COPD affects 4-10 % of the population, varying by country. Globally, it’s a top-three cause of death, claiming three million lives annually. Despite its prevalence, COPD is both preventable and treatable, albeit irreversible.
Many patients are diagnosed in late stages of COPD. This is because they seek out a respiratory specialist when the symptoms become so bad to them that they choose to do something about it. This is usually the case in later stages of the disease. Those patients often extensively suffer from other diseases too, which can make things more difficult.
The medicines used in these devices have similar effects in your lungs. They are very effective medicines, but one important consideration is to make sure that you can use the device that you’re given properly. Having a device you can use properly makes sure that the medicine gets into your lungs, so it can get to work.
Advantage
No hand-breath coordination required.
Challenge
Requires sufficient inspiratory flow and sufficient cognitive and physical skills.
Advantage
Suitable for patients with low inspiratory flow since MDIs require slow, deep breathing.
Challenge
Using your inhaler with a holding chamber allows you to release the aerosol into the chamber a moment before breathing it in. Once you’ve pressed the MDI, and the spray is in the holding chamber, you should breathe in deeply and smoothly, as soon as you can, after the activation of the spray. This can make a big difference to how much medicine reaches your lungs
Advantage
No special breathing technique necessary as the natural breathing is sufficient.
No hand-breath coordination necessary.
Challenge
Longer inhalation times than with MDIs or DPIs.
Peak Inspiratory Flow (PIF) measures how quickly you can breathe in. This is important for some of the devices you might be given.
This is because, if your Peak Inspiratory Flow (PIF) is not sufficient to use a DPI, you should be offered an MDI instead. Having what is known as a ‘suboptimal PIF’ is quite common amongst COPD patients. More than 50 % of COPD patients experiencing exacerbation had suboptimal PIF [1][2], – this means they could not breathe in quickly enough to make the device work properly - while 1 out of 5 outpatients with severe COPD did not achieve optimal PIF for DPI [3].
Patients with suboptimal PIF should rather use a MDI instead of a DPI. Up to 87 % of COPD patients make at least one inhaler technique error [4]. Additionally, many COPD patients suffer from cognitive impairment and diminishing coordination abilities.
Using MDIs with holding chambers requires less hand-breath coordination and provides an easy solution.
Inhaler mishandling is frequent and associated with increased severe COPD exacerbation [5]. The GOLD Report 2024 recommends considering nebulisers if other inhalers have not worked [6]. Nebulisers may be beneficial for patients with inadequate symptom relief despite appropriate use of inhalers or for those with compliance issues [7].
In general patients with severe to very severe COPD and / or reduced cognitive and physical abilities can benefit from being given a nebuliser [7].
It’s especially true for smokers, that making too much mucus in the airways is frequently observed in COPD. As this gets worse, the mucus builds up more and this makes your natural mucociliary clearance more difficult [8].
A recently published study that looked back at patient records has shown that when there is too much mucus it can block or ‘plug’ the airways & that is those blocks or plugs are in the medium to large airways there is an associated increased death rate[9] in COPD patients.
Therefore rehydration of the mucus layer is considered a valid approach in muco-obstructive diseases [10]. Nebulised hypertonic saline solution promotes the self-cleaning function of the lungs and can help to clear excess mucus.
It’s as simple as it sounds but one should consider asking the patient. A study showed that patients and their caregivers preferred nebuliser treatment over other devices due to ease of use, better overall symptom control and long-term relief [11].
Read the full interview with Prof. Usmani (National Heart and Lung Institute (NHLI), Imperial College London, UK) published in June’s edition of EMJ. It is illustrated that not all nebulisers are the same.
that is known to be efficient. (link to NICE Guidelines 2019 from original text). Learn more about how nebuliser efficiency can be objectively measured using the respirable drug delivery rate (RDDR): EMJ published a Poster review of research by Fischer et al. presented at the ERS in September 2023.
For help with this topic, please visit the PARI Device Selection Tool for COPD on the EMJ website.
Further reading can also be found on this topic in this Interview with international key opinion leader, Prof. Don Mahler of the Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
[1] Loh et al. Ann Am Thorac Soc Vol 14, No 8, pp 1305-1311, Aug 2017. (DOI: 10.1513/AnnalsATS.201611-903OC)
[2] Broeders et al. Respir Med. 2004;98:1173-1179. (DOI: 10.1016/j.rmed.2004.04.010)
[3] Mahler et al. J Aerosol Med Pulm Drug Deliv 2013;26:174-179. (DOI: 10.1089/jamp.2012.0987)
[4] Cho-Reyes et al. Chronic Obstr Pulm Dis. 2019;6(3):267-80. (DOI: 10.15326/jcopdf.6.3.2018.0168)
[5] Molimard, M., et al. European Respiratory Journal, 2017. 49(2): p. 1601794 (DOI: https://doi.org/10.1183/13993003.01794-2016).
[6] Gold Report 2024.
[7] Dhand et al. COPD: Journal of Chronic Obstructive Pulmonary Disease 2012; 9(1):58-72. (DOI: 10.3109/15412555.2011.630047)
[8] Dunican et al. Am J Respir Crit Care Med. 2021;203(8):957-68. (DOI: 10.1164/rccm.202006-2248OC)
[9] Diaz AA et al. JAMA. 2023;329(21):1832-9. (DOI: 10.1001/jama.2023.2065)
[10] Boucher RC. N Engl J Med. 2019;380(20):1941-53.v (DOI: 10.1056/NEJMra1813799)
[11] Dumra et al. International Journal of Chronic Obstructive Pulmonary Disease 2022:17;2277-2288. (DOI: 10.2147/COPD.S367819)
[12] National Institute for Health and Care Excellence (NICE). Chronic obstructive pulmonary disease in over 16s: diagnosis and management. 2019.
[13] Fischer et al. Journal of Aerosol Medicine and Pulmonary Drug Delivery, 2022. 36(3): p. 116.
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