1959: Nebu-Halent Inhaler

1954 ad for Nebu-Halent Inhaler (You could use bronchodilator of your choice)

The nebuhaler was a product that entered the market in the late 1950s following the release of the first inhalers: Medihaler Epi and Medihaler Iso. 

The new product was a Freon-powdered pocket unit with a reservoir chamber with a self-cleaning, baffling device.  

It was called the Nebu-Haler.  The medicine used was Nebu-Halent, or you could use the medicine of your choice.  

This device made it possible to deliver finer, smaller particle-sized aerosols to the patient.  

It did not gain the popularity of the original Medihalers that entered the market in 1956, although it was another option for asthmatics.  

1954: The DeVilbiss Pocket Nebulizer

During the 1930s the DeVilbiss number 40 nebulizer could by found in the homes of many asthmatics.  It was a nice product that provided quick relief by the use of one or another epinephrine product (such as Asthma Nefrin, a.k.a., epinephrine).  

Chances are if you knew an asthmatic you probably saw one of these at one point or another.  Either one of these or a similar brand of glass nebulizer with rubber bulb syringe.  Either one of these or one or another brand of asthma powder.

Yet there were obvious flaws with the DeVilbiss No 40, such that it was made of glass and was fragile, and the aerosolized particles were too large for getting inhalents to the bronchi and alveoli.

This product was improved upon in the 1950s based on suggestions of doctors (and probably patients too) with the DeVilbiss Number 41 Pocket Nebulizer.  You can see a 1954 advertisement for the product here.  

1940s: The Collision Nebulizer

Photo compliments of E.M. Collision's own book (5, page 4)

While the 1930s gave us the first electric nebulizer, they were large, bulky, and expensive.  Most people who needed aerosolized inhalations simply resorted to other means, such as a glass nebulizer with rubber bulbs like the DeVilbiss number 40, or by igniting asthma powders of various sorts. Some people still resorted to using asthma cigarettes.

It was believed that the aersolized particles produced by most nebulizers or atomizers were large and impacted in the upper airways.  This was proved by experiments performed by Huckel and published in 1925.  He determend that aerosol particle had to be 5 microns or less, and be dense enough, to make it to the bronchi and alveoli to be effective. (1, page 10-11)

Another concern of physicians was that experiments "demonstrated that atomization robs air of oxygen."  This was a major concern especially when a treatment was given with a rubber face mask.  It was for this reason atomization was mostly "limited to hand sprays, and it's employment confined to quite short inhalations of a palliative nature to stop an asthma attack or for the treatment of the upper air passages." These short treatments were generally accomplished with two or three puffs using glass nebulzers.(1, page 6-7)

1, page 23)

So there was an obvious need for an improved product that would solve these problems.  And such a product was invented in the early 1930s  by W.W. Collisoin and introduced to the market in 1932 by a company named Collision.  The product was aptly called the Collision Nebulizer.(2)

It was an interesting product that was connected to the top of an oxygen tank, and this pretty much solved the oxygen dilemma.

Flow was adjusted to meet the demands of the patient, and was generally set between 7-8 liters per minute.  (1, page 5, 14, and 25)  

Flow from the oxygen tank filled a reservoir bag, so flow was monitored by monitoring "movements of a bag."  (1, page 5)

It also had a baffle in it to filter out large particles, and this ensured most of the particles inhaled by the patient were small enough and dense enough to make it into the smaller airways where they could do some good.  In this way, this product distinguished an "atomizer" from a "nebulizer."  Atomizers from this point on were used for perfume, disinfectants and paint products, and nebulizers were used for respiratory medicine. 

Studies at this time also showed that the rate and depth of breathing also effected where the aerosolized particles deposited.  If the patient breathed too fast and too deep most of the particles impacted in the larger airway, so it was determined the patient should breathe calmly.  (5, page 14)

Worded another way, laminar (smooth) air flow was preferable to turbulent airflow. Turbulent air is fast and furious and has an increased risk of causing the aerosolized particles to impact in the larger airways, such as the mouth and throat. A smooth, laminar flow is needed for the medicine to make it to the smaller airways. This is created by slow, or simply normal breathing during a breathing treatment.

This device was nice because it allowed the physician to prescribe a "precise" dose of medicine, and also be assured the medicine would reach the lungs where it's desired and have the greatest effect.  Collision describes his own device this way:

"It presents none of the tiresome features associated with medical apparatus, and is readily understood by patients.  While providing a vapour that meets the requirements of modern medicine, it embodies most simple and easily understood controls, and is comparatively small and compact.  These features have overcome the impracticability of patients taking a proper course of duly prescribed treatment at home, and of having the inhalations available at any time and during the hours of the night." (1, page 21)

There were two phials, one amber and one and one white.  The amber phial was for photosensitive inhalents.  A large teaspoon of each inhalent prescribed was placed in one or the other phial.  For daily curative (preventative) treatments Collision recommended placing camphor, menthol, or creosote in the white phial.  The recommendation was for these treatments to be taken every day as a preventative therapy.  Many asthmatics, however, stopped taking the medicine when they felt good. (1, page 22-3, 32-33)

To end an acute episode of asthma, Collision recommended placing adrenaline in the amber phail.  If the patient had an asthma attack while inhaling from the white phial, a handle can be switched from "white phial" to "amber phial." Or, when necessary, the handle could be switched to "both phials" to take in medicine from both.(1, page 22-3)

Rubber tubing leads to a mask with two one way valves, one opens on inspiration, and the other opens on expiration.  This prevents exhaling into the system, and allows expiration into ambient air.  A small hole allows for some ambient air to be drawn in during inspiration.  (1, page 24)

After each use the oxygen gauge should be checked to assure there's enough oxygen in the tank to support a treatment, if the patient requires one for an asthma attack during the night. 

References:

1. Collision, W.E., "Inhalation therapy technique," 1935, London, William Heinemann
2. Rau, Joseph L, "Conference Proceedings:  Design Principles of Liquid Nebulization Devices Currently In Use," November 2002, Volume 47, Number 11, Page 1257einemann

1932: The first use of the term 'Aerosol'

Many asthmatics participate in what is sometimes referred to as Aerosol Therapy. When you take a breathing treatment you are basically aerosolizing medicine so it can be inhaled.  While aerosols are present through history, the term wasn't used until the 1930s.

It was first used in 1932 by R. Whitlaw and E. Gray Patterson.  The term is derived in the following manner (1, page 173):

• Aer = air
• sol = solution

In subsequent years various generic terms have also been used, which include the following (1, page 173, (2 page 5):

• Mist
• Micromist
• Fog
• Fume
• Spray
• Haze
• Smog

The term aerosol basically refers to "the suspension of a liquid or solid particle in a gaseous medium. The term originated as the gas phase analogue to hydrosols (meaning 'water particle' in Greek) and refers to suspension of particles in a liquid." (2, page 3)  Most "theories describing aerosol behavior assume the particles are spherical." (2, page 6)

Aerosolized particles generally average in size from barely larger than a molecule to as large as 100 micrograms.  Although for the purpose of aerosolized particles to reach the respiratory tract, the following is necessary (3):

1. Greater than 10 um deposits in the nose
2. Greater than 5 um deposits in the mouth
3. 5-10 um deposits in the first six generations of bronchi (large airways)
4. 1-5 um deposits in the last 5-6 generations (small airways)
5. Greater than 3 um have a tendency to impact the conducting airways
6. 0.8-2 um are optimal for alveolar deposition

Bronchospasm, as what occurs in asthma, generally occurs in the smaller airways. For this reason, the ideal particle size is 2-5 um for best airway deposition. This is the particle size that is generally created by most hand held nebulizers. Particle size less than 2 um are too small to be therapeutic.

Particles smaller than 10 micrograms generally hold their contents well, so the medicine is not likely to be lost upon aeroslization.  (2, page 9)  It's for this reason respiratory medicine can be mixed together in the same solution.

References:

1. Korting, Monika Schafer, editor, "Drug Delivery," 2010, Germany, Springer-Verlag Berlin Heidelberg.  The reference used for this information is Aiche, 1990)  Although a more specific reference would be Whitlaw-Gray, R, and Patterson, H.S., in "Smoke: A Study of Aerial Disperse Systems," (Arnold, London, 1932), 192 pages
2. Kulkarni, Pramod, Paul A. Baron, Klaus Willeke, editors, "Aerosol Measurement: Principles, Techniques and Applications," 3rd edition, 2011, Wiley
3. Elliot, Deborah, Patrick Dunne, "A Guide to Aerosolized Drug Delivery," American Association of Respiratory Care, page 9.  I wrote about this at RT Cave as you can see here. 

1927: Harold Beck: My Life With Asthma

My Life With Asthma

By Harold Beck

(Note: The following is from the July, 2003, issue of Asthma News. I just think Harold's story fits into the theme of this blog just perfectly. It answers the question: What would it be like to live with asthma during the 1920's, 30's, 40's, 50s' and 60's in London. Okay? So I am going to publish Beck's whole story here)

Harold Beck, now 78 year's old, has had more asthma treatments than most -- from asthma cigarettes to a device to change the shape of his jaw. Here, he tells his story. 

North Kensington, London, 1927-1934 

I was told that I developed asthma after an attack of measles when I was three years old. One of my earliest memories is of waking up on a number of occasions in the middle of the night, shoulders up, struggling for breath, then sitting on the landing stairs where there was a much higher ceiling and seemingly fresher air. Often mum or dad would call out for me to come into their bed, which was warm and snug. This was quite a perk, but I hope for my parents' sake it did not happen too often.

Harold Beck

The standard treatment at that time was Potters Asthma Cure, a powder that was pouredon to a saucer to form a cone, which was then lit at the top. The pungent smoke from this spitting Vesuvius had to be inhaled deeply. Its beneficial effects were short lived - the inhalation provided some relief but was certainly not a cure. Later I switched to the upmarket Potters Asthma Cigarettes, which were more convenient to use and less intrusive on other members of the family.

I would guess my mother started on the trek around London hospitals and clinics in search of a cure as soon as my asthma was diagnosed, but I remember only the later episodes. At one time it was thought that inhaling sea air instead of the polluted and sometimes thick and acrid air of London would do the trick. When I was about five years old I spent four months in a convalescenthome at Ventnor on the Isle of Wight. Similarly, family holidays were taken at places like Hunstanton, on the Norfolk coast, which was reputed to be "good for asthma".

I underwent allergy tests to determine sensitivity to various substances. A nil result was obtained. Likewise with visits to an osteopath, who twisted my neck on the theory that this would alleviate my asthma. Presumably there was another theory that I needed both external and internal lubrication, for he also prescribed that I should wear a band of cotton wool soaked in castor oil around my neck, and imbibe a nightly cocktail of castor oil and port. It was not the best induction to the joys of drinking in general and port wine in particular. I was also taken to see a psychologist who, after giving me several tests, pronounced me as too intelligent (so my parents said) to benefit by that method.

Harold Beck

North Kensington and Regent Street, 1934-1939

I had lost much schooling when I was at Oxford Gardens LCC infant and primary schools, due to days off for asthma treatment and asthma attacks. However, by the time I started my secondary education at Regent Street Polytechnic, there had been a great step forward in the treatment of asthma, namely the atomiser. It came from Germany, and used a pumping device containing a liquid called Bronchovydrin. This produced a spray of droplets that had to be breathed into the lungs, producing relief in a much more socially acceptable manner and with fewer side effects than the Potters method. 

By good fortune the UK sales office for the atomiser was just off Regent Street. In that office was a motorised atomiser (which we now call a nebuliser) and I was invited to make use of it whenever the hand operated atomiser proved insufficient to control an attack. So at lunchtime on some days I would make my gasping way slowly down Regent Street, past Mr Forte's new milk bar and Hamleys, to the wonderful machine in the sales office. There was a spring in my step on the return journey and occasionally I even stopped to look at the toys in Hamleys.

The school was very understanding of my condition and gave me permission to ride up in the lift when I had an asthma attack. Many of our classes were held on the 4th floor and some, such as physics and chemistry, were, I think, even higher. So riding in the lift was a very helpful concession. Indeed it was something of a perk because some well known people used the lift. I got quite a thrill when I was a fellow passenger to Griffiths Jones, a popular film star of the late 1930s.

I applied myself to my studies and did quite well. However, as I was the youngest in the form it was decided that I might be less prone to asthma attacks if I took an extra year. Sport was then regarded as out of the question so my muscles and coordination were very underdeveloped. I was a tall and very weedy child and my father affectionately referred to me as "Tin Ribs". The search for solutions to my asthma continued: I remember having to take soya flour, lettuce and honey in a tin for lunch, but that didn't last for long.

We are and Minehead, Somerset, 1939-1942

My school was evacuated two days before the outbreak of the Second World War. One of my brothers and I went to Weare and were billeted on a farm. It was harvest time and, needless to say, within a day or two I was in the throes of an asthma attack. I was moved into the village proper to stay with two kindly schoolteachers and within a few days I was able to breathe normally again.

Soon, the whole school moved to Minehead and there I tried some sport by entering a team for a high jump competition. I considered the short run up would enable me to make the effort before the asthma triggers had time to notice, but I made such a hash of the take off that I never tried again. I did, however, get some exercise walking on Minehead's North Hill, in the lovely combes accessed from Alcombe and over Grabbist to Dunster.

Bristol, Blackpool and London, 1942-1944 

When I joined King's College, London, it was in its final year of evacuation to Bristol. The heavy bombing of Bristol had taken place earlier. The only asthma related incident that I remember is when I took beginners classes in rowing: lack of strength and breathlessness forced me to give up and concentrate on swimming. 

Sometime during the year my parents moved to Blackpool to provide a safe base for the scattered family. While on a visit there, I sustained a particularly paralysing and persistent attack. I remember a GP coming and giving me injections of adrenaline and morphine until I could breathe well enough again. When the attack subsided it was agreed by my parents and the GP that I should have a course of Peptone injections, which apparently were universal desensitisers. What good they did me I cannot say, but at least they appeared to do me no harm.

When in 1943 King's College moved back to the Strand, London, I was referred to a chest hospital for treatment. This consisted of fitting me with an orthodontic device that changed the shape of my jaw. It was explained to me that as there was virtually no asthma among people in the Middle East, there might be a connection between that and the fact that Middle Eastern people were lantern jawed. If I was made lanternjawed, I might be rid of asthma. (I am relating here what I understood was said to me as a 19 year old student.) So I was fitted with a plate with springs in it pressing against individual teeth. The net result was that there was no discernible improvement in my asthma and I was left with a somewhat lopsided bite.

North Kensington, 1944-1947

In addition to the atomiser, the treatment for more persistent attacks was ephedrine and belladonna. Thus when a persistent attack took place in June 1944 while I was taking the final exams of my two year wartime degree course, I was dosing myself with these compounds. Asthma was certainly not the only reason why I failed to get my degree first time round I did not work hard enough but the ephedrine in particular, while improving the breathing, also produced in me a feeling of jittery excitement that probably affected my judgement to a considerable extent.

Meanwhile having no degree made me eligible for call up. I was asked to report for a medical and as a result was declared unfit for military service. I left retaking finals a year but continued studying, while I researched an electronic circuit and ran a radio business to bring in some money. I got my degree in 1947. 

London, Chrishall, Saffron Walden, Cambridge and Harpenden, 1947-2003 

From when I started work after graduation and got married, my asthma for most of the time took the form of wheezing and some shortage of breath, especially in the evenings and at night. It was easily controlled using the atomiser, which became my constant companion. But there were constant external reminders of its existence, such as a 20% reduction in pension insurance benefits and reports of scarring of my lungs due to asthma whenever I went for mass X ray. I gave up my moderate smoking of cigarettes and a pipe in the mid 1960s, and cigars about ten years later.

In 1986 I had my first serious attack of asthma in nearly 40 years. My peak flow was found to be 150. I was sent to St Albans Hospital where I was immediately put on a crash course of Prednisolone steroid tablets, and was loaned a nebuliser and ventolin capsules. In a few days the attack was under control. This was the point at which I caught up with advances in asthma treatment - the change from its treatment as an acute problem to regarding it as a long term condition, with preventers as well as relievers. Since then I normally have one dose of Duovent followed by one of beclomethasone (with spacer), night and morning. I measure my peak flow each night and morning and adjust the number of doses accordingly. I also have a nebuliser to increase inhalation of my reliever on the rare occasions it is necessary. 

In the mid 1990s, conscious of the debt I owed to research into asthma, I spent two years of intense activity as chairman (and sometimes also secretary and treasurer) of the local branch of the National Asthma Campaign, raising funds and disseminating information. I am now 78 years old and, thanks to the application of asthma research, the complaint that I have had for 75 years is far less of a problem than it was. Telling my story has also led me to realise how much my brothers and sister were affected by my asthma - yet I never heard a word of resentment from them, for which I owe them my lungfelt thanks.

Harold Beck.

• Original Source: Beck, Harold, "My Life With Asthma," Asthma News, July, 2003, pages 21-23, http://haroldbeck.org.uk/6_Publications/P6_SPI/Medical/03g%20asthma.pdf, accessed February 26, 2016. Reprinted here without permission, although without any intent to profit from it. Please check out original article to view pictures. 

1930: Pneumostat, the first electric nebulizer

Pneumostat in use (2)

While a variety of steam inhalers were available in 1850, it was learned that the best way of getting medication to the lungs was not by steam but by mist. Between the 1850s and 1930 there were a ton of inhaler and nebulizer devises made, but none were ideal.

The problem with these early mist producing inhalers was that they required manpower to create the flow needed to create the mist. As with other industries, the ability to control electricity changed everything. Marketers soon started playing with the idea of creating an electric nebulizer.  

The first one to enter the market was produced by Weil in Frankfort.
It was a compact unit, meaning it was a combination compressor and nebulizer.  The comperssor created the electricity that created the flow to turn the solution of water and medicine to a mist. 

According to "Hugh Smyth, in his book, "Controlled Pulmonary Drug Delivery," it was a "110-120 volt machine was supplied in UK by Riddle to nebulize bronchovydrin (papaverine and eumydrine)."   (1, page 68)

Pneumostat (2)

Bronchovydrin also had adrenaline (epinephrine) and atropine in it.  It was a solution used to provide quick relief of an asthma attack.  I really had a hard time finding any other information on it, although it was used by lifelong asthmatic Harold Beck.

The electric nebulizer of the 1930s was epensive, so the physician may prefer to have the patient use a nebulizer where the flow is generated by hand power, like it was prior to the electric device.  One option would be the Adrenaline Inhaler or the Devilbiss No. 40 Glass Nebulizer.

Considering the bulkiness and cost of this machine, it was common for a pharmacist to own one, and for patients in need to visit that pharmacist. (3)

References:

1. Smyth, Hugh D.C., "Controlled Pulmonary Drug Delivery," 
2. Sanders, Mark, "Pneumostat," Inhalatorium.com, page 131, http://www.inhalatorium.com/page131.html
3. Nickander, K, Mark Sanders, "The early evolution of nebulizers," MedicaMundi, 2010, 54/3, pages 47-53

Additional reading and viewing:

1. 'Pneumostat' inhaler, London, England, 1934-1935
2. Therapeutic inhaler, London, England, 1935-1942

My good-bye party

You can't go off to spend 6-8 weeks at an asthma hospital without a send-off party. And that's exactly what my family threw for me on the evening of Saturday, January 6, 1985.

Nearly every member of my family, including all my friends and the friends of my parents, showed up at our house for my good-bye party. My cousin Scott and his band played music in our living room. My Uncle Torrin mocked Willie Nelson in a version of "On the Road Again" by plugging his nose while singing. I knew there was going to be a good-bye party, but I had no idea it was going to be this BIG!

At the time, I really didn't understand why they were throwing me such a large party. I was only going to be going away for 6-8 weeks. Surely this seemed like a long time to me, but it wasn't going to be forever.

Yet, in retrospect, I know now that my parents, doctors, nurses, and respiratory therapists taking care of me during all these years were worried that asthma was going to kill me. I did not think of asthma that way. To me it was like an annoying cold that wouldn't go away. Like any person with a chronic disease, one you are born with, I just learned to deal with it.

The party really didn't stop when the party ended. Almost as soon as i was admitted to the hospital the letters started to coming, and they came from nearly every person at the good-bye party. I think, over the first six weeks, I received over a hundred letters. Probably half of them were from my grandma Bottrell, my Aunt Dolly, and my aunt's Virgie, Mary and Tossi. Oh, I should also add into this letters from my parents and brothers.

It was great back then because it was nice to receive a letter or package every day. It was also nice now as I'm trying to tell my story, because these letters helps me remember what I was doing back then, and what was happening outside the hospital too. It was nice. I don't know if I ever did enough to thank all who wrote me letters.

Anyway, the day after the party I boarded a United Airlines flight to Denver with mom. I don't know if I can ever truly tell this story. I have tried to sit down and write it down, starting with when I was there. I will make a gallant effort here, albeit 30 years after these events occurred.

Still, I have learned that, as you start thinking of things, the memories do seem to roll back into your mind. Some events, or most of them, were almost blacked out. This includes the horrible moments (and there were a few), but it also included some very good memories.