Requirements, Strengths and Weaknesses of Inhaler Devices for COPD Patients from the Expert Prescribers' Point of View: Results of the EPOCA Delphi Consensus

Figures & data

Table 1. Most important characteristics to consider in the choice of an inhaler device in patients with COPD.

		Likert scale of importance
	Characteristics	% participants who scored 7–9	Mean ± SD
Characteristics of the ideal inhaler (≥ 85% of the experts scoring 7–9)	High lung deposit	99.0%	8.4 ± 0.8
	Correct dispensation with low inspiratory flow rates	96.9%	8.4 ± 0.9
	Does not require coordination	93.8%	8.3 ± 0.9
	Exact and reproducible dosing	93.8%	8.2 ± 1.0
	Easy to teach	93.8%	7.9 ± 1.0
	Patient's awareness of correct inhalation	89.6%	8.0 ± 1.2
	Intuitive mechanism	88.5%	7.9 ± 1.1
	Inclusion of safety mechanisms to prevent overdosing	87.5%	7.6 ± 1.2
	Reduced oropharyngeal deposit	85.4%	7.7 ± 1.2
Other characteristics	Dose counter	84.4%	7.6 ± 1.3
	Fewer steps before inhalation	82.3%	7.6 ± 1.4
	Can be used for several active ingredients	81.3%	7.3 ± 1.6
	High fine-particle fraction	80.2%	7.5 ± 1.2
	Multidose	69.8%	7.1 ± 1.5
	Activation by inspiration	68.8%	6.8 ± 1.8
	Easy to clean	62.5%	6.6 ± 1.6
	Transportation and size	50.0%	6.0 ± 1.8
	No need to shake the device	41.7%	5.8 ± 2.2

Figure 1. Comparison of the most important characteristics to consider the choice of an inhaler device according to the work experience of the pneumologists. Only the p-values for the significant comparisons are shown.

Table 2. Advantages and disadvantages considered most important for the election of an inhaler device in patients with COPD.

		Advantages	Limitations
MDIs or SMIs	Conventional MDI	It can be used with a spacer chamber (86.3%)	It requires coordination (66.0%)
		Portability and size (50.5%)	High oropharyngeal deposit (28.8%)
		It can be used for several active ingredients (15.7%)	No dose counter (26.6%)
	ModulIte®	High pulmonary deposition (52.2%)	No dose counter (24.2%)
		It can be used with spacer chamber (43.4%)High fine-particle fraction (54.3%)	It cannot be used for several active ingredients (22.0%)It requires coordination (48.5%)
	Respimat®	Correct dispensation with low inspiratory flow rates (70.5%)	It is not easy to teach (63.9%)
		High lung deposition (47.4%)	High number of steps before inhalation (53.2%)
		Accurate and reproducible dosing (18.9%)	Non-intuitive handling mechanism (43.7%)
sdDPIs	Aerolizer®	Does not require coordination (52.1%)	High number of steps before inhalation (43.8%)
		Easy to teach (43.8%)	Requires high inspiratory flow rates (41.1%)
		Accurate and reproducible dosing (42.5%)	High oropharyngeal deposit (28.8%)
	Breezhaler®	Perception of correct inhalation (29.5%)	High oropharyngeal deposit (33.7%)
		Easy to teach (29.5%)Does not require coordination (53.7%)	Requires high inspiratory flow rates (28.4%)High number of steps before inhalation (38.9%)
	Handihaler®	Does not require coordination (56.8%)	High number of steps before inhalation (38.9%)
		Easy to teach (36.8%)	Requires high inspiratory flow rates (35.8%)
		Patient's awareness of correct inhalation (15.8%)	High oropharyngeal deposit (21.1%)
	Spinhaler®	Does not require coordination (40.0%)	High oropharyngeal deposit (40.0%)
		Accurate and reproducible dosing (16.0%)	High number of steps before inhalation (24.0%)
		Portability and size (16.0%)	Requires high inspiratory flow rates (20.0%)
mdDPIs	Accuhaler®	Dose counter (55.8%)	High oropharyngeal deposit (38.9%)
		Does not require coordination (53.7%)	Patient's unawareness of correct inhalation (34.7%)
		Accurate and reproducible dosing (21.1%)	Requires high inspiratory flow rates (32.6%)
	Easyhaler®	Does not require coordination (40.7%)	High oropharyngeal deposit (33.3%)
		Fewer steps before inhalation (34.6%)	It cannot be used for several active ingredients (30.3%)
		Dose counter (28.5%)	Patient's unawareness of correct inhalation (27.2%)
	Ellipta®	Does not require coordination (57.4%)	Patient's unawareness of correct inhalation (51.1%)
		Fewer steps before inhalation (45.7%)	Low fine-particle fraction (31.9%)
		Dose counter (34.0%)	High oropharyngeal deposit (27.7%)
	Genuair®	Does not require coordination (37.9%)	Incorrect dispensation with low inspiratory flow rate (40.0%)
		Dose counter (28.4%)	Low fine-particle fraction (33.7%)
		Patient's awareness of correct inhalation (27.4%)	High oropharyngeal deposit (29.5%)
	NEXThaler®	Does not require coordination (41.5%)	It cannot be used for several active ingredients (57.4%)
		High pulmonary deposition (37.2%)	High oropharyngeal deposit (24.5%)
		High fine-particle fraction (33.0%)	Incorrect dispensation with low inspiratory flow rate (23.4%)
	Novolizer®	Does not require coordination (49.9%)	High oropharyngeal deposit (40.1%)
		Easy to teach (25.5%)	Incorrect dispensation with low inspiratory flow rate (37.1%)
		Dose counter (20.7%	Low fine-particle fraction (21.8%)
	Spiromax®	Does not require coordination (51.6%)	It cannot be used for several active ingredients (46.6%)
		Fewer steps before inhalation (40.4%)	High oropharyngeal deposit (33.0%)
		Intuitive use mechanism (26.8%)	Patient's unawareness of correct inhalation (25.2%)
	Turbuhaler®	Does not require coordination (48.4%)	Incorrect dispensation with low inspiratory flow rate (38.9%)
		Portability and size (33.7%)	Patient's unawareness of correct inhalation (36.8%)
		Dose counter (27.4%)	High oropharyngeal deposit (34.7%)
	Twisthaler®	Does not require coordination (52.1%)	Patient's unawareness of correct inhalation (46.5%)
		Easy to teach (32.0%)	It cannot be used for several active ingredients (40.6%)
		Fewer steps before inhalation (22.3%)	Incorrect dispensation with low inspiratory flow rate (37.9%)

Abbreviations: MDIs, metered dose inhalers; SMIs, soft mist inhalers; sdDPIs, single-dose dry powder inhalers; mdDPIs, multidose dry powder inhalers.

Table 3. Main advantages and disadvantages to prescribing each inhaler device in patients with COPD in relation to the ideal device.^*

	Device	High lung deposit	Correct dispensation with low inspiratory flow rates	Does not require coordination	Exact and reproducible dosing	Easy to teach	Patient's awareness of correct inhalation	Intuitive mechanism	Inclusion of safety mechanisms to prevent overdosing	Reduced oropharyngeal deposit
MDIs or SMIs	Conventional MDI	—	—	↓↓	—	—	—	—	—	↓
	ModulIte®	↑↑	—	↓	—	—	—	—	—	—
	Respimat®	↑	↑↑	—	—	↓↓	—	↓	—	—
sdDPIs	Aerolizer®	—	↓	↑↑	—	↑	—	—	—	↓
	Breezhaler®	—	↓	↑↑	—	↑	↑	—	—	↓
	Handihaler®	—	↓	↑↑	—	↑	—	—	—	—
	Spinhaler®	—	—	↑	—	—	—	—	—	↓
mdDPIs	Accuhaler®	—	↓	↑↑	—	—	—	—	—	↓
	Easyhaler®	—	—	↑	—	↑	—	—	—	↓
	Ellipta®	—	—	↑↑	—	—	↓↓	—	—	↓
	Genuair®	—	↓	↑	—	—	↑	—	—	↓
	NEXThaler®	↑	—	↑	—	—	—	—	—	—
	Novolizer®	—	↓	↑	—	↑	—	—	—	↓
	Spiromax®	—	—	↑↑	—	—	—	↑	—	↓
	Turbuhaler®	—	↓	↑	—	—	—	—	—	↓
	Twisthaler®	—	↓	↑↑	—	↑	—	—	—	↓

^* Abbreviations: MDIs, metered dose inhalers; SMIs, soft mist inhalers; sdDPIs, single-dose dry powder inhalers; mdDPIs, multidose dry powder inhalers.

^↑↑: More than 50% of participants consider this characteristic an advantage of the inhaler device

^↑: Between 25% and 50% of participants consider this characteristic an advantage of the inhaler device

^↓↓: More than 50% of participants consider this characteristic a disadvantage of the inhaler device

^↓: Between 25% and 50% of participants consider this characteristic a disadvantage of the inhaler device

^—: Less than 25% of participants have mentioned this characteristic as an advantage or disadvantage of the inhaler