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Fernando González-Torralba,1 Adolfo Baloira,2 Araceli Abad,3 Antonia Fuster,4 Juan Luis García-Rivero,5 Patricia García-Sidro,6 Eduardo Márquez-Martín,7 Marta Palop,8 Néstor Soler,9 José Luis Velasco10 1Respiratory Department, University Hospital of Aranjuez, Madrid, Spain; 2Respiratory Department, University Hospital of Pontevedra, Pontevedra, Spain; 3Respiratory Department, University Hospital of Getafe, Madrid, Spain; 4Respiratory Department, University Hospital Son Llatzer, Palma de Mallorca, Spain; 5Respiratory Department, University Hospital Marqués de Valdecilla, Santander, Spain; 6Respiratory Department, University Hospital of La Plana, Castellón, Spain; 7Respiratory Department, University Hospital Virgen del Rocío, Sevilla, Spain; 8Respiratory Department, Hospital of Sagunto, Valencia, Spain; 9Respiratory Department, Hospital Clinic, Barcelona, Spain; 10Respiratory Department, University Hospital Virgen de la Victoria, Málaga, SpainCorrespondence: Adolfo Baloira, Email adolfo.baloira.villar@sergas.esPurpose: The pharmacological treatment of chronic obstructive pulmonary disease (COPD) is largely based on inhaled bronchodilators. Inspiratory flow and lung deposition are key parameters to be considered in inhaled therapy; however, the relationship between these two parameters, the patient specificities, and the suitability of the inhaler type for COPD management has not been fully addressed. The present study follows a Delphi Panel methodology to find expert consensus on the role of inspiratory flow and lung deposition as key decision factors in COPD inhaled therapy.Methods: A two-round Delphi Panel, consisting of 38 statements (items) and completed by 57 Spanish pulmonologists, was carried out to measure the experts’ consensus degree with each item.Results: A high degree of consensus was reached on most of the items consulted, among these inspiratory flow or inspiratory capacity should be periodically considered when choosing an inhalation device and to ensure the suitability of the inhaler used; the outflow velocity and particle size of the different devices should be considered to ensure adequate lung deposition; an active device (pressurized metered-dose inhalers (pMDI) or soft mist inhalers (SMI)) should be used in patients with low inspiratory flow to achieve adequate lung deposition; and, the use of dry powder inhalers (DPI) should be re-evaluated in patients with severe obstruction and severe exacerbations.Conclusion: This study shows the relevance of inspiratory flow and the degree of particle deposition in the lung in the choice of an inhalation device for COPD management, as well as the convenience of an SMI type device in cases of low inspiratory flow. Moreover, it highlights the scarcity of information on the specific features of inhalation devices in COPD guidelines.Keywords: dry powder inhalers, pressurized metered-dose inhalers, soft mist inhaler, inhaled therapy device, exacerbations

Adolfo Baloira,1 Araceli Abad,2 Antonia Fuster,3 Juan Luis García Rivero,4 Patricia García-Sidro,5 Eduardo Márquez-Martín,6,7 Marta Palop,8 Néstor Soler,9 JL Velasco,10 Fernando González-Torralba11 1Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain; 2Hospital Universitario de Getafe, Madrid, Spain; 3Hospital Unvidersitario Son Llàtzer, Palma de Mallorca, Spain; 4Hospital Comarcal de Laredo, Cantabria, Spain; 5Hospital Universitario de la Plana, Castellón, Spain; 6Hospital Virgen del Rocío, Sevilla, Spain; 7CIBERES, Instituto de Salud Carlos III, Madrid, Spain; 8Hospital de Sagunto, Valencia, Spain; 9Hospital Universitario Clínic, Barcelona, Spain; 10Hospital Universitario Virgen de la Victoria, Málaga, Spain; 11Pulmonology Section, Hospital Universitario del Tajo, Aranjuez, SpainCorrespondence: Fernando González-TorralbaPulmonology Section, Hospital Universitario del Tajo, Av. Amazonas Central, s/n, Aranjuez, 28300, Madrid, SpainTel +0034 918 01 41 00Email docbectorralba@hotmail.comBackground: Our aim was to describe: 1) lung deposition and inspiratory flow rate; 2) main characteristics of inhaler devices in chronic obstructive pulmonary disease (COPD).Methods: A systematic literature review (SLR) was conducted to analyze the features and results of inhaler devices in COPD patients. These devices included pressurized metered-dose inhalers (pMDIs), dry powder inhalers (DPIs), and a soft mist inhaler (SMI). Inclusion and exclusion criteria were established, as well as search strategies (Medline, Embase, and the Cochrane Library up to April 2019). In vitro and in vivo studies were included. Two reviewers selected articles, collected and analyzed data independently. Narrative searches complemented the SLR. We discussed the results of the reviews in a nominal group meeting and agreed on various general principles and recommendations.Results: The SLR included 71 articles, some were of low–moderate quality, and there was great variability regarding populations and outcomes. Lung deposition rates varied across devices: 8%– 53% for pMDIs, 7%-69% for DPIs, and 39%– 67% for the SMI. The aerosol exit velocity was high with pMDIs (more than 3 m/s), while it is much slower (0.84– 0.72 m/s) with the SMI. In general, pMDIs produce large-sized particles (1.22– 8 μm), DPIs produce medium-sized particles (1.8– 4.8 μm), and 60% of the particles reach an aerodynamic diameter < 5 μm with the SMI. All inhalation devices reach central and peripheral lung regions, but the SMI distribution pattern might be better compared with pMDIs. DPIs’ intrinsic resistance is higher than that of pMDIs and SMI, which are relatively similar and low. Depending on the DPI, the minimum flow inspiratory rate required was 30 L/min. pMDIs and SMI did not require a high inspiratory flow rate.Conclusion: Lung deposition and inspiratory flow rate are key factors when selecting an inhalation device in COPD patients.Keywords: COPD, lung deposition, inspiratory flow, inhalation devices, systematic literature review