The Woolcock Institute of Medical Research

Current best practice in asthma management recommends all people with asthma aged 12 years and older should use a preventer inhaler, either regularly or as a combination preventer and reliever inhaler. However, many people with asthma continue to rely on a traditional blue puffer alone.

In a recent study of 2,686 adults with asthma, 55 per cent said they had not used a preventer inhaler in the previous four weeks, including 37 per cent who said they had not used a preventer in the previous year.

Asthma causes the lining of the airways to swell, limiting flow of air to and from the lungs. This causes symptoms including shortness of breath, wheezing or chest tightness. These symptoms often occur during or after exercise, or during the night.

Asthma flare-ups, also called attacks or exacerbations, are often associated with respiratory viruses such as colds and the flu, allergies, and environmental factors including air pollution and even thunderstorms under certain conditions.

Deaths from asthma, while uncommon in Australia, do still occur. In 2020, 421 people died from the condition.

Professor Helen Reddel is a Professor of Respiratory Medicine at Macquarie Medical School, a Research Leader at the Woolcock Institute of Medical Research, and Chair of the Science Committee of the Global Initiative for Asthma (GINA), which is dedicated to the better management of asthma worldwide.

Every year, GINA updates its asthma management guidelines based on a review of new scientific evidence.

Professor Reddel says despite the availability of effective, accessible and affordable management options, health outcomes for Australian adults with asthma are worsening – particularly for those who consider themselves to have mild asthma.

For some time, best practice has focused on the use of preventer inhalers containing inhaled corticosteroids, which reduce the inflammation in the airways. These inhalers reduce the frequency and severity of symptoms and the risk of asthma attacks.

However, in the past, most patients relied on reliever inhalers – the familiar blue puffers containing salbutamol that provide short-term relief of asthma symptoms.

Although these puffers can be lifesaving in an asthma attack, using too much on an ongoing basis can make asthma worse.

How much is too much?

“Overusing reliever puffers is associated with more asthma attacks, and more severe attacks,” she says.

“Reliever puffers are available over the counter in Australia, and in many patients’ minds, that signals that they’re safe to use.

“But if someone uses a reliever puffer regularly for as little as two weeks, they may notice it isn’t working as well and that they need more of it. In the case of a severe attack, this can be critical.”

Professor Reddel says the overuse of puffers has been almost normalised by visits to hospital emergency departments.

When someone having a severe asthma attack goes to the emergency department, they may be given 12 puffs of salbutamol every 20 minutes for the first hour, which can lead them to consider it is safe or appropriate to do the same thing at home.

“Research has found that people with asthma using three or more blue puffers a year have a doubled risk of having a severe attack requiring hospitalisation,” she says.

“Most people take two puffs at a time, so that can mean using your puffer an average of more than three or four times a week.

“And the more you use it, the higher the risk. People going through one blue puffer a month – two puffs, three or four times a day – are at a greatly increased risk of dying of asthma.

“On the other hand, using a preventer regularly cuts your chance of dying from asthma by 50 per cent.”

Professor Reddel says that even when a preventer inhaler is prescribed, people with mild asthma or infrequent symptoms often don’t take it regularly.

One puffer for relief and prevention

Professor Reddel was instrumental in setting up studies to test the use of a combination of budesonide and formoterol – found in inhalers like Symbicort – as both preventer and reliever for patients with mild asthma. Budesonide is an anti-inflammatory medication, and formoterol is a fast-onset, long-acting bronchodilator to open the airways.

This combination inhaler was already widely used in patients with more severe asthma. The new studies, in almost 10,000 patients with mild asthma, showed that when it was used as needed for symptom relief, it reduced the risk of having a severe attack by almost two-thirds compared with using a blue puffer alone.

As a result, it was approved in Australia for as-needed use in people with mild asthma in 2019.

The same year, GINA used this evidence to recommend against using only blue reliever inhalers for standard asthma management in adults, and to promote the use of the combination inhaler in most adult patients – either as-needed-only in patients with mild asthma, or both regularly and as needed in patients with more severe asthma.

Professor Reddel says unfortunately, ongoing use of asthma preventers in Australia is very poor, even many people who have daily symptoms won’t use one regularly.

“People are prescribed an inhaler, but then they stop using it,” she says.

“Many patients don’t perceive the risk associated with treating their asthma with a blue puffer alone because when they use it, it makes them feel better. It’s hard to accept that something you take that helps in one situation could possibly harm you.

“There’s also the problem that some people can be hesitant to take them because there is confusion between the corticosteroids in asthma inhalers and anabolic steroids.

“Corticosteroids fight inflammation, while anabolic steroids are an artificial version of the male hormone testosterone used to build up muscles. The two are not related and do not resemble each other in any way.

“I can’t stress enough that if you have asthma, even if you think it’s only mild, it’s very important to use a preventer inhaler.”

The GINA recommendations at a glance

• All asthma patients over the age of 12 should be using a preventer inhaler.
• The best protection from severe attacks is using a combination of an inhaled corticosteroid with formoterol as your reliever, with people with moderate or severe asthma taking the same inhaler regularly every day.
• All patients should have an asthma action plan that details normal treatment and what to do when symptoms worsen or in case of an attack.
• Talk to your GP if you
  • are using your blue puffer three times a week or more
  • are waking at night because of your asthma
  • are not using a preventer regularly
  • do not have an asthma plan in place or have one but have not reviewed it in the past 12 months.

This story was first published in Macquarie University's The Lighthouse.

Find out more

• Green inhalers and asthma care: A fine balance
• Asthma care: Living in the past
• About Respiratory Services at the Woolcock Clinic