Most people with asthm,a who use a DPI maintenance inhaler should and can use a DPI SABA as a reliever for breakthrough symptoms and for exacerbations, as the vast majority of people hospitalised with exacerbations of asthma or COPD are able to inhale at the correct inspiratory flow rate to use DPIs, especially the Easyhaler (see Ville A Vartiainen, Federico Lavorini, Anna C Murphy & Klaus F Rabe (2023) High inhaler resistance does not limit successful inspiratory maneuver among patients with asthma or COPD, Expert Opinion on Drug Delivery, 20:3, 385-393, DOI: 10.1080/17425247.2023.2179984).  Most people used MDI incorrectly on admission.

A MDI+Spacer SABA should be prescribed for those people who use a pMDI maintenance inhaler.

There maybe a minority of people with asthma who might need a MDI+spacer as an exacerbation pack. I would consider in those with a history of very severe / near fatal asthma, and those who are adamant that they need one for exacerbations.

There may be a need to consider the diagnosis and whether this is true asthma.

Later in 2023, it is thought there may be a ICS/LABA that obtains a licence for PRN only use, in line with GINA guideline recommendations.

NEXThaler, Easyhaler and Turbohaler all reservoir DPI devices, and load each dose by vertical drop via gravity, so must be loaded/primed in the upright position. Each device has a dose counter, and there are no data to say one is better than the other.

Inhaler technique videos are available at: https://www.asthma.org.uk/advice/inhaler-videos/

Eosinophil counts >0.3 in severe asthma helps identify people with severe eosinophilic asthma phentoypes who may be eligible for certain biologic therapies if they continue to exacerbate at least 3-4 tims a year/

Realistically it’s hard to get everyone to use a placebo inhaler. Check technique with their usual inhalers during asthma reviews.

For new prescriptions, use your own placebo devices to demonstrate good inhaler technique and tell them to ask their community pharmacist to check their inhaler technique – add a script note to ask the pharmacist do do this via their commissioned New Medicines Services.

MART therapy may be an option for these patients, if they understand the rationale, and allows them to adjust their dose according to their symptoms and prevent exacerbations.

Getting the diagnosis right is not always easy, I agree, especially, in the case of asthma, there isn’t one definitive test. With regards to DNA rates for spirometry the key is making sure the patient is on board from the outset, knows why they are doing the test, how it will help with diagnosis/get them on the right treatment pathway and ensure they have good information prior to the appointment and any questions are answered.
You make a very valid point regarding ‘normal spirometry’. The most important factor in making a diagnosis of asthma is testing the patient while they have symptoms and ideally before any medication. Capture a PEFR in surgery, make sure they have a PEFR metre at home from the outset of suspicion, know how to use it and record in their diary. So often it also comes down to a really good history and examination. Spirometry can be useful if you have good access and it can be done while they are symptomatic and have access to trained staff who can perform and interpret. FeNO is just one part of diagnosis and will only be positive in patients who have eosinophilic asthma i.e.about 60% of patients. Again a normal FeNO, just like spirometry, does not rule out asthma. It is a useful tool in the right hands but can be dangerous if used without adequate training/results taken out of context. The machines are also expensive and likely not needed in every GP practice. We are looking into FeNO provision across West Yorkshire.

Education is needed to advise on the benefits – better drug delivery, and people are gnerally more likely to use correctly. Reasure that the higher resistance is good – even during exacerbations, as doses are delivered at lower inspiratory flow rates.

most people use MDI incorrectly, so they have to double up the dose to get the benefit they should experience with the first dose (and maybe don’t realise there would be a better response).