Hi everyone. Another infomercial for you all! Hopefully this will be relatively short (but you know me... they never are š ), and itāll definitely shorten my next post (add-ons from consultants)! So here we go...
Home nebs are almost always frowned upon by consultants (and definitely disapproved of by AUK without con/tertiary approval) and they should be given strict personal rules if they are prescribed for you (not just āhave at itā š ). If you have home nebs you should definitely be under a consultant, and probably (depending on usage) being referred to a tertiary centre. If you are not under consultant care, but have been prescribed/told to get a home neb, please speak to AUK, and also ask your GP for a referral!
Many things can be driven through nebulisers, so Iāll cover some of what an asthmatic may be told to do at home (and mention what other things may be used for other conditions, or other emergency situations). As always this is based in the UK!
SALINE NEBS
Often prescribed/suggested to help with mucus clearance for all sorts of resp conditions, like bronchiectasis and COPD. Saline can come in different solution %, so if you find that you are having issues OR itās inefficient, please discuss this with your team! Asthmatics also need to be warned: it is not uncommon for saline nebs to trigger asthma issues, so keep an eye out if you donāt know how youāre going to react. Those with truly brittle asthma (going from fine to nearly resp failure in minutes), you may want to see how you react whilst in hospital if youāve never had it before!
SALBUTAMOL
Comes in 2 doses; 2.5mg/2.5ml and 5mg/2.5ml and only available on prescription in the UK, preferably with a consultants approval (not your GPs). Tho often equated to 10 puffs of ventolin through a spacer, past a certain point they can make it a lot easier to breathe in as you donāt need to worry about coordination etc, which is why they are usually used in emergency care. Some doctors (and patients) find that there is a limited difference in improvement between 1x2.5s and 1x5s, however side effects are often a lot worse, so often they suggest 2x2.5 over 5s in hospitals if they feel you need the additional salbutamol. The benefits of 5 is speed tho so they are often given in ambulances or a&e.
If you are prescribed home salb nebs make sure you have a clear plan and follow it! The main reason consultants donāt like home salb nebs is because they can mask the underlying issues leading to people not seeking help until itās too late. If you have one, follow your rules. If you donāt have rules, get some and if you do have rules donāt allow anyone other than the prescribing medic (that you trust) change them!
The number of times medics decide they can undertreat/discharge early just because you have a neb at home is unbelievable. Just like the number of a&e docs that tell you to over treat at home so they see you less š¤¦āāā. For example my personal rules (yours may be different) are; maximum 2x2.5/day (informing hosp when regularly on 1, and as soon as had 2) and never back to backs. If I break these rules I have to go to hospital no matter how good Iām feeling, and if they think Iām regularly ignore the rules they will put a hold on the nebule prescriptions. However on multiple occasions a&e have tried (and succeeded before I learnt) to send me home on b2bs and/or needing nebs every 2-4 hrs. Something that my consultants and asthma team strongly disapprove of, and has caused emails between depts in the past š . I have now learnt to ignore people trying to change the rules and inform them that I wonāt comply to their advice without my consultants approval (which I know I wonāt get š ), which usually stops them sending me home to neb.
The benefits for home nebs for āsevere and uncontrolledā asthmatics, mean that you may be able function more if you have constant issues, or for brittle asthmatics they mean you can start treatment whilst waiting for the ambulance. However as I said, they should be consultant prescribed, not be done as a request from you to your GP. If you have a home neb and do not have a consultant you need to be referred - especially if itās part of your daily treatment. Be sensible - the reasons cons donāt like them is cause people donāt go to hosp when they should, so if they say no then just remember they are doing it to keep you safe!
In acute situations (ambulances/a&e/itu etc), you can b2b salb nebs almost endlessly (only in a hospital setting (!) where they can monitor you), however ideally they should last 4hrs minimum, so if you have a home neb and itās not lasting you need hospital. If youāre in hospital and they are not lasting they should possibly be thinking about escalating care. The other issue is hypokalemia (low potassium) which is a common side effect of salbutamol, so if youāre using a lot of salbutamol (in whatever format) keep an eye out for muscle cramps/weakness/twitchiness etc and get them to check if you are concerned you have this. Donāt b2b at home without instruction (usually from ambo dispatch) as this is dangerous and follow your rules!
IPATROPIUM BROMIDE (atrovent)
Typically given in hospital in acute situations, rarely atrovent nebs can be given at home. This is a SAMA (short acting muscarinic antagonist), so LAMAs (like spiriva) should be stopped if using them. Unlike salb nebs, they have a limit to 4 a day (spread out). Home atrovent nebs for asthma are really really not approved of, so should only be prescribed by a tertiary consultant.
STEROIDS/ANTIBIOTICS
Typically not used for asthmatics, however people with COPD or bronchiectasis they may be advised to nebulise these rather than use inhalers or tablets. This is mainly to have a more direct effect in the lungs and to make is easier to coordinate etc.
ADRENALINE
Occasionally used in emergency situations, but usually in babies etc for croup. It can be used for asthma, if the donāt want to inject it.
MAGNESIUM (and other elements)
Very very rarely, an asthmatic may nebulise magnesium as part of their treatment. This helps a very very small number of asthmatics by relaxing the airways through direct absorption (as opposed to IV infusion in emergency situations). They would only be prescribed by a tertiary doctor. Other conditions can also nebulise other elements (gold etc).
RULES
As Iāve previously mentioned, if you have a home neb for prescribed drugs (ie salbutamol) you should have rules about when to seek further help. This will reduce the risk having one has. Maybe your rule is āonly use when waiting for amboā or āmax 2 a dayā or ā4hrly, get help if need any salb between nebs, including ventā etc etc. Rules will be personal but they should be sensible and given by your consultant. If youāre needing nebs as part of maintenance (and āonlyā asthmatic) you should definitely be under a tertiary hospital (or on the waiting list for one). The other thing to ask is when to use it! If your rules are ācouple times a day maxā, when do you switch from 10 vent to using a neb. This is something Iāve not found out for myself yet! š I have asked and have gotten no clear answer so have made up my own rule as to when to use nebs š
If you are one that bought a neb machine at the start of covid, and use it for saline, then officially you do not have one. No one in a&e should be changing your neb rules/changing your neb meds for discharge (ie giving atro nebs) without your consultant/tertiary consultant approving. If this happens you should either refuse or contact your team to tell them what happened and to get advice. Doctors can abuse home nebs, just like patients can, and all it does is put us at more risk by masking issues and stopping us getting the care we need. Be sensible; get rules and do not break them!
MACHINES
There are both portable and mains driven devices. Most people have a preference to a brand but like all things thereās pros and cons to each of them. Speak to your doctor about which one they suggest. The important thing is to make sure the particle size is correct. Each medicine will have different particle sizes, and if what you are using has a larger size than your device can handle youāll end up not receiving the drug (and potentially breaking your device). This is mainly (only?) an issue to the mesh portable ones (not compressor ones), which can only be really used for salbutamol and atrovent. If you donāt know what particle size you need, before you order speak to someone - either your doctor/AN who is saying to buy it, or the company selling it. I know evergreen is really helpful on answering these sorts of questions (evergreen-nebulizers.co.uk/... )
WHAT ARE THE ISSUES?
As Iāve hopefully already covered (in depth š ), the main issue is that home nebs make people āfeel betterā without treating the underlying issue. This can make them reluctant/delay going to hospital, as they can just neb away the problem. This is really tempting for anyone which a neb cause who wants to go to hospital when they feel like theyāve treated the issue?! The issue comes when the neb stops working, and suddenly your lungs are really inflamed the the hospital canāt use that as a treatment method. This reason is why my personal rules are set as they are, so I donāt over treat at home and risk myself, and I have also told the hospital of the issue so they can either try and get me into hot clinic or advise me to get help.
Another issue on this regard is you neb at home, respond, go to hospital and get sent back home again cause youāre appearing ok. I strongly advise anyone with a home neb to get their consultant to write a letter saying if presenting to a&e, you need more than nebs, and probably need admitting. Needing more nebs than your rules allow shows that youāre not controlled, but if you have a home neb, youāre a severe asthmatic and have probably maxed out any home āsolutionsā to fix the problem (like prednisolone or add on therapy). Because post neb you may not present to a&e like an emergency, you can be dismissed, whilst had you not had a neb already theyād treat. Tbh personally I feel all severe asthmatics should have some sort of consultant letter/hospital passport as we tend to limbo on max therapy, but then get treated like we arenāt on max therapy in a&e leading to under treatment and no resolution.... but thatās a separate issue š . You may also find doctors try to discharge early just because you have a neb, and they try to change your rules - if you arenāt on regular home nebs in the rules then you shouldnāt be discharged on them. This leads to under treatment and and escalation of issues. So if you want/have a home neb you must able to tell the doctors (a&e/ward/GP etc) that you will not abuse it without approval from tertiary con. If you donāt feel able to say this in this situation then Iād strongly suggest not getting a home neb!
Another thing that causes issues is people not cleaning/replacing nebs/parts. If you donāt clean/sterilise the parts, germs can fester, then then suddenly your neb isnāt helping your asthma but giving you a chest infection. If you step back and are honest with yourself, and think youāre too lazy to do the cleaning/buy replacements (as you canāt get on prescription for asthma) then home nebs are not for you.
The last issue that is often forgotten is nebuliser maintenance. Nebs are medical machines and this need to be serviced - who, how and when, are all questions to ask if youāre advised to get one. Who will do it?, how will they do it (send it off? Take it in?) and how long will you be without for?, when should it be serviced (annually?) etc etc. If itās not serviced regularly youāll find that it stops working properly and then itās not there for when you need it! If you need to know more about servicing/cleaning your neb, this website is great; naratbc.org.uk/
For more about home nebs; asthma.org.uk/advice/severe... or about nebs in general; asthma.org.uk/advice/nhs-ca...
Anyway hope this helps anyone who has a home neb, or who has had it suggested to them! If you feel like Iāve missed anything, or should like to extrapolate on mag nebs (I know thereās at least 1 person on here who uses them! šš) or would like to give your rules comments below, feel free! Or any questions of course!
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