Patient Fit Matters Most When Choosing the Right COPD Inhaler

There isn’t yet a perfect chronic obstructive pulmonary disease (COPD) inhaler, and even a well-chosen inhaler can fall short if the patient isn’t using it correctly, explained experts who spoke at a pre-conference session at the GOLD International COPD Conference.

During the session, the speakers urged clinicians to give the method of drug delivery as much attention as the drug itself.

Why Matching the Device to the Patient Matters

The process of selecting the right inhaler is really about matching the device to the patient, explained David Halpin, DPhil, MBBS, MA, FRCP, FERS, consultant physician and honorary professor of respiratory medicine at the University of Exeter and a member of the Global Initiative for Chronic Obstructive Lung Disease Board of Directors and Science Committee.

“The best inhaler for a patient is one that they learn to use quickly, that they can use, that they will use, and they’ll continue to use, and they’ll do correctly,” he said.

It falls on providers to be able to demonstrate how to use the inhaler and ensure patients can do it correctly, but they rarely give it the attention it deserves. One study found that more than 80% of health care professionals felt the molecule was more important than the device.¹ Halpin felt the roots of this thinking go back to medical school, where the importance of the device is not emphasized.

“We learn about the molecules, we learn about the classes of molecules, but there's very little emphasis on how they get into the lights,” he said. “And the consequence of that is that over the last 60 years, patients have continued to make errors.”²

What Happens When Training Lapses or Devices Change?

Showing patients how to use the inhaler cannot be a one-time thing. Other research showed that even for patients who were able to use the device correctly, the clinician would begin making the same technique errors again 30 days later. Halpin said clinicians needed to reinforce the technique at every visit.

“Patients forget what you told them,” he said. “It’s human nature. People get lazy.”

When patients have poor inhaler technique, there can be serious consequences. A Dublin study found that patients who were hospitalized with COPD and discharged on a dry powder inhaler (DPI) had a threefold increase in the risk of death when they had poor technique and poor adherence to therapy.³

In the US, a study found that payer-mandated switches to a new device also resulted in poor outcomes.⁴ When the payer moved everyone from pressurized metered-dose inhalers to DPIs without explaining the change, there was an associated increase in hospitalizations and exacerbations.

“If we are going to change the device, we need to make sure that we train the patient on the new device,” Halpin said. “It really does matter,”

Which Patient Factors Should Guide Selection

There are also patient characteristics that might determine which device is the best fit, but age alone shouldn’t drive the decision, Halpin said. While he cited some factors that come with age, such as comorbidities, cognitive function, and manual dexterity influencing device math, he was clear that age itself is not the issue.

In addition to hand function mattering and impacting whether the patient can load the capsule properly or be able to actuate the device, cognitive impairment can undermine both technique and adherence. Halpin recommended giving a formal cognitive screening test to older patients before giving them an inhaler.

Halpin outlined an algorithm to help in device selection that asks

1. Is the patient on an inhaler?
2. If they are on an inhaler, are they using it correctly?
3. If they are, is the current or a new therapy available in the same device?

If the answer is yes to those questions, then they are on the right device, but if the answer is no to any of them, then the clinician needs to undergo an iterative process of selecting a device with shared decision-making.

“If a patient currently has an inhaler and is doing well with it, if you can maintain the same device, that is really very important,” he said. “You want to minimize the number of different devices for a patient.”

Spacers and Dose Counters Can Protect Drug Delivery

Edward Portillo, PharmD, associate professor and associate dean for advancement at the University of Wisconsin School of Pharmacy, ran through different types of inhalers and proper use of them all during his presentation. He noted that more than two-thirds of patients make at least 1 error when using an inhalation device.⁵

One safeguard that can help protect against patients not getting the drug is a dose counter for a metered-dose inhaler. This safeguard lets patients know when it’s time to request a refill rather than spraying nothing. In addition, spacers can help reduce the amount of medicine that is lost to the back of the throat.

“If you just gave someone a spacer, you’d likely increase their dose of their medicine,” Portillo said.

When Nebulizers Belong in the Conversation

Brian Bizik, MS, PA-C, DFAAPA, clinical supervisor and asthma, allergy, and COPD care coordinator at Terry Reilly Health Centers, focused on nebulizers, which he said are underused.

“We spend so much time on the molecule and which medication we’re going to give, and we spend a lot less time on the device and how to deliver that,” he said.

While nebulizers aren’t for everyone, they should be considered as an option, which they currently are not. A 2026 COPD Foundation Nebulizer Consortium survey of 347 patients and 39 health care providers found a disconnect between physicians and patients when it came to nebulizers.⁶

Roughly two-thirds of patients who answered reported lower copays with nebulized therapy and about 65% reported better symptom control and 71% preferred nebulizers. However, 47% of providers are not prescribing nebulizers, 82% of providers believed nebulizers were preferable during exacerbations, and 67% thought they were more expensive, which didn’t align with what patients experienced.

Bizik said patients who are doing well on their current device should not be switched, but for those who are struggling, he said nebulizers can help.

“They really do well, and the impact can be life-changing for patients,” Bizik said.

References

1. Hanania NA, Braman S, Adams SG, et al. The role of inhalation delivery devices in COPD: perspectives of patients and health care providers. Chronic Obstr Pulm Dis. 2018;5(2):111-123. doi:10.15326/jcopdf.5.2.2017.0168
2. Sanchis J, Gich I, Pedersen S; Aerosol Drug Management Improvement Team (ADMIT). Systematic review of errors in inhaler use: has patient technique improved over time? Chest. 2016;150(2):394-406. doi:10.1016/j.chest.2016.03.041
3. Cushen B, Sulaiman I, Greene G, et al. The clinical impact of different adherence behaviors in patients with severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2018;197(12):1630-1633. doi:10.1164/rccm.201712-2469LE
4. Rabin AS, Seelye SM, Weinstein JB, et al. Budesonide-formoterol metered-dose inhaler vs fluticasone-salmeterol dry-powder inhaler. JAMA Intern Med. 2025;185(8):1005-1013. doi:10.1001/jamainternmed.2025.2299
5. Grandmaison G, Grobéty T, Vaucher J, Hayoz D, Suter P. Prevalence of critical errors and insufficient peak inspiratory flow in patients hospitalized with COPD in a department of general internal medicine: a cross-sectional study. Chronic Obstr Pulm Dis. 2024;11(4):406-415. doi:10.15326/jcopdf.2024.0505
6. Melamed KH, Martinez S, Cambridge L, et al. Understanding nebulizer utilization by patients and healthcare providers: a COPD Foundation Nebulizer Consortium survey study. Int J Chron Obstruct Pulmon Dis. 2026;21:552041. https://doi.org/10.2147/COPD.S552041