changes in respiratory symptoms, presence of 
adverse events, and use of concomitant medication will be questioned and 
documented. Symptom diary will be reviewed. It will be confirmed that the patient 
has not applied the morning dose of study medication. Dyspnea questionnaire 
(mMRC) and quality of life questionnaire (CAT) will be completed. Pulmonary 
function tests will be performed: FeNO, impulse oscillometry, slow spirometry, forced 
spirometry and simple plethysmography. Standard doses of SABA (400 mcg of 
salbutamol) will be applied and after 20 minutes post-bronchodilator tests of impulse 
oscillometry, slow spirometry and forced spirometry will be performed. You will be 
instructed in the technique of inhalation of study medication and a corresponding 
dose will be applied. Study medication will be provided for one month of treatment. 
A symptom diary will be provided and a follow-up visit 2 will be scheduled 30 days 
after the randomization visit. Instructions for said visit will be given.  
 
Follow-up visit 2 (Visit 2, 30 days -2/+1 day): Exacerbations during the period, 
frequency of adverse events, newly diagnosed comorbidities and use of concomitant 
medication will be questioned and documented. Symptom diary will be reviewed. 
Devices dispensed at visit 1 will be reviewed to calculate adherence to treatment 
(≥80%). It will be confirmed that the patient has not applied the morning dose of 
study medication. Dyspnea questionnaire (mMRC), quality of life questionnaire 
(Saint George and CAT), and adherence to inhaled medication questionnaire (TAI) 
will be completed. Baseline pulmonary function tests will be performed: FeNO, 
impulse 
oscillometry, 
slow 
spirometry, 
forced 
spirometry 
and 
simple 
plethysmography. Short-acting bronchodilator (SABA) will be applied, the patient will 
be left to rest for 20 minutes. Post-bronchodilator tests will be initiated in the following 
order: impulse oscillometry, slow spirometry, forced spirometry. You will be instructed 
in the technique of inhalation of study medication and a corresponding dose will be 
applied. Study medication will be provided for two months of treatment. A symptom 
diary will be provided and a follow-up visit 3 will be scheduled 12 weeks after the 
randomization visit. Instructions for said visit will be given.  
 
Follow-up visit 3 (Visit 3, 12 weeks -2/+1 day): Exacerbations during the period, 
frequency of adverse events, newly diagnosed comorbidities and use of concomitant 
medication will be questioned and documented. Symptom diary will be reviewed. 
Devices dispensed at visit 1 will be reviewed to calculate adherence to treatment 
(≥80%). It will be confirmed that the patient has not applied the morning dose of 
study medication. Dyspnea questionnaire (mMRC), quality of life questionnaire 

(Saint George and CAT), and adherence to inhaled medication questionnaire (TAI) 
will be completed. Baseline pulmonary function tests will be performed: FeNO, 
impulse 
oscillometry, 
slow 
spirometry, 
forced 
spirometry 
and 
simple 
plethysmography. Standard doses of SABA (400 mcg of salbutamol) will be applied 
and after 20 minutes post-bronchodilator tests of impulse oscillometry, slow 
spirometry and forced spirometry will be performed. Participation in the protocol will 
be terminated and monitoring by the INER Tobacco and COPD clinic will continue.  
All data will be collected in questionnaires designed for this study, including a 
symptom diary. Additionally, some of the data and questionnaires will be collected in 
redCAP, once the visit and medical note are completed. Subsequently, the 
information will be entered into a database also designed in redCAP for this project 
a maximum of 3 days after the visit.  
 
8. Results analysis plan:  
Frequencies and comparisons between groups for continuous variables will be 
analyzed with unpaired t-tests and X2 for proportions. All efficacy analyses will be 
based on treatment data. To analyze the exacerbation rate, a generalized linear 
mixed negative binomial model will be used for each group with the treatment 
variable as a covariate where the number of moderate and severe exacerbations will 
be considered during the 4-week period.  
 
The model analyzed terms for treatment, type of exposure (biomass or tobacco 
exposure), initial smoking and current biomass use, and severity of airflow limitation. 
For the analysis of the treatment effect according to the values of R5, R5-R20, Ax 
and Fres, Friedman's 2-way analysis of variance will be used and the differences 
between triple therapies will be analyzed post hoc by Wilcoxon for paired samples. 
Program (software) to use for data analysis.  
Data analysis will be performed in Stata 16.1 software.  
 
 
ETHICAL CONSIDERATIONS  
The type of risk must be considered in accordance with the provisions of Art. 17 of 
the Regulations of the General Health Law on Health Research:  
• Research with minimal risk.  
 
 

 
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