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How to Pick an Inhaler
for a COPD patient
WEAKER HANDS STRONGER HANDS
Consider Parkinson's disease, essential tremor, osteoarthritis, rheumatoid arthritis, frailty, etc.
STRONGER
LUNGS
Weak hands, but strong lungs
Turbuhaler Diskus
Ellipta Genuair
Both strong hands and lungs
Any inhaler is likely appropriate.
Cost and convenience may be the foremost
considerations. Consider choosing the same
device type if more than one inhaler is
needed.
WEAKER
LUNGS
i.e. airflow
limitations or
severe COPD
Both weak hands and lungs
Genuair
Strong hands, but weak lungs
Breezhaler Handihaler Genuair
metered-dose inhaler Respimat
How to Pick an Inhaler
for a COPD patient
Why does picking the right inhaler matter? In COPD, medications in each class are generally considered to be equally effective. Each medication in a class comes in a different inhalation device. Unfortunately, up to 50% of patients with COPD are unable to demonstrate proper inhaler technique with their prescribed device.^5 -^7 Individualizing the inhaler to the patient may help prevent inhaler errors, and therefore improve COPD outcomes. What is the Hands vs Lungs Approach? The idea is that to pick an inhaler, you have to consider just two factors: the capability of the patient's hands, and the maximum inspiratory effort of the patient's lungs. In general, a patient with weak hands (for example, due to shakiness from Parkinson's disease or joint pain from arthritis) should use a device that requires low dexterity. Meanwhile, a patient with weak lungs (i.e. due to severe COPD) may require a device that can be inhaled even with a low inspiratory effort. Where does each inhaler fit? The metered-dose inhaler, or MDI , requires patients to have sufficient hand strength to actuate the canister from the top. The device also requires hand-to-breath coordination. The device generates a spray that requires a very low inspiratory effort to inhale. Adding a spacer device to the MDI is recommended to ensure a full dose and reduces the need for hand-to-breath coordination. The Respimat device is spring-loaded, and patients require sufficient hand strength to properly engage the spring. The device also requires hand-to-breath coordination. The device generates a "soft mist" that requires a very low inspiratory effort to inhale. The Breezhaler and Handihaler devices both have capsules that must be loaded into the device; patients require dexterity to load these capsules properly. Patients also require sufficient hand strength to push the spring that pierces the capsule. These devices require a very low inspiratory effort to use. The Ellipta , Diskus , and Turbuhaler devices all require patients to be able to aerosolize a compacted powder using a sharp, fast breath. The Turbohaler requires a particularly strong breath (e.g. 60L/min vs 30L/min).^9 These devices require very little hand dexterity to operate. The Genuair device can be used in nearly every situation.^10 It has a large button to load the device which requires little strength or dexterity to use. It does require a sharp, fast breath to inhale, but features a feedback mechanism which notifies users if the inspiratory effort was insufficient. Thus if patients consistently cannot get the dose from their device, there is an opportunity to re-teach inhaler technique.
Inhaler Best for Weak Hands? Best for Weak Lungs?
