Steroid Inhalers for Asthma Can Cause Fungal Laryngitis

It is a big bummer to be an asthmatic. Not only is breathing a problem, but even the treatment for asthma can cause problems.

Take for example steroid inhalers like advair, symbicort, fluticasone, etc.

All asthma patients know to rinse their mouth out after inhaler use due to risk of oral thrush, but what about from the back of the mouth down to the vocal cords??? This nether region can’t be gargled very easily. One can swallow water to rinse this area out, but the vocal cord region would still not be addressed (otherwise aspiration would occur).

And that leads to potential vocal problems… like fungal laryngitis (or thrush of the voicebox). Here’s a picture of what that looks like. To compare, normal is shown in the smaller picture.

Note the white patches indicative of fungal growth. This fungal infection can lead to symptoms of a mild (if any) sore throat, but most patients complain of hoarseness as their only symptom.

Treatment is ideally to stop the steroid inhaler triggering the infection, but if an asthmatic needs it… than they need it. As I often tell patients, breathing is more important than voice. Often, anti-fungal medications like diflucan and nystatin can eliminate the fungal laryngitis, but problem is, as long as steroid inhalers are used, it comes right back. And repetitive anti-fungal treatment can place the patient at risk for a drug-resistant fungal infection.

So what to do???

There is one type of little-known (unpleasant) treatment an asthmatic patient can perform to minimize risk of fungal laryngitis while still maintaining steroid inhaler use.

It’s called laryngeal washes and it takes a lot of time, patience, and period of discomfort. Think of it as gargling of the voicebox.

The patient takes a curved luer-lock cannula (picture shown) attached to a syringe filled with salt-water. While opening the mouth and sticking the tongue out, the curved end of the cannula is directed such that the end is pointed straight down into the throat. After taking a deep breath in, while saying “ah”, salt-water is dripped down into the throat thereby “gargling” the voicebox. Coughing may be inevitable after performing.

This needs to be done after every steroid inhaler use. Or during an active fungal infection, at least 4 times per day.

Gagging is the biggest problem preventing correct usage of this technique. Coordinating the injection while saying “ah” is another issue since if it is incorrectly performed, can lead to aspiration and severe coughing. As such, it is not for everyone.

One can purchase such “luer-lock laryngeal cannulas” from any ENT medical supply company.

Using Inhalers Correctly

A few years ago, we had a neighbor kid with asthma that regularly played with our kids. One day, he had an asthma attack at our house and mom, a nurse, gave him his inhaler. He took a puff from the inhaler and continued to hyperventilate without a pause, which doesn’t give the medication time to work.

Fast acting inhalers use a liquid and propel the medicine under pressure

© Getty Images

At least he was using the correct type of inhaler, a fast-acting bronchodilater. Some patients have a hard time keeping the different kinds of inhalers straight and wrongly use long-term steroid inhalers for asthma attacks. This little guy probably should have used a spacer for his inhaler as well, which would have mixed the medication in the air better before he inhaled it.

A study presented at CHEST 2007 — a conference of the American College of Chest Physicians — shows how often asthma and COPD patients screw-up their inhalers, at least the daily long-term kind. According to the authors from the University of Heidelberg in Germany, one third of asthma and COPD patients incorrectly used their dry-powder inhalers. In most cases, the patients didn’t correctly inhale all the medication powder for one reason or another.

Using a spacer with an inhaler helps distribute the medicine properly

© David McNew/Getty Images

The researchers tested four different types of dry powder inhalers: Aerolizer, Diskus, HandiHaler, and Turbuhaler. The most errors occurred with patients using the HandiHaler; more than half got it wrong with this device. With all the devices it helped if patients were taught how to use them correctly, reducing overall mistakes by half.

The big difference between fast-acting inhalers that contain liquid and these dry powder inhalers is the way the medication is propelled out of the device. With typical fast-acting inhalers, the medication is squirted out under pressure. On the other hand, dry powder medications have to be sucked out by the patient, which is really difficult when you’re having shortness of breath.

Anything that interfere’s with a patient’s ability to inhale can create more problems when trying to use the dry powder inhalers. Those over 60 years old had twice as much trouble and people with impaired breathing were three times more likely to make mistakes using dry powder inhalers.

If you’re using a dry powder inhaler for your asthma or COPD, check with your doctor if you don’t think the medication is working well. The problem may be the inhaler rather than the medication itself. Whether your medication is working for you or not, check with your doctor to make sure you’re using it correctly. Two minutes getting educated may help you breathe a lot easier.