The Best Asthma Inhaler Isn't Always the One Insurance Covers

I've been living with asthma since I was two years old, and I've been a respiratory therapist for nearly 30 years. During that time, I've used just about every type of asthma inhaler imaginable, from the old chlorofluorocarbon (CFC) metered-dose inhalers to today's combination inhalers.

One thing I've learned, both as a patient and as a respiratory therapist, is that not all inhalers work the same for everybody.

That's why I get frustrated when insurance companies, and sometimes hospitals, limit patients to one preferred combination inhaler. The assumption seems to be that if two medications belong to the same class, one can easily replace the other.

But it's not always that simple.

My Experience With Combination Inhalers

For years, I used Advair, a combination of fluticasone and salmeterol. It worked well for me, and I tolerated it without significant side effects.

Then, because of insurance coverage, I was required to switch to Symbicort, which contains budesonide and formoterol.

Both medications combine an inhaled corticosteroid (ICS) with a long-acting beta-agonist (LABA). Both are effective asthma medications. But they contain different drugs, and I noticed a difference.

I experienced more side effects with Symbicort than I had with Advair.

More recently, I tried Breztri, which combines budesonide, glycopyrrolate, and formoterol. Once again, I experienced bothersome symptoms, including jitteriness and palpitations.

I eventually switched back to Trelegy, which contains fluticasone furoate, umeclidinium, and vilanterol. Since making that change, those symptoms have improved.

Trelegy is currently my preferred maintenance inhaler, and thankfully, my insurance covers it.

My experience doesn't prove that formoterol was responsible for every symptom. Other medications, caffeine, and individual health factors can contribute to palpitations and tremors. But the pattern has been consistent enough that I take it seriously.

And I believe patients deserve to have those experiences taken seriously, too.

Not All LABAs Are the Same

Advair contains salmeterol. Symbicort and Breztri contain formoterol. Trelegy contains vilanterol.

All three are long-acting beta-agonists, medications that relax airway smooth muscle and help keep the airways open.

But they aren't identical molecules.

They differ in their pharmacological properties, including onset of action, receptor interactions, duration of activity, and pharmacokinetics.

Formoterol, for example, has a relatively rapid onset of action, whereas salmeterol has a slower onset. That's one reason formoterol-containing ICS combinations can be used in certain maintenance-and-reliever treatment strategies, while salmeterol-containing combinations are not used that way.

Like other beta-agonists, LABAs can cause systemic effects such as tremors, palpitations, and increased heart rate.

A patient might tolerate one LABA very well while experiencing troublesome side effects with another.

That doesn't mean formoterol is a bad medication. It works very well for many patients. In fact, it worked just as well as the other LABAs at keeping my airways open. The problem wasn't its effectiveness. It was the side effects, which I found much harder to tolerate.

It simply means that a medication can work well for one patient and still not be the best choice for another.

The Delivery Device Matters, Too

Another issue that sometimes gets overlooked is the inhaler itself.

There are important differences between dry-powder inhalers (DPIs) and pressurized metered-dose inhalers (pMDIs).

Dry-powder inhalers depend on the patient's inspiratory effort to disperse and deliver the medication. Metered-dose inhalers use a propellant to generate an aerosol.

Both types can deliver medication effectively into the lungs, but their performance depends on factors such as particle size, formulation, inhalation technique, and inspiratory flow.

I remember the transition from the old CFC inhalers to hydrofluoroalkane (HFA) inhalers.

The change was primarily driven by environmental concerns, but it also created opportunities for improved aerosol formulations.

One example was HFA beclomethasone, marketed as QVAR. Its extrafine aerosol formulation demonstrated greater deposition in the peripheral airways compared with older CFC-beclomethasone formulations.

That was an important advancement.

However, greater lung deposition can also influence systemic drug exposure.

When inhaled medication deposits in the lungs, some of it may be absorbed into the pulmonary circulation. With beta-agonists, increased systemic exposure can potentially contribute to side effects such as tremors and palpitations.

That doesn't mean every HFA inhaler produces greater systemic effects than every DPI. Nor does it mean that deeper deposition always results in more side effects.

The specific medication, formulation, dose, and delivery characteristics can all influence how a patient responds.

And that's precisely my point.

You cannot assume two inhalers will behave identically simply because they contain medications from the same therapeutic classes.

The Problem With One-Size-Fits-All Formularies

I understand why insurance companies establish preferred drug formularies.

Healthcare resources are limited, and negotiating lower drug prices can help make medications more affordable.

Hospitals also have legitimate reasons for limiting the number of inhalers they stock, including purchasing costs, inventory management, and staff familiarity with devices.

But those considerations shouldn't automatically outweigh individual patient needs.

Suppose a patient has been well controlled on Advair for years, with minimal side effects. Then an insurance company changes its formulary and requires that patient to switch to Symbicort.

On paper, the substitution may appear reasonable. Both are ICS/LABA combinations approved for asthma maintenance treatment.

But what happens when the patient develops bothersome tremors or palpitations with the replacement?

Should that patient simply be expected to tolerate the symptoms because the preferred medication is cheaper?

I don't think so.

The same issue can arise when hospitals substitute one inhaler for another during an admission.

A formulary alternative may be clinically appropriate for many patients, but individual tolerance, inhaler technique, and previous treatment experience deserve consideration.

A patient who has successfully used one inhaler for years shouldn't have that experience dismissed.

Patients Are Individuals, Not Formularies

As respiratory therapists, we're taught to evaluate the patient, not just the numbers.

The same principle should apply to inhaler selection.

We need to consider whether the medication controls symptoms, whether the patient can use the device correctly, whether the dosing schedule is practical, and whether side effects interfere with treatment.

A medication that works beautifully in a clinical trial may not be the best choice for every individual patient.

And a medication that is theoretically equivalent to another may not feel equivalent to the person taking it.

That doesn't make the patient difficult or noncompliant.

It may simply mean the patient responds differently.

Give Patients and Clinicians Some Flexibility

I'm not arguing that every patient should receive the most expensive inhaler on the market.

I'm not arguing that Advair or Trelegy is superior to Symbicort or Breztri for everyone.

And I'm certainly not suggesting that patients should change their maintenance medications without appropriate medical guidance.

What I'm advocating is flexibility.

If a patient is doing well on a particular inhaler, there should be a good reason to change it.

If a formulary-required substitution causes significant side effects or poorer asthma control, there should be a reasonable way for the patient and prescribing clinician to obtain an alternative without unnecessary obstacles.

And if a patient has been doing well on a particular medication for years, a change in the insurance company's formulary shouldn't make it significantly more expensive to continue that treatment. In my case, I had been doing well on Advair when my insurance company decided to favor Symbicort. I could still get Advair, but my copay increased to $100, compared with just $20 for Symbicort. Eventually, I gave in and switched. As much as I preferred Advair, I simply couldn't justify spending $100 every month for a single inhaler. Unfortunately, that meant switching to a medication that caused side effects I hadn't experienced with Advair.

My own experience has taught me that I tolerate salmeterol- and vilanterol-containing inhalers better than the formoterol-containing combinations I've tried. Another patient might have exactly the opposite experience. And that's okay.

The best inhaler isn't necessarily the one an insurance company prefers. It's the one that provides effective asthma control, with acceptable side effects, that the patient can use correctly and consistently.

After nearly a lifetime with asthma and almost three decades working as a respiratory therapist, that seems like a pretty reasonable expectation.

Apparently Adults Cannot Be Trusted With Albuterol

I walked into the Walmart pharmacy and asked whether albuterol inhalers were finally available over the counter for around thirty dollars. I had heard that they might be.

The pharmacist shook her head. Not in the United States, she explained. If albuterol became available without a prescription, people might buy it and never see their doctor.

Notice the argument.

She did not say albuterol was too mysterious for ordinary people to understand. She did not say it had suddenly become dangerous after more than forty years of widespread use. The concern was that adults might make the wrong decision about their own medical care.

Therefore, somebody else must make the decision for them.

Apparently, struggling to breathe is not enough evidence that you may need a rescue inhaler. First, you must obtain professional permission.

Let me state the obvious before someone accuses me of claiming that albuterol is completely harmless. It is not. Like any medication, it can be overused, and repeated doses can cause tremors. If someone suddenly needs the inhaler far more often than usual or it stops providing relief, that may mean the asthma itself is getting worse and medical attention is needed.

But “this medication can be misused” is not an argument against over-the-counter access. It is a description of nearly every medication sold in the store. If zero risk were the standard, the pharmacy shelves would be empty.

Albuterol is not an experimental drug. It has been used for more than forty years. As a respiratory therapist, I have administered more albuterol treatments than I could possibly count. As a lifelong asthmatic, I have taken more than I could possibly count, too. Other than Breathin Stephen, I rank second in lifetime albuterol doses.

So that gives me lots of credibility.

In hospitals, we sometimes give treatments back-to-back or even continuously during severe attacks. Those patients are monitored, of course, but albuterol itself is one of the most familiar and thoroughly understood rescue medications in respiratory care history. Over decades of clinical use, we have learned that the side effects of albuterol are essentially negligible.

The real issue is not whether albuterol is perfectly safe. Nothing is perfectly safe.

The issue is whether capable adults should be trusted to make informed decisions for themselves.

The standard defense of the prescription requirement assumes that denying someone albuterol will somehow drive that person into a doctor’s office. But a prescription requirement does not provide insurance, create an available appointment, arrange transportation, pay the office bill, or eliminate social anxiety.

It merely creates another obstacle.

The person who cannot afford a doctor does not suddenly acquire one because Walmart refuses to sell him an inhaler. He may simply go home without the doctor and without the albuterol.

How is that safer?

The human math is not complicated:

It is far better for someone to have affordable albuterol and no doctor than to have neither.

Some people may want advice from a pharmacist, and pharmacists should certainly be available to help them. But advice should be available, not compulsory. I should not have to request permission or endure a lecture every time I purchase a medication I have used safely for decades. And Lord knows I do get them. 

Place clear dosing instructions on the package. Include prominent warnings explaining that frequent use, worsening symptoms, or declining effectiveness requires medical attention. Tell people about the possible side effects.

Then put the inhaler on the shelf.

Give adults the information and allow them to decide what is best for themselves. That is not recklessness. It is personal responsibility.

We trust adults to make consequential decisions every day. Breathing should not be the exception.

Is Modern "Health Insurance" Even Insurance Anymore?

Let’s be honest about what insurance is supposed to be.

Take car insurance. When your car needs an oil change, new tires, brake pads, or a replacement alternator, you generally pay for it yourself. Routine maintenance and predictable repairs are your responsibility.

The actual insurance is there for the expenses you could never reasonably absorb on your own—totaling your car in a major collision, seriously injuring someone, or being sued after an accident.

Health insurance, as it operates today, is nothing like that.

Rather than serving primarily as protection against catastrophic medical bills, it has become an enormously expensive and heavily managed prepayment plan. It is expected to cover routine appointments, minor illnesses, maintenance medications, preventive care, and countless other everyday expenses.

Now imagine if your auto insurance covered oil changes and windshield wipers—but required your mechanic to obtain prior authorization from a desk jockey three towns away before replacing your transmission.

You would immediately recognize that the system was absurd.

Yet that is essentially how American healthcare works. A third-party payer is inserted into nearly every transaction, from a routine office visit to a maintenance inhaler. Doctors and hospitals must employ armies of billing specialists, medical coders, insurance negotiators, and prior-authorization experts just to get paid for providing care.

Insurance companies then employ their own armies of workers to review, delay, approve, or deny those claims.

Every layer adds cost. Every layer adds friction. And eventually, patients pay for all of it through higher premiums, larger deductibles, copays, coinsurance, and medical bills.

Yes, healthcare has other cost problems too: outrageous hospital prices, expensive medications, and massive healthcare systems with little competition. But forcing nearly every healthcare dollar through an enormous administrative bureaucracy makes all of those problems worse.

The irony is that people can pay thousands of dollars a year for health insurance and still be unable to afford to use it. They pay the premium, then face a deductible so high that routine care remains effectively out of reach. If they do need treatment, they may still have to fight the insurer for permission to receive it.

That is not how genuine insurance is supposed to work.

Real insurance pools risk so that nobody is financially destroyed by cancer, a heart attack, a serious accident, or another medical catastrophe. Routine and predictable care should be transparent, competitively priced, and affordable enough to purchase without navigating a maze of claims and approvals.

Instead, we have created a prepayment plan wrapped in red tape—one that tries to manage every doctor visit and prescription while making protection against genuine catastrophe increasingly unaffordable.

And patients are footing the bill for the entire machine.

RT Creed: HFNC Has to Prevent Lung Collapse... Right?

From the Desk of the RT: When Surgeons Play Physicist

Published in the Real RT News

Well, sometimes we get interesting orders. Today we got one for a High-Flow Nasal Cannula by a surgeon to prevent a lung from collapsing when the patient has a hemothorax. Apparently, there's a belief that you can just blow some warm, humidified air up a patient's nose and somehow magically vacuum or push blood out of the pleural space like you're clearing a clogged sink.

It’s always an adventure when a surgeon channels their inner physicist and forgets basic anatomy. A hemothorax is blood sitting outside the lung in the chest cavity, crushing the parenchyma from the outside. Pumping flow through a nasal cannula isn't going to evacuate fluid, fix the pressure gradient, or act like some sort of magical structural pillar holding the lung open. If a lung is getting squashed by a pool of blood, it needs to be drained—not treated with a piece of plastic tubing delivering liters of room air.

Sure, high-flow can wash out dead space and help with oxygenation while you actually wait for someone to fix the underlying problem, but pretending it prevents a collapse from a hemothorax is a stretch. If we started blowing enough positive pressure down someone's nose to push back against fluid filling up their chest cavity, you'd run into major pressure issues before you ever solved the bleed. At the end of the day, keep trusting your clinical training—because sometimes you just have to chuckle at the orders and let science do the talking.

Page 677: The Hemothorax-High-Flow Pneumatic Shunt Method

(An Excerpt from the Real Physicians Medical Manual in Response to RT Insubordination)

Today I would like to present a brilliant surgical theory as to how we can prevent a lung from collapsing when a patient presents with a hemothorax, specifically in direct rebuttal to local respiratory therapists whining about basic physics. Many times an RT will look at you with utter confusion when you place an order for a High-Flow Nasal Cannula to manage a chest full of blood. You know what I mean? The chest tube is sitting right there, but you decide to bypass it with sheer aerodynamic genius.

RTs will cringe at this because they can't seem to grasp the deeper physics of the upper airway. Shallow minds they have, you might say. Your RT will whine, "The blood is outside the lung! Pumping humidified air up the nose isn't going to evacuate fluid or fix the pressure gradient!"

Once again, ignore their silly rants. You may even add a note on the chart that says something like, "Trust the flow, ignore the blood!" That usually sets the RT in his place. Anyway, I digress.

Surely we doctors think too much and RTs not enough, that's my point. RTs need to stop thinking and just do what they're told, because this technique explains why we prescribe high-flow for a completely external pleural space issue.

It has to do with pneumatic mass-displacement. Think of it like clearing a clogged sink by blowing air through the faucet. By delivering high liters per minute through a nasal cannula, we generate a powerful positive-pressure force that travels all the way down the trachea, punches through the visceral pleura, and magically pushes the pooled blood right back out of the chest cavity.

Get the idea? If you have a hemothorax compressing the lung from the outside, you just turn up the high-flow to act as an internal structural pillar holding the lung open. It doesn't matter that the fluid is in the pleural space and not the alveoli. Surely RTs will cringe at this idea, but who cares what RTs think anyway.

How to accomplish absolutely nothing in six hours as an RT

I have been busy all day. Busy busy. Running all over the hospital. And yet, somehow, I have accomplished absolutely nothing.

My first patient was a Bipap setup. The nurse said he was in distress. I walked in and the guy was pale, gray, diaphoretic, looked like death warmed over, and informed me he was nauseated. 

Now, maybe I’m old fashioned, but slapping a tight-fitting positive pressure mask on a nauseated patient seems like a poor life choice. I had visions of projectile vomit firing directly into the mask while the Bipap enthusiastically redistributed it into the lungs.

So I called the doctor and he agreed. No Bipap.

About a half hour later the patient passed away anyway. So that whole mission sort of ended itself.

Then I got called to do an oxygen walk. These are always exciting because sometimes you discover the patient desperately needs oxygen and qualifies for home O2.

This gentleman started at 94%.

Then I walked him.

His oxygen saturation climbed to 98%.

Apparently ambulation cured him.

So that got nowhere fast.

Next stop: ER breathing treatment. The patient had wheezing, shortness of breath, and what appeared to be another heart-failure episode masquerading as asthma. I gave the breathing treatment anyway because that is what we do in healthcare. We obey the sacred ancient traditions.

Shockingly, the Albuterol did not cure the patient’s failing left ventricle.

Medicine remains mysterious.

Then came Room 5.

A nurse informed me the patient needed Bipap immediately because “his gases are worse.”

Now those words will get an RT moving pretty quickly. So I looked at the blood gases.

pH: 7.40
CO2: 72

Which, if you work with COPD patients long enough, basically translates into: “Tuesday.”

The patient himself denied shortness of breath and looked comfortable.

But the nurse insisted he needed Bipap right now.

At this point I was starving. Not hungry. Hangry. The sort of hunger where you start wondering if oxygen tubing is technically edible.

I briefly considered just throwing the patient on Bipap to end the conversation and move on with my life. But instead I did something I hate doing: I interrupted a physician meeting.

I explained the situation.

And lo and behold, the doctor calmly explained he only wanted nighttime Bipap and wanted to see whether the patient qualified for home Bipap.

In other words, this entire panic originated from poor communication.

Later I told a coworker about the exchange and he said, “She’s as dumb as…”

Well. Never mind. We’re trying to be nice here at the RT Cave.

So here I am, six hours into my shift. I have been everywhere in the hospital. I have sweated. Walked miles. Reviewed gases. Dodged unnecessary Bipap setups. Interrupted meetings. Performed sacred aerosol rituals.

And if you really think about it...

I have accomplished absolutely nothing.

Why I'm Leaving Walgreens?

Back in the 1990s, I hated Walgreens.

I honestly don't remember exactly why anymore. I just remember the pharmacists constantly lecturing me about how often I was using my albuterol inhaler. That always bothered me because I had severe asthma. Of course I was using a lot of albuterol. This was before many of the excellent asthma medications we have today. Back then, albuterol wasn't a rescue medication I occasionally needed. It was often the only thing standing between me and an emergency room visit.

Fast forward a few decades.

After my divorce in 2018, I was using Meijer Pharmacy. The problem wasn't the pharmacists. The problem was the wait. Every time I needed a prescription, I felt like I spent half my life standing in line. Eventually I got tired of it.

At the time, I really wanted to switch to Rite Aid. I had used Rite Aid before and always had good experiences there. Unfortunately, there were already rumors that Rite Aid was headed for trouble. As it turned out, those rumors were true. Rite Aid eventually closed, so I ended up going with Walgreens instead.

To be fair, Walgreens in Ludington was pretty good for several years. I had very few complaints.

Then came COVID.

Something changed after that. Whether it was staffing shortages, increased workloads, vaccines, or a combination of everything, the pharmacy became slower and harder to use. The lines got longer. The drive-thru took forever. Calling the pharmacy often meant listening to a phone ring endlessly.

I tolerated it because, frankly, what other choice did I have?

Then Rite Aid closed.

If the lines were bad before, they became even worse afterward.

Recently, my mom asked me to pick up one of her prescriptions at Walmart. I wasn't expecting much. In fact, I had never seriously considered Walmart Pharmacy before.

Then I walked in.

Three employees were working the counter.

No line.

No waiting.

No frustration.

I remember standing there thinking, Well, this is different.

For the first time, I started wondering if Walmart might actually be the better option.

Then came the final straw.

On July 3, I ordered five prescriptions through Walgreens. Two of them were albuterol medications: an inhaler and nebulizer solution. I paid the extra four dollars to have them delivered. Walgreens advertised delivery in two to three days.

Two weeks later, I still didn't have them.

The website continued to show the prescriptions as "in progress."

I called the pharmacy.

The phone rang.

And rang.

And rang.

Nobody answered.

So I called Walgreens corporate customer service.

They were polite enough, but they couldn't solve the problem.

At that point I found myself asking a simple question:

Why am I still using Walgreens?

If I have to wait thirty minutes in line, wait forever in the drive-thru, struggle to reach someone on the phone, and then wait two weeks for medications that were supposed to arrive in three days, what exactly am I getting in return?

The answer is: not much.

This isn't about one delayed order. Every pharmacy makes mistakes. This is about a pattern I've been watching develop for years.

Good customer service matters.

Communication matters.

When people are waiting for medications—especially medications they rely on to breathe—service matters.

I don't wish Walgreens any ill will. In fact, I remember when they did a pretty good job. But somewhere along the way, the customer experience stopped being good enough for me.

So after years of frustration, I think I'm finally done.

Unless something changes dramatically, my next prescription will probably be heading to Walmart.

And honestly, I should have done it sooner.

So I finally picked up the phone and called Walmart Pharmacy.

"Look, here's my issue," I said, explaining everything that had happened with Walgreens, the delays, the unanswered phone calls, and the missing delivery.

The woman on the other end listened for a moment and then said, "Okay, we'll call Walgreens and transfer your prescriptions over."

I was almost caught off guard by how simple it sounded.

"Is there anything you need from me?" I asked.

"Just your name and date of date of birth and phone number."

That was it.

No arguments. No waiting on hold. No explaining my life story.

A few minutes later, the process was already underway.

Maybe Walmart will be better. Maybe it won't. But at least they're answering the phone.

Right now, that's a pretty good start.

Why Health Insurance Was Invented

We spend a lot of time complaining about health insurance today. Patients hate the premiums, doctors hate the paperwork, and hospitals are constantly fighting over what gets covered. We act like the system is broken, but we’re missing the bigger picture. We assume insurance has always been the standard, but for most of our history, it didn’t exist. It didn’t exist for a simple reason: nobody needed it.

Before the 20th century, if you got sick, the doctor came to your house. They’d look you over, try whatever they could, and you either got better or you didn't. There were no ICUs, no ventilators, and no complex surgeries. Because medicine couldn't do much, it didn't cost much. It was a personal expense, just like groceries. Hospitals weren't treatment centers back then, either; they were mostly places you went to die.

Everything shifted in the early 1900s. Medicine finally started to actually work. We got X-rays, blood transfusions, and better anesthesia. Joseph Lister’s antiseptic techniques changed everything. Hospitals transformed from dying rooms into hubs of life-saving technology. But those advances brought a new reality: high costs. By the 1920s, a hospital stay cost twice as much as it had twenty years before. Hospitals were building new wings and buying fancy tech, but they had a huge problem. They were running on a pay-as-you-go model, and they were lucky to collect 60 cents on every dollar they billed.

Then 1929 hit, and the Great Depression made everything worse. The money dried up, but the patients kept coming. That’s when a guy named Justin Ford Kimball stepped in. He wasn't a doctor; he was a former school superintendent managing Baylor University Hospital’s finances. He noticed teachers were landing in the hospital with huge, unpaid bills they couldn't afford on a teacher's salary. Kimball didn't want the hospital to eat those losses, but he knew the teachers were tapped out. So, he made a deal: if every teacher paid 50 cents a month—six dollars a year—the hospital would guarantee them a set number of hospital days if they got sick.

It worked perfectly. It kept the hospital's revenue steady and gave the teachers peace of mind. It even changed patient behavior because people stopped waiting until they were half-dead to seek care. Other hospitals caught on and copied the model. Before long, these plans all unified under a name you definitely know: Blue Cross.

We need to stop looking at health insurance as some ancient, unchangeable institution. It was a financial hack born out of a desperate crisis. What’s ironic—and what most people forget—is that the American Medical Association and a lot of doctors actually hated the idea at first. They were terrified of third-party interference and wanted to keep medicine a direct, personal transaction between doctor and patient. But once the genie was out of the bottle, it never went back in.

We love to blame insurance companies for the cost of medicine, but the reality is that modern medicine created the insurance industry. Without the high-tech, expensive advancements of the early 20th century, there wouldn't have been a reason to invent this system. When you actually look into it, you realize things aren't the way they are because they’re perfect. They’re the way they are because someone faced a problem and tried to solve it—even if that solution ended up creating the mess we’re dealing with today.