What is the best recommendation for a 62-year-old man with low inspiratory flow on low-dose budesonide-formoterol (Metered-Dose Inhaler) MDI who experiences inadequate symptom relief?

Using a Spacer with MDI is the Best Recommendation for This Patient

For this 62-year-old man with low inspiratory flow using budesonide-formoterol MDI, using a spacer with his inhaler is the best recommendation to improve medication delivery and symptom relief.

Analysis of Current Technique Issues

The patient's current inhaler technique has a critical flaw that significantly reduces medication effectiveness:

• He actuates the inhaler at the end of inhalation
• He has low inspiratory flow
• He reports inconsistent symptom relief

This technique error means most of the medication is being deposited in the oropharynx rather than reaching the lungs, explaining his inadequate symptom control.

Why a Spacer is the Optimal Solution

Adding a spacer to his current MDI offers several advantages:

1. Improves drug delivery despite poor coordination: A spacer eliminates the need for perfect coordination between actuation and inhalation 1, 2

2. Accommodates low inspiratory flow: Spacers allow medication to be inhaled at a slower rate, which is ideal for patients with low inspiratory flow 1, 2

3. Increases bioavailability: Clinical evidence shows spacers significantly increase both total systemic and lung bioavailability of budesonide-formoterol

   • Increases lung exposure of budesonide by 146% and formoterol by 173% 3
   • Particularly beneficial for patients with poor inhalation technique 3

4. Maintains current medication: No need to change a medication that may otherwise be appropriate for the patient

Why Other Options Are Less Suitable

1. Spacer with mask: Not necessary for this patient who can create a proper seal with his lips and follow instructions; masks are typically reserved for very young children, elderly with cognitive impairment, or those who cannot create a proper seal 1, 2

2. Switching to DPI formulation: Contraindicated due to:

   • Patient's low inspiratory flow would make DPI activation difficult 1, 2
   • DPIs require adequate inspiratory flow (>30 L/min) for proper activation 2
   • The patient would still need to learn a new device technique

3. Increasing to medium-dose budesonide-formoterol: Addressing the technique issue is more appropriate than increasing medication dose when the primary problem is poor delivery technique 1, 4

Proper Spacer Technique Instructions

Teach the patient this corrected technique:

1. Shake the inhaler well for 5 seconds
2. Attach the inhaler to the spacer
3. Exhale completely away from the device
4. Place the spacer mouthpiece between teeth and seal lips
5. Press the inhaler canister once to release medication into the spacer
6. Inhale slowly and deeply through the mouth
7. Hold breath for 10 seconds
8. Wait 30-60 seconds before repeating for second puff if needed

Follow-up Recommendations

1. Demonstrate proper technique and have the patient practice during the visit
2. Schedule a follow-up within 2 weeks to assess response 1
3. Consider regular technique assessment at each visit 2
4. If symptoms persist despite proper technique with spacer, then consider adjusting medication regimen

By addressing the fundamental issue of medication delivery with a spacer, this patient is likely to experience improved symptom control without needing to change his medication or increase the dose.