Asthma inhalers are often divided into two categories: medicines that control airway inflammation over time, and medicines that provide relief when symptoms occur. The distinction is useful, but modern asthma regimens can be more nuanced. Some patients use separate maintenance and reliever inhalers, while selected combination inhalers may be prescribed for both maintenance and symptom relief. Follow the directions for your exact inhaler rather than identifying its purpose by color.
What Is a Controller Inhaler?
A controller inhaler is used to reduce inflammation, prevent symptoms, and lower the risk of asthma flare-ups.
Controller medications may include:
- Inhaled corticosteroids
- Inhaled corticosteroid and long-acting bronchodilator combinations
- Long-acting muscarinic antagonists in selected regimens
- Other add-on treatments
Inhaled corticosteroids reduce swelling and inflammation inside the airways. NHLBI identifies inhaled corticosteroids as a central treatment for persistent asthma and recurrent wheezing.1
A controller may need to be used consistently even when the patient feels well.
What Is a Rescue Inhaler?
A rescue or reliever inhaler is used when breathing symptoms occur.
Short-acting beta-agonists such as albuterol rapidly relax muscles surrounding the airways. Possible side effects include tremor, nervousness, or a faster heartbeat.
A rescue inhaler may be used for:
- Wheezing
- Chest tightness
- Shortness of breath
- Cough related to asthma
- Symptoms triggered by exercise, when prescribed
Frequent reliance on a rescue inhaler may indicate that asthma is not adequately controlled.
Can One Inhaler Be Used for Both Purposes?
Sometimes.
Maintenance-and-reliever therapy may use an inhaled corticosteroid and formoterol combination as both the scheduled maintenance treatment and the as-needed reliever, an approach NHLBI's updated asthma guidelines recognize as the preferred treatment for many patients ages 4 and older with moderate to severe persistent asthma.2
This approach applies only to selected products and treatment plans. A combination inhaler containing a different long-acting bronchodilator should not automatically be used as a rescue inhaler.
The pharmacy label and written asthma action plan should state exactly how the inhaler is used.
Why Does Inhaler Technique Matter?
A powerful medication cannot work properly when most of the dose lands on the tongue, roof of the mouth, or inside the device.
Common technique problems include:
- Failing to prime the inhaler
- Inhaling too quickly or too slowly
- Poor coordination
- Not sealing the lips around the mouthpiece
- Failing to hold the breath
- Not loading a dry-powder device correctly
- Using an empty inhaler
- Failing to clean the device
- Not using a spacer when recommended
Patients should demonstrate their technique to a pharmacist, respiratory therapist, or prescriber.
The Global Initiative for Asthma (GINA) recommends reviewing inhaler technique and medication adherence as part of routine asthma assessment.3
Should You Rinse After Using an Inhaled Steroid?
Patients are commonly instructed to rinse the mouth and spit after using an inhaled corticosteroid.
This can reduce local side effects such as:
- Oral thrush
- Hoarseness
- Throat irritation
Do not swallow the rinse water unless specifically instructed otherwise.
How Do You Know an Inhaler Is Empty?
Some inhalers have dose counters. Others require tracking doses.
Do not test an inhaler by shaking it or spraying it into the air unless the manufacturer's instructions recommend doing so.
Record the date opened and understand how many doses the device contains.
When Asthma Symptoms Are an Emergency
Seek urgent medical assistance when:
- Breathing is severely difficult
- The rescue medicine is not helping
- The patient cannot speak in complete sentences
- The lips or fingertips appear blue or gray
- The chest or neck muscles are pulling inward
- Symptoms rapidly worsen
- The patient becomes confused, exhausted, or difficult to awaken
Follow the patient's asthma action plan.
The Bottom Line
A controller inhaler helps prevent the fire. A reliever inhaler helps when smoke is already filling the room. Some treatment plans combine those roles, so know the name, active ingredients, and exact directions for every inhaler you carry.
Frequently Asked Questions
Can I use my controller inhaler as a rescue inhaler during an attack?
Only if your specific prescribed regimen is a maintenance-and-reliever combination product designed for that purpose (typically an inhaled corticosteroid and formoterol combination). A combination inhaler containing a different long-acting bronchodilator should not automatically be used this way. Follow your pharmacy label and written asthma action plan.
How often should I be using my rescue inhaler?
Frequent reliance on a rescue inhaler may indicate that asthma is not adequately controlled and is worth discussing with your prescriber, who may adjust your controller therapy.
Why do I need to rinse my mouth after using my inhaled steroid?
Rinsing and spitting after use can reduce local side effects such as oral thrush, hoarseness, and throat irritation. Don't swallow the rinse water unless specifically instructed.
How do I know if I'm using my inhaler correctly?
Common technique errors include not priming the device, inhaling too fast or slow, and poor mouthpiece seal. Ask a pharmacist or respiratory therapist to watch you demonstrate your technique — this is a routine part of asthma follow-up care.
A controller inhaler helps prevent the fire. A reliever inhaler helps when smoke is already filling the room. Some treatment plans combine those roles, so know the name, active ingredients, and exact directions for every inhaler you carry.
References
- National Heart, Lung, and Blood Institute (NHLBI), NIH. Asthma — Treatment and Action Plan. nhlbi.nih.gov/health/asthma/treatment-action-plan
- National Heart, Lung, and Blood Institute (NHLBI), NIH. 2020 Focused Updates to the Asthma Management Guidelines. nhlbi.nih.gov/health-topics/asthma-management-guidelines-2020-updates
- Global Initiative for Asthma (GINA) 2022 strategy report, summarized in: Key Recommendations for Primary Care from the 2022 GINA Update. npj Prim Care Respir Med. nature.com/articles/s41533-023-00330-1