Inhalers for Chronic Obstructive Pulmonary Disease (COPD)

The drugs inside inhalers

The drug inside an inhaler goes straight into the airways. Therefore, you need a much smaller dose than if you took the drug as a tablet or liquid by mouth. The airways are treated, but little of the drug gets into the rest of the body. So, side-effects are unlikely to occur, or are minor.

In the treatment of COPD, the drugs inside inhalers can be grouped into 'short acting bronchodilators', 'long acting bronchodilators' and 'steroids'. It can get confusing as there are different brands of some types of inhaler made by different companies. Also, for some drugs there are different inhaler devices that deliver the same drug.

Short acting bronchodilator inhalers

An inhaler with a bronchodilator drug is often prescribed. These relax the muscles in the airways (bronchi) to open (dilate) them up as wide as possible. They include:

• Beta agonist inhalers. For example, salbutamol and terbutaline.
• Antimuscarinic inhalers. For example, ipratropium.

These inhalers work well for some people, but not so well for others. Typically, symptoms of wheeze and breathlessness improve within 5-15 minutes with a beta agonist inhaler, and within 30-40 minutes with an antimuscarinic inhaler. The effect from both types typically lasts for 3-6 hours. Some people with mild or intermittent symptoms only need an inhaler 'as required' for when breathlessness or wheeze occur. Some people need to use an inhaler regularly. The beta agonist and antimuscarinic inhalers work in different ways. Using two, one of each type, may help some people better than using one type alone.

Long acting bronchodilator inhalers

These include the beta agonist drugs called formoterol and salmeterol, and the antimuscarinic drug called tiotropium. They work in a similar way to the short acting inhalers, but each dose lasts at least 12 hours. One may be an option if symptoms remain troublesome despite taking a short acting bronchodilator.

Sometimes a combination of a short acting and a long acting inhaler is used. Sometimes a combination of both types of long acting inhaler is used. This is mainly used for people with more severe symptoms, or for people who have frequent flare-ups of symptoms.

Steroid inhalers

A steroid inhaler may help in addition to a bronchodilator inhaler if you have more severe COPD or regular flare-ups (exacerbations) of symptoms. Steroids reduce inflammation. There are several brands of steroid inhaler. A steroid inhaler may not have much effect on your 'usual' symptoms, but may help to prevent flare-ups.

Inhaler devices

Different inhaler devices suit different people. They can be divided into four groups.

• Pressurised MDIs (Metered Dose Inhalers)
• Inhalers with spacer devices
• Dry powder inhalers
• Nebulisers

Spacer devices

• If your dose is more than one puff, then do one puff at a time.
• Shake the inhaler before firing each puff.
• Start breathing in from the mouthpiece as soon as possible after firing the 'puff' into the device.
• Try to hold your breath for a few moments when you have breathed in.
• Breathe in and out a few times before firing the next puff. Try to hold your breath for a few moments each time you breathe in.
• Check that the valve opens and closes with each breath.
• 'Static charge' can build up on the inside of the plastic chamber. This can attract particles of drug, and reduce the output when the spacer is used. To prevent this, wash the plastic spacer as directed by the maker's instructions. This is usually before first use, and then about once a month with washing up liquid and water. Let it dry in air without rinsing or wiping.

Dry powder inhalers

These types of inhaler do not have a gas propellant to 'squirt' the drug out of a canister. Instead, each dose contains a tiny amount of drug in a powder form that you suck in.

Various devices are made by different companies. Each has a different method of providing the correct amount of powder for each dose. Some types are shown below.

Nebulisers

This is a device that generates an aerosol vapour of the drug. There are many types. You need to wear a face mask, or use a mouthpiece to inhale the vapour. You do not need any co-ordination to use these - you just breathe in and out, and you will breathe the vapour in.

Nebulisers are used mainly in hospital for severe attacks of COPD when large doses of inhaled drugs are needed. They are used less commonly than in the past as modern spacer devices are usually just as good as nebulisers for giving large doses of inhaled drugs.

Common questions and further information

Do you get side-effects from inhalers?

Usually not. At standard inhaled doses, the amount of drug is small compared to tablets or liquid drugs. This is one of their main advantages. Read the packet insert for details of possible side-effects.

One problem that might occur when using a steroid inhaler (especially if you are taking a high dose) is that the back of your throat may get sore. Thrush infection in the mouth may develop. This can usually be treated easily with a course of pastilles that you suck or liquid that you hold in your mouth.

If you rinse your mouth with water and brush your teeth after using a steroid inhaler you are less likely to develop a sore throat or thrush. Also, some inhaler devices (such as spacers) are less likely to cause throat problems. A change to a different device may help if mouth problems or thrush occur.br2]
If you use a high dose of inhaled steroid over a long time it may be a 'risk factor' for osteoporosis. You can help to prevent osteoporosis by taking regular exercise, not smoking, and eating a diet with enough calcium. See leaflet called 'Osteoporosis' for details.

Which is the best inhaler device to use?

This depends on various factors such as:

• Convenience. Some inhalers are small, can go easily in a pocket, and are quick to use. For example, the standard MDI inhaler.
• Your age. Some elderly people find the MDI inhalers difficult to use.
• Your co-ordination. Some devices need more co-ordination than others. In particular, the standard MDI.
• Side effects. Some of the inhaler drug hits the back of the throat. Sometimes this can cause problems such as thrush in the mouth. This tends to be more of a problem with higher doses of steroid inhalers. Less drug hits the throat when using a spacer device. Therefore, a spacer device may be advised if you get throat problems, or need a high dose of inhaled steroid.

Often the choice of inhaler is just your personal preference. Most GPs and practice nurses have a range of devices to demonstrate, and let you get a feel for them. If you are unhappy with the one you are using then it is reasonable to try a different type after taking advice from your GP or practice nurse.

Further help and information

British Lung Foundation

73-75 Goswell Road, London EC1V 7ER
Tel (Helpline): 08458 50 50 20 Web: www.lunguk.org

www.ourasthma.co.uk

Website that aids patients in understanding the effects of the transition from CFC-containing inhalers to CFC-free inhalers. The site is sponsored by Trinity-Chiesi Pharmaceuticals Limited.