All asthma inhalers are not created equal, and doctors say the difference can be deadly.

The death last month of Sascha Franzel, a Colorado State University junior from Hawaii, should be a warning to asthma sufferers not to rely solely on "rescue inhalers," which become ineffective after frequent use, Hawaii doctors warn.

"She was using the rescue inhaler very frequently, more than what’s recommended," said Dr. Jeff Yim, chief of the pulmonary division at the Queen’s Medical Center. "That’s always a red flag you need to get treatment.

"There are a lot of deaths like hers. They find them dead with their rescue inhalers in their hands. They think they can get by with just the rescue inhalers."

More than 4,000 people die from asthma in the United States annually, sometimes because they’re not using enough of the asthma controller medication that prevents airway inflammation that leads to blocked airways, said Dr. Matthew Lau, an allergy/immunology specialist with Kaiser Permanente Hawaii.

The Hawaii Health Data Warehouse reports that between 19 and 30 people died from asthma per year in Hawaii from 2005 to 2009, an average of 22.8 deaths per year, the latest Department of Health data show.

Lau emphasizes there are two classes of inhalers: the rescue inhaler and asthma controllers.

Asthma controllers are used regularly and for a long time, and also often come in an inhaler form. They include Qvar, Flovent and Asmanex.

These are not to be confused with rescue inhalers, which often contain albuterol under such names as Ventolin, Proventolin and Proair.

Lau said those who are confused as to what they are being prescribed should check with their doctors.

He urges patients who are using the rescue inhalers more than twice a day to see a doctor.

But other doctors say even that is too frequently.

Yim says someone using a rescue inhaler two to three times a week needs to go on long-term medication or step up their long-term medication.

An asthma attack can come on within minutes and can become near fatal rapidly, but most patients gradually worsen within a day or two, and this varies with each individual, Yim said.

Education is key to controlling asthma, Yim said.

"Asthma is becoming more and more prevalent, and the people who are well-controlled do fine. They can live a normal life. Those not using the medication properly or who don’t want to use the medication run into the problems."

Franzel, a 19-year-old Mid-Pacific Institute graduate known for her compassion and for helping others, died Sept. 9 in Colorado. The Larimer County coroner found her death was due to asthma and albuterol intoxication.

Albuterol, the active ingredient in her inhaler, opens up the air passages to the lungs to make breathing easier.

Franzel’s friends noticed she used her inhaler a lot at a party she attended that night. She returned to her dorm room, where she died at her desk, her mother said, adding her roommates tried to revive her, but it was too late.

"Looking at her tragic story, the problem was she was having increasing or sudden asthma symptoms that maybe she was not using any preventive medication for … just relying on rescue inhalers," Lau said.

Some asthmatics deliberately avoid their medicine, doctors say.

"With kids, it’s tough because they don’t want to be perceived differently," Yim said. "They wait till the last minute" to use their rescue inhalers.

Many adults, on the other hand, don’t want to rely on their long-term asthma controllers for fear of becoming addicted.

Some think, "I’m doing well, why do I need to take it?" which could exacerbate a problem and lead to death, Yim said.

"If you’re self-medicating, you may not be doing it properly," Yim said. "It’s always good to work with a doctor. A lot of times we’ll step down to a lower dose as opposed to stopping it completely."

Rescue inhalers made with chlorofluorocarbons (CFCs) as a propellant were phased out in 2008 and replaced by eco-friendly hydrofluoroalkane (HFA) propellants.

There is a campaign to legalize CFC-propelled inhalers even though CFCs were found to be harmful to the Earth’s protective ozone layer.

Yim said a lot of patients complain they feel like they’re not getting the medication with the HFAs compared with the CFCs, which give a strong blast when they take the medication. "I try to educate them that they are not going to feel it as a strong blast in the back of their throat. They’re still getting the same amount of medicine."

Lau said the devices should be kept clean to avoid clogging.

He also advises asthma sufferers to avoid tobacco smoke, get a yearly flu shot and work with a doctor to find what their allergic triggers are.

He also recommends visiting a website — www.asthmacontrol.com — to take a five-question test to see whether one’s asthma symptoms require them to see a doctor.