Updated COPD guidelines are reshaping how soon patients start daily inhalers—and what therapies make the most sense based on symptoms and risk.
In this episode, TRC Healthcare Associate Editor and Clinical Pharmacist Don Weinberger, PharmD, PMSP, reviews practical, guideline-based strategies for treating and managing chronic obstructive pulmonary disease (COPD). Don highlights common factors that increase exacerbation risk and explains how current recommendations aim to better match therapy to patient needs.
He also clarifies key differences between COPD and asthma, walks through the main goals of COPD management, and reviews where short- and long-acting bronchodilators, as well as inhaled corticosteroids, fit into care. The discussion includes when to escalate treatment, common inhaler technique mistakes that limit effectiveness, and non-drug strategies that can help keep patients out of the hospital.
In this episode, you’ll hear about:
- How updated guidelines approach COPD treatment and escalation
- When to use short-acting inhalers, dual bronchodilators, or triple therapy
- Common inhaler technique errors that increase exacerbation risk
- The role of smoking cessation, vaccinations, and adherence in improving outcomes
This is an excerpt from our February 2026 Pharmacy Essential Updates continuing education webinar series.
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CE Information:
TRC Healthcare offers CE credit for this podcast for pharmacist subscribers at our platinum level or higher and pharmacy technician subscribers. Log in to your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses. None of the speakers have anything to disclose.
Clinical Resources from Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights:
- Article: Clear the Air With New COPD Guidelines
- Chart: Inhaled Medications for COPD
- Algorithm: Improving COPD Care
- Algorithm: Stepwise Treatment of Asthma (12 Years and Older)
- Algorithm: Stepwise Treatment of Asthma (Under 12 Years of Age)
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Transcript:
This transcript is automatically generated.
00:00:04 Narrator
Welcome to Clinical Capsules from TRC Healthcare, your trusted source for practical, evidence-based updates.
00:00:11 Narrator
On this episode, Associate Editor and Clinical Pharmacist Don Weinberger shares practical guidance on managing chronic obstructive pulmonary disease (COPD).
00:00:21 Narrator
Including how updated guidelines approach inhaler selection, escalation of therapy, proper inhaler technique, and reducing exacerbation risk, in an excerpt from our popular Pharmacy Essential Updates webinar series.
00:00:33 Narrator
This podcast offers continuing education credit for pharmacists and pharmacy technicians.
00:00:38 Narrator
Please log in to your Pharmacist’s Letter or Pharmacy Technician’s Letter account and look for the title of this podcast in the list of available CE courses.
00:00:46 Narrator
None of the speakers have anything to disclose.
00:00:49 Narrator
Catch new episodes of Clinical Capsules every 2nd and 4th Tuesday, bringing concise, actionable insights from TRC experts straight to your ears.
00:00:59 Narrator
Let’s take a closer look…
00:01:06 Don Weinberger
So let’s talk about treatment and management for patients with COPD.
00:01:13 Don Weinberger
And we’re talking about this today because you’ll see patients start daily maintenance inhalers sooner as part of those updated COPD guidelines on helping to better match therapy to symptoms, exacerbation history, and emphasizing non-pharmacological options to help keep patients out of the hospital and breathing a little better.
00:01:35 Don Weinberger
Okay, so let’s go ahead and start off with a hospital case this time.
00:01:38 Don Weinberger
We have Patti, and she was admitted to the hospital with a COPD exacerbation.
00:01:45 Don Weinberger
You were called down to the ED to perform a medication reconciliation.
00:01:51 Don Weinberger
When interviewing the patient, you discover the following.
00:01:55 Don Weinberger
Albuterol inhaler, 2 puffs every three hours.
00:01:58 Don Weinberger
Tiotropium, olodaterol inhaler, one puff every other day.
00:02:02 Don Weinberger
Propranolol, 40 milligrams, three times daily for heart failure.
00:02:06 Don Weinberger
And looking at the social history, you see that she doesn’t drink alcohol, but she does smoke one pack of cigarettes per day.
00:02:14 Don Weinberger
Do you see any potential reason or reasons that could have increased her risk of a COPD exacerbation?
00:02:23 Don Weinberger
Now, before we get started on COPD, I did look at the past comments that we had when we presented COPD.
00:02:30 Don Weinberger
And a lot of people actually asked, what are the main differences between COPD and asthma?
00:02:36 Don Weinberger
So let’s go and get to that right out of the gate.
00:02:41 Don Weinberger
Because on the surface, they do look pretty similar, but the details tell a bigger story.
00:02:49 Don Weinberger
Asthma often starts earlier in life and is driven by airway inflammation.
00:02:53 Don Weinberger
It’s commonly associated with allergic triggers like pollen and non-allergic ones like exercise or illness.
00:02:59 Don Weinberger
The key thing to remember is that asthma symptoms, like shortness of breath, cough, and wheezing, can vary day-to-day, and some patients even improve as they get older.
00:03:10 Don Weinberger
COPD, on the other hand, usually shows up later in adulthood.
00:03:14 Don Weinberger
It’s caused by progressive damage to the lungs, you know, as we said earlier, most often from smoking or the long-term exposures.
00:03:23 Don Weinberger
Patients still have shortness of breath and cough, as with asthma, but they’re more likely to have other symptoms, including sputum production and mucus, and those symptoms usually worsen over time, rather than come and go with asthma.
00:03:41 Don Weinberger
So if a person has both asthma and COPD, how do you treat it?
00:03:46 Don Weinberger
Well, both guidelines state to follow asthma rules first.
00:03:52 Don Weinberger
How do you find those?
00:03:54 Don Weinberger
We have these great new charts on our website that you can go to.
00:03:58 Don Weinberger
So please type in asthma on our website for more information.
00:04:03 Don Weinberger
Okay, let’s get back to the main event, which is COPD.
00:04:05 Don Weinberger
When we think about treating COPD, it really comes down to two key goals: symptom control and risk reduction.
00:04:14 Don Weinberger
So starting with symptom control, this is what patients experience every day.
00:04:19 Don Weinberger
Our aim is to reduce shortness of breath, cough, and wheezing, and to help patients tolerate activity better.
00:04:26 Don Weinberger
Also, the target is risk reduction, which is just as important, even if patients don’t immediately feel it.
00:04:33 Don Weinberger
You know, looking back at it, how many times has a patient said they don’t take their meds regularly because they feel fine?
00:04:41 Don Weinberger
In my experience, it’s been quite a few.
00:04:44 Don Weinberger
So here, the focus is on slowing disease progression and, importantly, preventing exacerbations.
00:04:50 Don Weinberger
Since each exacerbation increases the risk of hospitalization and contributes to long-term decline, up to mortality.
00:04:57 Don Weinberger
So prevention is a major priority.
00:05:00 Don Weinberger
Ultimately, effective COPD management means balancing both—helping patients feel better today while also reducing the risk of exacerbation and disease progression tomorrow.
00:05:13 Don Weinberger
And if we think about the main buckets of inhaled medications for treating COPD,
00:05:18 Don Weinberger
There are the short-acting bronchodilators, which open up airways quickly, like albuterol and ipratropium.
00:05:25 Don Weinberger
Next, we have the inhaled corticosteroids, like fluticasone, which reduce inflammation in those with COPD.
00:05:30 Don Weinberger
And lastly, we have the combination, the PDE3 and PDE4 inhibitor, like ensifentrine.
00:05:39 Don Weinberger
So before you’ve started with therapy, make sure all patients with COPD continue to get a short-acting bronchodilator, like albuterol, as needed to relieve symptoms, in addition to whatever maintenance therapy they are currently taking.
00:05:52 Don Weinberger
So let’s go ahead and take a look at how GOLD, which is the Global Initiative for Chronic Obstructive Lung Disease, their guidelines recommend for treating COPD initially.
00:06:05 Don Weinberger
And we’re going to start with Group A.
00:06:07 Don Weinberger
So Group A is the group with the mild symptoms, like the occasional shortness of breath or cough, and more importantly, no moderate or severe exacerbations in the past year.
00:06:17 Don Weinberger
These patients are typically early in their disease and may not need that complex therapy yet.
00:06:24 Don Weinberger
For this group, the recommendation is to start with a bronchodilator.
00:06:28 Don Weinberger
So we have a short-acting beta agonist, also called a SABA, or a short-acting muscarinic antagonist, also known as a SAMA, which can be used as needed if symptoms are truly infrequent.
00:06:38 Don Weinberger
However, the GOLD guideline makes it clear that long-acting bronchodilators are generally preferred over short-acting agents.
00:06:45 Don Weinberger
So for many patients, starting a long-acting beta agonist, a LABA, or a long-acting muscarinic antagonist, a LAMA, provides more consistent symptom control and reduces reliance on those rescue short-acting inhalers.
00:07:02 Don Weinberger
Let’s put the microscope on those treatment options now.
00:07:06 Don Weinberger
Short-acting bronchodilators we commonly use in COPD, primarily for quick symptom relief.
00:07:11 Don Weinberger
Again, we have those SABAs, like albuterol and levalbuterol, used for rescue therapy to provide that quick opening of airways.
00:07:19 Don Weinberger
And we also have the short-acting muscarinic antagonist, or SAMAs, with ipratropium being the main example.
00:07:27 Don Weinberger
This works through different mechanisms and can be an alternative or addition to a SABA in COPD.
00:07:34 Don Weinberger
Now, looking a little more closely at short-acting bronchodilators, these are medications we think of as rescue inhalers for COPD, particularly used as needed, non-daily schedule, to help those with COPD symptoms like shortness of breath, wheezing, or chest tightness.
00:07:51 Don Weinberger
Another key point is combination therapy, using a short-acting muscarinic antagonist like ipratropium together with a short-acting beta-agonist like albuterol—for example, products like Combivent or Duoneb—which may provide better symptom relief than either medication alone in some patients.
00:08:12 Don Weinberger
And looking at long-acting bronchodilators in COPD, we have the two classes, again, the LAMAs and the LABAs, which include meds like olodaterol or salmeterol.
00:08:24 Don Weinberger
So it makes sense that these meds are used on a daily basis for maintenance for patients with persistent symptoms, since they’re longer-acting than short-acting bronchodilators.
00:08:36 Don Weinberger
When we’re talking about long-acting bronchodilators, like LABAs or LAMAs, the actual choice often comes down to practical factors, things like cost, payer coverage, and what’s actually available.
00:08:47 Don Weinberger
These medications are meant to be taken on a scheduled daily basis and not as rescue inhalers.
00:08:53 Don Weinberger
A common counseling point is reminding patients they shouldn’t expect immediate relief from a LABA or a LAMA, or at least not as fast as they would from a SABA or a SAMA.
00:09:03 Don Weinberger
Also, if patients have asthma, LABAs cannot be used alone, since there also needs to be an inhaled corticosteroid, like fluticasone, with that LABA.
00:09:13 Don Weinberger
We’ll talk more about this later.
00:09:16 Don Weinberger
For sudden or worsening COPD symptoms, patients should still rely on a short-acting bronchodilator, like albuterol, for quick relief.
00:09:24 Don Weinberger
So let’s move on to our next group.
00:09:26 Don Weinberger
So Group B is a lot like Group A, but they have more of the mild symptoms, more cases of breathlessness and cough, but still no moderate or severe exacerbations in the past year.
00:09:38 Don Weinberger
For these patients, the first-line therapy recommended is dual long-acting bronchodilation, which means a long-acting beta agonist, a LABA, and a long-acting muscarinic antagonist, like a LAMA.
00:09:52 Don Weinberger
And all those combo LABA-LAMA inhalers are equally effective.
00:09:57 Don Weinberger
So if we look at examples of LABA-LAMA combos available, we can really suggest one mainly based on patient preference and payer coverage.
00:10:06 Don Weinberger
And pretty much all of them cost at least $400 a month.
00:10:11 Don Weinberger
But this is generally less than having two separate inhalers versus the combination.
00:10:17 Don Weinberger
Okay, lastly, let’s look at that last group, which is Group E.
00:10:22 Don Weinberger
These are patients with moderate to severe symptoms and at least one moderate or severe exacerbation in the past year.
00:10:29 Don Weinberger
For most of these patients, you’ll start them off with a LABA plus a LAMA, like you did in Group B.
00:10:34 Don Weinberger
Now you’ll notice the addition here, which is the inhaled corticosteroid, but that’s not automatic for everybody.
00:10:41 Don Weinberger
So ICS is added only if there is a clear indication.
00:10:45 Don Weinberger
Specifically, the patient has concurrent asthma or a key inflammation indicator, such as a blood eosinophil count of 300 cells per microliter or higher.
00:10:56 Don Weinberger
So inhaled corticosteroids are commonly used in patients on triple therapy, which includes that ICS plus a LAMA plus a LABA.
00:11:05 Don Weinberger
These combination inhalers are effective, but they can be expensive, often costing $680 or more per month.
00:11:14 Don Weinberger
These are labels to communicate that patients should always rinse their mouth after use of an inhaled corticosteroid to reduce the risk of oral thrush and fungal infection that occur with inhaled steroid use.
00:11:27 Don Weinberger
So now the other pharmacotherapy options for COPD.
00:11:30 Don Weinberger
And these ones are used not really as routine add-ons, but more if the patients aren’t responding to max therapy.
00:11:38 Don Weinberger
You’ll see biologics like ensifentrine and long-term azithromycin.
00:11:44 Don Weinberger
What they all have in common is that these are patients with persistent COPD exacerbations despite maximum inhaled therapy, which means LABA plus LAMA and, when appropriate, ICS use.
00:11:59 Don Weinberger
What medications may have been used in the past for COPD, but we need to avoid according to current guidelines?
00:12:07 Don Weinberger
First, theophylline and IV aminophylline.
00:12:10 Don Weinberger
These agents have not been shown to reduce COPD exacerbations, and they come with a narrow therapeutic index, significant side effects, and drug–drug interactions, all major red flags from a pharmacy standpoint.
00:12:24 Don Weinberger
So second, OTC epinephrine products like Primatene.
00:12:29 Don Weinberger
These are not indicated for COPD-related shortness of breath and can give patients a false sense of control when they should be on the medications indicated for COPD in the guidelines.
00:12:43 Don Weinberger
And some practice pearls highlight key steps for safely managing COPD inhalers.
00:12:50 Don Weinberger
First, start by using barcode scanning and other verification tools to prevent mix-ups, especially as you’ve seen from the medications I described earlier.
00:13:00 Don Weinberger
A lot of them look similar.
00:13:02 Don Weinberger
Mix-ups do happen.
00:13:04 Don Weinberger
Be sure to discontinue unused prescriptions for COPD so patients don’t accidentally double up on meds.
00:13:12 Don Weinberger
Provide accurate directions and billing, and clarify vague instructions like inhale as directed.
00:13:18 Don Weinberger
Inhalers tend to be frequent targets for audits, so clear documentation is essential.
00:13:26 Don Weinberger
Attach appropriate auxiliary labels to note important details, such as beyond-use dates after opening, and make sure patients rinse their mouth with water after using an inhaler.
00:13:40 Don Weinberger
Okay, so let’s talk about how we can help improve COPD outcomes beyond medication usage.
00:13:47 Don Weinberger
Other fundamental measures to improve COPD outcomes include things like smoking and vaping cessation if needed.
00:13:54 Don Weinberger
Ensure patients know that it’s never too late to quit smoking.
00:14:00 Don Weinberger
Also, update vaccinations if needed, such as flu, COVID, pneumococcal, and RSV vaccines.
00:14:08 Don Weinberger
Medication adherence is a biggie, and it usually is one of the primary factors behind COPD exacerbations and hospitalizations.
00:14:16 Don Weinberger
So if they’re getting their rescue inhalers too soon, it could be a sign of worsening COPD disease or not using their maintenance inhaler effectively, or they may need to be stepped up in therapy.
00:14:28 Don Weinberger
And lastly, inhaler technique.
00:14:31 Don Weinberger
Before I jump into this, let me ask you, what percentage of patients do you think use their inhaler incorrectly?
00:14:40 Don Weinberger
The number may or may not shock you.
00:14:43 Don Weinberger
Approximately 70 to 80% of patients make at least one critical error when using their inhaler.
00:14:50 Don Weinberger
It’s a big number.
00:14:52 Don Weinberger
To me, it seems like inhaler misuse is the norm and not the exception.
00:14:57 Don Weinberger
How do we fix this?
00:15:01 Don Weinberger
I’m going to talk about some of the most common mistakes people make when using their inhalers, because even small issues can keep the medication from working as well as it should.
00:15:09 Don Weinberger
One problem that’s often seen is that the mouth isn’t tight enough around the inhaler, which lets some of the medicine escape instead of going into the lungs.
00:15:17 Don Weinberger
Another issue is when the tongue or teeth get in the way, blocking airflow without the person even realizing it.
00:15:24 Don Weinberger
Inhaling at the wrong speed is also very common, which can both affect how much medication actually reaches the lungs.
00:15:31 Don Weinberger
Don’t forget that some inhalers need to be shaken or primed before use, so check the package inserts, things like that.
00:15:38 Don Weinberger
Skipping that step can mean they’re not getting the right dose.
00:15:42 Don Weinberger
It’s easy for patients to unknowingly use an empty inhaler.
00:15:45 Don Weinberger
So checking the dose counter when available is the best way to track remaining medication.
00:15:50 Don Weinberger
Now, back in my day, I’m going to date myself here, patients would say they use the float test, which involves placing the inhaler in water to judge fullness, which is inaccurate and, like myself, probably outdated.
00:16:04 Don Weinberger
Buoyancy depends on the propellant, canister design, and moisture, not how much medication is left.
00:16:11 Don Weinberger
And also, different inhalers float differently, and submerging the canister can damage the valve or introduce moisture into that canister.
00:16:20 Don Weinberger
If they’re using a spacer, ensure it’s used correctly so the medication flows the way it’s supposed to.
00:16:26 Don Weinberger
Finally, your body and head position matter more than you might think.
00:16:30 Don Weinberger
Sitting here or standing upright with the head slightly tilted can help the medicine get deeper in the lungs.
00:16:35 Don Weinberger
Keeping these things in mind can make a big difference in how well the inhaler actually works.
00:16:43 Don Weinberger
Okay, so what about other things?
00:16:45 Don Weinberger
So looking at disease–drug interactions.
00:16:49 Don Weinberger
So first, those non-selective beta blockers, like propranolol, can worsen bronchoconstriction by blocking beta-2 receptors in the lungs.
00:16:58 Don Weinberger
When possible, there should be a recommendation to switch to a more selective option, like metoprolol.
00:17:06 Don Weinberger
The other key class to watch for is opioids, things like oxycodone, especially when they’re combined with sedatives.
00:17:13 Don Weinberger
They can suppress respiratory drive, which can be a huge issue in those with COPD.
00:17:17 Don Weinberger
All right, let’s go ahead and get back to our hospital patient, Patti.
00:17:23 Don Weinberger
There’s definitely more than one thing wrong with this.
00:17:25 Don Weinberger
So she’s using her short-acting inhaler, her rescue inhaler, too often.
00:17:29 Don Weinberger
She wasn’t using her maintenance inhaler often enough.
00:17:33 Don Weinberger
And she was on propranolol, which is a non-selective beta blocker, which could be having issues with her breathing.
00:17:42 Don Weinberger
She also smokes about a pack a day, in which smoking cessation would be recommended to her.
00:17:49 Don Weinberger
And for more information on COPD, check out our resources on our website. Inhaled Medications for COPD and Managing COPD go over more on guideline changes and how treatments stack up.
00:18:04 Narrator
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00:18:09 Narrator
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00:18:21 Narrator
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00:18:26 Narrator
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