A note from DH: The first two medications you're on (Albuterol,
Pulmicort) can be compounded together for use in a nebulizer.  DH used
to work at a mail order pharmacy who, while he would never want to
work for them again, says that they are very, very good at what they
do.  They specialize in compounding for nebulizers.
www.bronchodose.com   FABNAYY (formerly affiliated but not anymore,
yadda, yadda)  :)

Elise
Gossamer & Jeeves

Sorry I haven't gotten back earlier -- I needed to check some references
on Spiriva.

Albuterol is a straightforward drug proven for breakthrough
bronchoconstriction (tight airways). Servent is of the same general
class, but has very different timing effectiveness than albuterol.  
Albuterol takes effect quickly, but its effects last only a few hours.
It's useful for breakthrough, in patients with mild asthma that only
need occasional help, and for periods of the day/events that you know
are especially hard on your breathing.

Serevent takes at least half an hour to take effect, but lasts for 12
hours or more. I cannot emphasize strongly enough that Serevent has NO
role in the treatment of an acute attack, but is helpful for long-term
coverage. There are contradictory reports of whether or not it has an
anti-inflammatory as well as a bronchodilating effect; the manufacturer
claims only the latter.

There are many corticosteroid drugs (or, more specifically,
glucocorticoid -- that is tha type of corticosteroid that affects
inflammation. There are other corticosteroid effects that can be a side
effect or the goal, depending on the condition). Pulmocort is one of
many corticosteroid inhalers. Inhalers mostly differ in the physical
inhalation mechanism -- some types work better for different people --
and the amount of drug delivered and the activity of that drug by weight.

One of the problems of corticosteroid treatment in general is getting
enough drug to the right place. For oral (e.g., prednisone) or injected
(e.g., methylprednisolone) therapy, you just give more pills or more
drug in the injection.  Preparations intended for use on the skin have
the toughest job of getting enough drug to the site, so you use the
corticosteroids that have the most potency per weight -- typically
fluorine-substituted drugs.  Things like injection into a joint also
call for the very high potency drugs.

For inhalers, the potency requirement is medium compared to dermatology,
but having different drugs and physical inhalers available, the
clinician can better tailor the dose to you.

On a prelimiary search on Spiriva, with which I wasn't familiar and
wasn't in the main drug data base I use, it seems a somewhat
controversial replacement for Atrovent. The major advantage is
once-a-day dosing. A 2003 FDA panel
(http://www.emphysema.net/newdrug.html), however, recommended against it
being licensed without more data. I haven't checked out the later
studies, since it obviously was licensed.

Both beta-adrenergic agonists (an agonist is the opposite of an
antagonist/inhibitor) and anticholinergics like Atrovent open clogged
passages, but by different mechanisms. Beta-adrenergic agonists tend to
work directly against the wall of the passage, where anticholinergics
more focus on drying secretions.  Anticholinergics are most proven in
chronic obstructive pulmonary disease, which is mostly in the lower part
of the lung. Beta-agonists work more in the upper lungs and the passages
leading to it.

By the best current standards, someone with moderate to severe asthma
should receive enough drugs to prevent symptoms. Symptom-preventing
drugs, which have no useful role in treating active symptoms, are the
antiinflammatories (corticosteroids, cromolyns, leukotriene inhibitors,
specialized immunosuppressants) and long-acting beta-agonists such as
salmeterol (Serevent).

A breakthrough episode is where the preventive drugs fail to prevent
symptoms developing, and you need things that directly act on the
symptoms of decreased airflow due to spasm and mucus. On an outpatient
basis, these are the fast-acting beta-agonist inhalers (e.g., albuterol)
and ipratropium bromide (Atrovent -- if it works for you). Theophylline
reduces symptoms, but not quickly -- it's more preventive than anything
else, and a fairly toxic drug anyway.

There were some reports today about safety concerns with Serevent. I
want to see more detail -- is there a true problem with the drug, or is
it that patients aren't being properly educated in its use?  Serevent
has no role in the treatment of active symptoms (breakthrough). There
have been reports for years of people found dead with a Serevent inhaler
in their hands, while they might have survived had they inhaled
albuterol. Barring any new safety revelations about Servent, it must be
realized that the drugs are complementary and do different things.