Chronic obstructive pulmonary disease (COPD) is common in older people, with an estimated prevalence of 10 % in the US population aged >75 years. Inhaled medications are the cornerstone of treatment for COPD and are typically administered by one of three types of devices (pressurized metered dose inhalers, dry powder inhalers, and nebulizers). However, age-related pulmonary changes may negatively influence the delivery of inhaled medications to the small airways [79]. In addition, physical and cognitive impairment, which are common in older patients with COPD, pose special challenges to the use of handheld inhalers in the old. Nebulizers should be considered for patients unable to use handheld inhalers properly. Airway mucus hypersecretion (AMH) is a key pathophysiological characteristic of COPD. Corticosteroid is the first-line anti-inflammatory treatment used to alleviate COPD, but its therapeutic effects are controversial and long term treatment often leads to undesirable side effects [80]. According to recent reports PPARy agonists can inhibit mucin synthesis both in vitro and in vivo, but only nebulized TGZs lead to a reduction in mucus production in the airways, whereas oral administration has no such effect [81]. Administration of the PPARy agonist ciglitazone via nebulizer reduces OVA-triggered mucus gland hyperplasia and airway occlusion by approximately 75 % [82 i . It has been proposed that PPARy activation may ease AMH through a pathway involving MMP-9, providing molecular mechanism of action for COPD treatment [83].

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