Commentary

The meta-analysis by Dolovich et al included 59 RCTs and showed equivalent improvement in pulmonary function with different inhaled medication delivery devices. Of particular importance was that no differences were noted in the effectiveness of nebulisation compared with delivery by MDIs with spacers. Use of MDIs alone was not studied in most of the reviewed trials, and evidence of their effectiveness when used without spacers is weak.

The findings have implications for practice in that other qualitative or individual level factors can be considered when determining which devices to prescribe. The authors note that patients’ skills in using medication devices were not assessed in these individual trials. This is an important consideration given the association between poor inhaler technique and reduced medication delivery and the improvements in inhaler technique that can be obtained with training.¹ The authors’ recommendation to select, when feasible, the same medication delivery device for different prescribed medications in a given patient is sound and practical advice in that patient education is limited to one device. This could facilitate patient skill acquisition and reduce variability in technique over time and between medications. The findings of equivalence of device effectiveness can eliminate both patient and provider concerns about out-of-pocket medication costs as lower cost options can be selected if appropriate. A further consideration in medication and delivery selection is patient preference. Given that medication delivery is equally effective, prescribing according to a patient’s preference may in fact improve treatment adherence. Rather than narrowing the options available to practitioners and patients, the results of this meta-analysis support a wide range of medication delivery options, such that other qualitative factors can be considered when making treatment decisions.