To neb or not to neb...that is the question!

After seeing a number of posts on here about the use of home nebulisers, I thought it would be interesting to hear peoples thoughts on the matter. There are a wide variety of Asthma suffers who use these boards so we should have a good mix of people who are a for/against the recommendations below.

Lets hear your thoughts!

The 2008 British Guideline no longer recommends nebulised therapy for the majority of asthma care. It cites evidence suggesting that a spacer and metered dose inhaler (MDI) combination can be as effective, if not more effective, in many situations in which nebulisers were formally used. This includes both acute and stable asthma.

A spacer plus MDI is to be preferred because of the following issues:.

•More effective treatment with fewer side-effects because of better pattern of deposition

•Problems of poor inhaler technique largely overcome but spacers need to be used properly too

•Easily used by children and the elderly (except those with weak or arthritic hands)

•As effective as a nebuliser in treatment of acute attacks but light, cheap, maintenance free, portable and available on prescription

•Useful for treatment of first attacks of wheezing in patients who have not used inhalers before

•Useful for administration of bronchodilator when testing reversibility in the surgery to establish the diagnosis of asthma

•Reduced prescribing costs by basing treatment on the much cheaper metered dose inhalers

There are few cases in which the British Guideline recommends nebuliser use. It initially states that there are insufficient data to make a recommendation about their use in life-threatening asthma. However, later the Guideline does recommend that the nebulised route (oxygen-driven) is used for the delivery of high-dose beta agonists in acute asthma with life threatening features. Nebulisers have however certainly been used in this situation to deliver high-dose inhaled drugs. If a nebuliser is used in the emergency situation, there are theoretical risks of oxygen desaturation whilst using air-driven compressors. Therefore nebulisers should be oxygen-driven with a ""high flow regulator"" fitted to the cylinder in order to provide the necessary flow rate of 6 l/min.

Nebulisers are less useful for domiciliary management of stable asthma, but patient preference should be taken into account, and some patients - especially those with brittle asthma - may have more confidence in nebulisers than in MDIs. Such patients require a verbal and written plan for self-treatment and it is essential that repeated use of the nebuliser does not lead to failure to seek medical help and the prompt use of steroids.

26 Replies

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  • Hi,

    I'm in the States, and I found your post really interesting for a few reasons. I think here people tend to have their own nebs more, and most say that when they're ""bad"" that they work better than spacers. However, I got to an asthma specialist who doesn't prescribe them, and then had a brief stent with another lung doctor who does. With the result that I got very confused by when to go to the hospital for help and it was very scary (and really quite a bad thing). We also don't take so many puffs of ventolin here before we go (or at least we aren't supposed to!). I'm supposed to take two at a time, and can take four if I really need to, but after that it is off to the hospital where I go, and I would have to be extremely bad to call an ambulance. I've been told to twice so far, but haven't yet. I think partly it just sounds like it would be so expensive and I don't think insurence always covers it.

    So anyways, those are the differences here. I still have my neb and will use it occasionally, but more if I'm having a flare, I'm on a ton of meds, and using it once in a day would make a huge difference. And if the difference didn't last I would go in.

    Oh...I do like my spacer because I do get less side effects from the ventolin with it, which makes me very happy!

    Also, I know there is some action here about making health care more accesible etc., but I do think we don't quite have the how to save cost effectively yet. For instance, if spacers really do work every bit as well as nebulizers, then that would be more cost effective, for the majority of patients at least, wouldn't it?

    Bee

  • What a great idea!

    When my brain is less sleep deprived I will come back with a proper answer.

    Em xx

  • We've found a home nebuliser very useful and I wouldn't be without it. We brought it about 7 years ago and used to use it quite a lot for our son. In the event of an attack, we'd have a 25 min drive to out of hours clinic or A&E, a wait to see a doctor, then a wait for them to do what? - yes, put him on a nebuliser. After this happened a few times, our then GP lent us the surgery nebuliser. When they wanted it back, I brought my own.

    We still get the Ventolin nebules on repeat prescription, but havent needed it in over a year. And of course if son is bad enough to need a nebuliser, we get medical help/advice asap.

    In son's case, lots of puffs of reliever via the spacer just doesnt give the relief of the nebuliser.

    Who am I to question medical opinion, but I think doctors discouraging the use of the home nebuliser is more about them not wanting to lose control than anything else. They assume we patients don't know how to treat ourselves (and maybe some don't) and that we can't be trusted to self medicate.

  • It's a very interesting point, and one I am very interested in hearing peoples view/experiences on.

    Our local hospital decided a few years ago that unless you had low sats (less than 92 I think) you could be treated with a spacer. Not too bad if you only require 10 puffs of Ventolin (equivilent of a 2.5mg neb) but not so much fun if needing back to back with additional Atrovent! 42 puffs with a spacer when you are struggling and tired is not the best idea in my opinion!!

    My understanding is a majority of people with asthma will only ever use a couple of puffs of Ventolin and if thats not working may use a couple more then go to A&E because it's not helping. In these cases I would assume if sats are OK that 10 puffs with a spacer will do the job and will give the Pred time to kick in. No problem. However, what do you if someone like my son comes along? He usually presents after at least 48 hours of using 10 puffs every 2-3 hours and already on 40mg Pred.I know by this point the spacer isn't making a great deal of difference as he is tired and not taking in good breaths. He needs nebs at this point, but his sats are usually above 92% so what to do? Well, I now have a plan that states if his attends the ward (he has an emergency card so goes straight to paeds ward) he requires back to back nebs with Atrovent and if there is no significant improvement he needs IV's. If we go to A&E or present at a different hospital we have all sorts of problems as he doesn't wheeze and often looks very well. One hospital refused to treat him at all saying he had a panik attack even tho his pf was only 33% because he was breathing too fast! He had a typical asthma breathing pattern of short inhaled breath and prolonged expiritory breath.

    So I am one who is for nebs in hospital even without low sats, but do think a spacer is an effective method for alot of attacks that do not necessitate hospital treatment. When Jay over does the exercise he regularly requires 30 - 40 puffs of Ventolin in one go to calm things down. It usually does the trick (he's only needed an ambulance once because it didn't work). My biggest fear for Jay is that if he had a neb at home he would refuse to go to hospital and would try to deal with it on his own. The fact we don't have one means he has to admit he needs nebs so reluctantly goes to hospital.

  • For me my home neb is my life line - if i didnt have it i would live in hospital. Take last night as an example -woke at just after 4 coughing and really struggling i needed 3 5mg nebs to get back on top of things (if i needed more i would have gone in as per my protocol) they are is absolutely no way i could have dealt with that attackk using a spacer it just wouldnt work and as i can deteriorate very quiickly it would have also been quite dangerous.

    However- i have seen the use of a home neb being abused big time by another patient on my resp ward and its quite worrying as she was buying her nebs on line as GP would only prescribe her a certain amount. When she used them she seemed to show no obvious syptoms of struggling (no wheeze, cough accessory muscle useage etc) and she never seemed to use a complete neb -so as far as im concerned she would be an ideal candidate for spacer treatment.

    How can this be regulated though ? Should drs have stricter guidelines in neb prescriptions? Should medical companys have to have a letter from a con or GP before they will sell someone a neb? I think there is so much to look at it just wont happen.

  • I was under paediatrics for years until late 2006-early 2007 I was finally moved over to adult respiratory, on paediatrics they are much less keen I have found to prescribe home nebs, I was on 4 hourly 10 puffs through spacer plus on as needed basis. However when I moved to adults one of the first things they did and I don't know whether admissions to ITU a few weeks before the first appointment had any bearing on this in addition to history of uncontrolled asthma but home nebs were prescribed on an up to 4 hourly basis, however I had issues with actually getting the machine, the hospital didn't loan them out for asthma and my consultant felt it was important I had one so in the end my GP lent me a compressor and a young carers charity (I care for my mum) funded the cost of a compressor.

    Being completely honest I thought this was a good thing because I felt that if I had a home nebuliser I would be able to stop attacks faster instead of my old routine and completely irresponsible might I add of just using a salbutamol inhaler til it basically ran out/ I got too tired because we had been at a point where I was being admitted to hospital for hourly nebs every 2 weeks and then IV Aminophylline started being used cos nebs just didn't seem to work as well anymore. Anyway to the point - my home nebuliser has not stopped me from being admitted to hospital for example I had 9 admissions last year, it has however stopped the attacks where I'd need to maybe going in for nebs and steroids and being able to do this at home has helped a lot (under guidance of consultant and respiratory nurses) and its helped quality of life wise, there has been one time last year when I did over do the nebs and it resulted in my oxygen levels going dodgy for longer than they usually would in addition to needing IV treatment, it really was prolonging the inevitable and I haven't done that since and have come into hospital as soon as I felt nebulisers were not helping.

    I use a spacer as well as a nebuliser, it is much more convenient than trying to find a plug socket or batteries for a nebuliser and is less time consuming, so when my breathing isn't too laboured I will use up to 10 puffs in a spacer and I've found it works quite well, but in an attack or when I'm struggling I would find it difficult to be using a spacer. I will add also my mum has moderate asthma and when she has an attack we don't use my nebuliser, she has a spacer and a MDI ventolin and I give her 10 puffs through that and it is usually effective, however if like at New Year she didn't seem to be responding to it too well so took her to the walk in centre who said her chest was still a bit wheezy and checked her sats which were a little low so they gave her a neb and she was fine after that but I took her because I did not have a sats monitor and it wasn't my place to apply what happens to me to my mum whose asthma is different to mine, for someone like my mum who has moderate asthma a home nebuliser would be a completely bad idea as she wouldn't go in basically despite maybe being ill enough to need oxygen. I have found when I am struggling I can't use nebulisers for long as they are not obviously oxygen driven but are compressed air unless one has a home oxygen so it becomes tiring to use a nebuliser and obviously at this point an ambulance is called as soon as possible.

    sorry for length of post!

    simi x

  • Hi My Son and I have brittle asthma and find using the spacer just isn't enough. I have combivent (0.5mg atrivent with 2.5mg ventolin) plus 2.5 or 5mg ventolin added every 4 hours when asthma is bad, would be getting through a lot of med canisters without neb!It keeps me at home for longer, when I'm not in control of my asthma I make sure I get help immediately.

  • Great idea for a debate Koolkat! I am definitely interested to hear other people's views on use of home nebs.

    I used to be againist the idea of having 1 myself because I thought that if 10-20 puffs through a spacer doesn't work then it is a good idea to get checked out at A&E. However after an extremely sudden attack where I wasn't able to use my spacer at all whilst on holiday my mind has been changed a little! Also my travel insurance company had to buy me a portable neb to get me home! That was in March and since then I have just used my spacer, we only live about 5 min walk from the nearest hospital here in Aberdeen. I am waiting to my appointment here at the difficult asthma clinic to discuss with my new consultant if/when I should ever use the neb. I am therefore interested to hear people's opinions before my appointment!

    Bryony

  • I think this is really interesting!

    I don't personally have a home neb but know at times I've really wanted one. About a year ago when i was just constantly in hospital i thought that having a nebuliser at home would solve everything but my consultant refused point blanc (i'm still under paeds) and said that she never has and never will prescribe a home nebuliser. I couldn't really understand it at the time as i was only ever treated in hospital with nebulisers and steroids and so having one at home seemed as though it would stop any admissions. However as my attacks started to get more severe and i often ended up needing IV's my oxygen levels could get a bit dodgy and i realized that the right call had definitely made. I crashed in hospital and ended up quite poorly and i realized just how nasty that could have been if i hadn't been in hospital at the time. What's more im very stubborn and try everything before going to hospital, if i had a neb i know i would push it and that's just something i can't afford to do.

    I think at home a volumatic and MDI work just as well as a nebuliser however i do think during an attack a nebuliser definitely becomes more effective. I think a bit more effort is needed to get the medication out of the spacer which is obviously problematic in an attack, so in A&E nebulisers are definitley better.

    Really intresting to hear others views!

  • I asked my con if I could have a home neb as I drop quite quickly and then take

    lots of my easyhaler 200 up to 12 puffs.

    He said he didn""t think I would need one and said if I had problems after taking lots of reliever

    get help.

    My meds have kept me out of admitions this year but have had to go to AnE and have 2 nebs to

    settle me down again so at the moment I am managing using my easyhaler as a neb with odd visits to

    AnE xxx

  • Hello,

    I am brittle type one & two and have a home neb for many years. I use it regularly but have strict guidelines as to its usage. (It basically keeps me at home) If, two in a row don't work, then I am heading for A&E etc and then I neb (Often Back to back) on Oxygen while waiting for the ambulance. (Acute / brittle type two attack)

    I know to my cost of over relying on nebs in the past. I was trying to use up to 5-6 nebs which is not good and would result in a prolonged admission.

    I still use my ventolin inhaler a lot and will try it before a neb.

    A spacer plus MDI inhaler works for most people. the aim of asthma medication is management of the symptoms by Prevention.

    I think a lot of people see it as a quick fix, which if you are having a severe attack, it gives really good improvement and people see it as a wonder drug!

    Having a neb in A&E or by paramedics, you can be closely observed for deterioration.

    Steroids - Oral, yes a lot of people are reluctant to take them when deteriorating but a short five day course is very beneficial, can prevent further deterioration and keep you out of hospital / A&E.

    There are also a lot of add on meds that can be used before going down the neb route.

    I feel they should only be prescibed if you have

    - type 2 Brittle asthma etc and have sudden severe attacks where a neb for emergency will save vital minutes.

    - Have very difficult to manage / control asthma / type one brittle and spend silly amounts of time in hospital.

    - there may be a few other valid reasons too, but most nebs are or should be prescribed by a hospital consultant.

    And only then, with good written protocols.

    Just my thoughs...

    Kate

  • Home Nebulisers

    Hi folks,

    My daughter was given a home nebuliser by her resp. con. but with a strict protocol. For her it kept her at home a bit longer and enabled her to manage her asthma a bit better to a certain extent. My daughter also used her reliever when required and only used her nebuliser when her reliever wasn't working as well. She also had home Oxygen and like Kate used this whilst waiting for paramedics when she had to go to A&E.

    Regards being stubborn, I'd ask you not to take any chances with your life asthma attacks can be very precarious or at least that was my experience with my daughter. Even although my daughter was hospitalised every 2-3 weeks if it wasn't a respiratory ward she was in then I would stay with her as very often they were caught off guard with her crashing when seemingly responding to the treatment. It's not nice seeing your daughter having a respiratory arrest in front of you and having to be ventilated as an emergency in the ward. So please don't let stubborness get in the way of your treatment. All the best to everyone. LIZ x x

  • To Neb or not to neb

    Interesting question....... I have been refused home nebs by my hospital for now because I have been admitted to hospital too many times and had complications. If the use of a spacer worked i would probably stay home. However 10 puffs of ventolin doesn't always work and I deteriorate quite quickly as brittle asthmatic. I was also told that nebs are quicker for medical staff to administer in an emergency setting so they use this rather than spacers which could be more time consuming.

    Sometimes I end up having back to back nebs(4-17), intravenous drugs, oxygen, whatever until it settles which can take hours which is definately impractical for home nebulisors. Recently I noticed that nebs are ineffective and magnesium has to be used. So I guess home nebs are out of the question for now.

    Hmmm...gill

  • Very good topic.

    I have moderate to severe asthma and I have a nebuliser, which in the past has literally been a life saver, but I don't use it without consulting either GP or Resp consultant, preferring to rely on MDI and spacer. Also as Kate said, I will probably have resorted to oral steroids before nebs.

    However, I got the nebuliser because (at that point) I lived a long way from A&E and it provided a back stop for serious situations particularly as with small children at home, trekking to hospital in the middle of the night was not to be undertaken lightly. I think my GP thought that after one harrowing episode we would all feel better if I had a nebuliser rather than relying on a small child to call 999, when my husband was away.

    I am very lucky with my doc's as I pretty much able to decide when to take oral steroids and or anti-biotics, and change my add ons or if I need nebs. This only happened after years of having the same doctors, and a great resp. consultant.

    Like everyone else here I think it depends on the individual circumstances and on having a strict protocol on usage, as kate said you can get yourself in a real mess by over relying on nebs.

  • hi peeps

    i am allergic to propellants in canisters and aerosols so i can only use accuhalers. an accuhaler in an attack is not easy to use. i am a brittle asthmatic confirmed by many tests from a specialist. My nebuilser is my reliever due to my complex allergy to propellants. i like kate moss have a strict protcol for using it. if two nebules in a row do not stop attack i have to go to hospital.

    i am thankful that i can have a nebuilser because otherwise i would not have a reliever for in an asthma attack. it can at times be a logestical nightmare to just stop and have a neb because i have symptoms appearing but all the same it keeps my asthma reasonably well controlled most of the time or as well as expected for brittle asthma. i have found the fighting for breath report a great way to explain to my friends how much my asthma impacts my life.

    plumie

  • hi. after id had a few chest infections in a row and was struggling with my asthma an nhs proffessional suggested i have a neb at home. after looking into this i was told by loads of other nhs workers that it wasnt a good idea for asthmatics as they tend to rely on them rather than go to hospital which could lead to very bad attacks and poorly controlled asthma. i suppose this makes sense - for me anyway, as i know i would rely on it as i hate hospitals....so my opinion is maybe people who have copd or the likes might benefit but when an attack can come out of nowhere hospital is best-youve no idea how hard that is for me to write lol x

  • Bumped up for 1-winged-angel.

  • Well bumped. thanks angievere :)

    I notice that the guidelines also state that SPO2 readings shouldn't be used to prejudice against the use of O2 and nebs... or i could have got the wrong end of the stick

  • I was so against a neb. Preferring an mdi. Despite gp and practice nurse pushing me to take one I always refused. Saying if I needed a neb then I needed inpatient treatment. I finally had to admit my asthma was being more difficult to manage . Now without my neb i would have more lengthy admissions. Less quality of independence when home and constantly multi dosing. However with the neb I have instructions of when to seek medical attention. So I don't get the false sense of security.

  • 100% agree with Gussypoo. If nebs are included in a strict asthma plan why should there be a 'false sense of security'? Valuable time can be lost getting medical assistance - we certainly found that before we got our home neb.

  • I have a nebuliser.

    When I got it, I got a note from my GP to give to my chemist. Because of this he was able to get the VAT deducted. As this is now 20%, it make a nice difference to the overall cost.

  • Hi everyone

    Having spent 3 days in hospital between Christmas and New Year . My doctor says if you need to use a nebuliser you need to be in hospital.Am now back at home still suffering. Constantly using seretide salbutamol and atrovent inhalers. Also take singulair tablets. Am off work at the moment. Also taking and steroids and antibiotics at the moment. Don't know what else I can do The hospital say I do all the right things but continue to have these flare ups every 2/3 months.

  • I try every other method of my asthma management plan & is my neb is THE absolute last resort before hosp. Over Christmas it kept me out of hospital until the prednisolone and antibiotics kicked in. The positive point of having home neb is a reduction in hospitalisastion. The negative point is that both the atrovent & salbutamol 5mgs make me feel shaky, agitated & fidgety. So they really are a last resort in every way.

  • Judith,

    If you're still concerned about your asthma even after coming out of hospital it might be worth making an appointment with your GP soon-ish to check that nothing else can be done and that you are on the right medication for the current state of your lungs. Especially if as you say you're needing to constantly take your inhalers.

    As an aside you say you are constantly taking seretide - I assume you know that it is not to be used as a reliever and is taken for maintenance purposes (usually twice a day).

    Sorry if I sound patronising but there are a few people that use these boards who underestimate how severe asthma can be, or who do not properly understand their medications and take them at the wrong times etc.

    Hope that you feel better soon.

    Emma

  • Another bump for Howie.

  • Wooohooo, i got bumped ;)

    Got lot of people posting & lots of info all in one place if anyone thinking bout gettin own nebulizer

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