Do any of you use a nebulizer? My asthma is getting worse and I'm wondering if any of you who use one can tell me whether or not it shortens your episodes and works better than your inhalers (I use five of these suckers each day). Does anyone have a portable one? They are expensive, so before I buy one, I'd like any advice you have to offer.

Thanks - Mary

The super-portable ultrasonic nebulizers can't be used to nebulize Pulmicort.

They've found the traditional aerosol nebs that work continuously don't work so great unless you top up the fluid that goes in them -- like use more than just 2.5mL. Try going at least 5. Treatment lasts longer but you get more drug at the end of the day.

It's tough to say if they actually work better -- they are certainly a hell of a lot more expensive -- the theory is that either they work just as good as MDIs and the real benefit comes from making the patient sit and calm down and breathe deeply, or if they actually do improve lung deposition. The jury's still out on that, but if you DO buy a nebulizer, buy a good one, like a Pari. The Pari neb cups are about five times as expensive as the traditional ones but they also last six times longer, and come with a warranty, and actually work better.

If you don't actually need one, and your MDI puffers do fine, it might not be such a great investment -- medications for the nebulizer are more expensive than MDI medications, and you end up actually taking a larger dose of drug. Ventolin in MDI you get 200mcg per actuation, whereas a neb of Ventolin is 2.5 mg. It's a great way to give drugs in emerg -- in high doses -- but you'll have to check it out and see if there's a good chance of you having clinical benefit from it. They're a lot more upkeep, you have to keep replacing parts, cleaning parts properly, make sure the equipment gets maintained properly.

If you're in some parts of Canada, I know there's government agencies that will loan you the lightweight compressor required to jet nebulize medications. They'll take care of the maintenance for you.

Hi Mary. I have a nebulizer but only use for Ventolin and Atrovent when I am getting too close to a visit to the emergency ward. Researchers say that a puffer and spacer work just as well, but personally I find the nebulizer does work better if I get to the point where I have virtually no air movement (I know you're not supposed to even let it get that bad, but sometimes things happen). Most hospitals in this part of Canada still use nebulizers in their emergency wards. I also use a nebulizer for a few days immediately after a hospital stay but try to switch to puffers as soon as possible.

I would suggest talking to your doctor about it. I agree with everything Wrin warned about. This is definitely not a cost saving or time saving alternative. It takes 10-20 minutes to do a treatment, depending on what you are putting in the mix.

Have you tried some of the combination puffers? I used to take up to 14 'puffs' a day when I was using Pulmicort and Serevent separately. Now I get by fairly well on just two puffs a day of Advair (combination of Flovent and Serevent).

Barb

Wrin and Charleyhorse: thanks for your info.

Every day morning and evening I do one Advair, two puffs Flovent, and 4 puffs Intal. When asthma onsets, I add Combivent (4 puffs/every 4 hours), which I'm afraid of since it's contraindicated if one is allergic to peanuts and since it makes me feel very jittery, and 4 puffs Albuterol, the latter two of which are supposed to be done only every four hours. But I need them more frequently. I nave night-time asthma but lately it's happening daytime as well. I'm usually down two days in bed with extreme exhaustion. I mentioned a portable neb since I would need to bring it to work on bad days. I do have, thank God, a physician that will give me sleeping pills on bad nights. I was hoping to shorten the two days in bed by using a nebulizer. I live in California. I think you're both in Canada so we may have different names for different meds. I'm going to have to download some of the info you gave me and ask questions in a separate post because I didn't understand some of your advice.

Thank you both so very much for taking time to answer. I'll be back.

Mary

Problem with you going to nebulized solutions is you can't get advair as a nebulized solution.

You can't get flovent as a nebulized solution, and you can't get serevent as a nebulized solution.

The only corticosteroid you can get as a nebulized solution is Pulmicort, which comes as a drug suspension, and thusly can't be used in an ultrasonic nebulizer setup. This means that the portable neb that you would buy would have to be a lightweight jet compressor type unit.

Intal and combivent you can get as a nebulizer solution no problem. They can even be mixed, makes for a faster treatment.

It sounds to me like if you have to take 4 puffs of combivent every 4 hours (That's a puff an hour, or roughtly twice the recommended dose,) it's possible yo0u're not taking the puffers properly. Look into purchasing a spacing device before you get a nebulizer. They're a hell of a lot cheaper, and if that's all it takes to do the job, then great!

The different-names-for-different-meds up here ... most everything is called the same thing, except for Albuterol, which in Canada is called Ventolin. (Airomir is what 3m is marketing their HFA as but you can get some generic ones that are still called Ventolin HFA.)

Please post questions -- we'd be happy to answer!

We have an Omron CompAir elite and love it...its the smallest compressor nebulizer available. The neb does seem to work better and breaks flares up faster.

If you end up with a neb, you can less expensive ones before buying an expensive portable one..

1 daughter uses Pulmicort and Albuterol via neb, one daughter uses Xopenex via neb and one daughter uses Albuterol via neb.

Mary-
My asthma recently got very bad. As a child, I had a neb at home, but it had been so long since my sister or I had used it or needed it that my mom donated it.

My doctor recently prescribed me a new nebulizer (HMO route through insurance) and it was at no cost to me (but I believe it sold for $100 w/o insurance), plus it is a lot smaller than the old one I had. I keep it in my car in case I get an attack at work, it's roughly 4"x6"x5" and really lightweight.

I find I get better relief with my neb than with my rescue inhaler which has a built-in spacer. But before I was using an inhaler with a built-in spacer I found that using a spacer helped a lot. My doctor told me that most of the time a lot of the medicine from a regular inhaler doesn't get inhaled because they aren't being used correctly.

It sounds like you are on a lot of meds and I think that you might really find a neb helpful if you are having a bad attack (it may be a bit slower in relief, but I think it works better overall). The only bad thin about it is I find that if I take my neb (Albuterol) after taking my rescue inhaler (several times) or if I take more than 1 neb treatment in 6 hours it makes me nauscious.

I hope this helps...

Dear all: Thank you so very much for your valuable information. First, I believe I mislead you with my current med regimen. Twice each day, I take 2 puffs Flovent; 1 puff Advair; 4 puffs Intal. Once each day, I take pills: Singulair and theophyll (also known as Uniphyl). I use Combivent and Albuterol for fast action.

Yesterday, I did a lot of research on nebulizers on the web, all of which basically matches what you all have said. However, I ran across an article that noted that hormones can affect asthma and since I recently stopped taking them since I am postmenopausal, I had a eureka of sorts. I had been doing very well on the meds noted above, used with spacer, until I stopped the hormones. I'm going to start taking them again and see if how I do. If there is no substantial change, then a neb it is. It must be portable, however, since I spend at least 9 hours per day at work five days each week. It appears that the jet nebulizer is the one to go for. I'll also consult with the pulmonologist before making a final decision (he is currently on mini sabbatical for about another month).

If there are any women who are post menopausal, too, and even if you aren't, let me hear from you.

Again, thank you all so very much.

Mary

1. You cannot get Flovent or Advair (or even Serevent) in nebulized solution.

2. You CAN get combivent and ventolin in nebulized solution.

3. You CAN get Intal in nebulized solution. Intal is best taken more often than twice a day. Try spacing your puffs of Intal out, 2 puffs every 4 hours or something. What does your dr. think? On a neb this might be tougher to do, though.

4. You CAN get an inhaled steroid in nebulized solution -- down side is that it looks like you're going to be switching to Pulmicort if you go to neb.

5. When you switch to neb, because neb dosages and MDI dosages are different, make sure they keep an eye on your theophylline levels for the first little while to make sure they don't fluctuate.

THe hormones is a good thing to look into. Congrats on paying so much attention! http://www.healthboards.com/ubb/biggrin.gif

Do you do daily peak flows?

Originally posted by Mary Grant:

If there are any women who are post menopausal, too, and even if you aren't, let me hear from you.
Funny you should mention hormones. My Dr. just told me that menopausal women were the hardest to control, asthma-wise. Looks like I'm in for a long, rough ride.

First: I love you ALL for replying. Can't thank you enough.

Now: Wrin: No, I don't do daily peak flows because with me, they are not predictive. I do have a meter, thogh. The PF can be great at 9:00 p.m. and at 4:00 a.m., I'm grabbing for the albuterol. What is ventolin? What is pulmicort? Rescue or long-lasting meds? Steroids or not steroids? The intal, 4 puffs morning and evening, is what the doctor prescribed. I hear you about medicating per the printed label, but that would be hard to do with my work schedule and distance from a place to rinse my mouth. Perhaps that's why he prescribed the twice-per-day regimen. What is pulmicort? Steroid or no? Does it have another name? Thanks for the heads-up on the theophylline levels. I saw that in the literature. Overall, my doctors say the manufacturers are covering their behinds with a lot of the cautionary info they hand out, but I'm included to think we have to be more proactive than they are.

All: So the nebs are used for both fast-acting meds (albuterol) and the longer, maintenance acting meds (Advair, Intal, etc.). I thought it was used solely for rescue med purposes.

Carolyn B: drat on the nausea thing. I want some damn relief from being sick for as many as three days per week each week! Yes, I am complaining.

Charleyhorse: what is atrovent? Isn't that combivent with another name?

Lyn HW: Yup. Guess it is harder for postmenopausals. Wouldn't you think all these highly educated types, and especially my allergist who is postmenopausal, would know about this hormone thing?

Cripes.

I'll be back. I'm having trouble getting the hormones reordered since I went off. I will let you know how this works out.

Again, thank you. Thank you very much.

Mary

Ventolin is the brand name for Albuterol. I think they call it something like Proventil in the States? All over the world it's Ventolin/Salbutamol, and only in the USA is it Proventil/Albuterol. Silly kittens.

Pulmicort is an inhaled corticosteroid, sort of like Flovent, but a little different. I found I couldn't tolerate Flovent, so I'm on Pulmicort. Some people found they couldn't tolerate Pulmicort, so they're on Flovent. Flovent works a little FASTER, but neither one works really "better" than the other. Pulmicort is more classically prescribed for little ones because ... well, it's FDA approved for munchkin-type-sized people, and because it's the only corticosteroid that comes as a nebule.

Peak flows don't predict a whole lot for me either, unless I'm so desperately sick that it's not even funny, they don't work very well for me. Of course, it helps to that peak flows tend to add to my bronchoconstriction. Yum!

Intal, 4 puffs in the morning and evening is what your doctor prescribed. Ah. Okay. Nothing wrong with that, I just happen to know that spaced more closely together they tend to work better than high doses spaced far apart. The drugs are great, great ideas, but they don't work as horribly well as one would hope they did. Tilade (kind of like Intal) works a little better but tastes SO NASTY that most people just don't take it. It's not a very popular drug anymore. Nice thing is, you don't have to rinse your mouth if you take it, unlike an inhaled steroid.

Besides, even with an inhaled steroid, I understand that it'd be difficult to do with your work schedule and distance from a place to rinse your mouth -- but hell, if you have to, swig from a water bottle and spit on the ground, or swallow it. It's better than nothing. Or make an effort to eat after you take your inhaled corticosteroid. Whatever keeps the drug from SITTING in your mouth will do the trick.

Pulmicort can also be called "budesonide".

The theophylline thing .. well, they DO call theophylline the 'poison of asthmatics'. It's a derivative of caffeine. I'm sure you know you have to constantly have your levels checked, and I'm willing to bet you've had it explained why. It's because at low levels it doesn't work, and at therapeutic levels it works rather well, and at high levels it causes seizures and heart arrhythmias and death. Be ESPECIALLY cautious if you are put on antibiotics -- the list of drugs that interact with theophylline (to either increase or decrease blood levels) is as long as my arm. And I'm not exaggerating.

The manufacturers ARE covering their behinds with the info they hand out -- do you know what malpractise insurance in the states is like? It's ATROCIOUS. You go into surgery, dr says you're going to have a scar, guy comes out and sues for malpractise cos he has a scar. It's insane. I think the warnings are great to have -- butt-covering is NEVER a bad thing. Doctors aren't omnipresent or omnipotent either -- it's good that you know that -- we DO have to be very aware of what kind of things our medications are doing to us.

Nebs can be used for any drug that's available for nebulizer. That includes everything from Acetylcysteine (which smells like rotten eggs and is used to break up mucus) to racemic epinephrine (which is used to shrink swelling in the throat with things like croup and that) up to and including lidocaine (for things like vocal chord spasm). You could even theoretically take morphine IV solution and nebulize it and give it that way. Lots of things can be delivered via inhalation -- it's just that sometimes the solution has other properties that do things that you don't want happening in your lungs. Like nebulizing alcohol to get real drunk real fast -- it'd work, technically, but it'd also break up your lung's surfactant and make all your little alveoli collapse. Bad thing!

But yes, you've got that right. You can't get Advair for nebulizer, though. You can only get Pulmicort, which like I said, is kind of like Flovent but a little bit different.

Atrovent is not combivent with another name. Atrovent is combivent without the Ventolin in it. Atrovent and Ventolin are two bronchodilators that work two different ways -- Ventolin works by stimulating your sympathetic nervous system (hence why it's called a sympathomimetic bronchodilator) to force the muscles to relax. Atrovent, on the other hand, works by keeping your parasympathetic nervous system from getting stimulated, (hence why it's called a parasympatholytic bronchodilator,) which keeps the muscles from contracting as much in the first place.

The sympathetic and parasympathetic sides of your nervous system are in a constant state of opposition -- so one drug sort of works like taking your foot off the brake of the car and one drug works sort of like putting your foot on the gas. Both will make you go faster, just when you do both at the same time it works REALLY good.

This hormone thing is actually relatively rare (<3% of the population) and so it isn't the first thing that most people think about when it comes to exacerbations of asthma, until the patient actually comes up with something saying 'when I pms then I get all asthma-y'. They know about it -- just within the realm of all the information they have in their head, it isn't the first thing that comes to mind unless you specialize in that sort of thing.

Wrin: What a font of information you are.

Yes, the brand name for albuterol is Proventil. And Yes, the USA is a tad out of step in many, many ways. Note that we did not adopt the metric system, either.

The hormone thing: bummer. I thought I was on to something, but I did get them refilled successfully--it only took a week. We'll see.

The thing with the medical system here is that it is impacted. I'm lucky and one of the few people I know who have such good medical insurance--probably because my workplace is unionized. Most research used to be done in academia; now it is mostly private. With the move to HMOs, access is more bureaucratic and we have millions of people without any kind of insurance at all, which strains the few free clinics and the ERs. Then we have the state and federal budget crisis, which has caused many facilities to close and access for the lower economic levels is almost nil. We're developing an underclass, much like a third-world country, and an overclass since the corporations have just perpetuated the largest, wholesale highjacking of the middle class in the USA in history. Nary a citizen protested. But I digress.

The pulmonologist's office says do the peak flow. I will do the peak flow; and the hormones; and see if I can get the insurance company to up the amount of Intal I can re-order (with 8 puffs per day, I'm out in 25 days and insurance only permits one every 30 days), to obviate the guaranteed episode on the 27th day or so. I'm existing on low doses of prednisone because I have to work. I'm four years from retirement but am wondering if I can last. I might also bring in a "spitoon" of sorts and take the Intal as you suggested to see if this helps. It would also cut down on the amount of time in the morning it takes to medicate.

Why couldn't you tolerate Flovent?

I will ask about Tilade if I don't get better on the hormones. I don't care what it tastes like. I don't plan on any kissing any time soon.

I also didn't know about the caffeine in theophylline. No wonder my heart is pumping when I'm trying to settle down to sleep. Now that you mention it, I've just had another sort of eureka. I recently switched from espresso to tea, which I bring to work in a thermos. I think I will switch back to coffee and see if that combo with hormones will do the trick. Many thanks for the heads up on the antibiotics.

Hope you are feeling well.

Mary

Meh, some would disagree.

I'm not saying I mind that you guys have different names for it -- it's actually rather convenient, when someone comes into hospital insisting and insisting that Ventolin doesn't do it for them, when their chart says opposite, and you give them Ventolin anyway, with some Berotec on standby in case they ARE right, and are greeted with cries of "OH WOW this works WONDERS What's it CALLED?"

".... Albuterol."

You were on to something with the hormone thing -- it's real, it happens! Just because it's rare doesn't mean it doesn't happen to anybody.

Yes, the medical system in the states I find incredibly foreign -- I'm used to a healthcare system that's not allowed to turn a profit, and thusly doesn't spend as much money stuffing pockets. Unfortunately, it means we lose a lot of good doctors and other healthcare professionals to the States, meaning we're chronically understaffed. Me, personally, I wouldn't trade working here for working in the US : I'm not a real big fan of getting sued, but that's another story.

Try cutting your intal down to 6 puffs a day, 2 morning, 2 lunch, 2 before bed. See how that puts you through. I have a feeling that by spacing the doses out, and giving the drug a shorter time to get down below its effective dose, your loading dose will not need to be as high. Talk to your doctor about this, however. Even if you have to take a swig of water from a bottle and spit in a toilet, DO IT. The low-doses of prednisone is insane -- then again, I have a bias against the stuff. Are you taking it at 8am every other day? That's the best way to take oral steroids -- mimicks your body's own steroid pattern, and keeps you from getting horribly adrenally suppressed. Again, ask your doctor first.

I couldn't tolerate flovent because for some reason it gave me this incredibly hoarse voice. I think it had to do with the fact that Flovent is absorbed much quicker than Pulmicort is, and if any of it settled on my vocal chords, I didn't have a chance to cough it out or rinse it off before it burrowed its way in there and hypertrophied my favourite muscles. (I sing, so this was more annoying than I thought IMAGINABLE.)

The tilade thing -- hey, whatever works for you. I'm not sure if it actually DOES work better -- just something I've heard mentioned. Worth a try, though, if the Intal's being spaced apart doesn't work better.

There isn't really caffeine 'in' theophylline -- caffeine is a molecule closely related to theophylline -- in fact, back in Tha Day, they used to use caffiene to treat asthma. Since then, they've managed to come up with a few drugs that have varying amounts of real, live theophylline in them. Theo-dur is one of the stronger ones. Aminophylline, if I remember correctly, is not.

Wrin: I am in contact with the doctor's office, and will be going in as soon as they can schedule an appointment.

You're right about the profit thing. Healthcare should not be profitable. We have a lot of horror stories about people being denied medical care, and I feel deeply about this issue. The right to access shrinks daily. In fact, HMOs have pulled out of the rural areas in California, leaving many residents without viable alternatives.

I started doing the Intal four times per day, as you suggested, and yes, I do it first thing when I get up. I'm afraid to cut back to six doses since I'm symptomatic every day now. I hear you about the prednisone, but I have to work. The doctor knows I'm doing this. I haven't had a chance to call the HMO about giving me two inhalers per month. The doctor was "astounded" at the peanut warning with Combivent. I faxed the package insert. He advised they did not have this information! This is one of the biggest medical centers in the country, a teaching hospital. I realize I'm jumping around here, but must leave the office now.

Thanks for replying. I appreciate your input greatly.

Mary

No problem at all.

I see your logic with the Intal thing -- if you find taking it qid works much much better than bid, then you can maybe try cutting it down to two puffs tid and see if you can get away with it.

*crosses fingers*

I didn't even know about the peanuts thing. I will have to look that up. Aiee!

Wrin: what an angel you are.

Again, of course, I am hurrying off to yet another meeting, but I feel human today for the first time in weeks. I don't know if hormones can kick in that quickly and the combined readministration of Intal can work so quickly, but nonetheless, I am myself today. The true test will come after I take the last prednisone. Taxes are due here in the U.S. April 15th and I've been to ill to address the issue. This is usually a time-consuming effort but nonetheless a wonderful result since I always receive money back and usually earmark this "pour moi."

Can't wait to hear from the doctor's office about the Combivent peanut warning. Perhaps they can prescribe something in its place. At any rate, they are setting up an appointment. This takes a long time because, as I said, the system here in the U.S. is so impacted.

Today I must find time to call the insurance company.

My best regards to you.

Mary

I've looked up the combivent thing -- you can still take Ventolin/Albuterol, it's the Atrovent in combivent that they don't want you to have.

From Rxlist:
"Ipratropium bromide inhalation aerosol is contraindicated in patients with a history of hypersensitivity to soya lecithin or related food products such as soybean and peanut."

I have a feeling if you're not INCREDIBLY allergic to peanuts, it won't kill you. I didn't know about this, and I'm going to guess that a few ER staff I know of didn't know about it either. I think it'd be a good idea to take it under supervision of your doctor. I think they're afraid it might cause the same kind of reaction that peanuts would? Not sure! I can't seem to figure out WHY, but the documentation IS there.

I hope the Intal is working for you -- and the hormones, too. Like you say, the real test will come when you're tapered off the prednisone, but I've got my fingers crossed! If this means you can cut down on the amount of medication you take (the hormones) then by all means, right?

Wrin: well hopefully the word on peanut allergies and Combivent will get out and I'm glad I could potentially help someone else. I am highly allergic to these suckers and constantly read food package content info to see if they've slipped any peanuts in whatever I'm thinking of buying. I don't usually have a problem because I eat little junk food, but I do have to ask when I go to Thai or Chinese restaurants. Peanut oil is also a concern.

I read that you think I'm taking too many meds. I am also concerned about that as well but don't plan on cutting back on anything until I've stabilized and have several weeks if not months behind me of feeling well. It's been five years since I've had "several months" of feeling well. But I'm determined to try.

I would also like to do more exercise to strengthen my lungs, diaphragm, etc.; however, when I underwent some advanced breathing tests not long ago, my blood oxygen fell to 85% just walking around the clinic corridor and they made me sit down. This was without active asthma, no symptoms, feeling great. Any advice?

Hope you are feeling well.

Again, thanks for replying.

Mary

Hi Mary. I want to share that my son who will be 18 months old tomorrow has now been off nebulizer treatments for 2 months after 13 months of use. Thankfully I got educated and learned that most products in the home (cosmetics, personal care items, and cleaners) contain toxic chemicals that irritate and trigger asthma and allergies. My son was on Xepenox (albuterol) and Pulmicort treatments 2-4 times a day. After we got all the toxic chemicals out of the home and started using safer, healthier products at home and after he was taken out of daycare where they are required to continually disinfect everything is when he got better. He no longer wheazes and his breathing is great. Outgassing is very real -- just think of all the horrible fumes that come from the aisle of cleaners at the store -- all those cleaners are tightly closed yet that aisle stinks -- that is what happens in the home and it affects your health. I heard about others having success after detoxifying their home and I was skeptical, but I gave it a shot. My son's health is priceless and it worked for us. Good luck to you.

------------------
Lori K

Don't worry about the combivent then; most asthmatics don't find it makes that huge a difference. It usually works better for people with things like emphysema anyway.

I do think you're taking a LOT of medications, but if they're all working, it's probably not 'too much' per se. You're doing this the smart way -- let's get under control, and THEN we shall begin to wean off some of the drugs.

Most low-impact cardio tuning exercises are wicked for your cardiovascular system. Your heart and lungs are irriversibly and unignorably intertwined. Take care of one and the other will have a slightly easier time of things. My favourite cardio tuning exercise is stationary bike -- winters up here are kind of nasty, and I've got some seasonal allergies, so this is what's kindest to my body. Lots of asthmatics swear by swimming pools, especially if you don't have a chlorine allergy, because the dust/pollen counts inside a swimming pool are so low.

Hope it works out!