Jane Scullion looks at the increasing complexity of the multitude of MDI and DPI devices that are available and the therapeutic options they offer, in the second of two feature articles.

scullion jane

Figure 3: Therapeutic options for inhaler devices*. Download a PDF of this image

* For more information about dosages and administration, please refer to the BNF and the summary of product characteristics for individual drugs.

Developed by Jane Scullion and John Haughney.

Prescribing the right device and the right drug

Patients requiring inhaled therapies should receive education and training on the use of appropriate medication for their symptoms. The healthcare professional should be aware: of the availability of other drugs in the same device; device effectiveness; personal technique and experience with the device; inspiratory flow rate; cost; and local formularies.4 Some patients, including the elderly and children, may find it difficult to use certain inhaler devices and consideration should be given to this. In terms of prescribing, we should prescribe both the drug and the device. Given the growth of generic formulations and new devices, it is also recommended that we should prescribe by brand name;2,4 this prevents the dispensing of inhaler devices that the patient may not have seen before and may not be able to use.

As prescribers and those involved in patient teaching, we need to be capable of using and demonstrating effective use of inhalers. Prescribing inhaler devices and associated medications will be an expensive and ineffective option if patients are not taught how to use them correctly.10 The BTS/SIGN British guideline on the management of asthma states that inhalers should only be prescribed to patients once they have received training on the use of the device, and have demonstrated satisfactory technique.2 Furthermore, the NICE guideline, Chronic obstructive pulmonary disease in over 16s: diagnosis and management recommends that a patient’s ability to use an inhaler should be assessed at regular intervals by a competent healthcare professional, with the correct technique being re-taught as necessary.11 Asthma UK12 and Right Breathe13 provide useful patient information entitled Using your inhalers, which includes instructional videos on using different types of inhaler devices.

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  1. Scullion J, Fletcher M. Inhaler standards and competency document. London: Respiratory Futures, 2016. Available at: www.respiratoryfutures.org.uk/media/69774/ukig-inhaler-standards-january-2017.pdf
  2. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 153, updated 2016. Available at: www.sign.ac.uk/guidelines/fulltext/153 and www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/
  3. Usmani O, Capstick T, Chowan H et al. Choosing an appropriate inhaler device for the treatment of adults with asthma or COPD. Originally developed for Guidelines 2016; also published on Guidelines for Nurses 2016. Available at: www.GuidelinesforNurses.co.uk/WPG/inhaler-choice
  4. Scullion J, Holmes S. Maximising the benefits of inhaler therapy. Practice Nursing 2013;24 (12): 594–600.
  5. Barnes N. The properties of inhaled corticosteroids: similarities and differences. Prim Care Respir J 2007; 16 (3): 149–154.
  6. NICE, British National Formulary (BNF). Asthma, acute. Available at: bnfc.nice.org.uk/treatment-summary/asthma-acute.html (accessed 11 April 2019).
  7. NICE, British National Formulary (BNF). Asthma, chronic. Available at: bnfc.nice.org.uk/treatment-summary/asthma-chronic.html (accessed 11 April 2019).
  8. NICE, British National Formulary (BNF). Respiratory system, drug delivery. Available at: bnfc.nice.org.uk/treatment-summary/respiratory-system-drug-delivery.html (accessed 11 April 2019).
  9. Cazzola M, Lopez-Campos J et al. The MABA approach: a new option to improve bronchodilator therapy. Eur Respir J 2013; 42: 885–887.
  10. Chrystyn H, Price D. Not all asthma inhalers are the same: factors to consider when prescribing an inhaler. Prim Care Respir J 2009; 18 (4): 243–249.
  11. NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE Guideline 115. NICE, 2018. Available at: www.nice.org.uk/ng115.
  12. Asthma UK. Using your inhalers. Available at: www.asthma.org.uk/advice/inhalers-medicines-treatments/using-inhalers/ (accessed 11 April 2019).
  13. RightBreathe.www.rightbreathe.com (accessed 11 April 2019).