Do I Need To Use A Spacer With My Inhaler?

Is A Spacer Necessary With My Inhaler?

Dr. Mahler:

The pharmacist at the local drug store told me that I should use a spacer with my inhalers. I am confused because Bevespi and ProAir inhalers, which I take for my COPD, seem to be working fine. I asked my nurse practioner about it, and she said that it wasn’t necessary. What are your thoughts?

Judy from Chattanooga, TN


Your question is quite common and can certainly be confusing. Here are brief responses to the following questions.

What Is A Spacer?

It is a tube or extension device which adds space and volume between the inhaler (called a pressured Metered-dose Inhaler; it is abbreviated pMDI) and the mouth. In practice, the correct name is a valved holding chamber (as shown below). It has one-way valves to contain, or hold, the aerosol until it is inhaled.

Valved holding chamber is a spacer

Valved holding chamber to use with pressurized metered-dose inhaler

How Do You Use a Spacer?

► Place the inhaler into the end.

► Breathe out completely away from the device.

► Put the mouth around the mouthpiece of the spacer and close lips.

► Press down on the top of the canister to release aerosol into spacer.

► Then, breathe in with a slow and steady effort. Fill your lungs with air.

► Hold your breath for as long as possible.

► If the device makes a whistle sound, you are breathing in too fast.

Actual use of spacer

Woman using valved holding chamber (spacer) with pMDI

What Are The Advantages Of A Spacer?

The device slows the speed of the aerosol from the inhaler and also allows the size of the aerosol particles to be smaller. They also decrease the amount of aerosol that hits the back of the throat.

However, studies have shown that there are no differences in breathing tests (lung function) comparing use of an inhaler (pMDI) with or without a spacer if the person uses good technique.

What Are The Disadvantages Of A Spacer?

They are larger and somewhat cumbersome compared with inhaler alone. They typically cost between $15 – 40. Your health insurance may or may not cover this expense. There is possible contamination if it is not cleaned as directed.

When Should A Spacer Be Used?

In my practice, I recommend using a valved holding chamber for two conditions:

► If you have difficulty with coordinating breathing and pressing down on the canister of the inhaler (pMDI)

► If the pMDI contains an inhaled corticosteroid

If the inhaler has a corticosteroid, you should rinse your mouth with water, swish, and then spit the water out. This reduces the chances of a yeast infection in the back of your mouth (called oral thrush).

Judy – as long as you use good technique with the two inhalers and they are working for you (making it easier to breathe), then a spacer device is not necessary.

Best wishes,

Donald A. Mahler, M.D.

Atrial Fibrillation: Which Inhalers Are Safe?

Which Inhalers Are Safe For Atrial Fibrillation?   

Dear Dr. Mahler:

What are the safest COPD inhalers for someone with atrial fibrillation, who is on Eliquis? Thank You.

Ingrid from High Point, NC

Dear Ingrid:

As you know, atrial fibrillation is an irregular heart rhythm. The upper chambers of the heart (called atria) do not beat in synchrony with the lower chambers (called ventricles). As a result, there is a risk for blood clots to form in the heart. Eliquis is a medication used to reduce the risk of blood clots from forming.

Atrial fibrillation is a common heart disease in COPD

The curved arrows in the right and left atrium (upper chambers) in atrial fibrillation indicate chaotic electrical activity.

In those with atrial fibrillation, the heart rate may be normal or, in some people, may beat fast without any apparent reason.

There are two different classes of bronchodilators. These are called beta-agonists and muscarinic antagonists. In general, beta-agonist bronchodilators are more likely to cause the heart to beat faster than muscarinic antagonists. However, both classes are considered safe for those with COPD. In my practice, I use both classes of bronchodilators in those who have atrial fibrillation and COPD.

You did not mention whether you are using any inhaler(s) at the present time. Most likely, your health care professional has prescribed albuterol (brand names are ProAir, Proventil, and Ventolin) which is a short-acting beta-agonist medication. This is typically used as needed for shortness of breath.

Have you noticed any change in your heart rate or felt any palpitations after you inhale albuterol or a long-acting bronchodilator? If so, you should discuss this with your health care professional.

Please note, the advice provided is not a substitute for asking your health care professional about your specific situation.


Donald A. Mahler, M.D.

Is Heat-Not-Burn Vaping Safer Than Smoking Cigarettes?

What Is Heat-Not-Burn Vaping?

Dear Dr. Mahler:

I keep reading about a “tobacco unit” that heats tobacco instead of burning it. The information states that the tobacco is heated just enough to release a flavorful vapor that contains nicotine. What do you think?

I am desperate to quit smoking because I have severe COPD. I have tried everything including the patch, gum, spray, and Chantix. My friend told me that hypnosis helped her quit, but my insurance does not cover this. Should I consider trying IQOS as a safer alternative to cigarettes? 

Andrew from Peterborough, Ontario, Canada

Dear Andrew:

I appreciate your situation as many others in my practice continue to struggle with quitting smoking. I am sure that Canada has some Help Quit phone numbers to assist you to give quitting another try.

Unfortunately, there is no published research by independent universities to answer your question.

Here is a brief review of different tobacco products –  cigarettes, electronic cigarettes, and heat-not-burn – to help you and other viewers understand your choices.

Tobacco Cigarettes

Lighting a cigarette creates a fire that burns tobacco at a temperature of more than 600 degrees Centigrade. This creates smoke that contains nicotine and other toxic chemicals as well as ash. The latest statistics in the United States is that 15% of adults smoke cigarettes daily – an all-time low.

A cigarette sits in an ashtray

Electronic Cigarettes

E-cigarettes do not contain any tobacco, but instead vaporize a liquid that usually contains nicotine and possibly favoring. Apparently, many smokers are not satisfied with e-cigarettes because they do not provide the “throat-hit” that smokers are used to with cigarettes.

Vaping e-cigarette may cause e-cigarette explosion

A person vaping e-cigarette.

Heat-Not-Burn Tobacco Products

These products heat tobacco at temperatures about 350 degrees Centigrade which releases a vapor containing nicotine without burning the tobacco. Because the tobacco is heated and not burned, tobacco companies claim that there are lower levels of harmful chemicals compared with cigarettes.

IQOS is a product for heat-not-burn vaping

A heat-not-burn product called IQOS which means “I quit ordinary smoking.” Image shows charger and holder.

There are several different heat-not-burn vaping tobacco products called 3T, Glo, IQOS, iSmoke OneHitter, Pax 2, Ploom Tech, and V2 Pro. Many of these are currently available in about 30 countries including Canada (where you live), the United Kingdom, and Japan.

Once again, there is no independent research to support the claims that these products are safer than cigarettes.

The United States Food and Drug Administration (FDA)

The FDA has announced plans to cut nicotine levels in cigarettes to become less or non-addictive. For those who can’t or won’t quit, the FDA plans to allow lower-risk products that deliver nicotine without the deadly toxic chemicals.

At a two day meeting next week before the FDA, scientists from Philip Morris International and its US partner Altria will try to convince government experts that IQOS is less harmful than cigarettes. If successful, IQOS could then be advertised as the first “reduced risk” tobacco product sanctioned by the FDA. 

Please note, the advice provided is not a substitute for asking your health care professional about your specific situation.


Donald A. Mahler, M.D.

Is Cold Air Dangerous For My Lungs?

How To Deal With Cold Air and Breathing

Dear Dr. Mahler:

I have had COPD for about 4 years and live in Mankato, Minnesota, where it gets very cold during the winter months. I try to go outside most days, but I am worried that the cold air will bother or hurt my lungs. It always seems harder to breathe when it is below zero. During other times of the year, I am quite active. My inhalers include Bevespi twice a day and Ventolin for rescue. What are your thoughts?

Debra from Mankato, MN

Dear Debra,

Breathing in cold and dry air can irritate the breathing tubes, particularly if you have asthma or COPD. Typical symptoms are cough, shortness of breath, and even feeling as if your lungs “hurt.”

There is no evidence that the lungs actually freeze if someone breathes in cold air. The nose and mouth are built to warm and humidify cold and dry air before this air reaches deep into the lungs.

Here are some tips for dealing with cold air and your COPD.

  1. Place a scarf over your nose and mouth or wear a cold weather face mask. A scarf helps to lock in warm air that you are exhaling. In addition, the common cold virus replicates more rapidly in your nose when bathed by cold air.
    Person wearing scarf shows how to deal with cold air and breathing

    Woman using scarf over mouth to keep in warm air that is exhaled

    An alternative approach is to purchase a cold weather mask as shown below. Wearing a face mask will keep your mouth and nose from the cold and wind. Masks are often made of water and wind resistant neoprene shells and feature breathing holes that are used to easily allow air passage to where your mouth is. Make sure to choose a face mask that’s lined with fleece that will provide comfort and warmth to your skin.

    Wearing a face mask will keep your mouth and nose from the cold and wind. Masks are often made of water and wind resistant neoprene shells and feature breathing holes that are used to easily allow air passage to where your mouth is. Make sure to choose a face mask that’s lined with fleece that will provide comfort and warmth to your skin.

    Man wearing a cold weather face mask in Toronto

  2. Pre-heat your car or truck. If possible, ask a family member to start the vehicle for a few minutes before you go out.
  3. If you use oxygen, place your oxygen tubing inside your coat to keep it warm. The cold temperature may stiffen the tubing, possibly reducing the flow of oxygen.
  4. Minimize exertion outdoors when it is cold. See if someone else can carry your oxygen system and any packages.
  5. Drink a warm glass of tea, coffee, or cocoa when you return home. This will help to “warm you up.”

Debra – I hope that these simple “tips” are helpful to you dealing with cold air. Keep active indoors during the winter months.

Please note, the advice provided is not a substitute for asking your health care professional about your specific situation.

Best wishes,

Donald A. Mahler, M.D.


Medicare Part D Coverage for Lonhala Magnair

What Is the Difference Between Medicare Part D and B? How Will Lonhala Magnair Be Covered?

Dr. Mahler:

Do you think Lonhala Magnair will be covered under Medicare Part D or Medicare Part B?

Daniel from Buffalo, NY

Dear Daniel:

Lonhala Magnair is the brand name for glycopyrrolate – a nebulized  bronchodilator. Until its approval by the Food and Drug Administration on December 5, 2017, ipratropium bromide (brand name Atrovent) was the only muscarinic antagonist available for use in a nebulizer. However, it is short-acting and lasts 4 to 6 hours. Therefore, it needs to be used at least three if not four times in 24 hours.

Lonhala Magnair is a muscarinic antagonist bronchodilator solution that will covered by Medicare Part D

Lonhala Magnair is a long-acting bronchodilator delivered by the e-Flow nebulizer

In contrast, Lonhala Nagnair is the first long-acting muscarinic antagonist (called a LAMA) available for use in a nebulizer. It lasts 12 hours and should be used twice a day. See my post on December 7, 2017, for more information about this medication including its unique e-Flow nebulizer.

Nebulized medications are generally covered by Medicare Part B. However, Sunovion Pharmaceuticals announced that Lonhala Magnair will be covered by Medicare Part D. It is expected that Lonhala Magnair will become available in the Spring 2018.

Medicare Coverage

Many patients in my practice ask questions about Medicare coverage. Here is a brief summary of the different types of Medicare health insurance. I will try to make this complicated program as simple as possible. However, that is a challenge.

Brief History of Medicare The law providing Medicare health coverage for those over 65 years of age was signed by President Johnson on July 30, 1965, and took effect in January 1966. In 1972, Medicare coverage was expanded to include those less than 65 years of age who had long-term disability and end-stage renal disease..

Original Medicare

This program is administered directly by the federal government and has four parts:

  1. Part A is hospital insurance. It covers most medically necessary care in the hospital, skilled nursing facility, home health, and hospice. It is free if you have worked and paid Social Security taxes for at least 40 calendar quarters (10 years). You will pay a monthly premium if you have worked and paid taxes for less time.
  2. Part B is medical insurance. It covers most medically necessary doctors’ services, preventive care, durable medical equipment like oxygen, hospital outpatient services, laboratory tests, x-rays, mental health care, and some home health and ambulance services. You pay a monthly premium for this coverage.
  3. Part C allows private health insurance companies to provide Medicare benefits. See below for more information.
  4. Part D is out-patient prescription drug insurance. It provides coverage for the medications that you take at home. However, if you have Original Medicare (Parts A and B), you must choose a separate plan for Part D plan coverage. You must sign up with a private insurance company for Part D coverage that works with your Medicare health benefits.

Medicare Advantage Plans

You can choose to get your Medicare coverage through a Medicare Advantage Plan instead of through Original Medicare. These are private health health insurance companies that are approved by Medicare. Many are known as health maintenance organizations (called HMOs) and preferred provider organizations (called PPOs).

Daniel – I hope this lengthy answer is helpful. I have tried to explain Medicare health coverage as many patients tell me that this subject is quite confusing.

Please note, the advice provided is not a substitute for asking your health care professional about your specific situation.


Donald A. Mahler, M.D.

How Can I Stop Coughing Up Mucus Each Day?

Are There Treatments To Reduce Mucus?

Dear Dr. Mahler:

I am tired of coughing up “junk” everyday and find it disgusting. It takes me a good hour or two in the morning to clear it out of my lungs and then I can breathe better. My PA has called it different names, including mucus, phlegm, and sputum. Do you have any suggestions for getting rid of it? A few years ago I was told that I had COPD with chronic bronchitis. I used to smoke, but quit soon after the diagnosis. I take Advair twice a day and ProAir a few times a day when needed. Thanks for your help.

Janice from Hagerstown, MD

Dear Janice:

Before reviewing possible treatments, let me start by describing how and why the lungs make this material.

What Is Mucus?

It is a liquid made by goblet glands located inside the breathing tubes

Goblet cells produce mucus

View of the lining of the breathing tubes from a microscope. The Goblet cells are dark blue and secrete mucus. Cillia are hair-like that carry mucus toward the throat.

(airways) (similar glands are also found in the intestines). Its purpose is to protect the lining inside the breathing tubes. The problem occurs when there is too much production. Cigarette smoking is a common cause of mucus being produced in the breathing tubes.

Other irritants can stimulate mucus production include dust, air pollution, chemicals, as well as bacteria and viruses. The purpose of the excess mucus is to capture these irritants and them get out of the lungs by coughing. However, too much mucus can cause a chronic cough that doesn’t go away.

Here is a picture of chronic bronchitis which is one of the types of COPD.

Chronic bronchitis with mucus

At the bottom is a breathing tube which has mucus inside. This is common in those with chronic bronchitis.

As you can see, thick yellow mucus is inside the breathing tube and narrows the opening causing shortness of breath.

Are There Treatments?

First, it is great that you quit smoking years ago. Second, it is important that you avoid inhaling irritants in the air including second-hand smoke, air pollution, and anything else in the air that makes you cough. And third, keep well hydrated by drinking water. This helps to thin the liquid material and make it easier to cough it out of the lungs.

The two major types of treatment are expectorants and mucolytics. An expectorant works by signaling the body to increase the amount of water in secretions. This results in clearer secretions and also lubricates the irritated lining of the breathing tubes. Guaifenesin is one of the most common expectorants and is available over-the-counter without a prescription required.

Mucolytics are medicines that thin mucus, making it less thick and sticky and easier to cough up. Acetylcysteine is a prescription medication that is used to thin mucus in people with certain lung conditions such as chronic bronchitis, cystic fibrosis, and bronchiectasis. It is liquid inhaled from a nebulizer machine. Your health care professional will decide whether to use the 10% solution (dose is 6 to 10 mLs) or 20% solution (dose is 3 to 5 mLs) usually 3 – 4 times a day.

How Effective Are Mucolytics?

In 2015, there was a review of all studies published in medical journals to determine whether treatment with mucolytics was helpful for chronic bronchitis or COPD (Cochrane Database Systematic Review July 29, 2015). The authors stated that, “We are moderately confident that treatment with mucolytics may produce a small reduction” in flare-ups and a small benefit on overall quality of life.

In 2017, Dr. Mario Cazzola performed an analysis (called a meta-analysis) of a mucolytic pill called erdosteine (published online in Pulmonary and Pharmacologic Therapeutics December 9, 2017). Based on 10 studies involving 1,278 patients, erdosteine improved the clinical score of those with chronic bronchitis and COPD and also reduced the chances of a flare-up (called an exacerbation). It also reduced how long the flare-up lasted. The usual dose is 300 mg twice a day.

Although erdosteine is approved for use as a treatment of COPD with chronic bronchitis in over 50 different countries, it is not currently approved for use in the United States.

Janice – I hope that this information is helpful to you. Please note, the advice provided is not a substitute for asking your health care professional about your specific situation.

Best wishes,

Donald A. Mahler, M.D.

Asthma and Emphysema: What is the Best Treatment If I Have Glaucoma??

Asthma and Emphysema: Concerns of Treatment with Glaucoma 

Dear Dr. Mahler:

What is a good medication to treat someone with ASTHMA/Centrilobular Emphysema who also has closed angle glaucoma?

Darlene from Tulsa, OK

Dear Darlene:

Both asthma and emphysema (a type of COPD) are diseases of the lung. In asthma, the primary problem is inflammation and narrowing in the breathing tubes (airways), while in emphysema the primary problem is damage/destruction of the air sacs (alveoli). In someone who had both asthma and COPD, the condition is called asthma-COPD overlap. The figure shown below illustrates the overlap between asthma and COPD (chronic bronchitis and emphysema).

Diagram shows overlap between asthma and emphysema

Diagram shows overlap between asthma and COPD (chronic bronchitis and emphysema)

It is estimated that about 25% of those with COPD have features of asthma. In general, those with both features of asthma and COPD have worse symptoms (cough and/of shortness of breath), poorer quality of life, and an increased risk of flare-ups (exacerbations) compared to those with COPD alone.

Treatment for Both Asthma and Emphysema

First, it is important that you not smoke and avoid all irritants in the air, such as dust, fumes, particles, smog, etc. Inhalers are used to treat the inflammation of asthma and bronchodilators to open the breathing tubes for both asthma and emphysema. Use of one or more inhaled medications depends to a great extent on how severe are your symptoms and whether you have had frequent flare-ups. Typically, “triple therapy” is used that includes an inhaled corticosteroid and both types of long-acting bronchodilators – beta-agonists and muscarinic antagonists.

Types of Glaucoma

You mentioned that you have “closed angle glaucoma.” As you know, glaucoma is an increase in pressure in the eye. There are two major types of glaucoma – open angle and closed or narrow angle.

In a healthy eye, excess fluid leaves the eye through the drainage angle, keeping pressure stable.

In a healthy eye, excess fluid leaves the eye through the drainage angle, keeping pressure stable.

Open angle is the most common (90%) type and typically occurs after age 50. Closed angle is usually hereditary and affects those who are far-sighted (trouble seeing near).

The prescribing information for the muscarinic antagonist bronchodilators (brand names are Atrovent, Combivent, Incruse, Seebri, Spiriva, and Turdoza) states that these medications “should be used with caution in patients with narrow angle glaucoma.” A safe approach is for you to use a combination of a beta-agonist and inhaled corticosteroid. There are different combination inhalers  (brand names are Advair, Breo, Dulera, and Symbicort) approved for treatment of asthma and/or COPD

Darlene – If these medications do not control your breathing symptoms, then you should ask your eye doctor (ophthamologist) whether a muscarinic antagonist can be tried safely.

Please note, the advice provided is not a substitute for asking your health care professional about your specific situation.


Donald A. Mahler, M.D.


Vaping To Help Quit Smoking: Is It Safe? Is It Effective?

Is Vaping OK to Help Quit Smoking?

Dear Dr. Mahler:

I have a question about vaping. Is it ok to use a vape when you have COPD when trying to quit smoking?

Daniel from Albuquerque, NM

Dear Daniel:

Your question is a frequent one that I have been asked in my practice. Please read my March 1, 2016, post in response to a question similar to yours, “Can e-cigarettes help to quit smoking?” At the time I wrote that, “The World Health Organization takes the view that there is not enough evidence to recommend e-cigarettes for quitting smoking. In one review, there was no difference in quit smoking rates between those using e-cigarettes and those using nicotine replacement products (as examples, gum and patches).”

Vaping e-cigarette may cause e-cigarette explosion

A person vaping e-cigarette.

To provide an up-to-date answer to your question, I searched PubMed, the online search site for published medical articles. Here is what I found:

Current Perspectives of E-cigarettes in Patients with COPD

A recent review was published in the November 2017 issue of the International Journal of COPD (volume 12; pages 3202-3210) on the topic of your question. The battery of an e-cigarette heats an element that vaporizes a solution of glycerol, propylene glycol, and flavoring with and without nicotine.The authors emphasize that e-cigarettes do not contain tobacco and do not rely on combustion to operate.  However, they can deliver nicotine that closely matches the rate and level of tobacco cigarettes.

Of interest, the US Food and Drug Administration consider both glycerol and propylene glycol as Generally Recognized as Safe.

In one study, those with COPD who stopped smoking  or considerably reduced tobacco consumption by using e-cigarettes were followed for two years. Over this time period, flare-ups of COPD were reduced by 50% and there was an improvement in general health status.

The authors concluded that although e-cigarettes are not risk free, they are much less harmful than smoking tobacco cigarettes.

Advice From Former-Smoking E-cigarettes Users to Current Smokers  

4,192 individuals who quit smoking using e-cigarettes were surveyed online. They were asked to provide advice to current smokers who were considering vaping as a way to help them quit. Their advice covered four themes: 1. Find a combination of vaping device, flavor of e-liquid, and nicotine strength that “works for you”; 2. It is OK to continue to smoke for a while after starting to vape; 3. It is common for people to fail to quit smoking using approved aids (like nicotine patch) before success with e-cigarettes; and 4. Many respondents noted an awareness of improved health and hygiene since switching to vaping.

This reports was published online on August 3, 2017, in the journal Nicotine Tobacco Research (doi: 10.1093/ntr/ntx176

My Comments

As your have COPD, the most important thing that you do is to quit smoking cigarettes. I advise patients in my practice to quit any way possible. This includes quitting “cold turkey,” use of nicotine patch or gum or lozenges, acupuncture, hypnosis, and prescription medications.

I also support the use of e-cigarettes as a substitute for tobacco cigarettes. Why? Cigarette smoke contains over 4,000 chemicals, including 43 known cancer-causing (carcinogenic) compounds and 400 other toxins. In contrast, vape smoke contains only three (nicotine, glycerol, and propylene glycol) along with possible flavoring.

Good luck on quitting. Please note, the advice provided is not a substitute for asking your health care professional about your specific situation.

Donald A. Mahler, M.D.

Quitting Smoking: “I Need Help To Stop”

Ways for Quitting Smoking

Dear Dr. Mahler: 

I have COPD and breathe hard with most activities. I was in the hospital two months ago for a chest infection and had to quit smoking then. I did great for about 3 weeks, but then started smoking 1 – 2 cigarettes a day. Gradually, it increased to about 10 per day. It is frustrating because I know that I should quit. I try to stay busy, but a friend may come over to visit and we both enjoy smoking together. It helps me relax. 

My doctor has told me that I have Stage 3 COPD, and take Spiriva and Advair inhalers. I make sure to get a flu shot each year.

Is there any advice can you give me?

Miriam from Corpus Christi, TX

Dear Miriam:

It is great that you want to quit smoking. Here is some general information on smoking in the US followed by recommendations to help you quit.

General Information on Tobacco Use In The United States

According to the Centers for Disease Control and Prevention, in 2015, 20% of adults (49 Million) use a tobacco product either every day or some days. That includes cigarettes (15%), e-cigarettes (3.5%), cigars or cigarillos (3.4%), smokeless tobacco (2.3%), and regular pipes, water pipes, or hookahs (1.2%).

Smokers need help quitting smoking

Cigarette Smoking

Current use of tobacco is higher in men (25% versus 15% in women), those less than 65 years of age, persons living in the Midwest; persons of annual household income of less than $35,000 per year (28% versus 13% with income of at least $100,000 per year); persons who were single, never married, or not living with a partner; persons insured through Medicaid; persons with a disability, and those who identified as lesbian, gay, or bisexual (27% versus 20% in heterosexuals).

Ways For Quitting Smoking

I have provided information on ways for quitting smoking in Chapter 3 (Can You Help Me Quit Smoking?) of COPD: Answers to Your Questions published in 2015 (for more information see heading Books on my website). Various websites and phone numbers are listed in a Table on page 23.

In addition, QuitNow offers a FREE program which will help you create an easy-to-follow Quitting Plan that will show you how to get ready, take action, and then live the rest of your life as a non-smoker. The website is, and the phone number is 1-800-784-8669.

According to the website, you get: Quitting Aids including FREE nicotine replacement products (patches or gum) if it is part of your personalized Quitting Plan; Quit Guide – an easy to use workbook; Quit Coach – assistance over the phone from someone who specializes in helping people quit; Web Coach – a private online community where you can complete activities, watch videos, and track your progress; and Text2Quit – text messages allows you to connect with your Quit Coach, interact with your Web Coach, use medications correctly, manage urges, and avoid relapse.

Finally, Miriam, I encourage you to discuss your desire to quit smoking with you health care professional. He or she can offer suggestions based on knowledge about your specific situation.

Mark Twain has a famous quote about quitting smoking

Mark Twain

I often quote Mark Twain about quitting smoking: “Giving up smoking is the easiest thing in the world. I know because I’ve done it thousands of times.”

Best wishes on success on quitting smoking.

Donald A. Mahler, M.D.

Can Too Much Antioxidants Be Bad for You?

Antioxidants: Balancing Benefits and Risks

Dear Dr. Mahler:

Is there such a thing as too much anti-oxidants and anti-inflammatory supplements for we COPD patients? I ask because I have recently been diagnosed with moderate COPD, and actually returned a bottle of concentrated tart cherry recommended by a local health food store after reading several articles.

Thank you for your time and consideration in responding.

William from Oak Brook, IL

Dear William:

Thanks for an interesting and challenging question. I’ll start by stating that I don’t have a definite answer for you. However, I searched recent published articles in PubMed and provide the following comments after providing general information for other readers.

What is Oxidative Stress? This is a natural process that occurs in everyone and damages cells in the body. Oxidative stress is thought to contribute to aging and has been implicated in numerous diseases including hardening of the arteries (atherosclerosis), diabetes, and cancer.

There is growing evidence of the role of oxidative stress in those with COPD. Cigarette smoke is a potent source of inhaled oxidants and free radicals present in both the gas and tar phases of the smoke. In COPD the number of inflammatory (redness and swelling) cells are increased in the breathing tubes (airways) and air sacs (alveoli). These inflammatory cells produce reactive oxidative species, a major oxidant that damages and destroys cells.

What are Antioxidants? Our body has a wide number of natural antioxidants that protect against oxidative stress. However, when the number of oxidants is greater than available antioxidant defenses, there is damage to cells.

Many individuals consume herbs and foods that are antioxidants in an attempt to reduce oxidative stress and cell injury. On June 11, 2015, I posted a response to a question from someone about drinking herbal tea which has antioxidant properties. On February 27, 2017, I posted information on a study that showed that eating fruits and vegetables can prevent or reduce the risk of developing COPD.

2017 Articles about Oxidative Stress and Antioxidants      1. An  article in the February 2017 issue of the journal Scandinavian Journal of Immunology (volume 85; pages 130-137) reported that patients with very severe COPD had higher levels of markers of oxidative stress compared those with mild, moderate, and severe disease.                                                           

N-acetyl cysteine is one of many antioxidants

N-acetyl cysteine has antioxidant and anti-inflammatory effects

 2.  N-acetylcysteine (NAC) is an antioxidant with anti-inflammatory effects available in a capsule. An analysis of 12 studies involving a total of 2,691 patients with COPD showed that long-term (at least 6 months or longer) use of NAC reduced the frequency of flare-ups (exacerbations) with no change in results of breathing tests. This review was published in the March-April 2017 issue of the journal HeartLung (volume 46; pages 120-128).                                                                                                      

3. The RESTORE study compared the effects of erdosteine (a pill that thins mucus and is an antioxidant) and placebo in 445 patients with COPD for one year. Erdosteine reduced mild flare-ups (exacerbations) by 19% compared with placebo, but had no effect on moderate or severe flare-ups. A mild flare-up is one when the patient uses more albuterol as rescue therapy, while a moderate flare-up is one when treated with an antibiotic and/or prednisone. In addition, erdosteine reduced the number of days of flare-up symptoms by 25%. This study was published on-line October 12, 2017, in the European Respiratory Journal.  

Antioxidants and Cancer William – Thanks for sending the links to articles about the potential harm of antioxidants making cancer worse. Please note that these studies were performed in mice, and it always hard to apply such results to humans. 

Blueberries are rich in antioxidants

Blueberries are rich in antioxidants

My advice is to eat lots of fruits, vegetables, and nuts which are heart healthy foods and also rich in antioxidants. Taking supplements with antioxidants such as concentrated tart cherry is entirely up to you. I am not aware of any studies to provide guidance. Based on the results in mice, I recommend against antioxidant supplements in someone who has cancer.

Best wishes on a healthy life,

Donald A. Mahler, M.D.

Health Risks from Mold Related to Water Damage

Health Risks from Mold Due to Flooding

Flooding raises questions about health risks form mold

Flooding from hurricane Harvey in Texas.

Over the past few weeks, I have received several questions from people who live in Texas, Louisiana, and Florida about the health risks of mold due to water damage from flooding. Many with COPD and their families are concerned that inhaling mold will cause breathing problems including possible lung infection (fungal pneumonia). Here are some typical questions. 

What Is Mold?

Mold refers to a fungus that grows in thread-like structures called hyphae. If it is a single cell, it is called a yeast.

Mold can  be found in damp building materials where it often appears like stains and comes in a variety of colors. A must smell is an indication of microbial growth even when there it is no visible. If mold is allowed to grow in homes or offices, it can contribute to poor indoor air quality.

Spores from green mold growing on an orange,

Mold growth requires moisture. This is a particular concern with flooding, but other sources of moisture could be air humidifiers or leaks from plumbing or from a roof. Poor ventilation contributes to higher humidity levels which also allows mold growth.

Molds can release small “spores” into the air. These spores are small enough that people can actually inhale them deep into the lungs.

How Do I know If There Is Mold in My Home?

Mold on walls causes health risks from mold

Mold growing on walls

Mold may be visible as shown in the photo on the right, but may not always be seen or smelled. Kits are available for testing for mold at home, but may not always be accurate. One option is to hire a certified industrial hygienist to do testing.

What Should I Do To Avoid Mold?

Anyone with a chronic lung disease, such as COPD, may be sensitive to mold. Inhaling mold can make your breathing worse. You should avoid buildings contaminated with mold.

What are the Symptoms and Health Risks from Mold?

Some people exposed to mold may have stuffy nose, irritated eyes, or skin irritation. Allergies to mold may cause shortness of breath, wheezing, and/or coughing. Those with weakened immune systems and with chronic lung disease (like COPD) may develop fungal infections in their lungs.

How Do I Prevent Mold Growth? 

Reducing moisture is critical for preventing mold growth. Keep your residence clean and dry by opening windows, use fans, air conditioners, and dehumidifiers, clean surfaces with detergent and water. For items that cannot be washed and disinfected, remove and discard mattresses, carpeting, rugs, upholstered furniture, pillows, drywall, and insulation.

How Do I Protect Myself from Mold While Cleaning Up?

Buy an N95 mask at your local home supply store. This type of mask must cover both the nose and mouth to keep you from breathing in mold and dust. If it does not have a snug fit, it will not work properly.

Correct fit of the mask requires contact with smooth skin. It will not work properly for people with beards or facial hair. Even one-day beard growth has been shown to let air leak in. Always use both straps on the mask to hold it in place to keep air from leaking around it.

Couple using N95 masks while cleaning up damage to home from floods in Houston September 2017

This information about health risks from mold is summarized from Mold After a Disaster @ and Ten Things You Should Know About Mold @ https;//

For Pain and Breathlessness: Is Any Medication Helpful?

Medications to Relieve Both Pain and Breathlessness

Dear Dr. Mahler:

Working on trying to get off pain medication-in addition to COPD I have hip and back pain issues. My doctor has been changing the drugs and manufacturers – they don’t agree with me, Considering cannibus- do you know of any specific type that might help me for both pain and breathlessness? Any suggestions will be greatly appreciated- thank you.

Gerald from Miami, OH

Dear Gerald:

Your question is quite relevant because many individuals who have COPD also suffer from pain.

The first question that I ask is do you know the cause(s) of pain in your hip and back? This is important because certain problems may be treated with surgery. For example, hip replacement is possible for severe arthritis of the hip. Also, back surgery (laminectomy) can be performed for some individuals with spinal stenosis. I encourage you to ask your health care professionals about why you are experiencing pain. It is possible that an evaluation with an orthopedic physician may be appropriate if not already done.

Can Cannabis Relieve Pain?

On July 5, 2017, I posted information about the two major components of the the marijuana plant (which is officially called Cannabis sativa)  –  cannabidiol (abbreviated CBD) and tetrahydrocannabinol (abbreivated THC). CBD is thought to have anti-inflammatory effects, while THC provides the “high” that people experience when smoking or eating marijuana.

Here is information from the July 5 post:

“CBD oil is taken by mouth, rubbed on the skin, or may be inhaled. One of the main uses is to relieve pain and stiffness. In one study involving rats and mice, CBD significantly reduced chronic inflammation and pain. CBD is already in use for humans who have multiple sclerosis and fibromyalgia – both of which can cause chronic pain.”

Can cannabis sativa relieve pain and breathlessness?

Cannabis sativa plant

Can Cannabis Relieve Breathing Difficulty?

To my knowledge, there is no evidence that either CBD or THC makes t easier to breathe. In the book Breathe Easy (published June 2017), I provide information on medical treatments for COPD (Chapter 5) as well as other treatments to relieve shortness of breath (Chapter 9). Information about the book is available under the heading Books on my website.

Are There Medications to Help Both Pain and Breathlessness?

Opioids are narcotic medications that are used to treat both pain and breathing difficulty. I have two posts on my website about similar questions to yours. The posts were on June 29, 2016, and April 22, 2017. I suggest that you check this out by typing in “Opioids” in the Search function of the website.

I hope that this information is helpful to you.

Best wishes,

Donald A. Mahler, M.D.

Trelegy Ellipta: Is There Any Downside To Taking All Three Medications Together?

Is There Any Downside to Taking Trelegy Ellipta?

Dear Dr. Mahler:

I read your recent post and have heard of Ellipta, though now Trelegy may be one step newer…
Is there any downside to taking all these helpers at once?
I was thinking, although it is more to do in a day, that keeping them separate might be a good thing.  More effect from each on their own?
Maybe not!

Katherine from Greensboro, NC

Dear Katherine:

Thanks for commenting on my recent post about a new 3-in-1 approved inhaler by the Food and Drug Administration (FDA) for those with COPD on September 18.

Please note that this single inhaler contains three different medications for treatment of those with COPD. These medications are already combined together and are available. These are Anoro Ellipta (different bronchodilators – vilanterol and umeclidinium) and Breo Ellipta (a bronchodilator – vilanterol – and an inhaled corticosteroid – fluticasone). So, the pharmaceutical company, GlaxoSmithKline, combined all three medications together in a dry powder inhaler called Trelegy Ellipta. They performed various studies (called randomized clinical trials) as required by the Food and Drug Administration. The company then submitted the results to the FDA for review and consideration of approval.

Although it may seem confusing, the different Ellipta inhalers along with numerous other inhalers developed by other pharmaceutical companies provide many options for health care providers to hopefully make it easier for you to breathe with activities and to reduce the chances of having a flare-up (called exacerbation). These treatment strategies are provided by the a group of experts in COPD called the GOLD committee.

You asked about a downside to taking all three medications together. Please note that current recommendations for the use of inhaled corticosteroids in treating those with COPD is for those individuals who have had 2 flare-ups (exacerbations) in the past one year OR one flare-up that was “bad enough” to require hospitalization. The reason for this recommendation is that inhaled corticosteroids can have side effects. The most concerning is an increased risk of pneumonia. Other possible side effects include a yeast infection in the throat, bruising of the skin, and thinning of the bones (called osteoporosis).

As with all medications, your health care provider should consider the likely benefits of the medications along with possible side effects. Some people call this “weighing the balance.”

A scale to weigh the benefits and risks of Trelegy Ellipta

A scale represents weighing the benefits and risks of a medication


I hope that this information is helpful. I encourage you to discuss the available inhalers with your health care professional.

Best wishes,

Donald A. Mahler, M.D.

Why is Menthol Added to Cigarettes?

Menthol in Cigarettes – The Soothing Taste Makes Smoking More Appealing

Dear Dr. Mahler:

I am writing about my father who smokes about 10 menthol cigarettes each day even though he has moderate COPD. He believes that this counteracts the nicotine and toxins in cigarette smoke. He uses two different inhalers to breathe each day. I notice a lot of advertisements promoting mentholated cigarettes. Please provide information to share with my father. Thanks.

Jasmine from Newark, NJ

Dear Jasmine,

Menthol is a natural substance found in mint plants, such as peppermint and spearmint. It gives a soothing sensation, and may be used to relieve minor pain and irritation.

Mint plant contains menthol

Mint plant

Why do Tobacco Companies Add Menthol to Cigarettes?

Newport is the most popular menthol cigarette

Newport is a popular menthol cigarette in the US

The “soothing” taste allows many smokers to feel less irritation in their throat while smoking and to take deeper breaths.  It is currently the only flavor that be added to cigarettes by law. Metholated cigarettes represent about 25% of all cigarettes on the market with Newport being the most popular brand in the US.



Is There Harm in Smoking Mentholated Cigarettes? In 2013, the US Food and Drug Administration published a report that menthol cigarette use is one reason that young adults start smoking. Also, the report cited evidence that menthol in cigarettes is associated with greater nicotine addiction. Mentholated cigarette users are also less likely to successfully quit smoking.

Can Menthol Contribute to Nicotine Addiction? Studies show that it reduces metabolism (the breakdown) of nicotine by the body.   

What About Mentholated Cigarettes in African-Americans? In the United States, menthols comprise about 30% of the total cigarette market. However, these flavored cigarettes are purchased disproportionately by African-American smokers as more than 80% of African-American smokers currently use mentholated cigarettes. This may be a result, at least in part, of adds, discount coupons, and free samples of metholated cigarettes targeted at this group. Studies show that African-Americans suffer higher rates of smoking related health problems even though they smoke at similar rates as Caucasians.

Jasmine – Please share this information with your father. Hopefully, it will help him decide that it is time to quit smoking.


Donald A. Mahler, M.D.

What is Triple Therapy? My Doctor has Mentioned This to Me

Triple Therapy: What Is It? What are the Benefits?

Dear Dr. Mahler:

I am curious about “triple therapy.” My doctor suggested this to me at my last visit, but said that he wanted to read more about the results of studies.

 My doctor has told me that my COPD is severe. Last winter I had a flare-up and had to be hospitalized.  I am doing fine now, taking Spiriva HandiHaler and Serevent Diskus. What are your thoughts?

Jeff from Wilmington, NY 

Dear Jeff,

“Triple therapy” refers to three different inhaled medications to treat COPD. Two are bronchodilators, and the other is an inhaled corticosteroid.

You state that you are currently taking a long-acting beta agonist – Serevent Diskus – twice a day – and a long-acting muscarinic antagonist – Spiriva HandiHaler – once a day in the morning. These dry powder bronchodilators act in different ways to open the breathing tubes by relaxing the muscle that wraps around the airways.

Serevent is one component of triple therapy

Serevent Diskus dry powder inhaler

Spiriva is one component of triple therapy

Spiriva HandiHaler dry powder inhaler







Inhaled corticosteroids are a different type of medication used to treat COPD. It is anti-inflammatory – that means it reduces redness and swelling inside of the breathing tubes.

At the present time, two different inhalers need to be used to provide “triple therapy.” According to an international group of experts in COPD called GOLD, triple therapy should be used in those patients who are short of breath with walking on the level and have had 2 or more flare-ups (called exacerbations) or one requiring hospitalization in the past year.

Pharmaceutical companies are working on putting all three types of medications – beta-agonist bronchodilator, muscarinic antagonist bronchodilator, and corticosteroid – into one inhaler. This is also called “closed triple therapy” because all medication are “closed” within one device.

Currently, the Food and Drug Administration (FDA) is reviewing a proposed “closed triple therapy” inhaler for us in the US. At the present, “triple therapy” requires use of two different inhalers.

David Lipson, MD, is first author of article on Triple therapy

David A. Lipson, M.D., of Perelman School of Medicine in Philadelphia

In the August 15, 2017, issue of the American Journal of Respiratory and Critical Care Medicine (volume 196; pages 438-446), Dr. Lipson and colleagues published one of the first reports of triple therapy in one inhaler. It is called the FULFIL study. The 3-in-1 inhaler was compared with twice daily beta-agonist and inhaled corticosteroid for 24 weeks in a total of 1,810 patients with COPD. Triple therapy showed greater improvements in breathing tests and in quality of life scores along with a 35% reduction in flare-ups compared with dual therapy. The safety was similar between the two inhaled medications.

Once again, triple therapy is recommended for those who are symptomatic (short of breath walking on the level) and are at risk for a flare-up (exacerbation) based on 2 episodes in the past year or one leading to hospitalization.


Donald A. Mahler, M.D.

Can Albuterol Cause Weight Loss? I Use Albuterol in Nebulizer 3x/day Along with Ventolin As Needed

Can Albuterol Cause Weight Loss?

Dear Dr. Mahler:

I continue to lose weight. 9 lbs in 6 months, more before that.  No apparent explanation so I am on the hunt to try to figure it out. I can’t get an appt with an endocrinologist for 3 months.

Have you heard of people with COPD losing weight from taking a lot of albuterol or just from having diminished lung capacity?

I use Albuterol in the nebulizer 3x day plus several puffs of Ventolin during the day. Along with Albuterol I use Budesonide inhalation 2xday as prescribed. I tried all of the other newer “2 in 1” bronchodilators, but either they didn’t work or I had side effects.
I’d appreciate your thoughts.

Sidney from Tacoma, WA

Dear Sidney:

I have not come across your question in my practice previously. To provide an answer to your question – Can Albuterol Cause Weight Loss? – I first summarize information about beta receptors in the body. Second, I review how albuterol works. Third, I include information based on a search of the medical literature on PubMed.

Beta Receptors

There are three types of beta-receptors in the body that work in different ways. Beta1 receptors are located mainly in the heart. When stimulated with a medication, heart rate increases and the heart pumps more blood. Beta2 receptors are located in the breathing tubes and in the blood vessels (arteries) that provide  blood to muscles in the arms and legs. When stimulated with a medication, the muscle that wraps around the breathing tubes relaxes allowing more air to go in and out of the lungs.  This makes it easier to breathe. Beta3 receptors are located in the fat (adipose) tissue of the body. When stimulated, there is break down of fat tissue (called lipolysis).

Muscarinic Receptors

In addition to beta receptors, there are muscarinic receptors located in the breathing tubes that work in a different way to allow more air to go in and out of the lungs. It is common to prescribe both beta2 and muscarinic antagonists because they dilate the airways be different mechanisms and work better than only one type of bronchodilator.

Albuterol Sulfate

Albuterol is a short-acting beta2-agonist bronchodilator. What does this mean? Short-acting means that it lasts for 3 – 4 hours, and then wears off. Beta2 means that is attaches to beta2 receptors – located in the breathing tubes and arteries of skeletal muscle –  and has minimal effect on beta1 and beta3 receptors. Bronchodilator means that it relaxes the smooth muscle that wraps around the breathing tubes to open them and make it easier for air to move in and out.

Smooth muscle wraps around the outside of the breathing tubes. This address Can Albuterol Cause Weight loss

View of smooth muscle wrapping around the outside of the breathing tubes

In general, albuterol is used mainly as needed. This means either as rescue for sudden breathing attacks OR before doing an activity that is expected to cause some breathing difficulty. For maintenance therapy, long-acting bronchodilators are used to treat those with COPD because they keep the breathing tubes open from 12 – 24 hours. I assume that you were tried on long-acting bronchodilator medications and either they did not work for you, or you had side effects.

Can Albuterol Cause Weight Loss?

There is not a lot of medical information to answer your question completely. There is one study published in 1993 in the journal Thorax (Amoroso is first author) which showed a slight increase in metabolism in 10 healthy adults with four puffs of albuterol compared to a placebo over an hour.

A review of side effects of albuterol in listed the following side effects: 16 MAJOR side effects with shakiness and trembling as More Common, fast, irregular, pounding heart rate as Less Common, and 13 different reactions as Rare, none of which was weight loss. There were 11 MINOR side effects listed, again none of which included weight loss.

My Comments

Based on this information and my experience, I consider it very unlikely that your frequent use of albuterol in the nebulizer and by inhaler are causing your weight loss. Ideally, you would try using long-acting bronchodilators so that you would not need to use so much albuterol to breathe.

To know for sure about your concern, you would need to reduce albuterol use markedly. Obviously, that would require you to use long-acting bronchodilators to replace short-acting albuterol.

Finally, I support your effort to look for another reason for weight loss. I would start with your primary care provider, and then with an endocrinologist as you are planning.

Best wishes in finding an answer.

Donald A. Mahler, M.D.

CBD (cannabidiol) and THC Oil: Health Benefits and Risks

CBD (cannabidiol) and THC (tetrahydrocannabinol) Oil Use in COPD

Dear Dr. Mahler:

My father is 81 yrs old and suffers terribly with advanced COPD. A few

Bottle of CBD (cannabidiol) and THC (tetrahydro cannabinol) used by the father

Bottle of CBD (cannabidiol) and THC (tetrahydro cannabinol) oil used by father of person submitting question

months ago he agreed to try cbd oil and has been making some progress in his condition.  I was wondering if when he has a flare up and is coughing terribly would a tincture of cbd oil help stop the coughing? He has been making great progress on the low thc cbd oil. Should he have a stronger dose of thc is my other question? Here is a photo of the bottle of oil that he is taking.

Many thanks.

Bridgett from Squamish, British Columbia

Dear Bridgett:

The photo of the bottle shows that the oil contains both CBD and delta-9 tetrahydro-cannabinol (THC). THC is the most well known compound in cannabis; it is psychoactive and gives the “high.” CBD is not psychoactive, but appears to produce changes in the body that may have medical benefits.

Where Do CBD and THC Come From?

Both are obtained from the plant cannabis sativa, which is also known as marijuana, grass, pot, dope, and Mary Jane along with many other names. However, there are varieties of cannabis sativa.

CBD (cannabidiol) is derived from the cannabis plant

Cannabis sativa plant

CBD (cannabidiol) comes from two main sources – medical marijuana plants and industrially grown hemp plants.  The medical marijuana plants are grown to be high in CBD, but also contain various amounts of THC. I don’t know the legal status in Canada. In the United States, they are sold to licensed dispensaries and prescribed by physicians for specific conditions depending on the state where you live. Medical marijuana is legal in 29 states and in the District of Columbia.

CBD that comes from industrial hemp plants is totally different. In the United States, the Food and Drug Agency considers hemp oil to be a dietary supplement not a medication. It contains virtually no THC, and does not give a “high” feeling. For those readers who live in the US, you don’t need a prescription and can legally purchase CBD oil in any state.

Hemp oil contains CBD (cannabidiol)

Hemp oil in bowl and in syringe

How Does CBD and THC Work?

All cannabinoids, including CBD and THC, attach themselves to certain receptors in the body. The two main cannabinoid receptors are called CB1 and CB2. CB1 receptors are found in brain and deal with coordination, movement, pain, mood, thinking, appetite, and memory. THC attaches to these receptors. CB2 receptors are more common in the immune system that deals with inflammation and pain.

Potential Health Benefits of CBD

CBD oil is taken by mouth, rubbed on the skin, or may be inhaled. One of the main uses is to relieve pain and stiffness. In one study involving rats and mice, CBD significantly reduced chronic inflammation and pain. CBD is already in use for humans who have multiple sclerosis and fibromyalgia – both of which can cause chronic pain.

There is also promising evidence that CBD (cannabidiol) may help people quit smoking. It is also being studied as a treatment for anxiety, mood symptoms, epilepsy. difficulty sleeping, cancer, type 1 diabetes, acne, and Alzheimer’s disease.

In one report of four individuals with COPD there was no difference in ratings of breathlessness when breathing a gas mixture of carbon dioxide (causes more breathing) with 10 mg of cannabidiol and a placebo (published in Chronic Respiratory Disease; year 2011; volume 8; pages 109-118).

Potential Side Effects and Health Risks

Small scale studies have found that CBD is well tolerated in adults. The most common side effect noted is tiredness, while some have noticed diarrhea and changes in appetite.

Bridgett – I am glad that your father “has been making some progress.”   Although I am not aware of any studies evaluating whether CBD/THC affects coughing frequency, a search on the internet reveals that there are anecdotal reports (stories by individuals) that THC taken by mouth (not inhaled) reduced coughing fits. One report suggested that THC “latches onto the nerve cells in the upper airways of mammals and short-circuits the signals that cause coughing spasms.”

My suggestion: it seems reasonable to continue the oil as it is working and not causing side effects. Any higher dose will require you and your father to “experiment” if you believe/consider that there is a reasonable likelihood that the benefit (less coughing) outweighs possible side effects.

Thanks for such an interesting and challenging question.

Donald A. Mahler, M.D.



Carrier for Alpha-1 Antitrypsin Deficiency Emphysema: What Does it Mean?

Carrier for Alpha-1 Antitrypsin 

Dear Dr. Mahler:

I am 74 years old and was recently hospitalized for a flare-up of my COPD due to a chest cold. The hospital doctor referred me to the local pulmonologist, who told me that my breathing tests show “very severe” COPD. She tested me for alpha-1 antitrypsin deficiency. At my follow-up appointment, she gave me a copy of the test result and told me that I had a normal level (265 mg/dL), but that my Genotype was MF. Based on my discussion with the pulmonologist, I understand this means that I am a carrier for alpha-1 antitrypsin deficiency.  Can you help explain what all of this means? 

Otherwise, I am doing fine.  I take Advair in the round disk and Incruse powder, and do maintenance pulmonary rehab at the nearby hospital.

Many thanks.

Gloria from Northbrook, IL 

Dear Gloria:

Thanks for your question about being a carrier for alpha-1 antitrypsin deficiency, a hereditary form of emphysema. I will try to provide a simple answer to your question on a topic that can be complicated.

This structure includes possibility of a carrier of alpha-1 antitrypsin deficiency

Structure of the alpha-1 antitrypsin protein

Here is a brief review of the alpha-1 antitrypsin protein. It is made in the liver and released into the blood. One of its functions is to prevent damage to the lung. Some defects in the gene (called an allele) block the release of the protein into the blood resulting in a lower blood level called a deficiency. This makes the lungs more susceptible to injury from cigarette smoking or inhaling irritants in the air. This can cause emphysema which may develop in someone as early as in his/her 40s. The other conditions that can occur in alpha-1 antitrypsin deficiency are shown in the figure.

These conditions do not occur in a carrier for alpha-1 antitrypsin deficiency

Conditions associated with Alpha-1 antitrypsin deficiency

The normal allele (part of a gene) for alpha-1 antitrypsin is called M. Normally, a person is MM. This means that the person inherited one M allele from each parent. The most common abnormal alleles are called S and Z.

You have one normal allele – M, and one abnormal allele F. The good news is that you do not have a deficiency of alpha-1 antitrypsin, and therefore no changes are necessary in your treatment. You may wish to share the test results with family members.

I agree with your pulmonologist that you are a carrier for alpha-1 antitrypsin deficiency. Current evidence suggests that those with the F allele have normal levels of the alpha-1 protein in the blood, but that it may not have totally normal function. As I mentioned earlier in this response, you should continue to use your inhalers and stay active with continued participation in pulmonary rehabilitation.

The Alpha-1 Foundation website [] is an excellent source of information about the disease.

Best wishes,

Donald A. Mahler, M.D.

Reduction in Opioids for Pain: Could This Make My Breathing Worse?

Reduction in Opioids and Breathing is Worse

Dear Dr. Mahler:

I have COPD-my Dr. has taken me completely off the Fentanyl patch which I used for years – I have several issues that cause me a lot of pain. I have also been on Vicodin – 8 each day. They are now cutting back on it.
My problem is my breathing has worsened and I have had increased breathing exacerbations with these cut backs. Do you think there could be a connection?
Do you have any suggestions for me? Between the pain and breathing issues my quality of life is bad and I am depressed that I can’t do the things I used to. I use the Stiolto Respimat and Albulterol when I have a bad breathing situation.
Would really appreciate if you would have any suggestions for me. THANK YOU.

Sandra from Little Rock, AK

Dear Sandra:

Your experience is not unusual.

opium poppy is source of natural opiods

Opium poppy

Both fentanyl and vicodin are opioids that act on receptors in the body to relieve pain. Opioids include opiates that found in the resin of the opium poppy (incluidng morphine) as well as medications made in laboratories that are called synthetic drugs. These include fentanyl and vicodin [hydrocodone and acetaminophin (brand name is tylenol)] which you are or were taking.

Opioids are also helpful to relieve shortness of breath. Usually, they are used for those with advanced disease for palliation. It is quite possible that your worsening in breathing is related to the reduction in opioids. Remember that opioids may cause side effects including tiredness, low energy, sleepiness, and constipation.

water exercise may help shortness of breath due to reduction in opioids

Seniors doing Water Aerobics

exercise may help with shortness of breath due to reduction in opioids

Man pedaling stationary cycle being supervised by rehabilitation specialist.

Could the combination of your COPD and use of fentanyl/vicodin led to an inactive life style? If so, is it possible for you to do more activities to improve your breathing, or does your pain limit activity level? Is participation in a pulmonary rehabilitation program a possibility for you? Are water activities possible with your pain problem?

Another question that I have relates to your report of exacerbations with reduction in opioids. Are you experiencing chest congestion and coughing up yellow or green mucus with these episodes? If so, I suggest that you ask your doctor to check for bronchiectasis (see post on April 21, 2017, under COPD News) and acquired immunodeficiency (see post on November 23, 2016, under COPD News). Both of these conditions may lead to frequent flare-ups.

Finally, you may wish to ask your doctor about starting an inhaled corticosteroid medication to help reduce the risk of future flare-ups. Your current use of Stiolto Respimat as a maintenance medication is excellent as it contains two different types of long-acting bronchodilators. The 2017 GOLD recommendations suggest that an inhaled cortiosteroid be added to a medication like Stiolto if you continue to experience exacerbations.

I hope this information is helpful. Best wishes,

Donald A. Mahler, M.D.

Chinese Herbal Product for Clear Lungs and Better Breathing

Chinese Herbal Product – ClearLungs

Dear Dr. Mahler:
I have recently been taking the Chinese Herbal product, “ClearLungs.”  I have felt my lungs clearing up but I cough a lot, I take no other medication.  Should I keep taking it, what is your opinion?
Lynn from Chattanooga, TN 

Dear Lynn,

Before discussing the Chinese herbal product, I have a few questions for you. You describe that “I cough a lot.” There are many causes for coughing and thus it is important to find out why. When you cough, is it a “dry cough” or do you raise mucus? Do you have allergies, asthma, or chronic obstructive pulmonary disease? Have you mentioned your coughing to your health care professional?

Chinese herbal product may help with coughing

Female with COPD coughing

 What is the Chinese Herbal Product – ClearLungs? As I am not familiar with this product, I searched the internet. The website stated that ClearLungs is a brand name that “contains 13 perfectly balanced herbal ingredients designed to help keep airways free of phlegm and mucus while supporting clear lungs and free breathing.” The website did not mention the actual names of the 13 herbal ingredients.

Who Makes ClearLungs? ClearLungs is manufactured by Ridgecrest Herbals, Inc., a Utah corporation.  The company makes over two dozen formulas, including both herbal supplements and over-the-counter (OTC) homeopathic medicines which contain herbs.

What is the Cost? Sixty tablets of ClearLungs cost $21.99 if ordered on the website.

My Comments Lynn – I can not recommend this product as I don’t know what are the actual 13 herbal ingredients. With most medications, studies called randomized clinical trials are performed to evaluate how good the medication works (efficacy) and safety.  It would be interesting to learn if the manufacturer has performed any such studies to evaluate ClearLungs.

I hope that this information is helpful.


Donald A. Mahler, M.D.

What is the Best Maintenance Bronchodilator Therapy for my COPD?

Maintenance Bronchodilator Therapy – Four Combinations Available in a Single Inhaler

Dear Dr. Mahler:

I have severe COPD and I was wondering roughly how long does it take to get on a maintenance program that works. This May will be a year and I still use my nebulizer with a duoneb every 4 hours and my emergency inhaler (Ventolin) when needed. My pulmonologist knows this. Should I see another pulmonologist??? I figure I should of been getting some relief. I have been smoke free for 3 months and will not go back to smoking again. Could you please point me in the right direction???

Jeff from Lubbock, TX

Dear Jeff:

DuoNeb is a very good short-acting combination of two different bronchodilators – albuterol and ipratropium. They work in different ways to open the breathing tubes by relaxing the muscle that wraps around the tubes. Short-acting bronchodilators last approximately 4 – 6 hours, and then the breathing tubes return to previous narrowing. Also, Ventolin is a brand name for albuterol delivered in an inhaler.

Maintenance bronchodilator therapy keep the breahting tubes open for 12 - 24 hours.

View of smooth muscle wrapping around the outside of the breathing tubes

All studies show that long-acting bronchodilators are more effective in keeping the breathing tubes open for a longer time and making it easier to breathe compared with short-acting medications. There are many choices of long-acting bronchodilators to use that are delivered in different types of inhalers.

In the past few years four different combination of long-acting bronchodilators in a single device have been approved for use in the United States by the Food and Drug Administration. I have several posts describing these medications used as maintenance bronchodilator therapy. They include in alphabetical order of brand names: Anoro Ellipta – a dry powder inhaler; Bevespi Aerosphere – a metered-dose inhaler; Stiolto Respimat – a soft mist inhaler; and Utibron Neohaler – a dry powder inhaler. Anoro and Stiolto are used once a day as their effects last for 24 hours, while Bevespi and Utibron are used twice a day because they last 12 hours.

Jeff – I suggest that you ask your pulmonologist about a trial of one of these dual long-acting bronchodilators instead of taking DuoNeb. In my practice, I give samples to be used for 2 – 4 weeks as a trial, and then schedule a follow-up appointment to assess whether the medication is helping the person “breathe easier.”

You may wish to share this post with your pulmonologist. If he or she is unwilling to try one of these long-acting combination medications, then I would consider seeing a different health care provider.

Best wishes,

Donald A. Mahler, M.D.

Ventolin Inhaler Recall in April 2017 Due to Defect – Delivers Fewer Puffs

Ventolin Inhaler Recall – How Does It Affect You?

Dear Dr. Mahler:

I read last week that Ventolin inhalers were recalled by the company. I don’t know if I need to do anything or not? My COPD has been stable for the past few years as I take Spiriva in the morning and use Ventolin whenever I need some relief of shortness of breath.  I usually use Ventolin once a day, especially if I am going shopping or helping to babysit my grandchild. What should I do?

Susan from Silver Springs, MD

Dear Susan:

On April 4, 2017, GlaxoSmithKline (GSK), the pharmaceutical company that makes Ventolin, issued a recall of more than 593,000 Ventolin inhalers from U.S. hospitals, pharmacies, retailers and wholesalers. The reason was a defect that may cause the inhalers to deliver fewer doses of the medicine than indicated.

GSK has issued a Ventolin Inhaler Recall

Ventolin Inhaler contains albuterol – a quick-acting bronchodilator

What is Ventolin Inhaler?  Ventolin is a a brand name for albuterol sulfate – a quick-acting bronchodilator that relaxes the muscle that wraps around the breathing tubes. It is used by patients who have asthma and COPD as a “rescue medication” to provide quick relief for breathing difficulty. The usual does is two puffs at a time, and it can be used every 4 – 6 hours “as needed.”

ProAir can be used as a substitute because of the Ventolin Inhaler Recall

ProAir inhaler contains albuterol

There are two other brands of albuterol sulfate – ProAir and Proventil. The different bands of albuterol should be able to be used interchangeably. Pharmacies may give you the brand of albuterol based on a contract

Proventil inhaler contains albuterol

with the pharmaceutical company for a lower cost. Whether you receive any reduced cost is dependent on your local pharmacy or mail order pharmacy.

What Is the Problem with Ventolin Inhalers? GlaxoSmithKline said it had received a number of product complaints about a bulging of the outside wrapper, indicating a leak of the propellant that delivers the medicine. The recall involves three lots of the Ventolin HFA 200D inhalers manufactured at GSK’s plant in North Carolina.

The U.S. Food and Drug Administration approved the voluntary “Level 2” Ventolin inhaler recall, which only affects products in the United States.

What Should I Do? The Ventolin inhaler recall does not pose a danger to you or other patients, so you are not being asked to return your Ventolin inhaler. However, it is possible that your Ventolin inhaler may not provide the expected 200 doses. If you do not believe that you received the full 200 doses, you might wish to discuss this with the pharmacist where to bought the inhaler. Consider asking for a free replacement or another brand. Certainly, there is no guarantee that this will happen, but most retail pharmacies want to help their customers and have them return for future business.

Best wishes,

Donald A. Mahler, M.D.

Smoking Marijuana: Is It Safe for Someone with Mild COPD?

Smoking Marijuana and the Lungs

Dear Dr. Mahler:

I live in Massachusetts where marijuana was legalized for recreational use this past November. What are your thoughts for smoking an occasional joint to “chill?” My primary care doctor has told me that I have mild COPD. I smoked cigarettes for about 20 years, but quit two years ago. I am currently taking Tudorza Pressair twice a day, and may use ProAir a few times a month. How safe is smoking marijuana for my lungs?

Brian from Wooster, MA

Dear Brian:

Marijuana is the second most commonly smoked substance after tobacco.

Plant used for smoking marijuana

Marijuana plant

Although the harmful effects of tobacco smoke are well known, there is less information about the health effects of smoking marijuana. As most people know, marijuana can be inhaled in many ways – a joint, vaping, and water pipes – are the most common. It is impossible to predict if you will experience any lung damage from smoking an “occasional joint.” Here is some health information for you to consider.

How can smoking marijuana damage my lungs? Smoke of any kind can cause bronchitis – inflammation and swelling of the breathing tubes. Marijuana smoke contains many of the same harmful chemicals as in tobacco smoke. We do not know if light users who smoke an amount equal to 1 – 2 joints a month over a long time may worsen your mild COPD. 

Smoking marijuana may cause a lung bullae

Arrows shows a lung bulla in the right upper lobe of the lung

There is evidence that smoking marijuana can cause large air sacs, called bullea, to develop in the lung. This is more likely to happen in younger marijuana smokers (less than 45 years of age). A bulla can cause someone to be short of breathe and may rupture or “pop.” Air leaking from a ruptured bulla can lead to a collapsed lung called a pneumothorax.

For anyone with asthma or COPD, smoking marijuana can cause a “breathing attack.”

What symptoms indicate that smoking marijuana is affecting my lungs? Like tobacco smoke, marijuana smoke can cause coughing, mucus, wheezing, shortness of breath, and swelling in the throat.

Does smoking marijuana increase my risk of lung cancer? The answer is unclear, but it may increase the risk of lung cancer as marijuana smoke contains over 450 unique chemicals including those that can cause cancer (called carcinogens).

Can marijuana increase my risk of a lung infection? Marijuana smokers can develop a lung infection from a mold called aspergillus. The mold, or fungus, lives on marijuana plants and is inhaled in smoke. 

Has marijuana been used to treat some medical problems? Yes, marijuana has been used to treat many conditions including nausea and chronic pain. Several states allow health care providers to prescribe marijuana for health reasons. However, the Food and Drug Administration (FDA) has not approved marijuana for any medical condition. The FDA has approved medications that contain tetrahydrocannabinol (THC), the active ingredient in marijuana, for treatment of pain and nausea.

In summary, smoke of any kind has the potential to damage your lungs, and is not recommended for anyone who has a lung condition. I hope that his information is helpful for you in making an informed decision.


Donald A. Mahler, M.D.



Inhaler Medication Reaction – Lightheadedness and Nausea with a Once Daily Bronchodilator

Inhaler Medication Reaction: What are the Alternatives?

Dear Dr. Mahler:

My doctor’s office asked me to try a ‘new’ inhaler – ANORO – which worked great for 2 days but I had a reaction when I first inhaled it – lighted-headed and nauseated.  That lasted for about 2 hours.  They will not let me continue on this .  Is there not something comparable?


Beverly from Avon, CT

Dear Beverly,

View of smooth muscle wrapping around the outside of the breathing tubes

An inhaler medication reaction to – Anoro Ellipta – with a feelings of lightheadedness and nausea is uncommon, but certainly can occur.

To answer your question, let’s first consider the anatomy of the the breathing tubes (airways). Smooth muscle wraps around the outside of the breathing tubes (see figure on right).  The smooth muscle can constrict which causes narrowing of the breathing tubes and reduces air flow. Certain medications can relax the smooth muscle allowing more air to move in and out during breathing.

Anoro Ellipta enables patients to breathe easier with two bronchodilators

Anoro Ellipta dry powder inhaler

Anoro Ellipta is a dry powder inhaler that contains two different classes of bronchodilators – one is called a long-acting beta-agonist and the other is called a muscarinic antagonist. These medications work in different ways to relax the smooth muscle that wraps around your breathing tubes (airways). By relaxing the smooth muscle, the tubes can open more (dilate) allowing more air to move during breathing.

Side effects can occur with any medication including inhalers. Fortunately, there are three other approved inhalers that are similar to Anoro as they also contain both classes of bronchodilators. Two of these are available at the present time – Stiolto Respimat and Bevespi Aerosphere.

Stiolto Respimat – a soft mist inhaler

Stiolto is a soft mist inhaler and releases a fine mist

Bevespi contains two different bronchodilators in a single device

Bevespi Aerosphere – a pressurized metered-dose inhaler

when you press down on the release button. The dose of Stiolto is two inhalations once a day. Bevespi is a metered-dose inhaler; the delivery system is the same as albuterol metered-dose inhaler. Bevespi delivers an aerosol after pressing down on the canister. The dose of Bevespi is two puffs twice a day about 12 hours apart.

I suggest that you contact your health care professional to ask about these other dual bronchodilators.


Donald A. Mahler, M.D.



COPD Severity on Breathing Tests: To Find Out Your Grade, Ask Your Health Care Provider

COPD Severity on Lung Function Tests

Dear Dr. Mahler:

I want to learn more about COPD severity. On the breathing tests, there are numbers to tell how well you are breathing. I’m still confused with moderate, severe, to very severe and what it means. Thanks.

Joseph of Kansas City, MO

Dear Joseph:

Your question about COPD severity is a common concern among many patients that I see in my practice at Valley Regional Hospital.

First, the grading of severity is based on how much air that you exhale in one second. This is abbreviated FEV1.  Here is a graph that shows what FEV1 represents.  

FEV1 is used to grade COPD severity

Diagram of spirometry to diagnose COPD. FEV1 is the amount of air exhaled in one second.

Your best value is then compared with what it is expected to be for someone your age, sex (female or male), and your height. This is called FEV1 percent predicted.

To add to the complexity of the grading of severity of COPD, testing should  be performed before and after inhalation of a bronchodilator. Albuterol is almost always used for testing.  This is called post-bronchodilator FEV1 percent predicted. Your health care provider may or may not order testing with albuterol.

Guidelines and strategies for COPD describe the following four grades for COPD based on breathing tests:

                                        Post-bronchodilator FEV1 percent predicted


MILD                                                 80% or higher

MODERATE                                         50 to 79%

SEVERE                                                 30 to 49%

VERY SEVERE                                   less than 30%

It is important to remember that your current inhaled bronchodilators can affect the results of testing. For example, if you took your inhalers at 8 am and had testing at 10 am, this likely represent the peak effect of many long-acting bronchodilators. However, if the testing is done at 3 pm, the results will not be as good.

As you can see, higher numbers for lung function are better. However, it is important to recognize that the test results are just numbers and don’t reflect how you feel or how you are breathing.

These grades are most useful in describing the types of patients with COPD in research studies. It allows comparison of different medications in similar types of individuals based on breathing test results.

Joseph – I hope that this information is helpful. Finally, you can move up or down in these grades based on more effective treatments (may go up) or following a flare-up or exacerbation (may go down).


Donald A. Mahler, M.D.

Coffee (Caffeine) Can Block Inflammation in the Body: New Research Findings

New Research Study Shows that Coffee (Caffeine) Blocks Inflammation

Dear Dr. Mahler:

I recently read in our local newspaper that researchers claim the coffee drinkers could live longer. What are your thoughts? I am 70 years old and have had COPD for eight years. I try to eat right and do some physical activity for 20-30 minutes each day. My doctor has prescribed Advair for me which I take twice a day. Thanks for answering my question.

Shannon from Birmingham, AL

Dear Shannon:

I have received many questions about drinking coffee (caffeine) and possible benefits. Also, my post “Will coffee help my COPD?” on January 18, 2015, is the most viewed topic on the website.

coffee beans contain caffeine

coffee seeds commonly called beans

Before discussing the recent study, here is some brief information about inflammation (redness and swelling). In Latin, inflammation means “set afire.”  It is an important part of the body’s immune system to heal an injury or fight an infection.

However, if this persists and is chronic, inflammation plays a key role in various diseases – like asthma, diabetes, heart disease, bowel disease – in addition to COPD.

In a recent study published in the journal Nature Medicine, researchers at Stanford University analyzed the genes of 114 individuals who were part of an aging study. They found that older people between the ages of 60 and 89 tend to increase the production of inflammatory cells. Too much of these over a long time has been linked to heart disease, cancer, and Alzheimer’s disease.

Cup of Coffee (caffeine) that reduces inflammation

cup of coffee

Based on what the subjects reported in a questionnaire, those in the less inflamed group consumed more caffeine drinks like coffee, soda, and tea. The researchers also looked at the effects of caffeine on inflammatory cells in a culture (like a test tube). The cells soaked in caffeine produced far lower levels of inflammatory cells compared with those not soaked in caffeine.

In summary, the study showed a correlation between caffeine consumption and older people with low levels of inflammation in the blood. One of the authors, Dr. Mark Davis, commented that, “That something many people drink – might have a direct benefit came as a surprise to us.” While the researchers did not prove that caffeine causes better health, they came up with a possible way (mechanism) it could be doing so.

In the mean time, enjoy your coffee or tea. There are many proven benefits. For someone who has COPD, caffeine relaxes the muscle that wrap around the breathing tubes that hopefully might make it a little easier to breathe.


Walking a Dog: It Helped Me Be More Active and Lose Weight

Walking a Dog – Helped to Lose Weight

Dear Dr. Mahler:

I am 79 years old and was hospitalized last month for a flare-up of COPD. Usually I have 1-2 episodes of bronchitis during the winter and need an antibiotic and prednisone. I usually get short of breath clearing snow off of my car and drying off my dog when he gets wet from rolling in the snow.

The reason that I am writing is to share my “secret” for losing weight.  I live alone in a trailer, but last May I got a dog for company and activity. He wants to go out at least 6 times a day, and I need to walk him with a lease. There isn’t enough space for him to run around in my small yard. To care for my dog, I walk several times a day, up to 20 min at a time. Although I had not planned on this, I have lost 18 pounds since last May. I feel so much better being more active and it is easier to breathe losing my belly fat. Please share my experience walking a dog with your readers.

Sally from Bennington, VT

Dear Sally,

Many thanks for you note. Congrats on losing 18 pounds and make sure to give your dog a treat for helping you lose weight.

Woman walking a dog

Woman walking her dog

Here is some information about walking a dog and health benefits. In general, dog owners get twice as much exercise as those who do not have a dog. One survey reported that on average dog owners walked with their dog 24 minutes twice a day which adds up to 5 hours and 36 minutes a week. Studies show that those who walk their dog have the following health benefits:

  • Lower blood pressure
  • Increased mental attitude and sharpness
  • A lower risk of heart disease

The amount of exercise required for your dog will vary depending upon their breed and energy. Your dog can be a great incentive to get outside.

Here are some suggestions for those who have dogs. Set a daily routine with your dog. Try to walk at the same time each day. Also, find a dog park for fun and variety.

Sally – thanks again for your email. Hopefully, your experience will help others have a new friend and find a way to lose weight.

Best wishes,

Donald A. Mahler, M.D.


Cleaning Inhalers: Is It Necessary? How do I Clean My Inhalers?

Cleaning Inhalers – Helps to Prevent Infection

Dear Dr. Mahler:

I recently read that I should clean my inhalers to make sure that they work correctly and to prevent infections. However, I can’t find any information that describes how to do this. I use Symbicort inhaler and Spiriva powder every day and ProAir as my rescue inhaler. What do you recommend?

Gerard from San Juan, Puerto Rico

Dear Gerard:

You ask an important question about keeping inhaler devices clean and working properly. Unfortunately, this topic – cleaning inhalers – has not received a lot of attention.

As I am sure that others with COPD have the same question or concern as you do, here is information for cleaning inhalers as well as nebulizers.

Metered-dose inhaler (abbreviated MDI)

Cleaning inhalers is important for metered-dose inhalers

Diagram of metered-dose inhaler

When you press down on the top of the chamber, the aerosol spray comes out of the metering chamber and enters the nozzle  (see above). There is concern that the spray might accumulate over time and clog the nozzle. Cleaning the actuator with running water and air drying is recommended periodically to reduce this possibility.

Dry-powder inhaler (abbreviated DPI)

Dry-powder inhalers

A clean, dry cloth should be used to wipe away any powder from the mouthpiece. This should minimize any contamination with bacterial or fungus. This should be done periodically.

Soft mist inhaler (abbreviated SMI)

Soft mist inhaler

All that is required with the soft mist inhaler is to clean the mouthpiece with a damp cloth. It is recommended that cleaning be performed periodically.


The main source of nebulizer contamination is the patient. People of all ages tend to drool into the mouthpiece which explains why bacteria are frequently found in the reservoir (cup) after use.

nebulizer is one delivery system in which cleaning inhalers is important.

Hand held nebulizer

Any liquid that remains in the cup after you have finished inhaling leaves a wet environment with potential for growth of bacteria. This has led to the recommendation that the nebulizer be rinsed, washed, and air dried after each use.

Here are specific recommendations: Detach the medicine cup and mouthpiece from the tubing. Wash the medicine cup and mouthpiece with warm soapy water and rinse them with water. Place the equipment on a clean towel to fully air dry. Make sure to do this after each treatment and daily.

  • Don’t wash the tubing. If it gets wet, replace the tubing. Also, don’t put any parts of the nebulizer into a dishwasher to clean it because the heat can warp the plastic. Tubing should be changed periodically, usually every two weeks.

Here is a way to disinfect the mouthpiece and cup every other day. Mix a solution of 1 part distilled white vinegar and 3 parts warm tap water in a clean bowl. Soak the nebulizer parts (except the tubing and mask) for 60 minutes, then rinse thoroughly and air dry.


Playing a Harmonica: A Breathing Exercise for COPD

Benefits of Playing a Harmonica 

Dear Dr. Mahler:

I recently read about a pulmonary rehab program that includes playing music on a harmonica in addition to usual exercises. What are your thoughts? I haven’t tried it, but it sounds like fun.

Claudia from Jackson, MS

Dear Claudia,

I found several stories on the internet about the benefits of playing a harmonica for those with COPD.

Woman with COPD playing a harmonica

Woman with COPD playing a harmonica while breathing oxygen

There were several stories about how patients with COPD enjoyed the harmonica and found it made their breathing easier.  These anecdotes came from pulmonary rehabilitation programs at hospitals in Mountain View, CA, Austin, TX, Jacksonville, FL, and Chicago, IL. A group of patients with COPD in Colorado found their own musical group which they call the Harmonicats.

The COPD Foundation lists the following benefits of Harmonicas for Health program.

♦ Learn better control of breathing

♦ Exercise the muscles that help to breathe in and breath out

♦ Strengthen abdominal muscles for a more effective cough

♦ Relieve stress

♦ Socialize with others and have fun

One individual with COPD commented, “While I am playing the harmonica, I am enjoying it and not thinking about my breathing. I have found that playing different tunes has gradually improved my breathing capacity.

I also searched for studies evaluating the use of harmonicas in patients with COPD on PubMed. There is one study published in the July-August 2012 issue of the journal Rehabilitation Nursing (volume 37; pages 207-212) that compared usual pulmonary rehabilitation (16 subjects) with the same program plus harmonica playing (9 subjects practiced 5 – 20 minutes, twice a day, for 5 days per week). The authors found no differences in functional or psychosocial outcomes between the two groups enrolled in pulmonary rehabilitation.

Claudia – despite the findings of this one study, you might consider trying a harmonica. Remember, it is one of the few musical instruments that is played breathing both in and out.  It is likely to help with better control of your breathing. Let me know how it goes if you decide to give it a try.


Donald A. Mahler, M.D.

Flu this Winter 2016-17: Important Treatment Information

What Should I Do if I get the Flu this Winter?

Dear Dr. Mahler:

I am concerned about what to do if I get the flu this season. My doctor has told me my COPD is severe, but I am doing pretty good. I use Anoro in the morning, and have Combivent as my rescue inhaler. I try to walk or do some activity every day depending on the weather. However, I worry about the flu this winter, and how I might get very sick. What is your advice?

Cecilia from Salinas, CA

Dear Cecilia:

Signs and symptoms of the flu

People who have the flu often feel some or all of these signs and symptoms:

  • Fever or feeling feverish/chills
  • Cough
  • Sore throat
  • Runny or stuffy nose
  • Muscle or body aches
  • Headaches
  • Fatigue (feeling tired)


How Flu Spreads

People with the flu can spread it to others up to about 6 feet away. Flu viruses spread mainly by droplets made when someone with flu coughs, sneezes, or talks.  A person might also get flu by touching a surface or object that has flu virus on it and then touching her or his mouth, eyes or possibly their nose.

Coughing can expel the virus and cause flu this winter

Man coughing flu virus into the air.

When is Flu Contagious?

The flu can be passed to someone else before you even know you are sick as well as when you are sick. Most adults are able to infect others starting 1 day before symptoms develop and up to 5 to 7 days after becoming sick. Some people, especially those with weakened immune systems, might be able to infect others for an even longer time.

When do flu symptoms start?

The average time is 2 days from when a person is exposed to flu virus to when symptoms begin. However, the range is 1 to 4 days.

How to prevent getting the flu?

You should stay away from sick people. Wash your hands often with soap and water, or use an alcohol based hand rub. Avoid touching your mouth, nose, and eyes with your hands.

Certainly, it is important to get the flu vaccine. If you haven’t received it yet, make sure to the shot as soon as possible.

Can the flu be treated?

Tamiflu capsules for treating flu symptoms


There are prescription medications  called antiviral drugs for treating the flu this winter. Since you have COPD, you are considered in the high risk group. Contact your health care provider as soon as symptoms start. Tamiflu is an antiviral pill that is used to treat acute, uncomplicated illness due to influenza A and B infection if you have symptoms of the flu for less than 48 hours.

When used for treatment, antiviral drugs can lessen symptoms and shorten the time you are sick by 1 or 2 days. They also can prevent serious complications like pneumonia.

Complications of the flu

Sinus and ear infections are examples of moderate complications from flu, while pneumonia is a more serious complication that can result from either influenza virus infection alone or from co-infection of flu virus and bacteria. Other possible serious complications triggered by flu can include inflammation of the heart, brain, or muscle tissues.

I hope that this information is helpful. Be safe and stay healthy.

Donald A. Mahler, M.D.

Are Cannabinoids Effective Therapy for Those with COPD?

InMed Researching Use of Cannabinoids for COPD

Dear Dr. Mahler:

I have been reading a lot about the use of marijuana as a treatment for COPD. What is the science behind cannabinoids as a possible therapy? I was diagnosed with COPD about five years ago. My pulmonary doctor has told me that my condition is “severe.” She has recently changed my inhaler to Stiolto which has helped my breathing, but I still cannot do all the things that I want. I completed pulmonary rehabilitation 2 years ago, and go 2-3 times a week for maintenance. I live in Colorado and can use marijuana products legally. Thanks.

Gay from Fort Collins, CO

Dear Gay,

Here is a brief description of the science of marijuana. Hopefully, it is easy to understand.

Cannabinoids are chemical compounds that are the active parts of marijuana. They alter release of neurotransmitters in the brain. Neurotransmitters relay signals between nerve cells (see diagram below).  Psychoactive drugs like marijuana exert their effects by altering the actions of some neurotransmitter systems. The primary psychoactive compound in marijuana is tetrahydrocannabinol (abbreviated THC).

Diagram whereby cannabinoids alter neurotramsmitter release in the brain

Diagram of two nerve cells. On the left, neurotransmitters are released and cross the space to bind to receptors on another nerve cell.


There are two known cannabinoid receptors called CB1 and CB2. CB1 is found mainly in the brain (in the limbic system where pleasure and pain are experienced). CB2 receptors are found in the immune system with high numbers in the spleen (an organ in the abdomen). CB2 receptors are responsible for the anti-inflammatory and possibly other therapeutic effects seen in animals.

InMed Pharmaceuticals is a pharmaceutical company located in Vancouver,
British Columbia, Canada, that specializes in developing novel therapies through the research and development of cannabinoids. It began its COPD program in June 2015. Research has shown that THC can dilate breathing tubes (bronchodilation) for up to two hours after use. Additional research shows that cannabinoids have anti-inflammatory effects by inhibiting two inflammatory enzymes (COX-1 and COX-2).

Cannabinoids are active part of marijuana plants.

Marijuana plant

Gay – as you have COPD, I advise against smoking marijuana which could be harmful for your lungs. Certainly, you can choose other options such as mixing marijuana with food.
Hopefully, future research will provide more information as to benefits of cannabinoids for relief of breathing difficulty.
Best wishes,
Donald A. Mahler, M.D.

Why am I More Short of Breath with Daily Activities?

More Short of Breath in Past Five Months

Dear Dr. Mahler:

I am writing because I am more short of breath with my usual activities. It has gotten bad enough that I have placed a chair between the kitchen and TV room to sit down and catch my breath.

My doctor has told me that I have “very severe COPD” based on my last breathing tests. I am taking Stiolto Respimat every morning, and use ProAir puffer 3 to 4 times a day, depending on how active I am. I have not had a chest infection for over 3 years, and am up to date on flu and pneumonia shots.

Pulmonary rehab can help with feeling of being more short of breath

Woman with COPD doing arm curls with hand weights.

This past summer I completed 10 weeks of pulmonary rehab, and really felt good and was able to do a lot more than before the program. Since then, I have been unable to exercise because my husband isn’t able to drive me to the hospital for maintenance phase of rehab. At my last visit, the PA told me that I had gained 7 pounds since August, and she could not find any evidence of a chest infection or a heart problem. Do you have any thoughts?

Marci from Rio Rancho, NM

Dear Marci,

Feeling more short of breath is a common problem for those with COPD. A chest infection or inhaling irritants in the air can cause breathing difficulty, but this should not last for five months as you report.

The five major causes for an increase in breathing difficulty in those with COPD over several months or longer are: anemia (low number of red blood cells); anxiety; deconditioning (or being “out of shape”); heart disease; or a gradual worsening of COPD.

Based on the information that you provided, it sounds like your reduced activities (deconditioning) and weight gain are the most likely reasons for the worsening in your breathing. To check for anemia, I suggest that you ask your doctor or PA whether it is reasonable to order a blood test called a complete blood count (CBC) that can determine whether you might have anemia.

These leaning positions help with feeling of being more short of breath

Leaning forward positions can help with breathing difficulty (figure from COPD: Answers to Your Questions, 2015; Two Harbors Press, Minneapolis)

Using a chair as a rest station is a good strategy. You might also lean on the back of the chair to help with breathing just as the man on the right is leaning on the end of a table. This leaning forward position stabilizes the shoulders and enables the neck muscles to assist the diaphragm with breathing.

Best wishes on being able to breathe easy.

Donald A. Mahler, M.D.