Bronchodilator or Steroid Inhaler: Which Should I Use First?

Man about to use asthma inhaler
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If you have chronic obstructive pulmonary disease (COPD) or asthma, your doctor may have prescribed more than one inhaler. Short-acting bronchodilators are rescue inhalers to be used as needed for acute breathing difficulties. 

Long-acting controller medications—either inhaled corticosteroids, long-acting bronchodilators, or combination inhalers—are taken twice-daily to prevent symptom flareups and asthma attacks.

If you are having difficulty breathing, reach for your rescue inhaler. These include:

Rescue Inhalers
  • Short-acting bronchodilators (albuterol)

  • Open and relax airways

  • Used during an attack

  • Work within minutes

  • Taken as needed

  • Typically an L-shaped inhaler

Controllers
  • Long-acting bronchodilators, inhaled corticosteroids, or combination of both

  • Used for preventing exacerbations

  • Taken twice daily

  • Take hours to start working

  • Usually a disk-shaped inhaler, but may be L-shaped

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 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 flareup.

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 six 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-power inhaler, tablets, syrups, and nebulizers.

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 doctor will also prescribe an inhaled corticosteroid for long-term symptom management.

According to the 2019 Global Initiative for Asthma 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 maintenance medications used for longer-term control of breathing difficulties. Commonly taken twice a day (every 12 hours), LABAs are available as a dry powder inhaler and 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.

In asthma treatment, long-acting bronchodilators should only be used in combination with inhaled steroids due to an increased risk of serious asthma exacerbations that can result in hospitalization or even death.

The decision to use over salmeterol and 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.

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 flareups and improved quality of life.

Steroid Inhalers Manage Inflammation

Inhaled corticosteroids are the top treatment for 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 in acute situations. 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 dried 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 doctor 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 doctor 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.

What If I Don’t Have a Rescue Inhaler Handy?

If you are having difficulty breathing and do not have a short-acting bronchodilator with you, reaching for a long-acting medicine will not help. Try to remain calm and try these alternatives:

  • Sit up straight and try to regulate your breathing by taking slow steady breathes
  • Move away from any triggers, such as cigarette smoke or environmental allergens
  • Nebulize with a short-acting bronchodilator, if available

If your symptoms continue or worsen, call 911.

A Word From Verywell

If you have asthma or COPD, it is important to use your inhalers exactly as prescribed. If you are unsure of which inhaler to use for acute breathing difficulty or are confused about how to take your medication, ask your doctor or pharmacist. If you need to use your rescue inhaler more than twice a week, notify your doctor. It may be a sign that your long-acting controller medication is not working properly.

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