SPACERS AND NEBULISERS

Because asthma makes the airways narrow, the best medicines to treat it are those that are breathed (inhaled) directly into the lungs. Here two devices are discussed - spacers and nebulisers, that get the medicines into the lungs effectively and safely.

There are two types of medicine:
Preventers

are those that guard against the symptoms of asthma happening at all.

Relievers

Relievers are those that rescue people from breathing difficulties as they happen by opening up the airways.

More information about these medicines is available in the 'Take control of asthma' booklet available from the National Asthma Campaign

Spacers

Large spacers are usually made in two clear plastic halves that click together. At one end there is a mouthpiece or mask which has a valve that only opens when you breathe in through it and closes when you breathe out. At the other end there is a hole for the aerosol inhaler to fit into.

To use the spacer the inhaler must be shaken, put into the device and then squirted once. The medicine enters the spacer and is inhaled by breathing through the mouthpiece. As with the inhaler alone, you can take one large breath in, although with a spacer there is no need to time it exactly. After you squirt the inhaler you have up to five seconds in which to take a breath in, which you should then hold for ten seconds. If you are short of breath do not try to take one large breath in, just breath in and out normally and squirt the inhaler whenever it is convenient. The dose can be repeated.

When to use a spacer

Spacers are more efficient than the inhaler alone, so they are used:

• To give inhaled medicines, particularly to babies, small children and those who have difficulty co-ordinating their inhaler techinique. Just an inhaler is no good for young children.
• To reduce the risk of mouth and throat side-effects from inhaled steroids and of absorbing steroids into the body.
• To give a higher dose of medicine during attacks.
• To allow the propellant time to evaporate before breathing in the medicine.

Which inhaler fits which spacer

Because drug companies make their inhalers in slightly different shapes, you need to find a spacer that fits your inhaler. Some inhalers are already attached to their own spacer (eg Becloforte Integra).

Spacer - Nebuhaler
Reliever - Bricanyl
Preventer - Pulmicort (inhaled steroid)

Spacer - Volumatic
Reliever - Ventolin
Preventer - Becotide/Becloforte (inhaled steroid) and Cromogen (sodium cromoglycate)

Spacer - Fisonair¹
Reliever - N/A
Preventer - Intal (sodium cromoglycate)

¹The Fisonair fits all inhalers, including Tilade, but not with a snug fit.

A smaller spacer, called the Aerochamber, is more suitable for children and fits all inhalers snugly. It comes in baby, child and adult sizes with a mask. For further details please call Medic-Aid on 01243 267321.

You can buy some of these spacers without a prescription from a chemist.

Masks

Small children cannot use the mouthpiece of a spacer. The age when they start to learn varies but it is likely to be around two.

Some large volume spacers, when used with a mask by young children, must be held so that the mouthpiece valve is open all the time. This may mean holding the valve up at an angle, with the child lying or leaning back.

The spacers above, except for the Fisonair, can fit children's masks onto the mouthpiece.

Tips for using the spacer and mask with babies

You may experience difficulties getting your child to use a spacer and mask. It is worth persevering though, and the following tips may help:

• Gently stroke their cheek with the mask so they get used to the feel of it.
• Remember that they will breathe in after crying, so keep the mask over their face.
• Use it when the baby is asleep.
• Hold the baby so that their arms are wrapped up.

Tips for older children

• Show them how to use it; you do not have to puff the inhaler to do this.
• Turn the spacer into a toy with stickers.
• Pretend it is a trumpet (it is alright to blow into the mouthpiece).
• Turn it into a counting game. The adult counts aloud as the child takes five breaths from the spacer.

The coffee cup spacer

Take a large disposable coffee cup and make a hole in the bottom which fits the inhaler, then squirt the inhaler while using the cup like a mask. Although some of the medicine is lost, it is very useful in an emergency. However, this is not recommended as a long-term measure.

Nebulisers

Nebulisers should only be used if a doctor recommends them.

What is a nebuliser?

A nebuliser is a machine that turns a liquid into a mist by blowing air or oxygen through it. There are several different designs of nebuliser but nearly all of them have four main bits:
The nebuliser unit itself
This is a small container that is filled with the liquid medicine. Blowing air or oxygen through it turns the medicine into a mist. It takes several minutes to empty.

A source of compressed gas
In hospital or health centres this will probably be oxygen but at home it will be a small electrical air pump. There are others which work on different voltages, ie car batteries and rechargeables or those for use outside the UK. There are also nebuhsers with hand or foot pumps but remember someone has to pump it. They me useful if you are travelling somewhere.

A mouthpiece or mask
This connects to the nebuliser unit so that the mist can be breathed in.

The liquid medicine
This goes into the nebuliser unit.
The 'ultrasonic' nebuliser is different from the others. It makes the mist by vibrating (shaking) the liquid medicine.

Getting a nebuliser

Even if a GP recommends using a nebuliser they cannot prescribe one on the NHS. If hospital consultants decide a nebuhser is essential they can prescribe one, but they may not always get the funding. Some people therefore have to buy their own nebuliser. There is no 'best buy' although your doctor or nurse may help you to choose one.

If you are on a low income and have to buy a nebuliser visit your nearest Citizens Advice Bureau for information about local sources of money. The National Asthma Campaign is unable to give such grants.

The times when a nebuliser is used

In an emergency
Most GPs, all hospitals and some ambulances have nebulisers which are used to treat severe attacks of asthma. A nebuliser is more effective than the reliever inhaler on its own because a much larger dose is given. Some doctors give patients their own nebuliser to use at home in case of severe attacks; however, spacers may also be used, especially for children, and can be just as effective.

Treating persistent asthma
A few people who have severe asthma most of the time find that their reliever inhaler does not work, even though they use a preventer. They may need the larger doses of reliever that a nebuliser can give. For the same reason, a few may also need a tlebulised steroid preventer.

Treating small children with a presenter
Occasionally a nebuliser is used to help a child inhale preventer medicines. However, a spacer with a mask is usually just as effective. Older children need only use the spacer on its own: it is much quicker. makes no noise and is easily portable.

The medicines which are used in a nebuliser

• Preventers
• sodium cromoglycate (Intal, Cromogen)
• budesonide (Pulmicort)
• Relievers
• salbutamol (eg Ventolin. Steri-neb Salamol)
• terbutaline (Bricanyl)
• ipratropium bromide (Atrovent, Steri-neb Ipratropium)

Most medicines come ready for use in a single dose. Some medicines need to be mixed with a diluted salty liquid called normal saline: you must not use tap, distilled or bottled water. The ideal amount of medicine and diluting solution is 4ml, but for some of the newer designs this may not be the case.

For further information on the side-effects, see 'Take control of asthma' and 'Steroid treatment for asthma' - also available in booklet form from the National Asthma Campaign

Some guidelines for using nebulisers at home

1. Ask your doctor, nurse or physiotherapist: how to set up the nebuhser and air pump; how to keep it clean; how to get it repaired or serviced; and how it works.

2. Be sure you know about the medicine: which one to use; how much to use; how to put it into the nebuliser; and when to take it. Make sure these instructions are written down for you.

3. Understand the warning signals that show an attack is on its way and, if the doctor has advised you to, start using the nebuliser. The doctor or nurse may have given you a self-management plan. This may include signs like:

• Your normal medicines are not working.
• Needing to use your reliever more often.
• A drop in your peak flow reading.
• A rise in your pulse rate.

4. Ask your doctor what you should do after using the nebuliser for an acute attack. You may have to: contact your doctor; have more nebuliser at set times; or start taking steroid tablets.

If the nebulised reliever is not working quickly in an accute attack, or if repeated doses are needed more often than every three hours, seek medical advice urgentlv.

5. Keep on taking your regular preventers; using a preventer regularly should mean that nebulised relievers can be kept to a minimum.

Further information

Please contact the National Asthma Campaign or call the Asthma Helpline on 0345 010203.