Conditions: Chronic Obstructive Pulmonary Disease
Keywords: COPD Bacteria
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 44
Healthy volunteers: no

Brief summary:
Determine the effect of twice-daily chlorhexidine oral rinse on oral and lung microbiota biomass in subjects with chronic obstructive pulmonary disease (COPD) with chronic bronchitis. Our primary outcome will be to compare the microbiota biomass (number of bacteria as measured by 16S rRNA copy number) of induced sputum and the oral cavity before and after 8 weeks of twice-daily chlorhexidine oral rinse (n=25) compared to controls (n=25) using qPCR and next-generation sequencing of the bacterial 16S rRNA gene comparing total bacterial biomass

Detailed description:
Our hypothesis is that 8 weeks of chlorhexidine oral rinse will decrease microbiota biomass compared to baseline and those on placebo. Furthermore, we hypothesize that chlorhexidine treatment will: i) decrease lung and oral microbiota diversity; ii) alter microbiota taxonomic composition in the lung and oral cavity; iii) decrease systemic inflammation as measured by blood high sensitivity C-reactive protein (hsCRP), fibrinogen and leukocyte count; and iv) demonstrate a trend towards improvement in respiratory health status as measured by the Breathlessness, Cough, and Sputum Scale (BCSS)\[1, 2\] and St. George's Respiratory Questionnaire (SGRQ).

Subaim 1: Determine if chlorhexidine alters the lung and oral rinse microbiota diversity and taxonomic composition. Our hypothesis is that chlorhexidine oral rinse will decrease the diversity (Shannon and inverse Simpson diversity indices) and taxonomic composition of both oral and lung microbiota compared to those on placebo as determined by next-generation sequencing of the bacterial 16S rRNA gene.

Subaim 2: Determine the impact of chlorhexidine on systemic inflammation. Our hypothesis is that the decrease in lung microbiota biomass is associated with a decrease in systemic inflammation as measured by blood hsCRP, fibrinogen, and leukocyte count.

Subaim 3: Determine if respiratory symptoms associate with the lung microbiota biomass. Our hypothesis is that chlorhexidine will demonstrate improved respiratory health status as measured by the BCSS and SGRQ.

Arms:
arm 1: Oral Rinse arm 2: Oral Rinse

Interventions: intervention 1: Chlorhexidine intervention 2: Placebo
Intervention descriptions: intervention 1: Oral Rinse intervention 2: Oral Rinse

Protocol document:
Prot_SAP_000.pdf: 
STUDY PROTOCOL 
Title:  The Effect of Chlorhexidine on the Oral and Lung Microbiota in Chronic Obstructive 
Pulmonary Disease 
Investigators:   
Chris Wendt, MD Principal Investigator 
Dennis Niewoehner, MD  
Ken Kunisaki, MD  
Kathyrn Rice, MD  
Erin Wetherbee, MD   
A. Specific Aims
Aim 1.  Determine the effect of twice-daily chlorhexidine oral rinse on oral and lung microbiota 
biomass in subjects with chronic obstructive pulmonary disease (COPD) with chronic 
bronchitis.  Our primary outcome will be to compare the microbiota biomass (number of bacteria as 
measured by 16S rRNA copy number) of induced sputum and the oral cavity before and after 8 weeks 
of twice-daily chlorhexidine oral rinse (n=25) compared to controls (n=25) using qPCR and next-
generation sequencing of the bacterial 16S rRNA gene comparing total bacterial biomass. 
Our hypothesis is that 8 weeks of chlorhexidine oral rinse will decrease microbiota biomass compared 
to baseline and those on placebo. Furthermore, we hypothesize that chlorhexidine treatment will: i) 
decrease lung and oral microbiota diversity; ii) alter microbiota taxonomic composition in the lung and 
oral cavity; iii) decrease systemic inflammation as measured by blood high sensitivity C-reactive protein 
(hsCRP), fibrinogen and leukocyte count; and iv) demonstrate a trend towards improvement in 
respiratory health status as measured by the Breathlessness, Cough, and Sputum Scale (BCSS)[1, 2] 
and St. George’s Respiratory Questionnaire (SGRQ).   
Subaim 1: Determine if chlorhexidine alters the lung and oral rinse microbiota diversity 
and taxonomic composition. Our hypothesis is that chlorhexidine oral rinse will decrease the 
diversity (Shannon and inverse Simpson diversity indices) and taxonomic composition of both 
oral and lung microbiota compared to those on placebo as determined by next-generation 
sequencing of the bacterial 16S rRNA gene. 
Subaim 2: Determine the impact of chlorhexidine on systemic inflammation.  Our 
hypothesis is that the decrease in lung microbiota biomass is associated with a decrease in 
systemic inflammation as measured by blood hsCRP, fibrinogen, and leukocyte count.  
Subaim 3: Determine if respiratory symptoms associate with the lung microbiota 
biomass. Our hypothesis is that chlorhexidine will demonstrate improved respiratory health 
status as measured by the BCSS and SGRQ. 
B. Background and Significance
COPD and Chronic Obstructive Bronchitis are major health concerns 
Chronic obstructive pulmonary disease (COPD) is currently the third leading cause of death in the 
United States with an estimated prevalence of 23.6 million among all U.S. citizens [3]. Within our 
Veteran population the prevalence of COPD is higher than the general population and thus 
smoking-related diseases are a targeted priority for research within the VA system. A recent 
Date: 3/31/2014
NCT: NCT02252588


 
screening with pulmonary function tests of Veterans in the upper Midwest identified a COPD 
prevalence of 40%[4]. Within our Veteran population COPD is also associated with a higher rate of all-
cause and respiratory-related health care utilization and a high prevalence of co-morbidities[5], thus 
COPD represents a significant burden to Veterans and to the VA health care system. Approximately 
one half of patients with moderate to severe COPD have symptoms of chronic bronchitis, also 
referred to as chronic obstructive bronchitis (COB), defined as chronic cough and phlegm 
production for > 3 months for at least the last two years. When adjustments are made for age, gender, 
and severity of airflow obstruction, patients with chronic obstructive bronchitis experience more 
exacerbations, have worse respiratory health status, and have higher mortality than do patients without 
chronic bronchitis[6, 7], highlighting the need to find therapies that will improve symptoms and other 
clinical outcomes in this patient subset.    
 
The role of bacteria in COPD 
 
Bacteria are known to be important in COPD with approximately 50% of COPD exacerbations attributed 
to respiratory pathogens [8, 9]. Patients with COPD are often colonized with bacteria in their lower 
respiratory tracts even during periods of stable disease. This community of bacteria, or microbiota, may 
be a key factor in the pathogenesis of COPD by causing exacerbations and promoting inflammation. 
Most studies on the role of bacteria in the pathogenesis of COPD have employed traditional culture-
based techniques, which identify only a small fraction (1%) of bacteria present. Current culture-
independent methods to describe the microbiota rely on the analysis of the bacterial 16S rRNA gene, 
which provides a sensitive method of determining which bacterial species are present in complex 
environmental mixtures [10-14]. Sze and colleagues evaluated the lung tissue microbiomes of eight 
very severe COPD patients at the time of lung transplantation and noted increased bacterial diversity in 
the COPD patients compared to controls. Our group’s data show that the microbiome in COPD is 
more diverse compared to healthy controls and that it is reflective of oral flora, suggesting that 
microaspiration and possibly decreased airway clearance plays a role in the lung microbiome[15]. 
Studies have demonstrated that individuals with COPD are more prone to aspiration due to reduced 
laryngotracheal mechanosensitivity [16, 17]. Therefore, we theorize that individuals with chronic 
obstructive bronchitis have an altered lung microbiota due to increased aspiration of the oral 
microbiota; this altered lung microbiota contributes to disease manifestations. 
 
Treatment options for chronic obstructive bronchitis are limited 
 
The most effective medications currently available for COPD are the long-acting inhaled 
bronchodilators and inhaled corticosteroids.  These medications have a modest effect in reducing 
exacerbations and hospitalizations for COPD, but have not proven to be very effective in improving 
symptoms or disability and have consistently failed to improve symptoms as measured by health status 
questionnaires [18, 19]. Approximately one half of patients with moderate to severe COPD have 
symptoms of COB and these patients have more severe outcomes [6, 7].  Therefore, COB patients are 
in need of better therapies and also represent a large portion of COPD patients.  They also readily 
produce sputum that can be used for microbiota analyses.  
 
Chlorhexidine 
 
Chlorhexidine is a cationic polybiguanide (bisbiguanide) that is primarily used as a topical antiseptic. 
The broad-spectrum bactericidal effect of chlorhexidine is primarily a result of the binding of this 
cationic molecule to negatively charged bacterial walls that results in a bacteriostatic effect in low 
concentration and disrupts bacterial membranes at higher concentrations. It is active against both 
gram-postive and –negative organisms and yeast. It is not effective against most viruses. Chlorhexidine 
is often used as an active agent in oral rinses to reduce dental plaque and oral bacteria and its clinical 


 
efficacy and safety has been documented in a variety of settings such as gingivitis, periodontitis, dental 
trauma and tooth extraction.  Chlorhexidine can be inactivated by anionic surfactants commonly used in 
toothpastes and mouthwashes.  Therefore, chlorhexidine mouth rinses should be used at least 30 
minutes after other dental products.  Food, drink, smoking and mouth rinses should be avoided for at 
least one hour after use. This product is safe and only a few side effects have been reported such as 
rare, mild oral discomfort and a transient decrease in taste[20]. Tooth discoloration[21, 22] has been 
reported when chlorhexidine treatment was followed by the ingestion of chromogenic beverages, such 
as tea[23]. Oral bacteria aspiration has been implicated in pulmonary infection as recent studies have 
demonstrated that oral decontamination with chlorhexidine reduces the incidence of ventilator-
associated pneumonia [24].  
 
Efficacy of Oral Decontamination in COPD 
 
The potential benefit of oral decontamination in the treatment of COPD remains unknown. We have 
compelling evidence that the COPD lung microbiota is more diverse than healthy lungs and is a 
reflection of the oral microbiota, presumably due to repeated aspiration and decreased clearance. In 
addition, it is well established that bacteria are a major cause of COPD exacerbations. Therefore, it 
seems plausible that the oral microbiota is a major contributor in COPD and especially in COPD 
exacerbations. Chlorhexidine is a broad-spectrum antiseptic that is safe, well-tolerated and shown to 
decrease respiratory infection associated with oral intubation. We hypothesize that twice daily oral 
rinses with chlorhexidine will result in a decrease in the lung microbiota biomass. If proven correct, this 
would be the basis for a large interventional trial to determine if oral decontamination with chlorhexidine 
will decrease COPD exacerbations. 
 
C. Work Proposed 
 
Overview 
 
The primary outcome of this pilot study is to determine if twice-daily chlorhexidine oral rinse decreases 
the microbiota biomass, as measured by 16S rRNA copy number, in the COPD lung and oral cavity as 
measured in induced sputum and oral wash. Our secondary outcome are to determine if chlorhexidine 
oral rinse: i) decreases lung and oral microbiota diversity; ii) alters taxonomic composition of the lung 
and oral cavity microbiota; iii) decreases systemic inflammation as measured by blood hsCRP, 
fibrinogen and leukocyte count; and iv) changes in respiratory health status as measured by the BCSS 
and SGRQ.  If our hypotheses are supported, this study will form the basis of an interventional trial to 
determine if altering the oral microbiota with chlorhexidine can prevent COPD exacerbations.  
 
Study Design Overview 
 
This study will determine if the microbiota of the oral cavity and induced sputum is altered by twice-daily 
chlorhexidine rinse. At baseline, the following studies will be done:  
1. Spirometry to determine study eligibility and to guide sputum induction protocol. 
2. Oral rinse and induced sputum for microbiota analysis.  An oral rinse of 15 ml sterile water and 
induced sputum will be obtained at baseline for microbiota analysis.   
3. Inflammatory markers (blood hsCRP, fibrinogen, and leukocyte count).   
4. Breathlessness, Cough and Sputum Scale (BCSS). This 3-item self-completed questionnaire 
focuses on common COPD symptoms. 
5. St George’s Respiratory Questionnaire (SGRQ).  This 50-item self-completed questionnaire 
quantifies respiratory health status.  


 
After baseline measurements have been obtained, subjects will be randomized to 8 weeks of treatment 
with either twice daily oral rinse and expectoration of 15 ml of chlorhexidine or twice-daily oral rinse and 
expectoration of 15 ml of placebo (sterile water with mint flavor and blue dye). At the end of 8 weeks 
the subjects will have a repeat of the above studies, with the exception of spirometry.  
 
 
Population and Setting 
 
Participants with a clinical diagnosis of COPD who express willingness to participate in the trial and 
who fulfill all eligibility criteria will be enrolled in the study. To maximize sputum collection, we will enrich 
our population with COPD patients with symptoms of chronic bronchitis and a history of a COPD 
exacerbation in the past year. Patients with these characteristics are prone to having a larger volume of 
sputum production.  
 
Inclusion and Exclusion Criteria:   
 
Inclusion Criteria 
o Willingness to undergo sputum induction 
o Capability to provide written informed consent 
o Age ≥ 40 years and ≤ 85 years 
o FEV1/FVC ratio (post bronchodilator) ≤70% 
o FEV1 (post bronchodilator) ≤ 65% 
o Presence or high likelihood of chronic cough and sputum production defined as one of the 
following: 
 
Presence of chronic cough and sputum will be defined by responses to the first two 
questions on the SGRQ.  Subjects who respond positively to both question 1 (cough) 
and question 2 (sputum) on the SGRQ as either “several days per week” or “almost 
every day” will be eligible. 
 
COPD exacerbation within the previous 12 months defined as taking antibiotics 
and/or prednisone for respiratory symptoms, hospitalization or emergency 
department visit for respiratory illness.  
o Current or former smoker with lifetime cigarette consumption of > 10 pack-years 
o Negative serum pregnancy test at the baseline visit if patient is a pre-menopausal female 
(menopause defined as absence of a menstrual cycle in the last 12 months) 
o Must be fluent in speaking the English language 
o Have a minimum of four teeth 
 
 
Exclusion Criteria:  
o Not fully recovered for at least 30 days from a COPD exacerbation. 
o Treated with antibiotics in the last 2 months. 
o The presence of dentures (full plate). 
o Active oral infection being treated by health care professional. 
o Current use of chlorhexidine or over-the-counter mouth washes in the last 2 months. 
o Known allergy or sensitivity to chlorhexidine 
o Unstable cardiac disease 
o Clinical diagnosis of asthma, bronchiectasis, cystic fibrosis, or severe alpha-1 antitrypsin 
deficiency 
o Active lung cancer or history of lung cancer if it has been less than 2 years since lung 
resection or other treatment.  If history of lung cancer, must have no evidence of recurrence 
in the 2 years preceding the baseline visit. 


 
o Undergoing active treatment for malignancy except for hormonal therapy (i.e. prostate 
cancer, breast cancer) or non-metastatic skin cancer and are not symptomatic 
o Prisoners or institutionalized patients 
o Participation in another study involving an investigational product within 30 days of the 
baseline visit 
o Pregnant or breast-feeding patients.   
o Chronically oxygen dependent or room air O2 saturations < 90% 
o Any concomitant condition that might endanger the patient through participation in the study 
or interfere with study procedures, as assessed by the investigator  
Recruitment Strategies  
 
Patients with COPD and chronic cough and sputum production will be drawn from patient populations 
at the Minneapolis VA HealthCare System. Some study participants will be identified through an 
Institutional Review Board (IRB)-approved database (3330B). Additional study participants will be 
identified through the Minneapolis VA Pulmonary Clinic, Pulmonary Function Laboratory or the 
Minneapolis VA COPD Disease Management Program. Potential participants will receive a letter 
requesting permission for us to contact them by telephone concerning a study. Upon receipt of the 
letter, the patient will have the opportunity to opt out by calling the number listed in the letter. If the 
patient does not opt out after receiving the letter, the study team will contact them to explain the study 
and determine whether they wish to participate further in the screening process.  A copy of this letter is 
attached to this protocol. In addition, patients’ providers will be encouraged to refer patients to the study 
team for consideration of study participation. Pulmonary and COPD Disease Management providers 
will be educated about this study during a department meeting. These referred patients will be 
contacted via phone. 
 
Study Intervention 
 
Study participants will be randomized to receive either 15 ml oral rinse of chlorhexidine twice daily, or 
matched placebo (placebo consists of sterile water with blue dye and mint flavor).  Participants will use 
the randomly assigned study mouth rinse for 8 weeks. At the initial visit, individuals participating in the 
study will undergo spirometry, SGRQ and blood sample for hsCRP followed by an oral rinse with sterile 
saline and sputum induction prior to initiating study drug.  After 8 weeks of study drug, subjects will 
have all samples collected again (spirometry, SGRQ, blood draw, oral rinse, and induced sputum). 
Briefly, sputum will be induced after pretreatment with albuterol.  Subjects will receive nebulized 3% 
saline (subjects with FEV1 > 35%) or normal saline (subjects with FEV < 35%) for 20 minutes and will 
be encouraged to cough a minimum of every two minutes.  
 
Intervention: The subjects will be instructed to use the study mouth rinse twice daily for 8 weeks. 
Subjects will be asked to swish 15 ml of study mouth rinse in their mouths for 30 seconds followed by 
expectoration.  The study mouthwash must be used at least 30 minutes after eating and/or tooth 
brushing.  This procedure will be performed in the morning and evening. Subjects will be instructed to 
not rinse with water or other mouthwashes, brush teeth, or eat immediately after rinsing for 1 hour. The 
subjects will be instructed not to ingest (swallow) the medication after rinsing. Subjects will be 
instructed to avoid: i) drinking tea to avoid tooth discoloration; ii) toothpastes containing the 
antimicrobial agent triclosan (list will be provided) and iii) mouthwashes other than the study drug. The 
participants will be asked to stop the study medication the night before the last clinic visit and to avoid 
routine dental clinic visit with cleaning during the study period. 
 
 
 


 
Outcomes 
 
Primary Outcome 
Our primary outcome will be to compare the microbiota biomass of induced sputum and the oral cavity 
before and after 8 weeks of chlorhexidine rinse (n=25) compared to controls (n=25) using next-
generation sequencing of the bacterial 16S rRNA gene. 
 
Secondary Outcomes 
Secondary outcomes will include: i) sputum and oral microbiota diversity; ii) sputum and oral microbiota 
taxonomy; iii) inflammatory markers hsCRP, fibrinogen, and leukocyte count; iv) BCSS score; v) SGRQ 
score; and vi) assessment of adverse effects.  
 
 
Methods and Data Collection Plan 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
 
During the baseline visit, after obtaining informed consent, the medical history will be reviewed with the 
participant to make sure all key components of the past medical history, including dental history, are 
obtained for eligibility and safety purposes.  The participant’s electronic medical records will also be 
reviewed. 
 
 
 
InformedConsent
Medicalhistory,Spirometry,
LimitedPhysicalExam,Medica on
history,administerSGRQ
Visit1-StudyDay0
Baselinecharacteris cs,
administerSGRQ,bloodtests,
oralrinse,inducedsputum,
randomize
ChlorhexidineRinse
15mltwicedailyx8weeks
Placebo
15mltwicedailyx8weeks
Visit2
Administer
ques onnaires,
bloodtests,oral
rinse,induced
sputum
Visit2
Administer
ques onnaires,
bloodtests,oral
rinse,induced
sputum
Ineligible
4weekcall


 
Medications/Supplement Use 
 
Participants will be asked to bring all medications (prescription and non-prescription, including inhalers) 
with them to the study visit.  All medications will be recorded and the VA medication dispensing records 
will also be reviewed electronically.  In review of the subject’s medications, the study team will be 
specifically looking for patients on antibiotics that may alter the microbiota. Non-prescription 
medications will be reviewed to make sure the patient is not taking over-the-counter mouth washes or 
toothpaste with triclosan that may alter the oral microbiota.  The patient’s respiratory and non-
respiratory medications will not be altered as a part of this study. 
 
Physical Examination 
 
After informed consent and review of both medical and medication history, a member of the study team 
will perform a focused physical.  The physical exam will focus on vital signs including resting oximetry, 
weight, and the oral and lung examination. At the final study visit the physical examination will be 
repeated.  
 
 
St George’s Respiratory Questionnaire (SGRQ) 
 
The first two questions of the SGRQ comprise eligibility criteria for the study (see inclusion criteria).  If 
subjects are randomized in the study, they will be asked to complete the entire SGRQ as part of the 
baseline visit and again at completion of the study intervention. The SGRQ is a self-administered 
questionnaire that was developed to measure health-related quality of life specifically related to 
pulmonary disease.  Since its development, it has been validated for use in many chronic lung 
diseases, including COPD[25].  The SGRQ contains 11 questions that ask for a scaled answer (from 1 
to 5), 39 questions that ask for true/false answers and one free-text answer. A copy of the SGRQ is 
attached to this proposal.  Subjects can complete the SGRQ in approximately 10-15 minutes. The 
questions evaluate three areas or domains: respiratory symptoms, activity limitations from 
breathlessness, and impact of respiratory disease on social and psychological functioning.  The SGRQ 
is scored on a scale of 0 to 100, with a score of 100 reflecting the most severe symptoms, activity 
limitations and psychosocial impact.  The minimum clinically important difference in the SGRQ is widely 
accepted as being 4 units[26].  
 
Spirometry 
 
Spirometry will be performed prior to randomization to ensure that participants meet eligibility criteria. 
Spirometry will be performed in compliance with standards jointly published by the American Thoracic 
Society and the European Respiratory Society[27].  Spirometry will be performed after patient inhales 2 
puffs of albuterol (90 mcg/inhalation). 
 
 
 
Eligible Subjects: 
 
Laboratory Evaluation 
 
After obtaining informed consent and determining the participant is otherwise eligible for the study, the 
patient will undergo an oral rinse with sterile water (rinse for 30 seconds and collect expectorant) and 
sputum induction. The oral rinse and 2 ml of sputum will be used for the microbiota evaluation.  
 


 
The blood draw will be performed by the VA laboratory or the study personnel. Blood will be sent to the 
VA laboratory to measure hsCRP, fibrinogen and leukocyte count. These biomarkers have been 
demonstrated to be predictive of COPD exacerbations[28].  
 
Induced Sputum: 
 
Sputum induction will be performed as outpatients. Subjects will have fasted for at least 2 hours prior to the 
study. Prior to sputum induction, the subject will rinse, gargle and spit into a sterile cup 15 ml sterile water 
that will be collected for microbiota studies. Next, all subjects will be pretreated with 360 ug albuterol 
administered by metered dose inhaler. Prior to initiation of the test peak expiratory flows (PEF) will be 
obtained and noted. This will constitute the baseline peak flow. To induce sputum the subject will receive 
nebulized sterile 3% saline (subjects with FEV1 > 35%) or normal saline (subjects with FEV1 < 35%) for 20 
minutes (150 ml in reservoir). PEF will be monitored every 4 minutes. If the PEF declines to less than 90% 
of their baseline, monitoring will change to every 2 minutes. If the PEF clines to less than 80% of baseline 
the nebulization will be discontinued. Subjects will be encouraged to cough throughout the nebulization. In 
addition, the nebulization treatment will be interrupted every 2 minutes at which time the subject will be 
encouraged to cough up secretions. Prior to coughing the subject will be asked to spit saliva into a plastic 
container that will be discarded at the end of the treatment. The sputum will be collected in a separate, 
sterile container.  
 
Microbiota studies  
 
The sputum sample will be weighed and the oral wash volume will be measured.  To identify the 
microbiota, DNA will be isolated from sputum and oral wash samples. Sputum samples will be treated 
with dithiothreitol (DTT) prior to isolation.  We will use a previously described protocol for DNA isolation 
that includes bead beating to lyse bacterial cells, followed by precipitation with isopropanol and 
digestion with RNase.  Samples will be subjected to PCR amplification using 16S rRNA gene primers 
specific to the constant regions flanking the V3 region[15, 29].  Amplicons will be gel purified and 
sequenced at the University of Minnesota Genomics Center using Illumina MiSeq equipment.  To 
minimize effects of random sequencing errors, we will use RDP Pipeline to eliminate (a) sequences that 
did not appropriately match the PCR primer and the barcode at the beginning of a read, (b) sequence 
reads with <50 bases after the proximal PCR primer if they terminated before reaching the distal 
primer, and (c) sequences that contained more than one undetermined nucleotide (N). Both the 
proximal and distal primers will be trimmed from high-quality reads before database searches are 
performed.   
 
Inflammatory Marker 
To measure the inflammatory state, hsCRP, fibrinogen, and leukocyte count will be measured in blood. 
 
Sample Banking 
 
The microbiota studies will be performed at the University of MN. All remaining sample will be returned 
and stored in Dr. Wendt’s laboratory at the VAMC. After completion, remaining sample will be stored for 
a maximum of 10 years for future confirmation studies and studies related to COPD.  Samples will be 
de-identified and will be identified only by a pre-assigned sample ID number. Clinical data will NOT be 
given to the Univ MN laboratory. 
 
Randomization procedure 
 
Patients will be randomized via permuted block sizes of 2 to active drug or placebo in a ratio of 1:1. 
Because there is some evidence of an interaction with inhaled corticosteroids and the lung microbiota, 


 
we will stratify randomization according to use of inhaled corticosteroids at baseline.  Only the 
Research Pharmacist will have access to the randomization list. The subjects will be instructed to use 
the study mouth rinse twice daily for 8 weeks as described above. The subjects will be asked to return 
all study medications at the last clinic visit. At the last visit the subjects will be asked whether they 
thought they were taking the active medication or placebo to assess the effectiveness of blinding. 
 
The Breathlessness, Cough and Sputum Scale (BCSS) 
 
The Breathlessness, Cough and Sputum Scale is an easy-to-use instrument for tracking the severity of 
respiratory symptoms and evaluating the efficacy of treatment in clinical trials in patients with COPD. It 
is designed as a daily diary in which subjects are instructed to answer three questions on a 0 to 4 scale, 
targeting breathlessness, cough and sputum. A total daily score is calculated from the question 
answers. This format allows investigators to assess symptom variability and trajectory over time. This 
tool has been validated in large clinical trials against the SGRQ[1, 2].  
 
Monthly calls 
 
Participants will be called at 4 weeks by the study coordinator to assess for: i) hospitalizations, ED 
visits; unplanned clinic visits; ii) new medication use including any systemic antibiotic use; iii) study drug 
compliance; iv) adverse events. 
 
Effectiveness of blinding 
 
At the last visit the subjects will be asked whether they thought they were taking the active medication 
or placebo to assess the effectiveness of blinding 
 
Monitoring adverse events  
 
Participants enrolled in this study will be monitored for adverse outcomes including adverse 
hospitalizations and death.  Patients will be questioned during the mid-study telephone call and at the 
final study visit regarding any adverse drug reactions.  In addition, participants will be given contact 
information for the study team and will be counseled to report any adverse effects. Participants will be 
questioned during the mid-study telephone call and at the final study visit regarding any 
hospitalizations. A report of every serious adverse event will be filed with the IRB per institutional policy. 
Electronic medical records will also be reviewed for 30 days after completing the study to capture any 
serious adverse outcomes, including hospitalization or death. If necessary, we will contact relatives or 
household members to obtain additional information.  
 
The risk to the participant is that of the induced sputum. Hypertonic saline sputum induction is a routine 
test performed in many clinical settings and clinical trials. It has been shown to be safe in the setting of 
COPD. We do not anticipate complications of chlorhexidine treatment since this is an ingredient in 
several over-the-counter products, including mouth washes, and chlorhexidine mouthwash is commonly 
prescribed following dental extractions. Listed below are potential complications. 
 
1. Bronchospasm: Bronchospasm is the main reported complication of sputum induction 
with hypertonic saline and will be treated with albuterol either by metered dose inhaler or 
nebulized.  
2. Intolerance to Chlorhexidine: Oral mucosal irritation and transient decrease in taste have 
rarely been reported with chlorhexidine. Mild tooth discoloration associated with 
concurrent tea ingestion has been reported.  
 


 
A Data Safety and Monitoring Board (DSMB) will not be formed as part of this study since this is a small 
study with a short follow-up period.   
 
 
Discontinuation of procedure  
 
The procedure may be terminated at anytime for any of the following reasons: 
o If the participant requests to withdraw from the study for any reason. 
o If the investigators or the participant’s physician believes the patient has experienced a 
serious adverse event that might be related to the study or that continued participation in 
the study might jeopardize the participant's medical care. 
o The participant becomes so mentally or physically incapacitated that he/she can no 
longer make an informed judgment about continued participation in the study.  
 
Unmasking of treatment allocation will occur in cases where such information is critical to 
ongoing care of the participant.  At the conclusion of the study, the participants will be informed of 
treatment allocation. 
 
Data Analysis Plan 
 
At the conclusion of the study, we will censor any subject who reports using systemic antibiotics during 
the 8-week study period.  This will prevent antibiotic use from confounding our microbiota results.  As 
this study is a randomized controlled study, the analysis for the primary outcome will consist of testing 
for differences in changes in bacterial biomass between the two patient groups using a 2 sample t-test 
with equal variances between groups. While it is widely recognized that the t-test is robust with regard 
to departures from the normality assumption, if the data appear very non-normal (as observed in a qq-
plot) even after standard transformations are considered (such as the Box-Cox transformation) then 
Wilcoxon’s test will be used. Similarly, if the variance is markedly different between the groups then 
Welch’s 2 sample t-test will be used. While randomization should ensure that the groups are balanced 
on important potential confounders (such as age) all such factors will be examined to check that there 
are not significant differences between the groups. If there are differences then linear models will be fit 
to account for these potential confounders (again, standard transformations will be considered to 
improve model fit and diagnostics will be performed to assess model assumptions).  
The analysis for secondary endpoints necessarily takes a different strategy as that investigates the 
relationship among variables that are not subject to direct randomization. Hence the analysis will 
consider regression models that investigate how changes in health status (as measured by changes in 
the SGRQ) depend on microbial diversity and inflammatory markers. Model selection will be guided by 
scientific plausibility, model diagnostics and measures of model quality (such as AIC).  
 
Sample Size and Power Calculation 
 
We can use the preliminary data on microbial diversity among COPD patients to estimate the power of 
the study. For concreteness we will assess the power for detecting a difference in the Simpson (1-D) 
diversity measure (the correlation between this measure and Shannon’s measure was 0.96 in our 
preliminary data). The standard deviation in this measure among moderately affected COPD patients is 
0.280 and is 0.298 among the severely affected COPD patients, and as there is no significant 
difference between the variances (p=0.80 by Bartlett’s test) we combine the data from both groups and 
obtain an estimate of 0.281 for the standard deviation. To obtain an estimate of the magnitude of 
differences that are reasonable to expect from a drug that decreases the diversity of the lung flora, we 
fit a linear regression model with diversity as the outcome and age as the predictor variable (the ages 
range from 55 to 78 among these subjects). Age has a significant positive impact on diversity (p=0.047) 


 
with an estimated slope of 0.017, so that over the course of 20 years the model predicts that there will 
be a change of 0.34 in diversity. Hence we investigated the power for values of the difference 
attributable to the effect of chlorhexidine from 0.22 to 0.32 and present the results in Table 1 (these 
results are from a 2 sample t-test with equal variance using the estimated standard deviation from the 
previous study and 20 subjects per group). These results indicate that the study should have 
acceptable power if chlorhexidine has an impact on the diversity of the lung microbiota that is 
comparable to what is observed due to the effect of aging. We will increase the sample size to 25 per 
group since we anticipate censoring at least 20% of the subjects because of antibiotic use during the 
study.  This population has a demonstrated exacerbation rate of approximately 20% and exacerbations 
are often treated with antibiotics. 
  
Effect size 
0.22 
0.24 
0.26 
0.28 
0.30 
0.32 
Power 
0.67 
0.75 
0.81 
0.87 
0.91 
0.94 
    
Table 1: The power of the study to detect a difference between the treatment groups as it depends on 
the magnitude of the difference in diversity between the 2 groups. 
 
Quality Control 
Members of the research team will become familiar with the study protocol and be trained in all 
procedural aspects.  Patient recruitment and data acquisition will be performed principally by a trained 
and experienced study coordinator employed full-time by the Pulmonary Section of the Minneapolis VA 
Health Care System. Dr. Chris Wendt will supervise all aspect of the study.  The study coordinator has 
expertise in performing spirometry, administering the questionnaires for this study, and in thorough 
documentation of study procedures. 
 
Source documents will include paper case report forms, printouts from spirometry machines, printouts 
of laboratory data, original surveys completed by the participants and any outside (non-VA) medical 
records that are obtained.  All data will be entered into a computerized database for statistical analysis, 
with retention of source documents for verification of all computerized data, should the need arise.  
All electronic data will be stripped of personal identifiers and stored in secure network drives that are 
password-protected.   Source documents will be secured in a locked file cabinet within a locked room 
for security.  The only method to link electronic data to individual data will be a key linking participant 
name to study subject number. 
 
Protection Against Risk 
 
The risk to the participant of this study is small.  
 
Induced Sputum: We will pre-treat with albuterol, either MDI or nebulizer, to prevent bronchospasm. 
Albuterol is a commercially available, FDA-approved drug. The common side effects associated with 
albuterol are mild, transient tachycardia, tremulousness, and nervousness. In addition, we will monitor 
peak flows and terminate the procedure for a significant drop. All bronchospasm will be treated with 
additional doses of albuterol.  
Spirometry.  The risks of spirometry are minimal.  Some participants may experience temporary 
shortness of breath or lightheadedness as a result of deep and rapid breathing that is required to 
perform spirometry.  These risks are small and spirometry is routinely performed in this patient 
population. Administration of albuterol prior to testing is also a standard procedure and is known to be 


 
very safe. Albuterol is a commercially available, FDA-approved drug. The common side effects 
associated with albuterol are mild, transient tachycardia, tremulousness, and nervousness.  
Laboratory evaluation.  Some patients will experience mild to moderate pain at the needle insertion 
site.  Other minimal risks include:  risk of bleeding/hematoma at needle puncture site, risk of infection 
by going through the skin, risk of lightheadedness or fainting.  The participants of this study will have 
their blood drawn by a study physician with experience performing blood draws or by a trained 
phlebotomist.   The study physician will use the proper protective equipment including gloves, lab coat 
and eye protection.    Blood will be collected in a standard fashion to minimize the above risks.   
 
SGRQ and BCSS.   Participants may feel uncomfortable answering questions about their respiratory 
symptoms or the impact of their lung disease on their lives.  In such cases, participants have the right to 
refuse to answer questions contained in these questionnaires. 
 
Medication assignment.  Chlorhexidine has a good safety profile as evidenced in the background 
section of this proposal.  The Chlorhexidine product being used in this study is 0.12% solution 
concentration.  Patients will be asked to perform an oral rinse for 30 seconds twice daily. They will be 
instructed to avoid tooth brushing or eating for 30 minutes prior and one hour after the rinse. 
Participants will be educated about potential adverse effects as part of the informed consent process.   
Participants will be screened for adverse effects at the 4 week telephone call and at the last clinic visit.  
Participants can elect to stop the study medication and withdraw from the study at any point for any 
reason. 
Protection of female participants.  Pregnant and breast-feeding women will be excluded.  There is 
insufficient data to determine if chlorhexidine is safe for a fetus or nursing child.  
Risk to patient confidentiality.  Confidential information will be collected as part of this study.  
Safeguards will be taken to protect this information.  Source documents will be kept in a locked cabinet 
in a locked room.  All electronic data will be stripped of personal identifiers.  The database will be 
password-protected and stored in a secured network drive behind the VA firewall.    Only the study 
team will have access to the source documents and the electronic data.   
 
Adequacy of Protection against risks: 
 
 
Recruitment and Informed consent: Study participants will be asked to sign an informed consent 
approved by the Institutional Review Board of the VAMC.  This includes a clear description of the 
study and its objectives, the number of patient contacts and procedures, the information to be 
collected, the tests (induced sputum) to be performed, possible benefits and risks to the patient, 
and permission to use the patient's health plan medical record data. The subjects will be informed 
that remaining sample would be used for future studies. 
 
Protections against Risk: We will take special precautions to protect the security of the research 
data. These include authorization to send and receive data, verification of identity, and encryption of 
all data. We will follow institutional guidelines on data access and security. Rigorous policies will be 
followed for maintaining secure backups for all research data and complete documentation of data 
files, both locally and centrally. All data processing procedures will be carefully documented and 
reviewed periodically.  
 All patients identified for inclusion in the research project will be assigned a unique study 
identification number.  Prior to any data transfer, all identifiers (e.g., names, medical record 
numbers, health plan enrollee numbers, etc.) will be removed. We will also utilize password 
protection programs for all computerized records.  In no instances will identifying information, either 
for patients or health plans, be publicly disclosed. 


 
All study staff will be trained and reminded to appreciate the confidential nature of research data.  Each 
investigator and staff member involved in the proposed study will sign a confidentiality agreement 
annually and be required to have participated in required IRB training. 
 
Risk to patient confidentiality.  Confidential information will be collected as part of this study.  
Safeguards will be taken to protect this information.  Source documents will be kept in a locked cabinet 
in a locked room.  All electronic data will be stripped of personal identifiers.  The database will be 
password-protected and stored in a secured network drive behind the VA firewall.  Only the study team 
will have access to the source documents and the electronic data.   
 
 
Potential Benefits of the Research to the Subject and Others  
 
A possible future benefit is that the research may improve health care for themselves and other patients 
with similar diseases.  
 
References:  
 
1. 
Leidy, N.K., et al., The breathlessness, cough, and sputum scale: the development of empirically based 
guidelines for interpretation. Chest, 2003. 124(6): p. 2182-91. 
2. 
Leidy, N.K., et al., Evaluating symptoms in chronic obstructive pulmonary disease: validation of the 
Breathlessness, Cough and Sputum Scale. Respir Med, 2003. 97 Suppl A: p. S59-70. 
3. 
Mannino, D.M. and S. Braman, The epidemiology and economics of chronic obstructive pulmonary 
disease. Proc Am Thorac Soc, 2007. 4(7): p. 502-6. 
4. 
Murphy, D.E., et al., High prevalence of chronic obstructive pulmonary disease among veterans in the 
urban midwest. Mil Med, 2011. 176(5): p. 552-60. 
5. 
Sharafkhaneh, A., et al., Burden of COPD in a government health care system: a retrospective 
observational study using data from the US Veterans Affairs population. Int J Chron Obstruct Pulmon Dis, 
2010. 5: p. 125-32. 
6. 
Ekberg-Aronsson, M., et al., Mortality in GOLD stages of COPD and its dependence on symptoms of 
chronic bronchitis. Respir Res, 2005. 6: p. 98. 
7. 
Kim, V., et al., The chronic bronchitic phenotype of COPD: an analysis of the COPDGene Study. Chest, 
2011. 140(3): p. 626-33. 
8. 
Sapey, E. and R.A. Stockley, COPD exacerbations . 2: aetiology. Thorax, 2006. 61(3): p. 250-8. 
9. 
Wilkinson, T.M., et al., Effect of interactions between lower airway bacterial and rhinoviral infection in 
exacerbations of COPD. Chest, 2006. 129(2): p. 317-24. 
10. 
Hugenholtz, P. and N.R. Pace, Identifying microbial diversity in the natural environment: a molecular 
phylogenetic approach. TIBTECH, 1996. 14: p. 190-197. 
11. 
Stahl, D.A., Comparison of nucleic acids from microorganisms: sequencing approaches. Methods in 
Enzymology, 1993. 224: p. 373-391. 
12. 
Stahl, D.A., The natural history of microorganisms. ASM News, 1993. 59: p. 609-613. 
13. 
Stahl, D.A., Phylogenecitcally based studies of micrbial ecosystem perturbation. Biotechnology for Crop 
Protection, ed. P. Hedin, J.J. Menn, and R.M. Hollingsworth1988, Washington, DC: AMecian Chemical 
Society. 373-390. 
14. 
Olsen, G.J. and C.R. Woese, Ribosomal RNA: a key to phylogeny. FASEB Journal, 1993. 7(1): p. 113-23. 
15. 
Pragman, A.A., et al., The lung microbiome in moderate and severe chronic obstructive pulmonary 
disease. PLoS One, 2012. 7(10): p. e47305. 


 
16. 
Clayton, N.A., et al., The effect of chronic obstructive pulmonary disease on laryngopharyngeal 
sensitivity. Ear Nose Throat J, 2012. 91(9): p. 370, 372, 374 passim. 
17. 
Cvejic, L., et al., Laryngeal penetration and aspiration in individuals with stable COPD. Respirology, 2011. 
16(2): p. 269-75. 
18. 
Calverley, P.M., et al., Salmeterol and fluticasone propionate and survival in chronic obstructive 
pulmonary disease. N Engl J Med, 2007. 356(8): p. 775-89. 
19. 
Tashkin, D.P., et al., A 4-year trial of tiotropium in chronic obstructive pulmonary disease. N Engl J Med, 
2008. 359(15): p. 1543-54. 
20. 
Helms, J.A., et al., Effects of chlorhexidine on human taste perception. Arch Oral Biol, 1995. 40(10): p. 
913-20. 
21. 
Brecx, M., et al., Long-term effects of Meridol and chlorhexidine mouthrinses on plaque, gingivitis, 
staining, and bacterial vitality. J Dent Res, 1993. 72(8): p. 1194-7. 
22. 
Waerhaug, M., et al., Comparison of the effect of chlorhexidine and CuSO4 on plaque formation and 
development of gingivitis. J Clin Periodontol, 1984. 11(3): p. 176-80. 
23. 
Watts, A. and M. Addy, Tooth discolouration and staining: a review of the literature. Br Dent J, 2001. 
190(6): p. 309-16. 
24. 
Koeman, M., et al., Oral decontamination with chlorhexidine reduces the incidence of ventilator-
associated pneumonia. Am J Respir Crit Care Med, 2006. 173(12): p. 1348-55. 
25. 
Jones, P.W., F.H. Quirk, and C.M. Baveystock, The St George's Respiratory Questionnaire. Respir Med, 
1991. 85 Suppl B: p. 25-31; discussion 33-7. 
26. 
Jones, P.W., St. George's Respiratory Questionnaire: MCID. COPD, 2005. 2(1): p. 75-9. 
27. 
Miller, M.R., et al., Standardisation of spirometry. Eur Respir J, 2005. 26(2): p. 319-38. 
28. 
Thomsen, M., et al., Inflammatory biomarkers and exacerbations in chronic obstructive pulmonary 
disease. JAMA, 2013. 309(22): p. 2353-61. 
29. 
Borewicz, K., et al., Longitudinal analysis of the lung microbiome in lung transplantation. FEMS Microbiol 
Lett, 2013. 339(1): p. 57-65. 
 
 

ICF_001.pdf: 
Department of Veterans Affairs       
VA RESEARCH CONSENT FORM 
Protocol #4526-B  
 
 
 
  (Page 1 of 11) 
Date: 
 
Title of Study: The Effect of Chlorhexidine on the Oral and Lung Microbiome in  
                       Chronic Obstructive Pulmonary Disease 
 
 
Principal Investigator: Chris Wendt, MD 
VAMC: Minneapolis 618 
 
 
Printed name and last 4 of SS# (If addressograph 
label is used, please mask all other information) 
This section for completion by IRB only 
Approval date: 02/27/2017 
Expiration date: 02/26/2018 
VA Form 10-1086  
June 1990 
Version date 02/15/2017 
MVAHCS form revised Dec 2013 
 
INTRODUCTION 
It is important that you read and understand the following explanation of the proposed 
research study before you agree to participate.  This consent form describes:  
• The purpose,  
• The description of the study, 
• The benefits, 
• The risks and/or discomforts (including any potential for pain), 
• Steps taken to decrease or eliminate the risks, discomforts, or possible pain, 
• Any other treatments that may be available, and 
• Confidentiality and use of research results. 
Whether you decide to participate or not, treatment at the VA for which you are eligible 
will not be affected. 
This consent form may contain words you do not understand.  Please ask the 
study doctor or the study staff to explain any words or information unclear to 
you. 
PURPOSE OF THE STUDY  
You are being asked to voluntarily participate in a research study to determine if a 
medicated mouth rinse called chlorhexidine will help improve the mucus in your 
airways.  You have been asked to participate in this study because you have chronic 
obstructive pulmonary disease (COPD) and chronic cough with phlegm production.  
Your participation in the study will last 8 weeks, and for this study you will participate 2 
days. Up to 50 people will be in the study at this site.  Our goal is to determine if the 
mouth rinse chlorhexidine changes the secretions in the lung by lowering the number of 
bacteria in those secretions.  
 
DESCRIPTION OF STUDY 
The following information describes what will happen while you participate in the study.  
 
Screening Exams 
If you agree to participate in the study, we will check to see if your medical condition 
matches our study entry criteria. To determine if you are eligible to participate, you will 


Department of Veterans Affairs       
VA RESEARCH CONSENT FORM 
Protocol #4526-B  
 
 
 
  (Page 2 of 11) 
Date: 
 
Title of Study: The Effect of Chlorhexidine on the Oral and Lung Microbiome in  
                       Chronic Obstructive Pulmonary Disease 
 
 
Principal Investigator: Chris Wendt, MD 
VAMC: Minneapolis 618 
 
 
Printed name and last 4 of SS# (If addressograph 
label is used, please mask all other information) 
This section for completion by IRB only 
Approval date: 02/27/2017 
Expiration date: 02/26/2018 
VA Form 10-1086  
June 1990 
Version date 02/15/2017 
MVAHCS form revised Dec 2013 
 
come to the clinic for a screening visit that will last a couple of hours. During this visit, 
the following will happen: 
 You will be asked questions about your health, your medical history and the 
medications you are taking. 
 
 You will have a limited physical exam that will include measurement of vital 
signs.  Your heart, lungs and mouth will also be examined.  
 You will be asked to perform breathing tests (spirometry). These tests measure 
your lung function.  
 You will be asked to fill out research questionnaires about your breathing and 
other respiratory related symptoms. There will also be questions concerning 
your overall quality of life.  
 
 
Research Treatment 
If you qualify for the study, you will be assigned at random (like flipping a coin) to one of 
two groups of patients. One group will rinse and spit the mouth wash, chlorhexidine, 
twice a day. The other group will take identical looking wash that is a placebo (no active 
medication).  
 
Patients in both groups will rinse their mouth with approximately 2 tablespoons of liquid 
twice daily for 8 weeks. You will be instructed not to eat or brush your teeth for one half 
hour before and one hour after the rinse and to not use other mouth rinses. We will also 
ask that you not receive a routine dental appointment with teeth cleaning while 
participating on this trial. You will be asked to keep a daily diary of symptoms by 
answering 3 simple questions related to breathlessness, cough and sputum. Your 
chance of getting chlorhexidine is 50%, which is the same chance of you getting the 
placebo. You will not know, until the end of the study, which rinse you are taking. The 
doctors and clinic staff will not know this either, though it will be possible for them to find 
out quickly in an emergency.  
 
All patients will continue on previously prescribed COPD treatments. 
 


Department of Veterans Affairs       
VA RESEARCH CONSENT FORM 
Protocol #4526-B  
 
 
 
  (Page 3 of 11) 
Date: 
 
Title of Study: The Effect of Chlorhexidine on the Oral and Lung Microbiome in  
                       Chronic Obstructive Pulmonary Disease 
 
 
Principal Investigator: Chris Wendt, MD 
VAMC: Minneapolis 618 
 
 
Printed name and last 4 of SS# (If addressograph 
label is used, please mask all other information) 
This section for completion by IRB only 
Approval date: 02/27/2017 
Expiration date: 02/26/2018 
VA Form 10-1086  
June 1990 
Version date 02/15/2017 
MVAHCS form revised Dec 2013 
 
After you are assigned to a group you will have the following procedures performed 
twice, once prior to starting the study medication and again during the last week of 
study medication: 
 You will have blood samples (approximately 15 ml or 1 tablespoon) taken to 
measure an inflammation markers in your blood. 
 You will rinse your mouth with approximate 1 ounce of sterile water and spit into 
a cup. This will be used to identify the bacteria in your mouth.  
 You will undergo a test called an ‘induced sputum’: You will be asked to fast for 
at least 2 hours prior to the study. Prior to the sputum test you will be treated with 
an inhaler, albuterol, to open your airways and be given approximately one 
ounce of sterile water to gargle and spit.  We will then treat you with a nebulizer 
treatment containing a high concentration of sterile saline, or salt water for 20 
minutes. This solution will loosen your sputum in your airways and may make 
you cough. We will stop the nebulizer every 2 minutes to encourage you to 
cough up sputum and check your lung function with a quick handheld breathing 
test. If your breathing test should drop by more than 20% or you feel short of 
breath, we will stop the sputum collection. You can eat immediately following the 
test. The fluid will be tested for bacteria. None of your genetic material will be 
extracted or used for analysis. These results will not be available to you or your 
family and will be used for this study only.  
 
Phone call during treatment phase: 
Approximately 4 weeks after you start the study medication the study team will call to 
see how you are doing. You may call at any time during the study if you have questions 
or concerns.  
 You will be asked a few questions to see if you are having any side effects from 
the study medication. 
 You will be asked if you have had any problems with taking the medication. 
 You will be asked about medication use over the proceeding weeks, such as 
antibiotics, prednisone and mouth washes. 
 You will be asked about clinic visits or hospitalizations related to your COPD. 
 
 
 


Department of Veterans Affairs       
VA RESEARCH CONSENT FORM 
Protocol #4526-B  
 
 
 
  (Page 4 of 11) 
Date: 
 
Title of Study: The Effect of Chlorhexidine on the Oral and Lung Microbiome in  
                       Chronic Obstructive Pulmonary Disease 
 
 
Principal Investigator: Chris Wendt, MD 
VAMC: Minneapolis 618 
 
 
Printed name and last 4 of SS# (If addressograph 
label is used, please mask all other information) 
This section for completion by IRB only 
Approval date: 02/27/2017 
Expiration date: 02/26/2018 
VA Form 10-1086  
June 1990 
Version date 02/15/2017 
MVAHCS form revised Dec 2013 
 
Final Clinic Visit  
Eight weeks after starting the study, you will have your final study visit.  You will need to 
come to the study site and this visit will take a couple of hours. You will repeat the tests 
described above. In addition, we will ask you to bring all of your unused study 
medication. The visit will include: 
 You will have a limited physical exam that will include your heart, lungs and 
mouth will be examined. 
 You will be asked to fill out a research questionnaire about your breathing and 
other respiratory related symptoms. There will also be questions concerning your 
overall quality of life.  
 You will be asked a few questions to see if you had any side effects from the 
study medication. 
 You will need to bring in any remaining study medication that you have in your 
home.  
 You will be asked if you had any problems taking the study medication. 
 You will undergo an oral rinse and induced sputum (described above). 
 
RISKS AND/OR DISCOMFORTS  
Induced Sputum 
The procedure may involve risks and/or discomforts.  Although the procedure has been 
performed safely in hundreds of individuals as part of research studies and routine 
clinical care, it is not a trivial undertaking.   
Common risks: 
 There can be some discomfort due to coughing and some mild shortness of 
breath. 
 
Uncommon risks: 
 A medication that can open your airways will be used to open your airways. This 
medication, albuterol, is often used to treat people with COPD. Albuterol 
sometimes increases heart rate or causes jitteriness or shakiness, but these 
effects usually disappear quickly.  
 Shortness of breath. On occasion the saline and coughing can induce significant 


Department of Veterans Affairs       
VA RESEARCH CONSENT FORM 
Protocol #4526-B  
 
 
 
  (Page 5 of 11) 
Date: 
 
Title of Study: The Effect of Chlorhexidine on the Oral and Lung Microbiome in  
                       Chronic Obstructive Pulmonary Disease 
 
 
Principal Investigator: Chris Wendt, MD 
VAMC: Minneapolis 618 
 
 
Printed name and last 4 of SS# (If addressograph 
label is used, please mask all other information) 
This section for completion by IRB only 
Approval date: 02/27/2017 
Expiration date: 02/26/2018 
VA Form 10-1086  
June 1990 
Version date 02/15/2017 
MVAHCS form revised Dec 2013 
 
shortness of breath and wheezing. To prevent this we will monitor your breathing 
every 2-4 minutes during the test and stop the test if your breathing function 
drops by more than 20%. If you should have persistent shortness of breath, it 
may require a second treatment with an inhaler, such as albuterol.  
   
 
Although the complications of induced sputum that are listed above have been reported 
with the procedure in the past, the principal investigator does not consider any of these 
complications as being likely (1) because the screening procedure will eliminate from 
this study individuals at particular risk of these complications and (2) because the 
physicians performing the procedures will be experienced.  
 
Breathing tests (spirometry) 
This testing may make you feel short of breath.  On rare occasions, people feel dizzy or 
faint.  A medication that can open your airways (albuterol) can give the side effects 
described above.  
 
Blood draws 
Blood testing will be done during the research study. Blood draws may cause mild 
discomfort and bruising. Very rarely, fainting, blood clots, or an infection at the site can 
occur. 
 
Questionnaires and Daily Diary 
You may be uncomfortable sharing information about your symptoms and how they 
affect your life. Questionnaires you complete will stay with your study file in the study 
doctor’s office. Only your study identification, not your name, will be recorded with the 
answers you provide on these questionnaires and diary. You have the option of leaving 
answers blank if they make you feel uncomfortable. There are no right or wrong 
answers. You should answer the questions based on how you feel.  
 
Risks of Chlorhexidine mouth rinse  
There have been multiple studies published using Chlorhexidine for a variety of dental 
conditions and a study to prevent lung infection. These studies did not report an 
increase in side effects with Chlorhexidine compared to placebo.  
 


Department of Veterans Affairs       
VA RESEARCH CONSENT FORM 
Protocol #4526-B  
 
 
 
  (Page 6 of 11) 
Date: 
 
Title of Study: The Effect of Chlorhexidine on the Oral and Lung Microbiome in  
                       Chronic Obstructive Pulmonary Disease 
 
 
Principal Investigator: Chris Wendt, MD 
VAMC: Minneapolis 618 
 
 
Printed name and last 4 of SS# (If addressograph 
label is used, please mask all other information) 
This section for completion by IRB only 
Approval date: 02/27/2017 
Expiration date: 02/26/2018 
VA Form 10-1086  
June 1990 
Version date 02/15/2017 
MVAHCS form revised Dec 2013 
 
There have been rare reports of irritation of the lining of the mouth, and some have 
reported allergy. However, this has not been more than placebo. A small number of 
people report a decrease in taste sensation that is temporary. This is less than 4 out of 
100 people. Also, people that drink tea and use chlorhexidine report a small increase in 
discoloration of their teeth. For this reason, we will ask you to avoid drinking tea while 
on the study medication.  
Risks Associated with Confidentiality  
Participation in any research carries the risk of breach of confidentiality because 
participants provide health information.  We will do our best to protect your 
confidentiality.  All paper documents with information obtained as part of this study will 
be secured in a locked file behind a locked door at all times.  Only study staff will have 
access to this information.  Electronic information will be kept in a password protected 
file on secured VA computers.  Only study staff will have access to this information. 
Unforeseen Risks 
In addition to the risks listed above, there may be uncommon or previously 
unrecognized risks that could occur during the study.  
There may be other unknown side effects that could occur. 
 
FUTURE USE OF SPECIMENS 
The specimens are being sent to an outside lab, (removed of all identifiers), and then 
the unused portion will be returned to the VA lab for banking, for future research related 
to COPD for 10 years. The specimens will be stripped of all identifiers, and dates, and 
held at the VAMC laboratory of Dr. Chris Wendt.  Only Dr. Wendt and her research 
personnel will have access to the specimens. The specimens will be de-identified for 
long-term storage and will be labeled with a unique code that does not include your 
name, date of birth, social security number or other information linked to you.  
EMPLOYEES AS RESEARCH SUBJECTS 
If you are a VA employee you are considered a special class of research subject 
who deserves special protections: 1) your decision to participate in this study 


Department of Veterans Affairs       
VA RESEARCH CONSENT FORM 
Protocol #4526-B  
 
 
 
  (Page 7 of 11) 
Date: 
 
Title of Study: The Effect of Chlorhexidine on the Oral and Lung Microbiome in  
                       Chronic Obstructive Pulmonary Disease 
 
 
Principal Investigator: Chris Wendt, MD 
VAMC: Minneapolis 618 
 
 
Printed name and last 4 of SS# (If addressograph 
label is used, please mask all other information) 
This section for completion by IRB only 
Approval date: 02/27/2017 
Expiration date: 02/26/2018 
VA Form 10-1086  
June 1990 
Version date 02/15/2017 
MVAHCS form revised Dec 2013 
 
should be free from pressure or coercion to participate; and 2) the VA research 
team will work to secure your information according to VA data security and 
privacy policies and every effort will be made to keep your information from your 
supervisor and co-workers. However, accidental disclosure or release of your 
private information could occur during the conduct of this study.  
BENEFITS  
There may be no direct benefit to you from being in the study.  If you do experience 
some improvement in cough and phlegm production and/or shortness of breath while 
taking the study drug, any symptom benefit would likely not last beyond the time you 
are in the study.  The knowledge gained from this study may benefit others in the 
future. 
 
COMPENSATION  
You will be paid $50 per visit (2 visits) for your participation for a possible total of $100. 
You will be given $5 in the form of a coupon to buy lunch in the cafeteria at each visit (2 
visits) In addition, if you are traveling over 50 miles one way to come to the Minneapolis 
Veterans Administration Medical Center for this study, you will be paid $0.415 (41.5 
cents) per mile for your travel expenses.  You will receive your payment within 6 weeks 
of completing the study.    
 
ALTERNATIVES (OTHER AVAILABLE TREATMENTS)  
The medication being studied will be added to your other breathing medications.  Your 
usual breathing medicines will not be altered as part of this study.  There are multiple 
inhaled and oral medications that are used to treat chronic obstructive pulmonary 
disease (COPD).  The medication Chlorhexidine should not interfere with your existing 
COPD therapies. 
 
CONFIDENTIALITY AND USE OF RESEARCH RESULTS 
The results of this study may be published or presented but your identity and records 
will not be revealed unless required by Federal Law.  A Federal Law allows the U.S. 


Department of Veterans Affairs       
VA RESEARCH CONSENT FORM 
Protocol #4526-B  
 
 
 
  (Page 8 of 11) 
Date: 
 
Title of Study: The Effect of Chlorhexidine on the Oral and Lung Microbiome in  
                       Chronic Obstructive Pulmonary Disease 
 
 
Principal Investigator: Chris Wendt, MD 
VAMC: Minneapolis 618 
 
 
Printed name and last 4 of SS# (If addressograph 
label is used, please mask all other information) 
This section for completion by IRB only 
Approval date: 02/27/2017 
Expiration date: 02/26/2018 
VA Form 10-1086  
June 1990 
Version date 02/15/2017 
MVAHCS form revised Dec 2013 
 
Food and Drug Administration, Office for Human Research Protections, Government 
Accountability Office and other Federal agencies, the Research and Development 
Committee and/or the Institutional Review Board (IRB)/Human Studies Subcommittee 
of the VA Medical Center to review records.  Because of the need for these inspections, 
absolute confidentiality cannot be guaranteed.  
 
 
COSTS TO YOU FOR PARTICIPATING   
 
There is no cost to you for taking part in this study.  All the study costs,  including any 
study medications provided by the sponsor, will be paid for by the VA Medical Center.  
Veterans who must make a co-payment for their usual medications or treatments 
will continue to be required to make such a co-payment for non-study related 
drugs.  There should be no additional medical costs to you for taking part in this study.  
However, frequent clinic visits may result in transportation costs and possible wages 
lost due to time missed from work. 
 
MEDICAL CARE IF YOU ARE INJURED   
In case you are injured from this research study, treatment will be available, including 
first aid, emergency treatment and follow-up care, as needed, by the VA Medical 
Center.  In the event you cannot reach a VA facility, the VA will pay for necessary 
medical care for any injury or illness directly related to your participation in this research 
study. If you receive this type of medical care, you must contact the Research 
Investigator for this study. You can find contact information in the section of this 
consent titled “Compensation for Any Injuries”. 
 
COMPENSATION FOR ANY INJURIES 
You have not released the VA Medical Center from liability by signing this form.  This 
includes but is not limited to: 1) free medical care other than as described in this 
consent form, 2) payment of lost wages, or 3) compensation for pain and suffering.  
Compensation for those items from the VA may be available under applicable Federal 
Law.  You should immediately report any injuries resulting from your participation in this 


Department of Veterans Affairs       
VA RESEARCH CONSENT FORM 
Protocol #4526-B  
 
 
 
  (Page 9 of 11) 
Date: 
 
Title of Study: The Effect of Chlorhexidine on the Oral and Lung Microbiome in  
                       Chronic Obstructive Pulmonary Disease 
 
 
Principal Investigator: Chris Wendt, MD 
VAMC: Minneapolis 618 
 
 
Printed name and last 4 of SS# (If addressograph 
label is used, please mask all other information) 
This section for completion by IRB only 
Approval date: 02/27/2017 
Expiration date: 02/26/2018 
VA Form 10-1086  
June 1990 
Version date 02/15/2017 
MVAHCS form revised Dec 2013 
 
study to Dr. Chris Wendt at (612) 467- 4400 during the day and during the evenings or 
week-ends, by calling the VA operator at (612) 725-2000 and ask to have the 
Pulmonologist on call paged.  Tell the operator you are in a research study. (If you do 
not live in the metropolitan area, you may call the toll-free number: 1-866-414-5058.) 
 
 
NEW INFORMATION 
You will be given any new significant information that is discovered during the course of 
this study which may influence your willingness to continue the study. 
 
 
OTHER INFORMATION   
Reasons for Removal from the Study 
The study doctor can end your participation in this study if you do not take your study 
medications as prescribed, if you miss scheduled study visits, or if s/he determines that 
it is in your best interest to end your participation.  In addition, you may be removed 
from the study by the doctor if you do not follow the study plan, have a study-related 
injury, if it is believed that being in the study may cause you harm, for administrative 
reasons, or for any other reason. 
 
If You Want to Withdraw From the Study 
At any point during this study, you can decide that you no longer want to participate.  If 
you no longer want to participate, you should notify the study coordinator,  
Ms. Sue Johnson (612) 629-7492 or Dr. Chris Wendt (612) 467-4400.  You will 
continue to get your usual care at the VA regardless of your study participation.  If 
desired, you can request that your specimens be destroyed. 
 
 
RESEARCH SUBJECT'S RIGHTS:   
I have read or have had read to me all of the above. 
 ___________________ has explained the study to me and answered all of my 
questions.  I have been told of the risks or discomforts and possible benefits of the 
study.  I have been told of other choices of treatment available.   


Department of Veterans Affairs       
VA RESEARCH CONSENT FORM 
Protocol #4526-B  
 
 
 
  (Page 10 of 11) 
Date: 
 
Title of Study: The Effect of Chlorhexidine on the Oral and Lung Microbiome in  
                       Chronic Obstructive Pulmonary Disease 
 
 
Principal Investigator: Chris Wendt, MD 
VAMC: Minneapolis 618 
 
 
Printed name and last 4 of SS# (If addressograph 
label is used, please mask all other information) 
This section for completion by IRB only 
Approval date: 02/27/2017 
Expiration date: 02/26/2018 
VA Form 10-1086  
June 1990 
Version date 02/15/2017 
MVAHCS form revised Dec 2013 
 
I have been informed that because this study involves articles regulated by the FDA 
(Food and Drug Administration), the FDA may choose to inspect research identifying 
me as a subject of this investigation. 
 
I understand that I do not have to take part in this study and my refusal to 
participate will involve no penalty or loss of rights to which I am entitled.  I may 
withdraw from this study at any time without penalty or loss of VA or other 
benefits to which I am entitled. 
The results of this study may be published but my identity and records will not be 
revealed unless required by law. We do not anticipate any commercial benefits from 
this study and you will not receive any additional benefits other than what is stated in 
this form. 
 
I authorize the use of my bodily fluids (blood sample, oral wash and sputum). 
 
In case there are medical problems or questions, concerns, or complaints, I have been 
told I can call Dr. Chris Wendt at (612) 467-4400 or Sue Johnson at (612) 629-7492 
during the day and the VA operator at (612) 725-2000 after hours and ask to have the 
Pulmonologist on call paged.  I will tell the operator I am in a research study.  (If I do not 
live in the metropolitan area, I may call the toll-free number: 1-866-414-5058.) 
If any medical problems occur in connection with this study the VA will provide 
emergency care. 
If I have any questions about the rights of a research subject, or would like to: 
 obtain information 
 discuss problems or concerns, or have questions about this study 
 offer input regarding this research study 
and would like to speak to an individual who is not part of the research team of this 
study, I may contact the Patient Representative at (612) 725-2106.  If I wish to verify 
the validity of the study and its authorized contacts, I may call the patient 
representative or contact the IRB office at 612-467-2800.  
 


Department of Veterans Affairs       
VA RESEARCH CONSENT FORM 
Protocol #4526-B  
 
 
 
  (Page 11 of 11) 
Date: 
 
Title of Study: The Effect of Chlorhexidine on the Oral and Lung Microbiome in  
                       Chronic Obstructive Pulmonary Disease 
 
 
Principal Investigator: Chris Wendt, MD 
VAMC: Minneapolis 618 
 
 
Printed name and last 4 of SS# (If addressograph 
label is used, please mask all other information) 
This section for completion by IRB only 
Approval date: 02/27/2017 
Expiration date: 02/26/2018 
VA Form 10-1086  
June 1990 
Version date 02/15/2017 
MVAHCS form revised Dec 2013 
 
My questions have been answered and I voluntarily consent to participate in this study.  
By signing this form, I have not given away any of my legal rights, which I have as a 
subject of this research study.  I will receive a signed copy of this consent form.  
 
 
 
 
 
 
 
 
 
 
 
__ 
Subject's Signature  
 
 
 
 
 
Date 
 
___________________________________               _____________ 
Signature of Person Obtaining Consent  
 
 
Date 
 
______________________________________ 
Printed Name Of Person Obtaining Consent