How to Make Sense of Inhaled Medications for COPD

Inhalers and nebulizers are necessary when managing chronic obstructive pulmonary disease (COPD) . Both are designed to deliver medication directly to the lungs, which helps in reducing symptoms, improving lung function, and enhancing the overall quality of life for individuals with COPD.

An inhaler is a portable handheld medical device with a mouthpiece to deliver the medication. A nebulizer is a machine that turns liquid medicine into a mist that can be inhaled into the lungs through a mouthpiece or a face mask.

"It's important now to have an inhaler that's [specifically] for COPD," says Jorge Mercado, MD , a pulmonologist at NYU Langone Hospital in Brooklyn, New York. "Treatments have come a long way. We no longer lump asthma and COPD together. We're able to prescribe treatments now that work on the inflammation in the lungs and open up the airways, which is much better at treating symptoms of COPD."

Types of Medications Used in Inhalers and Nebulizers for COPD

There are several types of medications used in inhalers and nebulizers, including beta agonists, muscarinic agonists or anticholinergics, and corticosteroids, as well as combined medications. Some are short-acting medications which work quickly, but also wear off fast, while others are long-acting, which take longer to kick in, but last much longer with fewer side effects.

Here is a list of inhaled medications:

Drug Class Drug Names Short-acting beta agonists

Albuterol (ProAir, Ventolin, Proventil)

Levalbuterol (Xopenex HFA) Short-acting anticholinergics

Ipratropium (Atrovent HFA)

Long-acting beta-agonists

Salmeterol (Severent Diskus)

Formoterol (Perforomist)

Indacaterol (Arcapta Neohaler)

Arformoterol (Brovana)

Long-acting anticholinergics

Tiotropium (Spiriva)

Aclidinium (Tudorza Pressair)

Ipratropium bromide (Atrovent HFA)

Revefenacin (Yupelri)

Corticosteroids

Fluticasone (Flonase)

Budesonide (Pulmicort Flexhaler)

Combination therapies

Vilanterol, Umeclidinium, Fluticasone (Trelegy Ellipta)

Olodaterol, Tiotropium (Stiolto Respimat)

Here is a list of nebulizer medications: Drug Class Drug Names Short-acting beta agonists

Albuterol (ProAir, Ventolin, Proventil)

Levalbuterol (Xopenex HFA) Long-acting beta-agonists

Formoterol (Perforomist)

Arformoterol (Brovana)

Short-acting anticholinergics ipratropium bromide (Atrovent) Long-acting anticholinergics

Glycopyrrolate (Lonhala Magnair)

Revefenacin (Yupelri)

Phosphodiesterase 3 and 4 inhibitor Ensifentrine (Ohtuvayre)

With the exception of the corticosteroids, which are primarily used for asthma and reducing inflammation, most of the medications used in inhalers and nebulizers fall into a class known as bronchodilators.

Bronchodilators relax the muscles in the lungs and widen the airways, or bronchi, to make breathing easier.

"The bronchodilators for COPD use a strong propellant that pushes the medicine deep into the lungs where it acts on the glands to reduce secretions of mucus, which allows the airways to open up," says Dr. Mercado. "When you look at the efficacy of long-term treatments, especially the anticholinergics and the combination inhalers, you see that patients need to use the rescue inhaler less and less."

Mercado cautions that the leading cause of COPD is smoking, and for a long-lasting inhaler to improve symptoms, the patient must quit smoking.

"Quitting smoking is the best course of action," he says.

Types of Inhalers

Finding the right inhaler can be a challenge for some people, since some may feel too cold when inhaled, while others leave a chalky feeling in the mouth.

Metered-dose inhalers (MDIs) deliver a specific amount of medication in aerosol form, using a propellant to push the medication out of the inhaler. While they are portable and convenient and deliver a tailored dose, MDIs require coordinated hand and breath control to work properly. Examples include beclomethasone (QVAR) and albuterol (ProAir, Ventolin, Proventil)

Dry powder inhalers (DPIs) deliver medication in a powder form that the patient inhales. The force of your inhalation is what disperses the powder into your lungs. While a DPI requires less coordination than an MDI, it demands a strong and deep inhalation effort, which may be difficult for some. "Some patients just don't like the dry powder in their mouth either," says Mercado. Examples include tiotropium (Spiriva) and salmeterol (Serevent, Advair, Trelegy, Breo)

Soft mist inhalers (SMIs) use a mechanical spring to produce a fine mist that makes it easy to inhale the medication deeply into the lungs. While an SMI requires a less forceful inhalation than a DPI and less coordination than an MDI, it is a more complex device, which requires more training to master. Examples include olodaterol/tiotropium (Stiolto Respimat) and ipratropium (Atrovent Respimat) .

Types of Nebulizers

You and your doctor may decide that a nebulizer is right for you, especially if you have trouble breathing. Nebulizers deliver a continuous medication mist that lasts several minutes, requiring less coordination of breath to use. However, nebulizers are not very portable and they need to be plugged in to work.

Using a nebulizer correctly is essential for a medicine to work effectively. Make sure you are comfortable using it, before starting to use it daily.

Jet Nebulizers The most common type of nebulizers, jet nebulizers use an air compressor to convert liquid medicine into a fine mist that is inhaled through a face mask or mouthpiece. Examples include arformoterol (Brovana) and formoterol (Perforomist) .

Mesh Nebulizers Instead of using an air compressor, these devices push the liquid medication through a vibrating mesh, where it is converted into the mist you breathe in.

Ultrasonic Nebulizers These nebulizers create high-frequency vibrations that turn liquid into aerosol or mist that is inhaled.

Choosing the Right Inhaler

To match a person to the right inhaler, several factors are considered, including preference, disease severity, convenience, and the person's ability to self-administer. And, just how comfortable someone is with a device may influence how long they are willing to stay on it or how frequently they use it.

A study

found that when the participants were involved in choosing the inhaler that felt best to them and reviewing inhaler techniques with the doctor, and having frequent check-ins with the doctor on the technique led to increased trust of the prescribing doctor, increased adherence to the therapy, and fewer exacerbations. The same goes for using a nebulizer. It is especially important to make sure you know how to use an at-home nebulizer properly. A review

that looked at 20 years of studies on at-home nebulizer use found that all stages of nebulizer use were a challenge, including set-up, operation, inhalation technique, and cleaning. In fact, the review found that at-home nebulizers were often covered in germs and bacteria due to improper cleaning and maintenance. COPD severity is classified as mild, moderate-to-severe, and very severe.

The severity is determined by responses to a questionnaire and performance on breathing tests. As COPD progresses, the choice of inhaler can significantly impact the effectiveness of the treatment, symptom control, and overall quality of life for the person.

• Mild stage People in the mild stage have occasional breathlessness and may only need a short-acting inhaler.
• Moderate-to-severe stage Here, people have increased breathlessness and need more symptom control at first. As it becomes more severe, a person will suffer frequent exacerbations and a diminished quality of life. This is when you may require a long-lasting inhaler. Those in more severe stages will need a combination therapy.
• Very severe stage This is when someone has extremely limited physical activity and increased breathlessness with frequent and severe exacerbations that will require them to have both a triple therapy combination inhaler and a short-acting rescue inhaler. People with severe impairment may do better with nebulized therapies.

"In general, I see patients on the more severe end of the scale, so I like to start them on a high-efficacy combination inhaler and see how they respond," says Mercado. "By starting with a triple-therapy, we have the best chance at long-term success, and then we can taper down and start to decline the dose or change medicines."

Common Inhaler Mistakes

Inhalers can be a lot more finicky than people expect. Mercado says there's a lot of coordination in timing the breath with the pump, and then people don't know how long they are supposed to hold the inhalation for. He also sees people shaking up medicines unnecessarily, spraying test pumps into the air, pressing down on the pump prematurely, or rinsing out their mouth immediately and washing away the dry-powder that needs to be inhaled.

Mercado adds that incorrect inhaler technique can not only reduce the effectiveness of the medication, but also increase the risk of side effects such as throat irritation or oral thrush .

"The medicine will only get deep into the lungs and do what it is supposed to do if the patient uses the inhaler properly," says Mercado. "That's why we spend a lot of time with the patient to make sure they understand how to use the inhaler and we practice with dummy and sample inhalers that have placebo. We spend a lot of time to make sure they feel comfortable with the proper techniques."

If you are prescribed to use a nebulizer, make sure you practice using it with your doctor and the office staff before taking it home. It is also helpful to read and follow the instructions that come with your device. The COPD Foundation also has instructional videos for using inhalers and nebulizers.

Cost and Coverage

Inhalers can be quite expensive, especially for patients without insurance, but recent changes have caused a dramatic shift. Up until recently, in the United States, long-lasting bronchodilators and combination inhalers were priced around $400 to $500 for a single inhaler for patients without insurance, while nebulizers cost anywhere from roughly $35 to nearly $400.

However, in January 2024, the U.S. Senate Committee on Health, Education, Labor, and Pensions launched an investigation into why the price of COPD and asthma inhalers were so much more expensive in the United States than in the rest of the world. That spurred three of the four leading inhaler companies (GlaxoSmithKline, AstraZeneca, and Boehringer Ingelheim) to announce in March 2024 , that they would cap out-of-pocket costs at $35 per inhaler.

Side Effects and Risks

Most inhalers are well-tolerated and effective with few side effects.

But overuse or improper use of an inhaler can produce unwanted side effects. Some of the most common side effects are headaches, dry mouth, oral thrush, sore throats and throat irritation, heart palpitations, and muscle cramps.

You should always report any side effects to your doctor, who can evaluate your inhalation technique and adjust your treatment plan as needed.

The Takeaway

Whether you are prescribed an inhaler or a nebulizer, it's vital to work with your doctor to find one you're comfortable using. Some inhalers provide long-lasting symptom relief while others are short-acting for acute exacerbations. With the right device and medication, you'll be able to breathe better and keep your COPD symptoms under control.

Resources We Trust

• Mayo Clinic: Consumer Health: Living With COPD
• Cleveland Clinic: Have COPD? Exercise Can Help Keep You Out of the Hospital
• World Health Organization: Chronic Obstructive Pulmonary Disease (COPD)
• Centers for Disease Control and Prevention: COPD: Symptoms, Diagnosis, and Treatment
• American Lung Association: Chronic Obstructive Pulmonary Disease (COPD)
• COPD Foundation: COPD Educational Video Series
• Allergy and Asthma Network: Respiratory Inhalers at a Glance

Editorial Sources and Fact-Checking

Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy . We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.

Sources

1. COPD: Diagnosis and Treatment. Mayo Clinic . April 2020.
2. Bivolaru S, Constantin A, Vlase CM, et al. COPD Patients' Behaviour When Involved in the Choice of Inhaler Device. Healthcare . 2023/1.
3. Sivadasan S, Krishnan A, Dhayalan SV, et al. A Systematic Review on KAP of Nebulization Therapy at Home. Journal of Pharmacy Technology . 10/2021.
4. COPD: Causes, Symptoms, Diagnosis, Treatment & Prevention. Cleveland Clinic . May 2022.
5. Chick DA et al. UMHS COPD Guidelines. University of Michigan . July 2020.
6. Drug Companies Step Forward With Voluntary Price Caps on Inhalers. Allergy & Asthma Network . June 2024.

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David Mannino, MD

Medical Reviewer

David Mannino, MD, is the chief medical officer at the COPD Foundation . He has a long history of research and engagement in respiratory health.

After completing medical training as a pulmonary care specialist, Dr. Mannino joined the Centers for Disease Control and Prevention (CDC) Air Pollution and Respiratory Health Branch. While at CDC, he helped to develop the National Asthma Program and led efforts on the Surveillance Reports that described the U.S. burden of asthma (1998) and COPD (2002).

After his retirement from CDC in 2004, Mannino joined the faculty at the University of Kentucky, where he was involved both clinically in the College of Medicine and as a teacher, researcher, and administrator in the College of Public Health. He served as professor and chair in the department of preventive medicine and environmental health from 2012 to 2017, with a joint appointment in the department of epidemiology.

In 2004, Mannino helped to launch the COPD Foundation, where he served as a board member from 2004 through 2015, chairman of the Medical and Scientific Advisory Committee from 2010 through 2015, and chief scientific officer from 2015 to 2017.

Mannino has over 350 publications and serves as an associate editor or editorial board member for the following journals: American Journal of Respiratory and Critical Care Medicine , Chest , Thorax , European Respiratory Journal , and the Journal of the COPD Foundation . He was also a coauthor of the Surgeon General's Report on Tobacco in 2008 and 2014.

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Jordan M. Davidson

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Jordan Davidson is a freelance health and science writer interested in everything from nutrition and fitness to hobby farming and medical breakthroughs. His work has appeared in many publications, including the Wall Street Journal, Psychology Today, Men's Health , Prevention , Science Friday, The Scientist , and General Surgery News . He is senior copywriter at FCB Health in New York.

Davidson spent years as an ESL teacher in New York City public schools before transitioning to journalism. He holds a bachelor's degree from Brown University and master's degrees in education and journalism from The City College of New York and the School of Journalism at CUNY. Davidson is now based in upstate New York after living in Bali, Indonesia, and volunteering on farms in Australia and New Zealand. He's always on the hunt for good pub trivia.

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