Why would a dry powder inhaler (DPI) with inhaled corticosteroid (ICS)/formoterol be beneficial for as-needed symptoms in a patient with stable asthma control and improper metered dose inhaler (MDI) use?

DPIs Are Beneficial Because They Don't Require Coordination Between Actuation and Inhalation

For this 13-year-old asthmatic patient with improper MDI technique, a dry powder inhaler (DPI) with ICS/formoterol would be beneficial because DPIs do not require coordination between actuation and inhalation. This is particularly important for adolescents who struggle with the proper MDI technique 1.

Why DPIs Are Superior for This Patient

Coordination Issues with MDIs

• MDIs require precise coordination between actuation and inhalation, which is difficult for many patients, including adolescents 1
• The patient's current improper MDI technique likely results in suboptimal medication delivery to the lungs
• When used incorrectly, MDIs deposit only 20-30% of medication in the lungs, with most medication being deposited in the oropharynx 1

Advantages of DPIs for Adolescents

• DPIs are breath-activated, eliminating the need for hand-breath coordination 1, 2
• British Thoracic Society guidelines specifically advise that adolescents have access to DPIs because spacers are unpopular among this age group 1
• DPIs are generally preferred by adolescents due to their ease of use and portability 1

Why Other Options Are Not Optimal

Why Not Just Add a Spacer to the MDI?

• While spacers/valved holding chambers can improve MDI technique, they:
  • Are unpopular among adolescents due to size and appearance 1
  • Reduce portability, making them less practical for school use
  • Still require proper technique and regular cleaning 1

Why Not Continue with Nebulizer for ICS?

• Nebulizers:
  • Are bulky and time-consuming 1
  • Not practical for use outside the home 1
  • Require regular maintenance to prevent bacterial contamination 2
  • Are less portable for an active adolescent

Benefits of ICS/Formoterol DPI for This Patient

Clinical Benefits

• Combining ICS and formoterol in a single DPI provides:
  • Controller medication (ICS) for underlying inflammation
  • Quick relief (formoterol) for acute symptoms 3
  • Potential for use as both maintenance and reliever therapy (SMART approach) 3

Practical Benefits

• DPIs include dose counters, helping track medication usage 1
• Studies show most patients select multi-dose DPIs as their preferred device when given options 1
• Real-world studies have generally favored DPIs over MDIs for asthma control 1

Implementation Plan

1. Switch from budesonide nebulizer to ICS/formoterol DPI

   • Maintain equivalent steroid dosing
   • Provide clear instructions on DPI technique

2. Proper DPI Technique Education:

   • Exhale completely away from the device
   • Place mouthpiece between lips and create a tight seal
   • Inhale forcefully and deeply through the mouth
   • Hold breath for 10 seconds if possible
   • Rinse mouth after using ICS-containing DPI

3. Follow-up:

   • Schedule follow-up within 2-4 weeks to assess technique and symptom control
   • Continue to monitor Asthma Control Test scores

Important Considerations and Caveats

• DPIs require adequate inspiratory flow (>30 L/min) for proper activation 2
• This patient's stable asthma control (ACT score of 21) and infrequent albuterol use (1-2 times monthly) suggest she has adequate inspiratory capacity
• DPIs should not be used with spacers, which may be a disadvantage if the patient needs very high doses of steroids in the future 4
• DPIs should be kept dry and require different maintenance than MDIs 2

By switching to a DPI formulation of ICS/formoterol, this patient will likely achieve better medication delivery without the coordination challenges of her current MDI, potentially improving her asthma control while simplifying her regimen.