C46-12 Albuterol Pressurized Metered-Dose Inhaler Coupling to a Spacer: If It Does Not Fit, You Must Replace the Spacer

Introduction The use of a spacer device is recommended with a pressurized metered-dose inhaler (pMDI) in patients with severe COPD to optimize pulmonary drug delivery. Case report A 60-year-old sarcopenic female (BMI, 15.95 kg/m2) with very severe COPD (FEV1, 0.54 L, 23% predicted) and chronic hypercapnic respiratory failure presented to the University of Illinois Lung Health Clinic for her scheduled appointment in August 2025. Since December 2024, she has had four COPD exacerbations, including one hospitalization. Earlier, she was prescribed a spacer to use with her albuterol pMDI. She reported that her albuterol pMDI was changed in late 2024 from generic ProAir® (Teva Pharmaceuticals; 8.5 Gm, elliptical mouthpiece) to generic Proventil® (Sandoz Group AG; 6.7 Gm, round mouthpiece). On examination, bilateral wheezes were audible at the lung bases. The patient’s transcutaneous oxygen saturation on room air was 95% at rest and 91% with exertion. She brought her current inhaler and spacer to the visit with complaints about not being able to use the two together. Inspection revealed that the round mouthpiece of the pMDI was incompatible with the elliptical opening at the back of the spacer. A new spacer compatible with both round and elliptical mouthpieces was then provided. Upon follow-up, the patient continues to be challenged by using the pMDI with the new spacer, despite education. Nebulized inhalation medications will now be considered. Discussion We reviewed the literature on commonly prescribed albuterol pMDI products and stand-alone spacers available in the US. Investigating eight out of multiple albuterol pMDIs, four featured round mouthpieces and four had elliptical designs. However, none of the corresponding package inserts, patient information leaflets, or current COPD clinical practice guidelines address pMDI mouthpiece-spacer compatibility. Additionally, a wide variety of spacers, some designed for round, elliptical or both types of mouthpieces, are available for purchase online or by prescription. Yet, packaging, and online product descriptions often lack clear information or visual guidance regarding compatibility with pMDIs. As illustrated in this case, the heterogeneity in product design poses a significant safety concern for patients with very severe COPD. Accordingly, we recommend that regulatory agencies require all marketed stand-alone spacers to be universally compatible with both round and elliptical pMDI mouthpieces. Whether this issue should also be addressed in future, updates of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines remains to be determined. This abstract is funded by: None