In this article I will go over everything you need to know about how an inhaler is chosen. The main things to consider are the indication (condition being treated), the medication in the inhaler and your ability to use that particular device in an effective way. Inhalers are truly fascinating treatments and one of the biggest advances in respiratory medicine.
This is a fairly long article, but I tried to make it as comprehensive as possible to save you from looking everywhere for clarifications on the important aspects. Feel free to jump to the sections relevant to you. Also check out the videos on my YouTube channel for demonstrations on how to use most inhalers.
1) You may not need the latest inhaler on the market
There are many new inhaler devices that come to market every year. However, the best inhaler is different for each patient. No two people or chest conditions are entirely similar. While some novel inhalers are really innovative (e.g. triple therapy such as Trelegy or Trimbow), most new inhalers only offer marginal improvements over established ones. There are also examples of excellent inhalers which for some reason have been forgotten or became less popular for no obvious clinical reason (e.g. Alvesco).
As you will see below, despite the diversity of devices, most inhaled medication only falls into a few large categories with similar mechanisms of action and the biggest difference can be type of device. The choice of a device is essential to ensure effective delivery of the medication to the airways. Having many inhaler options is great, because a device can be chosen based on personal preference and ability to use it. You should be able to use your inhaler with relative ease, otherwise you may not obtain the maximum benefit.
As long as the inhaler has a good effect and controls the condition being treated (asthma, COPD etc.) there is no need to chase marginal improvements. Too many changes may actually destabilize the chest condition.
2) What is contained in inhalers?
Several types of inhaled medications are available. They are chosen according to the goals of inhaler treatment:
- relieve chest symptoms (using a reliever inhaler)
- control symptoms in the long run (long duration bronchodilation), which is very useful in COPD
- control airway inflammation (with a controller inhaler), which is most useful in asthma
Bronchodilators
Most inhalers contain bronchodilators, which are medications that “open up” the airways. There are two main types of bronchodilators:
- short-acting
- long-acting
Short-acting bronchodilators can be used in both asthma and COPD (plus other conditions) to provide rapid relief of chest tightness, wheeze and breathlessness. Unfortunately, their effect only lasts for a few hours. There are two main pharmacological types (do not worry about the terminology):
- short-acting beta agonists (SABA) – the most common example is salbutamol (Ventolin, or some other “blue” inhaler). The effect lasts for up to 4-6 hours.
- short-acting muscarinic antagonists (SAMA) – most common is ipratopium (Atrovent). The effect lasts for up to 6-8 hours.
Sometimes, a SABA and a SAMA may be used together for a synergistic effect, especially if needed to stop a more severe asthma attack.
Long-acting bronchodilators have an effect which lasts for 12 hours or more. They are mostly used for long-term control of symptoms and there are many different types. However, they also fall within two similar categories:
- long-acting beta agonists (LABA) – drug names usually end in “-ol” (e.g. formoterol, indacaterol, salmeterol etc.)
- long-acting muscarinic antagonists (LAMA) – drug names usually end in “-ium” (e.g. tiotropium, glycopyrronium etc.)
The pharmacological names above are important to keep in mind as they define classes of medication (even if you only remember LABA and LAMA). Within each category there are several types of medication with a similar mechanism of action (i.e. how they exert their effect in the body). The main differences between drugs belonging to the same class is how quickly they start working (onset of action) and sometimes the total duration of action (i.e. how long do they have an effect). I will give some examples below.
Inhaled corticosteroids
Inhaled corticosteroids (ICS) represent a separate class of inhaled medication. ICS are anti-inflammatory drugs which are prescribed either on their own, or in combination with one or two different bronchodilators. The combination can be given either in separate inhalers or in combination inhalers (where the ICS is inhaled together with a bronchodilator from the same device).
Even though many people are concerned about side effects of corticosteroids, the dose contained in inhalers is extremely low. In addition, inhaled corticosteroids are specifically designed to be pharmacologically different from corticosteroids which may be given as tablets (to further reduce the risk of side effects by reducing their absorption from the airways to the rest of the body).
Inhaled corticosteroids are most useful in the long-term control of asthma, where they represent the gold-standard of treatment. They control the inflammation in the airways and thus prevent the occurrence of asthma attacks. In COPD, they are used mainly to prevent flare-ups (exacerbations).
3) Understand the condition for which the inhaler is prescribed
Most inhalers are usually prescribed for asthma or COPD. Sometimes they may be used in bronchiectasis, bronchial hyperresponsiveness, after a respiratory infection, in sarcoidosis, hypersensitivity pneumonitis and potentially in other situations.
For asthma we want to prevent asthma attacks from occurring in the first place, therefore the aim of inhaled therapy is to control the inflammation in the airways.
To achieve this, we generally require a controller (or maintenance) inhaler which contains an inhaled corticosteroid. A combination inhaler (additionally containing a long-acting bronchodilator) may be prescribed depending on the severity of the asthma to bring it under control. The controller inhaler is taken regularly, usually twice daily, although in milder forms of asthma, a single daily administration may be enough. Your doctor will prescribe the treatment plan depending on your symptoms and then review the inhaled medication doses every few months until the asthma becomes controlled.
In some very mild forms of asthma, or in the case of exercise-induced asthma, a short-acting bronchodilator (salbutamol) inhaler may be the only treatment given. This would then be used as needed (as a reliever) or to prevent attacks.
Reliever inhalers in asthma have a quick onset of their effect and are usually taken as required if an asthma attack occurs. Normally a reliever inhaler contains a short-acting bronchodilator medication such as salbutamol (Ventolin) or more rarely ipratropium (Atrovent) – see above for details. Some combination inhalers may also be used as reliever medication (such as Symbicort or Foster). Some doctors may actually prefer to recommend the controller and reliever medication in a single inhaler – this is called a MART treatment plan (maintenance and reliever therapy). In MART, a combination inhaler containing an inhaled corticosteroid and a long-acting bronchodilator with a rapid onset of effect is given.
In COPD, respiratory symptoms (breathlessness, wheeze) do not occur in “attacks” (such as in asthma) and may be present throughout the day. The aim is therefore to control symptoms for as long as possible.
Inhalers which contain long-acting bronchodilators are generally the main treatment. Most commonly, treatment for COPD would begin with long-acting muscarinic antagonists (LAMA), such as tiotropium inhalers (Spiriva or Braltus). If this single medication is not enough, a combination inhaler containing two different bronchodilators will be prescribed (LAMA + LABA in the same inhaler). Common dual bronchodilator inhalers include Anoro Ellipta, Ultibro Breezhaler and Spiolto Respimat.
If COPD is more advanced or there are frequent flare-ups (exacerbations), inhaled corticosteroids can be added to the bronchodilator medication. This is because in these cases there is a more significant element of airway inflammation. Inflammation is not normally the hallmark of COPD (unlike in asthma).
Asthma and COPD overlap is a syndrome in which COPD symptoms are present (breathlessness, wheeze, cough) but they are quite variable (which would be more consistent with asthma). In these cases, as the diagnosis of asthma vs. COPD is not as clear, the preference is to opt for treatment that would also be suitable for asthma. This is because there is quite significant airway inflammation, and this would require treatment to prevent attacks. It may be risky in these cases to treat only with bronchodilators – i.e. with inhalers only designed for COPD (which do not contain inhaled corticosteroids).
4) The duration of effect is important
The reliever effect of bronchodilators may be needed for a shorter or longer time. This plays a key role in choosing the right inhaler.
In mild cases of asthma, we tend to need quick relief for only a short period of time (once the asthma attack passes, the bronchodilator effect is no longer needed as breathing returns to normal). The same is true for exercise-induced asthma, when a short-acting reliever may be taken just before engaging in intense physical activity to prevent an attack.
However, in more severe cases of asthma, some level of bronchodilation may be required all the time, therefore long-acting bronchodilators would be preferred. In the vast majority of cases, the long-acting bronchodilator is given in combination with an inhaled corticosteroid in the same inhaler. In asthma, this combination is much safer than the long-acting bronchodilator on its own. The inhaled corticosteroid provides background asthma control, while the long-acting bronchodilator gives symptom relief.
In COPD, breathlessness is not as variable and generally present throughout the day. Here we would prefer treating with long-acting bronchodilators, sometimes even combining two different ones in the same inhaler for maximum effect. Long-acting bronchodilators can work for up to 12 or 24 hours, requiring only once or twice daily inhaler use.
Some ultra-long-acting bronchodilators are currently in development, with a duration of action exceeding 24 hours.
5) The onset of the effect is also very important
The bronchodilator effect can occur faster or slower depending on the medication used.
For instance, in asthma, a quick onset of action is needed to stop an attack. In the case of salbutamol (Ventolin), which is a short-acting bronchodilator, the effect is noticeable within a few minutes from administration. Some longer-acting bronchodilators such as formoterol (contained in Symbicort and Foster) also have a rapid onset of action, within 5-10 minutes. This allows formoterol-based inhalers to be used as relievers if needed (as part of a MART – maintenance and reliever treatment plan – see details above in Section 3).
There are differences in how quickly certain bronchodilators act to relieve breathlessness. For example, salmeterol, although being similar to formoterol (they are both LABAs – both long-acting), has a slower onset of the bronchodilator effect. Salmeterol (contained in Seretide) therefore cannot be used as part of a MART plan, and a rapid action reliever is also prescribed in this case (such as Ventolin).
The MART strategy is not suitable for all patients and not necessarily superior. Other factors such as the ability to use certain inhalers better than others, or biological differences between people may dictate which strategy is the best, on a case-by-case basis. Some people feel great on a Seretide controller, while others feel better on a Symbicort controller. There is no set rule, as long as asthma control is achieved.
6) The need for inhaled corticosteroids
In asthma and a few other conditions there is active inflammation in the airways and controlling it with inhaler treatment will control the symptoms. Controlling inflammation is essential to preventing asthma attacks which can sometimes be quite severe (and lead to hospitalization).
Inhaled corticosteroids can either be prescribed on their own (e.g. Clenil inhaler) or in a combination inhaler (with a bronchodilator – many options are available).
Despite the bad reputation of corticosteroids, the risks of inhaled corticosteroids are minimal. Very low doses are needed to treat airway disease and the medication is designed to exert most of its effects in the airways, preventing absorption to the rest of the body. Inhaled corticosteroids can be used safely for extremely long periods of time (many years). Overall, they are very well tolerated and lead to massive improvements in asthma and other inflammatory airways diseases.
Inhaled corticosteroids can sometimes also be used in COPD to control flare-ups (in patients who experience many such exacerbations or have more severe forms of disease).
7) Particle size
Inhalers can produce either a fine mist (aerosol) or may contain a dry powder for inhalation. The different devices will produce smaller or larger particles according to their design. These particles will deposit at different depths within the airway, depending on their size.
Small particles will penetrate deeper into the lungs, to the level of the small bronchioles (tiny airways that only have a smooth muscle wall structure, without any cartilage to keep them open). Asthma is one example of a condition that mostly affects the bronchioles, therefore the more medication can be delivered to these deeper parts of the lungs, the better. The choice of inhaler, as well as good inhaler technique are key to achieve this deep deposition within the lungs, for maximum effect.
Larger particle size inhalers will be better at treating the larger airways. This may be useful in the case of occupational lung disease, where the airways may have been affected by inhaling various dusts. T
While in practice choosing an inhaler based on its particle size may not be always feasible, it may prove useful in some cases. It is an opportunity to personalize treatment.
8) Device choice
We are lucky to currently have a very large choice of inhaler devices. The most suitable inhaler depends a lot on patient preference, taking into account the ability to use it effectively. Several things need to be considered, including the presence of arthritis, hand and finger size, how well you are able to operate the various parts of the inhaler, breathing coordination etc.
Most people who suffer with respiratory disease will use several devices in their lifetime. A treatment plan may include one or more different inhalers.
Generally speaking, there are 2 main types of inhalers:
1. Metered dose inhaler (MDI)
These are the “puffers” such as Ventolin which have a pressurized canister in a plastic holder. When pressing onto the bottom of the canister, a spray of aerosol is released from the opposite end. Many patients still prefer this type because it requires minimal inspiratory effort to administer the medication. However, effective use can be more difficult for “beginners”. They require a good amount of coordination to release the medication just as you are breathing in.
One advantage of MDIs is that in most cases they can be attached to a spacer device. A spacer is a chamber in which the “puff” can be released prior to inhalation. It is a way to increase the effectiveness of inhalers and reduce the potential for certain side effects (such as voice hoarseness with incorrect administration of inhaled corticosteroids).
2. Dry powder inhaler (DPI)
These inhalers do not release medication on their own. They contain a small amount of powder which is inhaled during a forceful breath in. There are very many types of DPIs and their engineering can be quite complex:
- Some will contain the powdered medication in a small capsule that needs to be loaded into the inhaler and pierced prior to inhalation. Examples include Spiriva Handihaler, Ultibro Breezhaler etc.
- Others will have a two-step action before they are ready to be used (1 – open the inhaler cover, then 2 – press a small lever or twist something to arm the inhaler, then inhale). Examples: Seretide Diskus, Symbicort Turbuhaler, AirFluSal Forspiro and others.
- Some only have a one-step action (i.e. opening the cover also arms the inhaler, making it ready for use). Examples: Foster NextHaler, DuoResp Spiromax, Anoro Ellipta etc.
9) Inhaler technique
The ability to use the inhaler correctly is the most important aspect of choosing certain devices over others. Without proper inhaler technique, the medication will not be inhaled deep into the airways where it needs to act.
Many people unfortunately do not use inhalers correctly, generally through no fault of their own. The most common issue is when patients are prescribed a new inhaler with insufficient instructions on how to use it correctly. In my experience as a pulmonologist, unless a healthcare provider actually takes the time to demonstrate the correct technique to the patient, the likelihood of correct use is extremely low. You need to see how it is done.
Another problem is when the inhaler is not a good match for the patient’s ability to use it. One example would be to prescribe a very complicated inhaler device to someone with advanced osteoarthritis in their hands. Another example is to recommend an inhaler which requires a lot of inspiratory force to release the medication to someone who really struggles to take deep breaths in.
I have said it before, the best inhaler is the one which the patient is able to use correctly and contains the required medication for their condition (even if it is not the most cutting-edge device).
Inhaler technique is briefly described below. I have many videos on my YouTube channel demonstrating how to use most inhalers. I do encourage you to see the actual demonstrations, as they will make a lot more sense than just a text-based description.
The biggest difference is how to use metered-dose inhalers (MDIs) versus dry powder inhalers (DPIs).
1. Metered-dose inhaler (MDI) technique
- You should get your inhaler ready and only start inhalation after you have completely emptied your lungs of air (breathe out and hold)
- Starting with empty lungs, start a slow inhalation AND
- Just as you are starting to breathe back in trigger the release of the medication from the inhaler and continue inhaling slowly and deeply to the top
- Hold your breath at the top for 10 seconds or as long as comfortable and then slowly release the air.
In other words, you are trying to catch the “puff” as you are slowly taking in a full breath.
You need to fully empty your lungs before you trigger the inhaler. If you do not take a full breath, the medication will not reach deep within the lungs. You need to trigger the release of the medication at the very start of the big breath in, and to continue inhaling slowly to get it all in.
If you breathe in too fast, the “puff” tends to just spray the back of your throat rather than going deep within the lungs. Sometimes you can tell that your inhalation was not ideal because you can taste a lot of the medication.
Practice makes perfect! Take your inhaler to your doctor’s appointments and show them your technique to get feedback. Ask for a demonstration if possible.
Remember it is a good idea to remove any remaining medication from your mouth and throat after finishing the inhalation. You can simply use some water, rinse your mouth, gargle the water and then spit it out. This is especially important if you are using inhaled corticosteroids in your inhaler.
2. Dry powder inhaler (DPI) technique
- You need to first get your inhaler ready for inhalation. This may include putting a capsule in, pressing a lever, twisting a part of the inhaler, or some other action to arm it ready for use (depending on the device).
- Only start inhalation after you have completely emptied your lungs of air (breathe out first and hold)
- Starting with empty lungs, breathe in forcefully (!) and deeply from the inhaler
- Hold your breath at the top of the breath for 10 seconds or as long as comfortable and then slowly release the air.
In other words, for DPIs, you are taking a strong breath in to get the powder to move. You want to get it all within a single forceful breath in.
If you breathe in too slowly, only some of the dry powder medication will be inhaled. If you do not fully empty your lungs prior to inhaling, the medication will not reach the deeper parts of the lungs.
Some dry powder medication may not have a taste.
Practice makes perfect! Take your inhaler to your doctor’s appointments and show them your technique to get feedback. Ask for a demonstration if possible.
Remember it is a good idea to remove any remaining medication from your mouth and throat after finishing the inhalation. You can simply use some water, rinse your mouth, gargle the water and then spit it out. This is especially important if you are using inhaled corticosteroids in your inhaler.
Conclusion
As you can probably understand, choosing the right inhaler is a complex process.
Usually, your doctor will recommend a small range of inhalers which may be useful in your case. Sometimes there may not be as many options as you may want, either because of the condition being treated, inhaler availability in your region, or cost.
Once you and your doctor decide on the inhaler, the most important thing is to learn how to use it correctly. Good inhaler technique may require a bit of practice, do not feel guilty if you cannot use it perfectly the first few times. Most inhalers are prescribed for long-term use, therefore just try to work on continuously improving your technique (bring your inhaler to consultations and ask for feedback).
The main point is to inhale the medication deep within the airways (it has no effect if it stays in your mouth or throat). The optimal technique for inhalation will differ between inhaler devices.
If your lung disease is stable under your current inhaler, there is usually no need to over-optimize by constantly changing inhalers. This may actually worsen disease stability. Remember that many inhalers do the same thing but just use different devices. Your doctor will generally try to personalize your treatment as much as possible.
