How to Make Sense of Inhaled Medications for COPD

“It’s important now to have an inhaler that’s [specifically] for COPD,” says Jorge Mercado, MD, a pulmonologist at NYU Langone Hospital in Brooklyn, New York. “Treatments have come a long way. We no longer lump asthma and COPD together. We’re able to prescribe treatments now that work on the inflammation in the lungs and open up the airways, which is much better at treating symptoms of COPD.”

Types of Medications Used in Inhalers and Nebulizers for COPD

Some are short-acting medications which work quickly, but also wear off fast, while others are long-acting, which take longer to kick in, but last much longer with fewer side effects.

With the exception of inhaled corticosteroids, most of the medications used in inhalers and nebulizers fall into a class known as bronchodilators.

“The bronchodilators for COPD use a strong propellant that pushes the medicine deep into the lungs where it acts on the glands to reduce secretions of mucus, which allows the airways to open up,” says Dr. Mercado. “When you look at the efficacy of long-term treatments, especially the anticholinergics and the combination inhalers, you see that patients need to use the rescue inhaler less and less.”

Mercado cautions that the leading cause of COPD is smoking, and for a long-lasting inhaler to improve symptoms, the patient needs to kick the habit.

“Quitting smoking is the best course of action,” he says.

Types of Inhalers

Metered-Dose Inhalers (MDIs)

MDIs deliver a specific amount of medication in aerosol form, using a propellant to push the medication out of the inhaler. While they are portable and convenient and deliver a tailored dose, MDIs require coordinated hand and breath control to work properly.

Examples include beclomethasone (QVAR) and albuterol (ProAir, Ventolin, Proventil).

Dry Powder Inhalers (DPIs)

DPIs deliver medication in a powder form that the patient inhales. The force of your inhalation is what disperses the powder into your lungs. While a DPI requires less coordination than an MDI, it demands a strong and deep inhalation effort, which may be difficult for some.

“Some patients just don’t like the dry powder in their mouth either,” says Mercado.

Examples include tiotropium (Spiriva HandiHaler) and salmeterol (Serevent Diskus, Advair Diskus, Trelegy Ellipta, Breo Ellipta).

Soft Mist Inhalers (SMIs)

SMIs use a mechanical spring to produce a fine mist that makes it easy to inhale the medication deeply into the lungs. While an SMI requires a less forceful inhalation than a DPI and less coordination than an MDI, it is a more complex device, which requires more training to master.

Examples include olodaterol with tiotropium (Stiolto Respimat) and ipratropium (Atrovent Respimat).

Types of Nebulizers

You and your doctor may decide that a nebulizer is right for you, especially if you have trouble breathing. Nebulizers deliver a continuous medication mist that lasts several minutes, requiring less coordination of breath to use. However, nebulizers are not very portable and they need to be plugged in to work.

• Jet Nebulizers The most common type of nebulizers, this device uses an air compressor to convert liquid medicine into a fine mist that is inhaled through a face mask or mouthpiece. Examples include arformoterol (Brovana) and formoterol (Perforomist).
• Mesh Nebulizers Instead of using an air compressor, these devices push the liquid medication through a vibrating mesh, where it is converted into the mist you breathe in.
• Ultrasonic Nebulizers These nebulizers create high-frequency vibrations that turn liquid into aerosol or mist that is inhaled.

How to Select the Right Inhaler

Several factors help match a person to the right inhaler, including personal preference, disease severity, convenience, and the person’s ability to use it. Just how comfortable someone is with a device may influence how long they are willing to stay on it or how frequently they use it.

• A: No Exacerbations, Minimal Symptoms People in this stage have occasional breathlessness and may only need a short-acting inhaler.
• B: No Exacerbations but Experiencing Symptoms Here, people have increased breathlessness and need more symptom control at first. This is when you may require a long-lasting inhaler or a combination therapy.
• E: Having Exacerbations This is when someone has exacerbations and will require them to have both a combination inhaler and a short-acting rescue inhaler. People with severe impairment may do better with nebulized therapies.

“In general, I see patients on the more severe end of the scale, so I like to start them on a high-efficacy combination inhaler and see how they respond,” says Mercado. “Then we can taper down and start to decline the dose or change medicines.”

How to Avoid Common Inhaler Mistakes

• Slouching, which doesn’t allow lungs to fully inhale
• Using an empty inhaler or not shaking the canister
• Holding it improperly
• Not placing in the mouth properly
• Inhaling the medicine too quickly

Mercado adds that incorrect inhaler technique can not only reduce the effectiveness of the medication, but also increase the risk of side effects such as throat irritation or oral thrush.

“The medicine will only get deep into the lungs and do what it is supposed to do if the patient uses the inhaler properly,” says Mercado. “That’s why we spend a lot of time with the patient to make sure they understand how to use the inhaler and we practice with dummy and sample inhalers to make sure they feel comfortable with the proper techniques.”

If you are prescribed a nebulizer to use, practice using it with your doctor and the office staff before taking it home. It is also helpful to read and follow the instructions that come with your device.

Cost and Coverage

Side Effects and Risks

• Nervousness or shakiness
• Throat or nasal irritation
• Headaches
• Heart palpitations or a rapid heart rate

Always report any side effects to your provider, who can evaluate your inhalation technique and adjust your treatment plan as needed.