This prospective, single centre, 8 weeks, open-label study is designed to evaluate in real-life the effect of triple Beclometasone/Formoterol/Glycopyrronium (BDP/F/G) therapy on cough efficacy, assessed by cough peak flow (CPF), after 8 weeks' treatment in patients with moderate to severe COPD.

The study's hypothesis is that in symptomatic moderate to severe COPD patients the administration of fixed dose combination BDP/F/G, by reducing lung hyperinflation (LH) and targeting small airways, may accordingly improve the cough efficacy. The increase in cough efficacy might in turn positively influence the quality of life of patients and underlie the prevention of acute exacerbations of COPD.

The cough is a vital defensive mechanism of respiratory system. Chronic obstructive pulmonary disease (COPD) is characterised by persistent inflammation in the small airways inducing pathological changes that reduce airflow and increase gas trapping and lung hyperinflation (LH). LH in turn leads to the changes in diaphragmatic excursions: this might decrease the efficacy of cough. In moderate to severe COPD patients, the cough efficacy, expressed as cough peak flow (CPF) and cough expired volume (CEV), is significantly reduced when compared to those of controls.

A triple combination inhaler containing beclometasone dipropionate/formoterol/glycopyrronium (BDP/F/G) was developed as an extrafine formulation to enable efficient delivery of an inhaled corticosteroid (ICS) combined with a long-acting beta2 agonist (LABA) and a long-acting muscarinic antagonist (LAMA) to the small airways, improving LH and associated symptoms.

The study's hypothesis is that the administration of fixed extrafine BDP/F/G 87/5/9 µg q.d. for 8 weeks will determine an increase of CPF, CEV, lung function and quality of life in COPD patients non adequately controlled by double combination of inhaled treatment with ICS plus LABA or ICS plus LAMA or LABA plus LAMA.

CPF, CEV, residual volume (RV), inspiratory capacity (IC), total lung capacity (TLC), RV/TLC ratio, forced expiratory volume at 1st second (FEV1), forced vital capacity (FVC) and FEV1/FVC ratio will be assessed at baseline (Visit 1, V1) and after 4 weeks' treatment with BDP/F/G (Visit 2, V2). The same assessments will be performed after 4 weeks' treatment (Visit 3, V3).

The switch from the double to triple therapy will be carried out according to clinical practice and to the summary of product characteristics.

At V1, V2, and V3 dyspnoea perception, assessed by the modified Medical Research Council (mMRC) scale score and the quality of life, assessed by the COPD Assessment Test (CAT), will be recorded.

V1, V2, V3 will be performed in the morning between 8:00 and 10:00 ante meridien.

Each patient will sign an informed consent prior to initiation of any study-related procedure. The study protocol was approved by the local Hospital's Ethical Committee (approval number n. 38097; September 22, 2021) and it will be conducted according to the Good Clinical Practices and the Declaration of Helsinki.

The population will consist of 40 adult patients. Assuming a p values < 0.05, a sample size of 40 patients (34 + 15% drop outs) is required to detect difference of 0.4 L/s (liters/second) with a standard deviation (SD) of 0.69 in CPF following a 8 weeks BDP/F/G treatment, with a power of 90%. Efficacy endpoints will be analysed using the intention to treat analysis (ITT) which will comprise all patients treated for 8 weeks with BDP/F/G 87/5/9 µg q.d. at visit 3.

Data will be collected in a dedicated electronic Clinical Records Form (CRF). The database will be saved on a password-protected company Personal Computer (PC) which will be updated at each visit and used exclusively for scientific research purposes. At the time of enrollment, each patient will receive an alphanumeric code so that any information collected during the study, and in particular sensitive data, is treated in an anonymous manner. Data reporting patients' identifications will only be used to file patients and collect informed consent.

Inclusion Criteria:

• Male or female adults aged ≥40 years;
• Signed informed consent;
• Current or ex-smokers with a smoking history of at least 10 pack years. An ex smoker will be defined as a subject who has not smoked for ≥ 6months at screening;
• Diagnosis of COPD according to the International Statement;
• COPD patients with a forced expiratory volume in the 1st second (FEV1) between 30% and 80% of predicted post-bronchodilator (salbutamol 400 µg) at baseline visit;
• COPD patients with lung hyperinflation with residual volume (RV) ≥ 120% predicted;
• COPD patients treated with ICS/LABA or LABA/LAMA or ICS/LAMA therapy from at least one month before baseline visit;
• COPD patients with elevated impact of disease and/or symptoms defined by a CAT≥ 10 score and/or a mMRC ≥ 2 score and an history of exacerbation (≥ 1 exacerbation in the previous year).

Exclusion Criteria:

• Patients with COPD exacerbation that required treatment with antibiotics, systemic steroids (oral or intravenous) or hospitalization in the 4 weeks prior to enrolment;
• Patients with concomitant other lung disease (e.g. asthma, lung fibrosis, primary bronchiectasis, sarcoidosis, interstitial lung disorder, pulmonary hypertension);
• Patients requiring long-term oxygen therapy (LTOT) ≥12 h a day on a daily basis for chronic hypoxemia;
• Patients with severe comorbidities associated to COPD, such as unstable cardiovascular diseases or cancer;
• Patients with narrow-angle glaucoma, symptomatic benign prostatic hyperplasia (BPH), bladder-neck obstruction, moderate to severe renal impairment or urinary retention. BPH patients who are stable on treatment will be considered for enrolment;
• Patients with clinically significant renal, cardiovascular (such as but not limited to unstable ischemic heart disease, New York Heart Association (NYHA) Class III/IV left ventricular failure, myocardial infarction), neurological, endocrine, immunological, psychiatric, gastrointestinal, hepatic, or haematological abnormalities which could interfere with the assessment of the efficacy and safety of the study treatment;
• COPD patients treated with triple LABA/LAMA/ICS therapy;
• Pregnant women;
• Subjects unable to meet the criteria of acceptability and repeatability of pulmonary function tests, according to the American Thoracic Society/European Respiratory Society (ATS/ERS) document.

The population will consist of 40 adult patients, referred at outpatient clinic of the Respiratory Disease Unit of the University Hospital of Parma (Italy)

Data will be collected in a dedicated electronic Clinical Records Form (CRF). The database will be saved on a password- protected company personal computer which will be updated at each visit and used exclusively for scientific research purposes. At the time of enrolment, each patient will receive an alphanumeric code so that any information collected during the study, and in particular sensitive data, will be treated in an anonymous manner. Data reporting patients' identifications will only be used to file patients and collect informed consent.

Data will be available during the course of the study. The Investigator will keep paper and electronic copies of all documentation at the Center for a period of at least 7 years after the completion of the study and then he will arrange for its destruction.

Only the personal delegated to collaborate with this study will be able to access to the database using a password to login.