“Hold Your Breath” Is Most Important Inhaler Step

Dear Dr. Mahler,

My COPD was diagnosed about 3 years ago when I was in the hospital for bronchitis. I needed hi-flow oxygen for the first 2 days, and thought that I was going to die. It was very scary.

I was discharged on Symbicort inhaler twice a day and Spiriva powder once a day. I continue to use albuterol inhaler which I had been using “as needed” before being in the hospital.

Overall, I am doing OK, but I don’t feel like the medications are doing much for me. I have read about how to use my inhalers in your book, but my different doctors and APRNs seem too busy at appointments to help me with “inhaler technique.”

Thanks for your advice.

Sheila from Key Biscayne, FL

Dear Sheila,

Sorry to hear that your maintenance inhalers aren’t “doing much” for you. Ideally, both Symbicort and Spiriva HandiHaler - bronchodilators - should OPEN your airways and make it easier to breathe. In addition, the combination of Symbicort and Spiriva (considered as “triple therapy” - three different medications) has been shown to reduce the risk for future flare-ups called an exacerbation.

Image of metered-dose inhaler - like Albuterol and Symbicort

‍For your inhalers to work for you, you need to use them correctly.. First, let’s consider Symbicort - a metered-dose inhaler. After shaking the inhaler and removing the cap, breathe out completely to empty air out of your lungs to allow more air and the spray (called an aerosol) into the lungs. Because the spray comes out fast after pressing down on the cannister, you need to breathe in “slow and steady.” If you breathe in fast, most of the spray will simply hit your throat. Finally, HOLD YOUR BREATH for as long as possible. In a recent study conducted by the COPD Foundation and published on-line in the Annals of the American Thoracic Society, holding your breath was the most important step to bronchodilate or open the airways. Repeat the steps for the 2nd puff. Since Symbicort contains an inhaled corticosteroid, you should rinse your mouth with water and spit it out. You may use a spacer with Symbicort to reduce thrush ( a yeast infection) in your throat.

A capsule containing a dry powder medication is placed into the HandiHaler.

Next, Spiriva HandiHaler is a dry powder inhaler. After you empty the air out of your lungs, then you should breathe in “hard and fast” to break up the powder inside the device and then HOLD YOUR BREATH for as long as possible. Thus, the “breathe in” instruction is different than with the Symbicort inhaler.

Why is HOLD YOUR BREATH the most important step? There are two main reasons:

• Longer residence time - this increases the chance that the inhaled particles contact the airway wall rather than being exhaled

• Gravitational sedimentation - gravity allows the inhaled particles to reach deeper into the lungs.

Sheila - To simplify things for you, there are two inhalers available in the US that contain similar three medications as in Symbicort and Spiriva. These are called Breztri - a metered dose inhaler, and Trelegy - a dry powder inhaler. I suggest that you ask your health care professional whether either of these inhalers are an option. If this is possible, you can use one inhaler rather than two and not have to use different efforts to breathe in.

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

Sincerely,

Donald A. Mahler, M.D.