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Edited by Mirabella Chan
Trying to figure out how often to use your inhaler can be like how Goldilocks has to find a bed that’s just right. You shouldn’t use your inhaler too little or too much; it has to be just the right amount for optimal asthma and COPD control.
Now you may be asking, “What is the difference between asthma and COPD?” While they are both chronic inflammatory diseases of the airways and share common symptoms such as coughing, wheezing, and shortness of breath, they are both distinct conditions that require different treatment plans.
In asthma, the main risk factor is a genetically heightened immune response. Asthmatic symptoms are mainly caused by bronchoconstriction, which is the irritation and narrowing of the airways in response to certain stimuli such as environmental irritants. Asthmatic symptoms often fluctuate and are reversible. However, if asthma remains uncontrolled, it may lead to COPD.
COPD (Chronic Obstructive Pulmonary Disease) refers to a group of lung diseases that includes emphysema and chronic bronchitis. In chronic bronchitis, inhalation of irritants causes inflammation of the lungs which triggers the airways to secrete a lot of mucous. As this mucus builds up, it plugs the airways and makes it difficult to breathe. In emphysema, inhalation of irritants leads to destruction of the alveoli, which are tiny structures in your lungs where CO2 is exchanged for oxygen when you breathe. Breathing difficulties occur when alveoli are destroyed and no longer able to efficiently exchange gas. The main risk factor in COPD is tobacco smoke. Unlike asthma, symptoms of COPD are persistent and are not fully reversible. COPD is also associated with increased risk of other illnesses as well as significant morbidity and mortality. This is why it is extremely important for patients with asthma and COPD to understand how to properly use their medications so that the condition does not worsen or progress further.
To figure out what the right balance of inhaler use is, you should first identify which of your inhalers is a “reliever” and which is a “controller.”
Relievers
Relievers are used as needed for quick relief of symptoms. Most are bronchodilators which help to quickly relax and open the airways. There are 2 types of bronchodilators: beta-2-agonists (which relaxes the muscles lining the airways) and antimuscarinics (which inhibits contraction of the muscles lining the airways) – both result in widening the airways. Some relievers also include corticosteroids which help decrease inflammation. Be sure to keep track of how many puffs you’re using and make sure it’s less than the recommended maximum per day!
If you need to use your reliever more than three times per week, it may mean your asthma is not under good control. You may need to temporarily increase your inhaler use as per your asthma action plan; and if there’s no improvement, you should talk to your doctor as they may need to change your inhaler regimen.
Ventolin, Bricanyl (short-acting beta-2-agonist bronchodilator)
Preferred asthma reliever for individuals <12 years old
Symptom relief begins in 1-3 minutes and lasts 4-6 hours
Must be used along with an inhaled corticosteroid controller to maintain asthma control
Side effects with frequent use (over the recommended maximum): fast heart rate, tremor, nervousness, headaches
Maximum puffs per day: 8 for Ventolin, 5 for Bricanyl
Symbicort (inhaled corticosteroid + long-acting bronchodilator)
Preferred asthma reliever for individuals >12 years old
Symptom relief in 3 minutes and lasts 12 hours
Also serves as a controller; can be used alone or with other controllers
Rinse mouth with water after use to prevent oral thrush, a fungal infection that can develop in the mouth due to the powdered drug left in the throat
Maximum 6 puffs on a single occasion, maximum 8 puffs per day
Atrovent (short-acting antimuscarinic bronchodilator)
Reliever in COPD
Symptom relief begins within 15 minutes and lasts 2-4 hours
Maximum 12 puffs per day
May also be used as a controller in COPD in certain cases (see below)
Side effects: Dry mouth, metallic taste
Controllers
Controllers should be used every day to maintain asthma or COPD control, even when you don’t have symptoms. They control inflammation by preventing mucous buildup and swelling, and lower frequency and severity of exacerbations or flare ups.
Products Containing Corticosteroids
Flovent, Advair, Alvesco, Asmanex, Zenhale, Symbicort, Breo, Zenhale, Trelegy
Rinse mouth with water and spit the water out after use to prevent oral thrush
Onset to maximum effects may take up to 4-8 weeks
Note: For asthma, everyone over 6 years old should use a controller inhaler containing corticosteroids along with their reliever, or use Symbicort as a reliever instead.
Ventolin/Bricanyl used alone will not control asthma over the long term and is associated with an increased risk of exacerbations and lower lung function
The controller should be ideally used every day.
Alternatively, the controller can be used whenever a reliever is used for those who don’t have symptoms on most days
Products Containing Antimuscarinics
Spiriva, Anoro, Ultibro, Inspiolto, Duaklir
Used for COPD
Onset to maximum effects may take up to 4-8 weeks
Atrovent
Used as an add-on controller in uncontrolled asthma despite the use of a corticosteroid and long-acting bronchodilator (e.g. Symbicort)
Spacers/Valved Holding Chambers (VHC)
Slows the speed of particles and allows more of drug to get into lungs
Recommended for people that have difficulty coordinating inhalation of metered dose inhalers* such as younger children, older adults, and individuals with a physical disability
Spacer/VCH with mouthpiece is recommended for children 3-6 years old, any child that has difficulty with coordination, and any child using an inhaled corticosteroid metered dose inhaler (Visit this page for instructions on how to use a VHC with a mouthpiece)
VHC with mask is recommended for children <3y years old (Visit this page for instructions on how to use a VHC with a mask)
*A metered dose inhaler (MDI) is one that sprays the drug and is also known as a puffer (e.g. Ventolin HFA).
Bottom Line
In short, relievers are only used as needed but frequent usage can indicate poor asthma or COPD control and also result in side effects. Controllers should be used every day. Your risk for exacerbations increases if you don’t use them or you don’t use them enough. Lastly, spacers and valved holding chambers helps to increase drug delivery to your lungs and are particularly useful for specific populations. Good asthma or COPD control is crucial to preventing the progression of inflammation in the airways, and good inhaler use is key!
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References
Asthma. Canadian Lung Association. Updated March 6, 2019. Accessed February 7, 2021. https://www.lung.ca/lung-health/lung-disease/asthma/medications
Chronic Obstructive Pulmonary Disease (COPD). Canadian Lung Association. Updated November 21, 2019. Accessed February 7, 2021. https://www.lung.ca/lung-health/lung-disease/copd/medication
Global initiative for Asthma. A Pocket Guide for Health Professionals. Global initiative for Asthma; 2020.
Kaplan, A. Asthma in Adults and Adolescents. In: Compendium of Therapeutic Choices. Canadian Pharmacists Association. Updated January 1, 2020. Accessed February 7, 2021. https://myrxtx-ca.proxy.lib.uwaterloo.ca/search
Moore, RH. The use of inhaler devices in children. In: Post T, ed. UpToDate. UpToDate: 2020. Accessed February 7, 2021. www.uptodate.com
