I have COPD and I’m on the “best” inhaler, but it’s not good enough.

The hallmark of therapy for those with chronic obstructive pulmonary disease (COPD) is a long acting inhaler. There are many on the market, and they can provide an increase in your stamina, improve the way you breathe, improve the way you feel, reduce the chances of you winding up in the hospital due to COPD, and even reduce your chances of death. However, for some, inhalers alone are not enough to overcome the daily symptoms and limitation caused by their breathlessness. So, what other options are there?

1. Quitting smoking

   • This might seem obvious, but to some, it may not be. Smoking is the leading cause of COPD and your lungs will continue to worsen with ongoing smoking. More than that, smoking causes a constant degree of injury and inflammation in your lungs that gets in the way of what the inhaler is trying to do for you. For some, this will be one of the most difficult things he or she will do in their life. But, if the goal is to live a better and longer life, this is a nonnegotiable.

2. The right inhaler

   • There are different types of inhalers. Some have steroids, some have long acting versions of albuterol, some have a different type of bronchial dilator that also act on mucus secretion, and then there are inhalers that combine two or all three of these types of medications. Not all people with COPD stand to benefit the same from one combination. A thorough look at your history, other health issues you may have, and how you’ve responded to other inhalers in the past can help make the right decision.

3. The right inhaler technique

   • I can’t tell you how many times I’ve had a patient come to me and tell me the inhaler isn’t working for them, so I ask them to show me how they use it, and they basically are wasting most of the medication by using a bad technique. Review you technique with your physician and ensure you’re getting the most out of your medication.

4. Pulmonary rehabilitation

   • Pulmonary rehabilitation is a structured physical therapy program specifically for people with lung disease. COPD is one of the qualifying diagnoses. Typically, insurance will cover this if either your forced expiratory volume in one second (FEV1) or diffusing capacity (DLCO) are < 60% of predicted. There are exceptions to this. The program generally consists of up to 36 sessions and has been shown to improve mortality, increase stamina and exercise capacity, improve self reported quality of life, and reduce the risk of hospitalization.

5. Oxygen (in some circumstances)

   • Those who have low oxygen levels at rest and/or have signs of strain on the heart as a result of low oxygen in the setting of COPD can expect to live longer and have less exacerbations with use of supplemental oxygen. This involves testing that can be done in the office.

6. A CT scan of your chest

   • At times, those with COPD have plugging of their bronchioles with mucus that blocks off areas of the lung and prevent more efficient breathing. A CT scan of your chest can tell if this seems to be the case. There are breathing therapies and exercises that can help with this.

7. Long term azithromycin therapy

   • For those who experience 2 or more exacerbations of their COPD per year, taking azithromycin (the antibiotic in a Zpak) a few times per week can help symptoms and reduce risk of exacerbations and hospitalizations.

8. Roflumilast

   • Roflumilast is a medication for those who suffer more from chronic bronchitis than emphysema itself and have reduced lung function. It can also improve breathlessness and reduce the rate of exacerbation of COPD. However, not all with COPD fit the profile for those the medication is labeled to help.

9. Ensifentrine

   • Ensifentrine is a newer and inhaled medication approved in 2024 based on results from the ENHANCE trial. It opens airways in a manner different from those discussed above seen in inhalers, and has been shown to improve shortness of breath, reduce exacerbation rates, and may also improve lung function.

10. Dupilumab

    • For those who have high blood levels of eosinophils (allergy cells), dupilumab has been approved as an injectable medication that has been seen to lead to fewer exacerbations, better lung function, better quality of life, and less severe respiratory symptoms.

If you thought an inhaler was your only hope to breathe better, clearly we can see this is not the case. On the contrary, your head may now be spinning with all the possibilities and be wondering which of these is the right one for you. Also, no medication is without its possible adverse effects and your history needs to be thoroughly evaluated prior to making a decision. This is a discussion to be had with your pulmonologist after some testing to find the right fit and to get you back to where you want to be.