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Efficacy and safety of different inhaler types for asthma and chronic obstructive pulmonary disease. a systematic review and meta-analysis
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  • Published: 16 February 2026

Efficacy and safety of different inhaler types for asthma and chronic obstructive pulmonary disease. a systematic review and meta-analysis

  • Michael J. Loftus1,2 na1,
  • Miranda S. Cumpston3 na1,
  • Shannon Barnes3,
  • John Blakey4,5,
  • Allan Glanville6,
  • Steve McDonald3,
  • Loyal Pattuwage3,
  • Megan Rees7,8,
  • Rachel Silk3,
  • Heath White3,
  • Tari Turner3 na2 &
  • …
  • Karin Leder1,2 na2 

npj Primary Care Respiratory Medicine , Article number:  (2026) Cite this article

  • 625 Accesses

  • Metrics details

We are providing an unedited version of this manuscript to give early access to its findings. Before final publication, the manuscript will undergo further editing. Please note there may be errors present which affect the content, and all legal disclaimers apply.

Subjects

  • Adverse effects
  • Asthma
  • Chronic obstructive pulmonary disease
  • Outcomes research

Abstract

Pressurised metered dose inhalers (pMDIs) contain propellant gases with high global warming potential yet remain a cornerstone of management for asthma and chronic obstructive pulmonary disease (COPD). The aim of this study was to determine whether non-propellant alternatives of dry powder inhalers (DPIs) and soft mist inhalers (SMIs) had similar efficacy and safety. A systematic review was performed finding 44 randomised trials (24,710 participants) and moderate certainty evidence for most outcomes. No statistically significant or clinically important differences were found between inhaler types for any assessed measure. For asthma maintenance, the mean difference in peak expiratory flow rate between groups was 1.07 L/min (95% confidence interval [CI] -0.93 to 3.06). For COPD, the mean difference in FEV1 between groups was 0.01 L (95% CI -0.01 to 0.02). While the choice of optimal inhaler for an individual patient is a multifaceted decision, this review provides reassurance that non-pMDI devices can perform equally well.

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Data availability

Our research protocol is publicly available on the Monash University research repository (https://doi.org/10.26180/26065789.v2). The datasets generated and/or analysed during the current study are also available on the Monash University research repository (https://doi.org/10.26180/28916777.v2).

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Acknowledgements

Thanks to Dr Kim Jachno of the Australian Living Evidence Collaboration in the School of Public Health and Preventive Medicine, Monash University, for statistical advice. Michael Loftus is supported by a Royal Australasian College of Physicians (RACP) Research Establishment Fellowship. Miranda Cumpston is supported by philanthropic research funding from the Walter Thomas Cottman Charitable Trust and The Phyllis Connor Memorial Trust, managed by Equity Trustees. The funders played no role in study design, data collection, analysis and interpretation of data, or the writing of this manuscript.

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Author notes

  1. These authors contributed equally: Michael J. Loftus, Miranda S. Cumpston.

  2. These authors jointly supervised this work: Tari Turner, Karin Leder.

Authors and Affiliations

  1. Planetary Health Division, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

    Michael J. Loftus & Karin Leder

  2. Health and Climate Initiative, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia

    Michael J. Loftus & Karin Leder

  3. Australian Living Evidence Collaboration, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

    Miranda S. Cumpston, Shannon Barnes, Steve McDonald, Loyal Pattuwage, Rachel Silk, Heath White & Tari Turner

  4. Respiratory Department, Sir Charles Gairdner Hospital, Perth, Australia

    John Blakey

  5. Curtin Medical School, Faculty of Health Sciences, Curtin University, Perth, Australia

    John Blakey

  6. Macquarie Respiratory and Sleep Unit, Macquarie University, Sydney, Australia

    Allan Glanville

  7. Department of Respiratory and Sleep Disorders Medicine, The Royal Melbourne Hospital, Melbourne, Australia

    Megan Rees

  8. Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia

    Megan Rees

Authors
  1. Michael J. Loftus
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Contributions

Author Contribution Statement : MJL: conceptualization, methodology, investigation, formal analysis, writing – original draft, writing – review and editing. MSC: methodology, investigation, visualisation, formal analysis, writing – original draft, writing – review and editing. SB: investigation, writing – review and editing. JB: conceptualization, methodology, supervision, writing – original draft, writing – original draft, writing – review and editing. AG: conceptualization, methodology, supervision, writing – original draft, writing – original draft, writing – review and editing. SM: methodology, investigation, writing – review and editing. LP: investigation, writing – review and editing. MR: conceptualization, methodology, supervision, writing – original draft, writing – original draft, writing – review and editing. RS: investigation, writing – review and editing. HW: methodology, investigation, writing – review and editing. TT: conceptualization, methodology, supervision, writing – review and editing. KL: conceptualization, methodology, supervision, writing – original draft, writing – original draft, writing – review and editing. All authors (except AG, who died in December 2024) read and approved the final manuscript.

Corresponding author

Correspondence to Michael J. Loftus.

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Competing interests

Author JB declares personal and institutional fees from Chiesi, Boehringer Ingelheim, GSK, AstraZeneca and Sanofi for educational presentations or speaking engagements, as well as support for travelling to conferences from GSK and AstraZeneca. Author JB has participated in a study steering committee for GSK, unrelated to this topic. All other authors declare no financial or non-financial competing interests.

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Loftus, M.J., Cumpston, M.S., Barnes, S. et al. Efficacy and safety of different inhaler types for asthma and chronic obstructive pulmonary disease. a systematic review and meta-analysis. npj Prim. Care Respir. Med. (2026). https://doi.org/10.1038/s41533-026-00488-4

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  • Received: 02 May 2025

  • Accepted: 01 February 2026

  • Published: 16 February 2026

  • DOI: https://doi.org/10.1038/s41533-026-00488-4

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