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Clinical Pathway

Inhaler Decision Guide

Choosing the class; technique & switching troubleshooting

Field: RespiratoryCode: RS-03Updated: June 2026Reference: Lung Foundation Australia / National Asthma Council
Use this for the clinical thinking; pin the Lung Foundation Australia and National Asthma Council wall posters for device photos, brand names and PBS-restriction symbols (both updated annually). Over 70% of patients have an inhaler technique error — check at every visit; the wrong device can mean no treatment at all.

Choosing the inhaler class

Match the clinical scenario, then look up the brand on the wall chart.

1
Asthma, mild/new — ICS-formoterol PRN (AIR); replaces SABA-only reliever.
2
Asthma, frequent sx — ICS-formoterol MART; one inhaler for maintenance + reliever.
3
Asthma-COPD overlap — ICS-formoterol; commonly covers both, see the NAC chart.
4
New COPD, Group A — LAMA or LABA monotherapy; a single bronchodilator is enough.
5
New COPD, Group B — LABA+LAMA combination; outperforms monotherapy for symptoms.
6
COPD Group E/flares — LABA+LAMA; add ICS only if eosinophils ≥300 cells/µL.
7
Still flaring, frail, or cost-limited — triple therapy (single device), or consider Respimat/breath-actuated/generic options.
Exact brands & PBS codes — For device photos, brand names and the current PBS-restriction legend (unrestricted / restricted / authority symbols), use the live Lung Foundation Australia COPD chart and National Asthma Council Asthma & COPD chart — replace your wall copy at each annual update and read the legend printed on that version.

Technique by device

  • pMDI (use a spacer): slow, steady breath; wait ~30 sec between puffs; mistake: inhaling too fast, or towel-drying the spacer.
  • DPI (Turbuhaler/Accuhaler/Ellipta/Breezhaler/Handihaler): fast, forceful single breath; pierce capsule devices and listen for the rattle; mistake: inhaling too slowly.
  • Respimat: slow mist, no need to rush; mistake: inhaling before the press.
  • Autohaler: slow, steady breath; auto-triggers, so needs less coordination; mistake: stopping when it clicks.

Switching logic

  • Poor technique on a DPI → switch to pMDI + spacer (a DPI needs a fast inhalation).
  • Poor technique on a pMDI → switch to Autohaler or Respimat (breath-actuated).
  • Polypharmacy/adherence concerns → consolidate onto a single combination inhaler.
  • Still symptomatic on dual COPD therapy → step up to a single triple-therapy device.

ICS step-down in COPD

Routine ICS withdrawal in stable triple therapy is not generally recommended (GOLD 2025). Reserve step-down for ICS started inappropriately, no response, recurrent pneumonia, or significant side-effects — low blood eosinophils (commonly <100 cells/µL) support a low-ICS-responsiveness call. Step down gradually (ICS+LABA+LAMA → LABA+LAMA), document the rationale, and monitor for symptom worsening.

Safety

  • Check technique at every visit — the single highest-yield, lowest-cost intervention.
  • Multiple ICS-containing inhalers → check for unintentional duplication.
  • SABA reliever use > 1 canister/month signals uncontrolled asthma — review urgently.
  • Always document the rationale when stepping down ICS in COPD.

Red flags / refer

  • ≥2 oral corticosteroid courses in 12 months — step up the controller or refer.
  • Worsening despite triple therapy — refer respiratory; consider biologics or alpha-1 testing.
  • Diagnostic uncertainty between asthma, COPD, and overlap.
  • Complex regimens — consider an annual pharmacist MedsCheck and asthma/COPD educator referral.

RS-03 v1.0 · Reviewed Jun 2026 · Review Jun 2027

For health-professional use. Decision framework adapted from LFA and NAC charts — verify current device/brand detail on the live posters. Companion to the RS-01 Asthma and RS-02 COPD pathways. Confirm exact PBS codes and restriction levels at pbs.gov.au or nationalasthma.org.au.