Breathe Easy: A Guide to Understanding & Using Asthma Inhalers

Medically Reviewed by Dr. Samantha Miller, MBChB

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Asthma is a chronic lung condition where the lung tissues become hypersensitive to external stimuli. This can lead to symptoms such as breathlessness, chest tightness, wheezing and coughing. In the United States, there are over 5 million children and 20 million adults with asthma, which is about 7–8% of the overall population. Of these folks, over 40% have had an asthma attack in the last 12 months. Although asthma can be life-threatening, attacks can be prevented with correct use of inhalers — and fast-acting, inhaled medications. 

Here, we’ll explore different types of inhalers and when to use them. Moreover, we’ll provide some helpful tips to help you make the most of your treatment.

    What Is an Inhaler?

    An inhaler is a portable, handheld device that’s designed to be small enough to fit in your hand and in your bag, so it may be carried around with you all of the time. Inhalers contain medication in powdered form that is delivered directly into the airways as a mist or spray, through inhalation. Typically, inhalers require a prescription, unlike tablets. But they also boast many advantages: in addition to being fast-acting, they can be administered in any setting. 

    It’s important to note that there are several different types of inhalers. Depending on the frequency and intensity of your symptoms, your doctor may recommend different types of inhalers. As with all types of medications, it’s important to understand when and how to properly use the asthma inhaler that’s right for you.

    Types of Inhaled Medications

    Asthma inhaler medications can be broadly divided into preventers and relievers.

    • Preventers are taken on a daily basis to control the disease and prevent lung inflammation from taking over and causing an asthma attack
    • Relievers, or rescue inhalers, are taken when symptoms worsen, for example feeling more breathless, chest tightness or wheezing, or during an asthma attack.

    Bronchodilators

    Bronchodilator medications, as the name suggests, cause dilation (widening) of the airways, allowing for a better airflow and relieving symptoms of breathlessness, tightness and wheeze.

    Most people with asthma will carry some kind of bronchodilator inhaler called a short-acting beta agonist (SABA). SABA inhalers act on the beta receptors in smooth muscle of the airways, triggering relaxation of the muscles and a widening of the tubes of the lungs. Examples of SABA medications include salbutamol (e.g. Ventolin), albuterol (e.g. ProAir RespiClick) and levalbuterol. Their effects are felt rapidly, however wear off quite quickly, and you may need further doses to relieve your symptoms. If you find yourself using your reliever inhaler often, consult your doctor who may recommend a preventer inhaled therapy.

    Inhaled long-acting beta agonists (LABA) also open the airways by relaxing the smooth muscles around the airways however last longer than the short-acting version. Examples of LABA medications are formoterol and salmeterol. LABA are typically used in combination with a corticosteroid inhaler.

    Corticosteroids

    Corticosteroid inhalers are the most common type of preventer medication that is typically taken on a daily basis. Steroids help to reduce inflammation in the airways and keep the airways clear of mucus. Not everyone with asthma needs a steroid inhaler. Examples include beclomethasone (e.g. Qvar), fluticasone (e.g. Flovent) and mometasone (e.g. Asmanex).

    Anticholinergic Medications

    Long-acting muscarinic antagonists (LAMA) or anticholinergics target a different receptor (the muscarinic receptor) and prevent the smooth muscle contraction that can lead to airway tightening. LAMA can both relieve symptoms, and provide ongoing prevention, and are typically used as a preventer in combination with a bronchodilator. Examples include tiotropium (e.g. Spiriva), ipratropium (e.g. Atrovent), aclidinium bromide (e.g. Genuair), umeclidinium (e.g. Incruse) and glycopyrrolate (Seebri Neohaler).

    Combination Inhalers

    Depending on the severity and frequency of your symptoms, each type of inhaler may play a role in treating your asthma. Other asthma inhalers may contain a combination of medications, such as two types of bronchodilators or a combination of long-acting bronchodilators and steroids to help treat both inflammation and narrowing of the airways. 

    Common combinations are:

    • Budesonide (a steroid) in combination with formoterol (a LABA), marketed as e.g. Symbicort or Pulmicort
    • Fluticasone (a steroid) and vilanterol (a LABA), marketed as Breo Ellipta
    • Fluticasone with both umeclidinium, and vilanterol, marketed as Trelegy Ellipta

    Speak to your doctor to learn what regime, if any, is right for you.

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    Types of Devices

    Inhalers

    • Metered dose inhalers (MDIs) give the medicine in a spray form (aerosol). These typically have a pressurized canister that’s pushed down to deliver the spray, at the same time as the user breathes in.
    • Breath actuated inhalers (BAIs), or autohalers, release a spray of medicine when you begin to inhale. They are often easier to use as you don’t need to press anything to deliver the medication, it’s automatically released when you breath in.
    • Dry powder inhalers (DPIs) administer a dry powder medicine instead of a spray.

    Nebulizers

    Nebulizers contain liquid medication which is delivered to the airways via a fine mist, using pressurized air or oxygen via a mask or tubing system. These are often used in the hospital setting and can deliver a high concentration of medication over several minutes or even hours.

    Spacers

    A spacer, sometimes referred to as an aero-chamber, is a small tube that can be attached between the inhaler and mouthpiece on certain metered dose inhalers. Attaching a spacer to the inhaler makes it easier to take the medication. Once the canister is pressed, the medication is trapped inside the chamber, allowing the patient to inhale slowly and deeply. This helps the medication infiltrate deeper into the airways and makes treatment more effective.

    A spacer also makes it easier to give young children an inhaler. These spacers have a mask on one end that fits over the child’s nose and mouth as they inhales.

    How to Use Your Inhaler

    Your physician should provide you with instructions on how to use your inhaler since different models are often used in a slightly different way. 

    Metered Dose Inhalers (MDI)

    A MDI requires you to press to release the medication, at the same time as breathing in. You should remove the cap and shake the device well. Some devices also have a dose counter on them, so check there is sufficient medication left. Breathe out and secure your lips around the mouthpiece. Start to breathe in slowly, whilst simultaneously pressing down on the top of the canister to release the medication. Continue to breathe in until you have taken a full breath. Hold your breath for around 5 seconds, or as long as is comfortable. Breathe out normally. Your doctor may have advised you to take two “puffs”, so repeat this process if that is the case.

    If you find you’re struggling to coordinate breathing and pressing at the same time, your device may be suitable for use with a spacer, which traps the medication in a plastic chamber, so you don’t have to worry about pressing and breathing at the same time.

    Breath Actuated Inhalers (BAIs)

    These devices do not require you to press anything at the same time as breathing. They will often come with a dose counter, and a cover that needs to be pressed until a click is heard, this “primes” the inhaler ready to release the dose. Breathe out fully, then place your lips around the mouthpiece. Take a deep continuous breath in, the medication will automatically be dispersed. Hold your breath for 5 seconds or however long is comfortable. Be sure to “reset” the counter if more than one dose is required.

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    Tips for Inhaler Use

    Always carry your reliever inhaler with you. Even if you are just popping out for a couple of minutes, it’s sometimes unpredictable when chest tightness will strike. For this reason, consider having spare inhalers in places you frequent, such as your car or office, just in case you forget to bring one with you. Other important inhaler-use tips, include the following: 

    • Inform your friends and family that you have asthma and show them how to assist you in administering your inhaler
    • Perform frequent checks on your inhaler for “use by” date and how much of the medication is left
    • It’s often easier to take a deep breath when standing up rather than sitting down
    • If you are using your reliever inhaler more often, see your doctor
    • Attend your doctor for a review of your asthma at least once per year
    • Keep a diary of symptoms, this may help you to identify triggers for chest tightness or cough
    • Create an “asthma plan” which details what to do if you feel your asthma is getting worse

    Environmental Concerns About Inhalers

    Chlorofluorocarbons (CFCs) were once used as propellants in various aerosol sprays including asthma inhalers. Because the main chemical compound is believed to damage the Earth’s ozone layer, the U.S. government began regulating the use of chlorofluorocarbons in the 1970s. While they were banned in products like hairspray, chlorofluorocarbons were allowed in medical products including asthma inhalers until fairly recently.

    In the spring of 2010, the U.S. Food and Drug Administration (FDA) announced plans to phase out asthma inhalers that contain chlorofluorocarbons. In response, some inhaler manufacturers have switched to hydrofluoroalkane, a propellant that’s believed to be safer for the environment.

    Next Steps

    Asthma can interfere with daily activities and impact your quality of life, but the right asthma inhaler can help you manage your symptoms. However, asthma medication is only effective if patients use their inhalers properly. Be sure to speak with your doctor not only about your symptoms, but about proper inhaler use as well. 

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