Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Optimizing inhaler techniques in elderly patients with COPD

  Chronic obstructive pulmonary disease becomes increasingly difficult to manage as people age. Reduced hand strength, arthritis, impaired vision, cognitive changes and breathlessness can all affect whether an inhaler is used correctly. A prescription may be appropriate, yet the medicine may never reach the lungs in a useful dose.

  Optimizing inhaler techniques in elderly patients with COPD requires a practical assessment rather than a quick demonstration at the pharmacy counter. Clinicians need to match the device to the person, simplify the regimen where possible and check technique repeatedly in real-world conditions, including during an exacerbation or hospital discharge.

  Device type	Useful features	Common barriers in older adults	Technique priority
  Pressurised metered-dose inhaler	Widely available and familiar	Requires coordination between actuation and inhalation	Slow inhalation; consider a spacer
  Breath-actuated inhaler	Reduces hand-breath coordination demands	Still requires adequate inspiratory flow	Firm, steady inhalation
  Dry-powder inhaler	Portable and propellant-free	Needs sufficient inspiratory effort and correct loading	Fast, deep inhalation
  Soft-mist inhaler	Slow-moving aerosol may improve deposition	Priming and loading can be complicated	Coordinate button release with inhalation
  Nebuliser	Helpful when inhalers cannot be used reliably	Time, cleaning and equipment burden	Correct assembly and maintenance

  Why technique deteriorates with age

  Older Australians with COPD may have several barriers at the same time. Osteoarthritis can make it difficult to press a canister or twist a dose-loading mechanism, while tremor, weakness and reduced dexterity can interfere with capsule insertion. Visual impairment may make dose counters and small labels hard to read.

  Breathlessness also changes behaviour. A patient who feels panicked may inhale too quickly through a metered-dose inhaler, skip breath-holding or take several doses without waiting. Mild cognitive impairment can affect sequencing, and hearing loss may limit the value of verbal instructions. These factors should be treated as clinical information, not as a lack of motivation.

  A useful assessment begins with an open request: “Show me how you use it.” Watching the full process reveals errors that a yes-or-no question will miss. The clinician should observe preparation, inhalation, breath-holding, device cleaning and dose tracking.

  Matching the device to the person

  Device selection should reflect inspiratory flow, coordination, grip strength, eyesight, cognition and living arrangements. A dry-powder inhaler may suit an older person with good inspiratory capacity and reliable technique, but it may be unsuitable during severe airflow limitation or marked weakness. A pressurised inhaler with a spacer can reduce coordination demands and improve lung deposition.

  Spacers are particularly useful for people who struggle to synchronise actuation with inhalation. In Australia, they are familiar in primary care and hospital settings, although their size may affect portability. Patients should be shown how to assemble, clean and air-dry the chamber, and they should understand that several gentle breaths may be acceptable when a single deep breath is difficult.

  The local market includes multiple inhaler brands and device platforms, with availability and subsidy arrangements changing over time. Prescribers and pharmacists should check the current Pharmaceutical Benefits Scheme listing and avoid switching devices without providing a fresh demonstration.

  Teaching a reliable inhaler routine

  Education works best when it is brief, physical and repeated. Demonstrate the steps with a placebo device, then ask the patient to repeat them. Correct one or two critical errors at a time rather than delivering a long technical explanation that may be forgotten.

  For a pressurised inhaler, the essential sequence is to exhale away from the device, seal the lips, begin a slow breath and release the dose during inhalation. The patient should continue breathing in steadily, hold the breath if able, and wait before a second puff. A spacer can make the timing easier and reduce oropharyngeal deposition.

  For a dry-powder inhaler, the patient generally needs to prepare the dose, breathe out away from the mouthpiece and inhale quickly and deeply. Exhaling into the device can add moisture and affect the powder. These distinctions should be demonstrated rather than assumed, since techniques are not interchangeable between products.

  Managing medicines and comorbidities

  Many older adults use long-acting bronchodilators, inhaled corticosteroids or combination therapy alongside medicines for heart disease, diabetes and arthritis. A medication review can identify duplicated inhalers, confusing schedules and unnecessary complexity. Colour, written prompts and a consistent dosing time may help, provided they do not replace clinical review.

  Mouth rinsing after an inhaled corticosteroid can reduce local adverse effects such as oral thrush and hoarseness. Clinicians should also ask about palpitations, tremor, dry mouth and urinary symptoms, which may influence adherence. A patient who stops treatment because of side effects may require a device or regimen change rather than repeated reminders.

  Sleep-disordered breathing deserves attention when COPD coexists with obesity, cardiovascular disease or daytime somnolence. The relationship between nocturnal breathing problems and heart health is explained in this sleep apnoea risk resource, which can support a broader respiratory assessment.

  Checking technique beyond the clinic

  A technique that looks satisfactory in a consulting room may fail at home. Ask the patient to describe when and where each inhaler is used, whether doses are missed during outings and how the device is stored. In regional Australia, long travel distances and limited access to respiratory educators can make simple written instructions especially valuable.

  Community pharmacists can reinforce education during dispensing, while respiratory nurses, general practitioners and occupational therapists may address different barriers. Family members or carers should be involved with consent, particularly when memory loss, poor vision or limited hand function affects medication use.

  A written action plan should distinguish regular maintenance treatment from reliever use and explain what to do when symptoms worsen. It should include local emergency arrangements, since access to urgent care can vary between metropolitan areas such as Melbourne or Sydney and remote communities.

  Measuring whether the plan works

  Review should focus on outcomes as well as technique. Ask about breathlessness during daily activities, night-time symptoms, reliever frequency, exacerbations and confidence using the device. Where appropriate, inhaler dose counters, pharmacy records and symptom diaries can help identify underuse or overuse.

  Technique should be reassessed after a hospital admission, exacerbation, device change or noticeable decline in function. It is also sensible to review it at routine COPD appointments, because skills fade and patients often develop workarounds that reduce drug delivery.

  A short checklist improves consistency: correct preparation, correct inhalation speed, full dose delivery, breath-holding when possible, mouth rinsing where relevant, cleaning and dose monitoring. Documenting the specific error and correction makes the next review more efficient.

  Making care practical in Australian settings

  Australia’s ageing population includes people living alone, in residential aged care and in culturally diverse households. Instructions may need large print, translated materials or carer participation. In residential care, staff should know which device belongs to which resident and record assistance without taking over tasks the person can still perform.

  Local customs and routines matter. A patient who spends weekends at a family barbecue, travels between a city and a coastal town, or carries medicines during hot weather may need advice about portability, storage and access to doses. Device choice should fit those routines rather than rely on an idealised clinical setting.

  The safest plan is the one the patient can perform consistently. At the next medication review, have the patient bring every inhaler and spacer, demonstrate each device without prompting, and record one corrected technique error before renewing the regimen.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)