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10 Common Misconceptions & Errors in Treating Asthma

Lawrence Martin, M.D.
Clinical Professor of Medicine
Case Western Reserve University School of Medicine
Cleveland, Ohio

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These 10 common misconceptions & errors in treating asthma are based on many years' experience taking care of adult asthma patients. Note that this list of misconceptions & errors applies to patients and doctors.

1. Thinking a written prescription for an asthma inhaler means the patient knows how to use it: The device itself.

There are many different kinds of asthma inhalers on the market. (Many of these inhalers are also prescribed for COPD, or chronic obstructive pulmonary disease; see yellow box below).

It is a mistake to write a prescription for an inhaler unless the patient already knows how to use it or is given a demonstration. None of the inhalers is intuitive as to how to use, in contrast to a pill or tablet which must merely be swallowed to be effective. For each inhaler, the patient must make some maneuver which, if not done correctly, means the medication is not inhaled properly or in sufficient amount. Mis-use of inhalers is a major and well-documented problem that occurs across the entire spectrum of patients. The problem stems from the plethora of inhaler types (lack of standardization), their inherent complexity (relative to swallowing a pill), and lack of training about how to use them among both caregivers and their patients.

If there was just one or two types of inhaler, health care providers (and by extension, their patients) would become very famililar with them and there would be less confusion than currently exists. Unfortunately there are many different types of asthma inhalers. The poster above displays only a partial list of inhalers asthma patients may receive.

NOTE: Several of these inhalers are FDA-approved for "COPD" (chronic obstructive pulmonary disease) and not, technically, for "asthma." For example, Spiriva is approved for COPD (chronic bronchitis and emphysema), and not asthma. Approval is based on the population of patients studied, as required by the FDA.

Generally, "asthmatics" are younger, have never smoked and their lung function returns to normal with maximum treatment. Generally, "COPD patients" are older, have a long smoking history, and their lung function does not return to normal with maximum treatment. However, there is a lot of overlap between "COPD" and "asthma" with many patients having features of both conditions. As a result, patients with chronic or difficult asthma -- who may never have been labeled as having "COPD" -- are often prescribed medications approved only for COPD. It is up to the physician to decide what medication is best for his/her patient.

Inhalers can be broadly classified into three groups:
  • Pressurized metered dose inhalers (pMDIs)
  • Dry powder inhalers (DPIs)
  • Propellant "soft mist" inhalers.
These three groups are described below, starting with pMDIs.


By pressing the cannister down into its plastic housing, pMDIs deliver (under pressure) a spray of medication from the mouthpiece. You can spray the medication into the air and see it as a fine mist, but of course the mist is supposed to be inhaled by the patient, whose mouth should be on on the plastic mouthpiece at the time of delivery (see picture below). The patient must inhale deeply and at the right time in order to get all of the medication delivered into the lungs.


pMDIs are the most common type of inhaler in the US; most of the inhalers shown on the poster above are pMDIs. Short acting bronchodilators are typically delivered via MDIs. To use this device you must inhale immediately after pressing the canister down into the plastic housing, as shown. This maneuver requires some coordination: squeezing the fingers together while making a deep inhalation with the device held tightly between your lips. Some people do it well, but many others exhale when they press down on the canister, so the medication doesn't enter the lungs.

Click here for information on how to use the pMDI

What about spacers for metered dose inhalers?

Spacers have long been used with pMDIs to make it easier for patients to inhale the medication. Another name for spacers is aerosol-holding chambers. Two examples are shown below: a rigid plastic spacer on the left and a collapsible spacer. The pMDI inserts in one part of the spacer and the patient inhales from a chamber that holds the medication. When the pMDI is compressed the medication aerosol enters the spacer and the patient can breathe normally via a mouthpiece without the need to closely coordinate inspiration with medication release. There are many different types of spacers available.


Pros: Spacers makes it easier to inhale the medication, helping assure that it enters the lungs and not the room environment or just the back of the throat. The Asthma Society of Canada recommends that anyone using a puffer consider a spacer.

Cons: They are bulky to carry around, and often not availble when needed (women can put them in a purse; not so for men). The aerosol medication can adhere to the chamber wall, lessening the amount available for treatment. Spacers need to be cleaned or replaced, adding expense to treatment regimen.

Bottom Line: If the pMDI is used as intended, there should be no need for a spacer. They seem to be most useful for children needing a pMDI. Only a small minority of adults regularly use a spacer with their pMDI.


With DPIs the patient's breath (rather than hand action) actuates delivery of the medication. You cannot see the spray because the only way to get the medication is to inhale it from the mouthpiece. Within the DPI category, there are two broad types:

DPI Type 1): the medication is contained within the inhaler device at all times, until inhaled, or

DPI Type 2): the medication comes in a separate capsule that must be placed into the inhaler device at the time of use.

One study that received wide publicity showed that up to 1/3 of patients use DPIs incorrectly. The error rate increased with patient's age, and correlated with lack of instruction to the patient.

DPI Type 1. Medication is contained within the device

  • Turbuhaler (also known as Flexhaler). Several medications are delivered via the tubuhaler, including the steroid Pulmicort (shown below; the manufacturer, Astra Zeneca calls their device a "Flexhaler," just another name for turbuhaler). The turbuhaler requires you to twist the dark cap shown at the bottom in order to activate the next inhalation. The turbuhaler (flexhaler) eliminates the type of coordinated effort needed for traditional MDIs, since once activated all you have to do is inhale from the mouthpiece. However, the bottom cap can twist both right and left, and it's not obvious which way activates the flexhaler. Thus some patients twist it so as to close the chamber, preventing delivery of medication when they inhale. For instructions on how to use the turbuhaler/flexhaler, see:
    National Jewish Hospitals web site
    Asthma Society of Canada web site
  • Twisthaler is another plastic device that contains dry powdered medication. Like the turbuhaler, the bottom cap (in this case pink; see picture below) must be twisted to prepare the medication for delivery by breath inhalation. Asmanex, an inhaled steroid, is delivered via a twisthaler (see below). When you inhale (after twisting the cap), the twisthaler automatically releases the medication. As with the other DPIs, when inhaled correctly the medication is delivered properly. For instructions on how to use the twisthaler, see National Jewish Hospital web site

  • Diskus inhaler (see below). Advair and Serevent come in this 'flying saucer' inhaler. The Diskus inhaler requires sliding two different levers on the side, one to activate the medicine for delivery and the other to open the channel so the medication can be inhaled. Each lever is accompanied by a 'click' and the patient is suppose to make sure there are "two clicks" each time they prepare to use the inhaler. However, many patients only do one click,which means the inhaler may actually be closed when they breathe in, so no medicine is delivered. For instructions on how to use the diskus inhaler, see:
    National Jewish Hospital web site
    Asthma Society of Canada web site

  • Diskhaler (see below). The diskhaler is not available in the United States, but is used in Canada, England and other countries. Serevent is one of the medications that comes in a diskhaler. The diskhaler is somewhat of a hybrid between the two types of DPI, in that the medication comes prepackaged on a disk, with each disk containing 8 separate doses. The disk is inserted into the inhaler, and only needs replacement after the 8 doses are used up. The patient need never touch the medication itself. For instructions on how to use the diskus inhaler, see:
    Asthma Society of Canada web site
    Serevent Diskhaler

  • Pressair inhaler (see below). The drug Tudorza comes in the latest type of dry powder inhaler called "Pressair." The full name of the drug is "Tudorza Pressair," with Tudorza being the drug and Pressair being the type of inhaler. Tudorza was approved by the FDA in July 2012 for treatment of bronchospasm associated with chronic obstructive pulmonary disease or COPD. (Technically Tudorza Pressair is approved only for COPD, not asthma. However, many patients with"asthma" also have chronic lung disease and are prescribed Tudorza.). The drug is inside the inhaler, ready to use as soon as the patient presses the large green button at the back of the inhaler; this action changes a small window in the front from red to green (see photo). The patient then inhales from the mouthpiece with enough effort to change the window color back to red; this action is also signified by a reassuring 'click'. Note that gentle inhaling won't do it. If the patient does not hear the 'click', the window does not change from green to red and the patient did not receive the drug. (Studies have shown that even patients with severe COPD can easily inhale with enough force to get the drug.) Tudorza is designed to be inhaled twice a day (one inhalation each time). Details of how to use Tudorza can be found in the Tudorza drug information (scroll down for drawings).


    DPI Type 2. Medication is separate from the inhaler, in a capsule

    • Handihaler (see below). The widely used drug Spiriva (tiotropium bromide) is delivered in this device. (Technically Spiriva is for chronic obstructive pulmonary disease, not asthma. However, many patients with"asthma" also have chronic lung disease and are prescribed Spiriva.) With the handihaler (as with the aerosolizer, below), the actual medication resides apart from the device, in capsules that are individually packaged. The patient must: retrieve the capsule from its wrapping, place it into the chamber of the handihaler, close the chamber with a cap, then pierce the capsule by pushing hard on a lever to the side of the handihaler. It's a lot of steps! Furthermore, there are anecdotal reports of patients who swallow the capsule instead of putting into the chamber for puncture. The drug works well IF the patient is instructed how to use the device and can perform the required maneuvers. Without adequate instruction, proper use is unlikely.For instructions on how to use the handihaler, see National Jewish Hospital web site.

    • Aerolizer. Like the handihaler (discussed above), the aerolizer consists of a plastic device to inhale medication. A capsule of powdered medication is placed in the device and its delivery is breath activated. Foradil, a long acting bronchodilator, comes in this device (shown below). For instructions on how to use the aerolizer, see National Jewish Hospital web site.

    • Foradil


    This is the latest type of inhaler for asthma and COPD. At this writing there is only one soft mist inhaler marketed in the United States, Combivent Respimat, shown in the photo.
    Combivent Respimat Combivent has long been available in a different format, with CFC (chlorofluorocarbon) propellant. The Respimat device does away with the propellant and delivers the drug as a fine mist. Why the change in delivery system? According to the drug company's web site:

    Under the Clean Air Act, the Food and Drug Administration (FDA) has ordered products containing certain propellants, including COMBIVENT MDI, to be removed from the market. COMBIVENT RESPIMAT does not contain any of these harmful propellants and uses a spring mechanism to release the medication. Supplies of COMBIVENT MDI may run out in the second quarter of 2013. For more information on the Clean Air Act and CFCs, see this information from the Food and Drug Administration.

    NOTE: Combivent is marketed for COPD, but many patients "with asthma" use it as well. Unlike the FDA, physicians can't and don't strictly categorize patients with airway obstruction into "COPD" and "asthma." In adult patients the conditions frequently overlap.

    As to the Respimat delivery system, it is anticipated that other drugs will soon be released using the device. As with ALL inhalers, its use is not intuitive, and patients should be shown at least once how to use the device. This can be done by the physician, nurse, medical assistant or pharmacist. The company gives placebo devices to physicians for demonstration purposes.

    NOTE: When these inhalers -- pMDIs, DPIs, Respimat "soft mist" -- are tested in drug studies there is virtually unlimited support and follow up to assure the study patients use them correctly. This support is funded by the drug companies, who obviously want to know if the medication is effective, so they spend whatever it takes to make sure the enrolled patients are properly instructed and know how to use the inhalers. That level of education and support for inhaler use is seldom available in clinical practice, resulting in discrepancy between the effectiveness of the drug in published studies vs. the real world. The medication itself may be good but the delivery system is complicated and prone to mis-use; as a result, improperly-used inhalers are often the 'weak link' in treating a patient's lung disease.

    2. Thinking a written prescription for an asthma inhaler means the patient knows when to use it: The drug's purpose.

    For treatment purposes all asthma inhalers fall into one of two broad categories:

    a) to provide quick relief ('rescue inhalers') and
    b) to improve chronic symptoms and prevent flareups ('maintenance inhalers').

    Examples of rescue inhalers are albuterol (brand names Proventil HFA, ProAir HFA, Ventolin HFA). levalbuterol (brand name Xopenex), and ipratropium bromide (brand name Atrovent). Combivent contains a combination of albuterol and ipratropium bromide. Although Combivent is marketed (and FDA-approved) for COPD, in fact patients often use it as a rescue inhaler as well.

    Maintenance inhalers include any inhaled steroid (IS), either alone (brand names Azmacort, Qvar, Pulmicort, Flovent, etc.) or in combination with a 'long acting bronchodilator' (LABD). Brand names of available combination IS-LABD products are:

    PROBLEM: The SAME type of delivery device (size, shape, mechanism of action) is commonly used for both rescue and maintenance inhalers. For example, as shown below, ProAir HFA (a rescue inhaler, on left) and Symbicort (a maintenance inhaler, on right) both come packaged as pressurized metered dose inhalers, and both are deep red in color. There is nothing intuitive about this. For a patient who may have both inhalers (quite common), and who becomes short of breath, it is all too easy to forget which is which.

    ProAir Symbicort

    This confusing situation happens often, even when the rescue and maintenance inhalers are of different color. The root problem is lack of standardization among inhalers, with unclear labeling to distinguish between rescue and maintenance inhalers. A contributing cause is lack of proper education for both the caregivers and their patients. All too often proper instructions were not given when the drug was first prescribed. And even when they are provided, patients sometimes don't really understand, or they forget. Either way, having similar inhalers for different purposes is an invitation to error. (This was less likely to be a problem when the drug was studied by the drug companies; see YELLOW BOX above, under 'DPI Type 2'.)

    The problem is compounded when patients are on multiple inhalers, eg, Proventil for rescue, Advair and Spiriva for maintenance. That's 3 separate devices with two different purposes -- easy for the patient to get confused. (Pills and capsules come in many colors and sizes, but they are all swallowed the same way.) What's needed is a universal delivery device for all inhalers, with perhaps just two colors: red for rescue drugs and green for maintenance drugs.

    Anyone with clinical interest in the inhaler problems discussed above (Errors 1 & 2) should definitely read Problems With Inhaler Use: A Call for Improved Clinician and Patient Education, by James B. Fink and Bruck K. Rubin (Respiratory Care, Sept 2005, Vol 50, No. 10, pages 1360-75).

    3. Not checking some objective measurement of the patient's air flow obstruction.

    Every patient should have a breathing test to ascertain the degree of impairment caused by the asthma. The most frequently performed test is 'spirometry', which takes just a few minutes and requires the patient to exhale forcefully thru a testing device (shown below).
    spirometry testing A patient performing the spirometry test

    spirometry graphs
    Graphs from a normal spirometry test; left panel, graph of flow vs. volume; right panel, graph of time vs. volume.

    Spirometry can be a valuable test in diagnosing and managing respiratory patients. The following article (in 2 parts) is for respiratory therapists, nurses, physicians and anyone else who may be responsible for ordering and/or interpreting spirometry.
    The Value of Spirometry in Clinical Practice, Part 1, June 2010
    The Value of Spirometry in Clinical Practice, Part 2, July 2010

    4. Missing the diagnosis of asthma because of "clear lung fields" on exam.

    A patient can have clear lungs if the exam is done only during quiet breathing. The examiner places the stethoscope over the lungs and pronounces them 'clear - no wheezing.' In fact wheezing may be heard, but only after a deep breath followed by a forceful exhalation. Here the problem is simply an inexperienced care giver (physician, nurse, nurse practioner, etc.). Many asthmatics with 'clear lung fields' on exam in fact have wheezes that are claerly heard only at the end of a forced exhalation.

    5. Smoking while suffering from asthma.

    I see many patients who continue to smoke while complaining of cough or shortness of breath. Sure, they admit to being addicted, or "I just can't stop", but there is still no excuse. Smoking could be a major contributor to episodes of wheezing and shortness of breath (what we generally call 'acute bronchitis'). Also, smoking greatly retards recovery, since cigarette smoke impairs clearing of mucus from the lungs. I tell my patients it's like complaining of a headache while banging your head with a hammer. Duh!

    6. Fear of prescribing oral steroids.

    Doctors are often reluctant to prescribe oral steroid medication (prednisone, methylprednisolone), yet many times it is the only drug that will effectively treat the patient's asthma. Instead, all too often physicians prescribe the latest inhaled steroid (IS) or long acting bronchodilator (LABD) or a combination IS+LABD inhaler. These drugs (all non-generic and expensive) have a definite role in asthma treatment maintenance, but not in treating the patient whose symptoms are acute, progressive or interfering with daily activity.

    If a patient in the office has wheezing and/or asthma symptoms interfering with daily acivity, I will usually prescribe a 'tapering' course of prednisone, e.g.
    • 20 mg tablets 3 times a day for 3 days, then
    • 20 mg tablets 2 times a day for 3 days, then
    • 20 mg tablets one a day for 3-5 days, then the drug is discontinued
    This 9 to 11 day course is safe and does not lead to the long term side effects of steroids that are rightly feared: weight gain, diabetes, weakening of bones, eye probems. More often than not patients will respond with elimination of symptoms and wheezing. At that point decision can be made about continuing treatment with inhaled medication.

    7. Over-using antibiotics to treat asthma.

    In adults, bacterial infections are almost never the cause of asthma exacerbations, and antibiotics are rarely needed. The most common triggers of an asthma attack in adults are viral infection, allergens (pollen, animal fur, etc.), and irritants (fumes, dusts, etc.), none of which responds to an antibiotic. An antibiotic may be needed if the patient has sinusitis or smoking-related chronic bronchitis.

    8. Not looking for other causes or precipitants of wheezing and shortness of breath when asthma medication is ineffective.

    Asthma starts in the lungs and almost always leads to wheezing. However, not all wheezing starts in the lungs or is 'asthma'; The problem may arise elsewhere in the body. Examples:
    • Congestive heart failure is fluid buildup in the lungs from heart disease, which can then cause wheezing. Diagnosis is usually not difficult, and starts with a detailed history, physical exam and chest x-ray. Treatment of so-called 'cardiac asthma' is different than traditional asthma, and must be directed to the heart problem.
    • Sinusitis is often present in many chronic asthmatic conditions, and requires treatment before the asthma can be improved; the best test to uncover sinusitis is a sinus CT scan. The figures below illustrate sinusitis, which can either lead to asthma or cause asthma symptoms to continue despite treatment. The drawing shows mucous in the left maxillary sinus (behind the left cheek bone). The sinus CT scan below the drawing shows extensive mucous in the patient's right maxillary sinus (patient facing you), and also a lesser amount of mucous in the left maxillary sinus. sinusitis
      normal sinus CT scan maxillary sinusitis Left image: normal CT scan of sinuses. Right image: CT scan showing maxillary sinusitis, with large fluid collection in the patient's right maxillary sinus and lesser amount of fluid in the left maxillary sinus.

    • Acid reflux can cause wheezing by spilling over of acid from the stomach into the lungs. In addition to treating the asthma medication is used to help control the acid (eg, proton pump inhibitors). In the most severe cases the patient may need a surgical procedure to prevent the acid reflux
    • Upper airway obstruction can cause wheezing. Here the problem is in the neck area (trachea, voice box), not the lungs. Tumors, vocal cord disease and other conditions in the upper airway can causes wheezes that sound like they are coming from the lungs; treatment with asthma medications usually has no benefit.

    9. Not considering environmental factors in managing asthma.

    Occupational asthma is a common problem, and should always be considered when evaluating an adult with asthma. The home environment (plants, animals, molds) may also trigger an asthma attack, either thru direct irritation or via an allergy mechanism. While treatment is usually the same regardless of precipitating causes, if triggers can be identified it is of paramount importance to avoid them. This may be difficult if one's livelihood is causing asthma, or even one's pets. (I have been more successful in getting patients to change offending jobs than in getting rid of offending pets.)

    10. Letting the asthma attack continue without getting proper treatment, or substituting holistic treatment for medication.

    In fact, many patients suffer too long before seeking medical treatment. The longer the asthma attack continues the more refractory it becomes. Patients have died because they didn't seek medical attention for symptoms that lasted days. After seeing a physician for treatment, patients must be encouraged to either call if they are not responding or go to an urgent care center or emergency department if they are getting worse.

    There are also plentiful "natural remedies" or "holistic treatments" for asthma, promulgated in books and on the internet. An excellent review of natural remedies is found at About.com: Natural Remedies for Asthma. Good web sites about natural or holistic remedies always carry a disclaimer, such as About.com's: "If you are experiencing symptoms of asthma, it's important to see your doctor to be properly diagnosed. Although alternative therapies haven't been shown to be as promising for asthma as they have for other conditions..."

    The problem with alternative remedies is two-fold:
    1. They are not proven effective for people with air flow obstruction;
    2. They may give a false sense of security while the asthma either doesn't improve or worsens.
    About.com lists 8 alternative remedies for asthma. One in particular that has received much attention is the Buteyko breathing method. This is based on the false assumption that hyperventilation -- literally, blowing off CO2 -- perpetuates asthma, and that by controlling one's breathing, asthma can be controlled or improved. This techniqe was developed by Russian-born researcher Konstantin Pavlovich Buteyko. It consists of shallow-breathing exercises designed to help people with asthma breathe easier. According to About.com:

    "The Buteyko Breathing Technique is based on the premise that raising blood levels of carbon dioxide through shallow breathing can help people with asthma. Carbon dioxide is believed to dilate the smooth muscles of the airways."

    That explanation is physiologic nonsense, not least because people cannot elevate their CO2 level to above normal. Furthermore, the Buteyko method has never been proven to work. National Institutes of Health Asthma Guidelines state: "The Expert Panel concludes there is insufficient evidence to suggest that breathing techniques provide clinical benefit to patients who have asthma." Yet the myth persists, and you can even buy an e-book on the technique at Amazon.com.

    Note that critcism of Buteyko and other alternative treatments pertains to symptomatic asthma. If you have a history of asthma, but are not currently having symptoms (shortness of breath, coughing, wheezing), and want to use an holistic method for relaxation or to reduce stress, that's fine. Another breathing technique promulgated for this purpose is yoga (specifically, pranayama).

    Books About Asthma and Sinusitis

    (With links to Amazon.com. Books listed in reverse order of publication)

    92 Tips for Dealing with the Symptoms and Treatment of Asthma, by Emily Kingfisher, Create Space, 2010.

    No More allergies, asthma, or sinus infections, Dr. Lon Jones, Freedom Press, 2010.

    The Allergy and Asthma Cure: A Complete 8-Step Nutritional Program, Fred Pescatore, MD, Wiley, 2008.

    Asthma-free naturally, Patrick McKeown, Conari Press, 2008.

    The Asthma Sourcebook, 3rd ed., Francis V.Adams, MD, McGraw Hill Books, 2007.

    The Sinus Cure: 7 Simple Steps to Relieve Sinusitis and Other Ear, Nose and Throat Conditions, Debra Fulghum Bruce PhD and Murray Grossan, MD, Ballantine Books, 2007.

    Sinus Relief Now: The Groundbreaking 5-Step Program for Sinus, Allergy and Asthma Sufferers, Jordan S. Josephson, MD, Perigee Trade, 2006.

    Asthma for Dummies, William E. Berger, MD, For Dummies, 2004.

    The Children's Hospital Guide to Asthma, Julian Lewis Allen, editor. Wiley, 2004.

    The Harvard Medical School Guide to Healing Your Sinuses, Ralph B. Metson, MD, and Steven Mardon, McGraw Hill, 2004.

    The Harvard medical School Guide to Taking Control of Asthma, Christopher H. Fanta, Lynda M. Cristiano, Kenan Hayer, Free Press, 2003.

    Forward any comments to: Lawrence Martin, M.D.

    Asthma home page | 10 Common Errors in COPD Management | Chronic Cough home page | Lakesidepress home page | Subject Index for all web sites

    Copyright © Lawrence Martin, M.D.
    Initially posted December 2008; Last revised December 21, 2012