Response

I thank Dr Beever for his response to the article on the latest chronic obstructive pulmonary disease (COPD) guidelines. He is absolutely correct that the 400/12 μg budesonide-formoterol inhaler is currently not available in Canada. In addition, he is correct about the current lack of official coverage for this drug for COPD in Canada. There are randomized controlled trials showing the efficacy of this drug in moderate to severe COPD. Therefore, our recommendations are evidence-based, in spite of the current position of Health Canada. This medication is indicated and available in many other countries. We did have discussions about whether or not we should include this medication for the reasons that Dr Beever stated. We decided to be inclusive and not exclusive, and therefore added the information as per its current use in other markets.

For any inhaled device, and regardless of stage of disease, it is essential to assess each patient’s technique with that device regularly during visits to the clinic and the pharmacy. Inadequate inspiratory flow rate is only one possible problem that reduces the effectiveness of the delivery of medications to the lungs.

I am regularly asked how those who have severe lung disease can use dry powder inhalers and whether or not they can create the proper inspiratory flow. Both asthma and COPD are obstructed airway diseases, and the issue with those diseases is blowing air out (ie, expiratory flow decrease). A peak inspiratory flow of 30 L/min has been shown to be sufficient in all conditions of concern, such as childhood asthma, acute severe asthma, and COPD, including severe exacerbations.1 Therefore, inspiratory pressures are quite sufficient to allow activation of all dry powder products except in the agonal stages when assisted respiration would be necessary.

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