6: Pulmonary Medications

“Drugs don’t work if patients don’t take them (properly).” – Former US Surgeon General, C. Everett Koop, MD

Written with gratitude to my Co-Author, Mark W. Mangus, Sr., BSRC, RRT, RPFT, FAARC

When it comes to living well with a pulmonary disease, fewer topics are less clearly understood than how to take your medications most effectively in order to get the maximum benefit from their use. If you have any doubts about this, just go to any online pulmonary support group and type in “how…” or “in what order should I take my medications.” I can assure you that within a few minutes, you will receive a virtual plethora of responses, comments, instructions and opinions. Some of them may come from laypeople—patients and caregivers, some may come from clinicians and other professional people, and some of them may even be correct. Unfortunately, many others will be based on misinformation, misunderstanding, misconception, myth or urban legend.

There are several reasons why this is so. First, the information, itself, is complex and in many cases, counterintuitive. The names of the medications seem to be in another language and their delivery devices can often be difficult to use. In addition, most (or at least, many) clinicians spend far too little time (if any) teaching their patients about their medications and making sure that they understand how to use them properly. It also doesn’t help that there is often disagreement, even among clinicians as to what works best. When you add all of these things up, is it really any wonder patients are confused?

For this important chapter, I have asked my friend and colleague, Mark Mangus, Sr., BSRC, RRT, RPFT, FAARC, (or as I like to call him, Respiratory Therapist-Laureate), to be my co-author. Mr. Mangus and I have been wrangling with people (and each other) for years over this important topic and for this chapter, in particular, we really wanted to get it right; so we can provide you with the absolute best and most current information, in a way that is also easy to understand and put into use.

Throughout this chapter, Mr. Mangus and I hope to clarify many important aspects of medication use and to suggest ways that will help you derive the most benefit from your own program. We will be presenting our best observations—information that we have gathered over the past 25 years working in cardiopulmonary physical therapy and rehabilitation; and EMS for me; and more than 40 years working in virtually every aspect of respiratory care for Mark.

DISCLAIMER: Please understand that we are not telling you what you should or shouldn’t do. Pleasedo not alter your routine because “Noah and Mark told me to.” That is not what we are doing. One more time: do not make any changes to your medication regimen based upon our observations without first discussing them with your physician and getting his or her okay.

Before getting into any of the actual medications, I think it would be helpful to provide you with a short glossary of terms so that if you do get lost, you will have a quick reference guide to help you get back on track. Once you understand these definitions, knowing which medication you take, why you take it, and how you should take it, should make much more sense.

Bronchoconstriction, Bronchodilation, and Inflammation

The prefix, “broncho” means relating to the bronchi or airways. As we have previously discussed, the airways begin with the trachea or windpipe, which first splits into the right and left mainstem bronchi. These airways continue to branch into smaller and smaller bronchi, bronchioles and alveoli, the tiny air sacs where gas exchange occurs.

Bronchoconstriction is the constriction, narrowing, or contraction of the smooth muscle lining the airways (bronchi and bronchioles).

Bronchodilation is the dilation, widening, or relaxation of the smooth muscle lining the airways (bronchi and bronchioles).

Inflammation is the body’s response to harmful stimuli or alien invaders. In the airways, inflammation causes swelling of the smooth muscle lining the inside of the airways and an increase in mucus production.

Bronchoconstriction, bronchodilation and inflammation all have their place in the normal functioning of a healthy respiratory system. As an example, imagine you’re walking outside on a hot summer day. Suddenly, a bus drives past you, spewing soot and who knows what else from its exhaust, right in your face. In response, your airways constrict and mucus production increases in order to protect you by trapping that airborne junk before it has a chance to enter your lower respiratory tract and lungs.

The problem arises, however, when inflammation, bronchoconstriction and increased mucus production become excessive or a more chronic, or permanent state as opposed to just a normal, healthy response to a trigger or alien invader.

Agonist versus Antagonist

An agonist is a chemical that binds to a specific receptor, causing a biological or physiological response. In other words, an agonist has a positive, pro- or stimulatory effect, increasing the action of those receptors.

An antagonist is the opposite of an agonist. An antagonist works by blocking or reducing a biological or physiological response. In other words, it has a negative, anti- or inhibitory effect, decreasing the action of those receptors.

Taking Your Medication Correctly: Easy as ABC!

This may sound crazy, but I have been trying to figure out an easy way for patients to keep their medications straight for years…literally!!! One day, it finally came to me in a song: ABC! 123! OMG! How could I have not seen this…for years??? As the Jackson 5 told us: “ABC, it’s easy as one, two, three, Baby, you and me!” Now, you may be wondering what this song has to do with pulmonary medications. That’s a good question and here is a good answer.

Inhaled pulmonary medications generally fall into one of two general categories, Bronchodilators and Corticosteroids. As the name implies, bronchodilators open up or dilate the airways. Corticosteroids reduce inflammation and edema (swelling) in the airways. Bronchodilators can be further broken down into two classes: Anticholinergics (now often referred to as Anti-Muscarinics or Muscarinic Antagonists) and Beta-2 Adrenergic Receptor Agonists or Beta-2 Agonists.

NOTE: For the purposes of this chapter (and ease of understanding), we will use the term anticholinergics as opposed to anti-muscarinic or muscarinic antagonist.

So…

A=Anticholinergic

B=Beta-2 Agonist

C=Corticosteroid (Inhaled)

Often, people with respiratory disease are prescribed one medication from each of the 3 classes, A, B, and C—in other words, one anticholinergic (A), one beta-2 agonist (B) and one corticosteroid (C). It reminds me of the old-style Chinese restaurant menus: one from Column A, one from Column B and one from Column C. These can be prescribed either as separate medications or as one of the combination medications now available. Many people are also prescribed a rescue inhaler for emergency use; typically, a short-acting beta-2 agonist to be taken either at regularly scheduled intervals or PRN (i.e. “as needed”).

There are certain things that you will need to understand if you want to get the maximum benefit from your medications. Remember, our goal is to maximally increase bronchodilation, decrease bronchoconstriction and reduce or prevent inflammation, all for as long as possible.

In order to achieve these goals, it is important to understand what medication(s) you take, why you take them, when you should take them and how you should take them. If you haven’t figured it out by now, you are the “who.”

Medication Class: Learning Your ABC’s

Anticholinergics (A)

The parasympathetic nervous system can be thought of as the “rest and digest” division of the autonomic nervous system. Its activity is primarily mediated by the neurotransmitter, acetylcholine. The cholinergic action of the parasympathetic nervous system on the lungs and the respiratory system, particularly on the muscarinic acetylcholine receptors causes bronchoconstriction.

BOTTOM LINE: Anticholinergics block or reduce bronchoconstriction, which, as Martha Stewart might say, “is a good thing.”

Table 1: Anticholinergics (A)

Generic Name Brand Name
ipratropium bromide ATROVENT
aclidinium bromide TUDORZA
tiotropium bromide SPIRIVA
umeclidinium bromide INCRUSE ELLIPTA
glycopyrrolate bromide SEEBRI NEOHALER

*Shaded areas indicate long-acting drugs.

Beta-2 Adrenergic Receptor Agonists or Beta-2 Agonists (B)

The sympathetic nervous system can be thought of as the “fight or flight” division of the autonomic nervous system. Its activity is primarily mediated by the neurotransmitter, adrenaline or epinephrine. The adrenergic action of the sympathetic nervous system on the lungs and the respiratory system, particularly on the beta-2 adrenergic receptors causes bronchodilation.

BOTTOM LINE: Beta-2 agonists stimulate or increase bronchodilation, which again, as Martha Stewart might say, “is also a good thing.”

Table 2: Beta-2 Agonists (B)

Generic Name Brand Name
albuterol sulfate PROAIR, VENTOLIN, PROVENTIL
levalbuterol tartrate XOPENEX
terbutaline BRETHAIRE
salmeterol xinafoate SEREVENT
formoterol fumarate FORADIL, PERFOROMIST
aformoterol tartrate BROVANA
indacaterol ARCAPTA NEOHALER
indacaterol maleate ONBREZ BREEZHALER
olodaterol STRIVERDI RESPIMAT

*Shaded areas indicate long-acting drugs.

Short-Acting versus Long-Acting versus Ultra-Long-Acting

Both anticholinergics and beta-2 agonists are available in short-acting, long-acting, and ultra-long-acting formulations. As we talk about pulmonary medications, you will often hear terms like SAMA, SABA, LAMA, and LABA. Every once in a while, you may hear a “Rama Lama Ding Dong” thrown in for good measure. These abbreviations refer to two things: duration or how long they last (short-acting versus long-acting) and the class of medication.

SA=Short-Acting. Short-acting medications have a rapid onset of action (1-5 minutes) and typically achieve their peak effect within 15-20 minutes. Their effects typically last up to 4-6 hours.

SAMA=Short-Acting Muscarinic Antagonist (anticholinergic)

SABA=Short-Acting Beta-2 Agonist

Due to their rapid onset of action, short-acting bronchodilators are often referred to as “rescue medications”. These are the medications that you should carry around with you and take when you need quick relief.

LA=Long-Acting. Long-acting medications have a slower onset of action with their effects lasting up to 12 hours. For this reason, they are usually taken twice per day (every 12 hours).

LAMA=Long-Acting Muscarinic Antagonist (anticholinergic)

LABA=Long-Acting Beta-2 Agonist

Ultra-Long-Acting medications can last for up to 24 hours. For this reason, they are usually taken once per day (every 24 hours).

Due to their long duration of effectiveness, long-acting and ultra-long-acting bronchodilators are often referred to as “maintenance” or “preventer” medications, although my personal preference is to reserve the terms “maintenance” and “preventer” for the anti-inflammatories.

IMPORTANT: Long-Acting and Ultra-Long-Acting Bronchodilators should NOT be taken in an emergency due to their longer onset of action.

Corticosteroids (C)

Corticosteroids, also known simply as “steroids” or anti-inflammatories reduce inflammation and edema (swelling) in the airways. They work on a long-term basis and are often referred to as “preventer medications” since their goal is to reduce and ideally, prevent inflammation before it occurs. These medications work over the long-term, meaning that unlike bronchodilators, there is no immediate impact on airway activity. Therefore, you should not expect to feel any different right after you take it. In fact, corticosteroids can often take days or even weeks to achieve their peak effect.

BOTTOM LINE: Corticosteroids reduce inflammation.

Table 3: Corticosteroids (C)

Generic Name Brand Name
beclomethasone dipropionate QVAR
budesonide PULMICORT
ciclesonide ALVESCO
flunisolide AEROBID
fluticasone FLOVENT
mometasone ASMANEX
triamcinolone acetoide AZMACORT
fluticasone furoate ARNUITY ELLIPTA

IMPORTANT: Unlike bronchodilators, corticosteroids do not directly dilate the airways. For that reason, corticosteroids should never be taken as a rescue medication.

NOTE: Corticosteroids often have a bad reputation because of their many side effects, which can include weight gain, osteoporosis, thinning of the skin, elevated blood sugar and ease of bruising. However, as compared to oral or intravenous (IV) medications, inhaled corticosteroids go directly to the respiratory system, with minimal amounts entering the systemic circulation. As a result, inhaled corticosteroids have significantly less side effects as their oral or IV counterparts.

COMBINATION MEDICATIONS

In recent years, a number of products have been approved that combine 2 classes of medication in one delivery device.

Table 4: Short-Acting Anticholinergic and Short-Acting Beta-2 Agonist

The first combination medications to become available contain ipratropium bromide, a short-acting anticholinergic, and albuterol sulfate, a short-acting beta-2 agonist.

BRAND NAME Anticholinergic Beta-2 Agonist
COMBIVENT (MDI) ipratropium bromide albuterol sulfate
DUONEB (nebulizer) ipratropium bromide albuterol sulfate

Table 5: Long-Acting Beta-2 Agonist and Inhaled Corticosteroid

The next combination medications to become available contain a long-acting beta-2 agonist and an inhaled corticosteroid.

BRAND NAME Beta-2 Agonists Corticosteroid
ADVAIR salmeterol fluticasone propionate
SYMBICORT formoterol fumarate dihydrate budesonide
DULERA formoterol fumarate dihydrate mometasone furoate
BREO ELLIPTA vilanterol fluticasone furoate

IMPORTANT: Long-Acting combination medications should not be taken in an emergency due to their longer time to onset of action.

Table 6: Long-Acting Anticholinergics and Long-Acting Beta-2 Agonist

More recently, both long-acting and ultra-long-acting anticholinergic/beta-2 agonist (dual bronchodilator) combinations have become available.

BRAND NAME Anticholinergic Beta-2 Agonist
BEVESPI AEROSPHERE glycopyrrolate formoterol fumarate
ANORO ELLIPTA umeclidinium vilanterol
ULTIBRO BREEZEHALER glycopyrronium bromide indacaterol maleate
ULTIBRON NEOHALER glycopyrrolate indacaterol
STIOLTO RESPIMAT tiotropium bromide olodaterol

IMPORTANT: Long-Acting combination medications should not be taken in an emergency due to their longer time to onset of action.

Table 7: Long-Acting Anticholinergics and Long-Acting Beta-2 Agonist

Most recently, a long-acting anticholinergic/beta-2 agonist (dual bronchodilator) combination plus a corticosteroid has become available.

Brand Name: TRELEGY ELLIPTA contains:

Anticholinergic: umeclidinium

Beta-2 Agonist: vilanterol

Corticosteroid: fluticasone furoate

Use the chart below to identify your medications.

Timing is everything!

In addition to knowing what medications you take, it is also important to know when they should be taken. This applies to the specific order (if any) as well as properly spacing them out over the course of the day so that you get maximum effectiveness for the longest period of time.

While it would be impossible to address every person’s individual medication regimen, we will explain the major principles and give you some general examples. However, questions concerning your own specific regimen should be addressed with your physician.

Let’s assume that you are probably taking one (long-acting) medication from each class (anticholinergic, beta-2 agonist and corticosteroid) plus a rescue medication. These can either be taken individually or as part of a combination medication (combination 1 or combination 2).

3 Individual Medications: A + B + C

Anticholinergic + Beta-2 Agonist + Corticosteroid

Example: Spiriva (A) + Serevent (B) + Flovent (C)

If you are taking 3 separate medications, we would suggest taking the long-acting anticholinergic (A) first, followed by the long-acting beta-2 agonist (B) about 5-15 minutes later and finally, the Corticosteroid about 5-15 minutes after that.

RATIONALE: By separating these medications by 5-15 minutes each, the first bronchodilator (the anticholinergic) starts to work, allowing better delivery of the second bronchodilator (the beta-2 agonist). Then, both bronchodilators work together, allowing for the best delivery of the corticosteroid.

There is very good evidence suggesting that by taking the anticholinergic and beta-2 agonist in close proximity to each other, their effects are multiplied as compared to taking either one alone or further apart.

IMPORTANT: Immediately after you take the steroid, it is crucial that you rinse your mouth out, gargle, spit and repeat. The reason for this is that if the steroid remains in your mouth or throat, it can cause a fungal infection called thrush (oral candidiasis). This is another reason why taking the steroid last “is a good thing.”

Combination 1: AB + C

Anticholinergic/Beta-2 Agonist Combination + Corticosteroid

Example: Anoro Ellipta (AB) + Pulmicort (C)

If you are taking a long-acting anticholinergic/beta-2 agonist combination plus a corticosteroid, we would suggest taking the anticholinergic/beta-2 agonist (AB) first, followed by the corticosteroid (C) about 5-15 minutes later.

RATIONALE: By separating these medications by 5-15 minutes, the anticholinergic/beta-2 agonist (both bronchodilators) start to work, allowing for better delivery of the corticosteroid.

IMPORTANT: Immediately after you take the steroid, it is crucial that you rinse your mouth, gargle, spit and repeat. The reason for this is that if the steroid remains in your mouth or throat, it can cause a fungal infection called thrush (oral candidiasis). This is another reason why taking the steroid last “is a good thing.”

Combination 2: A + BC

Anticholinergic + Beta-2 Agonist/Corticosteroid Combination

Example: Spiriva (A) + Advair (BC)

If you are taking a long-acting anticholinergic plus a long-acting beta-2 agonist/corticosteroid combination, we would suggest taking the anticholinergic (A) first, followed by the beta-2 agonist/corticosteroid (BC) about 5-15 minutes later.

RATIONALE: By separating them by 5-15 minutes, the anticholinergic (bronchodilator) starts to work, allowing for better delivery of the beta-2 agonist and the corticosteroid.

IMPORTANT: Immediately after you take the steroid, it is crucial that you rinse your mouth, gargle, spit and repeat. The reason for this is that if the steroid remains in your mouth or throat, it can cause a fungal infection called thrush (oral candidiasis). This is another reason why taking the steroid last “is a good thing.”

In each of these examples, the corticosteroid is always taken last. This is because it is the corticosteroid that will have the greatest long-term impact on reducing airway inflammation. For that reason, you want to take the steroid when your lungs are the most open (following maximal dilation), giving the medication the greatest chance of reaching the deeper areas of the airways (i.e. bronchi and bronchioles).

IMPORTANT: Once daily ultra-long-acting medications should be taken at the same time every day, 24 hours apart, so if you take it at 8 AM today, you should take it again at 8 AM tomorrow (and the next day and the next day). Remember, your body likes consistency.

Although some people think that when you take a once-daily medication doesn’t matter (since it is once daily, anyway), we would suggest taking it in the morning. In this way, the medication’s peak effect occurs during the day when you are likely to be the most active. In keeping with our principle of supply and demand, we want to have the greatest supply of air available to us when the demand for oxygen is greatest, which for most people is during the day.

Twice daily long-acting medications should also be taken at the same time every day, 12 hours apart. That means that if your first dose is at 8 AM, your second dose should be at 8 PM. Again, try to be as consistent as possible, remembering that your body likes consistency.

To put this concept in better perspective, let’s say that you were to incorrectly take your long-acting medication at 8 AM and again at 6 PM. This is only 10 hours apart, which is too short. More importantly, this means that it will be 14 hours until your next dose, which is too long. Again, consistency is key!

Your 24-Hour Medication Plan

We have already discussed the order in which you should take your medications within each individual sitting. Now, let’s put all of these pieces together in the context of your overall lifestyle and your activity level over the course of the day. Use the worksheets on the next pages to help you map out your most effective 24-hour medication schedule, timing your medications to both maximize their effectiveness and pair them with the appropriate level of activity.

As mentioned previously, you will make your long-acting medications the anchors around which you will build your overall schedule.

Let’s go back to our previous examples.

3 Individual Medications: A + B + C

Anticholinergic + Beta-2 Agonist + Corticosteroid

Example: Spiriva (A) + Serevent (B) + Flovent (C)

If you are taking 3 separate medications (a long-acting anticholinergic or muscarinic antagonist + a long-acting beta-2 agonist + a corticosteroid), you could take all 3 medications at 8 AM. Since most long-acting anticholinergics (Spiriva and Tudorza) are only once-a-day medications, at 8 PM, you would only take the long-acting beta-2 Agonist + the corticosteroid. In between, you could fill in with your rescue medication, as prescribed by your doctor.

If you generally need your rescue medication, (e.g. albuterol), only once per day, you could try taking it at 2 PM, allowing for even spacing between your morning and evening doses of the long-acting medications. So, your schedule would look like this:

8 AM           Spiriva + Serevent + Flovent

2 PM           albuterol

8 PM           Serevent + Flovent

If you generally need your rescue medication twice per day, you could try taking it at 12 noon and 4 PM, again, allowing for even spacing between your morning and evening doses of the long-acting medications.

So, your schedule would look like this:

8 AM           Spiriva + Serevent + Flovent

12 Noon     albuterol

4 PM           albuterol

8 PM           Serevent + Flovent

Combination 1: (A and B in combination) + C

Anticholinergic/Beta-2 Agonist Combination + Corticosteroid

Example: Anoro Ellipta (AB) + Pulmicort (C)

If you are taking a long-acting anticholinergic or muscarinic antagonist (LAMA)/long-acting beta-2 agonist combination, + a corticosteroid, you could take both medications at 8 AM. Since most long-acting anticholinergics/beta-2 agonist combination medications are only taken once daily, at 8 PM, you would only take the Corticosteroid. In between, you could fill in with your rescue medication, as prescribed by your doctor.

If you generally need your rescue medication, (e.g. albuterol), once per day, you could take it at 2 PM, allowing for even spacing between your morning and evening doses of the long-acting medications. So, your schedule would look like this:

8 AM           Anoro Ellipta + Pulmicort

2 PM           albuterol

8 PM           Pulmicort

If you generally need your rescue medication twice per day, you could take it at 12 noon and 4 PM, allowing for even spacing between your morning and evening doses of the long-acting medications.

So, your schedule would look like this:

8 AM           Anoro Ellipta + Pulmicort

12 Noon     Albuterol

4 PM           Albuterol

8 PM           Pulmicort

Combination 2: A + (B and C in combination)

Anticholinergic + Beta-2 Agonist/Corticosteroid Combination

Spiriva (A) + Advair (BC)

If you are taking a long-acting anticholinergic or muscarinic antagonist (LAMA) + a long-acting beta-2 agonist/corticosteroid combination, you could take both medications at 8 AM. Since most long-acting anticholinergics (Spiriva and Tudorza) are once-daily medications, at 8 PM, you would only take the combination medication. In between, you could fill in with your rescue medication, as prescribed by your doctor.

If you generally need your rescue medication, (e.g. albuterol), once per day, you could take it at 2 PM, allowing for even spacing between your morning and evening doses of the long-acting medications. So, your schedule would look like this:

8 AM           Spiriva + Advair

2 PM           Albuterol

8 PM           Advair

If you generally need your rescue medication twice per day, you could take it at 12 noon and 4 PM, allowing for even spacing between your morning and evening doses of the long-acting medications.

So, your schedule would look like this:

8 AM           Spiriva + Advair

12 Noon     Albuterol

4 PM           Albuterol

8 PM           Advair

How to Use Your Rescue Medication to Your Best Advantage

For many people, long-acting medications are sufficient to keep them breathing well all day. However, some individuals get tremendous benefit from the use of their short-acting (rescue) medication as a “booster”. This can either be done at a regularly scheduled time, when you know you usually start to get more short of breath, as above OR on an “as needed” or “PRN” basis.

Most people do not want to take any more medication than necessary, which is completely understandable. However, many people view their rescue inhaler as a last resort to be used only “in case of emergency”. Again, while we understand why someone might feel this way, we don’t necessarily agree with that approach for several reasons.

First, by the time you reach that dreaded “code red” situation, you are probably already in too much distress to take the medication properly. In addition, with a little planning, you can use the principle of supply and demand to get the most benefit from your rescue medication and maximize your ability throughout the day.

For example, if you know that you will be going outside in the cold and cold causes your airways to constrict, you could take your rescue medication 15-30 minutes beforehand so that your airways are maximally dilated before you go out. The same can be done before exercise. By taking your rescue medication 15-30 minutes before beginning exercise, you can ensure that you will get the most benefit from your workout. The same can be said for showering, many people have a very difficult time in the shower. By taking your rescue medication 15-30 minutes before showering, you decrease your chances of getting into trouble. By stacking the odds in your favor, you wind up working smarter, not harder.

How NOT to Use Your Rescue Medication

We have given you some “dos” related to using your short-acting (rescue) medication. There are also a few important “don’ts”.

Do not overuse your rescue medication. If you find yourself using your rescue medicine more frequently than every 4-6 hours, contact your physician because something is wrong. In fact, using these medications too frequently can actually make you “refractory” (i.e. resistant) to their effects. Taking your medications too frequently saturates the chemical binding sites in your lungs, meaning they will not work. This is akin to stepping on the gas too often and flooding your engine. This is especially true if you are also taking long-acting medications as well, which should significantly reduce the need to take your rescue medication, which leads to our next point.

Do not take your short-acting (rescue) medication before your long-acting medication. For example, if you are taking a long-acting beta-2 agonist PLUS a short-acting beta-2 agonist as a rescue medication. DO NOT take the SABA at the same time as or less than 2 hours before the LABA.

Many people take their short-acting bronchodilator before they take their long-acting bronchodilator (e.g. anticholinergic or beta-2 agonist), because they incorrectly believe that the short-acting bronchodilator opens up or “primes” the airways so that you get better delivery of the long-acting bronchodilator. Nothing could be farther from the truth. In fact, taking a short-acting medication before taking a long-acting medication in the same class can actually cause the exact opposite effect, requiring more frequent (but less effective) use of the rescue inhaler.

Both short-acting and long-acting beta-2 agonists bind to the same receptor sites, as short-acting and long-acting anticholinergics bind to the same receptor sites. Therefore, if you take the short-acting medication first, you will be taking up binding sites that should be reserved for the long-acting medications. As a result, this can make the long-acting medications less effective and again, actually increase the need for the short-acting ones.

Finally, if you do feel the need to take your rescue medication AFTER you have already taken your long-acting medications, try to wait AT LEAST one hour after the long-acting medication. This gives the long-acting medication time to bind to their appropriate binding sites without competition. If you cannot wait at least the minimum 4 hours before taking your rescue medication, please speak to your doctor as this indicates that your disease is poorly controlled on your current regimen.

Use the timeline below to plan out your daily medication schedule.

My Medication Schedule

6 AM           _____________________________________________________________

8 AM           _____________________________________________________________

10 AM         _____________________________________________________________

12 Noon     ______________________________________________________________

2 PM           ______________________________________________________________

4 PM           ______________________________________________________________

6 PM           ______________________________________________________________

8 PM           ______________________________________________________________

10 PM         ______________________________________________________________

12 Mid        ______________________________________________________________

“How do I use this thing?”

Patients often tell me that their “medications don’t work” or that “they aren’t doing anything” for them. When I ask them to show me how they take the medication, I can tell immediately why they are not seeing (or feeling) any results. The reason is that the medication is not going into their airways. Instead, it is winding up in the air, on their tongue or in their mouth and throat. This will not work.

This is like having a headache and instead of carefully placing the Tylenol in your mouth; someone throws it at you from across the room. Sure, every once in a while, one might wind up going in, but this technique would likely not do much to help your headache. This may seem like a ridiculous example, but it’s actually the same with your pulmonary medications. If they don’t get into your airways and lungs, they will not work.

For that reason, how you take your medication has a very significant impact on the effectiveness of the drug. If you want your medication to get into your lungs (which you do), you need to use them properly. The goal is not to haphazardly spray the medication somewhere in the direction of your mouth. It’s not Binaca breath spray. Instead, the goal is for the medication to join with a big whoosh of air so that it can be delivered as far down into the lungs as possible.

MEDICATION DELIVERY DEVICES

Metered Dose Inhaler (MDI)

Using a Metered Dose Inhaler WITHOUT a Spacer:

  • Remove the cap from the inhaler and shake the MDI vigorously for 15 seconds. This evenly disperses the medication throughout the entire solution that it is carried in, ensuring that the amount of medication in each ‘puff’ will be a consistent dose.
  • Before placing the inhaler in your mouth, take a deep breath in through your nose and out gently through pursed lips, emptying the lungs as much as you can. This will ensure that you will be able to take the deepest breath possible in order to breathe the medication deep into your lungs.
  • Place the inhaler in between your teeth with your lips sealed firmly around the mouthpiece OR hold the inhaler 2 inches from your mouth with your mouth open. Ideally, you should always use a spacer with gas-powered MDI’s. See below for information on using a spacer.
  • As you start to breathe in, squeeze the device, discharging the medication and breathe in as slowly and deeply as you can.
  • Hold your breath for a slow count of 5-10 seconds. This allows the medication droplets to “fall out” of the air you brought it in with and to settle on the airway surfaces where it can make contact with the binding sites.
  • Blow out gently through pursed lips.
  • Repeat as prescribed.

IMPORTANT: If you are supposed to take a second puff, the entire sequence must be repeated including shaking the container. Wait approximately 1-2 minutes in between puffs to give the first puff a chance to start working and give you a chance to catch your breath.

Spacers

One of the greatest ironies about inhaled pulmonary medications is that as a group, people with respiratory disease have the most difficulty coordinating their breathing. Yet, properly and effectively inhaling medications requires a very high level of coordination of breathing! For those who use gas-powered MDI’s, that’s where a spacer device comes into play. A spacer is a device that is used with your MDI in order to ensure that you are actually getting the medication and that it is going where we want it to go: into your airways and lungs. Spacers eliminate the timing and breath-coordination difficulties by receiving the medication mist and holding it suspended in the air within the device. This allows you to more easily take in the slow deep breath we talked about above and get the most medication into your lungs when you do breathe in. Many also make a noise to let you know if you are breathing in too quickly. If you do use an MDI, I would strongly recommend that you use a spacer as often as possible.

Using a Metered Dose Inhaler WITH a Spacer:

  • Remove the cap from the inhaler and shake the MDI vigorously for 15 seconds. This evenly disperses the medication throughout the entire solution that it is carried in, ensuring that the amount of medication in each ‘puff’ will be a consistent dose.
  • Remove the cap from the spacer and insert the MDI.
  • Before placing the inhaler in your mouth, take a deep breath in through your nose and out gently through pursed lips, emptying the lungs as much as you can. This will ensure that you will be able to take the deepest breath possible in order to breathe the medication deep into your lungs.
  • Place the spacer in between your teeth with your lips sealed firmly around the mouthpiece.
  • As you start to breathe in, squeeze the device, discharging the medication and breathe in as slowly and deeply as you can.
  • Hold your breath for a slow count of 5-10 seconds. This allows the medication droplets to “fall out” of the air you brought them in with and to settle on the airway surfaces where it can make contact with the binding sites.
  • Blow out gently through pursed lips.
  • Repeat as prescribed.

IMPORTANT: If you are supposed to take a second puff, the entire sequence must be repeated including shaking the container. Wait approximately 1-2 minutes in between puffs to give the first puff a chance to start working and give you a chance to catch your breath.

Dry Powder Inhalers (DPI)

There are a number of medications on the market that use devices that are categorized as dry-powder inhalers. As the name indicates, as compared to a liquid, the inhaled medication is in the form of a dry powder. In general, they work similarly to MDI’s. However, each device has a slightly different method of releasing the medication. Another difference is that when taking a DPI, you want to inhale the medication more quickly as opposed to slow and steady as you do with an MDI.

Using a Dry Powder Inhaler:

  • Open or Remove the cap from the inhaler and release the dose of medication into the device. This will vary depending upon the device.
  • Before placing the inhaler in your mouth, take a deep breath in through your nose and out gently through pursed lips, emptying the lungs as much as you can. This will ensure that you will be able to take the deepest breath possible in order to breathe the medication deep into your lungs.
  • Place the inhaler in between your teeth with your lips sealed firmly around the mouthpiece.
  • Breathe in fairly quickly and as deeply as possible.
  • Hold your breath for a slow count of 5-10 seconds. This allows the medication to “fall out” of the air you brought them in with and to settle on the airway surfaces where it can make contact with the binding sites.
  • Blow out gently through pursed lips. Do not exhale into the device.
  • Repeat as necessary until all medication is used.

Respimats

NOTE: Respimats differ from one company and medication to another. Some must be primed. Others don’t need priming. Be sure to carefully read the instructions that come with your specific Respimat.

Using a Respimat:

  • Hold the Respimat upright.
  • Turn the base toward the arrow until you hear a click, releasing the medication. This also loads the “spring – which is set to release and propel the medication out of the canister.
  • Open or Remove the cap from the Respimat.
  • Take a deep breath in through your nose. Then, breathe out through pursed lips, emptying the lungs as much as you can. This will ensure that you will be able to take the deepest breath possible in order to breathe the medication deep into your airways and lungs.
  • Place the inhaler in between your teeth with your lips sealed firmly around the mouthpiece.
  • As you start to breathe in, press the button, discharging the medication and breathe in as slowly and deeply as you can.
  • Hold your breath for a slow count of 5-10 seconds. This allows the medication droplets to “fall out” of the air you brought them in with and to settle on the airway surfaces where it can make contact with the binding sites.
  • Blow out gently through pursed lips. Do not exhale into the device.
  • Repeat as necessary.

Handihalers, Breezhalers, Neohalers, Rotohalers, Oh, My!

         There are also several other delivery devices including Handihalers, Breezhalers, Neohalers, Rotohalers and I am sure there will be others. It is crucial that you read all instructions very carefully and if there is something that you are unsure of, be sure to check with your doctor, pharmacist or other health care professional. If possible, ask them to demonstrate and watch you do it to make sure you are using it properly. 

Nebulizers

People who struggle to use MDI’s, DPI’s, Respimats, Handihalers, Breezhalers, Neohalers, or Rotohalers may benefit from using a nebulizer, instead. A nebulizer is a device that aerosolizes the medication and delivers it over a longer period of time, allowing you to breathe in a more relaxed manner, over several minutes. The other benefit is that the medication starts to work immediately, allowing for deeper and deeper breaths and wider distribution of the medication throughout your airways as you continue the treatment. There are a variety of different nebulizer devices available including ones that are powered by a compressor and hand-held ultrasonic devices, among others.

Using a Nebulizer:

  • Wash your hands.
  • Sit in a relaxed position.
  • Place the mouthpiece in between your teeth with your lips sealed firmly around the mouthpiece.
  • Turn the nebulizer on.
  • Take slow, deep breaths in and out of your mouth until medication is finished. Hold your breath for a count of 5 to 10 every several breaths to allow the medication to fall out of the air in your lungs.

When finished using the nebulizer, be sure to clean it according to the instructions that come with it. Failure to properly clean and maintain your nebulizer can lead to inefficient function or failure and puts you at increased risk of infection.

And there you have it, Ladies and Gentlemen; the Who, What, When, Where and Why of how to get the maximum benefit from your medications.

Now go get ‘em!

This free online publication was made possible by the Nora and Roger Gimbel Foundation.

If you have found this information helpful and would like to help support the Pulmonary Wellness Society in their mission to provide free educational and rehabilitation opportunities for those living with pulmonary disease, please consider making a tax-deductible donation to the Pulmonary Wellness Society.  No amount is too large or too small and every little bit helps.

The Pulmonary Wellness Research & Education Society is a 501(c)(3) Non-Profit Organization.  The Society’s mission to support the research efforts and free educational programs of Dr. Noah Greenspan and the Pulmonary Wellness & Rehabilitation Center. The Society also provides Pulmonary Wellness & Rehabilitation scholarships to individuals based upon medical, financial or other need.




 

 

 

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