Bronchodilator or Steroid Inhaler: Which Should Be Used First?

If you are having sudden breathing difficulty, reach for your short-acting bronchodilator (rescue inhaler) first, not your long-acting bronchodilator or steroid inhaler.

Your healthcare provider or pharmacist can tell you which of your inhalers is your rescue inhaler, but some common ones include:

• Proventil HFA, Ventolin HFA, ProAir HFA (albuterol)
• Xopenex HFA (levalbuterol)
• Alupent (metaproterenol)
• Maxair (pirbuterol)

While an important part of your asthma or chronic obstructive pulmonary disease (COPD) treatment plan, inhaled steroids, long-acting bronchodilators, and combination inhalers are considered maintenance medicines. In other words, they are used daily to prevent—not treat—acute symptom flare-ups and attacks.

This article discusses why you need to use a rescue inhaler first in the case of acute breathing trouble and why maintenance bronchodilators and steroid inhalers don't provide quick symptom relief. It also explains the role of these two medicines in your overall care.

Short-Acting Bronchodilators Work Quickly

Short-acting bronchodilators, known as short-acting beta-2 agonists (SABAs), provide quick relief of asthma attacks and COPD exacerbations. These are known as quick-relief or rescue inhalers.

SABAs, such as albuterol and levalbuterol, quickly work to open up (dilate) and relax constricted airways. If you are wheezing, feeling short of breath, or are having an asthma attack, use your short-acting bronchodilator inhaler. It should help you breathe easier in less than a minute.

SABAs bind to the beta-2 adrenergic receptor to relax the smooth muscle tissue of the lungs. This dilates the bronchi and bronchioles of the airways to quickly improve airflow and relieve bronchospasms that cause chest tightness and coughing during an asthma attack or COPD flare-up.

Used as a rescue or reliever inhaler, short-acting bronchodilators are taken as needed for acute symptom relief. They remain active in your system for four to eight hours.

SABAs are commonly delivered using a pressurized canister that delivers a metered dose via an L-shaped inhaler and should be used with a spacer. Short-acting bronchodilators are also available as a dry powder inhaler, tablets, syrups, and for nebulizers (machines that turn liquids into a mist).

Use for Asthma

Short-acting bronchodilators are used to treat an acute asthma attack, including severe shortness of breath, chest tightness or pain, coughing, and wheezing. 

In addition to a rescue inhaler, your healthcare provider will also prescribe an inhaled corticosteroid for long-term symptom management.

According to the 2019 Global Initiative for Asthma (GINA) recommendations, short-acting bronchodilators should only be used in conjunction with a corticosteroid controller medication to reduce the risk of severe asthma exacerbations.

Use for COPD

Short-acting bronchodilators are used to treat acute coughing spells and dyspnea (shortness of breath) associated with COPD.

In addition to dilating the airways to improve airflow and relieve bronchospasms, SABAs help to loosen mucus in the lungs, a hallmark symptom of COPD. This allows you to clear the airways by coughing up phlegm, helping to circulate more air in and out of your lungs.

Long-Acting Bronchodilators Keep Airways Open

Long-acting bronchodilators, known as long-acting beta-2 agonists (LABAs), are dry-powder maintenance inhalers used for longer-term control of breathing difficulties. Commonly taken twice a day (every 12 hours, symptoms or not), LABAs should not be used as a rescue inhaler.

Salmeterol and formoterol are the only inhaled LABAs available and are sometimes used in combination inhalers that include corticosteroid medications. Brands of long-acting bronchodilators include:

• Advair (fluticasone and salmeterol)
• Dulera (formoterol and mometasone)
• Foradil (formoterol)
• Serevent (salmeterol)
• Symbicort (budesonide and formoterol)

Like short-acting bronchodilators, LABAs bind to the beta-2 adrenergic receptor and relax the smooth tissue of the lungs. But unlike SABAs, long-acting bronchodilators take longer to start working and provide symptom relief for up to 12 hours.

Use in Asthma

LABAs are sometimes used in the treatment of asthma as a maintenance medicine to help keep airways open and prevent acute attacks. They are typically prescribed only after treatment with inhaled corticosteroids and short-acting bronchodilators fail to control symptoms.

The decision to use salmeterol or formoterol in the treatment of asthma should not be taken lightly due to an increased risk of fatal adverse effects. A 2014 Cochrane review of 102 studies on the safety and efficacy of LABAs involving 70,980 people with asthma could not definitively rule out a connection between LABAs and these safety concerns.

However, used in combination with inhaled steroids, LABAs help to improve lung function, decrease asthma symptoms, increase the number of symptom-free days, reduce the number of asthma attacks, decrease the use of rescue inhalers, and prevent exercise-induced asthma attacks.

For some people, the benefit of improved symptom control from LABAs may outweigh the risks. In that case, it is safer to take as a combination medication inhaler with salmeterol/formoterol plus a steroid, such as Symbicort, Advair, or Dulera.

Use in COPD

LABAs are used in the treatment of moderate to severe COPD for long-term symptom management. They are commonly prescribed when short-acting bronchodilators alone are unable to adequately control the disease.

Guidelines recommend that all people with COPD and shortness of breath or exercise intolerance (this includes most people with COPD) take a LABA along with another COPD medication called a long-acting muscarinic antagonist (LAMA).

LABAs are effective for medium- and long-term relief of COPD symptoms, including cough, wheezing, shortness of breath, and chest tightness, a 2013 Cochrane review reports. The analysis of 26 studies involving 14,939 people with moderate to severe COPD found LABA use in COPD resulted in fewer symptom flare-ups and improved quality of life.

Steroid Inhalers Manage Inflammation

Inhaled corticosteroids help with asthma and COPD management by treating airway inflammation. Steroid inhalers deliver medicine directly to your lungs to reduce inflammation and swelling and ease breathing.

Unlike a bronchodilator, which works through the nervous system, steroids work on the inflammatory cells in your airways. Corticosteroids mimic the hormone cortisol, an anti-inflammatory hormone naturally produced by the body.

Steroid inhalers are not rescue inhalers and should not be used for quick relief of symptoms. It can take weeks of daily steroid inhaler use before you notice improvement. Thereafter, it may take several hours or even a day for a steroid to do its job.

Inhaled corticosteroids are delivered as a dry powder. Common steroid inhalers include:

• Qvar (beclomethasone)
• Pulmicort (budesonide)
• Flovent (fluticasone)
• Azmacort (triamcinolone)
• Aerobid (flunisolide)

Use for Asthma

Inhaled corticosteroids are the most effective long-term asthma control medicine. Taken daily to prevent chronic symptoms and asthma attacks, inhaled steroids reduce swelling and inflammation in the airways, helping to prevent asthma attacks.

Steroid inhalers are the first line of treatment for managing asthma. Since they may take a while to start working, your healthcare provider may also prescribe a SABA rescue inhaler in case of an asthma attack.

Once steroids begin to work, you should find yourself needing your rescue inhaler less often, if at all.

Use for COPD

Inhaled corticosteroids are not typically prescribed on their own for the treatment of COPD. Steroids help to relieve airway inflammation and may be recommended if your COPD symptoms are not controlled with long- and short-acting bronchodilators.

Your healthcare provider may prescribe inhaled steroids for a trial of six weeks to three months to see if the addition of steroids helps to relieve COPD symptoms and improve breathing.

Summary

If you have asthma or COPD and are having breathing difficulty, pick up your short-acting bronchodilator (rescue inhaler) first. Using your maintenance inhaler, whether a long-acting bronchodilator, steroid inhaler, or combination inhaler—will not treat your symptoms.

If you are unsure which of your inhalers is which, ask your healthcare provider or pharmacist.