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 | |
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Advantages |
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Disadvantages |
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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 | |
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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®) |
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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
Respiratory Medication Device Proper Technique (Get more medication to the lungs)
- 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
- Jet nebulizers commonly covered by insurance.
- Vibrating Mesh nebulizers not usually covered by insurance
- 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
- 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.