Guidance on handheld inhalers in asthma and COPD guidelines

BACKGROUND: Inhaled therapy is the cornerstone of pharmacotherapy in patients with asthma and chronic obstructive pulmonary disease (COPD). Appropriate inhalation device selection is as important as drug choice but device-specific guidance appears to be lacking.

METHODS: To quantify the level of inhalation-device recommendations in clinical guidelines, a review was conducted by hand-searching national and international asthma and COPD guidelines (Global Initiative for Asthma [GINA] and Global initiative for chronic Obstructive Lung Disease [GOLD] guidelines) and an international guideline on device selection (the American College of Chest Physicians/American College of Asthma, Allergy, and Immunology [ACCP/ACAAI]). For each guideline, the number of pages, tables/figures and references relating to inhalation devices was identified.

RESULTS: GINA and GOLD guidelines contain very little inhalation device-specific guidance beyond recommendations for demonstrating and testing correct inhalation technique: <2% of pages or references and <3% of tables/figures are dedicated to devices. Device-related content in the ACCP/ACAAI device selection guideline was considerably higher with 54% of pages, 88% of tables/figures and 82% of references, respectively. Results in national guidelines reflect those on international guidelines.

CONCLUSIONS: These results indicate that there is a considerable lack of clear and specific guidance regarding inhalation devices in current asthma/COPD guidelines. More robust studies on the impact of inhalation devices are needed to increase the number of evidence statements and recommendations regarding inhalation devices.