Respiratory Help needed - no mist from the nebulizer mask

ButterflyWings

Forum mates,

I am giving DH breathing treatments (nebulizer) around the clock these days *for his asthma*, as often as every 4 hours. Stage 7a is throwing us a curve ball today as he is wheezing mightily, and coughing / choking, then OK to sleep for a while. I can't get the breathing treatment to work well enough today.

Can anyone help with a solution for how to get more mist out of the darn thing?

My problem is the duoneb solution mist is not coming out as much as it usually does. I'm sure it has something to do with the container part that's attached below the mask, where you squirt the inhalation solution. Sorry for all the technical terms. Its been a day. And a sleepless night.

• If I don't wash the little container part out after 1 or 2 uses I think it gets a little clogged maybe (?).
• If I do wash it, same thing. No mist to speak of even if I use 2 vials of inhalation solution
• The tube thing that connects the mask to the machine does not seem to have any moisture in it, so its not that. (Yeah, I don't try to wash them out anymore! Bad idea!)
• This clogging or whatever, seems to happen especially when DH takes the mask off mid-treatment (at least every couple of treatments he does this =|) and then lays it down or its hanging upside down briefly and I think it clogs somehow.

What can I do? Hospice brought us 2 new mask kit things last week. I can't keep doing that and right now its too late anyway. Warehouse is closed til 8a. So I am giving a bit of morphine and he is wearing the oxygen canula. Our inhalers and disks aren't an option anymore as he can't figure out the breathe-in or breathe-out part (either blows into the inhaler or spacer, or tries to chew on the pump/inhaler device).

Poor thing. He just needs to breathe and the treatment isn't getting into his lungs much at all. That means the mask is only restricting what little breathing he can manage on his own and the machine is just making noise.

Respiratory therapists, pulmonologists, experienced caregivers out there. What can I do with these contraptions to fix it?

ImMaggieMae

I don’t have a solution for you since it’s been years since I’ve had a nebulizer in the house and never had a blockage with one. You’ve probably checked internet sites already that deal with this, but have you checked YouTube? There seems to be information specific to different brands. I will be up for a little longer and could help you look if you tell me the name of the nebulizer.

There’s no way you could reach someone at hospice? This sounds like kind of an emergency.

ImMaggieMae

I have mild asthma symptoms and take 250mg of magnesium. It’s not as strong as an asthma inhaler, but usually eliminates the need for one with my mild symptoms. It might be something you have in the house. That’s all I can think of. I feel so bad for you having to deal with this. I hope you both ended up getting some sleep tonight.

Mint

Butterfly you may know these things so just thoughts in case you don’t, have not given a treatment in 5 years so some things could have changed that I'm not aware of in that period of time

When he takes the mask off there is a good possibility the medication is running out. At least in the nebulizer cups I'm use to you would lose your medication if you turned them upside down. I usually just held mask up to their face keeping the cup straight up and down if thought they would pull it off. They will not mist if head not at least half way up even if medication still in there. The straighter they ste sitting up the better. In general these cups last a very long time.

Check to see that tubing from nebulizer to whatever gas source you are using has a good tight connection and also connected tightly to cup.

is there any chance that your power source could be the issue? Nebulizer cups usually last a very long time. There is a defective one now and then but not common in my experience. If you are using a small compressor you plug in to electric to run it at home maybe it has become defective. If you are running it off of his oxygen source check and make sure oxygen flow is truly there . I have seen instances where flow meter says it is at a certain flow but in reality there was no flow.

Maybe home care company can help you trouble shoot it?????

Hope you get it worked out know this is stressful for you

M1

Dear friend, I fear this answer may not be what you want to hear, but: this strikes me as a tempest in a teapot. If he is choking and having that much trouble breathing, he is likely past the point of benefitting much from any nebulizer therapy. I would use oxygen and morphine and stop the nebulizers. It sounds to me like you are missing the forest for the trees here. It may be easier to focus on fixing the nebulizer flow than on the fact that he is entering his last days. I'm so sorry. I don't mean this to be insensitive.

ButterflyWings

@ImMaggieMae thanks so much, I forgot about YouTube or internet search in my frazzled state, trying to keep him comfortable. Will check there! I did talk with the on call nurse and they upped his morphine dose a tad until the warehouse opens and they can deliver a new set.

Did not know about the magnesium. I will add to his comfort regime for however long we have left. I can crush it (or open if it comes in a capsule) and sprinkle it in his protein smoothie, right?

ButterflyWings

@Mint - thank you! I knew you'd have some good ideas on this. Will check the power source - didn't think of that. It may be waning a bit. This nebulizer is a tiny one, but normally generates strong air flow. I will see if a different tubing helps. Yes, it spills some when he removes it before I can prevent him, but I can see enough liquid in the bottom; it just is not misting.

I think it is the cups though. What is the best way to rinse and dry them out to make sure there is no duoneb or albuterol residue, and no water? (which I've also noticed causes the same problem if moisture is in the wrong area somehow).

Just trying to keep him comfortable.

ButterflyWings

@M1 Thank you always for your wisdom and expertise. Not insensitive. I'm clear there's not much further to go than 7a, and that it would be kinder on him to go sooner than later. Just trying to keep him comfortable.

He always has had a coughing asthma - very thick congestion that's not yellow like infection, but always produced and now that he's in late stages it can actually choke him. This is the 2nd time that its gotten this bad and I do think its a combination of exposure to a couple of aides with masks but colds, or no masks. And then his asthma and mucous production gets triggered even more.

So, I'm just trying to keep him comfortable with the nebulizer treatments and guafinesin expectorant (sp?). Giving oxygen and morphine alone still lets the severe wheezing and periodic choking cough continue and he can't sleep nor can I. Keeps trying to cough to clear his lungs and actually gets almost into a spasming cough sometimes. It is a lot. And I can't help him much at those times, but just be there and say soothing things. He gets agitated even with so much less energy. I know he's freaking out. Plus he gets this really panicky look in his eyes and I can see he's feeling like he is suffocating. Just getting him moments of relief.

Here's what I'm remembering right now:

• He just can't figure out the inhaler any more, blowing instead of breathing in. So he isn't getting his daily maintenance med dose that kept him stable for years. (symbicort or wixela disk). So lungs are clogging.
• I think water is lacking too. Aide was here more hours this week while I've been in out due to something I'll call a witch hunt😡 and his routine is just off. I will remind her to keep him hydrated. This was needed way before Alz.
• The nebulizer mask "cup" issue really does need to be figured out, since I'm going through them fast lol
• And, as you said, this is also evidence of progression and with everything above combined, he's not going to make it too much longer. I know. I just don't want him to suffer needlessly in the final moments if I can help it.

I don't think he's on his actual final week or days as far as just end of life progression, though I don't think he will still be here by the end of this year. But if I can't figure these comfort meds and his hydration out he will not survive one of these choking/coughing/gasping for air episodes. He rips the oxygen off and tries to remove the mask if only a thin mist is coming out (or nothing) - desperately trying to cough his way clear to some fresh air. It almost is like he might feel like he's drowning on dry land. I feel so sorry for him and just keep speaking softly, telling him its OK, and restraining his hands lol. We probably look like a wacky wrestling match trying to keep the oxygen on him and fill the cup with a duoneb, drag him a bit more upright, etc.

His hospice nurse and I thought he was a goner a couple of weeks ago, with the same issue and last night was rough. She wants him on the nebulizer as well as singular, plus expectorant. Oxygen and morphine are the last resorts and I don't hesitate to use them, but do know what that means. It is morning now. No sleep, and heading back to court in a few hours so I hope I do get him a bit stable at least before then. I'd hate for him to go, struggling like this when the aide is here by herself. I will never forgive my steps and in laws for doing this, and definitely at the worst possible time. Its like they think he's been actively dying for the past year and are trying to position themselves to extract some kind of inheritance or whatever. I hope I don't get held in contempt of court today because after a night like DH just had, all I feel is contempt and I'm running on fumes so the filter may just not work like it should.

THANK YOU ALL for the ideas and just for being there. What would we do without this special family? I will keep you posted.

Mint

We just rinsed them out with water and shook it good and placed upside down to air dry. Never have seen albuterol or duoneb clog a nebulizer. You are correct something is not right if not seeing a good mist.

l understand a little of what you are going through. I took care of my sister at home and you want to do all you can to make him as comfortable as possible as that makes you more comfortable.

You are right, him not getting his maintenance meds is increasing his need for aerosols. Those two nebulizer meds don’t provide a steroid so he is losing their anti inflammatory effect. Dehydration is definitely playing a role also.

As disease processes progress treatments are just not as effective any more also. Sometimes comfort becomes the best treatment for the one we love and us. May you find peace Butterfly.

ButterflyWings

Thanks again @Mint you all are the best. Yes also to the point about a steroid. Historically for years, once a year in early spring we had to resort to prednisone. But since Alz, prednisone makes him absolutely crazy unmanageable. Like climb out the window, run in front of a car kind of escalation.

So, the only magic pill hospice found recently was a steroid I had never heard of... dexamethazone (?) I had forgotten that's what cleared him temporarily last month. I'll bet hospice is sending that today already, since my midnight phone call for nebulizing cup troubleshooting.

And I hear you as well as M1, that this is Stage 7 and only so much that can be done. I know we are almost at the end of this road.

M1

I know you are doing everything you can--and more, you're exhausting yourself. I think you are closer to the end than you think BW. I'm so sorry. Morphine is very, very effective at relieving the sensation of shortness of breath. Don't be afraid of it.

mrahope

So, so sorry to hear about your troubles @ButterflyWings. My DH also is a lifelong asthmatic with exacerbations in the spring and fall. Completely concur that an oral steroid will simply be a recipe for agitation and problems. FWIW, my DH uses ipratropium in his nebulizer, which according to my (admittedly limited) knowledge is used to help where spasms are impeding breathing along with albuterol. It's a shot in the dark, but perhaps hospice knows about this. A LO with breathing issues is a special level of hell. So sorry for what you are both going through.

Ed1937

I'm sorry to hear of those kind of problems. It's hard enough to just go peacefully. I hope you can hold it together in court, and get some good news. Things have to change for you sooner or later.

Mint

Agree with M1 about the morphine.

housefinch

Agree with @M1 about forest and trees, at least hearing this without seeing him. Am also a physician. Sending hugs.

ButterflyWings

I don't disagree with you all at all. He looks very thin to me too. Almost overnight. And right now seems to be itching!? I will check for med side effects and put some lotion on his arms and hands.

Following our hospice team's lead and balancing the duonebs (@mrahope) and morphine as needed. Oxygen whenever also. Thanks for the gentle coaching and hugs, friends.

midge333

It sounds like you and the hospice team are doing a great job in a very difficult situation. Good thoughts!

housefinch

Sending you and your family hugs, strength, and comfort. You’re doing an amazing job.

M1

unfortunately, all narcotics can cause itching--it's not an allergy but in fact a side effect. The lotion is a good idea, and antihistamines might help too....

ButterflyWings

*Early a.m. musings...it occurs to me, I wonder if hospice is being more cautious here because of the court stupidity. It is possible they would also have me stop the nebulizers now and just go with morphine but may be trying to avoid potential criticism aimed at me (and them) in the continuing proceedings, after DH passes.

I am trying to just stay focused. All the care notes from both agencies over 2 years, and every single specialist who has followed him reports spouse is providing "excellent" or "superior" care. It is so disheartening to have the distractions, stress, and mandated time away from him, to sit in court trying over and over to explain and defend dementia basics and best practices. This is nuts.

Litigation makes people nervous, so I do think it is possible they are taking extra care to not have any sense of the stereotype that hospice ends people's lives. If so, that is a shame. In the meantime, we both got more sleep last night. But DH is definitely responding to the disruption in our routines this week, and my stress probably. I need to go find @Ed's thread with some daily self-care commitments and get back on track there.

Final thought: DH is resting comfortably and has enough breath to be talking under it (what is that saying, "talking under your breath"?) anyway...I just caught something about pickles and such. I have no earthly idea of what memory he may have dredged up, or maybe its lunch time somewhere 😅