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Excessive use of blue inhalers strongly associated with severe asthma attacks

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The Asthma and Allergy Association (AAA) warns about over-reliance on the blue inhaler to treat asthma without accompanying preventor therapy.

According to MoH’s National Health Survey 2010, asthma is a chronic inflammatory airway disease that affects approximately 5% and 20% of adults and children, respectively in Singapore.

Asthma mortality rates in Singapore have dropped from 5 to 1.2 per 100,000 of total population over the last 30 years, as preventor therapy become widely used. However, asthma-related emergency department visits and hospitalizations are 2 to 3 times higher than other developed countries. This statistic seems to be linked to the situation where people with asthma still rely excessively on their blue inhalers for temporary symptom relief.

Since 2019, the Global Initiative of Asthma (GINA) stated that ‘using the blue inhaler alone is no longer recommended even in mild asthma patients above the age of 12 years old’. Apparently, the blue inhaler can worsen airway inflammation when used alone without preventor therapy.

According to the National Review of Asthma Deaths in the UK, excessive use of the inhalers has been strongly associated with severe asthma attacks (three or more cannisters a year), and life-threatening attacks resulting in deaths (one or more canister a month).

As shared by AAA, in the primary care sector, a SNAP-supported audit led by Dr David Tan, Family Physician and Senior Consultant, at National University Polyclinics (NUP) found that 45% of patients who were treated at NUP for severe asthma attacks were using their blue inhaler excessively. They also found that 40% of these patients had recurrent severe attacks (defined as 2 attacks within a 12-month period) requiring high-dose systemic corticosteroids and emergency nebulization.

“To use an analogy, the preventor is like a fire extinguisher that puts out the airway inflammation. The blue inhaler is only blowing cool air so you might feel less heat temporarily. Worse, if you continue to just take the blue inhaler alone, the fire gets bigger and that is when you get a severe asthma attack.”

Dr Lim Hui Fang, and Senior Consultant, Division of Respiratory & Critical Care Medicine, National University Hospital and Director of SNAP commenting about how patients remain reliant on the blue inhaler because they mistake rapid relief for adequate control.

To empower patients with user-friendly tips and tools, AAA, SNAP and the NUHS are launching the Beat the Asthma Blues Campaign to raise awareness of effective asthma management. Activities include a call to action for the public to share about asthma management tips along with the hashtag #beattheasthmablues and also a call for anyone to nominate their Asthma Hero, Champion, Idol. These can be stories of people with asthma who inspired others to live life to the fullest, perhaps by “…achieving great things or overcame their asthma in little ways every day”. More information is available on AAA’s website here.

References provided by AAA:

  1. Epidemiology & Disease Control Division MoH, Singapore. National Health Survey 2010.
  2. Chong PN, Tan NC, Lim TK. Impact of the Singapore National Asthma Program (SNAP) on preventor-reliever prescription ratio in polyclinics. Ann Acad Med Singapore 2008; 37:114-7.
  3. Institute for Health Metrics and Evaluation (
  4. OECD Health Statistics 2015, Accessed 1 Jun 2019.
  5. Thompson PJ, Salvi S, Lin J, Cho YJ, Eng P, Abdul Manap R, et al. Insights, attitudes and perceptions about asthma and its treatment: findings from a multinational survey of patients from 8 Asia-Pacific countries and Hong Kong. Respirology 2013; 18:957-67.
  6. Global Initiative for Asthma (GINA): Global strategy for asthma management and prevention. Update 2020 and online appendix. Available at Access 30 Apr 2020.
  7. Ameredes BT, Calhoun WJ. (R)-albuterol for asthma: pro [a.k.a. (S)-albuterol for asthma: con]. Am J Respir Crit Care Med 2006; 174:965-9; discussion 72-4.
  8. Dusser D, Montani D, Chanez P, de Blic J, Delacourt C, Deschildre A, et al. Mild asthma: an expert review on epidemiology, clinical characteristics and treatment recommendations. Allergy 2007; 62:591-604.
  9. Levy ML, Andrews R, Buckingham R, Evans H, Francis C, R H. Confidential Enquiry report. London: Royal College of Physicians; 2014. Why asthma still kills: The National Review of Asthma Deaths (NRAD) 2014.
  10. Yii ACA, Tay T-R, Puah SH, Lim H-F, Li A, Lau P, et al. Blood eosinophil count correlates with severity of respiratory failure in life-threatening asthma and predicts risk of subsequent exacerbations. Clinical & Experimental Allergy; 0.



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