Choosing the right inhaler for your asthma or COPD patient

Figures & data

Table 1 Advantages and limitations of commonly used inhalation devices

Inhaler	Advantages	Limitations
pMDI (general)	• Portable • Compact • Multi-dose device • Dose delivered and particle size independent of inhalation maneuver • Quick and easy to use • Less expensive than most other inhalers • Suitable for emergencies • Available for most treatments	• Coordination of inspiration and actuation necessary • Not suitable for young children (without use of spacer) • High oropharyngeal deposition of larger particles (without use of spacer) • Dose counter not available in all devices to assess remaining doses • Propellant required • Needs to be shaken well before each inhalation, and primed if not used within a prespecified time period
pMDI, extra-fine aerosols (mass median aerodynamic diameter, <2 μm)	• Clinically lower doses of drug can be used compared with large particle size drugs • Fewer side effects compared with large particle size drug	• Coordination of inspiration and actuation necessary • Not suitable for young children (without use of spacer) • Dose counter not available in all devices to assess remaining doses • Propellant required • Needs to be shaken well before each inhalation, and primed if not used within a prespecified time period
DPI (general)	• Small and portable • Breath-actuated • Less coordination required • Short treatment time • Available for most treatments	• Moderate to high inspiratory flow required • Not suitable for young children • May not be suitable for emergencies • Partly sensitive to humidity • Need proper dose preparation and loading to achieve optimal available dose for inhalation
DPI, single-dose capsule-based	• Patients can confirm that they have taken their medication by checking the capsule after use	• Need to insert each dose before use • Patient must continue or repeat inhalation until capsule is empty, which can cause dose variability
DPI, multi-unit	• Offers better protection from the environment compared with multiple-dose DPI	• Following dose preparation and actuation, the device needs to be kept horizontal before patient inhalation. Also, patients must not blow into the device before inhalation
DPI, multiple dose (reservoir)	• Built-in mechanism meters out each dose upon actuation	• Requires desiccant inside the powder bed reservoir
SMI	• Portable • Multi-dose device • Low dependence on inspiratory flow rate • Slow velocity aerosol • High fine particle fraction and lung deposition • Long plume duration • Requires less coordination between actuation and inspiration compared with other inhaler devices • No propellant • Dose indicator • Does not require a spacer (in those aged >5 years) • Suitable for use in children	• Dose loaded into the device • Not breath-actuated • Needs to be primed if not in use for over 21 days

Abbreviations: DPI, dry powder inhaler; pMDI, pressurized metered-dose inhaler; SMI, soft mist inhaler.

Figure 1 Challenges of inhalation therapy in pediatric patients, and age-appropriate inhaler devices and interfaces.

Note: Data from these studies.^53,55,90,91
Abbreviations: DPI, dry powder inhaler; pMDI, pressurized metered-dose inhaler; SMI, soft mist inhaler; VHC, valved holding chamber.

Figure 2 Challenges with the use of inhalation therapy in elderly patients, and an algorithm for appropriate inhaler device selection.^26,92,93

Abbreviations: COPD, chronic obstructive pulmonary disease; HCP, health care professional.

AriAFinkJBGuidelines for aerosol devices in infants, children and adults: which to choose, why and how to achieve effective aerosol therapyExpert Rev Respir Med20115456157221859275

 PubMed Web of Science ®Google Scholar

KaminWFrankMKattenbeckSMoroni-ZentgrafPWachtelHZielenSA handling study to assess use of the Respimat(®) Soft Mist™ inhaler in children under 5 years oldJ Aerosol Med Pulm Drug Deliv201528537238125844687

 PubMed Web of Science ®Google Scholar

BerlinskiAPediatric aerosol therapyRespir Care201762666267728546371

 PubMed Web of Science ®Google Scholar

HamelmannESzeflerSJEfficacy and safety of tiotropium in children and adolescentsDrugs201878332733829368127

 PubMed Web of Science ®Google Scholar

TaffetGEDonohueJFAltmanPRConsiderations for managing chronic obstructive pulmonary disease in the elderlyClin Interv Aging20149233024376347

 PubMed Web of Science ®Google Scholar

BarronsRWheelerJWoodsJAOpportunities for inhaler device selection in elderly patients with asthma or COPDPatient Intelligence201575365

 Google Scholar

ScichiloneNBraidoFLavoriniFLevyMLUsmaniOSRoutine use of budesonide/formoterol fixed dose combination in elderly asthmatic patients: practical considerationsDrugs Aging201734532133028258535

 PubMed Web of Science ®Google Scholar