What is Oral Thrush? With Which Inhalers Should I Rinse My Mouth?

How To Prevent Oral Thrush

Dear Dr. Mahler:  

I am concerned about getting thrush. I was diagnosed with severe COPD, and have improved with Stiolto Respimat. My pulmonary doctor said that I am now in the moderate category.  A nurse who works at a community college with me asked if I was rinsing my mouth with water after inhaling the medication. She said that I should do this to prevent thrush. Is that correct?

Sophia from Key Biscayne, FL

Dear Sophia:

Oral thrush is a commonly used phrase for a fungal infection of the mouth and throat (oral cavity). The fungus is called Candida albicans, and the medical condition is called oral candidiasis. This happens when the fungus – Candida albicans – accumulates in your mouth and throat.

Oral thrush with white plaques on the tongue

Oral thrush with white plaques on the tongue

 Candida albicans is a normal organism in your mouth, but sometimes it can overgrow and cause symptoms. Oral thrush causes creamy white lesions, usually on your tongue, the sides of the mouth, and/or the back of the throat. Although oral thrush can affect anyone, it’s more likely to occur in the elderly, in people with suppressed immune systems, or  those who take certain medications. Inhaler medications that contain a corticosteroid (prednisone-like medication) increase the chances of oral thrush developing.
Symptoms of oral thrush include:
1. loss of taste or an unpleasant taste in the mouth
2. redness inside the mouth and throat
3. cracks at the corners of the mouth
4. a painful, burning sensation in the mouth
Oral thrush is diagnosed by an examination of the tongue and mouth

Oral thrush is diagnosed by an examination of the tongue and mouth

 Sophiayou are taking Stiolto Respimat – which contains two different types of bronchodilators. There is no inhaled corticosteroid in Stiolto. Therefore, it is not necessary for you to rinse your mouth after using the medication. Advair, Symbicort, and Breo are approved medications for those with COPD that do contain an inhaled corticosteroid. After inhaling these medications, it is recommended to rinse the mouth with water and then spit out the water.
Donald A. Mahler, M.D.

Is A Powder Inhaler or Spray Inhaler Better?

Powder Inhaler Versus Spray Inhaler: Is One Better For Breathing?

Dear Dr.Mahler:

My doctor has prescribed different inhalers for my COPD,  but I am not sure which ones work best for me. I have been tried on a couple different powder inhalers as well as various sprays. Of all the inhalers, Combivent seems to help me the most. I was diagnosed with COPD about 6 years ago, and still work 4 days a week at a pay booth collecting tolls. What are your thoughts?

Pete from Shelton, CT

Dear Pete,

The different inhaled medications and the different delivery devices can  be quite confusing for those with COPD and even health care providers. In fact, several new inhalers have been approved by the Food and Drug Administration this year.

Here is a simple (hopefully) way to think about inhaled bronchodilators.

First, bronchodilators relax the muscle that wraps around the breathing tubes to open them up and make it easier to breathe.

Second, there are two types of bronchodilators based on how they work: beta-agonists and muscarinic antagonists. It is not important for you to remember this information, but you should know that we frequently prescribe both types to gain the best benefit for your breathing.

Third, the medicines are either liquids or powders. The key thing is that the sprays from the liquid and the particles from the powder have to be inhaled deep into the breathing tubes to effectively open them up. If the spray or powder does not get into the lower parts of the lungs, it can not open the airways completely.

Fourth, these different bronchodilators are contained in various delivery devices. They are called metered-dose inhalers (puffers), soft mist inhalers, and dry powder inhalers.

Metered-dose inhaler

Metered-dose inhaler

Soft mist inhaler

Dry-powder Inhaler

Dry-powder Inhaler

The reason for the variety is that different pharmaceutical companies have developed the different inhaled bronchodilators, all of which are patented for a period of time.

Good inhalation technique (how you actually inhale the medication) is key to successful use. In my medical practice, I ask each individual how he/she uses the inhaler and whether the medication “makes it easier to breathe.” If the specific inhaler does not seem to help your breathing, the first thing to check is how you are inhaling the spray or powder. You should ask your health care provider or her/his nurse to watch you use the inhaler. If you are doing it correctly, then a trial of a different bronchodilator inhaler is reasonable.

So, there is no advantage of spray or powder bronchodilators. It is most important that you inhale the medication correctly.


Donald A. Mahler, M.D.



What Shortness of Breath feels like for Those with COPD

Work and Effort of Breathing  in COPD 

An on-line publication this week by Chang and colleagues in the journal Chest describes the experience of breathing difficulty as reported by those who have COPD.

The first author is Andrew Chang, a medical student at the Geisel School of Medicine at Dartmouth. He worked on this research study between his 1st and 2nd years of medical school with three Pulmonary doctors on the staff of Dartmouth-Hitchcock Medical Center. In the study, patients with different respiratory conditions answered “Yes” or “No” for each of 15 different statements that described  experiences of breathing discomfort. Then, each person was asked to select the “Best Three” that most closely matched how they felt when short of breath doing daily activities.

Here are the “Best Three” statements chosen by 68 individuals with COPD:

  1. I feel out of breath.
  2. My breathing requires effort.
  3. I cannot get enough air in.

Does your breathing difficulty match up with these statements?

These experiences are considered to be due to the work and effort required by the breathing muscles to breathe in (inspire). Because those with COPD have narrowed breathing tubes (airways), it is often difficult to get all of the air out when exhaling. As a result, air is trapped in the lung leading to hyperinflation of the lungs as shown in the figure.

On left: Normal size of lungs. On right: lungs are larger due to inability to exhale completely. This is called HYPERINFLATION.

On left: Normal size of lungs.
On right: lungs are larger due to inability to exhale completely. This is called HYPERINFLATION.


As a result of the hyperinflation of the lungs, the diaphragm (the main muscle of breathing) has to work harder when it contracts to breathe air in.  This added work and effort of the diaphragm is sensed by those who have COPD. This is the major reason why someone with COPD finds that it is hard to breathe or have shortness of breath.

Bronchodilator medications are the cornerstone for treatment of COPD because they open the breathing tubes (airways). This allows more air to be exhaled and thereby reduces hyperinflation – making it easier to breathe. Long-acting bronchodilators that last 12 – 24 hours provide more sustained benefit than the short-acting inhalers (typically last 4 hours).

Hopefully, this information will help you understand why taking your bronchodilator medications regularly is important for your breathing.


What’s New About Breathlessness

Dr. Denis O’Donnell (Kingston, Ontario, Canada) and I wrote a review called Recent Advances in Dyspnea (medical word for breathlessness) in the January 2015 issue of the journal CHEST (pages 232-241). The review covered new research information about breathing difficulty over the past 4 years.

Here is information about how breathlessness affects daily life.

Dr. Denis O'Donnell, Professor of Medicine at Queen's University, in Kingston, Ontario, Canada

Dr. Denis O’Donnell, Professor of Medicine at Queen’s University, in Kingston, Ontario,

  1. Of 2,258 individuals with severe COPD, breathlessness was worse upon awakening in the morning.
  2. Most individuals reported that their breathing varied from day to day and from week to week.
  3. Treatment with a long-acting bronchodilator reduced the variability in breathing difficulty.
  4. Women generally report more breathlessness than men.
  5. In the United Kingdom, 20% of menopausal women reported breathing difficulty. This may be related to low levels of estrogen and progesterone which could affect mood.
  6. Obesity is associated with an increase in breathlessness.
  7. Anxiety and depression are more common in those with heart and lung diseases.

Here are some of the key findings about treatment.

  1. Most long-acting bronchodilators inhaled once or twice daily improve breathing difficulty in those with COPD.
  2. In general. the improvement in breathlessness is greater with two different bronchodilators in a single inhaler compared with one bronchodilator in an inhaler.
  3. Individuals with COPD reported less breathlessness related to anxiety after 8 weeks in a pulmonary rehabilitation program compared with “usual care.”

Here is information on new therapies not yet approved to relieve breathing difficulty. These therapies require more testing before use.

  1. Those with COPD had less breathlessness after acupuncture compared with a sham, or pretend, treatment.
  2. Placement of valves or coils into breathing tubes through a scope can deflate the lung and improve breathing difficulty.
  3. Using a breathing machine connected to plastic tubes in the nose (nasal cannula) to assist breathing during walking improves breathing by allowing the breathing muscles to work less.