Inhaled Medications: How to Use Inhalers for Asthma and COPD

What Are Inhaled Medications and How Do They Work?

Inhaled medications are drugs that you breathe in through your mouth using a device called an inhaler. The medication travels directly to your airways and lungs, where it works locally to open breathing passages, reduce inflammation, or fight infection. This targeted delivery makes inhaled medications highly effective while minimizing side effects elsewhere in the body.

Inhaled medications represent one of the most important advances in treating respiratory diseases. Unlike pills or injections that must travel through your entire body to reach the lungs, inhaled medications go directly where they're needed. This direct delivery system means lower doses can be used, and the medication starts working faster—often within minutes for bronchodilators.

The principle behind inhalation therapy is elegantly simple yet scientifically sophisticated. When you inhale medication, tiny particles or droplets enter your respiratory system and deposit on the surfaces of your airways and lung tissue. The size of these particles determines where they land: larger particles (greater than 5 micrometers) tend to deposit in the upper airways and throat, while smaller particles (1-5 micrometers) reach the smaller airways and alveoli deep in the lungs where gas exchange occurs.

The medications used in inhalers come in different forms including powders, sprays, and liquid solutions. Each form requires a specific type of inhaler device and technique. Understanding these differences is essential for getting the full benefit from your prescribed treatment.

Why Are Inhaled Medications So Effective?

The effectiveness of inhaled medications stems from several key advantages over other delivery methods. First, the medication reaches the target tissue directly, meaning therapeutic concentrations can be achieved in the lungs with doses that would be too small to have much effect if taken orally. Second, because less medication enters the general bloodstream, there are fewer systemic side effects. Third, the onset of action is typically much faster than oral medications.

For someone experiencing an asthma attack, a rescue inhaler can provide relief within 15-30 seconds, whereas an oral medication might take 30 minutes or more to have any effect. This rapid action can be life-saving in emergency situations.

Common Conditions Treated with Inhaled Medications

The primary conditions treated with inhaled medications are asthma and chronic obstructive pulmonary disease (COPD). However, inhalers are also used for other respiratory conditions including bronchiectasis, cystic fibrosis, and certain respiratory infections. In hospital settings, nebulized medications are frequently used for acute respiratory distress and other critical conditions.

What Are the Different Types of Inhalers?

The three main types of inhalers are metered-dose inhalers (MDIs) that use a propellant to deliver medication as a spray, dry powder inhalers (DPIs) that release medication when you breathe in forcefully, and nebulizers that convert liquid medication into a fine mist for extended breathing. Each type requires different techniques and has specific advantages for different patients.

Choosing the right inhaler depends on many factors including your age, breathing ability, coordination, and the specific medication prescribed. Healthcare providers consider these factors carefully when recommending an inhaler type. Understanding the differences helps you use your device correctly and communicate effectively with your healthcare team about any difficulties you experience.

Metered-Dose Inhalers (MDIs)

Metered-dose inhalers are the most commonly prescribed type of inhaler worldwide. They consist of a pressurized canister containing medication dissolved or suspended in a propellant, fitted into a plastic actuator with a mouthpiece. When you press the canister, a precise "metered" dose of medication is released as a fine aerosol spray.

The key challenge with MDIs is coordination—you must press the canister at exactly the right moment while breathing in slowly and deeply. Studies consistently show that many patients struggle with this coordination, which is why spacers are often recommended. A spacer is a holding chamber that attaches to the MDI and holds the medication cloud, allowing you to breathe it in at your own pace without needing precise timing.

Modern MDIs use hydrofluoroalkane (HFA) propellants, which replaced the older chlorofluorocarbon (CFC) propellants that damaged the ozone layer. HFA inhalers may feel slightly different—the spray may feel softer and warmer—but they deliver medication just as effectively.

Dry Powder Inhalers (DPIs)

Dry powder inhalers contain medication in powdered form and rely on your own breath to draw the powder into your lungs. Unlike MDIs, there's no propellant—you activate the dose by breathing in quickly and forcefully through the device. This eliminates the coordination challenge but introduces a different requirement: you must be able to generate sufficient inspiratory flow to disperse the powder properly.

DPIs come in many designs. Some are single-dose devices where you load a capsule before each use. Others are multi-dose devices that contain 30, 60, or even 200 doses in a built-in reservoir. Examples include Turbuhaler, Diskus, Ellipta, Breezhaler, and Easyhaler. Each design has specific loading and inhalation instructions that must be followed precisely.

A critical rule for DPIs: never exhale into the device. Moisture from your breath can clump the powder and block the mechanism. Always breathe out away from the inhaler before placing it in your mouth.

Nebulizers

Nebulizers are devices that convert liquid medication into a fine mist that you breathe in through a mask or mouthpiece over several minutes. They don't require coordination or strong breathing effort, making them suitable for very young children, elderly patients, or anyone who cannot use handheld inhalers effectively.

Nebulizers are commonly used in hospitals and emergency departments for acute breathing problems. Some patients also use nebulizers at home for daily treatment, particularly those with severe disease or difficulty using other devices. The main drawbacks are that nebulizers are bulky, require a power source, take longer to deliver medication (typically 10-15 minutes), and need regular cleaning to prevent contamination.

How Do You Use an Inhaler Correctly?

Correct inhaler technique varies by device type, but all methods share core principles: prepare the device, breathe out completely before inhaling, coordinate medication release with breathing in, and hold your breath for about 10 seconds after. For MDIs, breathe slowly and deeply; for DPIs, breathe in quickly and forcefully. Always follow your specific device instructions and have your technique checked regularly.

Proper inhaler technique is perhaps the most important factor in successful treatment of respiratory conditions. Research consistently shows that 70-80% of inhaler users make at least one significant error that reduces the amount of medication reaching their lungs. Even experienced patients can develop poor habits over time, which is why regular technique reviews are essential.

The consequences of poor technique are not trivial. When medication doesn't reach the lungs effectively, symptoms may not be controlled, leading to more frequent attacks, increased use of rescue medications, emergency department visits, and hospitalizations. Many patients who believe their medication "isn't working" actually have excellent medication—they simply aren't using their inhaler correctly.

Using a Metered-Dose Inhaler (MDI)

The metered-dose inhaler requires careful technique to ensure the medication spray and your inhalation are perfectly synchronized. Here is the step-by-step process:

1. Prepare the inhaler: Remove the cap and check the mouthpiece for debris. If the inhaler is new or hasn't been used for several days, prime it by releasing one or more sprays into the air (check your specific inhaler instructions for priming requirements).
2. Shake vigorously: Shake the inhaler well for about 5 seconds to mix the medication with the propellant. This step is crucial for consistent dosing.
3. Breathe out completely: Standing or sitting upright, breathe out gently but fully, emptying your lungs. Do not breathe out through the inhaler.
4. Position the inhaler: Place the mouthpiece between your teeth and close your lips firmly around it to create a seal. Keep your tongue flat and out of the way.
5. Start breathing in slowly: Begin breathing in slowly and steadily through your mouth.
6. Press and continue inhaling: Almost immediately after starting to breathe in, press down firmly on the canister to release one puff. Continue breathing in slowly and deeply until your lungs are completely full.
7. Hold your breath: Remove the inhaler from your mouth and hold your breath for 10 seconds, or as long as comfortable. This allows the medication particles to settle in your airways.
8. Breathe out slowly: Exhale gently through your nose or pursed lips.
9. Wait before repeat dose: If you need a second puff, wait 30-60 seconds before repeating the process.

Using a Dry Powder Inhaler (DPI)

Dry powder inhalers require a different technique than MDIs. The key difference is that you must breathe in quickly and forcefully to draw the powder into your lungs—the opposite of the slow, steady breath used with MDIs. Here is the general process:

1. Prepare the device: Load or prepare the dose according to your specific device instructions. This may involve twisting, clicking, opening, or loading a capsule.
2. Breathe out completely: Before putting the inhaler to your mouth, breathe out fully. NEVER exhale into the device—moisture will damage the powder.
3. Seal your lips: Place your lips firmly around the mouthpiece to create a tight seal.
4. Inhale quickly and deeply: Breathe in as quickly and deeply as possible through your mouth. You should hear or feel the medication being released.
5. Hold your breath: Remove the inhaler and hold your breath for 10 seconds or as long as comfortable.
6. Breathe out slowly: Exhale gently away from the device.
7. Close the device: Replace any covers or close the device as directed.

Using a Nebulizer

Nebulizers are the simplest to use in terms of breathing technique, but they require more setup and maintenance. The general process involves:

1. Assemble the nebulizer: Connect the tubing, medication cup, and mask or mouthpiece according to the device instructions.
2. Add medication: Place the prescribed amount of medication solution into the nebulizer cup. Do not exceed the recommended fill line.
3. Position yourself: Sit upright in a comfortable position.
4. Start the nebulizer: Turn on the compressor. You should see a fine mist coming from the mask or mouthpiece.
5. Breathe normally: Place the mask over your nose and mouth or put the mouthpiece between your lips. Breathe slowly and deeply through your mouth. Occasionally take a deep breath and hold it for a few seconds.
6. Continue until finished: The treatment is complete when no more mist is produced, typically after 10-15 minutes.
7. Clean the equipment: After each use, rinse the nebulizer cup and mouthpiece with warm water and let air dry.

What Types of Medications Are Delivered by Inhalers?

The main categories of inhaled medications are bronchodilators (which open the airways) and anti-inflammatory drugs (which reduce swelling and mucus). Bronchodilators include short-acting relievers for quick symptom relief and long-acting medications for daily control. Inhaled corticosteroids are the cornerstone of asthma treatment, reducing inflammation and preventing attacks. Many patients use combination inhalers containing both types.

Understanding your inhaled medications helps you use them appropriately and recognize when something isn't working as expected. The medications fall into several categories based on how they work and when they should be used.

Short-Acting Bronchodilators (Relievers)

Short-acting beta-agonists (SABAs) like salbutamol (albuterol) and terbutaline are the classic "rescue" medications. They work within seconds to minutes by relaxing the muscles around the airways, providing quick relief from acute symptoms like wheezing, coughing, and breathlessness. These medications are used "as needed" rather than on a regular schedule.

If you find yourself using your rescue inhaler more than twice a week (other than before exercise), this is a sign that your underlying condition isn't well controlled and you should consult your healthcare provider about adjusting your maintenance treatment.

Long-Acting Bronchodilators (Controllers)

Long-acting beta-agonists (LABAs) like salmeterol and formoterol, and long-acting muscarinic antagonists (LAMAs) like tiotropium, provide sustained airway relaxation for 12-24 hours. These are maintenance medications used regularly to prevent symptoms, not for acute relief. LABAs should almost always be used in combination with an inhaled corticosteroid, not alone, due to safety concerns.

Inhaled Corticosteroids (ICS)

Inhaled corticosteroids like fluticasone, budesonide, beclomethasone, and mometasone are the most effective long-term controllers for asthma. They reduce inflammation in the airways, decrease mucus production, and reduce airway hyperresponsiveness. Unlike oral steroids, inhaled corticosteroids have minimal systemic side effects when used at appropriate doses.

These medications take days to weeks to reach full effect, so they must be used consistently even when you feel well. Stopping them because you "feel fine" often leads to gradual worsening and eventual flare-ups.

Combination Inhalers

Many patients benefit from combination inhalers that contain two or even three medications in a single device. Common combinations include ICS plus LABA (such as fluticasone/salmeterol or budesonide/formoterol) and triple therapy combinations containing ICS, LABA, and LAMA. Using a combination inhaler simplifies treatment regimens and can improve adherence compared to using multiple separate inhalers.

What Are the Side Effects and How Can You Prevent Them?

Common side effects of inhaled medications include oral thrush, hoarse voice, throat irritation, and tremors (from bronchodilators). Most side effects can be prevented or minimized through proper technique: rinsing mouth after corticosteroids, using a spacer with MDIs, and avoiding common technique errors. Serious side effects are rare when inhalers are used correctly at prescribed doses.

One of the major advantages of inhaled medications is their excellent safety profile compared to oral or injected alternatives. Because the medication acts locally in the lungs, much lower doses can be used, and less medication enters the general circulation. However, side effects can still occur, particularly with long-term use or poor technique.

Side Effects of Inhaled Corticosteroids

The most common side effects of inhaled corticosteroids are local effects in the mouth and throat. Oral candidiasis (thrush) occurs when the corticosteroid suppresses local immune function, allowing yeast overgrowth. It appears as white patches in the mouth and can cause discomfort. Dysphonia (hoarseness) results from steroid effects on the vocal cords. Both can be largely prevented by rinsing the mouth after each use and using a spacer device.

At higher doses, there is potential for systemic effects including skin thinning, easy bruising, and effects on bone density with very long-term use. However, these risks are much lower than with oral corticosteroids and must be balanced against the benefits of well-controlled asthma, which itself causes health risks when untreated.

Side Effects of Bronchodilators

Short-acting bronchodilators commonly cause tremor (shakiness), palpitations (awareness of heartbeat), and sometimes headache. These effects are usually mild and diminish with continued use. They result from the medication's stimulant-like effects on the nervous system and heart.

Long-acting bronchodilators generally cause fewer immediate side effects but may contribute to cardiovascular effects in susceptible individuals. Patients with significant heart disease should discuss inhaler choices carefully with their healthcare provider.

Prevention Strategies

• Use a spacer with MDI corticosteroids: This reduces medication deposition in the mouth and throat by up to 90%
• Rinse and gargle after corticosteroids: Rinse your mouth thoroughly with water and spit it out after every use
• Use the lowest effective dose: Work with your healthcare provider to find the minimum dose that controls your symptoms
• Maintain good technique: Regular technique checks help ensure medication reaches the lungs, not the throat
• Report persistent side effects: Many alternatives exist if one medication causes problems

What Are Common Mistakes When Using Inhalers?

The most common inhaler errors include not shaking MDIs before use, exhaling into DPIs, breathing in too fast with MDIs or too slow with DPIs, not holding breath after inhalation, not using a spacer when recommended, forgetting to rinse after corticosteroids, and using an empty inhaler. Studies show 70-80% of patients make at least one critical error that significantly reduces medication delivery.

Despite appearing simple, inhalers require careful technique that many patients never fully master. Understanding common mistakes helps you avoid them and get the full benefit from your treatment.

MDI-Specific Errors

• Failing to shake before use: The medication separates from the propellant and must be remixed
• Poor coordination: Pressing the canister before or after breathing in, rather than simultaneously
• Breathing in too fast: Rapid inhalation causes medication to impact the back of the throat rather than reaching the lungs
• Not using a spacer: When coordination is difficult, a spacer dramatically improves delivery
• Stopping inhalation when pressing: You should continue breathing in steadily after pressing

DPI-Specific Errors

• Exhaling into the device: This introduces moisture that clumps the powder
• Breathing in too slowly: DPIs require fast, forceful inhalation to disperse the powder
• Not loading the dose correctly: Each DPI has specific loading steps that must be followed
• Using when wet: Never store DPIs in humid environments like bathrooms

General Errors

• Not breathing out first: Full exhalation before inhaling allows deeper medication penetration
• Not holding breath: A 10-second breath hold allows particles to settle in the airways
• Using empty or expired inhalers: Check dose counters and expiration dates regularly
• Not rinsing after ICS: This simple step prevents the most common side effects
• Incorrect maintenance: Inhalers need regular cleaning according to manufacturer instructions

How Do Children Use Inhaled Medications?

Children under 5 typically use MDIs with a spacer and face mask, allowing normal breathing rather than requiring coordination. Children aged 5-8 can usually use MDIs with a spacer and mouthpiece. Older children may use DPIs if they can generate sufficient inspiratory flow. Nebulizers are an option for any age when other devices aren't suitable. Technique training and parental supervision are essential.

Delivering inhaled medication to children presents unique challenges due to their smaller airways, inability to perform complex breathing maneuvers, and difficulty understanding instructions. Age-appropriate device selection and proper technique training are crucial for effective treatment.

Infants and Toddlers (0-3 years)

The youngest children cannot coordinate breathing with medication delivery or use a mouthpiece effectively. The standard approach is an MDI with a spacer fitted with a face mask. The mask creates a seal over the nose and mouth, and the child simply breathes normally while the parent holds the mask in place. Typically 5-10 normal breaths are taken after each puff to ensure the medication is inhaled from the spacer chamber.

Preschoolers (3-5 years)

Children in this age group may begin to cooperate with breathing instructions but still need a spacer. Some can transition from a face mask to a mouthpiece, which is more efficient for medication delivery. Parents should make the process positive and game-like, perhaps using phrases like "big breaths like blowing out birthday candles."

School-Age Children (6+ years)

Most children over 6 can learn to use MDIs with spacers effectively and may transition to DPIs if they can demonstrate sufficient inspiratory flow (typically tested by a healthcare provider). However, technique should be verified regularly as children may take shortcuts or develop poor habits over time.

Regardless of age, children should begin taking more responsibility for their inhaler use as they mature, with parental supervision gradually decreasing. Adolescence presents particular challenges as teens may resist using inhalers in front of peers or skip doses when away from parental oversight.

How Should You Store and Maintain Your Inhaler?

Store inhalers at room temperature away from heat, humidity, and direct sunlight. Never leave inhalers in cars where temperatures can become extreme. Keep the cap on when not in use to prevent contamination. Clean the mouthpiece weekly according to manufacturer instructions. Check expiration dates and dose counters regularly, and replace empty or expired inhalers promptly.

Proper storage and maintenance ensure your inhaler works correctly when you need it. Medication degradation, contaminated mouthpieces, and empty canisters can all compromise treatment effectiveness.

Storage Guidelines

Keep your inhaler at room temperature, typically between 15-25°C (59-77°F). Extreme temperatures can affect medication potency and the performance of propellants in MDIs. Never leave inhalers in a car—summer heat can cause canisters to burst and cold can affect propellant function. Avoid storing inhalers in humid environments like bathrooms, particularly dry powder inhalers which are moisture-sensitive.

Cleaning Your Inhaler

Different inhaler types have different cleaning requirements:

• MDIs: Remove the canister and rinse the plastic actuator weekly with warm water. Let it air dry completely before reassembling.
• DPIs: Never wash with water. Use a dry cloth to wipe the mouthpiece. Follow specific manufacturer instructions.
• Nebulizers: Clean the cup and tubing after each use with warm soapy water. Disinfect weekly according to manufacturer instructions. Replace consumable parts regularly.

Tracking Doses and Expiration

Many modern inhalers have built-in dose counters that show how many doses remain. If your inhaler doesn't have a counter, mark the start date and keep track of uses. The old method of floating the canister in water is inaccurate and can damage the inhaler—don't use it.

Check expiration dates regularly and replace expired medication. Even if an inhaler seems to have doses remaining, medication potency decreases after the expiration date, and the device may not function correctly.

When Should You Seek Medical Help?

Seek immediate emergency care if your rescue inhaler doesn't relieve severe breathing difficulty, if you cannot speak in full sentences due to breathlessness, if your lips or fingernails turn blue, or if you need your rescue inhaler more than every 4 hours. Contact your healthcare provider if you use your rescue inhaler more than twice weekly, wake at night with symptoms more than twice monthly, or experience side effects from your inhalers.

Knowing when your symptoms represent a routine fluctuation versus a serious problem requiring medical attention is crucial for safety. Inhaled medications are highly effective, but they cannot resolve all breathing problems, and delays in seeking appropriate care can be dangerous.

Signs Your Condition Needs Review

You should schedule an appointment with your healthcare provider if you experience any of the following, which suggest your current treatment may need adjustment:

• Using your rescue inhaler more than twice per week (except for exercise)
• Waking at night with symptoms more than twice per month
• Needing to limit normal activities due to breathing
• Having symptoms most days despite regular controller medication
• Experiencing side effects from your inhalers
• Running out of controller medication before your next appointment