Selecting an Inhaler: Matching the Device with the Patient's Abilities

With asthma and chronic obstructive pulmonary disease (COPD) on the upswing, retail health clinicians see many patients who have these conditions, most of whom rely on inhalers to keep their airways open and facilitate breathing.

Compared to orally administered drugs, inhalers deliver the drug directly to the lungs, avoiding systemic circulation, improving safety, reducing adverse effects and increasing effectiveness. Almost half of patients with asthma still experience symptoms while receiving maintenance therapy, and adherence in COPD patients is low. Having and knowing how to use an inhaler is critical.

Inhalers can be expensive—costing up to $350 each—so selecting the best inhaler for the individual patient avoids wasted doses and improves outcomes. Inhalers differ in their requirements for dexterity, adequate grip strength, visual acuity, and lung capacity. Some inhalers are harder to use than others are, so prescribers should develop a quick familiarity with the various types.

Manufacturers market three main types of inhalers, and each has pros and cons:

· Multidose inhalers (MDI) are small, quick to use, and less costly than alternatives. They require the patient to coordinate breath and actuation, which can be a problem for patients with low grip strength or arthritis. MDI inhalers are a poor choice for patients with low cognitive ability or difficulty actuating the mechanism.

· Dry powder inhalers (DPI) differ from MDIs in that they are breath-actuated (breath-dose coordination is unnecessary) and easier to use. Patients need sufficient respiratory force to inhale the powder, and this can be a barrier for elderly COPD patients. A preparation step before inhalation may be needed; patients with low dexterity or cognitive impairment may find this difficult. Some DPIs require patients to insert a capsule before each use, and all require users to push a button or pull back on a lever to start the powder exposure process.

· The newest DPI, the Ellipta device, has one simple preparation step and is breath-actuated. Its air vents allow patients to inhale more slowly and with less force than other devices—advantages for patients with low lung capacity. In addition, it is prefilled and has a dose counter. Retail health care providers will need to teach patients to keep the vents clear and hold their breath for 10 seconds. This may be difficult for cognitively impaired patients.

· Respimat or SoftMist inhalers are the newest technology. They create a slower-moving, longer-lasting mist, eliminating breath-actuation coordination. Although they deliver lower doses, more of each dose reaches the lungs. Setting up the inhaler for the first time requires some education, and it’s helpful if a health care provider inserts the canister the first time.

How can you choose the correct inhaler for your patient? TheTablesummarizes the common inhalers and the things health care providers need to know about them. For inhalers that do not appear here, find the complete prescribing information. The “How Supplied” section will tell you what kind of inhaler it is, and all inhalers include patient directions in the labeling.

A final reminder: patients must be reminded and reeducated about inhalers often. Retail health care providers can ask patients to demonstrate how they use their inhalers, and use the teach-back method to ensure they use them correctly. Additionally, this is an area where YouTube comes to the rescue! It has many videos that show proper technique. Creating a library of the best videos saves time and helps provide appropriate education that patients can refer back to later.

TABLE:COMMON INHALERS AND WHAT TO KNOW ABOUT THEM

Brand

Generic

Special Notes

Dry powder inhalers (DPI)

For most DPIs, patients need not be able to coordinate breath and actuation. They do need to be able to inhale deeply with good force. Preparation steps could challenge patients with arthritis, low dexterity, or poor grip strength

Advair Diskus

flucticasone/ salmeterol

Prefilled with dose counter

Twice daily dosing

Spiriva HandiHaler

tiotropium bromide

Need to insert capsule before each use

Once daily dosing

ProAir Respiclick

albuterol

Does not require hand-breath coordination

Arcapta Neohaler

indacaterol

Need to insert capsule before each use.

Once daily dosing

Tudorza Pressair

aclidinium bromide

Indicated for COPD only

Twice daily dosing

Ellipta (DPI) Inhaler

All Ellipta DPI inhalers are preloaded with a dose counter integrated into the mechanism. Patients need to take one single step to prepare the device, making it easier for patients with poor grip strength or dexterity. DPI inhalers have a unique ventilation system at the mouth piece that provides steadier inhalation. Patients with visual impairment may find the dose counter and label information hard to read.

Incruse Ellipta

umeclidium

Once daily dosing

Breo Ellipta

fluticasone furoate and vilanterol

Approved for COPD

Once daily dosing

Anoro Ellipta

umeclidium and vilanterol

Once daily dosing

Respimat Inhaler

The Respimat inhaler delivers a slow-moving mist, so patients can breathe more slowly and normally. It delivers drugs very effectively, but the canister can be difficult to turn. Patients with visual impairment may find the dose counter and label information hard to read.

Spiriva Respimat

tiotropium

One daily dosing

Striverdi Respimat

olodaterol

Two inhalations once daily

Stiolto Respimat

tiotropium

Two inhalations once daily

Combivent Respimat

ipratropium bromide and Albuterol SUlfate

Only product for COPD exacerbation that uses Respimat technology

Once inhalation 4 times daily

COPD = chronic obstructive pulmonary disease; DPI = dry powder inhaler.

Resources

Brand P, Hederer B, Austen G, Dewberry H, Meyer T. Higher lung deposition with Respimat Soft Mist Inhaler than HFA-MDI in COPD patient with poor technique.Int J Chron Obstruct Pulmon Dis.2008;3:763-770.

Geller DE. Comparing clinical features of the nebulizer, metered-dose inhaler, and dry powder inhaler.Respir Care.2005;50:1313-1322.

Hashmi A, Soomro JA, Memon a, et al. Incorrect inhaler technique compromising quality of life of asthmatic patients.J Medicine.2012;13:16-21.

Kubus C, Wick JY. Drug-device combinations: Are they appropriate for the aging population?Consult Pharm.2016;31(5):240-250. doi: 10.4140/TCP.n.2016.240.

Svedsater H, Dale P, Garrill K, Walker R, et al. Qualitative assessment of attributes and ease of use of the ELLIPTA TM dry powder inhaler for delivery of maintenance therapy for asthma and COPD. BMC Pulm Med. 2013;13:72. doi: 10.1186/1471-2466-13-72.