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
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
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.
PRESSURIZED METERED DOSE INHALERS (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.
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
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.
DRY POWDERED INHALERS (DPIs)
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.
DPI Type 1. Medication is contained within the device
Turbuhaler (also known as Flexhaler).
Several medications are delivered via the tubuhaler, including the steroid
(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).
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.
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
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
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
(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.
a long acting bronchodilator, comes in this device (shown below).
For instructions on how to use the aerolizer, see
National Jewish Hospital web site.
PROPELLANT-FREE "SOFT MIST" INHALERS
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 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:
Dulera (Merck) (mometasone + formoterol; DOSES: 100/5 and 200/5, 2 puffs twice a day)
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.
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.
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).
A patient performing the spirometry test
Graphs from a normal spirometry test; left panel, graph of flow vs. volume; right panel, graph of time vs. volume.
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
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
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.
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
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
The problem with alternative remedies is two-fold:
They are not proven effective for people with air flow
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
"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
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,
Books About Asthma and Sinusitis
(With links to Amazon.com. Books listed in reverse order of publication)