Peak flow meters (standard and low range) are available on prescription in the community and in hospital via PECOS.

Spacer devices improve lung deposition and reduce oropharyngeal deposition of drugs delivered via a metered-dose inhaler.

• A spacer device is recommended for all patients inhaling high-dose steroids (greater than beclometasone 800 micrograms per day or equivalent) via a pressurised, metered-dose inhaler, and when inhaler technique is sub-optimal.
• Lung deposition data is superior for the Volumatic® as compared to the AeroChamber® Plus.
• If the Volumatic® device is available for a particular product (see below), consider it first choice.
• Where a number of different inhalers are prescribed for the same patient they should be compatible if possible with the selected spacer device.
• Advise patients to clean devices no more often than once a month and replace every 6 to 12 months. After cleaning spacers should be air-dried, not dried with a towel.

Haleraid® -120, -200 device is placed over Flixotide®, Serevent® and Ventolin® pressurised, metered-dose inhalers to aid when strength in hands is impaired. It is not available in the community.

In-Check DIAL® is a useful guide for inhaler use checking as part of inhaler assessment.

Nebulisers:

In hospital:

• Nebulised bronchodilator solutions should always be driven by oxygen when administered to a patient with asthma and by air when administered to a patient with COPD or any other diagnosis.

In primary care:

• In both COPD and asthma, only prescribe nebulisers in primary care following a formal assessment through the Respiratory Clinic; evidence suggests that maximising inhaled therapy through a spacer device is the preferred choice.
• For chronic domiciliary use electric compressors should be used to deliver nebulised therapy as the flow rate from an oxygen concentrator is insufficient to nebulise solutions effectively.
• In acute asthma in primary care, nebulisers should be driven by oxygen provided a minimum flow rate of at least 6 litres/min is available. As an alternative to air-driven nebulised therapy, high-dose salbutamol may be delivered by a large volume spacer (Volumatic®) to children aged over 2 years and adults.

There is no place for nebulised sodium chloride 0·9% solution in either COPD or asthma.