“My inhalers just aren’t working any more — I need something stronger”

When a COPD patient says their inhalers "aren’t working" and asks for "something stronger", resist reflexive escalation and CHECK THE BASICS first. The commonest reason for apparent inhaler failure is poor TECHNIQUE — ask the patient to demonstrate, correct critical errors (coordination with MDIs, inspiratory effort with dry-powder devices, breath-holding), consider a spacer or a better-matched device, and re-check; this alone often transforms control. Also review ADHERENCE, confirm a spirometry-based diagnosis (post-bronchodilator FEV1/FVC <0.7), look for asthmatic features (NICE NG115), and screen treatable contributors (ongoing smoking/exposure, heart failure, anaemia, anxiety, deconditioning, weight). Optimise NON-PHARMACOLOGICAL care, which is frequently more impactful than escalation: refer for PULMONARY REHABILITATION (strong evidence for breathlessness and quality of life; offer if MRC dyspnoea ≥3/functionally limited), ensure vaccinations (influenza and pneumococcal, and COVID-19 only if she meets current UKHSA Green Book eligibility), reinforce cessation, and provide a self-management plan with a rescue pack. Only then apply NICE NG115 escalation LOGIC: on LABA+LAMA with optimised basics, consider adding an INHALED CORTICOSTEROID (triple therapy) after 1 severe exacerbation needing hospital or 2 moderate exacerbations within a year, or as a 3-month trial for day-to-day symptoms affecting quality of life with a return to LABA+LAMA if there is no improvement (asthmatic features, including a higher blood eosinophil count, inform the choice, but NG115 sets no cut-off) — counselling the trade-off that ICS reduces exacerbations in the right patient but raises PNEUMONIA risk, using a single combination inhaler for adherence, and reviewing benefit (stopping ICS if none); beyond triple therapy, specialist options include azithromycin prophylaxis, roflumilast (NICE TA461) and, since 2026, dupilumab for raised eosinophils (NICE TA1142). Validate the patient’s frustration and fear of decline, reframe around fixable basics and rehab, keep NICE NG12 (Suspected cancer: recognition and referral, last updated April 2026) lung awareness for red flags, and follow up — reasoned care, not "stronger by default".