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My asthma

Hi there how are you today. Do you mind if ask you how do other people control there asthma during a really bad attack. After my last attack which was a really bad one it really scared me as i havn't sufferd an attack like that for some time. Went to see my asthma nurse today & she said my asthma is getting worse she also said that if things don't improve soon i might have to start using a neb during attacks because at the moment i just use my Ventolin Evohaler which helps most of the time but during my last attack it didn't really help. Also my GP said he might have to look at swaping my medication but he said before he does that he wants to discuss it with my asthma nurse it seems that no one wants to tell what is going on.

Thanks for reading this message

1 Reply

Hi Jonny,

Welcome to Asthma UK, I'm sorry to hear that you've been having problems recently. I hope you find us a good source of information and support. Something that I say to all new board members is that you should bear in mind that sites like this one inevitably attract a disproportionate number of people with severe asthma, so you may read accounts of things like hospital admissions and even Intensive Care admissions. Please don't be frightened or put off by this - the vast majority of people with asthma do not go through experiences like this, and can be completely or almost completely controlled once the right combination of medication is found.

Most importantly, I need to say to you that if you have an attack which is not responding to your usual reliever treatment, ie your salbutamol inhaler, you need to seek urgent medical help, by contacting your GP or dialling 999. Lack of response to your medication is a sign of a severe attack and you need urgent medical treatment in that situation.

The basic advice to control your asthma during a bad attack is the same as in a more mild attack. Sit yourself down in a comfortable position and try to remain calm. Take 1 - 2 puffs of your reliever (salbutamol) inhaler, or as recommended by your doctor. If this does not relieve your symptoms, continue to take one puff a minute until you are feeling better. If your symptoms are not improving after five minutes, that is the point at which you should call for emergency help by calling 999 or your doctor. Continue to take one puff of your inhaler every minute until help arrives.

In terms of whether a home neb would be useful - nebulised medication is very powerful medication, at a much higher dose than you would get from an inhaler, and if used inappropriately, it can be dangerous. The decision to give someone a home nebuliser is not one that is made lightly, and will usually be reached by a hospital respiratory consultant in conjunction with the patient, the GP and other healthcare professionals such as respiratory nurses.

There are two main reasons why someone would be given a nebuliser at home:

1) If someone has attacks that are so sudden onset and severe that they need to be able to use a neb while they are waiting for the ambulance - this is very rarely the case as the vast majority of people will get as much benefit from 10 - 15 puffs of salbutamol inhaler via a spacer. If someone has a neb for this reason, they should only use it when they have called an ambulance and are waiting for it to take them to hospital.

2) Occasionally, someone with very severe asthma who is already on pretty much maximal other treatment will find that they respond so poorly to inhalers that the only way of keeping their airways open is to use nebs fairly regularly. In order that they are not in hospital all the time, for quality of life reasons, they may be given a neb to use regularly at home. This usually happens after many hospital admissions for asthma, and after attempts whilst in hospital to get the patient off regular nebs by adding in other medication. No-one should have a neb for this reason unless they have exhausted all other treatment options without success. There is some risk inherent in this strategy, and many of us who are in this situation will have experienced attacks when they have not sought help in a timely fashion because they have a home neb. The risk has to be balanced against the quality of life issues if the patient does not have a neb at home.

In both these cases, the patient will have very strict protocols about when they can use the neb, how frequently, and how often they can use it before they have to go to hospital. Giving someone a neb at home is always done with a lot of thought and caution on the part of the doctors, and has to be very carefully considered.

There is a very real danger that someone who has a neb at home will have a false sense of security about how easily their asthma can be treated, and will keep nebbing when they really should be getting into hospital and having other treatment. In a severe attack, nebs will often not work alone, and other treatments like IV hydrocortisone, IV magnesium and IV aminophylline may be needed, or even, in an extreme case, intubation and mechanical ventilation. By the time someone gets to the stage where nebs aren't working, they are usually extremely unwell and need to be in hospital very quickly. The large majority of asthmatics, if they are ill enough to need nebs, should be in hospital. It is a very small minority of asthmatics who will benefit from and be safe to use home nebs.

In your case, I am a bit puzzled as to why your asthma nurse is suggesting a home neb. As I have said, most people will get just as much benefit from using 10 - 15 puffs of their reliever inhaler via a spacer - so it would be more usual for your asthma nurse to suggest this first (please do not do this without discussing it with your doctor or asthma nurse). You don't mention any hospital admissions, and it would be more usual for someone to have had the sort of severe attacks requiring hospital admission, and to have been assessed using nebulised treatment there, before they were considered for home nebs.

You don't say what preventative treatment you are on, if any - your profile states that you are only on the Ventolin Evohaler. It would be unheard of for someone to be given home nebs when they had only been on that very basic level of treatment - and it would be very bad medicine. The goal of treatment should be to adjust your preventer medication so that your asthma is better controlled, you are not having these severe attacks, and you don't have a need for stronger reliever treatment, rather than rushing in to prescribe potentially dangerous home nebs. There are lots of options in terms of preventative medication, and the vast majority of asthmatics - perhaps 95% - can be completely or almost completely controlled, once the right combination is found. If you have been managed by your asthma nurse, and have not seen a respiratory consultant, it is very likely that you have not tried all the options in terms of preventative medication. If I were in your situation, I would be keen to explore all these options before accepting the need for a home neb.

I know that when you first use one, a neb can seem like a 'magic bullet' that instantly and dramatically reverses symptoms of wheeze and tightness, and many people, once they have experienced this, understandably want access to this magical treatment at home. However, nebulisers can cause more problems than they solve, both in terms of side effects, and, as I have said, in terms of the effect on your asthma control and perception of symptoms. A good proportion of the deaths that occur in this country due to asthma are entirely preventable, and occur because people have underestimated their symptoms and have not got themselves into hospital quickly enough - and a lot of these are associated with the use of nebs.

I would strongly suggest that you go back to your GP or asthma nurse and pursue the issue of changing your preventer medication around in order to try to improve your control. If you are already on a lot of preventer medication, it may be worth asking for a referral to a specialist respiratory consultant, who will be able to assess you more thoroughly and have access to other treatments. If I were in your situation, I certainly would not be keen to rush in to getting a home neb.

Hope this helps, do let us know how you get on.

Take care

Em H


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