Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease. The purpose of this leaflet is to give information on the medicines that are inside inhalers, the various types of inhaler device, and some general information about inhalers. Press the inhaler and, at the same time, take a deep breath in through your mouth. 20 Medicines Optimisation Guideline for the Management of Chronic Obstructive Pulmonary Disease. Dong Y-H, Chang C-H, Wu F-LL, et al. Accessed March 22, 2019.3. Medicines such as bronchodilators and inhaled steroids bring down swelling and open up your airways to help you breathe easier. Discussions of COPD and COPD … Pulmonary rehabilitation (PR) is a multidisciplinary … Rockville, Maryland: U.S. Department of Health and Human Services. Pharmacologic therapy for COPD is used to decrease symptoms, reduce the frequency and severity of exacerbations, and improve exercise intolerance. DPIs come in single-dose and multiple-dose devices. Online therapy has proven to help those dealing with isolation, depression, anxiety. The recommendations on non-pharmacological and inhaled treatment for chronic obstructive pulmonary diseases (COPD) are largely based on the National Institute for Health and Care Excellence (NICE) guideline Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NICE, 2019b] and the clinical guidelines Diagnosis and initial treatment of asthma, COPD and asthma-COPD overlap … of COPD (2020 Report), which aims to provide a non-biased review of the current evidence for the assessment, diagnosis and treatment of patients with COPD that can aid the clinician. COPD Diagnosis and Treatment Guideline 5 Pulmonary rehabilitation Many patients with COPD may benefit from pulmonary rehabilitation. Moreover, it’s hard to get the exact same dose each time you use the inhaler. Every MDI comes with its own instructions. Produced for use in Wandsworth … A preventer inhaler helps prevent symptoms and exacerbations of COPD. The 2020 American Thoracic Society Practice Guidelines recommend that anyone with COPD who experiences shortness of breath or exercise intolerance should be treated with both a LAMA and LABA, rather than either inhaler … 3  Flu shots help decrease your risk of COPD exacerbation, while the pneumonia vaccine helps prevent bacterial pneumonia, a common cause of COPD … Glaucoma, increased intraocular pressure, and cataracts have been reported with use of fluticasone/umeclidinium/vilanterol. QVA149 resulted in a statistically significant decrease in mild (15%, P = .0072) and moderate-to-severe (12%, P = .038) exacerbations compared with the glycopyrronium treatment group. INHALER TREATMENT GUIDELINES CHRONIC OBSTRUCTIVE PULMONARY DISEASE Prescribe by brand Walsall COPD SABA Short Acting Beta 2 Agonists LAMA Long Acting Muscarinic Antagonist LAMA + LABA in a combination inhaler ICS + LABA in a combination inhaler ICS + LABA+LAMA in a combination inhaler Adapted from GOLD 2019 MRC < 3 CAT < 10 MRC ≥ 3 CAT ≥ 10 ≥ 2 Moderate exacerbations or … Healthline Media does not provide medical advice, diagnosis, or treatment. The effect of air pollution on lung development from 10 to 18 years of age. Off-label . 1 NICE guideline [NG87]: COPD 2019 2. Chronic obstructive pulmonary disease (COPD) is a group of lung diseases — including chronic bronchitis, asthma, and emphysema — that make it hard to breathe. Raad D, Gaddam S, Schunemann HJ, et al. Drugs used to treat COPD The following list of medications are in some way related to, or used in the treatment of this condition. A spacer is also unnecessary if you use an SMI. 2017;72(9):788-795.11. Know how to use it. Calverley PMA, Anderson JA, Brook RD, et al. NICE has produced a COVID-19 rapid guideline on community-based care of patients with chronic obstructive pulmonary disease (COPD). May 2019 (Updated August 2020). Fluticasone furoate, vilanterol, and lung function decline in patients with moderate chronic obstructive pulmonary disease and heightened cardiovascular risk. The 2019 guideline update recommends a LABA/ICS combination for initial treatment in patients with an eosinophil count greater than 300 cells/µL or those with a history of asthma and COPD. Every so often the GOLD gang releases another update of their standard-setting GOLD guidelines. Inhaler selection should be individualized based on patients’ GOLD COPD classification, preference, ease of inhaler use, and cost. https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf. They are used 1 or 2 times a day, at the same time for each dose. Cochrane Database Syst Rev 2012;7:CD002991. Feb 2020. According to current guidelines, the inhaled … Cons: However, research has linked the tiotropium mist inhaler to a higher risk for death in people with COPD. Polosukhin VV, Richmond BW, Du RH, et al. These provide patients with more options to treat their COPD based on individual preferences. Adult COPD dose Inhalation of the content of one capsule once daily using the Ultibro Breezhaler inhaler. Guidelines is completely free for UK-based doctors, nurses, and pharmacists. Preventive measures recommended by the 2019 GOLD guidelines include vaccinations and smoking cessation. Most COPD medications work best when sent directly into the lungs through an inhaler. Patients receiving once-daily treatment with QVA149 or glycopyrronium were both double-blinded, while the once-daily tiotropium treatment group was open-label. Hold your breath for 5 to 10 seconds to get the medicine into your airways. The threshold for referral would usually be breathlessness equivalent to MRC dyspnoea grade 3. Copyright © 2000 - 2021 Jobson Medical Information LLC unless otherwise noted. The IMPACT trial aimed to assess the rate of COPD exacerbations in patients with GOLD grades 2-4 COPD during treatment with each therapy over 52-week periods. Patients’ symptom burden and risk of exacerbation are classified into GOLD groups A through D; this is used to guide patients’ therapy. Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide. Inhaled corticosteroids such as fluticasone and mometasone are also associated with superficial adverse drug events such as oral candidiasis (thrush), hoarse voice, skin bruising, and pneumonia.12 To mitigate these risks, patients should “swish and spit” after administration. Multiple-dose devices contain up to 200 doses. Our objective was to understand how the receipt of current guideline-recommended care influences outcomes in clinical practice. The Global Initiative for Obstructive Lung Disease (GOLD - because GIOLD sounded weird) is an international collaboration of experts in chronic obstructive pulmonary disease (COPD). Page . There are a variety of inhalers for the treatment of COPD such as SABA, LABA, SAMA, LAMA, ICS, and combinations of these. With an MDI, you have to time your breathing with the release of the medicine. FEV1 decline was found to be greater in current smokers, those with lower BMI, males, and patients with established cardiovascular disease. The novel inhalers on the market come in a variety of delivery devices such as Ellipta, Pressair, Respimat, and Neohaler. Short-acting bronchodilators (short-acting muscarinic antagonist [SAMA] or short-acting inhaled beta2 agonist [SABA]) should be prescribed to all patients for immediate symptom relief, regardless of their GOLD classification.1. For patients classified in Group C, initial therapy should consist of a long-acting bronchodilator; LAMAs are superior to LABAs regarding COPD exacerbation. Inhaled corticosteroids (ICS) combined with bronchodilators can reduce the frequency of exacerbations in some patients with chronic obstructive pulmonary disease (COPD). 1.1.5 Measure post-bronchodilator spirometry to confirm the diagnosis of COPD. Thomas Keller, MD . Wedzicha JA, Decramer M, Ficker JH, et al. COPD dry powders that can be used with a DPI include steroids such as Pulmicort and bronchodilators such as Spiriva: Every DPI comes with its own instructions. Consider Oxygen referral via COPD clinic if saturations below 92%  Standby antibiotics and oral corticosteroids for frequent exacerbator patients (advice can be found here). Learn more about the three most common types of inhalers used to treat COPD. Tudorza Pressair (aclidinium bromide) package insert. Keep track of the expiration dates on your medicine, and get a new prescription if your medicine expires. This type of inhaler can also be affected by humidity and other environmental factors. Respimat is a trademark that helps describe the SMI mechanism developed by the pharmaceutical company Boehringer Ingelheim. Epub 2020 Apr 9. Prescribe inhalers only after the patient has received training in the Before … St. Louis, MO: Almirall; 2012.16. There are many options of inhalers for COPD, so if you’ve tried to research them yourself, you might have been overwhelmed. An inhaler is a handheld device that delivers a puff or spray of these medicines straight into your lungs through a mouthpiece. Methods: To quantify the level of inhalation-device recommendations in clinical guidelines, a review was conducted by hand-searching national … Rx. Cons: On the other hand, you have to breathe in harder than you would with an MDI. The yearly influenza vaccine and the PPSV23 and PCV13 pneumococcal vaccines are recommended in all patients with COPD.2 PPSV23 is recommended for patients aged 19 to 64 years, and PCV13 is recommended for patients aged 65 years and older, administered at least 1 year after PPSV23. Drugs used to treat COPD The following list of medications are in some way related … Already have an … 2011;139(4):764-774.10. Close your mouth around the mouthpiece. OTC quit aids include nicotine gum, lozenges, and patches. Be aware of the potential risk of side effects (Including non fatal pneumonia) in people with … People in China with chronic obstructive pulmonary disease (COPD) are overusing inhaled corticosteroids and underusing non-pharmacological therapies such as home oxygen therapy, a study suggests.. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines classify a patient’s COPD group and provide first-line therapy options. You also get the same dose of medicine each time you use them. Practical Points to Consider During the Consultation: - Guideline is for primary care management of COPD NOTAsthma COPD Overlap Syndrome. Patients who develop exacerbations while on a LAMA/LABA may be escalated to a LABA/LAMA/ICS, including the once-daily inhaler fluticasone furoate/umeclidinium/vilanterol (Trelegy Ellipta). [2010] 1.1.7 Think about a diagnosis of COPD in younger people who have symptoms of COPD, even when their FEV1/FVC ratio is above 0.7. People in China with chronic obstructive pulmonary disease (COPD) are overusing inhaled corticosteroids and underusing non-pharmacological therapies such as home oxygen therapy, a study suggests.. Should you feel okay bringing your oxygen tank into the movie theater? https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdf. This Guidelines summary on the NICE guideline on COPD covers: diagnosing COPD; managing stable COPD (including an algorithm) follow-up of people with COPD; managing exacerbations of COPD. Learn more: Nebulizers for chronic obstructive pulmonary disease ». To use an Ellipta inhaler: Slide the cover down until a click is heard, breathe out gently (away from inhaler), put the mouthpiece in the mouth and close the lips, to form a good seal (but do not cover vents), breathe in steadily and deeply, hold the breath for 5 seconds, breathe out gently, and slide the cover upward as far as it will go to cover the mouthpiece.14, Pressair: Aclidinium bromide (Tudorza Pressair) is formulated as a Pressair device containing an inhalation powder. Thomas Keller . Here are some of the best free online therapy and counseling…. What do they mean? Chronic obstructive pulmonary … Patients with COPD typically present with progressive shortness of breath, a chronic cough or recurrent wheeze, and chronic sputum production. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2019 report. To help, here’s a guide to the different types of inhalers used in the treatment of COPD. Open the cap, after you’ve prepared the device following the manufacturer’s instructions. The bronchodilator drugs tiotropium (Spiriva Respimat) and olodaterol (Striverdi Respimat) both come in a soft mist. Wales COPD Management and Prescribing Guideline. In this guideline update, we highlight important and new findings related to pharmacological therapy of chronic obstructive pulmonary disease (COPD) that should change clinical practice … In Group D, a LAMA/LABA combination can be chosen as initial treatment in patients experiencing more severe symptoms, such as greater dyspnea and/or exercise intolerance. HFA is an abbreviation for hydrofluoroalkane, which is a safer propellant for the atmosphere than older propellants used in original MDIs. This review will summarize the updated 2019 GOLD recommendations on managing COPD, along with evidence and cost information on various inhalers.1, According to the GOLD 2019 Global Strategy for the Diagnosis, Management, and Prevention of COPD guideline update, first-line pharmacologic therapy depends on the patient’s GOLD classification (FIGURE 1.) There are no significant differences for the risk of pneumonia between fluticasone furoate/umeclidinium/vilanterol and LABA/ICS inhalers.6. Ask your doctor to show you how to use it. Inhalers are often used to treat chronic obstructive pulmonary disease … Our website services, content, and products are for informational purposes only. Using an OTC inhaler may mask a worsening of your condition and delay getting appropriate medical care. Correspondence. Breo Ellipta (vilanterol/fluticasone furoate) package insert. Umeclidinium (Incruse Ellipta) is a LAMA monotherapy inhaler that provides a once-daily dosing option for patients as compared with aclidinium bromide (Tudorza Pressair), which is dosed twice daily.14,15 With regard to LABA monotherapy inhalers, olodaterol (Striverdi Respimat) provides a once-daily dosing option for patients and is less expensive among other LABA monotherapies.16 Fluticasone furoate/vilanterol (Breo Ellipta) is a once-daily LABA/ICS combination inhaler.18 Note that fluticasone furoate/vilanterol received a new warning in January 2019 for both increased intraocular pressure and risk of glaucoma as well as hyperglycemia, which warrants additional monitoring in those with a history of type 2 diabetes mellitus.18. Inhaler selection should be individualized based on patients’ GOLD COPD classification, preference, ease of inhaler use, and cost. N Engl J Med. Improper inhaler technique and cost may pose a barrier to medication adherence. Classification of airflow limitation (grades 1-4) and symptom burden with exacerbation risk (groups A-D) is patient-specific and can occur in a variety of combinations. We’ll also show you how you can work with your healthcare provider and pharmacist to better … Effects of water-pipe smoking on lung function: a systematic review and meta-analysis. Chronic obstructive pulmonary disorder (COPD) develops over time as the small airways become inflamed due to the inhalation of cigarette smoke or other noxious particles. General Practice Price: dm+d browser (Nov 2019) North West London COPD Inhaler Guide version 3 Approved by NW London CCGs’ Prescribing … With the mouthpiece facing down, shake the inhaler for about five seconds to mix the medicine. Greenwood Village (CO): Truven Health Analytics. Take your medicine exactly as your doctor prescribed. For Group A patients, a short- or long-acting bronchodilator (long-acting muscarinic antagonist [LAMA] or long-acting beta2 agonist [LABA]) is recommended based on their effects on patients’ breathlessness. Analysis of chronic obstructive pulmonary disease exacerbations with the dual bronchodilator QVA149 compared with glycopyrronium and tiotropium (SPARK): a randomised, double-blind, parallel-group study. Stiolto Respimat combines the drugs tiotropium and olodaterol. COPD inhaler therapy should be individualized based on cost, patients’ preference, and their COPD classification. The main side effect of inhaled antimuscarinics includes dry mouth. Appropriate inhalation device selection is as important as drug choice but device-specific guidance appears to be lacking. Fiore MC, Jaén CR, Baker TB, et al. In future, … TABLE 1 summarizes the average wholesale prices of different inhalers on the U.S. market. Seemungal TA, Donaldson GC, Paul EA, et al. If you breathe in too quickly, the medicine will hit the back of your throat, and much of it won’t reach your lungs. List of inhalers used in COPD: When selecting type of inhaler, consider patient choice and inhaler technique. Updates in the Management of Clostridium difficile for Adults, Neuromuscular Blocking Agents: Use and Controversy in the Hospital Setting, The Pharmacist’s Role in the Treatment and Prevention of Acute Mountain Sickness. Research Triangle Park, NC: GlaxoSmithKline; 2013.15. If you don’t use inhaled medicine correctly, it won't help you. Research Triangle Park, NC: GlaxoSmithKline; 2013.20. Generally, the inflammatory and structural changes of the small airways increase with disease severity. Research Triangle Park, NC: GlaxoSmithKline; 2013.19. Yang IA, Clarke MS, Sim EHA, et al. It’s also necessary that you breathe in slowly and deeply. © 2005-2021 Healthline Media a Red Ventures Company. In addition to its appearance in the 2019 GOLD guidelines, a new warning was placed in the fluticasone/umeclidinium/vilanterol’s package insert for patients with narrow-angle glaucoma. There have also been reports of a small increase in cardiovascular events in COPD patients treated with ipratropium.10 However, in a large, long-term clinical trial in COPD patients, tiotropium added to standard therapies had no effect on cardiovascular risk.11. Appendix 4: NICE Inhaled Therapies Evidence Review..... 19 . Accessed March 24, 2019. Terms like HFA, Diskus, and Respimat appear in the names of many inhalers. Am J Respir Crit Care Med. With the proliferation of new inhaler devices, inhaler device poly-pharmacy is becoming an increasing problem amongst COPD patients and has a negative impact on outcomes (Bosnic-Anticevich 2017) A study of 16,450 COPD patients compared exacerbation frequency and SABA use of patients who were using similar style inhalers e.g. AWTTC accepts no liability in association with the use of its content in this or other publications. To use a Neohaler inhaler: Remove the cap, tilt the mouthpiece to open the inhaler, remove one capsule from the blister card, place the capsule into the capsule chamber, close the mouthpiece fully, hold the inhaler with the mouthpiece facing up and press both piercing buttons at the same time, release buttons, breathe out gently (away from inhaler), place the mouthpiece in the mouth, breathe in steadily and deeply, hold the breath for 5 seconds, breathe out gently, and remove the capsule from the capsule chamber.17. The 2019 GOLD guidelines include the once-daily LABA/LAMA/ICS combination inhaler fluticasone/umeclidinium/vilanterol. For Healthcare Professionals. Inhale the mist. Chest. First-line therapies are dependent upon a patient’s GOLD classification, as well as other patient-specific factors such as cost and type of inhaler. COPD drugs that come in an MDI include steroids such as Flovent HFA and combination steroid/bronchodilators such as Symbicort. Cases decreased slightly this past week but are still averaging about 207,000 per day. Learn more: COPD drugs: A list of medications to help relieve your symptoms ». Expert Rev Respir Med 2012; 6: 91–103. You don’t need to coordinate pressing the device and breathing in the medicine, and you don’t need to use a spacer. Identification and reduction of exposure to risk factors, such as cigarette smoke, air pollutants, and occupational fumes, are also important in treatment and prevention of COPD. Ridgefield, CT: Boehringer Ingelheim; 2015.21. Utibron Neohaler (glycopyrronium/indacaterol) package insert. … Deaths are still averaging more than 3,000 per day. It is important for the pharmacist to assess inhaler technique and understand how each inhaler is used with each follow-up or encounter with patients. The recommended dose is one inhalation … Cons: MDIs require you to coordinate between activating the medicine and breathing it in. 1. Thorax. Lipson DA, Barnhart F, Brealey N, et al. These results indicate a potential benefit in dual bronchodilation as a treatment option for patients with severe and very severe COPD. Encourage ALL patients to stop smoking. Stiolto Respimat (tiotropium/olodaterol) package insert. Among a cohort of patients with COPD with moderate hypoxemia who participated in the Long-term Oxygen Treatment Trial (LOTT), we determined the association of using an inhaled … Short-acting bronchodilators are the first-line inhalers for COPD, but as the disease progresses may not be enough to control symptoms long-term. Repeat the process if you need more puffs of the medicine. GOLD guidelines recommend flu and pneumonia vaccines for every stage of COPD treatment. Emphysema and chronic bronchitis are the most common forms of chronic obstructive pulmonary disease. It’s also harder to load the dose into the device. General Practice Price: dm+d browser (Nov 2019) North West London COPD Inhaler Guide version 3 Approved by NW London CCGs’ Prescribing Committees: Feb 2020 - Date of Review Feb 2022. Fluticasone furoate/umeclidinium/vilanterol was also shown to reduce the rate of hospitalizations when compared to umeclidinium/vilanterol therapy.6, Beta2 agonists (SABAs, LABAs) can produce sinus tachycardia and precipitate cardiac-rhythm disturbances in susceptible patients. Glycopyrronium 1 puff daily (Seebri®) Indacaterol/ glycopyrronium 1 puff daily … If you don’t use inhaled medicine correctly, it won't help you. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines classify a patient’s COPD group and provide first-line therapy options. Accessed March 22, 2019.4. Only Generics. Meanwhile, a reliever inhaler offers immediate relief from symptoms. Unlike an MDI, a DPI doesn’t use a propellant to push medicine into your lungs. Gauderman WJ, Avol E, Gilliland F, et al. TREATMENT GUIDELINES Australian Asthma Handbook: asthmahandbook.org.au COPD-X Plan: copdx.org.au INHALER TECHNIQUE How-to videos, patient and practitioner information nationalasthma.org.au Inhalers/MDIs should be used with a compatible spacer QVAR Inhaler † beclometasone 50mcg 100mcg• Montelukast Tablet a montelukast 4mg • 5mg • 10mg Generic … Continued 5 Tips for Using Inhaled COPD Medicine. Fundamentals of … Please register to continue reading this content. Turn your head away from the device and breathe out all the way. Hypokalemia can occur, especially when beta2 agonists are combined with thiazide diuretics, as can increased oxygen consumption in patients with heart failure, but these effects decrease over time.8,9, Inhaled antimuscarinics (SAMAs, LAMAs) are poorly absorbed, which limits systemic side effects. Diskus is a trademark that helps describe the delivery device shape and rotating mechanism used to move a dry-powder dose compartment into the chamber. You may also need to use a spacer to get the medicine into your lungs. Some describe it as having a “lack of gender,” while others describe themselves as being gender neutral. - Consider referral to their usual community pharmacy when changing inhalers … Stem Cell Treatment for Chronic Obstructive Pulmonary Disease (COPD), COPD Associated with Increased Risk for Mild Cognitive Impairment, The Great American Smokeout and National COPD Awareness Month Help Smokers Quit, Illness Etiquette - COPD: A Healthy Sense of Decorum. Inhaled corticosteroids (ICS) should be prescribed in combination with a long-acting bronchodilator in people with chronic obstructive pulmonary disease (COPD). There is evidence, however, that ICS are frequently used in patients where their benefit has not been established. In the average COPD population, yearly exacerbations are between two and three.7 Common adverse events (1%-10% incidence) reported for the fluticasone furoate/umeclidinium/vilanterol group were pneumonia, lower-respiratory tract infection, cardiac arrhythmia, and anticholinergic effects such as dry mouth or confusion. Some patients using ipratropium reported a bitter, metallic taste following use. Compared to tiotropium, there was a statistically significant decrease in mild (16%, P = .0052) exacerbations in the QVA149 treatment group. COPD inhaler prescribing guidelines Fundamentals of COPD care • Smoking cessation - offer treatment and support to stop smoking • Offer pneumococcal and influenza vaccinations • Offer exercise advice and pulmonary rehabilitation if indicated • Develop a respiratory action plan with the patient • Chronic cough and mucus production - consider trial of mucolytic and refer to physiotherapist where service is … Most people with COPD also need to use long-acting controller medications to prevent symptoms and dangerous flare-ups. To comment on this article, /contact rdavidson@uspharmacist.com. East Hanover, NJ: Novartis; 2015.18. Can you tell a friend with COPD that you know he's sneaking cigarettes? By NICE 2019-09-12T13:34:00. Because the mist contains more particles than MDIs and DPIs and the spray leaves the inhaler more slowly, more of the drug gets into your lungs. Let your doctor know if you experience side effects, but never stop taking the medicine unless otherwise advised. Final. Two puffs (5 microgram) given from the Evaluation of appropriateness of inhaled corticosteroid (ICS) therapy in COPD and guidance on ICS withdrawal..... 17 . all MDI to those that were prescribed devices that required a different … BNSSG COPD treatment guidelines (adults) March 2018 Device (alphabetically) Ima ge LAMA LAMA/LABA LABA (only where LAMA not tolerated) ICS/LABA ICS/LABA/LAMA (triple inhaler) Prescribing Tips (respiratory team advice) Breezhaler® - Dry powder inhaler Hard/fast inhalation Requires capsule manipulation. Most COPD medications work best when sent directly into the lungs through an inhaler. Therefore, there is a need for a personalised approach to the use of ICS in COPD and to consider withdrawal of ICS in … If you have trouble doing this, you can use a device called a spacer. In this series: Chronic Obstructive Pulmonary Disease (COPD) Emphysema Spirometry Mucolytics Oral Bronchodilators COPD Flare-ups Use of Oxygen Therapy in COPD An inhaler is a device holding a medicine that you take by breathing in (inhaling). Medicines Management of Chronic Obstructive Pulmonary Disease (COPD) (Chronic & Acute) Guidelines for Primary Care Guideline Authors: Shaneez Dhanji (Wandsworth CCG) and Reena Rabheru-Dodhy (Merton CCG) Date Prepared: May 2010 Date Approved: August 2010 Update 1 & Approved: May 2012 Update 2 & Approved: November 2013 Date for Review: May 2015 . Overall, the dual bronchodilator QVA149 was superior in preventing moderate-to-severe COPD exacerbations as compared with glycopyrronium and tiotropium. Movie theater like MDIs, DPIs are also easy to use n't help you, are... T use inhaled medicine correctly, your inhaler will relieve your symptoms », Proventil,! 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