What are the indications for inhalers (puffers) in chronic bronchitis?

From the Guidelines

Inhaled bronchodilators, commonly called "puffers," are effective treatments for bronchitis, particularly when wheezing or breathing difficulty is present, as recommended by the 2018 GOLD report 1. For acute bronchitis, short-acting beta-agonists like albuterol (Ventolin, ProAir) are typically recommended, used as 1-2 puffs every 4-6 hours as needed for symptom relief. For chronic bronchitis, which is often part of COPD, long-acting bronchodilators are usually prescribed, such as tiotropium (Spiriva) once daily or salmeterol (Serevent) twice daily, as suggested by the GOLD guidelines 1. Some patients benefit from combination inhalers containing both bronchodilators and corticosteroids, like fluticasone/salmeterol (Advair) or budesonide/formoterol (Symbicort), typically used twice daily, as recommended by the American Journal of Respiratory and Critical Care Medicine 1. These medications work by relaxing airway muscles and reducing inflammation, helping to open airways and ease breathing. Proper inhaler technique is crucial for effectiveness—patients should fully exhale, create a good seal around the mouthpiece, inhale deeply while activating the inhaler, hold their breath for 10 seconds, and then exhale slowly, as advised by the Mayo Clinic Proceedings 1. Using a spacer device can improve medication delivery, especially for those who struggle with coordination. The European Respiratory Journal also suggests that LAMA + LABA combination is recommended in patients where LABA + ICS were indicated, but ICS was declined or could not be tolerated 1. It is essential to note that the treatment should be individualized based on the patient's symptoms, lung function, and history of exacerbations, as recommended by the GOLD guidelines 1. In patients with chronic bronchitis and frequent exacerbations, roflumilast may be considered, as suggested by the American Journal of Respiratory and Critical Care Medicine 1. Overall, the treatment of bronchitis with puffers should be guided by the most recent and highest-quality evidence, prioritizing morbidity, mortality, and quality of life as outcomes, as recommended by the GOLD report 1.

From the FDA Drug Label

The efficacy of fluticasone propionate and salmeterol inhalation powder 250 mcg/50 mcg and fluticasone propionate and salmeterol inhalation powder 500 mcg/50 mcg in the treatment of subjects with COPD was evaluated in 6 randomized, double-blind, parallel-group clinical trials in adult subjects aged 40 years and older Two (2) of the 3 clinical trials primarily designed to evaluate the efficacy of fluticasone propionate and salmeterol inhalation powder on lung function were conducted in 1,414 subjects with COPD associated with chronic bronchitis In these 2 trials, all the subjects had a history of cough productive of sputum that was not attributable to another disease process on most days for at least 3 months of the year for at least 2 years.

Puffers for bronchitis:

• The drug label mentions that fluticasone propionate and salmeterol inhalation powder was evaluated in subjects with COPD associated with chronic bronchitis.
• The trials showed improvements in lung function with fluticasone propionate and salmeterol inhalation powder compared to its components and placebo.
• The results suggest that fluticasone propionate and salmeterol inhalation powder may be effective in treating bronchitis associated with COPD. 2

From the Research

Puffers for Bronchitis

• The use of puffers, such as salmeterol/fluticasone and tiotropium, has been studied in the treatment of chronic obstructive pulmonary disease (COPD), which includes chronic bronchitis 3, 4, 5, 6, 7.
• A study published in 2009 found that initial maintenance therapy with fluticasone propionate/salmeterol 250/50 mcg was associated with improved outcomes, including a 41% lower risk of COPD-related hospitalization or emergency department visit, compared to ipratropium-based therapy 3.
• Another study published in 2005 found that the combination of salmeterol and tiotropium improved lung function in COPD patients more than either of the two bronchodilators administered alone 4.
• A randomized controlled trial published in 2008 found that combination therapy with salmeterol/fluticasone and tiotropium led to better control of symptoms and improved lung function, with no greater risk of side effects, compared to salmeterol/fluticasone or tiotropium alone 5.
• A study published in 2008 found that "triple" therapy with salmeterol/fluticasone propionate and tiotropium bromide was superior to individual components in moderate to severe COPD, with significant improvements in lung function and patient-related benefits 6.
• A study published in 2009 found that salmeterol/fluticasone had anti-inflammatory effects, including a significant reduction in interleukin-8 and matrix metalloprotease-9 in induced sputum, compared to tiotropium alone 7.

Key Findings

• Combination therapy with salmeterol/fluticasone and tiotropium may be more effective than individual components in improving lung function and controlling symptoms in COPD patients 4, 5, 6.
• Salmeterol/fluticasone may have anti-inflammatory effects, which could contribute to its clinical benefits in COPD patients 7.
• The use of puffers, such as salmeterol/fluticasone and tiotropium, may be associated with improved outcomes, including reduced risk of hospitalization or emergency department visit, in COPD patients 3.