Blue Inhaler Alone Insufficient for Asthma Control

Inhalers have been key to asthma management since the 1950s . The most common, salbutamol, comes in a familiar blue-coloured inhaler (or "puffer").

This kind of "rescue inhaler" brings quick relief from asthma symptoms. You may know these inhalers by their brand names such as Ventolin, Asmol or Zempreon.

But there is growing evidence that using this kind of inhaler without treating the underlying condition may not only be ineffective - it could actually increase the risk of an asthma attack.

Next month, the National Asthma Council is releasing updated guidelines that reflect this shift. Here's what's changing and what you need to know.

What is a bronchodilator?

Bronchodilators such as salbutamol act by relaxing smooth muscle in the airways. While they don't address inflammation, which is the key cause of asthma , bronchodilators are effective at quickly opening up constricted airways.

This means for people experiencing typical asthma symptoms - such as tightness of the chest and shortness of breath - a puff of salbutamol brings relief within ten minutes. The effect can last up to six hours.

Salbutamol is used by people with asthma and other respiratory conditions, such as chronic obstructive pulmonary disease (which includes chronic bronchitis and/or emphysema). As part of a management plan made with a doctor, salbutamol is used to relieve shortness of breath when it occurs.

In Australia, more than 60% of salbutamol is purchased over the counter (without a prescription) in pharmacies. Many of these purchases may be for people with infrequent asthma symptoms, meaning less than twice a month.

However, we now know there are safer and more effective ways for people with infrequent asthma to manage it in the long term.

So, what's wrong with using salbutamol?

Treating symptoms is only one part of asthma management. Salbutamol doesn't address the root cause - why the airways of people who get asthma become constricted in the first place.

It's a bit like taking pain relief for a swollen elbow without treating the tendonitis causing the pain.

In asthma, chronic inflammation is usually a result of genes and environment interacting .

Some people have airways that overreact to triggers in the environment. These triggers include pollens, moulds and dust mites, or air that is cold or humid.

Over the long term, chronic inflammation can lead to changes in the airways. The airway walls become thicker and produce more mucus, allowing less space for air to flow through them.

Using short-acting treatments such as salbutamol without addressing chronic inflammation in the airways poses risks.

Salbutamol can become less effective with regular use. This means people with shortness of breath don't gain the relief they expect and need, and paradoxically, their airways may become more "twitchy" (sensitive to environmental triggers) and inflamed. One response to this is people use more salbutamol and the problem is compounded.

Strong data links increased use of short-term inhalers such as salbutamol to higher risk of asthma flare-ups, hospital admissions and even death.

Purchasing three or more salbutamol inhalers per year is considered overuse .

According to asthma guidelines in Australia and globally , needing salbutamol for symptom relief on more than two days a week is an indicator of poorly controlled asthma, requiring review and possibly anti-inflammatory treatment.

What do the new guidelines recommend?

In 2019, the Global Initiative for Asthma, an independent not-for-profit organisation, radically changed its recommendations for salbutamol use. This is based on its committee of asthma experts reviewing the evidence.

Australian asthma guidelines from the National Asthma Council are set to follow suit.

The council's 2025 Australian Asthma Handbook now states that salbutamol alone is inadequate treatment for asthma in adults or adolescents.

Previously, the guidelines recommended people with infrequent symptoms to use salbutamol when needed and "alone" - that is, without an anti-inflammatory preventer.

The new recommendations specifically warn against anyone with asthma using a short-acting bronchodilator such as salbutamol by itself, due to the increased health risks mentioned above.

People with asthma who use salbutamol, for example, should also use an anti-inflammatory treatment that provides preventive cover, such as an inhaled corticosteroid.

The 2025 Australian Asthma Handbook now recommends anti-inflammatory relievers from day one when it comes to asthma treatment in adults and adolescents.

These inhalers contain, in a single dose (one puff), both a bronchodilator (to relieve symptoms) and a low-dose anti-inflammatory corticosteroid (to treat underlying inflammation).

They are recommended instead of salbutamol-only inhalers for symptom relief, even for those whose symptoms are infrequent.

When used in place of salbutamol-only inhalers, anti-inflammatory relievers have demonstrated improvements in quality of life for people with asthma, as well as lower risks of hospitalisations and death.

In the case of children with asthma, global guidelines emphasise the use of anti-inflammatory inhalers and discourage over-reliance on bronchodilators.

Will I need to change my inhaler?

Currently, combination anti-inflammatory relievers are only available with a prescription from a doctor. These prescriptions with repeats can allow people with asthma up to 12 months of treatment.

In Australia you can still buy salbutamol in a pharmacy without a prescription, after consultation with a pharmacist.

However, if you have asthma and you're concerned about the new guidance, you should speak to your pharmacist or doctor for advice.

Stephen Hughes receives research grant funding from the Australian Government Department of Health and Aged Care Medical Research Future Fund, The Australian Research Council and Asthma Australia. He is a past Board Member of the National Asthma Council of Australia and current member of its Finance and Risk Management Committee.

Bandana Saini has received funding from 1) Australian Government Department of Health Initiatives (via MRFFs or Community Pharmacy Agreement based investigator initiated grants, 2) National Health and Medical Research Council or from 3) organisations such as Asthma Australia.