Nebulizer Therapy – Can It Help Me Breathe Easier?

When to Consider Nebulizer Therapy

Dear Dr. Mahler:

I have severe COPD and attend pulmonary rehab sessions at the nearby hospital.  I take Advair in the purple disk twice a day and Spiriva powder in the capsule each morning. One of the other patients at rehab told me that she uses medicines in a nebulizer machine and this helps her breathe much better than when she used different inhalers in the past. Do you think that nebulizer therapy might help me?

Tracy from Bellingham, WA

Dear Tracy,

There are four different delivery systems for inhaled medications to treat those with COPD: metered-dose inhalers (commonly called puffers); dry powder inhalers; soft mist inhalers; and nebulizers. Some examples are shown below. In general, pharmaceutical companies have mainly been developing new bronchodilator medications as dry powders.

Metered-dose Inhaler

Metered-dose Inhaler

Examples of dry-powder inhalers

Examples of dry-powder inhalers

With dry powder inhalers, you need to take a hard and fast breath in – in order to pull the powder out of the device and overcome its internal resistance. Some individuals, especially those with more advanced COPD, may not have enough strength to successfully break up the powder packet in the inhaler device and then inhale the powder particles deep into the lower parts of the lungs.

Nebulizer therapy is used frequently to deliver bronchodilator medications to those with COPD who are experiencing a flare-up (exacerbation) both in the Emergency Department and in the hospital. Many patients with COPD find that this approach works better because you just breathe in and out normally when inhaling the medications from the nebulizer, and you don’t have to have to hold your breath as you do with the other delivery systems.

Inhaler machine for nebulizer therapy

Hand held nebulizer

There are four major reasons why your health care provider might prescribe nebulizer therapy: you have difficulty using the other inhaler devices [because of arthritis of the hands and wrists or because of difficulty following instructions (dementia)]; you have difficulty coordinating the steps to release the medication from the device, inhaling correctly, and then holding your breath for as long as possible; you are not able to breathe easier with inhaler devices; AND you do not have adequate force when breathing in to pull the powder out of the inhaler.

I suggest that you ask your health care provider whether a trial of nebulizer medications is appropriate, especially since you don’t feel it is easier to breathe with your current inhalers. Both types of bronchodilators (beta-agonists and muscarinic antagonists) as well as an inhaled corticosteroid are available in solutions for use in a nebulizer. These three different types of medications are similar to the Advair and Spiriva dry powder inhalers that you are currently using.

Best wishes,

Donald A. Mahler, M.D.

Errors are Common in Inhaler Use: A Systematic Review

Errors in Inhaler Use – both Metered-dose and Dry-powder 

Background: Correct use of inhalers is “key” for those with COPD to benefit from best available medications. Unfortunately, the medical profession has not done a good job in providing on-going education on proper use.

Study: Dr. Sanchis and colleagues performed a systematic review of articles published over 40 years (1975 – 2014) which reported on direct observation of inhaler technique by trained nurses and respiratory therapists. The purpose was to identify common errors and the percentage of patients.  The article was published on-line on April 6, 2016, in the journal CHEST.

Results: Information was available in 54,354 subjects. The most common errors with pressurized metered-dose inhalers were:

Example of pressurized metered-dose inhaler.

Example of pressurized metered-dose inhaler.

  1. no breath hold after full inhalation – 46%
  2. poor co-ordination between pushing down the canister and inhaling – 45%
  3. incorrect speed and/or depth of breathing in – 44%

The most common errors with dry-powder inhalers were:

Examples of dry-powder inhalers

Examples of dry-powder inhalers

  1. not breathing out completely before inhaling the powder – 46%
  2. no breath hold after full inhalation – 37%
  3. not preparing the inhaler correctly – 28%

Conclusions: Incorrect inhaler technique is common and has not improved over the past 40 years. There is an urgent need for new approaches in education.

My Comments: Many of those with COPD need repeated review of correct inhaler use. Remember, the medication needs to reach the small breathing tubes deep in the lungs to make it easier to breathe. If you are not sure that you are inhaling correctly, ask your health care provider or nurse to watch you perform all of the steps.

Incruse Ellipta is Now Available

On April 30, 2014, the United States Food and Drug Administration approved umeclidinium (brand name: Incruse Ellipta) as a once-daily inhaled bronchodilator for treatment of those with COPD, including chronic bronchitis and emphysema. As of January 2015, this medication is available in US pharmacies.

Incruse Ellipta is a once-daily dry powder bronchodilator

Incruse Ellipta is a once-daily dry powder bronchodilator

Incruse Ellipta is in the class of bronchodilators called long-acting muscarinic antagonists (LAMA).  Other approved medications in this class are tiotropium (brand name: Spiriva HandiHaler and Respimat) and aclidinium (brand name: Tudorza Pressair). These medications open the airways and make it easier to breathe by blocking a receptor in the muscles that wrap around breathing tubes.

Picture of Spiriva Respimat mist bronchodilator

Spiriva Respimat is a once daily bronchodilator that delivers a mist


Tudorza Pressair is a twice daily dry powder bronchodilator

Tudorza Pressair is a twice daily dry powder bronchodilator


Information about the bronchodilator (called the package insert) states that Incruse Ellipta should be used with caution in those with narrow-angle glaucoma and with urinary retention due to enlargement of the prostate. The most common reported side effect in studies was nasopharyngitis (irritation of nose and throat). Also, you should not take this medication if you are using Spiriva or Tudorza as they are the same type of brocnhodilators.

As always, you should discuss any new medication with your doctor.