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.

Smog in the Air – What are the Health Risks for Breathing?

Smog in the Air – Is it Safe for Breathing?

Dear Dr. Mahler:

I am travelling to Shanghai and Beijing for business in a few months. and am concerned about the smog in China. I have stable, but moderate COPD and don’t want to have any breathing problems on the trip.  My COPD medications are Spiriva and Advair Diskus. What are your thoughts?  I can’t have someone else go in my place because I work for a small company which is trying to expand business in China.
Thank you.

Bob from Sacramento, CA

Dear Bob:

Do you have any breathing problems with smog or air pollution living in northern California? Is your COPD under good control at the present time? Have you had a COPD “flare up” (exacerbation) in the past 3 months?  If the answers to these questions indicate that you are doing fine, then here are some things to consider on your trip to China.

As you probably know, smog develops in the atmosphere when certain gases are produced when fossil fuels like gasoline, oil, and coal are burned. Nitrogen oxide is emitted from power plants, motor vehicles, and other sources of high-heat combustion.   Volatile organic compounds come from motor vehicles, chemical plants, refineries, and factories. Carbon monoxide is emitted mainly from motor vehicles. When these gases are exposed to sunlight, they react and form ozone smog.

Smog in city.

Smog in city.

Breathing in ozone can cause shortness of breath, wheezing, and coughing and can also increase inflammation (redness and swelling) in the airways of your lungs. The risks are greater if ozone levels are high, if you are breathing faster because of exerting yourself outdoors, and if you spend a lot of time outdoors.

I suggest that you discuss the following with your host in China  before you leave on the trip:

  1. Let the host know that you have well controlled COPD and need to avoid inhaling smog and other airborne irritants (such as cigarette smoke).
  2. Ask to spend as little time as possible outdoors, and request either a taxi or car service to travel from your hotel to the place of business.
  3. Make sure that you will not be expected to participate in any sightseeing that requires spending time outdoors.

I suggest that you discuss the following with your doctor before you leave on the trip:

  1. Ask your doctor if he/she considers it safe for you to travel to China for business.
  2. Ask your doctor to prescribe both an antibiotic and prednisone to have available in case you need either of these medications. Ask you doctor to write down when, if at all, to take these medications.
  3. Ask your doctor whether you are up to date on influenza (depending on the time of year that you are travelling) and pneumococcal vaccines.
  4. Ask your doctor whether it is advisable to wear a mask that covers the nose and mouth when outdoors.

    Mask to reduce inhaling smog in China

    Woman wearing mask to prevent inhaling smog in the air.

In preparation for your trip:

  1. Make sure to hand carry all of your medications with you on the plane, including your rescue albuterol inhaler. Do not pack these medications in checked baggage.

Safe travels,

Donald A. Mahler, M.D.