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I would suggest that you try to use a spacer that has an attached mask or place a silicone connector onto the mouthpiece of a spacer so you can attach a cushion style BVM mask. People often say that they can't use a puffer because they can't inhale...which makes me wonder how the nebulized meds make it down...
By the way, they make spacers for horses since they are prone to exercise induced asthma.
Many of them have just come off the field or ice and feel that they can't take a deep enough inhale to use it properly. After a minute or two on the neb they apparently open up enough to start "properly" using the neb.
I don't really have much of an idea of which one is more appropriate I will admit. My Athletic Trainer bosses usually give me the "it works when we do it this way, so we do it" type explanation. I'm trawling for knowledge here.