Inhaler therapy is the mainstay treatment for the management of asthma, COPD, and asthma-COPD overlap syndrome (ACOS).1,2 It allows for delivery of medication directly to the source of concern – the lungs. Despite their frequent use, there is a disparity in knowledge of correct administration, with 94% of patients using their inhalers incorrectly, making patient education on delivery and use for maintenance and/or rescue crucial.1,2
Inhaler Delivery and Device Types
Types of inhalation delivery devices include:3
Metered-dose inhaler (MDI): MDIs contain medications in a pressurized canister. These types of inhalers require patients to coordinate activating the propellant (medication) and inhaling the dose at the same time. MDI delivery examples include HFA, RediHaler, and Flexhaler.
Dry powder inhaler (DPI): DPIs contain medications in a powdered form. The medication itself is not delivered in a propellant therefore requiring patients to inhale the medication into their lungs through a deep, inward breath. Commonly prescribed DPI delivery examples include Digihaler, RespiClick, Diskus, Ellipta, Pressair, and Twisthaler.2
Soft mist inhaler (SMI): SMIs are similar to DPIs in that the patient must use their inward breath to inhale the medication. SMIs have more particles than both DPIs and MDIs and the medication itself enters the lungs more slowly (through mist), which allows patients the ability to receive more medication without strong inspiratory force. The SMI delivery system currently available is known as Respimat.
The above are all available by prescription. When it comes to selection, a study by Ding et al examined more than 7,300 individuals diagnosed with asthma, COPD, or ACOS to determine inhaler preferences from patients and physician perspectives. The research focused on the importance of individual device attributes and patient characteristics guiding inhaler decisions.2
The team found that over one-third of physicians did not have a preference for a maintenance/controller inhaler device when prescribing.2 They also identified that physicians placed most importance on ease of use and device suitability when selecting inhalers for patients with more severe disease and/or older patients.2 Finally, the researchers determined that less than one-third of patients reported being “extremely satisfied” with their inhalers.2
So how can physicians improve patient satisfaction with their respiratory management while also following evidence-based suggestions?
The tables below summarize available inhaler types by medication class including indication and considerations for selection and counseling. Note that some devices utilize a spacer, which is a holding chamber that can be added to certain inhalers to ensure consistent dosing.
Inhalers Based on Therapeutic Use
Short-Acting Beta Agonists
Short-acting beta agonists (SABA) are used for quick relief of bronchospasms. Beta-agonists, such as albuterol and levalbuterol, are bronchodilators that relax the muscles in a patient’s airway to promote easier breathing. These inhalers may be used in a patient with mild asthma or exercise-induced asthma symptoms. For individuals regularly using or relying on their rescue inhaler, a controller inhaler should be considered in addition.
Long-Acting Beta Agonists
Long-acting beta agonists (LABAs) are used for quick relief of bronchospasms. Similar to SABAs, long-acting beta-agonists (such as olodaterol and salmeterol) are bronchodilators that relax the muscles in a patient’s airway to promote easier breathing. These inhalers are used predominantly for patients with COPD, but are also indicated for asthma and exercise-induced bronchospasms for patients on ICS controller inhalers. For patients regularly using or relying on their rescue inhaler, a controller inhaler should be considered.
Short-Acting Muscarinic Agonists
Short-acting muscarinic agonists (SAMAs) are anticholinergic medications that are used to relieve COPD and asthma symptoms. They work to relax the muscles in the lungs, widen airways, and reduce mucus production to improve quality of breath.
Long-Acting Muscarinic Agonists
Long-acting muscarinic agonists (LAMAs) are anticholinergics used for the control and prevention of COPD symptoms. They work similarly to their short-acting counterparts to relax the muscles in the lungs, widen airways, and reduce mucus production to improve quality of breath. This class of inhalers is scheduled daily to prevent exacerbation of COPD symptoms.
Inhaled Corticosteroids
Inhaled corticosteroids (ICS) work to decrease airway inflammation and prevent asthma exacerbations. These are to be used as controller medications to prevent flares. It is recommended to start with a lower dose and increase dose as a patient’s symptoms worsen. It is also imperative that patients rinse their mouths with water after dose is completed to prevent thrush.
Combinations: SAMA and SABA
SAMA and SABA combination inhalers are used for quick relief of bronchospasms. The beta-agonist (albuterol) functions as a bronchodilator that relaxes the muscles in a patient’s airway to promote easier breathing. The muscarinic antagonist (ipratropium) functions as an anticholinergic agent that relaxes lung muscles, reduces mucus production, and widens airways to improve the quality of breath. This inhaler is indicated as-needed for bronchospasms in patients with a controller inhaler.
Combinations: LAMA and LABA
LAMA and LABA combination inhalers for control of COPD symptoms (controller inhaler). The LAMA functions to relax the muscles in the lungs, widen airways, and reduce mucus production to improve quality of breath. The LABA portion is a bronchodilator that is used to relax airway muscles to promote easier breathing. These inhalers are controllers and are scheduled once or twice daily for COPD maintenance.
ICS-LABA Combinations
ICS and LABA combination inhalers are used for asthma maintenance and COPD maintenance (for some of the inhalers). The ICS portion works to decrease airway inflammation and prevent asthma exacerbations. It is recommended to start with a lower dose and increase dose as a patient’s symptoms worsen. The LABA portion is a bronchodilator that is used to relax airway muscles to promote easier breathing. Due to the ICS component, patients must be reminded to rinse their mouths with water after dose is completed to prevent thrush.
ICS, LAMA, LABA Combination
These combination inhalers are typically reserved for severe COPD or asthma maintenance (Trelegy is the only one with both indications). These inhalers have 3 components: ICS, LAMA, and LABA. The ICS portion works to decrease airway inflammation and prevent asthma exacerbations. It is recommended to start with a lower dose and increase dose as a patient’s symptoms worsen. The LAMA functions to relax the muscles in the lungs, widen airways, and reduce mucus production to improve quality of breath. The LABA portion is a bronchodilator that is used to relax airway muscles to promote easier breathing. Due to the ICS component, patients must be reminded to rinse their mouths with water after dose is completed to prevent thrush.
Counseling Patients on Inhaler Priming, Use, and Care
Patient Education for MDIs5
Remind the patient to remove the cap from the inhaler’s mouthpiece.
If this is the patient’s first use of their rescue inhaler, they must be instructed to prime the inhaler (shake the inhaler for 5 seconds and release several puffs into the air). Priming is only for the first use of a new inhaler: patients should NOT prime after the first use.
After the inhaler has been primed, encourage the patient to shake the inhaler for an additional few seconds.
Place the inhaler so the medication canister faces upward (with index finger on the top of the canister and thumb supporting the bottom).
Advise the patient to breathe out as completely as possible away from the inhaler (turning their head to the right or left of the inhaler mouthpiece).
Once the patient has breathed out, have them place the inhaler mouthpiece into their mouth creating a tight seal. Have them keep their tongues down and out of the way.
Have them press the canister down to release the medication while inhaling deeply and slowly through their mouths until their lungs are completely filled (tell them not to breathe in with their nose).
Encourage them to hold the medication in their lungs for several seconds to help the medication fully enter the lungs.
After a few seconds, the patient should remove the inhaler from their mouth, turn their head away from the inhaler mouthpiece, and breathe out normally.
If the patient is required to do more than 1 puff, have them wait roughly 1 minute between puffs.
Once their puffs/doses have been completed, have them place the cap on the inhaler mouthpiece.
If the MDI inhaler contains ICS, encourage the patient to rinse their mouth with water and spit the water out to prevent thrush.
Patient Education for DPIs6
Instruct the patient to assemble inhaler according to the package insert instructions. These inhalers do not require priming.
Advise the patient to breathe out as completely as possible away from the inhaler (turning their head to the right or left of the inhaler mouthpiece).
Once the patient has breathed out completely, have them place their teeth on the inhaler mouthpiece and create a seal with their lips. Have them keep their tongues down and out of the way.
Instruct the patient to inhale rapidly and deeply to ensure powder dose enters the lungs.
Encourage them to hold their breath for 10 seconds, if able, to help the medication fully enter the lungs.
After 10 seconds, the patient should remove the inhaler from their mouth and breathe out slowly.
If the patient is required to do more than 1 puff, have them repeat steps.
Remind the patient to clean the mouthpiece after their dose(s) is/are completed with a dry cloth (no water).
If the DPI inhaler contains ICS, encourage the patient to rinse their mouth with water and spit the water out to prevent thrush.
Patient Education for SMIs7
Instruct the patient to prepare their inhaler using the instructions on the package insert provided with the inhaler.
Prior to the first dose, remind the patient that this inhaler should be primed (this only needs to be done once with the first use of new inhaler not for each use.)
Have them hold the inhaler upright with the clear piece pointing to the ground.
The patient should twist the inhaler base until they hear a click – this ensures the dose chamber is ready to administer the medication.
The patient should open the cap until they hear a click.
Holding the inhaler in one had with their pointer finger over the dose-release button, the patient should prepare to administer a dose by exhaling completely, placing their lips around the mouthpiece (to create the tight seal), and press the dose-release button while simultaneously taking a slow, deep breath to ensure the medication reaches the lungs.
Patients should hold their breath for 10 seconds or as long as they are able.
If the patient is required to administer another dose, have them repeat the earlier instructions.
If more than 3 days have passed since the last dose, the patient should release a mist dose toward the ground prior to use.
If more than 21 days have passed, the inhaler cap should be opened, the base should be turned, and the inhaler should be primed 3 times prior to use.
Inhaler Care5-7
Patients should be advised to store their inhalers at or near room temperature without moisture to ensure proper medication stability.
Patients should follow the instructions provided on the package insert for cleaning instructions.
Encourage patients to refill medications PRIOR to emptying their inhalers to avoid missed doses or inability to use rescue inhalers in an emergency.
Overall, when considering inhalers for select for patient use to manage either asthma or COPD, it is important to utilize guideline recommendations (such as the GINA 2023 and GOLD 2023 guidelines8,9), primary literature, patient preference (including ability to administer, need for spacer), and (most importantly) affordability of agent.
