Appendix 2

• MDIs should be used with a spacer device, as some people have difficulty coordinating the release of medication with inhalation.

• The spacer chamber acts as a reservoir for the aerosol released from an MDI. The patient can then inhale from this chamber without having to coordinate the release of the medication.
• Use of spacers with inhaled corticosteroids reduces side effects of oral candidiasis and hoarseness, as well as optimising medication delivery.
• MDI with spacer is as effective as a nebuliser if an equivalent dose is taken; 10-15 puffs of 100mcg salbutamol MDI via a spacer is therapeutically equivalent to a 5mg salbutamol nebule.
• Spacers are cheap, portable, easily cleaned and maintained, do not require electricity and are simple and quick to use.
• A small volume spacer is preferable when the vital capacity is less than 1.5L.

• Breath-activated MDI containing 200 doses of medication.
• Use can improve lung deposition in patients with poor MDI inhaler technique. As the patient starts a slow, deep breath through the mouthpiece, a flap valve is triggered, and the dose automatically releases.

• Breath-activated multi-dose DPI containing 60 individually sealed doses. A dose counter shows the number of doses remaining. It gives accurate and consistent drug delivery over a range of inspiratory flow rates (30-120 L/minute).
• Lactose powder is combined with the active medication for patients to taste and reassure them that they have inhaled a dose.

• Breath-activated single-dose powder inhaler that comes with a sheet of 60 capsules in push-out foil sheet. One capsule is loaded into the inhaler and pierced before inhaling.
• Gives consistent drug delivery over a range of inspiratory flow rates.

• Breath-activated multi-dose inhaler, containing 60 (Oxis, Symbicort) or 200 (Pulmicort, Bricanyl) doses; ensures delivery without the need to coordinate inspiration with drug release.
• Dose delivery is halved if the patient cannot produce inspiratory flow above 30 L/min. Very few patients with COPD cannot produce a rate of >60 L/min.
• Produces very fine powder, so patients often don’t taste anything.
• Dose indicator shows when there are 20 doses remaining, and then when the inhaler is empty (it contains a drying agent that can be heard when the inhaler is shaken, which can be misinterpreted as available medication).

• Breath-activated dry powder inhaler. A capsule containing tiotropium is dropped into the HandiHaler, and pierced by pressing a button. The patient then inhales through the mouthpiece for effective drug delivery. Studies have shown that patients with a wide range of disease severity are able to generate sufficient inspiratory airflow (as low as 20 L/min) to evacuate the powder from the capsule.

Seebri (glycopyrronium 50mcg)

Ultibro (indacaterol 110 mcg/glycopyrronium 50 mcg)

• Breath-activated single-dose powder inhaler
• Capsules come in foil packs containing 30 capsules in a cardboard carton
• Breezhaler inhalation device allows oral inhalation of the content of the capsule shell. One capsule is loaded into the inhaler and pierced before inhaling.
• Gives consistent drug delivery over a range of inspiratory flow rates.

Brimica (aclidinium 340 mcg/ formoterol 12 mcg)

• Breath activated multi-dose DPI (containing 30 or 60 doses) with an integral dose indicator, a green dosage button and a coloured control window. Before inhaling the dose, the green button should be pressed all the way down and then released. The coloured control window changes to green suggesting the dose is ready for inhalation. If the full dose is inhaled correctly, the control window turns red. Genuair is equipped with a dose indicator, displaying intervals of 10 (60, 50, 40, 30, 20, 10, 0). When a red striped band appears in the dose indicator, only a few doses are left in the device. Bretaris Genuair also contains lactose.

• Breath activated multi-dose DPI containing 14 or 30 doses. The active substances are in separate blisters in powder form inside the device. It has a dose counter; when fewer than 10 doses are left, half of the dose counter shows red.

Spiolto Respimat (tiotropium 2.5 mcg/olodaterol 2.5 mcg)

• Push-button activated solution for inhalation. The cartridge is inserted and primed before first use of the Respimat. To deliver the inhalation, the clear base is turned until it clicks, the cap is opened, and the patient closes their lips around the mouthpiece. The dose-release button is pressed, and the mist is inhaled with a slow, deep breath, then a breath hold. A dose indicator shows a low number of doses left, and the inhaler locks when empty.  May be suitable for patients with poor inspiratory effect.

• Corticosteroid or ipratropium bromide aerosol should not be allowed to enter the eyes to avoid the risk of side effects such as glaucoma or urinary outlet obstruction. Patients should be advised to wipe their face dry after using the nebuliser to remove medication from the skin.
• Ipratropium can be combined with beta-agonist, but not with corticosteroid.