Introduction

What is an inhaler?

Who hasn't heard of inhalers or used them at some point? Inhalers are small, portable devices through which medication is inhaled from the mouthpiece into the lungs. The most commonly used medications include bronchodilators and corticosteroids.

There are three types of inhalers: pressurized metered-dose inhalers (pMDI), dry powder inhalers (DPI), and soft mist inhalers.¹

Common use for asthma management 

Two inhalers are dispensed, one for daily use and another for emergencies or rescue. Daily-use inhalers are used both to prevent and manage symptoms. Fast-acting inhalers or rescue inhalers, are used to control asthma attacks. The medication that is usually prescribed is inhaled corticosteroids (ICS). If this method is not enough, doctors often opt for a long-acting bronchodilator.¹

Purpose of the outline 

To explore the effects of inhalers on individuals without asthma 

In this case, the inhalers themselves are not the most important part, but rather the medication inside them. It's also important to note that there are different types of medications that can be placed in an inhaler, depending on the specific needs of the patient. However, some doctors have prescribed rescue inhalers and inhaled corticosteroids for respiratory conditions other than asthma. As with any medication, you should only use an inhaler that has been prescribed to you.¹

To understand potential benefits and risks

Generally, as long as inhalers are not used regularly, their use is not dangerous. In terms of benefits, it could include a very slight increase in airflow. In cases of repeated use, the side effects may include an increased heart rate, muscle spasms, headaches, feelings of anxiety or nervousness, and discomfort in the mouth Among other effects that we will analyze later.²

Mechanism of action 

Delivery of medication directly to the lungs 

Metered-Dose Inhalers (pMDI)

They are also known as "puffs." Their canisters are pressurized and consist of a mouthpiece that dispenses one dose at a time. By pressing the canister while inhaling, a propellant will carry the medication into your lungs.¹

Dry Powder Inhalers (DPI)

Unlike metered-dose inhalers, dry powder inhalers (DPI) do not use a propellant. They rely on the patient taking a quick, deep breath to deliver the medication into the lungs. This medication is stored in powder form inside capsules or containers. These inhalers come in various shapes, such as tubes or discs.¹

Soft Mist Inhalers

Their main difference is that these inhalers transform the liquid medication into a fine mist. This mist, containing the medication, is inhaled and deposited into the lungs.¹

Types of medications used (e.g., bronchodilators, corticosteroids)

Long-term asthma control medications

It is the most important treatment for people with chronic asthma and is taken regularly. The most important medications are the inhaled corticosteroids.³

Quick-relief medications (rescue medications)

They are very effective in preventing or treating sudden asthma attacks, but they are only useful in the short term. The most important ones are the short-acting beta-agonists such as albuterol ( also called salbutamol).³

Medications for allergy-induced asthma

They reduce the body's sensitivity to a particular allergen. They can be taken sporadically or regularly.³

Biologics

They are used to treat severe asthma symptoms and stop the underlying biological responses that cause inflammation in the lungs.³

Intended effects on asthmatic patients 

Relief of airway inflammation

Inhaled corticosteroids have proven to be the most effective medications for relieving airway inflammation. These medications allow you to prevent symptoms and attacks, helping to better manage asthma, improve lung function, and reduce visits to emergency rooms. It's important to note that these medications are preventive and do not relieve symptoms. Therefore, daily use is essential for them to take effect.⁴

Relaxation of airway muscles

Bronchodilators are the perfect medications to relax the airway muscles, widening the airways and making breathing easier. These medications do relieve symptoms, unlike corticosteroids, which prevent them. There are two types:⁵

• Short-acting: Useful in the short term to relieve sudden asthma attacks
• Long-acting: Used in the long term to help control asthma episodes where there is shortness of breath, and they also increase the effectiveness of corticosteroids

There are three main types:⁵

• Beta-2 agonists like salbutamol
• Anticholinergics like ipratropium
• Theophylline

Effects of inhalers on non-asthmatics

Short-term effects 

Potential respiratory improvements 

Enhanced airflow

There is little evidence regarding a possible significant improvement in enhanced airflow. The study by Amund Riiser et al. demonstrated that β2-agonists such as Albuterol, Formoterol, and Terbutaline could improve anaerobic performance in healthy non-asthmatic adults by 5%. The study was conducted with non-asthmatic athletes, and although the results were positive, the recommended dosage to achieve these effects would need to be higher than those approved by WADA (World Anti-Doping Agency). Additionally, it was concluded that the oral administration of the drug yielded better results than the inhaler version. Therefore, more studies are still needed to validate this finding 100%. ⁶

Temporary relief of respiratory discomfort 

Rescue inhalers are often recommended for people with respiratory discomfort, particularly those containing the medication salbutamol. They are typically used in situations where activities that might affect breathing, such as climbing stairs or exercising, are expected, or if you occasionally experience coughing, wheezing, or chest tightness.⁷

No significant impact on healthy individuals 

So far, no study has shown a significant enough impact on healthy individuals. An example is the study “Effects of inhaled salbutamol in exercising non-asthmatic athletes,” which demonstrated that inhaled salbutamol, even in high doses, had no significant effect on endurance performance in healthy athletes. The article also notes that there is a possibility that the medication may have initially improved respiratory adaptation at the beginning of exercise (similar to the case in Amund Riiser's article). Even so, for now, a significant impact has not been demonstrated.⁸

Long-term effects 

Potential risks and side effects 

Oral thrush (for steroid inhalers) 

Corticosteroids, although targeting the lungs, sometimes leave certain amounts in your mouth. If the area is not cleaned, many bacteria use steroids as food, which can lead to a fungal infection in the mouth, known as oral candidiasis.⁹

Possible impacts on lung function

Can steroid inhalers damage your lungs? The likelihood of impacting lung function is low. However, there is some risk of developing lung infections, and some of these infections, like pneumonia, can have long-term effects on lung function.¹⁰

Lack of significant health benefits for individuals without respiratory conditions

Currently, it is known that corticosteroids have almost no effect on non-asthmatic individuals, and bronchodilators might enhance airflow but only to a very slight extent. In reality, as discussed, the positive effects are minimal and do not outweigh the risks of negative effects. Therefore, there are few reasons for someone without asthma to use an inhaler, especially on a regular basis.²

Other potential risks, misuse, and over-reliance

Other risks associated with improper use

Impact on oral health

Corticosteroid inhalers can not only cause oral thrush, but they can also lead to complications with your teeth, gums, tongue, and cheeks.¹¹

Studies suggest that asthma medications found in inhalers affect teeth, in some cases leading to cavities. Inhalers wear down the enamel, which is the protective layer of the tooth. Therefore, the more you use them, the higher your risk of developing cavities.¹²

Another major concern is the possibility of developing xerostomia, or dry mouth. This condition not only increases the likelihood of cavities but also causes mouth sores and gum disease.

Obviously, all these effects can be managed with proper hygiene and regular visits to your dentist, but it might be an unnecessary risk if you don't have asthma.¹³

Long-Term health concerns

Using high doses of inhaled corticosteroids over a long period of time also increases the likelihood that this medication will affect the rest of the body, potentially causing bruising, an increased risk of diabetes, or weakening of the bones (osteoporosis).¹⁴

To provide data, lead investigator Samy Suissa and his team recently discovered that diabetes diagnoses increased by 34% in people using inhalers. In fact, among patients treated with the highest-dose inhalers, the increase was 64% for the onset of diabetes and 54% for diabetes progression.¹⁵

There is also growing concern about moderate or high doses of inhaled corticosteroids and their link to reduced bone mineral density, fractures, and osteoporosis.¹⁶

Misuse and over-reliance

Over-reliance on medication

The Asthma Society warns that using a reliever inhaler more than twice a week is a sign of excessive dependence. These inhalers are strongly linked to severe asthma exacerbations and asthma-related deaths. While this warning is directed at people with the condition, it also serves as a reminder that inhalers are not toys and their responsible use should be taken seriously.¹⁷

Disruption of natural breathing patterns

The use of albuterol or salbutamol can, in some cases, cause wheezing and difficulty breathing immediately after inhalation. Therefore, it's important to consult your doctor before using these substances.¹⁸

Summary

Inhalers are small, portable devices that deliver medication directly to the lungs. There are three types: metered-dose inhalers, dry powder inhalers, and soft mist inhalers. They are commonly used for asthma management and include both preventive and rescue inhalers.

For people without asthma, inhalers generally offer minimal benefits. Short-term effects may include slight improvements in airflow or temporary relief from respiratory discomfort. However, there is little evidence of significant benefits for healthy individuals. Long-term use can lead to oral health issues such as candidiasis and cavities and increase risks such as diabetes and osteoporosis.

Improper and irresponsible use of inhalers, especially without a prescription, can even disrupt natural breathing patterns. Excessive use of rescue inhalers may indicate dependence, which can lead to severe asthma exacerbations and related complications.