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Tuesday, May 12, 2015

New recommendations for instructing inhalers

The following was originally published on June 19, 2014, at

One of the neat things about participating in this asthma community is when we gain access to new wisdom we can share it.  That said, there appears to be new guidelines regarding how to use inhalers.

The new information is regarding the following questions:
  1. How long do I need to wait between puffs of my inhaler?
  2. If I have more than one inhaler, which one do I need to take first?
I first learned how to use an inhaler in 1980.  Back then, and even as recently as 1995, when I attended respiratory therapy school, I was taught that you should wait one to five minutes between puffs of your rescue inhaler (such as albuterol).  The reason I was given:

“The first puff opens up your lungs, and the second puff does the mop up job.”

Many times over the years I have shared this wisdom, as recently as April in my post “How to Properly Use an Inhaler,”and May in my post “What is a Spacer?”  

Likewise, I was taught that when you have more than one inhaler, you should always use your rescue inhaler first.  The reason here was because the rescue inhaler opens up your lungs, making your other inhalers (Qvar, Serevent, Azmanex, Spiriva, etc.) work better.  

This wisdom, based upon science and practical experience, appears to no longer be valid.  So, what are the new answers to our questions?

1.  How long do you need to wait between puffs of your inhaler  The new wisdom is that you do not have to wait between puffs.  However, you will need to use the inhaler properly.  The experts at Partners Healthcare: Asthma Center explain:

"If you were to use your inhaler several times in rapid succession, without any pause between "puffs," it might begin to deliver medication erratically. Due to evaporation, cooling takes place at the metal nozzle of the canister, possibly interfering with its precise functioning and exact delivery of the same amount of medication each time. However, with slow, careful inhalations followed by brief breathholding, enough time elapses between puffs to prevent any problems. There is no justification for the recommendation to wait one full minute between inhalations. No benefit derives from delaying one minute before taking the next "puff" from your metered-dose inhaler, only added frustration and impatience with your medications."

Dr. Phil Lieberman, writing for The American Academy of Allergy, Asthma and Immunology (AAAAI) takes this a step further.  He said:

"As far as the interval between puffs, one to two minutes is usually adequate for all inhalers, regardless of whether or not you are taking a second puff of the same inhaler or using an inhaler containing a different drug. One minute is usually considered the minimal wait, and two minutes is certainly adequate as far as the mechanics are concerned."

So, while you don’t necessarily have to, the ideal answer to this question may be to play it safe by waiting a minute or two between puffs.  

2.  If you have more than one inhaler, what one do you take first? The asthma experts at Partner’s Healthcare explain that they no longer recommend using a rescue inhaler before other inhalers.  They explain:

"For one thing, you would have to wait 5-10 minutes or more for the beta-agonist bronchodilator (an example of which is albuterol) to work fully before continuing with your antiinflammatory inhaler. For most people, this delay would be very impractical; time is too precious to wait between doses of medications. For another thing, in most circumstances the bronchial tubes are sufficiently wide open to permit delivery of the antiinflammatory medication without any need for pre-treatment with a bronchodilator."

The experts at AAAAI answer this question this way:

"There are no well-documented, definitive answers to your questions. However, the literature has dealt with this issue to some extent.

"First, it is doubtful that the order of administration regarding the types of inhalers used makes a great deal of difference. It has been postulated that bronchodilators should be administered prior to inhaled corticosteroids based on the rationale that "opening the bronchial tubes" would permit enhanced deposition of an inhaled corticosteroid. However, adequate bronchodilatation takes time. It is usually not achieved until 15 to 20 minutes after the inhalation of a short acting bronchodilator or formoterol (Symbicort, Dulera) and takes longer after salmeterol (Advair).

"This is usually inconvenient and impractical, and in addition, there is no strong evidence in the literature to suggest that it alters the outcome of treatment favorably. Thus, the order of the administration of two inhalers of different types is of little importance."

Another reason for the change is that, if you take your asthma controller medications every day as prescribed (Advair, Symbicort, Azmanex, Qvar, Dulera, Breo, Spiriva) then you shouldn’t need to use your rescue inhaler (albuterol) unless you are feeling short of breath.  In other words, you should not need to use your rescue inhaler on most days. Therefore, your lungs should be open enough for your controller inhalers to work just fine without the need for taking a rescue inhaler first.

So, let me give you an example here.  Say your doctor prescribes the following inhalers: Albuterol, Advair, and Spiriva. In the past we would recommend taking albuterol first, then Advair, and then Spiriva.  However, based on our modern wisdom, the experts now say it doesn’t matter which one you take first.  In most cases, you shouldn’t need to use your albuterol at all.  

Now, how do we use this new wisdom?   I think that I would continue to teach my patients that, when a medicine that provides quick relief (such as albuterol, Symbicort,and Dulera) is due, I would still recommend using this inhaler first.  I would then recommend taking other bronchodilators (such as Spiriva) second, followed by any other inhalers. But that’s just me because I’m old school.

Just for the record here, as I peruse the various asthma websites on the Internet, I see that many asthma experts continue to use the old recommendations, which I think is just fine.  I think the bottom line here is that you should do what works best for you.  

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