What are the options for metered-dose inhaler (MDI) therapy for a patient with asthma or chronic obstructive pulmonary disease (COPD) experiencing throat irritation with their current inhaler?

MDI Therapy Options for Asthma and COPD

For patients experiencing throat irritation with their current MDI, the most effective solution is to add a spacer device to the existing MDI, which reduces oropharyngeal deposition and local side effects while maintaining therapeutic efficacy. 1

Primary MDI Options with Spacers

Most bronchodilator therapy should be delivered via MDI with an appropriate spacer device as first-line treatment. 1 This approach provides:

• Reduced throat irritation by decreasing oropharyngeal drug deposition 2
• Equivalent or superior efficacy compared to nebulizers at standard doses 3
• Better cost-effectiveness and convenience for most patients 2

Recommended Bronchodilator Medications via MDI

Short-acting β2-agonists:

• Salbutamol (albuterol) 200-400 μg four times daily 1, 2
• Terbutaline 500-1000 μg four times daily 1, 2

Anticholinergics:

• Ipratropium bromide 40-80 μg (2 puffs) four times daily 1, 2

For doses up to 1 mg salbutamol or 160 μg ipratropium, MDIs with spacers remain the preferred delivery method. 1

Alternative MDI Devices for Coordination Difficulties

Breath-actuated MDIs are available for patients who cannot coordinate actuation with inhalation, even when using a spacer device. 2, 4 These devices eliminate the need for precise timing between pressing the canister and inhaling. 4

Critical Technique Requirements

Proper inhaler technique must be demonstrated and verified before considering device changes. 2 Common errors include:

• Not exhaling before inhalation (affects 65.8% of patients) 5
• Not continuing slow inhalation after actuation (affects 69.6% of patients) 5
• Incorrect use correlates directly with poor disease control 6

When to Consider Nebulizer Therapy

Nebulizers should be reserved for specific situations rather than used as first-line therapy for throat irritation. 1

Appropriate Indications for Nebulizers:

• High-dose requirements: salbutamol >1 mg or ipratropium >160-240 μg 1, 2
• Inability to use MDI despite proper instruction and spacer devices 1, 2
• Acute severe exacerbations requiring intensive treatment 1
• Regimens requiring >10 puffs from MDI (patient acceptability concern) 1

Nebulizer Dosing When Indicated:

For stable disease:

• Salbutamol 2.5 mg four times daily OR 2
• Terbutaline 5 mg four times daily OR 2
• Ipratropium bromide 250-500 μg four times daily 2

For acute exacerbations:

• Salbutamol 2.5-5 mg PLUS ipratropium 250-500 μg every 4-6 hours 1, 2

Inhaled Corticosteroids and Throat Irritation

If the throat irritation is from inhaled corticosteroids (not mentioned but common), adding a spacer device significantly reduces local oropharyngeal effects. 2 Additionally:

• Rinsing mouth after each use prevents local deposition
• Switching to breath-actuated devices may improve control and reduce side effects 6

Critical Pitfalls to Avoid

Never switch devices without first:

• Verifying proper technique with current device 2
• Ensuring adequate spacer use if not already implemented 1
• Confirming the throat irritation isn't from improper technique 5, 6

Do not prescribe home nebulizers without formal assessment by a respiratory specialist, including demonstration of at least 15% improvement in peak flow over baseline. 2

Older patients require more intensive instruction and follow-up as they have significantly more difficulty with correct inhaler use. 5

Practical Algorithm for Throat Irritation

1. First step: Add spacer device to existing MDI if not already using one 1, 2
2. Second step: Verify and re-teach proper technique, checking all critical steps 2, 5
3. Third step: If coordination remains problematic, switch to breath-actuated MDI 2, 4
4. Fourth step: Only consider nebulizer if unable to use any MDI device effectively after proper instruction 1, 2

Patients should be transitioned back to MDI with spacer as soon as their condition stabilizes, as this permits better long-term disease management and earlier hospital discharge when applicable. 1, 2