This article was sponsored by PARI GmbH.
Your Patients: Support your choice with the
Selecting the COPD Device Most Likely to Benefit
Respiratory
Introduction
Inhalation therapy is central to the treatment of patients with COPD,1 a condition that affects an estimated 480 million people; roughly 10% of the global population.2
Inhaled therapies deliver medication directly to the lungs, with the benefit of rapid onset of effect and reduced systemic exposure compared with oral or intravenous administration.3
1. Cazzola M et al. The future of inhalation therapy in chronic obstructive pulmonary disease. Curr Res Pharmacol Drug Discov. 2022;3:100092.
2. Boers E et al. Global burden of chronic obstructive pulmonary disease through 2050. JAMA Netw Open. 2023;6(12):e2346598.
3. Dhand R et al. Recalibrating perceptions and attitudes toward nebulizers versus inhalers for maintenance therapy in COPD: past as prologue. Int J Chron Obstruct Pulmon Dis. 2024;19:2571-86.
4. 2025 GOLD Report. Global Initiative for Chronic Obstructive Lung Disease - GOLD. Available at: https://goldcopd.org/2025-gold-report/. Last accessed: 20 March 2025.
5. Mahler DA, Halpin DMG. Personalizing selection of inhaled delivery systems in chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2023;20(10):1389-96.
6. Izquierdo-Condoy JS et al. Challenges and opportunities in COPD management in latin america: a review of inhalation therapies and advanced drug delivery systems. Pharmaceutics. 2024;16(10):1318.
7. Cho-Reyes S et al. Inhalation technique errors with metered-dose inhalers among patients with obstructive lung diseases: a systematic review and meta-analysis of U.S. studies. Chronic Obstr Pulm Dis. 2019;6(3):267-80.
8. Hindle M et al. Investigations of an optimal inhaler technique with the use of urinary salbutamol excretion as a measure of relative bioavailability to the lung. Thorax. 1993;48(6):607-10.
9. Loh CH et al. Suboptimal inspiratory flow rates are associated with chronic obstructive pulmonary disease and all-cause readmissions. Ann Am Thorac Soc. 2017;14(8):1305-11.
10. Broeders MEAC et al. The course of inhalation profiles during an exacerbation of obstructive lung disease. Respir Med. 2004;98(12):1173-9.
11. Ghosh S et al. Peak inspiratory flow rate in chronic obstructive pulmonary disease: implications for dry powder inhalers. J Aerosol Med Pulm Drug Deliv. 2017;30(6):381-7.
12. Mahler DA. The role of inspiratory flow in selection and use of inhaled therapy for patients with chronic obstructive pulmonary disease. Respir Med. 2020;161:105857.
13. Sharafkhaneh A et al. Perceptions and attitudes toward the use of nebulized therapy for COPD: patient and caregiver perspectives. COPD. 2013;10(4):482-92.
14. Berlinski A. In vitro comparison of different nebulizers delivering 7% hypertonic saline. Respir Care. 2021;66(10):1582-7.
15. NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng115. Last accessed: 1 April 2025.
16. Vecellio L et al. Disposable versus reusable jet nebulizers for cystic fibrosis treatment with tobramycin. J Cyst Fibros. 2011;10(2):86-92.
17. EMJ Reviews. Efficiency assessment of 15 nebuliser systems by the respirable drug delivery rate: a comparable quality parameter. EMJ Respir. 2023;11[1]:69-73.
18. Fischer R et al. Efficiency assessment of 15 nebuliser systems by the respirable drug delivery rate. Eur Respir J. 2023;62(Suppl 67):PA4603.
19. Cuevas Brun E et al. Aerodynamic particle size distribution and delivered dose efficiency of a continuous-output mesh nebuliser and a novel breath-actuated device using terbutaline sulphate. 2021. Available at: https://ddl-conference.com/wp-content/uploads/2021/10/06.Cuevas-Brun.pdf. Last accessed: 21 March 2025.
20. Heijerman H et al. Inhaled medication and inhalation devices for lung disease in patients with cystic fibrosis: A European consensus. J Cystic Fibrosis. 2009;8(5):295-315.
21. Arunthari V et al. A prospective, comparative trial of standard and breath-actuated nebulizer: efficacy, safety, and satisfaction. Respir Care. 2012;57(8):1242-7.
22. Sabato K et al. Randomized controlled trial of a breath-actuated nebulizer in pediatric asthma patients in the emergency department. Respir Care. 2011;56(6):761-70.
23. Li J et al. In vitro comparison between inspiration synchronized and continuous vibrating mesh nebulizer during trans-nasal aerosol delivery. Intensive Care Med Exp. 2020;8:6.
24. GlobeNewswire News Room. Verona pharma announces US FDA approval of OhtuvayreTM (ensifentrine). 2024. Available at: https://www.globenewswire.com/news-release/2024/06/26/2904839/0/en/Verona-Pharma-Announces-US-FDA-Approval-of-Ohtuvayre-ensifentrine.html. Last accessed: 21 March 2025.
25. Du D et al. The availability of drugs for stable COPD treatment in China: a cross-sectional survey. NPJ Prim Care Respir Med. 2025;35(1):6.
26. Stolbrink M et al. The availability, cost, and affordability of essential medicines for asthma and COPD in low-income and middle-income countries: a systematic review. Lancet Glob Health. 2022;10(10):e1423-42.
27. Widysanto A et al. Chronic Bronchitis. [Internet] (2025) Treasure Island: StatPearls. Available at: http://www.ncbi.nlm.nih.gov/books/NBK482437/. Last accessed 4 March 2025.
28. Cerveri I et al. Revisited role for mucus hypersecretion in the pathogenesis of COPD. Eur Respir Rev. 2010;19(116):109-12.
29. Curran DR et al. Advances in mucous cell metaplasia: a plug for mucus as a therapeutic focus in chronic airway disease. Am J Respir Cell Mol Biol. 2010;42(3):268-75.
30. Shen Y et al. Management of airway mucus hypersecretion in chronic airway inflammatory disease: Chinese expert consensus (English edition). Int J Chron Obstruct Pulmon Dis. 2018;13:399-407.
31. Decramer M et al. Mucoactive therapy in COPD. Eur Respir Rev. 2010;19(116):134-40.
32. Jin KN et al. Mucus plugs as precursors to exacerbation and lung function decline in COPD patients. Arch Bronconeumol. 2025;61(3):138-46.
33. Diaz AA et al. Airway-occluding mucus plugs and mortality in patients with chronic obstructive pulmonary disease. JAMA. 2023;329(21):1832-9.
34. Okajima Y et al. Luminal plugging on chest CT scan: association with lung function, quality of life, and COPD clinical phenotypes. Chest. 2020;158(1):121-30.
35. Dunican EM et al. Mucus plugs and emphysema in the pathophysiology of airflow obstruction and hypoxemia in smokers. Am J Respir Crit Care Med. 2021;203(8):957-68.
36. Shah BK et al. mucus hypersecretion in chronic obstructive pulmonary disease and its treatment. Mediators Inflamm. 2023;2023:8840594.
37. Khan SY et al. Is nebulized saline a placebo in COPD? BMC Pulm Med. 2004;4:9.
38. Cole E et al. Inhaled 7% hypertonic saline is safe to administer in patients with moderate to severe chronic obstructive pulmonary disease (COPD). 2017. Available at: https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2017.195.1_MeetingAbstracts.A5714. Last accessed: 25 March 2025.
39. Taube C et al. Airway response to inhaled hypertonic saline in patients with moderate to severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2001;164(10 Pt 1):1810-5.
40. Valderramas SR et al. Effectiveness and safety of hypertonic saline inhalation combined with exercise training in patients with chronic obstructive pulmonary disease: a randomized trial. Respir Care. 2009;54(3):327-33.
41. Coppolo DP et al. Non-pharmaceutical techniques for obstructive airway clearance focusing on the role of oscillating positive expiratory pressure (OPEP): a narrative review. Pulm Ther. 2022;8(1):1-41.
42. Alghamdi SM et al. Oscillatory positive expiratory pressure therapy in COPD (O-COPD): a randomised controlled trial. Thorax. 2023;78(2):136-43.
43. Price E et al. Development and evaluation of a tool to optimise inhaler selection prior to hospital discharge following an exacerbation of COPD. ERJ Open Res. 2024;10(2):00010-2024.
44. Voshaar T et al. [Recommendations for the choice of inhalatory systems for drug prescription]. Pneumologie. 2001;55(12):579-86. (In German).
45. EMJ. COPD Device Selection Tool. 2025. Available at: https://www.emjreviews.com/pari-devise-selection-tool/. Last accessed: 2 May 2025.
References
References
| September 2025
Burden of CIDP disease and treatments
Many patients with self-reported CIDP missed work or school due to treatment administration.11
A UK study found that 17% required a wheelchair at the nadir of illness 12, while a population-based study from Iceland reported 10%.13
Burden of CIDP disease and treatments
Long IV infusion times
Poor corticosteroid tolerability11
Burden of CIDP disease and treatments
Interactive Device Selection Tool
10
%
Interview Summary
Interview Summary
Chronic Obstructive Pulmonary Disease (COPD) is a leading cause of morbidity and mortality worldwide. Inhaled therapies are the mainstay of COPD treatment, including pressurised metered dose inhalers (pMDI), pMDIs with a spacer, soft mist inhalers (SMI), dry powder inhalers (DPI), and nebulisers. Inhalation devices each have distinct advantages and challenges, and selecting the most appropriate device for a COPD patient is crucial to maximising the benefit of inhaled therapy.
In this expert interview, pulmonologist Donald Mahler, offers insights into the nuances of inhaler selection, emphasising how clinical and patient-specific factors should guide decision-making. He clarifies the roles of different delivery systems, including the role of nebulisers in certain clinical scenarios, and describes how nebuliser efficiency can be objectively measured in terms of the ability to deliver therapeutic doses of medication into the lungs. A case study illustrates the benefits of switching to nebuliser therapy when a patient’s symptoms do not improve with an appropriately used handheld device.
Mahler also addresses the impact of mucus overproduction in patients with COPD, highlights therapeutic strategies including nebulised agents and positive expiratory pressure (PEP) therapy, and introduces a new interactive COPD Inhalation Device Selection Tool designed to help healthcare providers (HCP) to make tailored, evidence-informed choices for their patients.
Support statement: This article was sponsored by PARI GmbH.
Disclosures: Mahler has royalties or licenses with Johns Hopkins University Press as an author and pharmaceutical companies for the use of the Baseline Dyspnea Index and Transition Dyspnea Index in clinical trials; has received advisory board consulting fees from AstraZeneca, Boehringer Ingelheim, Theravance, Verona, and Viatris; and has other financial or non-financial interests for an educational website for those with COPD and their families.
Disclaimers: The opinions expressed in this article belong solely to the named interviewee
Acknowledgements: Writing assistance was provided by Nicola Humphry, Nottingham, UK Original Citation (if required): EMJ. 2025;10[2]:36-43. https://doi.org/10.33590/emj/WTFF9955
Keywords: Chronic obstructive pulmonary disease, COPD, inhaler, nebuliser, mucus, inhalation device.
480
m
It is critical to ensure that any inhaled drug reaches the site of action in sufficient quantity to exert the desired therapeutic effect.1 To optimise the benefit-risk ratio of inhaled therapy, the most suitable device should be selected.4
To discuss these issues, the European Medical Journal sat down with Donald A. Mahler, a pulmonologist with extensive experience and expertise in COPD, based at Valley Regional Hospital in Claremont, New Hampshire, USA.
Interviewee: Donald A. Mahler1,2
1. Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
2. Valley Regional Hospital, Claremont, New Hampshire, USA
Inhalation devices and factors affecting selection
Mahler outlined the differences between currently marketed inhalation devices, highlighting patient challenges and how they should inform device selection.
Numerous publications have shown that not all inhalation devices are suitable for the treatment of all COPD patients. This can result in poor patient outcomes. Can you share your perspective of this issue?
Inhaled therapy in COPD is delivered via four principal device types: pressurised metered-dose inhalers (pMDI), dry powder inhalers (DPI), soft mist inhalers (SMI), and nebulisers.5 While drug availability is an important consideration, effective treatment hinges on aligning the device with individual patient factors.5 For HCPs, selecting the optimal device can be complex;5 with each system presenting unique handling requirements, physiological demands, and logistical considerations.
Key distinguishing features of inhalation device types:
pMDIs
Deliver medication in aerosol form using a propellant5,6
Handheld; compact and portable6
Require coordination between device actuation and slow, steady inhalation6
The use of holding chambers can help to optimise lung deposition6
Breath-actuated pMDIs have been developed to provide better drug deposition at low flow rates, but drugs that can be used with them are limited5,6
Deliver dry powdered medication, usually attached to a bulking agent to improve flowability5
Handheld; compact and portable6
Do not require coordination between device actuation and inhalation6
Require strong inspiratory flow to de-aggregate the powder into respirable particles5,6
Effectiveness can be affected by factors such as ambient humidity6
DPIs
Deliver a prolonged, fine mist of medication using a spring mechanism5
Handheld; compact and portable6
Requires coordination between device actuation and slow, steady inhalation5
SMIs
Deliver a liquid medication as fine aerosol for inhalation through a mask or mouthpiece6
Do not require coordination between device actuation and inhalation as the patient uses tidal breathing5
Compared to handheld devices, nebulisers are larger, require a power source and regular maintenance, and may have longer administration time6
Breath-enhanced and breath-actuated nebulisers have been developed to improve efficiency by delivering more medication during inhalation and minimising waste3,5
Nebulisers
Studies show that up to 87% of patients with COPD make at least one inhaler technique error with pMDIs.7
It is believed that these errors restrict delivery of the inhaled medication into the lower respiratory tract,5,8 resulting in an increased risk of COPD exacerbations, worse health status, overuse of inhaled corticosteroids, and frequent hospitalisation.3,5
Key distinguishing features of inhalation device types:
pMDIs
87
%
In addition, at least half of patients with acutely exacerbated COPD do not reach optimal peak inspiratory flow (PIF) for DPI usage.9,10
This may result in worse COPD-related symptom burden, and a greater likelihood of COPD-related hospital readmissions.9,11
DPIs
What key patient-specific factors influence the choice of an optimal inhalation device? How can HCPs assess and prioritise these factors to ensure effective therapy?
HCPs should consider three key questions when selecting an inhalation device to prescribe:
The answers to these questions can narrow down the most appropriate inhalation devices for the patient.5,12 For example, nebulisers may be the most suitable devices for patients with impaired cognitive function or poor manual dexterity, and DPIs are unlikely to be suitable for patients with suboptimal PIF.5,12
It is important to teach patients with COPD to use their prescribed inhalation device correctly, and this can include the use of the “teach-back” approach, handouts, and training videos.4
If a patient reports little symptom improvement with the use of their current inhaler, they should be asked to demonstrate their inhaler technique. If they are using their inhaler correctly but not getting any benefit, their HCP should consider switching to a different inhalation device.5
Nebulisers are typically prescribed when patients are unable to use handheld devices correctly, due to impaired cognitive function, poor manual dexterity, or suboptimal PIF, or when a handheld device is not providing the patient with adequate symptom relief.5
The specific case of nebulisers
Patient preference is also a consideration,13 and Mahler explained that
Nebulisers are typically prescribed when patients are unable to use handheld devices correctly, due to impaired cognitive function, poor manual dexterity, or suboptimal PIF, or when a handheld device is not providing the patient with adequate symptom relief.5
some patients choose to use a nebuliser to administer on-demand short-acting bronchodilators, while others use a nebuliser for maintenance medication
How do different nebuliser types compare in terms of clinical efficacy and efficiency for COPD treatment, and to what extent should these factors influence device selection in clinical practice?
Nebulisers can be divided into three main types: jet, ultrasonic, and vibrating mesh, depending on the mechanism by which they generate an aerosol.3 Jet nebuliser systems can be continuous, or more efficient types include breath-actuated (delivery during inhalation only), or breath-enhanced (delivery increased during inspiration and reduced on expiration).14
The selection of a specific nebuliser should be based on the efficiency of the device, in order to optimise medication delivery.15-17
There have been a significant number of in vitro studies that demonstrate breath-enhanced and breath actuated nebulisers deliver medication more efficiently than continuous nebulisers,19-23 Comparative data on respirable drug delivery rate (RDDR) is available to help HCPs select the most effective device for their patients.
What limitations can HCPs face when selecting the correct nebuliser?
In many countries, long-acting beta agonists (LABA), long-acting muscarinic antagonists (LAMA), and inhaled corticosteroids are all available.3,5 The phosphodiesterase (PDE) 3/4 inhibitor ensifentrine was only available in the USA at of the time of writing.24 In some countries/regions, there is limited or no access to these COPD medications, which restricts the use of nebulisers to on-demand, rather than maintenance therapy.6,25,26
Case study of nebuliser therapy that improved outcomes for a Patient with COPD
A 67-year-old patient with moderate COPD (FEV1 58% predicted) was referred for pulmonology consultation following two emergency department visits within three days for acute dyspnoea. Treatment during these visits included short-acting muscarinic antagonist (SAMA) delivered via nebulisation, azithromycin, and a short course of oral prednisone (40 mg/day).
At the time of assessment, the patient reported persistent shortness of breath during minimal exertion (e.g., walking between rooms). Routine testing revealed normal alpha-1-antitrypsin levels, and a clear chest X-ray. Maintenance therapy consisted of a LABA/LAMA combination via SMI, and the patient reported frequent reliance (6–8 times daily) on a SABA pMDI, with limited symptom relief.
Based on clinical history and persistent symptom burden, the patient was prescribed a combination SAMA/SABA therapy via jet nebuliser for on-demand use, while continuing their existing maintenance regimen.
At a follow-up visit 3 weeks later, the patient reported marked improvement in symptom control and overall satisfaction with the new inhalation strategy. This case highlights how transitioning select patients to nebulised therapy may enhance bronchodilation and reduce emergency care utilisation.
IMPACT AND OPTIONS FOR EXCESSIVE LUNG SECRETION
How does excessive mucus production in patients with COPD impact their respiratory function, quality of life, and clinical outcomes?
A subtype of COPD, chronic bronchitis is characterised by a productive cough caused by excessive mucus production,15 airway obstruction, and inflammation.27 These patients often report feeling that they cannot cough up the mucus in their lungs.
Excessive mucus production is increasingly recognised as an important factor in COPD, though its precise role in the pathogenesis of the disease is not fully understood.28-31 Recent studies have indicated that the presence of mucus plugs on CT scan is associated with increased mortality, higher exacerbation rates and lung function decline,32-35 demonstrating the importance of their management for optimal patient outcomes.
What are the treatment options for patients with COPD who experience excessive mucus production?
It is important to recommend smoking cessation as a simple and effective way to reduce mucus production among patients with COPD who smoke.4,36 Patients should also drink plenty of water, as this may help to hydrate and thin the mucus.
Lifestyle changes
Interventions
Although there is a lack of robust clinical studies to support the recommendation of specific interventions for excessive mucus production in COPD, several therapies have been considered.4 For example:
The use of mucolytic drugs has been shown to reduce exacerbations.4,31
Nebulised hypertonic saline is sometimes used to assist mucus clearance in patients with COPD.37-40
Oscillatory positive expiratory pressure (OPEP) therapy may improve mucus mobilisation.4,41,42
OPEP devices generate oscillating intra-thoracic pressure in the lungs, reducing the viscoelasticity of bronchial secretions and helping to move mucus plugs towards the central and upper airways.41
Interventions
Lifestyle changes
The COPD inhalation device selection tool
Mahler explained that there are some published tools or instruments available to support HCPs with the choice of inhalation device for their patients.4,12,43,44 He outlined the first interactive, open access tool that has recently been developed to address this need: the COPD Inhalation Device Selection Tool.45
How does excessive mucus production in patients with COPD impact their respiratory function, quality of life, and clinical outcomes?
The objective of the COPD Inhalation Device Selection Tool is to support HCPs in the personalised selection of an inhalation device to improve individual patient outcomes. The tool narrows down the suitable options for a patient, simplifying the HCP’s choices.
Upon opening the online interactive tool, the first screen displays a grid with cognitive function and/or manual dexterity on the x-axis and PIF on the y-axis, allowing HCPs to select the grid segment that best represents their patient’s profile.
Clicking on the appropriate segment reveals the most suitable delivery system option(s) for that patient.
Additional information is supplied in pop-up boxes to provide further guidance, such as the advantages and disadvantages of each device, and why one device might be more appropriate for their patient than another.45
A key advantage of the interactive selection tool is that it can be accessed on a laptop, an electronic tablet, or even a mobile phone. It could be used by a medical assistant to screen a patient and report the recommended devices to the HCP, potentially saving them some face-to-face appointment time.
The COPD Inhalation Device Selection Tool is available to all healthcare settings, yet it may be of particular value to primary care, supporting HCPs by simplifying the selection of the most appropriate device(s) for each of their patients.
Selecting the appropriate inhalation device is complex and highly dependent on patient-specific factors. The COPD Inhalation Device Selection Tool was developed to support HCPs in navigating this complexity, enabling more personalised, effective treatment, and ultimately improving patient outcomes.
Conclusion
Does the patient have sufficient cognitive function to follow instructions and use handheld devices?
Does the patient have sufficient manual dexterity to use the handheld device correctly?
Does the patient have sufficient PIF to de-aggregate the powder in a DPI?
Nebuliser efficiency depends on the respirable dose of medication that reaches the lungs per minute.17
The respirable dose is dependent on both the aerosol output of the nebuliser and the respirable fraction of the aerosol (the proportion of particles <5 µm).17
Therefore, the RDDR can serve as an objective measure to compare the efficiency of different nebulisers in delivering medication to the lower respiratory tract.17,18
Low RDDR Less active substance in the lungs per minute
High RDDR More active substance in the lungs per minute
Select an option above by clicking on it
YES
YES
Lung Secretion
If lung secretion is present, click "yes" For more information click on ⓘ
Nebulised saline and/or PEP device: Consider in patients who feel congested and/or have sticky mucus and/or mucus plugs present on CT scan.
Nebulised saline thins sticky mucus and helps patients to clear their airways. GOLD report recommends oscillating PEP therapy for mucus mobilisation. Mucus clearance treatments may improve symptoms and quality of life in COPD patients.
Nebulised saline | O-PEP
Chest congestion, sticky mucus, mucus overproduction, mucus plugging on CT scan
Nebuliser
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Report 2025 states that a nebuliser should be considered for patients unable to use pMDI with or without spacer, DPI, or SMI, or those who prefer nebulisers over other hand-held devices:
Consider maintenance nebuliser therapy if long-acting bronchodilators (LABA and LAMA), inhaled corticosteroid (ICS), or dual phosphodiesterase inhibitor (PDE3/ PDE4) solutions are available in your country.
Consider adding nebulized short-acting bronchodilators (SABA and SAMA) to inhaled therapy for patients experiencing acute or persistent symptoms.
SMI
SMI: Consider in patients with normal cognitive and manual capabilities, Patient‘s instructions should be: "Inhale slow and steady.“ Check manufacturer‘s instruction for more information.
Advantage: Portable, generally reimbursed. Disadvantage: Inhaled corticosteroids are not available in this device.
pMDI
pMDI: Consider in patients with normal cognitive and manual capabilities. Patient‘s instructions should be: "Inhale slow and steady.“ Check manufacturer‘s instruction for more information.
Advantage: Broad range of drugs and drug combinations available, portable, generally reimbursed. Disadvantage: High degree of patient's coordination required, relatively high carbon footprint.
Recommendations:
Use in COPD patients who feel congested and have sticky mucus, or have mucus plugs present on CT scan. Nebulised saline thins sticky mucus and helps patients to clear their airways. GOLD guideline recommends oscillating PEP therapy for mucus mobilisation. Mucus clearance treatments may improve symptoms and quality of life in COPD patients.
Select an option above by clicking on it
YES
YES
Lung Secretion
If lung secretion is present, click "yes" For more information click on ⓘ
Nebulised saline and/or PEP device: Consider in patients who feel congested and/or have sticky mucus and/or mucus plugs present on CT scan.
Nebulised saline thins sticky mucus and helps patients to clear their airways. GOLD report recommends oscillating PEP therapy for mucus mobilisation. Mucus clearance treatments may improve symptoms and quality of life in COPD patients.
Nebulised saline | O-PEP
Chest congestion, sticky mucus, mucus overproduction, mucus plugging on CT scan
Nebuliser
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Report 2025 states that a nebuliser should be considered for patients unable to use pMDI with or without spacer, DPI, or SMI, or those who prefer nebulisers over other hand-held devices:
Consider maintenance nebuliser therapy if long-acting bronchodilators (LABA and LAMA), inhaled corticosteroid (ICS), or dual phosphodiesterase inhibitor (PDE3/ PDE4) solutions are available in your country.
Consider adding nebulized short-acting bronchodilators (SABA and SAMA) to inhaled therapy for patients experiencing acute or persistent symptoms.
SMI
SMI: Consider in patients with normal cognitive and manual capabilities, Patient‘s instructions should be: "Inhale slow and steady.“ Check manufacturer‘s instruction for more information.
Advantage: Portable, generally reimbursed. Disadvantage: Inhaled corticosteroids are not available in this device.
DPI
DPI: Consider in patients with normal cognitive and manual capabilities, and optimal PIF. Patient‘s instructions should be: "Inhale hard and fast.“ Check manufacturer‘s instruction for more information.
Advantage: Broad range of drugs and drug combinations available, portable, generally reimbursed. Disadvantage: Patients require high inspiratory flow to de-aggregate medication. Some patients with COPD cannot achieve an optimal PIF.
pMDI
pMDI: Consider in patients with normal cognitive and manual capabilities. Patient‘s instructions should be: "Inhale slow and steady.“ Check manufacturer‘s instruction for more information.
Advantage: Broad range of drugs and drug combinations available, portable, generally reimbursed. Disadvantage: High degree of patient's coordination required, relatively high carbon footprint.
Recommendations:
Use in COPD patients who feel congested and have sticky mucus, or have mucus plugs present on CT scan. Nebulised saline thins sticky mucus and helps patients to clear their airways. GOLD guideline recommends oscillating PEP therapy for mucus mobilisation. Mucus clearance treatments may improve symptoms and quality of life in COPD patients.
Select an option above by clicking on it
YES
YES
Lung Secretion
If lung secretion is present, click "yes" For more information click on ⓘ
Nebulised saline and/or PEP device: Consider in patients who feel congested and/or have sticky mucus and/or mucus plugs present on CT scan.
Nebulised saline thins sticky mucus and helps patients to clear their airways. GOLD report recommends oscillating PEP therapy for mucus mobilisation. Mucus clearance treatments may improve symptoms and quality of life in COPD patients.
Nebulised saline | O-PEP
Chest congestion, sticky mucus, mucus overproduction, mucus plugging on CT scan
Nebuliser
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Report 2025 states that a nebuliser should be considered for patients unable to use pMDI with or without spacer, DPI, or SMI, or those who prefer nebulisers over other hand-held devices:
Consider maintenance nebuliser therapy if long-acting bronchodilators (LABA and LAMA), inhaled corticosteroid (ICS), or dual phosphodiesterase inhibitor (PDE3/ PDE4) solutions are available in your country.
Consider adding nebulized short-acting bronchodilators (SABA and SAMA) to inhaled therapy for patients experiencing acute or persistent symptoms.
pMDI + Valved Holding Chamber
pMDI + Valved Holding Chamber: Consider VHC in patients with poor hand-breath coordination and those using corticosteroids in pMDIs. Advantage: Reduced dysphonia, reduced oropharyngeal deposition. Disadvantage: Higher bulkiness, higher maintenance requirements compared to pMDI alone.
Recommendations:
Use in COPD patients who feel congested and have sticky mucus, or have mucus plugs present on CT scan. Nebulised saline thins sticky mucus and helps patients to clear their airways. GOLD guideline recommends oscillating PEP therapy for mucus mobilisation. Mucus clearance treatments may improve symptoms and quality of life in COPD patients.
Select an option above by clicking on it
YES
YES
Lung Secretion
If lung secretion is present, click "yes" For more information click on ⓘ
Nebulised saline and/or PEP device: Consider in patients who feel congested and/or have sticky mucus and/or mucus plugs present on CT scan.
Nebulised saline thins sticky mucus and helps patients to clear their airways. GOLD report recommends oscillating PEP therapy for mucus mobilisation. Mucus clearance treatments may improve symptoms and quality of life in COPD patients.
Nebulised saline | O-PEP
Chest congestion, sticky mucus, mucus overproduction, mucus plugging on CT scan
Nebuliser
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) Report 2025 states that a nebuliser should be considered for patients unable to use pMDI with or without spacer, DPI, or SMI, or those who prefer nebulisers over other hand-held devices:
Consider maintenance nebuliser therapy if long-acting bronchodilators (LABA and LAMA), inhaled corticosteroid (ICS), or dual phosphodiesterase inhibitor (PDE3/ PDE4) solutions are available in your country.
Consider adding nebulized short-acting bronchodilators (SABA and SAMA) to inhaled therapy for patients experiencing acute or persistent symptoms.
pMDI + Valved Holding Chamber
pMDI + Valved Holding Chamber: Consider VHC in patients with poor hand-breath coordination and those using corticosteroids in pMDIs. Advantage: Reduced dysphonia, reduced oropharyngeal deposition. Disadvantage: Higher bulkiness, higher maintenance requirements compared to pMDI alone.
Recommendations:
Use in COPD patients who feel congested and have sticky mucus, or have mucus plugs present on CT scan. Nebulised saline thins sticky mucus and helps patients to clear their airways. GOLD guideline recommends oscillating PEP therapy for mucus mobilisation. Mucus clearance treatments may improve symptoms and quality of life in COPD patients.
Select an option above by clicking on it
YES
YES
Lung Secretion
If lung secretion is present, click "yes" For more information click on ⓘ
Nebulised saline and/or PEP device: Consider in patients who feel congested and/or have sticky mucus and/or mucus plugs present on CT scan.
Nebulised saline thins sticky mucus and helps patients to clear their airways. GOLD report recommends oscillating PEP therapy for mucus mobilisation. Mucus clearance treatments may improve symptoms and quality of life in COPD patients.
Nebulised saline | O-PEP
Chest congestion, sticky mucus, mucus overproduction, mucus plugging on CT scan
pMDI + Valved Holding Chamber
pMDI + Valved Holding Chamber: Consider VHC in patients with poor hand-breath coordination and those using corticosteroids in pMDIs. Advantage: Reduced dysphonia, reduced oropharyngeal deposition. Disadvantage: Higher bulkiness, higher maintenance requirements compared to pMDI alone.
Recommendations:
Use in COPD patients who feel congested and have sticky mucus, or have mucus plugs present on CT scan. Nebulised saline thins sticky mucus and helps patients to clear their airways. GOLD guideline recommends oscillating PEP therapy for mucus mobilisation. Mucus clearance treatments may improve symptoms and quality of life in COPD patients.
Select an option above by clicking on it
YES
YES
Lung Secretion
If lung secretion is present, click "yes" For more information click on ⓘ
Nebulised saline and/or PEP device: Consider in patients who feel congested and/or have sticky mucus and/or mucus plugs present on CT scan.
Nebulised saline thins sticky mucus and helps patients to clear their airways. GOLD report recommends oscillating PEP therapy for mucus mobilisation. Mucus clearance treatments may improve symptoms and quality of life in COPD patients.
Nebulised saline | O-PEP
Chest congestion, sticky mucus, mucus overproduction, mucus plugging on CT scan
SMI
SMI: Consider in patients with normal cognitive and manual capabilities, Patient‘s instructions should be: "Inhale slow and steady.“ Check manufacturer‘s instruction for more information.
Advantage: Portable, generally reimbursed. Disadvantage: Inhaled corticosteroids are not available in this device.
DPI
DPI: Consider in patients with normal cognitive and manual capabilities, and optimal PIF. Patient‘s instructions should be: "Inhale hard and fast.“ Check manufacturer‘s instruction for more information.
Advantage: Broad range of drugs and drug combinations available, portable, generally reimbursed. Disadvantage: Patients require high inspiratory flow to de-aggregate medication. Some patients with COPD cannot achieve an optimal PIF.
pMDI
pMDI: Consider in patients with normal cognitive and manual capabilities. Patient‘s instructions should be: "Inhale slow and steady.“ Check manufacturer‘s instruction for more information.
Advantage: Broad range of drugs and drug combinations available, portable, generally reimbursed. Disadvantage: High degree of patient's coordination required, relatively high carbon footprint.
Recommendations:
Use in COPD patients who feel congested and have sticky mucus, or have mucus plugs present on CT scan. Nebulised saline thins sticky mucus and helps patients to clear their airways. GOLD guideline recommends oscillating PEP therapy for mucus mobilisation. Mucus clearance treatments may improve symptoms and quality of life in COPD patients.
Suboptimal
Optimal
Peak Inspiratory Flow
IMPAIRED
NORMAL
Cognitive Function and/or Manual Dexterity
Optimal
>60 L/min for low to medium-high resistance DPIs
>30 L/min for high-resistance DPIs
Suboptimal <60 L/min for low to medium-high resistance DPIs
<30 L/min for high-resistance DPIs
Disclaimer: The proposals of the device are based on the recommendations of international guidelines. However, the interactive Device Selection Tool does not replace the expertise of the treating healthcare professional.
Click here to learn more about Selecting the Inhalation Device Most Likely to Benefit Your Patients with COPD.
Select the optimal device for inhalation therapy for your patient by moving your mouse to the area of the chart that best describes your patient's level of cognitive function and/or manual dexterity, as well as their peak inspiratory flow. Click on the ⓘ fields for some guidance. Once you have made your selection, click on the relevant device for more details.
Interactive Device Selection Tool for COPD
Impaired
Cognitive: Dementia, intellectual disabilities, memory loss, trouble completing tasks, and/or difficulty following instructions
Manual: Impaired fine motor activities, tremor, reduced handgrip strength, arthritis
Example of a breath-enhanced nebuliser generating aerosol
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References cont...
References cont.