Inhaled Corticosteroids: Overview and Practice Questions

Inhaled corticosteroids are essential for treating various respiratory conditions, offering powerful anti-inflammatory effects directly to the lungs. They help manage chronic respiratory diseases like asthma and chronic obstructive pulmonary disease (COPD) by reducing airway inflammation, swelling, and mucus buildup.

For millions of individuals worldwide, inhaled corticosteroids provide long-term control of symptoms, minimizing the risk of flare-ups and improving overall lung function.

This article explores how inhaled corticosteroids work, their benefits, potential side effects, and key considerations for effective use.

What are Inhaled Corticosteroids?

Inhaled corticosteroids are medications used to reduce inflammation in the airways, making them essential for managing respiratory conditions like asthma and chronic obstructive pulmonary disease (COPD). They work by suppressing the immune response that causes swelling and mucus production, helping to open airways and improve breathing.

Common inhaled corticosteroid medications include budesonide, fluticasone, and beclomethasone. They are typically administered through inhalers or nebulizers, delivering the medicine directly to the lungs with minimal systemic side effects.

Regular use helps prevent asthma attacks and control chronic symptoms, though they are not suitable for immediate relief during acute breathing emergencies.

Side Effects

While inhaled corticosteroids are generally safe and well-tolerated, some patients may experience side effects due to the medication’s localized action in the respiratory tract.

Common side effects include:

• Cough: Often triggered by inhaler irritation or improper inhaler technique.
• Sore Throat: Due to medication residue irritating the throat lining.
• Hoarseness or Difficulty Speaking: Caused by vocal cord irritation.
• Bronchoconstriction: A paradoxical reaction where the airways temporarily narrow after inhalation.
• Oral Fungal Infections (Thrush): A yeast infection in the mouth caused by residual medication, especially with improper inhaler use.

To minimize side effects, patients are advised to use a spacer device with MDIs, rinse their mouths after inhaler use, and maintain proper inhaler technique.

Inhaled corticosteroids should not be used for acute asthma attacks or COPD exacerbations, as they are intended for long-term inflammation control rather than immediate symptom relief. Regular consultations with healthcare providers ensure safe and effective treatment management.

Types of Inhaled Corticosteroids

Inhaled corticosteroids come in various formulations tailored for managing respiratory conditions like asthma and chronic obstructive pulmonary disease (COPD).

These medications are typically delivered through metered-dose inhalers (MDIs), dry powder inhalers (DPIs), or nebulizers, depending on the patient’s needs and severity of their condition.

Some of the most commonly prescribed ICS include:

• Budesonide (Pulmicort): Often used with nebulizers, especially in pediatric asthma management.
• Beclomethasone (QVAR): Known for its effectiveness in controlling persistent asthma symptoms.
• Fluticasone Propionate (Flovent): A widely used inhaler offering various dosing options.
• Ciclesonide (Alvesco): A prodrug activated in the lungs, reducing systemic side effects.
• Flunisolide Hemihydrate (AeroSpan): Offers built-in spacers for easier administration.
• Fluticasone Furoate (Arnuity Ellipta): A long-acting formulation for once-daily use.
• Mometasone Furoate (Asmanex): Effective in reducing airway inflammation with once- or twice-daily dosing.

Note: The appropriate type, dosage, and administration frequency depend on the patient’s specific respiratory condition, age, and treatment goals as determined by their healthcare provider.

Mouth Rinsing After the Use of Inhaled Corticosteroids

Mouth rinsing after using inhaled corticosteroids is an essential practice to reduce the risk of side effects such as oral thrush (a fungal infection) and sore throat.

After inhaling the medication, patients should rinse their mouths thoroughly with water and spit it out—without swallowing. This helps remove any residual corticosteroid particles that may settle in the mouth or throat, where they could cause irritation or infection.

Using a spacer device with metered-dose inhalers further minimizes medication deposition in the mouth, enhancing drug delivery to the lungs. Consistent mouth rinsing supports better oral health while ensuring effective respiratory treatment.

Inhaled Corticosteroid Practice Questions

1. What are corticosteroids used for?  
Corticosteroids are used for the maintenance and control of chronic asthma by reducing airway inflammation.

2. What other disease are corticosteroid drugs used to treat?  
Chronic obstructive pulmonary disease (COPD)

3. What are intranasal aerosol agents used for?  
They are used to treat seasonal and perennial allergic/non-allergic rhinitis.

4. What are the three adrenal cortical hormones?  
Glucocorticosteroids, mineralocorticoids, and sex hormones.

5. What is the onset and peak for inhaled steroids used for maintenance?  
Onset: 12 hours; Peak effects: 24 hours.

6. What disease response shows an increased FEV1 greater than 12%?  
An asthmatic response indicates improved airflow.

7. An FEV1 of greater than what shows that an asthmatic episode is subsiding?  
Greater than 80% predicted.

8. How much energy is used in normal breathing?  
About 5% of total body energy.

9. When the hypothalamus and pituitary glands are inhibited, what is this known as?  
Hypothalamic-Pituitary-Adrenal (HPA) suppression or adrenal suppression.

10. What does endogenous mean?  
It means that the body produces it internally.

11. What is the diurnal steroid cycle also known as?  
The circadian rhythm.

12. What are three signs of inflammation?  
Redness, flare, and wheal.

13. What is alternate-day steroid therapy?  
It mimics the body’s natural diurnal rhythm by administering steroids early in the morning when tissue cortisol levels are naturally high.

14. What does increased vascular permeability cause?  
Leaky capillary syndrome, leading to fluid leakage into tissues.

15. What is it called when white cells emigrate through capillary walls (diapedesis) in response to attractant chemicals (chemotaxis)?  
Leukocytic infiltration

16. What is it known as when white cells and macrophages in the lungs ingest and process foreign material such as bacteria?  
Phagocytosis

17. What is a mediator cascade?  
The release of histamine and chemoattractant factors at the injury site, triggering an inflammatory response.

18. What are the most common diseases affected by airway inflammation?  
Chronic bronchitis and asthma.

19. Why are treatments with anti-inflammatory agents such as glucocorticoids important?  
They reduce airway hyperresponsiveness, inflammation, and the risk of acute obstructive episodes.

20. In asthma, what comes first: inflammation or bronchoconstriction?  
Inflammation occurs first, leading to bronchoconstriction.

21. What combination corticosteroids are most common?  
Fluticasone propionate/salmeterol (Advair).

22. What is a risk of intranasal corticosteroid use?  
An increased risk of infection due to immune suppression.

23. What are intranasal corticosteroids used for?  
They treat allergic or inflammatory nasal conditions, including seasonal and perennial allergic/nonallergic rhinitis.

24. What three effects do corticosteroids have on white blood cells (WBCs)?  
Demargination: Depletion of neutrophil stores reduces accumulation at inflammation sites; Increased WBC Count: Elevated white cell count due to reduced migration; and Microvascular Constriction: Reduces leakage of cells and fluids into inflammatory tissues.

25. What effects do steroids have on beta receptors?  
Steroids make beta receptors more responsive to beta-agonists, enhancing bronchodilation.

26. When are aerosol steroids used in asthma?  
Aerosol steroids are used during the early stages of asthma management or during acute severe asthma episodes.

27. When are aerosol steroids used in COPD?  
They are used to relieve symptoms, especially when there is little or no improvement in FEV1 with bronchodilators.

28. What does endogenous mean?  
Produced naturally within the body.

29. What does exogenous mean?  
Originating from outside the body and introduced into the body.

30. What are adrenal cortical hormones?  
Steroids secreted by the adrenal cortex, including glucocorticoids, mineralocorticoids, and androgens.

31. What is the correct pathway sequence for the hypothalamic-pituitary-adrenal (HPA) axis regulation of corticosteroid secretion?  
Stimulation of the hypothalamus > Release of Corticotropin-Releasing Factor (CRF) > Release of corticotropin (ACTH) > Secretion of glucocorticoids from the adrenal cortex.

32. What corticosteroids are delivered via oral inhalation?  
Ciclesonide (Alvesco) and Budesonide (Pulmicort).

33. What cells mediate inflammation in the airway?  
Eosinophils, neutrophils, and macrophages.

34. What is true regarding alternate-day steroid therapy?  
Alternate-day therapy mimics the natural diurnal rhythm by administering steroids early in the morning when tissue cortisol levels are naturally high.

35. What is a synthetic trifluorinated glucocorticoid with high topical anti-inflammatory potency?
Flunisolide (AeroSpan).

36. What should the respiratory therapist do prior to administering inhaled corticosteroid therapy?
Evaluate the patient’s pulse, respiratory rate, breathing pattern, and breath sounds through auscultation.

37. What is the site of secretion of epinephrine?  
The adrenal medulla.

38. What hormone regulates body water by increasing the amount of sodium reabsorption in the renal tubules?  
Mineralocorticoids, primarily aldosterone.

39. What side effects are seen in the systemic administration of corticosteroids?  
Hypertension, cataract formation, and immunosuppression.

40. What are corticosteroids normally secreted by?  
The adrenal cortex.

41. What are some clinical indicators for intranasal aerosol steroids?  
Seasonal and perennial allergies.

42. What is the description of corticosteroids?  
Corticosteroids are anti-inflammatory agents used to reduce inflammation in the airways and other tissues.

43. What occurs during an asthma attack?  
Bronchospasm, mucosal edema, and increased mucus secretion.

44. What drugs are found in fluticasone propionate and salmeterol?  
They are found in the combination drug Advair HFA.

45. What are general symptoms of inflammation?  
Redness, swelling, heat, and pain.

46. What are the major effector cells of the inflammatory response regardless of the type of asthma, allergic, or non-allergic?  
Mast cells and eosinophils.

47. What are the side effects of aerosol administration of corticosteroids?  
They typically cause minimal side effects due to localized action.

48. What minimizes local side effects associated with the use of inhaled corticosteroids?  
Using a spacer, rinsing the mouth after use, and administering the lowest effective dose.

49. What is recommended to avoid complicating side effects seen with systemic treatment with steroids?  
Switching to aerosol administration reduces systemic side effects.

50. What is caused by an early asthmatic response?  
Eosinophil activation and inflammation of the airways.

51. What are some common side effects of inhaled steroids?  
Oral thrush (candidiasis) and dysphonia (hoarseness).

52. What is Symbicort?  
A combination of budesonide and formoterol used as a maintenance treatment for asthma and COPD.

53. What is the indication if a drug such as flunisolide shows a peak plasma level quickly within 2 minutes?  
It indicates good absorption by the lungs.

54. What drugs are mometasone and formoterol found in?  
Dulera

55. What is one of the primary reasons for using aerosolized glucocorticoids?  
To minimize adrenal suppression by delivering the drug directly to the lungs.

56. What can be suggested to a patient with severe asthma who has been prescribed corticosteroids and wants to minimize side effects?  
Use inhaled corticosteroids, as they have fewer systemic side effects.

57. What is one advantage of using ciclesonide over other inhalation steroids?  
It reduces the risk of developing oral thrush (Candida albicans).

58. What is the best way to monitor changes in peak expiratory flow rate in a person with asthma taking inhaled steroids?  
Use a peak flow meter.

59. What is recommended to prevent the need to increase inhaled corticosteroid use in a person receiving a low dose?  
Add a long-acting beta-2 agonist (LABA).

60. What are the causes of airway inflammation?  
Direct trauma (gunshot, stabbing), indirect trauma (baseball bat, steering wheel), chronic bronchitis, asthma (allergic stimulation), and inhalation of toxic or noxious substances.

61. What are the major cells responsible for an inflammatory response in asthma?  
Mast cells and eosinophils (activated during the early phase of an asthmatic reaction within 15 minutes to 1 hour).

62. What is a significant side effect of corticosteroid use?  
Suppression of the Hypothalamic-Pituitary-Adrenal (HPA) axis.

63. What can long-term use of oral steroids cause?  
HPA suppression, leading to reduced natural steroid production.

64. Can patients with adrenal suppression be abruptly withdrawn from oral corticosteroids and placed on an aerosol dosage?  
No, oral steroids should be tapered off gradually while introducing aerosol corticosteroids.

65. What rhythm do the rise and fall of glucocorticoids in the body follow?  
A diurnal or circadian rhythm.

66. What is the problem if a patient has no signs of infection but has an elevated white blood cell (WBC) count?  
The patient is likely taking glucocorticoids, which can increase WBC count due to demargination.

67. What are the beneficial effects of glucocorticoids on β-adrenergic receptors?  
They restore β-adrenergic responsiveness by increasing receptor availability and affinity for β-agonists.

68. What can be suggested if a patient experiences chest tightness and wheezing four to six times a week while using albuterol MDI with relief?  
Consider adding a corticosteroid like beclomethasone MDI to reduce airway inflammation.

69. What are the primary inflammatory cells in COPD?  
Neutrophils

70. What are the common side effects of inhaled corticosteroids?  
Oropharyngeal fungal infections (oral thrush), dysphonia (hoarseness), and pharyngeal irritation.

71. What can be suggested if a patient using a corticosteroid MDI complains of oral thrush and hoarseness?  
Use an antistatic valve holding chamber/spacer and rinse the mouth after use.

72. What are the side effects of systemic steroid treatments?  
HPA axis suppression, psychiatric reactions, fluid retention, and increased WBC count.

73. What dosage forms of corticosteroids are available for use in the United States?  
Dry Powder Inhaler (DPI), Metered-Dose Inhaler (MDI), and nebulizer solutions.

74. What do glucocorticosteroids do medically?  
They reduce inflammation by inhibiting the migration, activation, and survival of inflammatory leukocytes, reducing edema, and impairing fibrosis and wound healing.

75. What is the upper limit for exhaled nasal nitric oxide (FeNO) in adults?  
35 parts per billion (ppb).

76. What is the generic name of QVAR?  
Beclomethasone dipropionate HFA.

77. What is the generic name of AeroSpan?  
Flunisolide hemihydrate HFA.

78. What is the generic name of Flovent HFA?  
Fluticasone propionate.

79. What is the generic name of Pulmicort?  
Budesonide.

80. What is the generic name for Asmanex HFA?  
Mometasone furoate.

81. What is the generic name of Advair HFA?  
Fluticasone propionate/salmeterol.

82. What is the generic name of Symbicort?  
Budesonide/formoterol fumarate HFA.

83. What is the generic name of Dulera?  
Mometasone furoate/formoterol fumarate HFA (a combination of an inhaled steroid and a bronchodilator).

84. What are the two most common inflammatory lung diseases?  
Asthma and chronic bronchitis.

85. What does inflammation produce?  
Redness: Local dilation of blood vessels, occurring within seconds; Flare: Reddish color several centimeters from the site, occurring 15-30 seconds after injury; and Wheal: Local swelling, occurring within minutes.

86. What are the causes of airway inflammation?  
Trauma: Direct (gunshot, stabbing) or indirect (baseball bat, steering wheel); Chronic Bronchitis: Respiratory and systemic infections; Asthma: Allergic stimulation; and Toxins: Inhalation of toxic or noxious substances.

87. What are the major cells responsible for an inflammatory response?  
Mast cells and eosinophils.

88. What is the early asthmatic response?  
The early phase of an asthmatic reaction occurs within 15 minutes to 1 hour.

89. What are the four symptoms that an asthmatic patient will exhibit in an acute state?  
Wheezing, breathlessness, chest tightness, and cough.

90. What does the adrenal cortex produce the three types of corticosteroid hormones?  
Glucocorticoids (Cortisol), Mineralocorticoids (Aldosterone), and Androgenic Corticosteroids (Testosterone and estrogen, responsible for secondary male sex characteristics).

91. What is the corticotropin-releasing factor (CRF) produced by?  
The hypothalamus.

92. What is caused by the long-term use of oral steroids?  
HPA suppression (Hypothalamic-Pituitary-Adrenal axis suppression).

93. What must be done for patients with adrenal suppression who cannot be abruptly withdrawn from oral corticosteroids?  
The aerosol should be started while the oral drug is tapered off gradually.

94. What do glucocorticoids exert?  
An anti-inflammatory effect in the body by suppressing immune responses and reducing inflammation.

95. What are the side effects of glucocorticoids?  
Muscle wasting and steroid-induced diabetes.

96. What is the primary reason for using aerosolized glucocorticoids instead of systemic ones?  
To minimize HPA suppression by delivering smaller, targeted doses.

97. How should an adrenally suppressed patient be withdrawn from oral corticosteroid treatment?  
The oral corticosteroid should be tapered off slowly while introducing aerosolized corticosteroids.

98. When are cortisol levels the highest?  
In the morning at around 8 AM (night shift work can interfere with this natural rhythm).

99. How do corticosteroids act?  
They prepare the body for starvation and dehydration by mobilizing energy stores into glucose and glycogen (glucocorticoids) and conserving water by reducing urine production (mineralocorticoids).

100. What should a patient always do after using an inhaled corticosteroid?  
Rinse their mouth and spit to prevent oral thrush (candidiasis).

Final Thoughts

Inhaled corticosteroids play a vital role in managing chronic respiratory conditions, offering relief from persistent symptoms and reducing the frequency of severe flare-ups.

When used consistently and as prescribed, they improve lung health and enhance the quality of life for individuals with asthma or COPD.

While they are generally well-tolerated, understanding potential side effects and following proper inhaler techniques can maximize their effectiveness. Consult your healthcare provider to determine if inhaled corticosteroids are the right choice for managing your respiratory health.