What is the recommended inhaler and medication regimen for a continent adult or older adult patient with a chronic respiratory condition, such as asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Recommended Inhaler Order for Chronic Respiratory Conditions

Inhaler technique must be demonstrated to the patient before prescribing inhalers and should be re-checked before changing or modifying inhaled treatments. 1

Device Selection Priority

Metered dose inhalers (MDIs) are the cheapest delivery device and should be the first-line choice, but only if the patient can use them correctly. 1 If proper technique cannot be achieved, more expensive alternatives are justified despite higher cost. 1

Critical Technical Failure Rates

• 76% of COPD patients make important errors when using MDIs 1
• 10-40% make similar errors with dry powder inhalers (DPIs), depending on the device 1
• 88.9% of patients with asthma or COPD make at least one mistake in inhalation technique 2

Algorithmic Approach to Device Selection

Step 1: Assess Patient's Physical and Cognitive Capability

For elderly patients or those with coordination difficulties:

• Many elderly patients cannot use MDIs satisfactorily due to impaired cognitive function, memory loss, weak fingers, or poor coordination 3
• Adding a large-volume spacer attachment to the MDI can simplify technique for patients with coordination difficulties 4
• Alternative delivery options include: MDI with spacer and face mask, breath-actuated inhaler, DPI, or nebulizer 3

Step 2: Choose Appropriate Device Based on Capability

If patient can coordinate MDI technique:

• Start with standard MDI as most economical option 1
• MDI is portable, convenient, multi-dose, and can deliver various medications 5

If patient has coordination difficulties but can breathe adequately:

• Use MDI with spacer device - this obviates the need for hand-lung coordination and requires only minimal inspiratory effort 6
• Spacer use is particularly important in acute attacks for effective emergency treatment outside hospital 6

If patient cannot use MDI even with spacer:

• Consider DPI if patient can generate adequate inspiratory flow 3
• Patients using DPIs made significantly fewer non-skill mistakes than those using MDIs 2

If patient has severe disease or cannot use handheld devices:

• Nebulizers should only be used when controlled coordinated breathing is difficult or handheld inhalers are ineffective, not simply for convenience 4
• Nebulizers should only be supplied after full assessment by a respiratory physician who can advise on risk/cost benefit 1

Step 3: Medication Selection by Disease Severity

For COPD - Mild Disease:

• Patients with no symptoms require no drug treatment 1
• Patients with symptoms: trial of inhaled β2-agonist OR anticholinergic taken as required 1
• If these drugs are ineffective, they should be stopped 1

For COPD - Moderate Disease:

• Symptomatic patients will benefit from inhaled bronchodilators 1
• Most will be controlled on a single drug; few will need combination treatment 1
• Oral bronchodilators are not usually required 1

For COPD - Severe Disease:

• Most will justify combination of β2-agonist and anticholinergic bronchodilators if they derive increased benefit 1
• Theophyllines can be tried but must be monitored for side effects 1
• High dose treatment including nebulized drugs should only be prescribed after formal assessment 1

For Asthma - Adults and Adolescents ≥12 Years:

• Dosage is 1 inhalation twice daily, approximately 12 hours apart 7
• Starting dosage strength should consider disease severity, previous therapy including ICS dosage, current symptom control, and future exacerbation risk 7
• Maximum recommended dosage is 500/50 mcg twice daily 7
• If shortness of breath occurs between doses, use inhaled short-acting β2-agonist for immediate relief 7

For Asthma - Children 4-11 Years:

• For patients not controlled on ICS: 1 inhalation of 100/50 mcg twice daily 7

Special Considerations for Elderly Patients

Anticholinergics Preferred Over Beta-Agonists:

• The response to anticholinergics declines more slowly with advancing age compared to β-agonists 3
• Ipratropium bromide is the preferred alternative for elderly patients, as it reduces cough frequency, severity, and sputum volume 8, 3
• Beta-agonists cause more tremor in elderly patients and should be avoided at high doses unless necessary 3

Safety Precautions:

• When using anticholinergics in elderly patients, administer via mouthpiece rather than face mask to avoid acute glaucoma or blurred vision 8, 3
• Elderly patients with ischemic heart disease require caution with β-agonists, potentially needing ECG monitoring for first dose 3
• Beta-blocking agents (including eyedrop formulations) should be avoided at all stages 1

Critical Pitfalls to Avoid

Never assume proper technique without demonstration:

• Inhaler technique must be demonstrated before prescribing and re-checked before any treatment modifications 1
• Regular instructions and checkups of inhalation technique should be standard routine procedure 2

Do not prescribe nebulizers without proper assessment:

• Most patients can be treated with bronchodilators delivered by MDIs with spacers or DPIs 1
• Assessment must include confirming correct diagnosis, ensuring optimal use of MDIs/DPIs has been attempted, documenting patient response, and conducting home trial with peak flow measurements 1

Avoid inappropriate medication combinations:

• Patients using combination ICS/LABA inhalers should not use additional LABA for any reason 7
• More frequent administration or greater number of inhalations than prescribed is not recommended as some patients experience adverse effects with higher LABA doses 7

For patients with dementia:

• A patient with dementia is unlikely to manage nebulizer maintenance independently (daily washing/drying, annual compressor servicing) 4
• Caregiver support must be arranged for nebulizer maintenance if this route is chosen 4

Post-Inhalation Care

After inhalation, the patient should rinse mouth with water without swallowing to help reduce risk of oropharyngeal candidiasis. 7