Keeping up with medications can be tricky and overwhelming. If you have ever used a “days of the week” pill case, or if your morning routine includes three medications placed strategically next to your coffee pot, so you don’t forget them, you understand how it can be stressful to keep up with a variety of pills.

Just ask anyone who has accidentally taken a sleep aid in the morning, mistaking it for a daily supplement! That is a mistake few people make twice.

Especially as we get older, many adults take numerous medications and some at different times. Whether that regimen includes a blood pressure pill and a multivitamin, or a daily allergy medication along with an oral contraceptive and a prescription eye drop, most of us have more than one medicine to keep up with each day.

For those with respiratory conditions, you may be adding an inhaler to this mix. And in some cases, a doctor may even prescribe two inhalers, giving you even more instructions to remember.

We will take a look at the proper sequence for inhaler use if you are prescribed more than one, as well as everything you need to know about inhalers, how to use them correctly, how to care for them, and what medicines your doctor may prescribe.

What is an Inhaler?

Most people are familiar with inhalers even if they have not used them. For example, you may have seen them used by a runner before a race to prevent exercise-induced asthma.

You may have witnessed a parent helping a child use an inhaler when an allergic asthma flareup makes it difficult for them to breathe. Or you may have a friend or family member suffering from a serious lung disease, such as COPD, who frequently uses an inhaler for relief.

They are simple devices to operate, although they can be a bit overwhelming at first. Inhalers dispense medication directly into the lungs, with the aim of opening up a patient’s airways. Inhalers are commonly used to treat asthma and Chronic Obstructive Pulmonary Disease (COPD).

While a metered dose inhaler is the one most people think of first, several different types of devices are used to dispense medication directly into the patient’s lungs.

Types of Inhalers

Metered-Dose Inhaler

A metered-dose inhaler delivers medication in aerosol form, and it is the most common type of inhaler. This small, handheld device comprises a metal, pressurized canister, where the medication is stored, a plastic actuator, which allows the medicine to be released, and a metering valve.

Patients hold the metered-dose inhaler between their thumb and forefinger, and once you push down on the plastic actuator, the medicine is released in your mouth.

You may also see some patients using a spacer with a metered dose inhaler. This attachment holds the asthma medicine in place until you are ready to inhale it, meaning the delivery of the medicine to your lungs is more effective.

Dry Powder Inhaler

Some physicians and patients prefer a dry powder inhaler; this device differs from the metered dose inhaler in that it does not store its own medicine. The patient inserts a dose of powdered medication into a chamber before using it. The powder is then inhaled and dispersed to the lungs.

It is important to use only medications prescribed by your doctor for use in this device; never insert a new medication into a dry powder inhaler without discussing it with your doctor first.

Soft Mist Inhaler

Soft mist inhalers are used to “mist” a patient with medication and serve as a useful alternative to those patients who are not comfortable with metered dose inhalers. The metered-dose inhaler requires a bit of coordination that may be challenging for young patients, and the mist inhaler provides more ease of use.

Nebulizer

Finally, another form of inhaler is a nebulizer, which works more slowly, releasing medication to the lungs over a period of time rather than in a short burst. A nebulizer works by distributing liquid medication through a face mask, generating a slow mist that is easier to use with small children in particular.

Medicines Used in Inhalers

Several different medications are used in inhalers. Some inhaled medication includes corticosteroids, long-acting beta-agonists, and quick-relief medications.

Corticosteroids

An inhaled corticosteroid is taken long-term to control and prevent asthma flareups; these are some of the most commonly used medications for asthma patients and act as an anti-inflammatory. In addition, asthma causes swelling and tightening in the chest, and these medications work to relieve that.

Inhaled corticosteroids include:

• Fluticasone
• Budesonide
• Mometasone
• Beclomethasone
• Ciclesonide

Long-Acting Beta Agonists

Long-acting beta-agonists are sometimes used in combination with an inhaled corticosteroid; they are bronchodilator medications that can relieve swelling and help control moderate to severe asthma. Long-acting beta-agonists include:

Salmeterol

Quick Relief Medications

While the previous categories included long-term control asthma medications, there is another group used in inhalers to provide quick relief. You may have heard these medications referred to as “rescue” inhalers.

These medications provide quick relief, often working within five minutes or less. They open up airways and can even stop an asthma attack in progress. Many patients with less severe asthma will use a quick-relief medication or “rescue inhaler” occasionally as needed.

However, it is important to note that they do not control asthma in the long term. Therefore, your physician will ask if you are using the inhaler frequently and may change your course of treatment if you are.

Quick-relief medications used in rescue inhalers include:

• Albuterol
• Levalbuterol

Which Inhaler Should I Use First?

To effectively treat your respiratory condition, your physician may prescribe numerous medications: you could take over-the-counter allergy pills daily, visit an ENT office weekly or monthly for immunotherapy (allergy shots), use a nebulizer each evening before bed to open up your airways, or a metered-dose or dry powder inhaler with corticosteroids.

If your doctor has prescribed the use of more than one inhaler, you should be aware that there is a specific order to follow when inhaling the medications. Your doctor should review this information with you in detail when prescribing your medication, but the general rule of thumb to follow is “rescue inhaler first.”

You want to use the medication that works the quickest to reduce swelling, and the rescue inhaler works within minutes. You may then follow that with the corticosteroid inhaler.

Always follow your doctor’s specific instructions for not only inhaled medications but for any other medicines you are using to treat asthma, COPD, or any respiratory conditions. You should never abruptly stop the use of prescription medication without consulting your physician.

Possible Side Effects of Inhalers

Inhaled corticosteroids work wonders for those who suffer from asthma and COPD; their ability to reduce swelling can make a tremendous difference in a patient’s quality of life.

However, as with any medication, there are always some risks and possibilities for side effects.

The side effects most often reported after the use of inhaled corticosteroids include:

• Sore throat
• Dry cough
• Hoarseness
• Minor nosebleeds
• Oral thrush

Oral thrush occurs commonly with the use of inhaled corticosteroids and is essentially a yeast infection that develops in the mouth. A telltale sign of oral thrush is a white film on a patient’s tongue, and it can also cause dry and cracked skin around the corners of the mouth.

In addition, oral thrush will typically produce bumps on the tongue that can be painful to the touch or even bleed when they are scraped.

Two ways to prevent oral thrush from developing are:

• Consistently rinsing your mouth out with water after you use your inhaler
• Using a spacer with your inhaler

Some patients are reluctant to try inhaled corticosteroids based on previous reactions to oral steroids. However, the side effects from inhaled corticosteroids are much less severe than those that often accompany the use of oral steroids (such as irritability and mood swings, difficulty sleeping, weight gain, and unwanted hair growth).

Inhaled corticosteroids tend to provide benefits to patients with asthma that far outweigh the risks or side effects. However, if you have concerns about using an inhaler with corticosteroids, speak to your physician to understand the best course of treatment.

Overuse of Rescue Inhalers

One of the most important things for asthma patients to understand is that they will more than likely need a variety of medications to treat asthma; if a patient begins to rely too much on a rescue inhaler and overuses it, it will actually become less effective at managing symptoms.

Therefore, your doctor will want to monitor how often you are using the rescue inhaler to determine the best course of medication to manage both your long-term and short-term needs.