Newsletter Signup

Ensuring Safe Transitions of Care in Patients with
Chronic Obstructive Pulmonary Disease

Guide to Device Selection

One of the unique aspects of treating COPD is that therapies include both the prescribed medication as well as the device to deliver that medication. Currently there are four types of devices to deliver the various COPD medications: pressurized metered dose inhalers (pMDI), dry powder inhalers (DPI), soft mist inhalers (SMI), and nebulizers. It is well established that device technique errors contribute to poor drug effectiveness in COPD. Therefore, healthcare providers must be knowledgeable about not only the molecules being prescribed, but also the device used to deliver them.

Each delivery system has unique advantages and disadvantages that can be used in shared decision-making process between the clinician and patient to select the right delivery system. Healthcare providers need to be able to consider how personalized patient factors can impact successful use of specific devices. For example, pMDIs require a spacer along with breath-actuation coordination that can be difficult for some patients. Dry powder inhalers require sufficient inspiratory flows to disaggregate the powder to small enough particle size for adequate drug delivery to the lung. There is ongoing work to understand the proper ways to measure peak inspiratory flow to determine which patients are not able to generate sufficient inspiratory flow rates. It is important that patients be re-assessed at each care transition, as their abilities to use a particular device can change throughout their healthcare journey.

In this section, we provide useful resources including summary tables of the characteristics of different delivery devices, the various inhaled therapies across devices, and several flow algorithms for selecting the proper delivery device for a particular patient.

The Advantages and Disadvantages of Different Medication Delivery Systems

Understanding the differences in inhaled medication delivery devices is important when considering the proper device for a patient. This table outlines some key advantages and disadvantages of the four delivery systems for COPD medications.

Metered Dose Inhaler Dry Powder Inhaler Soft Mist Inhalers Nebulizer
Advantages
  • Portable
  • Combination molecules available
  • No priming
  • Once-daily dosing available (in some)
  • Portable
  • Combination molecules available
  • Inspiratory flow independent
  • Once-daily dosing
  • Portable
  • Combination molecules available
  • Minimal coordination
  • Inspiratory effort independent
Disadvantages
  • Priming
  • Requires spacer for administration
  • Requires actuation-inhalation coordination
  • Weekly cleaning
  • Impacted by inspiratory flow
  • Can be impacted by humidity
  • Device loading and priming can be challenging
  • Longer administration time
  • Portability issues
  • Cleaning after each use
  • Weekly disinfection
  • Change nebulizer cup and filter

Specific Inhaled Agents by Delivery System and Medicine

When prescribing inhaled COPD therapies, healthcare providers must remember that she is prescribing both a medicine and a delivery device for that medicine. Therefore, it is necessary to be knowledgeable on the various combinations of medicines and devices that can deliver them. This table summarizes the currently available COPD inhaled therapies, categorized by medication class and device.

Metered Dose Inhaler Dry Powder Inhaler Soft Mist Inhalers Nebulizer
SABA Ventolin® HFA
ProAir® HFA
Albuterol® HFA
Xopenex® HFA 		ProAir®
RespiClick® 		Albuterol®
Xopenex®
SAMA Atrovent® HFA Ipratropium
SABA/SAMA Combivent® DuoNeb®
LABA Arcapta®
Serevent® 		Striverdi® Brovana®
Perforomist®
LAMA Spiriva® HandiHaler®
Seebri®
Incruse®
Tudorza® 		Revefenacin (Yupelri®)
Glycopyrrolate (Lonhala®)
ICS Pulmicort®
LAMA/LABA Bevespi® Utibron®
Anoro® 		Stiolto®
LABA/ICS Advair® HFA
Symbicort® HFA 		Advair® Diskus®
Symbicort® Turbuhaler®
Dulera®
Breo®
LABA/LAMA/ICS Trelegy®

SABA: Short Acting Beta Agonist, SAMA: Short Acting Muscarinic Antagonist, LABA: Long Acting Beta Agonist, LAMA: Long Acting Muscarinic Antagonist, ICS: Inhaled Corticosteroid

Selecting the Appropriate Respiratory Medication Delivery Device

Does patient have any cognitive, health literacy, or language barriers that prevents them from understanding or following all the necessary steps of proper inhaler technique?
Yes
No
Consider nebulizer
Does patient have any physical issues that prevents them from following all of the necessary steps of proper inhaler technique? (For example: muscle weakness, impaired dexterity (e.g., arthritis, Parkinson’s), stroke, joint pain, declined vision, poor hearing)
Yes
No
Consider nebulizer
Can patient produce a fast and deep inhalation? Children less than 5 years old cannot generate sufficient inhalation to use DPI.
Yes
No
Consider DPI
Can patient produce a slow deep inhalation while pressing down button? May consider pMDI or SMI as well.
Is patient able to hold breath after breathing in medication?
Yes
No
Depending on patient preference, continue DPI, pMDI, or SMI.
Consider nebulizer or pMDI with spacer
Is the patient able to produce a slow deep inhalation?
Yes
No
Can patient breathe in slowly & press button at same time?
Yes
No
Consider pMDI or SMI
Is patient able to hold breath after breathing in medication?
Yes
No
Consider pMDI or SMI
Consider nebulizer
Consider nebulizer
Consider nebulizer or pMDI with spacer
Is patient able to hold breath after breathing in medication?
Yes
No
Consider pMDI or SMI
Consider nebulizer
Reset

Respiratory Medication Device Proper Technique (Get more medication to the lungs)

Is the respiratory medication delivered via an inhaler or nebulizer?
Inhaler
Nebulizer
Read Manufacturer Instructions
  • Prime MDI and SMI prior to use
  • Shake MDI for 5 seconds (use a spacer with MDI for better lung deposition)
  • Sit or stand up straight
  • Breathe out fully away from inhaler mouthpiece prior to inhaling medication
  • Form a good seal with lips on mouthpiece, keep tongue and teeth out of the way
  • Breathe in:
    • MDI/SMI slow deep breath in while pressing button
    • DPI fast deep breath
  • Hold breath up to 10 seconds or as long as possible
  • Rinse and spit after use of inhaler with corticosteroid to help prevent thrush
  • Clean:
    • MDI once weekly remove canister and wash casing, shake off extra water, and air dry. Re-prime as directed. Some exclusions apply.
    • SMI once weekly clean mouthpiece with damp cloth
    • DPI occasionally wipe with dry cloth
    • Spacer once weekly disassemble and soak in warm soapy water, rinse, and air dry.
  • Additional resources:
    • Nationaljewish.org
    • Copdfoundation.org
    • Use-inhalers.com
    • Manufacturer websites
Read Specific Manufacturer Instructions
  • Jet nebulizers commonly covered by insurance.
  • Vibrating Mesh nebulizers not usually covered by insurance
Jet
Vibrating Mesh
Jet Nebulizers
  • Treatment time: depending on manufacture up to 15 minutes
  • AC, DC, and/or battery operated
  • Rinse nebulizer cup after each use, shake off excess water and air dry
  • Clean in warm soapy water daily and air dry
  • Disinfect weekly
  • Replace nebulizer cup set up: Disposable: every 2 weeks, Reusable every 6 months
  • Replace filter every 6 months or as recommended
Vibrating Mesh
  • Treatment time: depending on manufacturer up to 4 minutes
  • AC and battery operated
  • Portable
  • Virtually silent
  • Rinse nebulizer cup after each use, shake of excess water and air dry
  • Clean daily and air dry
  • Disinfect weekly
  • Replace mouthpiece/nebulize cup as directed.
Reset