Bronchodilator Versus Steroid Inhaler for COPD or Asthma Attack

First dilate your airways, then reduce inflammation.

Man about to use asthma inhaler
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A very common and excellent question for people with​ a COPD or asthma attack is, "Which inhaler should I use first?"

There are actually two good reasons why these should be used in a specific order. But it's important to talk about how your inhalers work first. Once you know the "mechanism" by which they work, you don't have to worry about forgetting the order of use ever again.  Instead, you'll be able to think out the answer.

Basics on Short-Acting Bronchodilators

A bronchodilator is used to open up and relax constricted airways making it easier to breathe. They come in both short acting and long acting forms, but here we'll talk about the short-acting forms. This is the inhaler you want to use first if you feel the need to use your inhaler.

Which inhalers are bronchodilators? It's good to know which inhalers fit this category, because if you happen to have two of these that do the same thing, you wouldn't be the first (since there are so many different brand and generic names).

Unfortunately using two of these doesn't add anything, but will clearly increase the side effects you experience.

Brands of short-acting B-agonist bronchodilators include:

Basics on Steroid Inhaler 

Steroid inhalers deliver corticosteroids to your airways, which reduces inflammation and swelling in the airways.

Since it takes awhile for the medicine in these inhalers to do the job, this is the inhaler you want to use secondly. As with bronchodilators, there are several brand and generic names, and it's not uncommon for people to get confused and end up using two different brands thinking they are getting different medicines.

Some examples of steroid inhalers include:

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

So let's talk about why you should use your bronchodilator first, and then your steroid inhaler.

Reason Number 1 to Use Your Bronchodilator First

If you're feeling short of breath, your bronchodilator inhaler is going to relieve your symptoms fast. In fact, within seconds of using your bronchodilator, your airways will start to dilate and you will (hopefully) note relief from your wheezing and shortness of breath.

Of course, this is not always the case. If your airways have been tightly closed, the bronchodilator will cause them to dilate and some people will note an increase in wheezing—because more air is moving through the airways.

If your bronchodilator is not working, it's time to call your doctor, or even 911 if your symptoms are severe. Since many people are prescribed inhalers, it may seem like these aren't very strong drugs—but they are.

In fact, one of the reasons cited for the death rate from asthma despite advances in medicine is that people treat their symptoms themselves too long before seeking emergency care. 

Now let's talk about another reason for choosing this order: bronchodilator first followed by your steroid inhaler.

Reason Number 2 to Use Your Bronchodilator Before Your Steroid Inhaler

The second reason to use your bronchodilator inhaler first is so that your steroid inhaler can get to where it's needed.

The purpose of your steroid inhaler is to reduce inflammation and swelling in your airways, but this doesn't happen very quickly.  It may take several hours or even a day for the steroid to do its job. In contrast to working through the nervous system as with a bronchodilator, a steroid inhaler needs to work on the inflammatory cells present in your airways, and this can take time.

If you use your steroid inhaler first, it won't get down into the smallest airways that are closed off and obstructed.  Yet it's often those smaller airways added up that are causing a lot of your symptoms.

Therefore, it makes perfect sense to use the bronchodilator first, wait a few minutes, and then to use the steroid inhaler, after the airways have been opened up and are more relaxed. This way, the steroid can penetrate the lungs more effectively, and get down to decrease inflammation in your smaller airways.  Having the steroid reach these smaller airways may even work to decrease your need for your bronchodilator later on.

What if You Only Have Time for One Inhaler?

Hopefully not having time to use one of your inhalers won't be a problem. But if this should occur the choice depends on how you are feeling. If you are acutely wheezing or short of breath, of course, use your bronchodilator. On the other hand, if you are not having any symptoms, use your steroid inhaler. How you are feeling tomorrow won't depend much on your use of your bronchodilator (unless your symptoms are severe) but will depend on whether or not you have used your steroid inhaler.

A Word From Verywell

As a last note, make sure you are using your bronchodilator properly. If the medicine doesn't get where it's supposed to go, it won't do much good, and studies suggest that many people are not using these in the way which is most helpful.  And make sure you know the warning signs of an attack and that you have an asthma emergency plan or COPD emergency plan in place.

Source:

American Lung Association. (2016). Understanding Your Medications. 

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