Long-acting bronchodilators are recommended in patients who remain symptomatic despite adequate treatment with short-acting bronchodilators. Nevertheless, guidelines do not recommend a specific long-acting bronchodilator. Based on a systematic review of the literature, tiotropium is not superior on clinically relevant outcomes than salmeterol. In addition, tiotropium is more expensive by which the cost-effectiveness balance for this drug is unfavourable. In conclusion, tiotropium has its intrinsic merits but is currently too expensive from a medical and payer’s perspective.