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Most asthma emergencies we treat happen in patients who own a preventer inhaler and do not use it. The belief that inhalers are habit-forming is the most damaging myth in respiratory medicine.
Reliever versus preventer
A reliever inhaler — usually blue — opens the airways within minutes and is used during symptoms. A preventer inhaler — usually brown, orange or purple — contains a low-dose inhaled steroid that reduces the underlying airway inflammation, and is used every day whether or not there are symptoms.
Patients feel the reliever working and do not feel the preventer working, so they use the first and abandon the second. That single behaviour explains the majority of asthma attacks and hospital admissions.
Worth knowing
Needing your reliever more than twice a week means your asthma is not controlled. That is a signal to review the preventer, not to buy more reliever.
Why inhaled steroids are safe
The dose delivered by an inhaler is measured in micrograms and goes directly to the airway, compared with milligram doses of oral steroids that circulate through the whole body. The systemic exposure is a tiny fraction, which is precisely why inhalers are preferred over tablets.
Inhalers are not addictive and do not weaken the lungs. Uncontrolled asthma, on the other hand, causes airway remodelling — permanent structural narrowing that no medication reverses. The inhaler is what prevents that.
Technique: where most of the benefit is lost
- Shake the inhaler and remove the cap
- Breathe out fully, away from the inhaler
- Place the mouthpiece between the teeth and seal the lips
- Start a slow, deep breath in and press the canister once at the same moment
- Continue breathing in slowly and fully
- Hold your breath for ten seconds
- Wait thirty seconds before a second puff
- Rinse the mouth and spit after using a steroid inhaler, to prevent oral thrush
Use a spacer
A spacer is a plastic chamber attached to the inhaler. It removes the need to coordinate pressing and breathing, dramatically increases how much medicine reaches the lungs rather than the throat, and reduces side effects. It is recommended for all children and for most adults.
If a spacer is unavailable, a clean 500 ml plastic bottle with a hole cut for the inhaler works surprisingly well as an improvised alternative. Wash spacers in warm soapy water monthly and air dry without wiping the inside.
When an attack needs emergency care
- Reliever inhaler not helping, or its effect lasting less than two hours
- Too breathless to speak in full sentences
- Lips or fingertips turning blue
- The chest not moving much despite obvious effort
- Drowsiness, confusion or exhaustion
- Peak flow below 50% of your personal best
Key takeaways
- Preventer inhalers work invisibly — stopping them because you feel well causes attacks.
- Inhaled steroid doses are micrograms delivered directly to the airway and are not habit-forming.
- Using a reliever more than twice a week means asthma is not controlled.
- A spacer substantially increases lung delivery and should be used by all children.
A note on medical advice
This article is general health education written and reviewed by the Department of Pulmonology at SIMS. It is not a substitute for an examination, a diagnosis or the advice of your own treating doctor, and it cannot account for your history, medicines or reports. If a symptom is sudden or severe — chest pain, stroke symptoms, breathing difficulty, serious injury, seizures or heavy bleeding — call 9281862028 or come straight to the emergency department instead of reading further.
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