Transcript
Announcer:
You’re listening to Clinician’s Roundtable on ReachMD. On this episode, we’ll hear from Mr. Brian Bizik, who’s a physician assistant and respiratory care coordinator at Terry Reilly Health Centers in Boise and Nampa, Idaho. He’ll be sharing highlights from his presentation at the 2026 GOLD International COPD Conference on when to transition a patient to nebulized therapy. Here’s Mr. Bizik now.
Mr. Bizik:
When we're considering whether or not patients with COPD should use or consider using nebulized therapy, it's important to set the context. With the GOLD guidelines, we are encouraged to make sure we've got an accurate diagnosis. Once we initiate therapy—usually, that's a LAMA and a LABA, but sometimes, it's just one bronchodilator—and the patient is using that and they come back and they're still struggling, then we want to advance. We want to go to the next step, and GOLD says if they are still struggling and they have eosinophils over 300 or if they're continuing to exacerbate over 100, go ahead and add an inhaled corticosteroid. So move them to a triple inhaler.
At that point, if they're still struggling, we have a whole other category, a new group of medications that we may want to advance them to. But when we are considering if we need to add something, like a biologic, before we do that, we want to ask the question: Is the medication I'm giving getting to the targeted tissue? You spend a lot of time getting them on the right inhaler, getting it through insurance, and going through these steps, but is that medication actually going in and getting to the targeted tissue? And if it's not, then any advancement would be premature. We would want to reconsider that and say, "Okay, I'm advancing therapy, but I'm going to make sure that they're getting the medication in."
The other part of this is that now, and for the last few years, we've had all three categories of medications available in nebulized form. So once you get to this point and you're asking yourself, "Okay, should I consider moving this patient to nebulized therapy because something's going on and they're continuing to struggle?" some questions you can talk to the patient about and ask yourself when you talk to them are: Do they have the strength in their hands to actually actuate the inhaler, meaning press down with enough force to get the medication to actuate out of the metered-dose inhaler? Can they click the button if it's a soft mist inhaler? If not, then we may need to make adjustments. Do they have cognitive issues that may make using an inhaler difficult? If so, we may need a change there. And then another one that comes up a lot, and it's somewhat of a hot topic, is inhalation capacity. Can they inhale deep and long enough to get that medication, especially a dry powder, because those take a little more force initially? Do they have the inhalation capacity to move that medication into their lungs? If not, I might want to consider a nebulizer.
So if you've gone ahead and moved them to nebulized therapy, some patients just do better. So what might indicate that a patient is going to do better and is going to be successful with that? One is if they have the time because nebulized therapy, if you're doing it twice a day, for instance, takes some time—maybe 15-20 minutes from the time they start to get the medication ready, do the nebulization, and finish. So there is a time commitment. For most patients with moderate or severe COPD, that's not an issue, but it might be, so it’s something to consider.
They also need to have some support at home because this does require cleaning the mouthpiece or the mask, and there is some additional work that's above and beyond what you would get with inhalers. So for those patients, they tend to do better if they have that, and always, they need to have insurance coverage. So if Medicare is present and their ability to afford the medication is good, that's somebody that's going to be successful because if they can't afford it, they're not going to stick with it, obviously.
And then the last thing I'll say is if they feel better, that's the key. If I put them on nebulized medicine, I want to follow up quickly, within a week or two if I can, or I call them. If they feel better, that's a patient that's going to stick with it. They're going to be willing to do the extra work, the extra time, and the cleaning. All that's going to be okay with them because they have a noticeable improvement in their breathing or their quality of life. So if that's the case, they tend to do a little better and stick with it longer.
Announcer:
That was Mr. Brian Bizik talking about when to move patients to nebulized therapy in COPD management. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
