Are You Taking the Right Inhaler? A Personalized Approach

Background

For a variety of reasons, information on treatment of COPD has focused primarily on the inhaled medication with only limited consideration of the actual delivery system (type of inhaler). Clearly, both the type of medication (two different types of bronchodilators and inhaled corticosteroids) and the different types of inhaled delivery systems are BOTH important.

pressurized metered-dose inhaler (pMDI)

In previous postings on this website, I have discussed the four different inhaler types: pressurized metered-dose inhaler; slow mist inhaler; dry powder inhaler; and nebulizer.

Report

Dr. David Halpin of the University of Exerter in the United Kingdom and I wrote a perspective on “Personalizing Selection of the Inhaled Delivery System in COPD,” published in 2023 in the Annals of the American Thoracic Society (volume 20; pages 1389-1396). The article was written to provide guidance for health care professionals for selecting the most appropriate type of inhaler. This information can be helpful for you as well. In brief, we prosposed that your health care professional match the features of the different devices with your unique abilities considering any possible impairments.

slow mist inhaler

Devices

With both a pressurized meterd-dose inhaler and the slow mist inhaler, the medication is released by pressing down on the canister or on a button. Your inhalational effort is to breathe in “slow and steady” after actuating (pressing down) the device. In contrast, with a dry powder inhaler (shown below) you should breath in “hard and fast” to break up the powder medication into small particles that can be inhaled deep into your lungs.

Different dry powder inhalers

With a nebulizer, you breathe in and out normally – no special effort is required.

Hand held nebulizer

Thus, there are three different breathing in efforts depending on the device. Ideally, and if possible, your health care professional should prescribe the same device type so it easier for you. Unfortunately, this is not always possible as health insurance companies often determine the inhaled medication and delivery system – without any concern for what is best for the individual patient.

Patient Factors

Your ability to use the inhaler devices is quite important. For example, cognitive impairment - that can include memory loss, trouble completing tasks, and/or difficulty following instructions – impacts a person’s ability to use the devives correctly. It is estimated that 20 to 25% of patients with COPD have some cognitive impairment.

Another factor is finger/hand dexterity and strength – both are required for patients with COPD to prepare and operate handheld devices. In response to an on-line survey, patients with COPD reported having these conditions – arthritis (44%), difficulty with fine motor activities (36%), and tremor (15%). These factors may affect the ability to use a handheld device.

Finally, the ability to breathe in “hard and fast” to create turbulent energy inside a dry powder inhaler is important for breaking up the powder into small particles to inhale deep into the lungs. It is simple to measure your peak inspiratory flow – which is the maximal airflow during a forceful inhalation – to estimate your ability to create turbulent energy and break up the powder medication. If your peak inspiratoy flow is low, then it is probably best to use a different type of inhaler device.

Diagram of how a dry powder inhaler works

Conclusions

Your health care professional should personalize the selection of inhaled medication delivery system. The goal it to match an appropriate medication(s) with the unique features of the delivery system based on your cognitive function, finger/hand dexterity and strength, and peak inspiratory flow so that you use the right inhaler.

My Comments

As two bronchodilators are currently recommended as initial treatment for COPD, you should experience that it is easier to breathe during activities IF you are using the device correctly and getting the medication deep into your lungs. If you are not getting any benefit, then you should ask a health care professional (medical assistant, nurse, doctor) to watch you inhale from your device(s). Correct inhalation technique is KEY! If you are still not benefiting from treatment, ask you health care professional about trying a different medication and/or inhaler device.

Finally, I encourage you to take an active role in determining whether you are taking the right inhaler for your individual situation. Shared decision-making is a communication process in which patients and health care professionals work together to arrive at the best decisions for each individual.