Galdeano, UCI, Salbutamol, & asthma in the pro-peloton

Discussion in 'Cycling Equipment' started by Marianne, May 7, 2003.

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  1. Marianne

    Marianne Guest

    From the UCI website it looks like the UCI considers salbutamol to be bad at 100ng/ml unless a rider
    is asthmatic, and then it lets you get up to 1000ng/ml. The CPLD (French anti-doping agency) permits
    its use if an athlete has a doctor's certificate confirming him or her as asthmatic, and if he or
    she shows up at less than 100 nanograms per millilitre in competition. According to CPLD, Galdeano's
    half-dozen over the limit tests during last years TdF included 796, 904 and 1,360ng/ml. If so then
    even by UCI rules Galdeano should have been pitched from the tour last year for his sample of
    1360ng/ml? So I guess I am confused. Do CPLD and UCI use independent tests and ignore each other's
    results? What is the limit according to UCI? Why are the limits different? What is considered a
    theraputic amount for asthmatics to have in their system? Another question I have is how many pros
    have asthma anyhow?

    Eurosport.com has the following today (6May2003): "While Galdeano's prescriptions are legitimate,
    there is some speculation about the legality of his use of Salbutamol. According to a report in the
    French daily Le Monde, 30 percent of professional cyclists complain of having asthmatic symptoms,
    and therefore justify their use of drugs like Salbutamol, which can offer the same
    performance-enhancing benefits as anabolic steroids. The general population, by comparison, shows an
    asthma incident rate of just 7 percent.

    Cycling professionals insist that the exertion of a bike race means six times the regular amount of
    oxygen inhaled, which also means six times more pollen and pollution.

    In the case of Galdeano, French doping officials found that his levels far exceeded the normal
    dosage, further fueling suspicion among the public at-large over what Le Monde sarcastically labeled
    "a peloton crippled by asthma."

    So - Are symptoms of asthma induced or aggravated by cycling at the pro level? Their oxygen intake
    is greater, so they inevitably take in more pollen/pollution etc… But I don't know, I am still
    struggling with the percentages – 7% in the general population with asthma to 30% of the peloton is
    not statistically insignificant! Does anyone have any insight?
     
    Tags:


  2. Robert Chung

    Robert Chung Guest

    "marianne" <[email protected]> wrote in message
    news:[email protected]...
    > From the UCI website it looks like the UCI considers salbutamol to be bad at 100ng/ml unless a
    > rider is asthmatic, and then it lets you get up to 1000ng/ml.

    Uh, not exactly. The issue between the CPLD and UCI is a turf war. The CPLD (and the WADA and the
    IOC) think that for a level of salbutamol above 100ng/ml, you have to have a doctor's prescription
    and it must have been administered by inhaler. In addition, a level above 1000ng/ml is defined as a
    positive test whether you have a doctor's okay or not. The UCI thinks that if you have a doctor's
    prescription and it was administered by inhaler, you can exceed 1000ng/ml, i.e., it doesn't have the
    1000ng/ml limit.

    > The CPLD (French anti-doping agency) permits its use if an athlete has a doctor's certificate
    > confirming him or her as asthmatic, and if he or she shows up at less than 100 nanograms per
    > millilitre in competition. According to CPLD, Galdeano's half-dozen over the limit tests during
    > last years TdF included 796, 904 and 1,360ng/ml. If so then even by UCI rules Galdeano should have
    > been pitched from the tour last year for his sample of 1360ng/ml?

    Maybe, maybe not, but the reason he wasn't pitched was given above. He didn't exceed the
    UCI's levels.
     
  3. Robert Chung

    Robert Chung Guest

    BTW, I'm not quite sure where Le Monde got the 30% of the peloton complains of asthma, compared to a
    rate in the general population of 7%. One has to be careful to compare apples with apples.

    A couple of years ago, the BMJ reported on estimates from the 1999 UK National Asthma audit that
    about 4% of British adults had asthma symptoms severe enough to require treatment. Meanwhile, at the
    Sydney Olympics in 2000, 6% of the athletes gave notification that they needed to take Beta2
    agonists for asthma. Needing to take a Beta2 agonist (like salbutamol) isn't the same thing as being
    diagnosed with asthma, or being diagnosed with exercise-induced asthma, so you can see that a number
    like "30% of the peloton complains of asthma" is hard to evaluate.
     
  4. Arthur Clune

    Arthur Clune Guest

    Robert Chung <[email protected]> wrote:
    : (and the WADA and the IOC) think that for a level of salbutamol above 100ng/ml, you have to have a
    : doctor's prescription and it must have been administered by inhaler. In addition, a level above
    : 1000ng/ml is defined as a positive test whether you have a doctor's okay or not. The UCI thinks
    : that if you have a doctor's prescription and it was administered by inhaler, you can exceed
    : 1000ng/ml, i.e., it doesn't have the 1000ng/ml limit.

    Does anyone know, very roughly, what levels of 100ng/ml and 1000ng/ml correspond to?

    e.g. I take a Salbutamol inhaler twice a day (morning and evening) [two puffs of a Becotide '100'
    inhaler]. What sort of blood level would that correspond to?

    What I'm trying to get a feel for is how likely is someone to have a 1000ng/ml blood level normally.

    Arthur

    --
    Arthur Clune http://www.clune.org Power is delightful. Absolute power is absolutely delightful -
    Lord Lester
     
  5. Marianne

    Marianne Guest

    yeah well. my feet are ruined by jogging them flat to 14+ and if shim wud getittogether with a 14+
    at $99 and a synthetic upper for those of us who live in the temperate zones. ski. sure. boy
    there's agood reason for not clipping in.good thinking. alone at the end of the hot afternoon when
    the senses have faded to absolute expletive deleted zero and prango zip into the canal Crazy
    dude!! seriously,are there any long distance touring types around?? i imagined a rattrap with
    sumkinda toe grip. what do cyclists crossing the vast interior wastelands pedal on? well,
    answering my own BS cyclists that cross the VIW use $200 shoes and speeedfrogs 'cause cyclists who
    cross are nuts to begin with.no? Iyam not sure but there are experts out there somewhere.the
    bottom line being starting out with a right field combo is not good, narrowing the field much
    better. try talking with mail odor from Paducah while the box is in guam.THEY know!! this only
    leads to further teeth gnashing. I spoke with a clip in learner who spoke at length on routine
    visits to the vet for skin repair.
     
  6. Robert Chung

    Robert Chung Guest

    "Arthur Clune" <[email protected]> wrote in message news:[email protected]...
    > Robert Chung <[email protected]> wrote:
    > : (and the WADA and the IOC) think that for a level of salbutamol above 100ng/ml, you have to have
    > : a doctor's prescription and it must have been administered by inhaler. In addition, a level
    > : above 1000ng/ml is defined
    as
    > : a positive test whether you have a doctor's okay or not. The UCI thinks
    that
    > : if you have a doctor's prescription and it was administered by inhaler,
    you
    > : can exceed 1000ng/ml, i.e., it doesn't have the 1000ng/ml limit.
    >
    > Does anyone know, very roughly, what levels of 100ng/ml and 1000ng/ml
    correspond
    > to?
    >
    > e.g. I take a Salbutamol inhaler twice a day (morning and evening) [two
    puffs
    > of a Becotide '100' inhaler]. What sort of blood level would that
    correspond to?
    >
    > What I'm trying to get a feel for is how likely is someone to have a
    1000ng/ml
    > blood level normally.

    The CPLD addressed this. They announced that the 1300 ng/ml reading "cannot be regarded as the
    consequence of the use of Ventolin according to normal therapeutic practices."

    Salbutamol is a beta2 agonist which is an excellent bronchodilator. However salbutamol can also be
    an anabolic agent, which is why the WADA puts a 1000 ng/ml limit on it. Oddly, the benefit of
    anabolic agents for enhancing performance in an aerobic activity like bike racing is in dispute.
    Since you're an asthmatic, you probably know that bronchodilators don't open the bronchioles wider
    than normal -- they relax the spasms that constrict them. This suggests that a bronchodilator may
    not have a performance-enhancing effect on those who don't have asthma.
     
  7. Robert Chung

    Robert Chung Guest

    "marianne" <[email protected]> wrote
    > Do you have any take on the second half of my question? ie: Are asthmatic symptoms induced or
    > aggravated by cycling at the pro level? Their oxygen intake is greater, so they inevitably
    > take in more pollen/pollution etc. Does this account for the high percentage of pros diagnosed
    > with asthma?

    I have exercise-induced asthma, but a very mild case. It's usually worse when it's cold out and when
    I'm exercising heavily, and the symptoms disappear within maybe 15 minutes after I stop riding. I
    don't get it treated because I don't have to ride for a living.

    So, yes, asthmatic symptoms can absolutely be induced or aggravated by exercise. The part I don't
    know is its prevalence, and part of that is my apples-to-apples comparison. Not everyone bothers to
    get diagnosed and treated unless it's important. It's important for athletes, so they have an
    incentive to get it diagnosed and treated.

    And, as I pointed out elsewhere in this thread, bronchodilators may not (or may) have a
    performance-enhancing effect on those who don't have asthma, and anabolic agents like salbutamol may
    not (or may) have a performance-enhancing effect on cyclists.
     
  8. Robert Chung wrote:
    > "marianne" <[email protected]> wrote
    >
    >>Do you have any take on the second half of my question? ie: Are asthmatic symptoms induced or
    >>aggravated by cycling at the pro level? Their oxygen intake is greater, so they inevitably
    >>take in more pollen/pollution etc. Does this account for the high percentage of pros diagnosed
    >>with asthma?
    >
    >
    > I have exercise-induced asthma, but a very mild case. It's usually worse when it's cold out and
    > when I'm exercising heavily, and the symptoms disappear within maybe 15 minutes after I stop
    > riding. I don't get it treated because I don't have to ride for a living.

    I do as well, somewhat treated. Its gotten bad enough that I've basically blacked out and fallen
    down while running one day (I was sprinting back to the boathouse for the last .5 mile of an
    approximately 4 mile run - my legs were fine, my lungs died). I get it biking, especially during
    high pollen/spore times of the year, or when its cold (lung irritants seem to be the common
    factor). I often have to sit or lie down for 15-20 minutes, and then I'm usually fine for the next
    2 or 3 hours.

    > So, yes, asthmatic symptoms can absolutely be induced or aggravated by exercise. The part I don't
    > know is its prevalence, and part of that is my apples-to-apples comparison. Not everyone bothers
    > to get diagnosed and treated unless it's important. It's important for athletes, so they have an
    > incentive to get it diagnosed and treated.

    I always find it amazing the varrying numbers people give for the percentage of asthma. IME, a lot
    of people are just undiagnosed. You'll hear rowers complain of "race lung" - coughing, wheezing,
    and other nastiness after sprint races. Just recently some reserach has shown this is actually a
    form of EIA - probably not enough to need treatment, but use of an inhaler beforehand will prevent
    the bronchoconstriction that causes it, and slightly improve performance. You'd be amazed how many
    rowers I've seen with these symptoms and no idea, or even people with full blown EIA that don't
    know about it.

    Jon Bond
     
  9. Kinkycowboy

    Kinkycowboy Guest

    On 7 May 2003 16:07:43 GMT, "Arthur Clune" <[email protected]> wrote:

    >Robert Chung <[email protected]> wrote:
    >: (and the WADA and the IOC) think that for a level of salbutamol above 100ng/ml, you have to have
    >: a doctor's prescription and it must have been administered by inhaler. In addition, a level above
    >: 1000ng/ml is defined as a positive test whether you have a doctor's okay or not. The UCI thinks
    >: that if you have a doctor's prescription and it was administered by inhaler, you can exceed
    >: 1000ng/ml, i.e., it doesn't have the 1000ng/ml limit.
    >
    >Does anyone know, very roughly, what levels of 100ng/ml and 1000ng/ml correspond to?
    >
    >e.g. I take a Salbutamol inhaler twice a day (morning and evening) [two puffs of a Becotide '100'
    > inhaler]. What sort of blood level would that correspond to?
    >
    >What I'm trying to get a feel for is how likely is someone to have a 1000ng/ml blood level
    >normally.
    >
    >Arthur

    OK, as I seemed to have missed it if somebody posted numbers in this thread before.

    Typical inhaled dose of Salbutamol/Albuterol/Ventolin is 200 microgram (2 puffs at 100microgram
    each) or 200000 nanogram Typical amount of blood in a body is 4500ml

    So if all your salbutamol ended up in your blood (unlikely, as any user will know) you could get a
    blood concentration of 44ng/ml from one dose, and if you took another one before the first had been
    metabolized or excreted, and so on,I suppose you might get up to almost twice this concentration or
    90ng/ml. To do this, you'd be taking 2 puffs on your inhaler every 3 to 4 hours throughout the day.
    I've done this when I've been suffering very badly with asthma, and believe me when you need this
    much salbutamol just to be able to walk around the apartment, the last thing on your mind is going
    for a bike ride, much less competing in a race. So there is no way anybody taking inhaled salbutamol
    for therapeutic reasons should be walking around with a level above 100ng/ml, because if they needed
    more than this they'd probably be admitted to hospital. Because the inhalation method is so
    effective, the dose required is very small. Taking salbutamol orally for the same effect requires a
    dose of about 4 milligram, 20 times the level of the inhaled dose. As a result, you might
    conceivably have a blood concentration of 900ng/ml from taking one 4mg tablet. When I was a boy,
    inhalers were uncommon and I had the 4mg tablets; the high blood concentration of salbutamol makes
    the side effects much worse, which is why most people are prescribed inhalers these days.

    Now we need somebody to tell us the relationship between these blood concentrations and the amount
    likely to be found in a urine sample. Just for the sake of waving our arms in the general area, if
    you excreted the whole 200 micrograms in 500ml of urine, that would be 400ng/ml.

    Kinky Cowboy

    *Your milage may vary Batteries not included May contain traces of nuts.
     
  10. Robert Chung

    Robert Chung Guest

    "Jonathan Bond" <[email protected]> wrote in message
    news:[email protected]...
    >
    > I do as well, somewhat treated. Its gotten bad enough that I've basically blacked out and fallen
    > down while running one day (I was sprinting back to the boathouse for the last .5 mile of an
    > approximately 4 mile run - my legs were fine, my lungs died).

    Yiiikes. That sounds a bit worse than what I suffer.

    > I always find it amazing the varrying numbers people give for the percentage of asthma. IME, a lot
    > of people are just undiagnosed. You'll hear rowers complain of "race lung" - coughing, wheezing,
    > and other nastiness after sprint races. Just recently some reserach has shown this is actually a
    > form of EIA - probably not enough to need treatment, but use of an inhaler beforehand will prevent
    > the bronchoconstriction that causes it, and slightly improve performance. You'd be amazed how many
    > rowers I've seen with these symptoms and no idea, or even people with full blown EIA that don't
    > know about it.

    Yes, this is consistent with my observation. This makes it difficult to evaluate statements like, "x
    percent of the general population has asthma while y % of athletes have asthma."
     
  11. Robert Chung

    Robert Chung Guest

    "KinkyCowboy" <[email protected]> wrote
    >
    [amazingly long-winded example snipped]

    > Now we need somebody to tell us the relationship between these blood concentrations and the amount
    > likely to be found in a urine sample. Just for the sake of waving our arms in the general area, if
    > you excreted the whole 200 micrograms in 500ml of urine, that would be 400ng/ml.

    So what you're saying is, you don't know?
     
  12. Kinkycowboy

    Kinkycowboy Guest

    On Thu, 8 May 2003 20:36:02 +0200, "Robert Chung" <[email protected]> wrote:

    >
    >"KinkyCowboy" <[email protected]> wrote
    >>
    >[amazingly long-winded example snipped]
    >
    >> Now we need somebody to tell us the relationship between these blood concentrations and the
    >> amount likely to be found in a urine sample. Just for the sake of waving our arms in the general
    >> area, if you excreted the whole 200 micrograms in 500ml of urine, that would be 400ng/ml.
    >
    >So what you're saying is, you don't know?
    >

    Yup!

    But I was saying something else as well; I know what the therapeutic dose is, I know salbutamol
    doesn't accumulate in the body so it must all be metabolised or excreted, and I have a rough idea of
    how much piss there is in a pot (I have shipped enough 24 hour urine samples to the pathology lab
    when I was a medical courier). I was leaving it to the biochemists among us to refine my numbers,
    but it seems obvious to me that anybody excreting urine with more than 1000ng/ml of salbutamol in it
    has some questions to answer about exactly what they're using the drug for.

    There's a quick and dirty summary of salbutamol excretion at

    http://www.ch.ic.ac.uk/local/projects/mohataren/Files/pharma.htm

    and

    http://www.ch.ic.ac.uk/local/projects/j_hettich/salbutamol/project/biobody.html

    To save everybody the trouble of looking, the relevant quote from the latter;

    "Studies have found peak plasma concentrations occur approximately 2-5 hours after inhalation and
    2-2.5 hours after ingestion. Salbutamol is metabolized in the liver, mainly by conjugation to the
    inactive salbutamol-4'-0-sulphate.  Salbutamol's plasma half life is reportedly
    2.7-5 hours after oral administration. The half life has been indirectly estimated through urine
    excretion studies to be 3.8 hours after inhalation. Unchanged drug and metabolite are 72% excreted
    in the urine within the first 24 hours."

    If I were taking as much as 1000microgram daily inhaled salbutamol, I wouldn't be racing; if I were
    pissing as little as 2500ml daily, I'd be impaired by dehydration. If these two numbers were a
    steady state condition, the mean concentration of salbutamol (unchanged or calculated from
    metabolite) in my urine would be 400ng/ml.

    Whichever way you look at it, genuine asthmatics using inhaled salbutamol at recommended therapeutic
    doses should have nothing to fear from UCI or IOC doping controls; people taking higher doses by
    other routes could be in trouble, whether they deserve to be or not.

    Kinky Cowboy

    *Your milage may vary Batteries not included May contain traces of nuts.
     
  13. Robert Chung

    Robert Chung Guest

    "KinkyCowboy" <[email protected]> wrote
    > There's a quick and dirty summary of salbutamol excretion at
    >
    > http://www.ch.ic.ac.uk/local/projects/mohataren/Files/pharma.htm
    >
    > and
    >
    >
    http://www.ch.ic.ac.uk/local/projects/j_hettich/salbutamol/project/biobody.html
    >
    > To save everybody the trouble of looking, the relevant quote from the latter;
    >
    > "Studies have found peak plasma concentrations occur approximately 2-5 hours after inhalation and
    > 2-2.5 hours after ingestion. Salbutamol is metabolized in the liver, mainly by conjugation to the
    > inactive salbutamol-4'-0-sulphate. Salbutamol's plasma half life is reportedly
    > 2.7-5 hours after oral administration. The half life has been indirectly estimated through urine
    > excretion studies to be 3.8 hours after inhalation. Unchanged drug and metabolite are 72%
    > excreted in the urine within the first 24 hours."
    >
    > If I were taking as much as 1000microgram daily inhaled salbutamol, I wouldn't be racing; if I
    > were pissing as little as 2500ml daily, I'd be impaired by dehydration. If these two numbers were
    > a steady state condition, the mean concentration of salbutamol (unchanged or calculated from
    > metabolite) in my urine would be 400ng/ml.
    >
    > Whichever way you look at it, genuine asthmatics using inhaled salbutamol at recommended
    > therapeutic doses should have nothing to fear from UCI or IOC doping controls; people taking
    > higher doses by other routes could be in trouble, whether they deserve to be or not.

    Excellent, thanks. This is much better info. OK, one of the issues is that steady-state calculations
    may underestimate. A more interesting number would be peak excretion rather than steady-state, and
    the half-life gives us a rough handle on that. The high reading (1360 ng/ml urine) was recorded
    after the sixth stage which lasted 4h23m. Using the figures above, we're in the ballpark: depending
    on how fast he was metabolizing and excreting the stuff, maybe he was taking something like twice
    the recommended dosage before and after the previous stages, and then took a triple or maybe
    quadruple dose just before the sixth stage began.
     
  14. Arthur Clune

    Arthur Clune Guest

    Robert Chung <[email protected]> wrote:

    : Yes, this is consistent with my observation. This makes it difficult to evaluate statements like,
    : "x percent of the general population has asthma while y % of athletes have asthma."

    Agrees with me as well. I never thought I had asthma till I went to the doc with a cough that
    wouldn't go away. The thought I might have mild asthma (a persistant cough can be one of the
    symptoms) and gave me an inhalher.

    THe cough has gone but it's also had the amazing (for me) affect that when I go hard on the bike I
    can now breath!

    Before I could never get my legs to really hurt, but just assumed it was
    me. Now I can breath, it's my legs slowing me down :)

    Arthur

    --
    Arthur Clune http://www.clune.org Power is delightful. Absolute power is absolutely delightful -
    Lord Lester
     
  15. Peter Vesel

    Peter Vesel Guest

    I haven't really been following this thread but I did notice the reference to 1000ug of salbutamol.

    This is about the amount it takes me to get through a 2 hour race. I also take 2000 ug of
    fluticasone propionate (Seretide) daily. I don't see this as being a lot...it's just how much I need
    not to wheeze.

    Lung tests have told me I have about 70% of the lung capacity of a normal 36 year old. Somehow I
    don't think I'm about to be drug tested though

    peter

    "KinkyCowboy" <[email protected]> wrote in message
    news:[email protected]...
    > On Thu, 8 May 2003 20:36:02 +0200, "Robert Chung" <[email protected]> wrote:
    >
    > >
    > >"KinkyCowboy" <[email protected]> wrote
    > >>
    > >[amazingly long-winded example snipped]
    > >
    > >> Now we need somebody to tell us the relationship between these blood concentrations and the
    > >> amount likely to be found in a urine sample. Just for the sake of waving our arms in the
    > >> general area, if you excreted the whole 200 micrograms in 500ml of urine, that would be
    > >> 400ng/ml.
    > >
    > >So what you're saying is, you don't know?
    > >
    >
    > Yup!
    >
    > But I was saying something else as well; I know what the therapeutic dose is, I know salbutamol
    > doesn't accumulate in the body so it must all be metabolised or excreted, and I have a rough idea
    > of how much piss there is in a pot (I have shipped enough 24 hour urine samples to the pathology
    > lab when I was a medical courier). I was leaving it to the biochemists among us to refine my
    > numbers, but it seems obvious to me that anybody excreting urine with more than 1000ng/ml of
    > salbutamol in it has some questions to answer about exactly what they're using the drug for.
    >
    > There's a quick and dirty summary of salbutamol excretion at
    >
    > http://www.ch.ic.ac.uk/local/projects/mohataren/Files/pharma.htm
    >
    > and
    >
    >
    http://www.ch.ic.ac.uk/local/projects/j_hettich/salbutamol/project/biobody.h tml
    >
    > To save everybody the trouble of looking, the relevant quote from the latter;
    >
    > "Studies have found peak plasma concentrations occur approximately 2-5 hours after inhalation and
    > 2-2.5 hours after ingestion. Salbutamol is metabolized in the liver, mainly by conjugation to the
    > inactive salbutamol-4'-0-sulphate. Salbutamol's plasma half life is reportedly
    > 2.7-5 hours after oral administration. The half life has been indirectly estimated through urine
    > excretion studies to be 3.8 hours after inhalation. Unchanged drug and metabolite are 72%
    > excreted in the urine within the first 24 hours."
    >
    > If I were taking as much as 1000microgram daily inhaled salbutamol, I wouldn't be racing; if I
    > were pissing as little as 2500ml daily, I'd be impaired by dehydration. If these two numbers were
    > a steady state condition, the mean concentration of salbutamol (unchanged or calculated from
    > metabolite) in my urine would be 400ng/ml.
    >
    > Whichever way you look at it, genuine asthmatics using inhaled salbutamol at recommended
    > therapeutic doses should have nothing to fear from UCI or IOC doping controls; people taking
    > higher doses by other routes could be in trouble, whether they deserve to be or not.
    >
    > Kinky Cowboy
    >
    > *Your milage may vary Batteries not included May contain traces of nuts.
     
  16. Kinkycowboy

    Kinkycowboy Guest

    On Sun, 11 May 2003 14:51:55 +1000, "Peter Vesel" <[email protected]> wrote:

    >I haven't really been following this thread but I did notice the reference to 1000ug of salbutamol.
    >
    >This is about the amount it takes me to get through a 2 hour race. I also take 2000 ug of
    >fluticasone propionate (Seretide) daily. I don't see this as being a lot...it's just how much I
    >need not to wheeze.
    >
    >Lung tests have told me I have about 70% of the lung capacity of a normal 36 year old. Somehow I
    >don't think I'm about to be drug tested though
    >
    >peter
    >

    1000microgram is a lot of salbutamol to be taking in 2 hours, most self medicating people are on a
    dosing rate of about 50microgram per hour for inhaled drug. When did you last have your inhaler
    technique tested? I've seen a lot of very poor inhaler technique, and you might just be wasting 90%
    of your salbutamol if you're doing it wrong. I don't wan't to restart last year's r.b.r flame war,
    but it's much easier to maintain effective delivery by using a spacer device. Even under laboratory
    conditions, a spacer tube seems to give the best value in terms of "drug in the lungs"

    http://link.springer-ny.com/link/service/journals/00228/contents/01/00382/s00228-001-0382-9-
    ch002.html

    Kinky Cowboy

    *Your milage may vary Batteries not included May contain traces of nuts.
     
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