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Respir Med. 2014 May;108(5):694-700. doi: 10.1016/j.rmed.2014.02.013. Epub 2014 Mar 1.

Guidance on handheld inhalers in asthma and COPD guidelines.

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Department of Pulmonary Diseases (454), Radboud University Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands. Electronic address:
Department of Respiratory Medicine, Lund University Hospital, SE-22185 Lund, Sweden.
Department of Experimental and Clinical Medicine, Careggi University Hospital, Largo Brambilla 3, 50134 Florence, Italy.
Service de Pneumologie, Saint-Pierre University Hospital Brussels, 322 rue Haute, B-1000 Brussels, Belgium.
University of Bordeaux, INSERM U657, 33076 Bordeaux Cedex, France.
Centre of Academic Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen, AB25 2AY Scotland, UK.



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.


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.


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.


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.


Asthma; Chronic obstructive pulmonary disease; Dry powder inhalers; Guidelines; Pressurised metered-dose inhalers

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