When to Reassess Inhalers and Consider Nebulizer Therapy

[Dr. Isaac Biney] (0:00 - 0:05) 

The number one reason why people's diseases are not controlled is because of poor inhaler technique. 

[Dr. Jill Ohar] (0:06 - 0:09) 

When the patient storms in and says, this doesn't work. 

[Dr. Isaac Biney] (0:10 - 0:29) 

And forcing the notion that holding the breath gives the drug a chance to get down into the lung and deposit where it needs to work. If you go on an exhale right away, what you inhale, most of it is going to come out. For me, if I were to select one frequently encountered, I run an inhaler technique, that would be what I would say. 

[Tralisa Willis] (0:36 - 1:44) 

Welcome to the Lung Health Champion podcast brought to you by the COPD Foundation. Each episode brings practical tips, expert insights, and a powerful lived experience. Today's episode is a part of our unobstructed series that focuses on technical insights from trusted healthcare practitioners. 

If you have lungs, you belong here. So let's take a deep breath together and get started. I'm your host, Tralisa Willis. 

And in this episode, we're focusing on device choice for inhaled medications, specifically when to reassess handheld inhalers and how to consider nebulizers as an evidence-based option for patients who struggle with technique or inspiratory flow. Inhalers can be extremely effective, but technique and flow rates drive lung deposition and real world results. We're joined today by two great guests. 

We have Drs. Isaac Beiney and Dr. Jill O'Hara. Dr. O'Hara, when you think about your COPD patients, what are the earliest clues that someone's inhaler isn't delivering medication effectively? 

[Dr. Jill Ohar] (1:45 - 2:39) 

Well, there are a few things. I think the first one is, is when the patient storms in and says, this doesn't work. That's just a good start off. 

I think the other thing is, is for the patients who are not as forthcoming, you find out that they're not refilling their inhalers, or they have some complaints where this tastes terrible, or they don't refill it because it, quote, tastes terrible. For ICS-containing medications, they end up with recurrence rush. They have a prolonged period of time where they say, my heart's beating, beating, beating, beating a lot. 

Now, that's common when you first start beta adrenergic, but usually that kind of side effect undergoes tachyphylaxis. It goes away in a week or two, but if they continue to have it, it means they're swallowing the drug, not inhaling it. 

[Tralisa Willis] (2:40 - 2:47) 

Oh, wow. Okay. And Dr. Beiney, what tips you off in the notes, the refill patterns, or even patient language? 

[Dr. Isaac Biney] (2:47 - 3:44) 

One common thing is a patient comes and says, oh, the medication doesn't work. This thing, it does nothing for me. I'm still short of breath. 

Sometimes you start a patient on an inhaler after they've come off an exacerbation or a flare that put them in the hospital or require them to get steroids and antibiotics. So you start them on treatment and you find out that those patterns are still continuing, that your drug hasn't really made any impact. The biggest thing with the medication for COPD, the inhaler, is that it makes the patient feel better, improve their lung function, and makes them breathe better. 

And so when I prescribe it and a patient comes back and says, it does nothing for me at all, then you question whether a patient is using the medication and inhale it the right way or not. So that is the biggest thing for me, I guess. 

[Tralisa Willis] (3:44 - 4:00) 

OK, and just to kind of add to that, what about adding spacers or valve holding chambers? Do you see those being very helpful and what barriers do you see or exist when accessing those? 

[Dr. Isaac Biney] (4:01 - 4:39) 

With the spacers, you know, they don't work for all inhaler types. It's only for the pressurized, metadosing inhalers. You can't use it for the dry powder inhalers. 

Unfortunately, in clinical practice, insurance dictates a lot of the things that we do. You're able to prescribe for somebody, you're not able to prescribe a specific type of inhaler. So if the patient does not have, if the patient is using a dry powder inhaler, you cannot give them a spacer. 

So even though it could help with drug delivery and everything, it depends on the type of inhaler the patient is using. 

[Dr. Jill Ohar] (4:40 - 7:21) 

I'd agree with that. And I'd like to add that often patients complain about the size. They like a PMDI because they can stick it in their pocket, go anywhere. 

I think it's important to kind of talk through the importance of that device in drug delivery and point out to the patients that most of the long-acting bronchodilators that we have today or once a day or twice a day. And so patients can just leave the meteredose inhaler plugged into the spacer on their sink in their bathroom. And when they get up in the morning and go to bed at night, it's there. 

And so they don't have to worry about carrying it around. The other thing is, is that in addition to dry powder inhalers, the slow miss cannot be used with a spacer. So it's only the meteredose inhalers that can be used with a spacer. 

I think the other thing that's kind of important too is explaining to patients. And this may get into the further discussion we're going to have about the idea of particle size, the rapidity of particle movement. And patients, if you explain that to them, it sticks with them better. 

And so meteredose inhalers, the spray is the particles are fast moving. They're big and they require an interaction with the atmosphere to slow down as well as the diluent and propellant. They need that time and interaction with the atmosphere to dry off, to leave just the actual drug particle down into delivery. 

So you want to evaporate the diluent and propellant and only get the drug down into the lungs. So the spacer gives the patient that space and that interaction with the drug so that the diluent and propellant can evaporate. It also provides the opportunity for the particles to slow down and then they don't impact on the back of the throat. 

And finally, it also impresses into the patient the idea that with a meteredose inhaler, the best way to get the drug down deep into the lungs is a slow, deep, deliberate breath whereby with a dry powder, it's hit again. So going through those with the patient sometimes helps them have a little bit better technique that stays with them longer. 

[Tralisa Willis] (7:22 - 8:08) 

Thank you for both of those wonderful answers. I'm hearing a lot surrounding inhaler technique. And so there are the differences, of course, within the inhalers. 

And technique is very important. A lot of responsibility falls on the patient to use the inhalers correctly. I've heard, Dr. O'Hara, I believe you said you know immediately when a patient says that it's not working or in the same Dr. Vaini and how you can recognize when a patient may not be using the inhalers correctly. So with that thought, what single inhaler technique error do you correct the most often? 

[Dr. Isaac Biney] (8:09 - 9:03) 

I think for me, the one that I've encountered the most is when the patient after the inhalation, they don't hold their breath for the 10 seconds. That is a requirement for all inhalers, regardless of what type it is. And sometimes they tell you that, oh, you know, I'm already having trouble breathing and you want me to hold my breath, you know, that kind of thing. 

So that is the biggest thing when I have to keep enforcing the notion that, you know, holding the breath, give the chance, give the drug a chance to get down into the lung and deposit where it needs to work. If you go on and exhale right away, what you inhale, most of it is going to come out. So that is for me, if I were to select one most frequently encountered error inhaler technique, that would be what I would say. 

[Dr. Jill Ohar] (9:03 - 9:56) 

I agree with that. I think, actually, and studies would actually underwrite that that comment. I think that many of the studies that have been done actually show that the failure to breath hold is is probably the most common error. 

Right up there with that is the failure to exhale fully before inhalation. And then the other one is confusing the hard and fast, the slow and deliberate. And so patients, you know, the dry powder, it's hard and fast. 

The meat dose inhaler, it's slow and deliberate. And because many patients may have a dry powder, for a maintenance therapy, but a meat dose inhaler for rescue, it's really difficult for them to figure out, it's just the slow and fastest, it's the hardest slow and deliberate. Which one do I be doing right now? 

[Tralisa Willis] (9:57 - 10:10) 

OK, so when you think about that, how are you able to assess inspiratory flow quickly to decide if a DPI is appropriate when in the office? And how does this assessment take into consideration bad breathing days? 

[Dr. Jill Ohar] (10:10 - 12:49) 

I think the big key here is is, you know, obviously, peak inspiratory flow. I think most clinicians, busy clinicians don't measure that. And I think eyeballing the patients is necessary, but not sufficient. 

What I mean by that is we know that elderly women, short stature, are the most common group of people to have low peak inspiratory flow rates. But we also know that people who are hyperinflated, so when you talk about bad days. So if you've got air trapping on a, quote, bad day, your PIF may be good on a good day, but bad on a bad day. 

We know that in just a random clinic that 50 percent of patients will do just fine. They have a great PIF. They can they can use their inhaler and it's kind of like a quarter and a quarter. 

A quarter will can do it, but don't routinely or don't always do it. And then about a quarter just cannot mount that force. And figuring out who that quarter is, certainly, you know, for sure. 

If you if you use a device to actually to measure that peak inspiratory flow, especially against the device that the patients are using, because each dry powder device has its own intrinsic resistance that's optimum and therefore it's optimum PIF against that resistance. And if you if you don't measure it, you don't know for sure. Now, how do you operationalize that? 

Well, if you have the the benefit of a nurse, a LPN, a respiratory therapist to measure that routinely on your patients, it's helpful. The other thing I like to do is I like to have patients demonstrate their inhaler technique for all their devices. Number one, it's helpful for the patient for for them to know you're checking and you can see whether they're using it effectively. 

The other thing is it's entertaining. It's it's amazing how patients will will incorrectly use their inhaler. One of my favorites is the smokestack technique, a metered dose inhaler. 

Patient inhales deeply, then puts the inhaler in their mouth, actuates it and exhales through it and all the mist goes shooting out the top of the mere dose inhaler like a smokestack. So it's entertaining. 

[Dr. Isaac Biney] (12:50 - 13:38) 

In my clinic, we don't do a formal assessment of the peak inspiratory flow. It's basically, as Jill said, the eyeball technique. You look at the patient, you look at their pulmonary function, test how deranged their pulmonary function is, and you kind of make a judgment call as to whether you think that they will be able to to have their inspiratory force to need that for for the use of the DPI. 

And then you have them demonstrated in the clinic for you. And you find out that those who have a hard time with it, they would, you know, struggle to with the technique of the DPI. And that might give you the indication that maybe you might be better with a different kind of device. 

[Tralisa Willis] (13:39 - 14:13) 

Thank you both. We know that many clinicians utilize a pathway of sorts, as you both have really have shared with us, in which you decide which type of medication is needed, what the dosage is, as you shared assessing inhaler technique. And if medication delivery remains unreliable over multiple visits, try trial of a nebulizer formulary. 

You've both kind of walked us through a bit of your personal decision tree. When you start a nebulizer trial, what do you document so that the next clinician understands your reasoning? 

[Dr. Jill Ohar] (14:14 - 15:31) 

I think even before that, I want to play off of what Isaac said earlier, and that is insurers and the constraints that insurers put on us. So often, if you want to start a nebulized medication, you have to have information in the chart as to how it was you assessed the patient failed the desired product and device of the insurer. And so that's where I believe, you know, having a formal assessment using the in check dial is helpful because it's a firm number where you can go to the insurer and say, hey, you know, this guy just can't do it. 

He cannot use it or she cannot use a dry powder. I think, you know, some of the other things we've already discussed, which is like recurrent exacerbations. It's another thing you'd want to document to the next clinician, but also for the insurer, more importantly, the insurer cat score. 

You know, despite adequate medicine, consistently high cat scores would be helpful. Isaac, what do you think? What are they? 

[Dr. Isaac Biney] (15:31 - 16:47) 

I agree. And, you know, then when you're treating COPD, the goals of treatment is, you know, make the patient feel better, improve symptoms and reduce exacerbations. So once you find the patient on, say, maximum therapy with one device and you're still having the same issues, then your clinical judgment say, OK, maybe I need to try something else. 

So it's like you you are you. So what you document that patient is on maximum therapy. And yet I'm still dealing with recurrent exacerbations and hospitalizations. 

I may need to do something different. And based on your clinical assessment of the patient, you can kind of tell that, OK, this is probably maybe they have some dexterity issue. So you know that the meta dose inhaler is not working for them. 

Poor lung function and a lot of air trapping. So the inspiratory flow generation is an issue for them. Then it's like, OK, with all these constraints, and I think that this is going to be the right medication for the patient. 

And so that is, I guess, how you go through documenting why you ended up with that device choice. 

[Tralisa Willis] (16:48 - 17:10) 

From the patient's viewpoint, how do you all frame this information? You know, when you're speaking to your patient, I'm about a necessity to maybe change the inhaler device or take a different route. How do you frame that information so that the patient doesn't view the device change as a step backwards in their health or even as a personal failure? 

[Dr. Jill Ohar] (17:11 - 19:11) 

Well, again, I think it's important to assess what what are the patient attributes and Isaac already touched on this concept. A lot of times people say to me, what is the best inhalation device? And I say there is no one best device. 

Each has its own attributes. So each is outstanding in its own right. But each also has its own set of warts and blemishes. 

So understanding that first and Isaac touched on this concept of dexterity, cognition, infantry force slash flow, which are essentially the same thing. And in assessing that and explaining those things to the patients, this isn't just a failure, it's what we call personalized medicine. You know, you're the guy, the unique person in front of me that's not like all the rest. 

And I want to individualize not only the drugs for you, whereby you say, you know, maybe just just long acting bronchodilators. No, you have a high unison fills a lot of exacerbations. Well, it's going to be triple therapy. 

So individualizing the drugs as well as individualizing the devices based on those attributes of the patient. So making sure that you understand that. And then I think what you're edging ever so closely to is the concept of when when you decide to bite the bullet and go with nebulizer therapy, how do you approach that with a patient? 

And generally, I think a lot of times patients actually broach it with you. They've had exacerbations, they've been to the ED. And what happens when they go to the ED, they get nebulizer treatments. 

And that, again, I think dovetails with what Isaac was saying earlier about. Doc, this doesn't work. Well, they come back from the ED and they go, they gave me this nebulizer. 

And I felt so much better. Why can't I have a nebulizer at home? And, you know, how many times I think of you heard that story? 

[Dr. Isaac Biney] (19:11 - 19:12) 

Oh, so many times. 

[Dr. Jill Ohar] (19:14 - 19:30) 

And then most patients actually have a nebulizer machine at home anyway. Because they're using it for rescue. So it's not that big a transition. 

As a matter of fact, it's often a very welcome one. So take it from there, Isaac. 

[Dr. Isaac Biney] (19:30 - 20:17) 

Yeah, that is very true. I mean, at that point, the patient just said like, I just want to feel better. Anything you can do to make me feel better. 

And so it's usually not a difficult conversation if you come to the point where you realize, OK, for this patient, this might be the right mode of delivery of the medication for them. Jill said they've already had the experience with a nebulizer in the hospital and they'll come back to the clinic and they say, hey, you know, I think this this is best suited for me rather than in here, rather than I'm using. And so can you prescribe it for me? 

So usually before, by the time you get to the point where now I'm converting, I may need to convert all your medications to nebulizer. The patient probably already has a nebulizer at home. 

[Tralisa Willis] (20:17 - 21:13) 

Thank you both for breaking that down. Understanding that the patient is now seeking your assistance based on prior health issues. And so we see that we know that correct medication and correct delivery are very important. 

And if the technique is impacting medication delivery, it is time to reassess the device. I want to move into another segment to kind of discuss nebulizers as an evidence based option and clear some of the misconceptions that surround nebulizers. Nebulizers turn liquid medication into small particle mist that can be inhaled with a normal breathing pattern over over several minutes. 

This can be helpful for people who are short of breath or fatigued and reduces the dependence on proper inhaler technique. Dr. Bynee, clinically, are there specific COPD phenotypes in which nebulizers perform best? 

[Dr. Isaac Biney] (21:14 - 22:32) 

I wouldn't say COPD phenotype per se, but it's, you know, when you take the patient as a whole, for instance, you have a patient who has like bad rheumatoid arthritis, for instance, affecting the hands and all that. So, you know, the coordination is going to be a problem. And sometimes even trying to use a spacer to mitigate that can be an issue. 

And then the same patient is so hyperinflated, very bad in spicaric capacity and all of that. So, you may give the dry powder inhaler a try for a bit, but if they see that it's not working, it's kind of like, you know, this is the patient who you may need to do a trial of a nebulizer therapy or the patient who has some degree of cognitive impairment. You know, obviously, you know that they're going to have a difficult time coordinating whatever inhaler they're using. 

So for me, it's not necessarily the COPD phenotype, but it's just the patient as a whole. And as Jela said earlier, like personalized medicine, what is going to work for this patient taking into consideration all their characteristics. 

[Tralisa Willis] (22:34 - 22:53) 

Thank you, Dr. Bynee. And to add to that, Dr. O'Harr, Dr. Bynee just shared a bit about, and so have you, about treating the patient and what each patient needs will vary. How do you decide between different types of nebulizers and how important is lifestyle in that decision for you? 

[Dr. Jill Ohar] (22:54 - 25:31) 

That's a really good question. And I think for the most part, you don't really get to choose different nebulizer machines, unfortunately. The home care company does that for you. 

What you can do is address special needs. That is to say that there are devices that can be used with very small portable devices that can actually be powered through a cigarette lighter. It's kind of interesting. 

It's very turnaround. You know, the very thing that brought you to this point will now deliver you from it. But for people who are working and, you know, would like to do their twice daily nebulizer treatments while in the car, because they do take longer than a few squirts or one deep inhalation from a dry powder. 

But learning to incorporate nebulizer use in your daily living. So pushing for that, for the busy professional who needs a nebulizer. For the people who are more stay at home, the nice thing about that, because when you're starting to think, who is that person? 

It's often somebody who may have an element of dementia, may be older, coordination issues. And so, BID dosing. So nebulizers, the treatments that can be set up by a caregiver for grandpa in the morning before the caregiver goes to work. 

And then in the evening, while the caregiver's either on their way home or before they have dinner. So that's another thing that tends to make nebulizer therapy easy for the patient population that for the most part needs it, the older, debilitated, demented, arthritic, those kinds of patients. As I say, for the patient who's mobile and needs to get going as it is, as to wherever it is, the duration of time, 10 to 15 minutes can be burdensome. 

But if you do it while you're in the morning commute, it's not burdensome at all. There are newer devices coming out on the market that will deliver treatments in a shorter period of time. But while they're available in the hospital, they're not available yet for home use, but they are coming soon to the market. 

[Tralisa Willis] (25:32 - 26:05) 

Oh, that's great to hear. I know that'll impact a great deal of lives. So I wanna move into some myths. 

There are many common myths that might hinder prescribing nebulizers. And so I wanna share a few of those with you guys. And I would appreciate if you could walk us through the accurate information for each, okay? 

So we're gonna start with myth number one. Inhalers are always superior. What is your evidence-based counter when the inhaler technique fails and their position is negatively impacted? 

[Dr. Isaac Biney] (26:06 - 27:39) 

I don't know of any evidence to say that inhalers are necessarily superior. You can say that they are more convenient and that you can just put it in your pocket, move around with it and stuff like that. But when it comes to treating the patient, and the research out there, it shows that there is really no difference in terms of when you look at measuring of lung function and how much lung function improves. 

But what is different actually is that patients who use nebulizers tend to say that they feel better than compared to those who use the inhaler therapy. So, I mean, that's the evidence out there. When I choose an inhaler over a nebulizer for a patient, it's more towards the convenience of it. 

And I look at the lifestyle of the patient. I think that this is gonna fit better into their lifestyle. And they are the type of patient who can effectively use an inhaler. 

But when it comes to the point where the patient really needs a nebulizer to feel better for you to fix the issues that are wrong with the patient, that is what I would say in that those who use a nebulizer report feeling better compared to those who use inhalers. 

[Dr. Jill Ohar] (27:40 - 30:41) 

I think this is a risky business. And I think Isaac's kind of mentioned that. There are some papers out there. 

There's an old paper over 10 years old looking at long-acting beta adrenergic some people with low PIFs got a lesser bump in their FEV1 after using MDI versus NIB. We put out a paper where people with a low PIF at the time of discharge after an exacerbation came back more frequently to the hospital than those who had an adequate PIF. There have been studies looking at insulin trend. 

And I think you'll Perry trying to show a difference of the problem is that neither of those drugs are available by meter dose inhaler or handheld device but similar products and trying to show that you get a better bump in the FEV1. And the results of those have been somewhat equivocal. We're looking right now at the fact that there is some literature out there. 

I think the first author is Melanie Hamilton looking at in vitro deposition, drug deposition and showing that it's quote adequate all the way down to a PIF in the thirties. And I think that that 60 threshold that was originally developed by an in vitro model and the point on the drug delivery PIF curve where there was an inflection in that curve and I think that illustration is available to you is 60 and that's how a sufficient PIF or adequate PIF or whatever was deemed to be 60. We're looking at patient outcomes as a surrogate for drug delivery. 

And it looks like it's in the mid forties where there's actually an inflection point in the curve of and these patient outcomes are hospital free days, mortality, one year mortality and one year readmission rate. So again, I think a lot of the studies that the hard data studies that may or may not have shown a true difference between a NAB and a handheld device were equivocal was because the threshold for PIF as inadequate or suboptimal was probably too high. 

[Tralisa Willis] (30:42 - 31:18) 

I'm gathering from both of you the most important thing is patient care, patient outcomes, does the patient feel better? And that is what is of the utmost importance. And now I have another myth. 

I'm gonna take this one to you, Dr. O'Hare. The myth is nebulizers are only for kids or emergencies. You've touched on this a bit as you've talked about the population that benefits most from nebulizers, but how do you reframe this for adults with COPD and other lung conditions who can't reliably, excuse me, use MDIs or DPs? 

[Dr. Jill Ohar] (31:19 - 31:33) 

Well, I think Isaac really beautifully discussed this issue of by the time a patient needs it, they've already, they're begging you. They know that their devices don't work. And he did a wonderful job, you know, covering this thus far. 

[Tralisa Willis] (31:33 - 32:12) 

I do agree, I do agree. So last myth that we want to cover. The myth is that they take too long to be practical. 

How do you implement a five to 10 minute routine into a real patient's mornings and evenings? Dr. O'Hare, you mentioned, you know, making patients that are mobile, you know, them having that time in the car to go ahead and do their treatment at that time. And then also those patients that are home, of course, they have much more time for their treatment and making that routine work in their daily treatments. 

But overall, how do you implement a five to 10 minute routine into a real patient's mornings and evenings? 

[Dr. Jill Ohar] (32:12 - 32:39) 

I think the things you really want to start out with is look at what is their routine? You know, what are you doing in the morning? What are you doing in the evening? 

And then find a little place to plug that in. And, you know, for the most part, I think again, the patients we're talking about, you know, a caregiver is crucial in helping to formulate that plan. Their input is critical. 

And Dr. Vaini? 

[Dr. Isaac Biney] (32:39 - 34:03) 

Yeah, to add to it, so, I mean, the truth of the matter is when an individual gets hit diagnosed with a sudden disease or whatever, depending on what it is, unfortunately, the reality is that you have to make adjustments in your lifestyle to accommodate what you need to do to help you feel better. I compare it to like the CF patient, for instance, and these are usually kids, high school kids, young professionals and all of that. And what they have to do every morning and evening, so many nebulized treatments and there are chest physiotherapy at it. 

It's kind of like a 30 minute plus routine that they've had to kind of adjust to incorporate that into their lifestyle to make it work because that's what they need to do to survive, to feel better and it's kind of the same thing. The patient comes to say, help me feel better. It's like, okay, this is what we need to do to help you feel better. 

How do we make it work with the kind of lifestyle that you have and you find a way to end. So, I mean, I think that it's something that can easily be achieved as long as the patient has the motivation, knowing that this is what I need to do to help me breathe better. And so I'm gonna find a way to, I'm incorporated into my routine. 

[Tralisa Willis] (34:04 - 34:17) 

Thank you both. Now, before we close, I'd love one final takeaway from each of you. What is the one thing that you want healthcare practitioners to take away from our talk today? 

We'll start with you, Dr. O'Hara. 

[Dr. Jill Ohar] (34:18 - 34:42) 

Hard and fast, slow and deliberate. I think that's a concept that's really lost on healthcare practitioners, that there is not just one technique, but dry powders, hard and fast. Meter dose inhalers and soft misses, miss, slow and deliberate. 

And Dr. Vaini. 

[Dr. Isaac Biney] (34:43 - 35:37) 

For me, it would be that, you know, a lot of times as healthcare providers, we are like, okay, this is what you need. I've prescribed it, that's it, I'm done. You've got the medication, you're supposed to feel better. 

But it is really important to know that the patient is actually using the medication correctly. And so when this patient keeps coming back with, I'm not feeling that or having exacerbation, you always have to ask the question, is the patient using the medication correctly? And if there is something that needs to change because of that, you know, work on it, rather than, okay, it's not working, we're gonna add this, we're gonna add this, we're gonna add this. 

Say the number one reason why people's diseases are not controlled is because of poor inhaler technique. And so that really needs to be looked at when you're seeing these patients. 

[Tralisa Willis] (35:38 - 36:38) 

Well, thank you so much, Dr. Vaini and Dr. Ohar for joining us today and discussing choosing the right device, helping us to understand when we need to reassess inhaler effectiveness and also debunking some of those myths that are out there surrounding nebulizers and inhalers. This episode focused on recognizing when inhalers are underperforming for patients and how nebulizers can provide an evidence-delined option for optimized care. We should proactively assess device fit at every patient contact. 

Can your patient consistently demonstrate appropriate inhaler technique and inspiratory flow to achieve optimal deposition? If medication isn't reliable, nebulizers can provide medication delivery even when patient barriers remain. If this episode resonated with you, check out the resources linked in the episode notes and share this episode with someone who needs to hear it. 

Thank you for listening to the Lung Health Champion podcast. 

[VO] (36:40 - 37:38) 

Thanks for listening to Lung Health Champion. If today's episode helped you breathe a little easier, be sure to leave us a rating or review on Spotify or Apple podcasts. It'll help the show reach other potential Lung Health Champs. 

If you have any questions about today's episode or have suggestions for topics you'd like covered on the show, feel free to reach out to us via email at share@COPDfoundation.org. For more insights on Lung Health, follow us on Instagram and Facebook by clicking the links in the show notes. For more info on what we do at the COPD Foundation, visit our website at COPDfoundation.org. 

And don't forget to subscribe or follow the show on your favorite podcast app to make sure you never miss an episode as we continue to empower everyone to breathe easy. This podcast is for educational purposes only and is not a substitute for medical advice. Always consult your healthcare provider with questions about your care.