How to optimize inhaler use for a Chronic Obstructive Pulmonary Disease (COPD) patient on Incruse (umeclidinium) and Ventolin (albuterol)?

Optimizing Inhaler Use for COPD Patients on Incruse and Ventolin

The most critical intervention is to directly observe and correct the patient's inhaler technique at every visit, as 76% of COPD patients make critical errors with metered-dose inhalers that lead to increased hospitalizations and exacerbations. 1

Immediate Assessment of Inhaler Technique

Demonstrate proper technique and have the patient perform a return demonstration at this visit. 1 The evidence is unequivocal that inhaler technique must be checked before any medication changes are considered, as errors in handling lead to:

• Increased emergency department admissions for acute exacerbations 1
• Higher hospitalization rates 1
• Greater systemic corticosteroid and antibiotic requirements 1
• Suboptimal disease control despite appropriate medication selection 2

Critical Steps to Verify for Each Device

For Incruse (umeclidinium) - dry powder inhaler: 3

• Patient opens cover fully until click is heard
• Inhales forcefully and deeply (not slowly like an MDI)
• Holds breath for 5-10 seconds after inhalation
• Does not exhale into the device before inhalation

For Ventolin (albuterol) - if using MDI: 1, 4

• Shakes inhaler before each use
• Exhales fully before actuation
• Coordinates actuation with beginning of slow, deep inhalation
• Holds breath for 10 seconds after inhalation
• Waits 30-60 seconds between puffs if multiple doses needed

Device Optimization Strategy

If the patient cannot demonstrate correct MDI technique after instruction, switch Ventolin to a dry powder formulation or add a spacer device. 1 This recommendation is based on data showing 10-40% error rates with dry powder inhalers versus 76% with MDIs in COPD patients. 1

Critically important: Using multiple devices with similar inhalation techniques (both dry powder inhalers in this case) reduces exacerbation rates compared to devices requiring different techniques. 1 Since Incruse is already a dry powder device, maintaining consistency by using a dry powder formulation for the rescue inhaler optimizes outcomes.

Medication Usage Pattern Assessment

Verify that Ventolin is being used "as needed" for acute symptom relief only, not on a regular schedule. 1 The patient should understand:

• Incruse (umeclidinium 62.5 mcg) is taken once daily at the same time every day for maintenance 3
• Never use Incruse more than once in 24 hours 3
• Ventolin is for breakthrough symptoms only
• If Ventolin use exceeds 2-3 times per week, the maintenance regimen requires escalation 5

When to Escalate Therapy

If the patient has persistent breathlessness despite correct inhaler technique and adherence to Incruse monotherapy, escalate to dual bronchodilator therapy (LAMA/LABA combination). 5 The 2023 Canadian Thoracic Society guidelines strongly support this approach for symptomatic patients. 1

For patients with ≥2 moderate exacerbations or ≥1 severe exacerbation in the past year, consider triple therapy (LAMA/LABA/ICS) in a single inhaler device. 1 Single-inhaler triple therapy demonstrates superior outcomes compared to using multiple separate inhalers. 1, 6

Common Pitfalls to Avoid

Do not add another anticholinergic medication to Incruse - this creates additive anticholinergic effects and increases risk of urinary retention and narrow-angle glaucoma complications. 3

Do not combine Incruse with another long-acting bronchodilator without discontinuing one - avoid duplicate therapy from the same drug class. 3

Screen for contraindicated medications: 1, 5

• Beta-blockers (including eye drops for glaucoma) must be avoided as they block Ventolin's bronchodilatory effects
• Review all medications at every visit

Environmental Considerations

When selecting between equivalent inhaler options, consider dry powder inhalers over MDIs for environmental impact. 1 Short-acting beta-agonists like Ventolin constitute 71% of total inhaler use in Canada, and MDIs have significantly higher carbon footprints than dry powder alternatives. 1

Follow-Up Protocol

Re-check inhaler technique at every visit, not just initially. 1, 4 Studies demonstrate that technique deteriorates over time, and regular reinforcement is essential. 4

Schedule reassessment in 4-6 weeks after technique correction to evaluate: 5

• Symptom control improvement
• Reduction in rescue inhaler use
• Need for therapy escalation if symptoms persist despite proper technique