When optimizing patients’ overall COPD care, pharmacists often focus on the choice of pharmacotherapy. It is important to understand that this process is more than just choosing the ideal pharmacotherapy. There are significant unrecognized or underrecognized barriers to care that need to be identified and addressed.

It certainly is important to choose an initial therapy based on the GOLD report classification (group A, B, or E) and adjust as necessary in follow-up visits. However, there are many other variables to consider. If a patient is not able to fully adhere to, use, or access their medication, it can appear as though their disease is poorly controlled with the prescribed therapy. These cases often can masquerade as a patient not engaging in their own care or not adhering to their treatment plan, which cannot be further from the truth. Pharmacists are uniquely positioned to consider and improve aspects of COPD care that are consistently overlooked, such as access to care or therapy.¹

Approximately 22 different inhaler devices are available to deliver approximately 33 different inhaled therapies.^1,48 In addition, no delivery system has been shown to be superior to another when they are used appropriately.⁴⁹ It does not matter which device type is prescribed, so long as the patient is using it correctly. They all deliver medication to the lower respiratory tract when used appropriately.

Patient-to-inhaler mismatch has potential consequences on patients’ health status and exacerbation risk.⁵⁰ If they are not using devices appropriately—for example, they are not cleaning a nebulizer or using it appropriately—the medication will not get into the lower respiratory tract, where it is efficacious. This is akin to having a rash and putting a prescribed cream next to the rash, as opposed to on top of the rash. In these cases, patients are not reaping the optimal benefit from those prescribed medications, no matter if the pharmacotherapeutic class is correct.

Therefore, device selection should not be purely an HCP decision. It should be HCP guided and patient driven through shared decision-making. HCPs should match patients to their preferred device, and that preference could be based on affordability, accessibility, and their ability to manipulate the device effectively.⁵¹

A really good paper published in late 2023 by Don Mahler⁵⁰ spoke to the process of device selection, which subsequently informed recommendations in the GOLD 2024 report. In addition, it highlights the importance of asking yourself specific questions, such as those on the slide, on behalf of patients to guide device selection.

First, HCPs should ask if the class of medication is correct. If initiating therapy, consider the appropriate classification. If adjusting therapy in follow-up, consider guidance via the GOLD report’s treatable trait algorithms.

Next, HCPs should consider the ideal formulation and device for each patient. Ideally, you also would use a device to assess patients’ inhalation technique to pair them with the best option for them. Alternatively, if patients are already prescribed a device, HCPs may have them demonstrate their use on their device.

Of note: when considering a dry powder inhaler, HCPs should assess patients’ peak inspiratory flow rate to determine if it is sufficient to mobilize the medication into their airways at the sight of action.

Key principles to device selection include patient preference and prior experience. Consolidating the device type the patient is using is important, as well. We are fortunate to have several combination products available, and these should be used to simplify regimens. If possible, prescribe 1 device to deliver a medication or a combination of medications, which will help decrease the number of errors a patient may make in adhering to their treatment. Furthermore, this principle will ensure that the medication gets into the lower respiratory tract where it belongs—optimizing patient outcomes.⁵⁰

HCPs should avoid switching patients’ prescribed device unnecessarily. For example, when a patient transitions from a metered-dose inhaler to a dry powder inhaler or from a dry powder inhaler to a soft mist or slow mist inhaler, their inhalation maneuver/technique might mimic the old device, which would cause the medication to enter the back of the oropharynx, where it is of no benefit, vs the lower respiratory tract, where it is of benefit.

In another example, a patient is not getting any of the needed medication into her lower respiratory tract because her peak inspiratory flow rate is insufficient for a dry powder inhaler. Therefore, HCPs should consider the patient’s cognition, dexterity, hand strength, and coordination related to the selected device. Again, we want to observe those things in clinical practice—how a patient manipulates and handles each device type—and then select the device using shared decision-making.⁵⁰

HCPs also should consider the device size and portability, while keeping in mind the number of times per day it will be administered. Furthermore, always assess the availability of the device, its cost to the patient, and whether it will be covered by insurance (if the patient has insurance).

Over the past few years, there have been great advances in smart inhalers, and these may fit with some of our patients who are in tune with artificial intelligence or handheld devices such as smart phones. Again, it is important that device selection is made following a shared decision-making process, and all HCPs should be familiar with the devices they are prescribing.

Some patient factors to consider when selecting a device include minimizing the complexity of the device with a single regimen when possible. Simplifying regimens leads to greater adherence and better outcomes.⁵²

Again, consider patients’ cognitive ability, manual dexterity, and coordination. Poor technique and errors when using devices are more common with advancing age, as dexterity and cognition generally decrease with increased age.⁵³

Finally, if prescribing a dry powder inhaler, ensure that patients’ peak inspiratory flow rate is sufficient.

Peak inspiratory flow rates are an objective, quantitative measure of maximal airflow that is generated during inspiration. Dry powder inhalers require sufficient peak inspiratory flow to disaggregate and disperse a powder formulation into its respirable particles. Dry powder inhalers are designed like a cup or bowl that is full of powder, which is then exposed when a device is activated. It is not as simple as generating enough inspiratory force to get that powder out of the device itself. Enough inspiratory force should be generated to lift the powder from the bowl (or the blister pack) and disaggregate the medication from its carrier molecule. That carrier molecule is typically lactose, and that is why patients talk about a sweet taste in the back of their mouth when they inhale using these devices.⁵⁴

The optimal peak inspiratory flow rate for medium- to low-resistance dry powder inhalers is 60 L/min or greater. Suboptimal peak inspiratory flow rates are linked to poor COPD-related outcomes, such as persistent dyspnea and increased exacerbations.⁵⁵

Now, I will discuss device-specific characteristics that should be considered when selecting the appropriate device for patients.

Using metered-dose inhalers requires patients to follow approximately 10 steps, and I have seen patients typically miss at least 1 of those 10 steps. In addition, the metered-dose inhaler requires coordination between activation and inhalation, which some patients may not be well suited to meet. It also requires patients to perform a slow and deep inhalation, followed by holding that breath for approximately 10 seconds.⁵⁶

Soft mist inhalers require the same coordination as metered-dose inhalers, but the medication itself is propelled over 1-1.5 seconds. During that propulsion of medication, coordination with inhalation is key. As with the metered-dose inhaler, inhalation should be slow and deep, and the inhalation plus the breath should be held for 10 seconds.⁵⁷

Dry powder inhalers require a different inhalation maneuver, which ties back to one’s peak inspiratory flow rate. The inhalation must be forceful or sharp and deep. Patients will then need to hold their breath for a few seconds.⁵⁸

When using a metered-dose inhaler, specifically when correct performance or optimal performance is in doubt, HCPs can add a spacer or valve holding chamber to enhance the efficacy of the medication. If a patient is not capable of using a valve holding chamber, cannot afford it, or prefers not to use it, then a different device should be chosen.¹

The In-Check DIAL G16 measures peak expiratory flow rate and can be used in both the inpatient and outpatient settings. The results when using this device can provide helpful guidance in choosing the correct device for patients.⁵⁹

In reviewing adherence and technique literature, the majority indicate that approximately 80% of patients make at least 1 mistake when using an inhalation device, regardless of the chosen device.^60,61 Some of the most commonly noted mistakes or missteps are noted on the slide.

For dry powder inhalers, device preparation, inhalation maneuver, and breath coordination are common mistakes. Then, for metered-dose inhalers and slow mist inhalers, common mistakes include failure to fully exhale before use, improper inhalation maneuver, and failure to hold the breath once inhaled.⁵⁰ Nebulized therapy is preferred in patients who are unable to master the maneuvers required to adequately use an inhaler device.

Device technique education via experts on the healthcare team is critical for providing accurate inhalation and device education to patients. These individuals also should be accessible. It would be great to see the In-Check DIAL G16 tool used in every community-based pharmacy as a teaching tool, with pharmacists then reinforcing device-specific inhalation maneuvers.

The teach-back method has proven itself to be a very effective educational strategy. It is particularly effective when it comes to retention of provided device technique education.⁶²

Comprehensive assessment of patient access and adherence must be considered; inhaled therapies are very costly, which significantly limits access. Adherence to inhaled therapy is generally low (2%-60%),⁶³ but several things weigh into that lack of adherence that HCPs may not consider or that are underrecognized. It is important to note that adherence is more than a patient’s engagement in the care process and has a lot to do with access to a device—specifically, the cost of the inhaled therapy and the patient’s device technique. If patients are using improper device techniques, they may be unintentionally nonadherent.⁶⁴

Pricing reform is desperately needed. For patients without insurance or those who find themselves in the donut hole of prescriptive care, these LABA, LAMA, and combination devices range from $300 to $1,000 in out-of-pocket costs per supply. Pharmacists should be aware of the costs of the prescribed inhaled therapy and should be equipped to circumvent cost as a barrier to care. Many inhalers are not available in generic form, which limits the ability to decrease costs by simply switching therapies.⁶⁵ Therefore, patient assistance programs may be one of the best options to mitigate costs as a barrier to care.

By improving adherence and access, we can start to improve outcomes. Persistent dyspnea, frequent exacerbations, and enhanced inhaler technique can improve COPD-related care.⁵⁵ Outcomes include improved FEV₁, symptom burden, and exacerbation frequency, as well as reduced healthcare costs.^66-68

There are several contributors to COPD-related barriers to care, including inadequate transitions of care. These can be affected by poor communication, not engaging with patients, and fragmented healthcare systems. As discussed previously, we know that there are many financial-related barriers for patients and the healthcare system. In addition, necessary tools and resources may not be available in clinics for HCPs to provide optimal care. Many of these barriers require a system-wide approach to be fully eliminated, but there are many ways individual HCPs also can address them.

As with other chronic health conditions, many health disparities exist as barriers to optimized COPD care. To truly eliminate these disparities, HCP-driven interventions also must be aimed at the healthcare system at large. It is difficult, if not impossible, for health disparities to be fully addressed by an individual. Therefore, all HCPs must work to reduce these disparities for them to be addressed within a system.

When considering the etiology of COPD, there are region-specific concerns and resources, so it is important to tailor interventions to patients’ demographics as needed. Remember, more people in the Midwest and Southeast smoke compared with Western states.⁷ In addition, looking at the Appalachian region, many people still use of biomass fuel for heating and cooking.⁶⁹

Economic resources are limited in certain areas of the country (urban vs rural). Regions may shape an HCP’s assessment or enhance clinical suspicion of COPD and its related diagnosis.

As shown on the corresponding slide, efforts to decrease healthcare disparities can be designed at various levels: patient, HCP, or system. Resources, such as enhanced educational offerings and environmental mitigations, can be beneficial at the patient level.

HCPs should engage in training to reduce their implicit bias and adjust clinic policies as needed. In addition, diversity and inclusion in healthcare are critical to ensure that HCPs are representative of the communities in which they serve, which can have a large, community-wide impact. Therefore, recruitment, admission, hiring, mentoring, and promotion practices all should be considered in terms of meeting these goals.

Finally, addressing health disparities at the system level may include enrolling more diverse participants in clinical trials, modifying EHRs, and enacting informed policy change.

Navigating financial barriers to care will differ based on patients’ financial and insurance status.

For any type of insurance, a first good step is to review the formulary coverage and step-therapy directions ahead of prescribing or recommending a treatment. EHRs now have some capacity to provide insights about which agents in a particular class will be covered via patients’ insurance. If a desired therapy is not covered, the payer may require a prior authorization, peer-to-peer consultation, or appeal letter in the case of a denial.

For commercially or privately insured patients, many manufacturers of brand-name agents will offer co-pay assistance cards. These can be found their respective website or at NeedyMeds. Co-pay cards often are not available for patients on Medicare or other government-funded insurance.

However, these patients, as well as those without insurance, can be eligible for applicable patient assistance programs to get their therapies fully covered. Those on Medicare may qualify only once they have reached the coverage gap, also known as the donut hole. HCPs can access this information on the Medicare website by entering the patient-specific information. Determining coverage status can prove to be overwhelming for patients, particularly older adults, but HCP efforts to educate them about these resources and assist in submitting applications is incredibly helpful. A good website to find up-to-date resources is NeedyMeds. Lastly, some patients on Medicare also may qualify for dual coverage with Medicaid or additional assistance via Extra Help.

Then, for those who are uninsured, free medical clinics and pharmacies are a great resource when addressing access and financial issues.

When combining all the principles discussed thus far, HCPs can consider this as a model for best practices in improving COPD care. Central to exemplary care delivery is an effective multidisciplinary team. Regardless of your clinic size or location, there should be a multidisciplinary approach to the care of patients with COPD. The tasks handled by the multidisciplinary care team appear in the left-most bubble of the slide. Ensure that there is comprehensive, affordable care for patients, including discharge bundles, 24-hour calls from the hospital after discharge, prompt follow-up with outpatient providers in 7-10 days, smoking cessation counseling, and device instruction.⁷⁰ 

One of the things that came to light during the COVID-19 pandemic is that home visits do not need to be only in-person visits. Instead, these can be facilitated virtually as telehealth sessions. The benefits of telehealth are expanded access to care for patients and reduced resource requirements for the healthcare team.

The GOLD report has done a wonderful job of addressing comorbidities to improve COPD-related outcomes. HCPs should screen for and assess a patients’ comorbidities, including cardiovascular disease, lung cancer, and depression and/or anxiety. Finally, pharmacists and respiratory therapists should be included and empowered to provide their expertise on the multidisciplinary care team.¹

At each stage in COPD care, HCPs need to assess patients’ risk, ensure that patients and/or caregivers are educated on the disease, and engage patients in shared decision-making. There are several great resources for improving transitions of care, such as the Transition of Care Checklist at copdcare.org.⁷⁰

With a multidisciplinary care approach, we need to ensure 360° accountability, and communication among HCPs and patients is paramount. As pharmacists, we are integrated into many healthcare settings and may have varying roles in this approach.

Inpatient pharmacists need to ensure that patients are appropriately staged and managed per their phenotype or treatable trait. Ensure that the right pharmacotherapies are chosen. In addition, the care process may start with us, so changing therapies ensures that patients can use the device when they leave the hospital.

In the ambulatory care setting, pharmacists should ensure that the most current GOLD report recommendations and other recent literature are considered. Sometimes this may include educating fellow HCPs about current standards—again, ensuring optimal pharmacotherapy and device selection for each patient, as well as addressing any issues with adherence.¹

In the community setting, these pharmacists likely have the greatest access to patients. Patients come back to the community pharmacy month after month for their maintenance therapy. Every time a patient comes to a community pharmacy, as allowed by one’s workflow and burden of work, the pharmacist should visit with the patient and assess his or her symptoms, annual exacerbation rate, and device technique.

Finally, creating a COPD action plan with patients can provide them with the confidence and tools they need to better self-manage their condition. Encouraging a patient to adhere to an agreed-upon COPD action plan goes a long way in optimizing patient care. The slide shows an example, where one has green, yellow, and red days, with directions patients should follow based on their current COPD control and symptoms.

COPD action plan reprinted with permission of the COPD Foundation.