How Your COPD Inhaler Helps You Manage Your Symptoms & Control Your Disease

How Your COPD Inhaler Helps You Manage Your Symptoms & Control Your Disease


Inhaled medications form the backbone of COPD treatment, and they're vital tools for keeping the respiratory symptoms of COPD under control. If you're like most people with COPD, you probably have at least one inhaler to help you manage your symptoms at home.


COPD inhalers come in many different shapes, sizes, and brands, each with their own unique dosages and medicine combinations. Most of these inhalers fall into one of three main types: maintenance inhalers (for daily use), rescue inhalers (for as-needed use), and steroid inhalers (for reducing exacerbations).


Many people with COPD use more than one type of inhaler, especially those whose symptoms are continuous and at least moderate in severity. In fact, typical treatment for the more advanced stages of COPD includes a daily maintenance inhaler, for baseline symptom control, and a rescue inhaler for quick relief when symptoms get worse.


But despite the fact that these medications are such an integral part of COPD treatment, many patients who use inhaled medications don't really understand how important they are or even how they work. That's why we've created this guide to tell you all about COPD inhalers, including how they affect your lungs and how they help your manage your disease.


In this post, we're going to go over the two main types of inhalers used to treat COPD—maintenance inhalers and rescue inhalers—to explain what they do, how they differ, and how they fit into COPD treatment as a whole. We'll also explain how these medications actually work inside your body that makes it easier to breathe.


If you or someone you love has COPD, it's worth taking the time to learn as much as you can about these key COPD medications, even if you're not taking them yet. After all, knowing what to expect can make it easier to adjust as your COPD symptoms, prescriptions, and COPD treatment needs inevitably change over time.


Learning about your medications and familiarizing yourself with these treatments can even help you use your medications more effectively and be more pro-active about managing your disease. The more knowledge you have, the easier it will be follow your COPD treatment plan, understand your medication instructions, and avoid common medication mistakes.


COPD Inhaler Basics: What Do They Do & Why Are They Important?


Because COPD has no real cure, the main purpose of most COPD medications—including COPD inhalers—is symptom management. That is, COPD medications can be used to reduce, delay, or prevent the negative symptoms (especially respiratory symptoms) caused by COPD, even if they can't fully stop or get rid of the disease


As we mentioned before, there are three main types of COPD inhalers, and each uses a different type of medication or combination of medications. Each medication is designed to target specific biological processes in the lungs and airways, and how they alter those processes determines their specific therapeutic effect.


These are the three main categories of COPD inhalers:

  • Rescue inhalers use short-acting bronchodilators, a type of medication that works very quickly to relax and open up your airways.
  • Maintenance inhalers use medications known as long-acting bronchodilators, which also relax your airways but have subtler, longer-lasting effects.
  • Steroid inhalers contain corticosteroid medications, which target the body's immune system to suppress inflammation in the lungs. These are mainly prescribed to reduce COPD exacerbations, and we discuss them in more detail in a separate guide.


As you can see, each type of inhaler plays a unique role in COPD treatment, which is why many patients need to use a combination of two or more types of inhalers to keep their symptoms in check. The most commonly used are the two types of bronchodilator medications, which are widely prescribed as a mainstay of treatment for people with moderate to severe COPD.


It's also important to note that some people with COPD use steroid combination inhalers, which contain both a corticosteroid medication and a long-acting bronchodilator. If you're interested in learning more about steroid inhalers, you can check out our guide on steroid medications and how they are used to treat COPD.



What Are Bronchodilator Inhalers?





The focus of this guide is bronchodilator inhalers, which include both rescue inhalers and maintenance inhalers. Both of these medications have similar effects on the lungs and play vital roles in the everyday management of COPD symptoms.


Both short-acting and long-acting bronchodilators help your airways open up wider by forcing the smooth muscles that surround your airways to relax. This effect is known as bronchodilation and it makes it easier to breathe by improving airflow to and from the lungs.


The “broncho” part of the word bronchodilation refers to the bronchial tubes, which are the main, large airways that carry air to and from the lungs. “Dilation” simply means to make something—in this case, the bronchial tubes—wider, larger, or more open.


Bronchodilation is the opposite of bronchoconstriction, which happens when the smooth muscle surrounding the airways contracts, squeezing the airways down tight and reducing the size of the space inside. Bronchoconstriction is a major cause of breathing problems in people with COPD, and it's what bronchodilator medications are mainly designed to correct.


There are two main types of bronchodilator medications: beta-2 agonists and anticholinergics, both of which come in both short-acting and long-acting varieties. Many COPD inhalers contain only one type of bronchodilator (a beta-2 agonist or an anticholinergic), while others use a combination of both.


We'll discuss these bronchodilator inhalers in more detail in just a bit, but first you need to understand why people with COPD have problems with bronchoconstriction in the first place. That's why, in this next section, we're going to give you a brief explanation of how COPD triggers the chronic bronchoconstriction that COPD inhalers are meant to relieve.


Of course, COPD is a complex disease, and there are many complex factors contributing to COPD symptoms that are beyond the scope of this guide. However, a general knowledge of how airway inflammation and constriction happen is vital for understanding how bronchodilator inhalers work


If you've learned about these topics already (perhaps from other guides in our Respiratory Resource Center), feel free to skip ahead to the section “How Bronchodilators Work in the Body to Make it Easier to Breathe.”



Airway Inflammation & Bronchoconstriction: Major Causes of Breathing Problems in People with COPD





You might already know that COPD affects not only your lungs, but also your airways, including the large bronchial tubes that carry the air to and from your lungs when you breathe. COPD causes your airways to be frequently—if not continuously—inflamed, which is one of the main causes of COPD symptoms, especially those associated with chronic bronchitis.


Bronchoconstriction is, in part, the body's reaction to this inflammation, and one of the major reasons for restricted airflow and shortness of breath in people with COPD. Inflammation also triggers the airways to produce more mucus than usual, which causes congestion in the airways that restricts even more air from flowing through.


This extra mucus is especially problematic when the airways are already constricted, because it makes it more difficult to remove the mucus from the lungs. Instead of allowing the mucus to move up and out of the airways (which is the main purpose of coughing and other mucus clearance techniques), bronchoconstriction causes the mucus to get stuck inside the narrow airspace, creating a particularly stubborn source of obstruction.


In this way, airway constriction is one of the main reasons why people with COPD experience symptoms like coughing and shortness of breath, which are the defining symptoms of the disease. The excess mucus and airway inflammation triggers the need to cough, while the bronchoconstriction and mucus obstruction makes it more difficult to breathe.


Additionally, it takes extra energy to breathe air through narrowed and obstructed airways, which wears out the muscles in your chest that you use to breathe. This breathing muscle exhaustion, in addition to bronchoconstriction, also makes it more difficult to empty your lungs completely when you exhale.


The air that you cannot push out stays trapped inside the lungs, preventing them from collapsing all the way. The stale air also takes up valuable space that's needed for the fresh, oxygen-rich air that you take in when you inhale.


This, in addition to other damage caused by inflammation, can eventually cause irreparable damage to the lungs, including a complication known as lung hyperinflation. This occurs when the lung tissue loses its elasticity, becoming too stiff to expand and collapse fully when you breathe; this essentially “stretches out” and enlarges the lungs, causing even more air trapping and making it more difficult to breathe.


All of these effects, which are largely a consequence of bronchoconstriction, are a major cause of shortness of breath and general breathing difficulties in people with COPD. Because of this, many COPD medications—including bronchodilators—are designed specifically to reduce bronchoconstriction.


In the next section we'll build on these concepts—particularly bronchoconstriction—to explain how bronchodilators work in your respiratory system to make it easier to breathe. Then, we'll discuss how long-acting and short-acting bronchodilators are used to treat COPD, including what they're prescribed for, why they're effective, and what you should know about their benefits and risks.



How Bronchodilators Work in the Body to Make it Easier to Breathe





As we've mentioned already, all bronchodilators have a similar effect, which is to “open up” or widen the space inside the airways. This reduces airway obstruction and allows air to flow through more freely, making it both easier to breathe and easier to move mucus up through the airways and out of the lungs.


This is the main way in which bronchodilators reduce shortness of breath, but they can also help mitigate other long-term complications related to airway constriction. This includes things like breathing muscle fatigue, air trapping, and lung hyperinflation.


However, the question of how bronchodilator medications are able to relieve airway constriction through biological mechanisms is a bit more complex. This is further complicated by the fact that there are three main classes of bronchodilator medications: beta-2 agonists, anticholinergics, and methylxanthines.


Beta-2 agonists and anticholinergics are the most widely used bronchodilators, while methylxanthines (such as theophylline) are sometimes also prescribed. However, the use of methylxanthines to treat COPD symptoms is somewhat controversial, partially due to their high toxicity and partially due to a lack of research and understanding of their effects.


Because of this, we're going to limit our discussion here to the two main types of bronchodilator medications: beta-2 agonists and anticholinergics. Both classes of medication work by reducing airway constriction, but they differ significantly in how they achieve this effect.



Beta-2 Agonists Bronchodilator Medications





The first major type of bronchodilator is a class of drugs known as beta-2 agonists. These medications work by activating a specific type of receptor, known as a beta-2-adrenoreceptor (or beta-2 receptor, for short), which is found in the airway tissues as well as other parts of the body.


This receptor has the ability to affect the smooth muscles in the airways; these are the same muscles that contract in response to inflammation, causing airway constriction in people with COPD. When the beta-2 receptor gets activated, it stops those smooth muscles from contracting, forcing them to relax, resulting in bronchodilation that opens up the airways and makes it easier to breathe.




Taking a beta-2 agonist medication via an inhaler or nebulizer delivers the medication directly to your lungs and airways, where it absorbs into the cells lining the insides of your airway walls. Once inside, they can activate the beta-2 receptors in those cells, triggering airway muscle relaxation.


However, not all of the beta-2 agonist medication stays in the lungs; some of it inevitably gets absorbed into your bloodstream as well. The bloodstream carries the drug to beta-2 receptors located in other parts of body (e.g. the smooth muscle of the heart and blood vessels); this can trigger unwanted side effects like an increased heart rate and blood vessel dilation.


If you use a short-acting beta-2 agonist, this relaxation happens very quickly, providing almost instant relief from shortness of breath. Long-acting beta-2 agonists, however, work much more slowly, taking several hours to begin working, and often taking days to provide noticeable symptom relief after you first start taking the medication.



Anticholinergic Bronchodilator Medications





Anticholinergics (also known as muscarinic antagonists) are a second type of bronchodilator medication that are used in COPD treatment. It's common for anticholinergics to be combined with a beta-2 agonist in a single inhaler.


Unlike beta-2 agonists, which relieve airway constriction by triggering airway muscles to relax, anticholinergics help prevent airway constriction by inhibiting a certain signal that triggers bronchoconstriction.


This “certain signal” is produced by an important type of receptor—known as a muscarinic receptor—which is found in cells all over the body, including the lungs and airways. These receptors are responsible for triggering the parasympathetic nervous system response, which affects different parts of the body in different ways.


In the lungs and airways, the parasympathetic response does two main things, both of which make it more difficult to breathe. First, it triggers the airway tissues to secrete more mucus (causing obstruction), and second, it triggers the airway muscles to contract (causing bronchoconstriction).


Here's where anticholinergics come in; these medications work by blocking muscarinic receptors in your lungs and airways, essentially rendering them inactive. This prevents the parasympathetic response from getting triggered in the first place, thereby preventing the airway narrowing and mucus obstruction it causes.


Just like beta-2 agonists (and other inhaled medications), a small amount of the anticholinergics you breath in will get absorbed into your bloodstream, even though most of it gets absorbed in the lungs. This leads to some muscarinic receptor activation in other parts of the body, which can cause negative side effects like constipation, confusion, and an irregular heartbeat.





There are several types of both short-acting and long-acting antocholinergics, which are used in short-acting and long-acting bronchodilators respectively. The quicker-acting versions work for up to 6 hours, while longer-acting anticholinergics can work for more than 24 hours.



Bronchodilators in COPD Treatment



Long-Acting Bronchodilators: Long-Term Symptom Relief






The purpose of long-acting bronchodilator inhalers in COPD treatment is to provide long-term relief from persistent COPD symptoms, particularly shortness of breath. They're considered a cornerstone of COPD treatment, and they're one of the most frequently-prescribed medications to treat COPD.


Long-acting bronchodilators are often referred to as “maintenance inhalers” because they help control the “stable,” everyday symptoms of COPD. This helps to reduce and stabilize symptoms, and helps prevent them from flaring up, which are some of the primary goals that doctors and people with COPD strive for with long-term disease maintenance.


Long-acting bronchodilators take a while after you start taking them (up to several days or weeks) to reach full effect, but they continue working for a long time (about 12-24 hours) once they do. This makes them essentially useless for immediate symptom relief, but extremely effective for sustained, long-term COPD symptom control.



Long-Acting Bronchodilator Therapy in COPD Treatment




Some people begin long-acting bronchodilator therapy as soon as the get diagnosed with COPD, but not everyone does. Some people who get diagnosed in the early stages of the disease don't require long-term treatment (or sometimes any treatment, yet) because their symptoms are still very mild or infrequent.


However, almost everyone who has COPD will need a long-term maintenance treatment eventually. As the disease progresses and COPD symptoms become more frequent, more persistent, and more severe, many patients need long-acting bronchodilators to keep their symptoms under control.


Most of the time, if you're prescribed a long-acting bronchodilator inhaler, you will need to use it once or twice a day, every day. Because long-acting bronchodilators take so long to work, it's vital to take them consistently so they can stay active in your body throughout the day.


This is why it's important to use your maintenance inhaler on a regular schedule; it ensures that the medicine works constantly and reliably to keep your symptoms suppressed. Try to avoid skipping or delaying your daily inhaler doses and do your best to follow the treatment plan precisely.





Unfortunately, some people mistakenly believe that they only need to use their maintenance inhaler when they're actively experiencing symptoms. This misconception leads them to use their inhaler inconsistently, or to stop using their inhaler altogether when their COPD symptoms improve.


However, this can be very dangerous; it can increase your risk for exacerbations, cause your symptoms to rebound, and make it more difficult to control your COPD symptoms in the long run. That's why, if your doctor prescribes you a daily maintenance inhaler, you need to follow his instructions exactly, and never stop taking your medication unless your doctor says it's okay.



Common Long-Acting Bronchodilator Medications Used to Treat COPD





Here we've listed some of the most common long-acting bronchodilator medications used to treat COPD. The brand names are listed first, and the pharmaceutical drug name is in parentheses.


Beta-2 Agonist Only:

  • Arcapta Neohaler (indacaterol)
  • Brovana (arformoterol)
  • Perforomist (formoterol)
  • Serevent (salmeterol)
  • Stiverdi (olodaterol)


Anticholinergic Only:

  • Incruse (umeclidinium)
  • Seebri (glycopryrrolate)
  • Spiriva Respimat (tiotropium)
  • Tudorza (aclidinium)


Combined Beta-2 Agonist and Anticholinergic:

  • Anoro (umeclidinium and vilanterol)
  • Bevespi Aerosphere (glycopyrrolate and formoterol)
  • Stiolto (olodaterol and tiotripium)
  • Utibron (indacaterol and glycopyroolate)


Short-Acting Bronchodilators: Short-Term Symptom Relief







Short-acting bronchodilators (also known as “quick-relief inhalers” or “rescue inhalers”) are important in COPD treatment because they can provide immediate, short-term relief from COPD symptoms. Just like maintenance inhalers, quick relief inhalers work by relaxing airway muscles to reduce airway obstruction and make it easier to breathe.


However, unlike long-acting bronchodilators, which take hours to work and require regular, scheduled doses, short-acting bronchodilators can be used as-needed throughout the day. That's because they work almost immediately (within seconds or minutes) and their effects usually wear off within just a few hours after use.


The quick-yet-temporary nature of short-acting bronchodilators makes them ideal for treating incidental COPD symptom flare-ups, such as the temporary bouts of increased breathlessness that most people with COPD experience occasionally, if not often. At the same time, rescue inhalers are not effective for long-term symptom management due to the short length of their effects.



How Short-Acting Bronchodilators are Used in COPD Treatment





Short-acting bronchodilators are often prescribed along with long-acting bronchodilators in a kind of dual therapy that works like this: The long-acting bronchodilator manages the baseline symptoms of COPD, reducing the risk of exacerbations and offering stable, long-term symptom relief. The short-acting bronchodilator is used for additional symptom relief, particularly for stopping sudden symptom flare-ups that inevitably occur.


However, some people with COPD are only prescribed short-acting bronchodilators and use them as the primary means to manage their symptoms.


This is most common in the early stages of the disease, when many patients only experience intermittent symptoms and thus don't need long-term symptom control. At this stage, COPD symptoms can sometimes be adequately spot-treated with quick-acting rescue inhalers whenever they occur.


Rescue inhalers are very effective at stopping sudden, severe symptom flare-ups, which can show up without warning and even be life-threatening in some situations. Because of this, if you've been prescribed a quick-relief inhaler, you should do your best to take it with you everywhere you go.


But though some flare-ups happen unpredictably without an obvious cause, many symptom flare-ups are at least somewhat predictable. For example, it's common to experience sharp increases in breathlessness during physical exertion or after breathing in lung irritants like allergens and smoke; when this happens, you'll definitely want to have your rescue inhaler nearby.


Most of the time, rescue inhalers are meant to be used during a symptom flare, especially ones that won't go away on their own. This can be particularly helpful when usual coping techniques—such as stopping to rest and using breathing technique

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