Effectiveness of Pressurized Metered Dose Inhaler (pMDI) Versus Dry Powder Inhaler (DPI) in Delivering Inhaled Corticosteroid and Long Acting Beta Agonist Among Patients with Uncontrolled Asthma in a Tertiary Care Hospital: pMDI versus DPI in Delivering Inhaled Corticosteroid and Long-Acting Beta Agonist

Xunaira Qamar; Muhammad Hussain; Salman Ayyaz; Sarwat Saif; Shahmeer Anjum; Laiba Qamar Butt

doi:10.54393/pjhs.v7i8.3989

Authors

Xunaira Qamar Department of Pulmonology, Services Institute of Medical Sciences, Lahore, Pakistan
Muhammad Hussain Department of Pulmonology, Services Institute of Medical Sciences, Lahore, Pakistan
Salman Ayyaz Department of Pulmonology, Services Institute of Medical Sciences, Lahore, Pakistan
Sarwat Saif Department of Pulmonology, Services Institute of Medical Sciences, Lahore, Pakistan
Shahmeer Anjum Department of Medicine, Services Institute of Medical Sciences, Lahore, Pakistan
Laiba Qamar Butt Department of Thoracic Surgery, Services Institute of Medical Sciences, Lahore, Pakistan

DOI:

https://doi.org/10.54393/pjhs.v7i8.3989

Keywords:

Asthma, Dry Powder Inhaler, Inhaled Corticosteroid, Long-Acting Beta-Agonist, Pressurized Metered-Dose Inhaler

Abstract

Uncontrolled asthma remains common in Pakistan despite regular use of inhaled corticosteroid and long-acting beta-agonist combination therapy. Drug delivery may differ according to the inhaler device. Pressurized metered-dose inhalers (pMDIs) and dry powder inhalers (DPIs) are the most frequently prescribed devices, but local comparative evidence remains limited. Objective: To compare the short-term effectiveness of pMDI and DPI in delivering inhaled corticosteroid and long-acting beta-agonist therapy among adults with uncontrolled asthma in a tertiary care hospital. Methods: This parallel randomized controlled trial was conducted at the Department of Pulmonology, Services Institute of Medical Sciences, Lahore. A total of 146 adults with uncontrolled asthma were randomized equally to pMDI (n=73) or DPI (n=73). The primary outcome was the proportion of participants achieving at least a 0.5-point reduction in Asthma Control Questionnaire (ACQ) score at 8 weeks. Secondary outcomes included mean ACQ change, change in forced expiratory volume in one second (FEV₁ % predicted), exacerbations, inhaler technique score, and adverse events. Results: Baseline age, sex, body mass index, asthma duration, baseline FEV₁ % predicted, and ACQ score were comparable between groups. Greater mean ACQ improvement was observed in the pMDI group than in the DPI group (4.6 ± 3.1 vs 3.2 ± 2.9; p = 0.006). FEV₁ improvement was also greater with pMDI (p=0.021). Exacerbations occurred in 24.7% of pMDI users and 39.7% of DPI users (p=0.048). Adverse events were mild and similar between groups. Conclusion: pMDI use was associated with better short-term asthma control and fewer exacerbations; larger multicentre studies are needed.

References

Ashraf H, Butt M, Akhtar S, Nadeem A, Kareem R, Ashfaq H et al. Asthma Incidence, Prevalence, and Mortality in the United States and Worldwide, 1990–2019: Findings from the Global Burden of Disease study. Journal of Asthma. 2025 Aug; 62(8): 1407-17. doi: 10.1080/02770903.2025.2482998.

Yuan L, Tao J, Wang J, She W, Zou Y, Li R et al. Global, Regional, National Burden of Asthma from 1990 To 2021, with Projections of Incidence To 2050: A Systematic Analysis of the Global Burden of Disease Study 2021. E-Clinical Medicine. 2025 Feb; 80. doi: 10.1016/j.eclinm.2024.103051.

Hang YQ, Piao X, Wu J, Jiang QW, Han Y. The Epidemiology of Asthma and Its Attributable Risk Factors from 1990 to 2021: A Systematic Analysis Based on the Global Burden of Disease Study 2021 and Mendelian Randomization Studies. Public Health. 2025 Jun; 243: 105731. doi: 10.1016/j.puhe.2025.105731.

Akashanand, Khatib MN, Balaraman AK, Roopashree R, Kaur M, Srivastava M et al. Patterns and Trends in Burden of Asthma and Its Attributable Risk Factors from 1990 To 2021 Among South Asian Countries: A Systematic Analysis for the Global Burden of Disease Study 2021. Journal of Asthma. 2025 Jun; 62(6): 1020-31. doi: 10.1080/02770903.2025.2453810.

Pan Z, Yang H, Jin Y, Zhou Q, Wang Q, Hao C et al. Analysis of Gender-and Age-Stratified Asthma Burden: Forecasting Prevalence Trends in 2030. Frontiers in Medicine. 2025 Aug; 12: 1612688. doi: 10.3389/fmed.2025.1612688.

Wu S, Ding R, Huang W, Shang Y, Xu W, Shi F et al. Age–Sex Differences in the Global Burden of Asthma and Risk Factors, 1990–2021: Results from the Global Burden of Disease Study 2021. BioMed Central Pulmonary Medicine. 2026 Dec; 26(1): 111. doi: 10.1186/s12890-025-03994-2.

National Heart, Lung, and Blood Institute. Global Initiative for Asthma: Global Strategy for Asthma Management and Prevention. In NHLBI/WHO Workshop Report. NHLBI publication. 1995.

Oh J, Kim S, Kim MS, Abate YH, Abd ElHafeez S, Abdelkader A et al. Global, Regional, and National Burden of Asthma and Atopic Dermatitis, 1990–2021, and Projections to 2050: A Systematic Analysis of the Global Burden of Disease Study 2021. The Lancet Respiratory Medicine. 2025 May; 13(5): 425-46.

Kim TH, Kim H, Oh J, Kim S, Miligkos M, Yon DK et al. Global Burden of Asthma among Children and Adolescents with Projections To 2050: A Comprehensive Review and Forecasted Modeling Study. Clinical And Experimental Pediatrics. 2025 Apr; 68(5): 329. doi: 10.3345/cep.2025.00423.

Rabe AP, Loke WJ, Gurjar K, Brackley A, Lucero-Prisno III DE. Global Burden of Asthma, and Its Impact on Specific Subgroups: Nasal Polyps, Allergic Rhinitis, Severe Asthma, and Eosinophilic Asthma. Journal of Asthma and Allergy. 2023 Dec: 1097-113. doi: 10.2147/JAA.S418145.

Juniper EF, Svensson K, Mörk AC, Ståhl E. Measurement Properties and Interpretation of Three Shortened Versions of the Asthma Control Questionnaire. Respiratory Medicine. 2005 May; 99(5): 553-8. doi: 10.1016/j.rmed.2004.10.008.

Morice AH, Peterson S, Beckman O, Kukova Z. Efficacy and Safety of a New Pressurized Metered-Dose Inhaler Formulation of Budesonide/Formoterol in Children with Asthma: A Superiority and Therapeutic Equivalence Study. Pulmonary Pharmacology and Therapeutics. 2008 Feb; 21(1): 152-9. doi: 10.1016/j.pupt.2007.01.006.

World Medical Association. World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. Journal of the American Medical Association. 2013 Nov; 310(20): 2191-4. doi: 10.1001/jama.2013.281053.

Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P et al. Inhaler Mishandling Remains Common in Real Life and Is Associated with Reduced Disease Control. Respiratory Medicine. 2011 Jun; 105(6): 930-8. doi: 10.1016/j.rmed.2011.01.005.

Zhang L, Jiang H, Yang G, Zhang J, Yuan S, Chen J et al. Global, Regional, and National Burden of Asthma from 1990 To 2021: A Systematic Analysis for the Global Burden of Disease Study 2021. British Medical Journal Open Respiratory Research. 2025 Jul; 12(1). doi: 10.1136/bmjresp-2025-003144.

Irfan HM, Yousaf S, Riaz M, Kazi A, Rizwan HM, Malik I et al. Faulty Technique of Inhaler Use among Patients with Uncontrolled Asthma Presenting to A Tertiary Care Hospital. Journal of Pakistan Society of Internal Medicine. 2024; 5(3): 600-604. doi: 10.70302/jpsim.v5i3.2448.

Sanchis J, Gich I, Pedersen S, Team AD. Systematic Review of Errors in Inhaler Use: Has Patient Technique Improved Over Time? Chest. 2016 Aug; 150(2): 394-406. doi: 10.1016/j.chest.2016.03.041.

Guruparan Y, Navaratinaraja TS, Selvaratnam G, Sri Ranganathan S. Effectiveness of Inhaled Therapies in Asthma Among Adults in Northern Sri Lanka, A Low and Middle-Income Country: A Prospective Observational Study. medRxiv. 2024 Jul: 2024-07. doi: 10.1101/2024.07.08.24309593.

Mao Z, Zhu X, Zheng P, Wang L, Zhang F, Chen L et al. Global, Regional, and National Burden of Asthma from 1990 to 2021: A Systematic Analysis of the Global Burden of Disease Study 2021. Chinese Medical Journal Pulmonary and Critical Care Medicine. 2025 Mar; 3(01): 50-9. doi: 10.1016/j.pccm.2025.02.005.

Miligkos M, Oh J, Kwon R, Konstantinou GΝ, Kim S, Yon DK et al. Epidemiology of Asthma Across the Ages. Annals of Allergy, Asthma and Immunology. 2025 Apr; 134(4): 376-84. doi: 10.1016/j.anai.2024.12.004.