Ventolin plus Inhaled Meds Delivery System

[Matman]

I'll start this Post with a nod of acknowledgement to EmmaF91 who touched on Ventolin Dosage in one of her recent Posts. This topic is such an important one I wanted to further highlight and elaborate on it.

Earlier this year I was surprised (having taken the precaution of visiting my local hospital as a result of a serious exacerbation) over the 'amount' of Ventolin I was encouraged to use to cope with my serious asthma attack. (I was also Nebulised, but that's not really relevant to the point I'm trying to make).

Here's the thing. Although I've had Asthma since childhood, no one had previously pointed out - until it got worse a couple of years ago - that, during a bad attack, I could take as much as 10 consecutive Puffs of Ventolin, preferably at one minute intervals (but all at once, via a spacer, if I preferred).

What really surprised me during my Hospital Visit, however, was that, although I dutifully reported I'd already had 10 Puffs in the last few hours, I was encouraged to take a further 10 Puffs. (I actually ended up having 26 Puffs within an 18 Hour Period).

The 'relevance' of this is that I'd been 'conditioned' (for years) either by myself or the absence of advice to the contrary, so that - to my mind - if I'd taken half a dozen Puffs of Ventolin over the course of a 'rough day', I wouldn't risk taking any more, in case I overdosed and did myself some serious damage.

I hope, therefore, it's useful (while advocating minimum use of Ventolin) to demonstrate from my Hospital Visit Experience that - for many (if not all) Asthmatics - the risk of overdosing on Ventolin during a 'Serious' Attack, is probably less than the dangers of 'under-medicating', especially when you factor in 'not only' the 'immediate' danger of a 'Serious' Asthma Attack, but also the long-term damage that under-treatment during 'severe' exacerbations may do to the lungs. (Minimising Long Term Lung Damage resulting from each 'Serious' Exacerbation is also an argument for 'not' delaying Oral Steroid Treatment, assuming you're one of those Patients that Steroids are able to help).

Regarding Inhaled Meds 'Delivery Methods' - especially when a 'severe' attack occurs - a Spacer is a great device to keep handy, even if you don't usually bother using it for Ventolin Dosing during 'mild' exacerbations. Getting Inhaled Drugs into your Lungs when you're 'seriously struggling to breath' can be quite a challenge. A typical MDI Device (such as Ventolin Inhaler) often fails to properly deliver - or effectively distribute - Dosage. This is most often due to a 'large' percentage of Users (including those who have been prescribed such devices for years) still - unknowingly - failing to use their Inhaler correctly on many occasions. Good Inhaler Technique is probably further compromised during a 'serious' attack when an Asthmatic is anxious, panicking, or attempting to 'dose' a child or someone unable to 'dose' themself.

Concerning Powder Inhalers, one of the issues with these devices is that they typically require the strength of your 'draw-of-breath' to inhale the Powder. A serious exacerbation can reduced what 'suction' you can muster, thereby adding to difficulties and increasing anxiety if the 'serious attack' warrants not only Ventolin, but also 'dosing' with any 'Powder' Inhaler you might also be using.

There are good points about Powder Inhalers, e.g. Better Airway Distribution, apparently, plus (possibly) reduced risk of inhaling bacteria that's bred inside your Spacer if you've failed to rinse it after use, or not cleaned it thoroughly enough (perhaps missing the area around / beneath a rubber seal).

Hope this helps someone.

Footnote:

I've had incidents where Ventolin seemed to deliver little relief during an Attack, but 'additional' Fostair provided some 'much appreciated' assistance. I'm no Medic, so please don't try this yourself unless you've checked with your GP first.

[EmmaF91 Community Ambassador]

😇💁‍♀️😂

See I was at the opposite end. I was never told a limit, so would happily take 30+ a day without seeking help!

I know I got told at the start that I could take up to 10 in one go, but didn’t get told that I needed to see someone if I did that, nor how long it should last (4+hrs), so might take 10 every hour! I still don’t have a ‘max’ but I’m aware when I start getting side effects (anxiety, tachy, palpitations, shakes) that I’m probably overdoing it so should see someone 😅. I should point out that I’m already on steroids when I’m like this - try not to do what I do!!!!

Yes the minimal amount for the maximum improvement is important! The spacer not only makes it easier to coordinate getting the drug into your lungs, it also makes you up to 70% more efficient at absorbing it (I think - long time since I had a convo about it). It’s cause if it goes straight into your mouth, more of it hits and sticks to your tongue and throat first (hence why you occasionally get that odd taste/feel after a puff if you angle it slightly wrong!

I’m one that prefers DPI but I always insist on getting my vent in both MDI and DPI forms, as I know when I’m bad I can’t use my DPI!

I hope you’re feeling better now, and not so paranoid about avoiding the pump if you need it! I always think that if the side effects are minimal, but the benefits are massive (and potentially life saving) it’s better to have too much, than too little!!! Look after yourself! X

[Matman in reply to EmmaF91]

Thanks for Commenting. Guess having a DPI plus MDI is a sensible tactic for some folk prone to severe exacerbations - and no more of an issue for the NHS than issuing just one Device as, eventually, both will get used-up.

[Lysistrata Administrator Community Ambassador]

This is a really good point to make Matman! I often see people on here who have never been told that the 'no more than 2 puffs 4x a day' is about CONTROL not really side effects/the danger of taking more. I've even seen people posting who have been led to believe the inhaler is like an epipen - only for emergencies not everyday symptoms, and have struggled on without it when they really need it!

I take more than that most days (don't follow my example anyone, I already know my lungs are crap at the moment and I can't reduce that) and while I can be tachycardic etc, I'm much more so if my asthma is playing up!

If you take/need more puffs than that in a day you certainly need to see someone but not because of 'overdosing' but because it implies asthma is out of control.

I personally use a spacer all the time because it's easier and I'm getting more in with fewer side effects. The large volume at home and the small volume for my handbag. I personally like to use the tidal breathing method as it's easier and especially when I'm struggling more. nnuh.nhs.uk/publication/usi...

Btw I'm sure many people have heard that '10 puffs through a spacer is as good as a nebuliser'. If you are frequently in a position to need either you've probably felt this is not true - I know I have - and also wondered in that case why the hospital is using nebs. I tend to reach a point in attacks (anyone else, do not do this please, I'm already aware I have bad habits!) where I have taken loads of Ventolin through a large spacer with tidal breathing and it is NOT WORKING, but a neb will start to shift things (sometimes needs several).

I challenged an AUK nurse on this and she said well yes if you are really struggling even tidal breathing is hard. I also once asked a nurse on the respiratory ward. She had a friend who was a nurse working on inhalation devices, who had said for everyday meds a spacer is best (assuming it's that type of device) - inhaled steroids via a neb for example are not considered the best way to dose for most people, though I know there might be individual exceptions. However, she said that if you are in hospital or having an attack and struggling, the nebuliser is easier because it is passive. It may waste medication but it gets it in without adding extra effort to someone who is struggling to breathe and can't really efficiently inhale.

[Matman in reply to Lysistrata]

Appreciate your Comment. Good point about the Nebs and yet another argument for maybe having a home nebuliser on stand-by, providing the Asthmatic is willing to pay for the device and the GP's happy to offer the drugs to load it with. (Maybe some Patients can get a Home Nebuliser via the NHS (including, maybe, those on Income Support who can justify asking for one).

[Lysistrata Administrator Community Ambassador in reply to Matman]

The willingness to prescribe the nebules is the key sticking point here! Many doctors don't feel it's safe because people may falsely rely on that and wait too long - at some point those don't help either and then you need to be in hospital, so only suitable for some with a strict plan.

I have been told a couple of times by specialist nurses that I could benefit from home nebs given I have frequent episodes which aren't quite hospital worthy (for me - it would be different for someone normally well controlled) but which the inhaler struggles to control. Suspect this will not happen any time soon though, as my consultant is one who dislikes it.

[Matman in reply to Lysistrata]

Wasn’t aware of the underlying argument you reference for ‘not’ prescribing Nodules. Useful to know. Thanks.

[EmmaF91 Community Ambassador in reply to Matman]

A lot of consultants/resp specialist are anti home nebs unless it’s your maintenance treatment, cause of the risk of patient abuse that Lysistrata said (ie avoiding further help, til it’s too late). I have one which my GP and hosp asthma nurses encouraged me to get (and a couple of hosp docs but not my consultant!) cause I was needing a neb or more a week at the GP plus hosp trips on top (I was very uncontrolled at the time).

Once my consultant found out I was getting one, he really didn’t like it but gave me rules so I only used it in emergency ie contact GP after 1, if need 2 in a day (esp back to back) go to hosp. And I have stuck to these rules, minus the times hosp docs have abused it ie you have a home neb so you can just do this at home (including from the same consultant 🙄)

That’s the difference cause mine for ‘emergencies’ not maintenance. Once you’re on maintenance nebs 1) you’re pretty severe and 2) you have very limited options left open to you. Cause I can be absolutely asymptomatic, my resp specialist hosp don’t want me to have one as I could potential avoid seeking further help if I ignored the rules and other docs can (and have) told me to ‘switch’ to maintenance nebs 🙄.

So theoretically it’s not hard getting nebules with your GPs support, but you’ll have an arguement in you hands regarding your consultant!

[Matman in reply to EmmaF91]

Thanks Emma, have noted.