The editorial by Jenkins and Beasley1 makes a speculative recommendation that tiotropium Respimat should not be prescribed in the treatment of chronic obstructive pulmonary disease (COPD), being primarily based on meta-analysis where mortality was not the primary end point. The meta-analysis by Singh et al 2 reported that treating 124 patients per annum with tiotropium Respimat 5 ug resulted in one additional death, although the associated 95% CI of 52 to 5682 clearly indicates that the data are not particularly robust. In considering the risk-benefit ratio of tiotropium one has to consider the seed and the soil, in terms of the degree of systemic exposure and the predisposing cardiovascular status. There is …