Asthma Treatment – Adults & Adolescents

Key Points – from RCH and Asthma guidelines 3.0

Background

• Medications and Delivery Devices:
  • Inhaled Corticosteroid (ICS): Reduces inflammation in the airways.
  • Short-acting β-agonist (SABA): Provides quick relief by relaxing the muscles around the airways.
  • Long-acting β-agonist (LABA): Provides prolonged bronchodilation, reducing asthma symptoms and exacerbations.
  • Metered Dose Inhaler (MDI): Delivers a specific amount of medication to the lungs in aerosol form.
  • Dry Powder Inhaler (DPI), including the Turbuhaler®: Delivers medication in powder form, requiring adequate inhalation technique.
• Risks of SABA Alone: High use of SABA alone (>3 MDI canisters per year) and low use of ICS is associated with more severe asthma exacerbations and death.
• Combination Therapy (ICS/LABA): Ensures use of anti-inflammatory with every reliever dose (anti-inflammatory reliever-based regimen). Currently, budesonide/formoterol is the only combination prescribed as a reliever.
• Traditional Management: Daily ICS as a preventer and SABA as needed is effective and may be preferred for those already on a working regimen or with difficulties using DPI/Turbuhaler®.
• Environmental Impact: MDI has a larger carbon footprint. Achieving good asthma control to reduce SABA need or switching to DPI can help reduce environmental impact.

Assessment

Differential diagnosis in adults and adolescents

Alternative or comorbid condition	Suggestive features
Inducible laryngeal obstruction	Dry cough or breathing difficulty triggered by strong smells, irritants or exerciseSymptoms worse when talking on the phoneSymptoms associated with throat tightness or voice changeBreathlessness worst at peak exercise. Inspiratory wheezing (stridor) – strongly suggests a laryngeal or upper airway abnormality
Rhinosinusitis	Cough co-occurring  with symptoms of rhinosinusitis
Chronic upper airway cough syndrome	Dry cough is dominant symptomThroat-clearingDysphonia‘Scratchy’ throatTriggered by talking, laughing, strong odours or smokeMay be associated with chronic rhinosinusitis or gastroesophageal reflux
ACE inhibitor-related cough	Cough is dominant symptom
COPD	Onset of dyspnoea/cough/ wheeze at age >40 yearsHistory of smoking or exposure to smoke/dustHistory of recurrent chest infectionsPersistent breathlessnessFamily history of emphysema
Bronchiectasis	Productive cough in a patient with a history of recurrent infections
Large airway stenosis	Breathlessness or wheeze
Pulmonary fibrosis	Breathlessness or dry coughFine crackles heard during inspiration on auscultation
Lung cancer	Persistent cough despite treatmentHaemoptysisChest painWeight loss
Poor cardiopulmonary fitness	Breathlessness on exertion
Heart disease	Chest tightness on exertionDyspnoea on exertion or when lying flatBasal crepitations
Pulmonary embolism	Sudden-onset dyspnoea
Dysfunctional breathing	Breathlessness with dizziness, light-headedness, or tingling fingers
Panic attacks	Breathlessness or chest tightness at rest or on minor exertion, accompanied by anxiety
Gastro-oesophageal reflux disease	Cough or chest tightness in patient with symptomatic reflux
Recurrent respiratory infections	As clinically typical

Features suggesting higher or lower probability of asthma in adults and adolescents

Asthma is more likely to explain signs/symptoms More than one of these symptoms: wheeze, breathlessness, chest tightness, cough Symptoms recurrent or seasonal Symptoms worse at night or in the early morningHistory of allergies (e.g. allergic rhinitis, atopic dermatitis) Symptoms obviously triggered by exercise, cold air, irritants, certain medicines (e.g. aspirin or beta blockers), allergies, viral infections Family history of asthma or allergies Widespread wheeze audible on chest auscultation FEV1 or PEF lower than predicted, without other explanation Eosinophilia or raised blood IgE level, without other explanation Symptoms rapidly relieved by a rapid-acting bronchodilator (e.g. SABA or ICS-formoterol)

Asthma is less likely to explain the signs/symptoms Dizziness, light-headedness, peripheral tingling Isolated cough with no other respiratory symptoms Chronic sputum production No abnormalities on physical examination of chest when symptomatic (over several visits) Change in voice Heavy smoker (now or in past) Cardiovascular disease Normal spirometry when symptomatic (despite repeated tests)

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Asthma Assessment & Diagnosis

History

Wheeze + dyspnoea = most predictive symptoms

History alone ≠ diagnosis → must show airflow variability

• Core symptoms
  • Wheeze
  • Breathlessness
  • Chest tightness
  • Cough
• Symptom pattern
  • Daytime vs night-time symptoms
  • Variability over time (weeks/years)
• Triggers
  • Exercise
  • Viral infections
  • Cold/dry air
  • Foods / medications
  • Allergens
• Environmental factors
  • Home exposures
  • Workplace exposures
• Smoking history
  • Tobacco
  • Vaping
  • Cannabis
  • Passive smoke exposure
• Allergy history
  • Allergic rhinitis
  • Atopic dermatitis
• Family history
  • Asthma
  • Allergies

Examination

• Respiratory
  • Chest auscultation (wheeze, crackles, inspiratory sounds)
• Upper airway
  • Allergic rhinitis
  • Rhinosinusitis
  • Nasal polyps
• Other signs suggesting alternative diagnosis
  • Cardiac murmurs
  • Crackles (interstitial/cardiac disease)
  • Inspiratory wheeze (upper airway pathology)

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Investigations

Spirometry (Core Investigation)

• Perform or refer (with bronchodilator response)
• Measure:
  • FEV1 before and 10–15 min after bronchodilator
  • ≥3 manoeuvres each time
• Diagnostic findings
  • Reduced FEV1/FVC → airflow limitation
  • Positive bronchodilator response:
    • ↑ FEV1 ≥ 200 mL AND ≥12% → confirms asthma (if clinical context fits)

📌 Notes:

• Low FEV1 alone = nonspecific
• Normal spirometry ≠ exclude asthma (especially asymptomatic)

FeNO (if available)

• Indicates type-2 airway inflammation
• FeNO ≥ 40 ppb
  • Supports asthma diagnosis
  • Sensitivity ~0.61, specificity ~0.82 (adults)

📌 Notes:

• Normal FeNO ≠ exclude asthma

Role of Lung Function Testing

• Essential to differentiate from:
  • COPD
  • Inducible laryngeal obstruction
  • Allergic rhinitis
  • Eosinophilic bronchitis

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Diagnostic Criteria (Asthma)

Diagnose Asthma if ALL Apply

• Typical symptoms
  • Recurrent or persistent:
    • Wheeze
    • Shortness of breath
    • Chest tightness
    • Cough
  • Variable in frequency and severity
• No better alternative diagnosis
  • Symptoms/signs not explained by another condition
• Objective evidence of variable airflow OR inflammation
  • Variable expiratory airflow limitation and/or
  • FeNO ≥ 40 ppb

Important Limitation

• Airflow variability may NOT be detected if:
  • Patient already on ICS (anti-inflammatory treatment)
  • Recent bronchodilator use

How to Demonstrate Variable Airflow Limitation

Any of the following:

• Bronchodilator responsiveness (spirometry)
  • ↑ FEV1 ≥ 200 mL AND ≥12% from baseline
  • Measured 10–15 min after bronchodilator
• Bronchial provocation test
  • Performed in respiratory lab
• Trial of ICS (4 weeks)
  • Pre-bronchodilator FEV1 improvement:
    • ≥ 200 mL AND ≥12%

Diagnostic Principle (GINA-aligned – Global Initiative for Asthma (GINA) is an expert group that publishes widely used, evidence-based asthma guidelines updated regularly)

• Diagnosis requires:
  • Typical symptom pattern
  • PLUS objective variability in expiratory airflow
  • (Current or historical documentation acceptable)

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If Initial Tests Non-Diagnostic

• Repeat spirometry + bronchodilator response
• Refer for:
  • Repeat spirometry + FeNO
  • Specialist (respiratory physician)

Further Testing (if still unclear)

• Bronchial provocation testing
• Contraindications:
  • FEV1 < 60%
  • Pregnancy

Referral

• Consider specialist referral if:
  • Diagnosis remains uncertain
  • Atypical features
  • Poor response to treatment

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Asthma treatment levels for adults and adolescents

Asthma treatment is adjusted to maintain good symptom control, reduce exacerbation risk, and minimise side-effects. The best treatment level may change over time depending on control, exacerbation history, adherence, inhaler technique, and patient preference.

Key principles

• All adults and adolescents with asthma require ICS-containing treatment
• Do not prescribe or recommend SABA-only treatment
• Start with low-dose budesonide–formoterol as needed when symptoms occur
• Advise patients to carry their reliever at all times
• Reliever may be used:
  • when breathless/wheezy/tight-chested
  • before exercise
  • before unavoidable trigger exposure
• Prescribe asthma medicines via inhalers, not nebulisers, unless there is a specific clinical indication

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AIR and MART in Asthma

AIR – Anti-Inflammatory Reliever

What it is

• A reliever-only strategy
• Uses low-dose ICS–formoterol as needed (PRN)
• No regular maintenance therapy

How it works

• Formoterol → rapid bronchodilation (like SABA)
• ICS (e.g. budesonide) → treats airway inflammation
• Both delivered together when symptoms occur

Typical regimen

• 1 inhalation when symptomatic
• Repeat after a few minutes if needed
• Max:
  • Usually ≤8 inhalations/day
  • Up to 12 inhalations/day (short term)

Indications

• Mild asthma
• Infrequent symptoms
• First-line option in Australian guidelines (instead of SABA-only)

Common inhalers

• Budesonide/formoterol combinations (e.g. Symbicort, DuoResp, Fobumix)

MART – Maintenance and Reliever Therapy

• Single inhaler used for BOTH:
  • Daily maintenance (preventer)
  • Symptom relief (reliever)

How it works

• Regular ICS controls baseline inflammation
• Extra PRN doses increase ICS automatically during worsening asthma

Typical regimen

• Maintenance: 1–2 inhalations BD
• Reliever: 1 inhalation PRN
• Max:
  • Usually ≤8 inhalations/day
  • Up to 12/day short-term if needed

Indications

• Persistent asthma
• Frequent symptoms / night waking
• Poor control on AIR or ICS alone

Key requirement

• Must use formoterol-containing ICS–LABA
  • (rapid onset → acts as reliever)

Common inhalers

• Budesonide/formoterol (e.g. Symbicort, DuoResp, Fobumix)
• Beclomethasone/formoterol (e.g. Fostair – ≥18 yrs)

🔥 Key Differences

Feature	AIR	MART
Daily preventer	❌ No	✅ Yes
Reliever	ICS–formoterol PRN	Same inhaler
ICS exposure	Only when symptomatic	Daily + PRN
Best for	Mild asthma	Persistent asthma
SABA needed	❌ No	❌ No

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Recommended treatment levels

Level	Preferred treatment	Description
Level 1	Low-dose AIR-only budesonide–formoterol as needed	AIR-only therapy. Used when symptoms occur.
Level 2	Low-dose MART	Maintenance low-dose ICS–formoterol plus – extra doses from the same inhaler as needed.
Level 3	Medium-dose MART	Medium-dose ICS–formoterol maintenance – usually by increasing inhalations from a low-dose inhaler plus extra doses as needed.
Level 4	Targeted intensive treatment	Specialist-level or more intensive treatment +/- ICS–LABA +/- LAMA +/- biologics +/- azithromycin or other add-ons

Alternative options at Levels 1–3

Level	Alternative option
Level 1	Maintenance low-dose ICS plus SABA as needed
Level 2	Maintenance low-dose ICS–LABA plus SABA as needed
Level 3	Maintenance medium-dose ICS–LABA plus SABA as needed

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( Level 1 ) – AIR-only

Indication: Infrequent symptoms

Brand	Type	Strength	Dose	Max dose	Age	PBS code
Symbicort Rapihaler	pMDI	100/3	1–2 puffs PRN	≤16/day (≤24 short-term)	≥12 yrs	12042T
Symbicort Turbuhaler	DPI	200/6	1 puff PRN	≤8/day (≤12 short-term)	≥12 yrs	12041R
Bufomix Easyhaler	DPI	200/6	1 puff PRN	≤8/day (≤12 short-term)	≥12 yrs	14166N

👉 Key: this replaces SABA; patient uses it whenever symptomatic.

Alternative Option: ICS + SABA as needed

Drug	Brand	Low dose
Budesonide	Pulmicort Turbuhaler	200–400 mcg/day
Fluticasone propionate	Flixotide	100–200 mcg/day
Beclometasone (extra-fine)	Qvar	100–200 mcg/day

( Level 2 ) Low-dose MART

Indication: Symptoms most days / exacerbation risk

Brand	Type	Strength	Maintenance	Reliever	Max dose	Age	PBS code
Symbicort Rapihaler	pMDI	100/3	2 puffs BD	1–2 PRN	≤16/day	≥12 yrs	12042T
Symbicort Turbuhaler	DPI	200/6	1 puff BD	1 PRN	≤8/day	≥12 yrs	12041R
Bufomix Easyhaler	DPI	200/6	1 puff BD	1 PRN	≤8/day	≥12 yrs	14166N

( Level 3 ) Medium-dose MART

👉 achieved by increasing maintenance dose

Indication: Persistent symptoms despite Level 2

Brand	Type	Strength	Maintenance	Reliever	Max dose	Age	PBS code
Symbicort Rapihaler	pMDI	100/3	up to 4 puffs BD	1–2 PRN	≤16/day	≥12 yrs	12042T
Symbicort Turbuhaler	DPI	200/6	2 puffs BD	1 PRN	≤8/day	≥12 yrs	12041R
Bufomix Easyhaler	DPI	200/6	2 puffs BD	1 PRN	≤8/day	≥12 yrs	141

(Alternative Level 2-3) ICS–LABA + SABA

Drug	Brand	Dose
Fluticasone–salmeterol	Seretide	100/50 to 250/50 BD
Budesonide–formoterol	Symbicort (non-MART use)	1–2 puffs BD
Fluticasone furoate–vilanterol	Breo Ellipta	100/25 OD

( Level 4) Targeted intensive asthma treatment

High-dose ICS–LABA

Short-term 3–6 month trial while assessing persistent symptoms/severe exacerbations or awaiting biologic eligibility. Specialist care recommended if not controlled on medium-dose ICS–LABA.

Drug	Example	Dose
Symbicort 200/6	DPI	up to 2 puffs BD
Seretide 500/50	Accuhaler	1 puff BD

Add-on LAMA

Drug	Brand	Dose
Tiotropium	Spiriva Respimat	2.5 mcg, 2 puffs OD
Triple therapy (ICS–LABA–LAMA)	Trelegy Ellipta	100/62.5/25 OD

Trial option for patients with normal eosinophils/FeNO, persistent symptoms or severe exacerbations, or while awaiting biologic assessment. May be long-term if clear benefit.

Add-on oral / other

Drug	Notes
Montelukast (Singulair) – May be considered as add-on therapy, especially in aspirin-exacerbated respiratory disease. – Limited role in severe asthma. – Counsel about neuropsychiatric adverse effects.	10 mg nocte (caution: neuropsychiatric effects)
Azithromycin – Specialist add-on option for persistent exacerbations despite medium-dose ICS–LABA. – Requires screening and caution	250–500 mg 3x/week (specialist use)

Biologics (specialist)

Targeted anti-inflammatory therapy based on allergic status and inflammatory phenotype. Used under specialist care.

Drug	Target
Omalizumab (Xolair)	IgE
Mepolizumab (Nucala)	IL-5
Benralizumab (Fasenra)	IL-5 receptor
Dupilumab (Dupixent)	IL-4/13

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Other Tests for airway inflammation (Asthma)

Types of tests

• Fractional exhaled nitric oxide (FeNO)
• Blood eosinophil count
• Sputum eosinophil count

Type 2 airway inflammation

• Driven by T-helper 2 lymphocytes
• Leads to:
  • Eosinophil and mast cell recruitment
  • Mucus hypersecretion
  • Airway oedema and thickening
  • Airway hyperresponsiveness
• Common phenotypes:
  • Allergic asthma (childhood onset, ↑ IgE, atopy)
  • Eosinophilic non-allergic asthma (adult onset)

FeNO (Fractional exhaled nitric oxide)

What it reflects

• Airway inflammation (especially eosinophilic/type 2)

Key points

• Performed in respiratory labs
• Easy to perform (>4–5 yrs)
• Medicare-rebatable (with spirometry + BDR + specialist report)

Interpretation

• Elevated in:
  • Asthma (type 2 inflammation)
  • Viral infections, allergic rhinitis, eosinophilic bronchitis
• Suppressed by:
  • Smoking
  • ICS / oral steroids
  • Biologics (e.g. dupilumab)

Diagnostic role

• Supports asthma diagnosis (not required)
• Adult:
  • ≥40 ppb → supports asthma
• Child:
  • ≥25 ppb → supports asthma
• Normal FeNO ≠ excludes asthma

Clinical use

• Predicts response to ICS
• Helps phenotype severe asthma
• High FeNO → better response to biologics
• Not routinely required in primary care monitoring

Blood eosinophil count

What it reflects

• Systemic marker of type 2 inflammation

Key points

• Not required for diagnosis
• Useful in difficult/severe asthma

Interpretation

• ≥200 cells/µL → ↑ risk of exacerbations
• ≥150 cells/µL (on high-dose ICS) → refractory type 2 inflammation
• ≥300 cells/µL → consider alternative causes (e.g. parasites)
• ≥1500 cells/µL → consider EGPA

Limitations

• Affected by:
  • Age, sex, time of day
  • Smoking, obesity
  • Infection, malignancy

Clinical use

• Risk stratification (exacerbations)
• Guides biologic eligibility (PBS)
• Combined with FeNO improves prediction

Sputum eosinophil count

• Limited availability in Australia
• Rarely used in primary care
• ≥2% (on high-dose ICS) → refractory type 2 inflammation

Key clinical takeaways

• None of these tests are mandatory for asthma diagnosis
• Diagnosis still requires:
  • Clinical history
  • Objective variable airflow limitation
• FeNO + eosinophils:
  • Helpful for phenotype
  • Guide ICS/biologic therapy
• Most useful in:
  • Uncertain diagnosis
  • Poor control / severe asthma
• Limited routine role in standard primary care management

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Asthma Monitoring & Follow-up

• Always assess:
  • SABA use
  • Exacerbation history
  • ICS adherence
  • Smoking exposure
• Identify red flags for escalation:
  • ≥1 severe exacerbation
  • High SABA use
  • Poor lung function
• Ensure:
  • Written asthma action plan
  • Preventer optimisation
  • Risk factor modification

Asthma management cycle

1. Symptom Control (assess every visit – past 4 weeks)

Ask:

• Daytime symptoms
  • How many days/week?
• Reliever use
  • How many days/week?
• Activity limitation
  • Any restriction of normal activities?
• Nocturnal symptoms
  • Night waking / early morning symptoms

2. Since Last Visit (interval history)

Time off work/school due to asthma

• Use of asthma action plan
• Any exacerbations:
  • ED visits
  • Urgent care presentations

3. Clinical Interpretation

• Symptom frequency + SABA use → predictors of severe exacerbation risk
• In AIR-only (as-needed ICS-formoterol):
  • Reliever ≥3 times/week → consider step-up to MART

Good control	Poor control
All of these over past 4 weeks: – Daytime symptoms ≤2 days per week – No limitation of activities – No symptoms during night or on waking – Reliever use ≤2 days per week*	Any of these over past 4 weeks: – Daytime symptoms >2 days per week – Any limitation of activities – Any symptoms during night or on waking – Reliever use >2 days per week*

Additional information

*Do not include short-acting beta₂ agonist (salbutamol or terbutaline) taken prophylactically before exercise. Do not include reliever use for patients using an anti-inflammatory reliever (budesonide-formoterol or beclometasone-formoterol) in an AIR-only or MART regimen.

4. Risk of Exacerbations

• Poor asthma symptom control
• Exacerbation in past 12 months
• High SABA use
  • ≥3 salbutamol canisters/year (~≥1.6 puffs/day)
• Coexisting chronic lung disease
• Poor lung function (even if asymptomatic)
• Reduced perception of airflow limitation/exacerbation severity
• Eosinophilic inflammation
  • Blood eos ≥300 cells/µL despite medium-dose ICS
• Smoke exposure
  • Cigarettes / vaping / biomass (fires)
  • Consider asthma–COPD overlap in smokers/ex-smokers
    • Smoking → ↑ exacerbations + persistent airflow limitation
    • Passive smoke → poor asthma control
• Socioeconomic disadvantage
• Mental illness

5. Risk of Life-Threatening Asthma

• Previous severe exacerbation:
  • ICU/intubation (ever)
  • ≥2 hospitalisations in past year
  • ≥3 ED visits in past year
  • ED/hospital visit in past month
• Sudden-onset acute asthma history
• Delayed presentation during exacerbations
• Very high SABA use
  • ≥12 canisters/year (~≥6.6 puffs/day)
• Comorbid cardiovascular disease
• Allergen sensitivity with unavoidable exposure (e.g. mould)
• No written asthma action plan
• Social isolation
• Socioeconomic disadvantage
• Mental illness

6. Risk of Thunderstorm Asthma

• Seasonal allergic rhinitis (spring)
• Ryegrass pollen allergy + exposure during high pollen periods

Risk of Accelerated Lung Function Decline

• Chronic mucus hypersecretion
• Severe exacerbation without ICS use
• Persistently poor lung function
• Eosinophilic inflammation
  • Blood eos ≥300 cells/µL despite ICS
• Smoking exposure
• Occupational asthma

Risk of Treatment-Related Adverse Effects

• Long-term high-dose ICS use
• Frequent oral corticosteroid (OCS) use

7. Lung Function Monitoring (Spirometry)

Perform:

• At diagnosis (confirm)
• If poor control or exacerbations
• Routinely ~every 2 years (even if well controlled)

Rationale

• Detects silent decline in lung function
• Prevents missed airway remodelling

8. What NOT to Use

• Do NOT rely on peak expiratory flow (PEF) in clinic
  • Less reliable than spirometry

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Approach to Asthma Not Responding to Treatment

• Review the Following:
  • Correct asthma diagnosis.
  • Adherence to treatment.
  • Inhaler technique.
  • Contributing factors like
    • allergic rhinitis
    • obesity
    • obstructive sleep apnea
    • gastro-oesophageal reflux
    • dysfunctional breathing
    • depression/anxiety
    • smoking/vaping
    • environmental factors.
  • Socioeconomic factors affecting access to healthcare.
    • Poor adherence to treatment
    • Denying or disregarding asthma symptoms
    • Avoiding regular review appointments
    • Life events (new school, moving house, family disruption, absent parent)
    • Family problems (e.g. family conflict, family dysfunctions
    • Psychological distress (e.g. feelings of hopelessness, bereavement or recent loss)
    • Mental health problems (e.g. depression, emerging mood disorders
    • Risky use of alcohol/other substances
    • Communication problems
• Consultation:
  • Consult respiratory/specialist asthma services if asthma control remains inadequate at Step 3 or if diagnosis is unclear.

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Choice of Inhaler – Key Considerations

pMDI = Pressurised Metered-Dose Inhaler – uses propellant to deliver aerosol dose	SMI = Soft Mist Inhaler – delivers medication as dry powder (requires strong inhalation)	DPI = Dry Powder Inhaler – delivers medication as dry powder (requires strong inhalation)	Breath-actuated pMDI = Breath-Actuated Pressurised Metered-Dose Inhaler -same device type but releases dose automatically when patient inhales

1. Dexterity & Coordination

pMDI

• Requires coordination (press + inhale) unless spacer used
• Needs:
  • Shaking before use
  • Priming if unused
  • Regular cleaning

Breath-actuated pMDI

• No coordination required

DPI

• No coordination needed
• Requires correct device handling:
  • Load dose correctly
  • Keep device orientation (horizontal/upright depending on type)
  • Do not breathe into device
• Single-dose capsule DPI:
  • Insert capsule each time
  • Risk of accidental swallowing

2. Inspiratory Flow Requirements

pMDI

• Low inspiratory flow required
• “Slow and steady” inhalation
• Suitable for:
  • Children
  • Frail/elderly
  • Acute bronchoconstriction
• Spacer improves delivery

DPI

• Requires moderate–high inspiratory flow
• “Quick and deep” inhalation
• Not suitable for:
  • Young children
  • Frail patients
  • Acute asthma exacerbation
  • Patients unable to generate forceful inhalation

3. Drug Deposition (Effectiveness)

pMDI

• Higher oropharyngeal deposition (↓ with spacer)
• Technique:
  • Slow inhalation over 3–5 sec
• Spacer:
  • ↑ lung delivery
  • ↓ local side effects

SMI (Soft mist inhaler)

• Slow inhalation (3–5 sec)
• Improved lung deposition

DPI

• Requires:
  • Full exhalation first
  • Forceful deep inhalation (2–3 sec)
• Adequate inspiratory effort critical

4. Cognitive Function & Usability

• Technique differs between devices → training essential
• Prefer:
  • Device patient already knows
  • Simplest option with correct technique
• Avoid multiple device types → ↑ error risk

5. Environmental Impact

• pMDIs → higher carbon footprint (propellants)
• DPIs / SMIs → lower environmental impact

6. Storage & Shelf-life

• Some DPIs:
  • Sensitive to humidity
• Some inhalers:
  • Limited “in-use” shelf life after opening
• Packaging (foil/pouch) important for stability

7. Practical Prescribing Tips

• Match inhaler to:
  • Patient ability (dexterity, cognition, inspiratory flow)
• Always:
  • Check inhaler technique
  • Demonstrate + recheck regularly
• Prefer:
  • Single device type where possible
• Use spacer with pMDI when:
  • Poor coordination
  • ICS use (reduce oral side effects)