Table 5 Devices for delivery of combination bronchodilators

pMDI

Drug is dissolved in propellant (generally HFA). When activated, a valve system releases a metered volume of propellant containing the medication

Can be more cost-effective than DPIs [84]

Can be difficult to synchronize actuation with inhalation [89, 90]

Pearl inhaler for glycopyrrolate + formoterol (Pearl Therapeutics) [86]

High fine-particle fraction, leading to better peripheral lung deposition

Evidence suggests fewer patients use pMDIs correctly without teaching [84]

Breath-actuated DPIs require no hand-lung coordination

DPI

Drug is delivered in powder form on inspiration by the patient; de-aggregation of the powder and generation of the aerosol provided by the patient’s inspiratory effort

Activated by inhalation, avoiding synchronization issues [84]

Can be more expensive vs MDIs [84]

Breezhaler® for indacaterol + glycopyrronium (single-dose, Novartis) [87]

Evidence suggests more patients have an accurate inhaler technique with DPIs without teaching [84]

Errors in inhaler technique can still occur [92]

Ellipta® Vilanterol (single-dose, GSK)

Pressair® for aclidinium (multi-dose, Almirall) [88]

Soft Mist™ Inhaler

Delivers a metered dose of medication as a slow-moving “soft mist” through a unique nozzle system, which should lead to improved lung and reduced oropharyngeal deposition vs other types of inhaler [85, 93]

Drug delivery is not dependent on patient’s inspiratory capacity or inspiratory effort, allowing consistent deposition regardless of lung function [85] and higher lung deposition in patients with poor inhaler technique [91]

Less clinical experience with this device; more safety data are required

Respimat® for tiotropium + olodaterol (Boehringer Ingelheim) [85]