The main goals of treatment of chronic obstructive pulmonary disease (COPD) are to relieve symptoms, reduce the frequency and severity of exacerbations, prevent disease progression, and reduce mortality. GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines for treatment of COPD were updated recently. Treatment of acute exacerbations is not discussed here. Drugs available for treatment of COPD are listed in Tables 1 and 3.

View the Comparison Table: Inhaled Drugs for Treatment of COPD

The FDA has approved Airsupra (AstraZeneca), a metered-dose inhaler containing the short-acting beta₂-agonist (SABA) albuterol and the inhaled corticosteroid (ICS) budesonide, for use as needed for treatment or prevention of bronchoconstriction and to reduce the risk of exacerbations in patients ≥18 years old with asthma. Airsupra is the first combination of a SABA and an ICS to become available in the US. It is not approved for use as maintenance therapy.

View the table: Some Inhaled Drugs for Treatment of Asthma

The goal of asthma treatment is to control symptoms, prevent exacerbations, and maintain normal lung function. Management of acute exacerbations of asthma in the emergency department is not discussed here.

The main goals of treatment for chronic obstructive pulmonary disease (COPD) are to relieve symptoms, reduce the frequency and severity of exacerbations, and prevent disease progression. Several guidelines and review articles on COPD treatment have been published in recent years. Treatment of acute exacerbations is not discussed here.

View the Comparison Table: Inhaled Short-Acting Bronchodilators for Treatment of COPD

View the Table: Correct Use of Inhalers for COPD

View the Comparison Table: Correct Use of Inhalers

The goal of asthma treatment is to control symptoms and prevent exacerbations. Management of acute exacerbations of asthma is not discussed here.

View the Comparison Table: Some Inhaled Drugs for Treatment of Asthma

View the Comparison Table: Inhaled Short-Acting Bronchodilators for COPD

The main goals of treatment for chronic obstructive pulmonary disease (COPD) are to relieve symptoms, reduce the frequency and severity of exacerbations, and prevent disease progression. Updated guidelines for treatment of COPD have been published in recent years.

View the Table: Correct Use of Inhalers for COPD

The short-acting beta₂-agonist albuterol sulfate is now available as a dry powder for inhalation (ProAir RespiClick – Teva) for prevention and treatment of broncho spasm in patients ≥12 years old. ProAir RespiClick is the only short-acting beta₂-agonist dry powder inhaler available in the US.



Metered-dose inhalers (MDIs) use a hydrofluoroalkane (HFA) propellant. They require coordination of inhalation with actuation; using them with a valved holding chamber minimizes this need, but decreases portability because of the size of the chamber. Dry powder inhalers such as ProAir RespiClick, which are breath-actuated, do not require a propellant and do not have to be primed before use. They do not require coordination of inhalation with actuation, but patients must be capable of performing a rapid, deep inhalation, which might be difficult during a severe asthma attack.

The recommended dose of ProAir RespiClick for treatment of bronchospasm is 2 inhalations, but 1 inhalation may be sufficient for some patients. The dose can be repeated every 4-6 hours as needed. For prevention of exercise-induced bronchospasm, the recommended dosage is 2 inhalations 15-30 minutes before exercise.

Each ProAir RespiClick inhaler includes a dose counter. Opening the mouthpiece cap readies a dose for administration and causes the counter to count down by 1; closing the cap without inhaling the medication wastes that dose. The inhaler should be cleaned with a dry cloth as needed.

ProAir RespiClick may contain trace levels of milk proteins; it is contraindicated for use in patients with a history of a severe hypersensitivity reaction to milk proteins.

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INHALATION DEVICES — Metered-dose inhalers (MDIs) require coordination of inhalation with hand-actuation of the device. Valved holding chambers (VHCs) or spacers help some patients, especially young children and the elderly, use MDIs effectively. VHCs have one-way valves that prevent the patient from exhaling into the device, minimizing the need for coordinated actuation and inhalation. Spacers are tubes or chambers placed between the canister and a face mask or mouthpiece, which also avoids the need to coordinate actuation and inhalation. Both VHCs and spacers retain the larger particles emitted from the MDI, decreasing their deposition in the oropharynx and leading to a higher proportion of small respirable particles being inhaled.

Inhalation is the preferred route of delivery for most asthma drugs. Chlorofluorocarbons (CFCs), which have ozone-depleting properties, are being phased out as propellants in metered-dose inhalers. Non-chlorinated hydrofluoroalkane (HFA) propellants, which do not deplete the ozone layer, are being used instead.

The goals of drug therapy for chronic obstructive pulmonary disease (COPD) are to reduce symptoms such as dyspnea, improve exercise tolerance and quality of life, and decrease complications of the disease such as acute exacerbations. Other guidelines for treatment of this condition have been published or updated in recent years.

No truly new drugs have been approved for treatment of asthma since omalizumab (Xolair) in 2003, but some randomized controlled trials of older drugs have been published, and new guidelines have become available.

Inhaled drugs for asthma are available in the US mainly in pressurized metered-dose inhalers (MDIs), which require a propellant, and dry powder inhalers, which do not. The chlorofluorocarbon (CFC) propellants in MDIs are being replaced by hydrofluoroalkane (HFA) propellants for environmental reasons: CFCs contribute to the depletion of the ozone layer. December 31, 2008 will be the last day that albuterol MDIs using CFC propellants can be sold in the US. The FDA is expected to announce a termination date for other CFC-containing products in the near future.

Three HFA albuterol inhalers and one HFA levalbuterol inhaler have been approved by the FDA. None is available generically. HFA inhalers require priming — firing 4 puffs into the air (3 with ProAir) — the first time they are used, and after 2 weeks of non-use (3 days with Xopenex HFA).

In general, HFA sprays taste different, are less forceful, and are warmer and mistier than CFC sprays. Some patients may have to be reassured that they are getting enough of their medication, but actually the smaller particles of the HFA sprays may reach the lungs more readily than CFC sprays.

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The goals of drug therapy for chronic obstructive pulmonary disease (COPD) are to reduce symptoms such as dyspnea, improve exercise tolerance and quality of life, and minimize complications of the disease such as acute exacerbations and cor pulmonale. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines developed by the World Health Organization and the National Heart, Lung and Blood Institute were updated in 2006. The American Thoracic Society and the European Respiratory Society jointly developed guidelines for COPD in 2004.