WhiteCoat

Treating Asthma on the Cheap

For people who suffer from asthma, most treatment involves an “MDI” or “metered dose inhaler.”

I won’t get into all the specifics here, but many people don’t use inhalers correctly which, in turn, significantly decreases the effectiveness of the inhaler. Putting the inhaler in your mouth and actuating it causes a substantial proportion of the medicine to be sprayed either on your tongue, on the roof of your mouth, or on the back of your throat. Ideally, patients should hold the inhaler 2 inches (2-3 finger breadths) in front of their mouth, open their mouth, actuate the inhaler, and then inhale deeply – with their mouth still open. Looks dorky, but that is what gets the most medications into your lungs. Often patients have difficulty coordinating the actions.
Here is a link describing proper MDI use.
aeroch6
Enter the spacer device. The spacer is a hollow chamber that fits on the end of a metered dose inhaler. The dose of medicine is sprayed into the chamber where it forms a mist. The patient then inhales the medicine from the other end of the inhaler so the particles get deeper into the lungs. Here’s a link about use of spacer devices. Use of a spacer device can increase the amount of medication delivered to the lungs by 300%.

While a spacer device can make you better, they’re expensive. You can get them from Canada for $65. In the US, they’re more like $80 to $100. If you lose them or they crack, you’re out another $100 to replace them.

So a patient came to the ED and was having trouble controlling her asthma. I recommended a spacer device to help her – in addition to adding steroids to her regimen. She told me that other doctors had recommended a spacer, but that money was tight and she couldn’t afford one.

Spacer Device So I MacGyvered a spacer device out of the water bottle she had sitting on the bed next to her. Basically, I used a pair of scissors to cut a hole in the bottom of the bottle that would just fit the end of the MDI (this is another version I made at home where the hole is a little too big).

This obviously isn’t an ideal device. Some of the medication will be deposited on the ribbed sides of the bottle. It’s probably a little bigger than it should be as well. But even if it doubles the amount of medication getting into the patient’s lungs, it’s better than using nothing at all.

It would be an interesting study to determine the amount of medication delivered via traditional spacer versus this jury-rigged version. If it helps keep patients breathing, it’s worth it.

UPDATE JULY 18, 2009
Thanks to the research from Allergy Notes! There were a couple of published studies showing no statistical difference between the use of homemade spacers and commercial devices.
See this Cochrane review
Also see this study in Lancet showing “a conventional spacer and sealed 500 mL plastic bottle produced similar bronchodilation, an unsealed bottle gave intermediate improvement in lung function, and a polystyrene cup was least effective as a spacer for children with moderate to severe airways obstruction.”

30 Responses to “Treating Asthma on the Cheap”

  1. Finn Haddie says:

    Nice improvising, but it raises the question: Why the hell does a small plastic tube with a cap on one end and (presumably) a flange on the other end cost more than $10?

  2. Danimal says:

    Finn Haddie: My guess is the cost is due to liability insurance.

    Great McGuyvering, Doc — hope you didn’t put yourself at legal risk.

  3. John Bratt says:

    I saw a guy make something like that in college. He didn’t have asthma though…

  4. This is speculation, but you may have violated federal or civil laws. Who knows how many? (I hope my observations are just a joke. Smile.)

    - Manufacturing an unlicensed medical device.
    - Using a non-sterile scissors to do it.
    - Or misusing a surgical scissors to do it.
    - Possible patent infringement on current devices.
    - Business interference with current devices.
    - Interfering with the recommended delivery or dosage of an approved medication.
    - Reusing a non-reusable disposable bottle.
    - A germ infested bottle, at that.
    - Insufficient labelling of a medical device.
    - Operating a pharmacy without a license.

    Maybe you could add a disclaimer
    “This post for entertainment purposes only”

  5. Michelle says:

    My son has asthma and I’m positive that we picked up a spacer from the pharmacy (we may have had a prescription for it) for probably less than $20. Also, my son’s pulmonology office has given him several spacers, though not as elaborate, that we continue to use. Perhaps those are references for future patients.

  6. Hank says:

    Another trick that I’ve seen the pediatricians use is to get a styrofoam 8 oz coffee cup and poke the inhaler through the bottom of it. Then you press the open end over the kid’s nose and mouth, and actuate.

  7. chuck says:

    Along the same lines as 100$ pieces of plastic:

    Albuterol is cheap. It has been around a long time and is generic.

    Xoponex is much more expensive and does not work any better.

    California is bankrupt, yet can you guess what medi-cal does and does not cover?

    Yep, you guessed it. Xoponex covered. albuterol, not covered.

    And people seem hell bent on putting the government in charge of all healthcare??

  8. Kath8562 says:

    Psst—
    There’s a fairly inexpensive valved spacer available–it’s called Easivent. Look it up and see if you can order it, and what your pricing is on it(in my pharmacy it retails for < $45)

  9. the psycho therapist says:

    Nice improv. I’ll assume your creativity stems from a vast experiential knowledge base (see bong reference above) onna counna I want to think of you as a man of many talents, great character and repertoire.

    (hee hee, could not resist, begging your pardon)

  10. pedidoc says:

    “It would be an interesting study to determine the amount of medication delivered via traditional spacer versus this jury-rigged version”

    The studies have been done…

    THE LANCET • Vol 354 • September 18, 1999 “Home-made spacers for bronchodilator therapy in children with acute asthma: a randomised trial” H J Zar, G Brown, H Donson, N Brathwaite, M D Mann, E G W e i n b e r g

    Archives of Disease in Childhood 2000;82:495-498 “Lung deposition of aerosol a comparison of different spacers” H J Zar, E G Weinberg, H J Binns, F Gallie, M D Mann

    …and reported in not throw-away journal.

    I have used water bottle spacers in developing countries. They work.

  11. AbbyPharmD says:

    Thanks so much for this post! As a pharmacist, it irritates me so much that most insurances will cover 3-4 albuterol (excuse me, ProAir) MDI’s each month, but won’t consider covering a spacer! Who knows, maybe if they covered a spacer Medco or Caremark or Anthem would only have to pay for 1 inhaler per month per patient. I will definetly be recommending this “alternative” for patients in the future!

  12. Liz RPh says:

    My pharmacy retails the Microchamber spacer for about $20, IIRC. (maybe $25? definitely under $30) Some insurances pay for it, some don’t, but I think that’s definitely reasonable for the added benefit that patients get.

    There are definitely some more “high end” priced spacers, there are less expensive ones available if you know which ones to look for.

    Also – in response to the commenter who mentioned California’s XIX covering Xopenex over Albuterol, it probably has something to do with drug company kick-backs. i.e. for every prescription filled for Xopenex in California, the manufacturer will pay the state of California $x. Iowa has/had a similar program for Xopenex – and only covered Ortho-brand-name birth control for the same reason. I don’t have details on dollars by any means, but I can definitely envision circumstances in which covering brand name medications is less expensive for a state versus generics.

  13. lexi says:

    Our camp nurse fashioned an elcheapo spacer using the tube from a TP roll (had been a “clean” roll … not used in a bathroom) that worked well for me when my plastic one broke at camp.

  14. Kim says:

    I though spacers were discouraged with the new HFA inhalers. I’m pretty sure mine even has some stern wording about not using a spacer right on the canister.

  15. Linda says:

    As of March 2009, California covers albuterol without a TAR. Some county programs will do Xopenex, but you can get a PA within 4 hrs to change to albuterol.

    FYI – albuterol inhalers have changed since Jan 2008. They no longer contain CFCs as the propellant (thus the HFA on the end of the name). Patients no longer feel the “puff” they used to feel, so they don’t think they are getting any medication (wrong).

    Since the new inhalers are HFA, they should be used with the lips around the mouthpiece – not outside as you’ve described (that was true with the old albuterol inhaler though). It is still best to use it with a spacer though. The newer inhalers for prophylaxis – Advair for example, requires the pt to put the mouthpiece in the mouth since inspiration is the actuator.

    Finally, the HFA’s (albuterol, atrovent, etc) now all need to have their inhaler cleaned more frequently. Without the CFCs, the drug & propellant will clog the inhaler faster – another thing older COPDs & asthmatics don’t get & claim they don’t work as well.

    Also, I’ve never sold a spacer for $100 – thats gouging or you’ve been told a tall tail. Spacers, even the ones for kids with a mask are only 30-45. Granted, that can be pricey, but if on public assistance, a PA can be done within hours & is always approved for children. And, for those not on assistance, what was the wait time worth to you to wait in an ED?

    • Kim says:

      There is legitimate research showing the HFA inhalers don’t work as well (although also some argument that this is not all bad as less medication is launched into the back of the throat). There is also legitimate research showing that inhaling ethanol directly into the lungs (several of the HFA inhalers include ethanol in the payload) causes irritation. Patients who “claim” to have trouble with this medication are not all Doing It Wrong.

      I’m not sure why we don’t just have breath actuated inhalers for rescue medications as well as prophylaxis…even with an MDI, without a coordinated inhalation the medication goes nowhere. Surely the good people at Glaxo wouldn’t mind taking money from all the HFA malcontents.

  16. Memune says:

    Long time asthmatic here – you can make a decent spacer out of a piece of PVC pipe or even cardboard tubing (paper towel roll). The styrofoam cup also works quite well, especially for infants and small children (it makes it seem like a game).

    Agree about albuterol vs Xopenex also. Xopenex doesn’t work as quickly as albuterol, so many pts believe it isn’t working and thus use more of it. I keep both handy as I believe albuterol is better as an immediate rescue.

  17. DefendUSA says:

    That’s a great idea! instead of using one of the 16oz bottles, they could use the 8 oz shorty with no ribbing on the side and it would be more contained.

  18. Nancy says:

    I’ve had to come up with an improvised spacer. My toddler was having an unexpected asthma attack and when I went to bring him his Pro-Air, I realized the spacer was still sitting on my desk at work. Luckily the daycare was well stocked with arts and craft supplies and I cut down some contact paper applied to construction paper and rolled that into a funnel and taped it up. It worked like a charm to fit over his mouth and nose.

    Had he been able to inhale only through his mouth on command, I would have used a bottle like you did.

  19. Shalom (R.Ph.) says:

    Retail costs at the pharmacy where I work:

    Aerochamber Plus, innovator product, $45.49
    Optichamber Advantage, generic of above: $11.29

    Aerochamber with paediatric mask: $61.29
    Optichamber with paediatric mask: $24.99

    There’s also the Vortex series, which has an aluminum tube that is claimed to be better than the plastic (something to do with anti-static). Also the mask is shaped like a cartoon duck, for whatever advantage that gives. It’s priced a couple dollars above the Optichambers.

    Note that all of these require a doctor’s prescription in the USA (“for sale by or on the order of a doctor”). Many insurances here in NJ pay for these on prescription, and those that don’t, will usually cover them as a DME (although these have to be billed differently and we’re not set up for that, we send them to a surgical supply instead).

    I had one inner-city patient who just couldn’t get the hang of the spacer, what it was for or how to use it. I finally said, “Look, just think of it as a high-tech version of a bong.” His eyes lit up and he said, “Oh, I get it…” Gotta speak their language.

  20. AprilRN says:

    I say, simply, good job! Thinking outside the box.

  21. Rachel says:

    I am so glad I came across this article! I lost my daughter’s spacer, her insurance will not pay for a new one, and I am extremely short on money. I’m going to try your water bottle spacer and hope it works for a day or two until I can buy a real one. Thank you for your creativity!

  22. Rorn says:

    Mcaid will also pay for a nebulizer (“breathing machine”), despite the fact that studies on spacers have shown them to make the inhaler equivalent to a nebulizer in effectiveness.

  23. Rorn says:

    P.S. The government is prohibited by law from taking “kick-backs,” so the pharmacy companies call them “incentives.” They say, “SSSShhh.” You can’t keep it secret; the citizens already know it!

    “A rose by any other name. . .”
    Likewise:
    “A cess pool by any other name. . .”

    Meanwhile, doctors can’t even accept a $2 pen from a drug rep. Guess we’re more corruptible than politicians. LOL.

    It has been said that politics makes strange bedfellows. When a pharmacy rep tells me their drug is now covered on [insert name] insurance company’s formulary, I ask, “Oh! Who slept with whom to make that possible??” Usually they laugh and reply, “That’s almost how bad it is!”

  24. Bavi Naidoo says:

    We use these plastic bottle spacers all the time in SA. Best way to get the mouthpiece to fit is to wrap a piece of flexible wire around the pump mouthpiece, then heat the wire till red hot. (Cigarette lighter works well). Then press the hot wire to the base of the plastic bottle. The wire will melt out a piece of plastic and voila! a perfect fit.

  25. Ken G says:

    Just made a spacer out of an 8 oz. baby bottle. Hope it works.

  26. In the spider-web of facts, many a truth is strangled. – Paul Eldridge

  27. Anotherme says:

    In CA, the spacer requires a prescription. I have always told them I could make one out of water bottle. Now I see great minds think alike!

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