Bronchodilators: Beta-2 Agonists
The "-terol" drugs. Know which one is the rescue inhaler and which is the maintenance inhaler.
Beta-2 agonists stimulate beta-2 receptors in the lungs, relaxing bronchial smooth muscle and opening the airways. They are split into short-acting (rescue) and long-acting (maintenance) drugs.
- Short-acting (SABA)albuterol (Ventolin, ProAir), levalbuterol (Xopenex)
- Rescue — relieves an acute attack within minutes. The go-to for acute bronchospasm.
- Long-acting (LABA)salmeterol (Serevent), formoterol
- Maintenance — prevents attacks; NOT for acute relief. Slow onset (~30+ min). Never used alone in asthma — always paired with an inhaled steroid.
Side Effects & Teaching
- Common: tachycardia, palpitations, tremor, nervousness/jitteriness (beta stimulation). High doses can lower potassium.
- If a SABA and an inhaled steroid are both ordered, use the SABA first, wait ~5 minutes, then the steroid.
- Overuse is a red flag: needing the rescue inhaler more than about twice a week means asthma is poorly controlled — notify the provider.
Albuterol = "all better" right now (rescue, acute attack). Salmeterol = "slow" (long-acting maintenance, not for an attack). If a question asks which inhaler to grab during an acute asthma attack, the answer is the short-acting one — albuterol.
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Anticholinergic Bronchodilators
Mainly for COPD. Block acetylcholine to open the airways and dry secretions.
Anticholinergics (antimuscarinics) block acetylcholine, producing bronchodilation and decreased respiratory secretions. They are used most often in COPD.
- Ipratropium (Atrovent)short-acting
- Often combined with albuterol (DuoNeb, Combivent)
- Tiotropium (Spiriva)long-acting
- Once daily; inhaled capsule via HandiHaler — do NOT swallow the capsule. Not for acute attacks.
- Most common side effect: dry mouth. Teach sips of water, sugar-free hard candy, and good oral care.
- Anticholinergic cautions: use carefully with narrow-angle glaucoma and BPH / urinary retention.
Ipratropium and tiotropium — the "-tropium" ending points to an anticholinergic bronchodilator used mainly in COPD. Dry mouth is the giveaway side effect.
Inhaled Corticosteroids (ICS)
Controllers, not rescuers. The "rinse your mouth" drugs.
Inhaled corticosteroids reduce airway inflammation. They are maintenance (controller) medications taken daily — they do not relieve an acute attack and take days to weeks for full effect.
- Examples: fluticasone (Flovent), budesonide (Pulmicort), beclomethasone, mometasone.
- Combination inhalers (ICS + LABA): fluticasone/salmeterol (Advair), budesonide/formoterol (Symbicort) — one inhaler for daily control.
- Side effects: oral thrush (candidiasis) and hoarseness from steroid residue in the mouth.
Key Teaching
- Rinse the mouth with water and spit after every use to prevent thrush.
- Use a spacer — it improves delivery to the lungs and reduces oral deposits.
- Use it every day, even when feeling well — it is a controller, not a quick fix.
If a client reaches for their fluticasone or budesonide during an acute asthma attack, that's wrong — it won't open the airways fast enough. The rescue inhaler is the short-acting beta agonist (albuterol). And always rinse and spit after the steroid to prevent oral thrush.
Leukotriene Modifiers
The "-lukast" drugs — daily prevention, including exercise-induced asthma.
Leukotriene modifiers block leukotrienes, reducing inflammation and bronchoconstriction. They are used for maintenance and prevention (asthma, allergic rhinitis, exercise-induced bronchospasm) — not for acute attacks.
- Montelukast (Singulair): taken once daily, usually in the evening; for exercise-induced asthma, take at least 2 hours before exercise.
- Zafirlukast (Accolate): take on an empty stomach; monitor liver function (hepatotoxicity).
Montelukast carries a warning for neuropsychiatric effects: mood or behavior changes, agitation, depression, and suicidal thoughts. Teach clients and families to report any new mood changes, irritability, or unusual behavior right away.
Methylxanthines (Theophylline)
An older bronchodilator with a narrow therapeutic range — toxicity is the test point.
Theophylline relaxes bronchial smooth muscle. It is used less often today because it has a narrow therapeutic range and many interactions, but its toxicity is heavily tested.
- Therapeutic level: 10–20 mcg/mL.
- Toxicity signs: nausea, vomiting, and restlessness early → tachycardia and other dysrhythmias, and seizures at higher levels.
- Caffeine is also a methylxanthine — it adds to the effect, so clients should avoid caffeine.
- Smoking increases metabolism and lowers blood levels; many drugs interact with it.
Therapeutic range is 10–20 mcg/mL — a narrow window. Teach clients to report nausea, vomiting, restlessness, or a racing heartbeat (early toxicity) and to avoid caffeine. Levels are drawn and monitored regularly.
Mucolytics & Expectorants
Thin and clear secretions — and one drug pulls double duty as an antidote.
- Guaifenesin (Mucinex, Robitussin)expectorant
- Thins and loosens secretions so they can be coughed up. Teach: increase fluid intake to help thin mucus.
- Acetylcysteine (Mucomyst, Acetadote)mucolytic
- Breaks down thick mucus (e.g., cystic fibrosis). Smells like rotten eggs (sulfur). Also the antidote for acetaminophen overdose.
Acetylcysteine is both a mucolytic (loosens thick mucus) AND the antidote for acetaminophen (Tylenol) overdose. The rotten-egg / sulfur smell is expected — warn the client so they aren't alarmed.
Antihistamines, Decongestants & Antitussives
Allergy and cold/cough drugs — know sedating vs non-sedating, and the blood-pressure caution.
Antihistamines
- 1st generationdiphenhydramine (Benadryl), hydroxyzine
- Sedating; anticholinergic effects (dry mouth, urinary retention). Caution in older adults, glaucoma, and BPH.
- 2nd generationloratadine (Claritin), cetirizine (Zyrtec), fexofenadine (Allegra)
- Non-sedating; preferred for daytime allergy control.
Decongestants
- Pseudoephedrine (Sudafed), phenylephrine: cause vasoconstriction → raise blood pressure and heart rate. Use cautiously or avoid in hypertension, heart disease, and hyperthyroidism.
- Topical (oxymetazoline / Afrin): using it longer than 3 days causes rebound congestion.
Antitussives (cough suppressants)
- Dextromethorphan (OTC) and codeine (opioid) suppress a dry, nonproductive cough. Do not suppress a productive cough that is clearing secretions.
Pseudoephedrine and phenylephrine raise blood pressure and heart rate — a real concern for clients with hypertension or heart disease. And teach that topical nasal sprays (oxymetazoline) cause rebound congestion if used more than 3 days, which makes the stuffiness worse.
Inhaler Use & Key Teaching
The how-to points that show up as "which statement indicates understanding" questions.
Order of Inhalers
When a bronchodilator and an inhaled steroid are both ordered, use the bronchodilator (albuterol) first, wait about 5 minutes, then use the steroid. The bronchodilator opens the airways so the steroid reaches deeper.
Metered-Dose Inhaler (MDI)
- Shake well, exhale fully, seal lips, press the canister while inhaling slowly and deeply, then hold the breath about 10 seconds.
- Wait about 1 minute between puffs. Use a spacer for better delivery and fewer side effects.
- Rinse the mouth after a steroid inhaler.
Dry-Powder Inhaler (DPI)
- Inhale quickly and forcefully; do NOT shake; keep it dry; do not exhale into the device.
Peak Flow Meter (asthma control)
- Green zone (80–100% of personal best)
- Good control — continue.
- Yellow zone (50–80%)
- Caution — use the rescue inhaler and follow the action plan.
- Red zone (below 50%)
- Medical alert — use the rescue inhaler and seek help.
1) Bronchodilator before steroid (open the airways first). 2) Rinse and spit after any inhaled steroid (prevent thrush). 3) Use a spacer with an MDI. These three account for most inhaler "which statement shows understanding" questions.
? A client with asthma uses both albuterol and fluticasone inhalers. Which should be used first and why?
Frequently Asked Questions
Common student questions on this topic.
What is the difference between a rescue inhaler and a maintenance (controller) inhaler?
Why do I have to rinse my mouth after using an inhaled corticosteroid?
If a client uses two inhalers, which one should be used first?
Why can't a long-acting beta-2 agonist like salmeterol be used alone for asthma?
What are the signs of theophylline toxicity?
Are decongestants safe for a client with high blood pressure?
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Respiratory Medications Cheatsheet
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