Question about order

[outofthisworld156]

Hi there, I don't post a lot, but read here daily. I have a question about the order of nebulized medications, I did a quick search but couldn't find any old posts.

So Hayley does Xopenex three times per day, usually with her vest and she then does her Pulmozyme 1 time per day, we do this at night after the vest is done, then she does her Flovent inhaler with an areochamber.

 

[kenna2]

The way she's doing them now is the correct order..
The order is supposed to be:
Bronchodilator (albuterol or other)
Hypertonic saline
Airway Clearance
Pulmozyme
Antibiotic (Tobi, Colistin, Cayston)
Steroid (Flovent or other)

This is what the CF foundation or whoever recommend the order being. They have been known to switch the order of Hypertonic Saline and Pulmozyme with each other, but whatever works the best for each person is fine.

 

[ethan508]

I second kenna's response with one exception. I do airway clearance (vest) concurrent with my nebulized medicines, stopping to huff cough as needed.

 

[Lynnfield mom]

Nope, nope, Nope. this is the scoop. I have a hand out from the clinic we go to that is from the foundation called "suggested order of therapies for daily care"

here you go:
broncodilator
hypertonic saline
mucolytic - pulmozyme or mucomyst
airway clearance - vest or acapella or PEP or percussor
inhaled antibiotics
inhaled steroids (if prescribed)

If you think about it, it makes sense. The things linke pulmozyme work to break up the mucus to make it easier to get up so you wouldn't want to use it after your vest or acapella or whatever you do for airway clearance. I bet if you ask someone at your center, they can get you a copy of the handout for the foundation.

Good luck

 

[Ratatosk]

I seem to recall discussion years ago that there were studies done with pulmozyme and whether it was appropriate to take it at night or morning, and during/before CPT/Vest or after and there wasn't a wrong answer. I think the study talked about how if done at night after airway clearance, then it was beneficial for some as it would prepare the lungs for morning airway clearance.

With ABX like tobi or cayston, etc. always after airway clearance.

 

[kenna2]

I remember that study as well and a lot of people do continue to argue which is the correct order. I've tried both ways and personally I get more benefit out of doing pulmo after my airway clearance. The order I gave is the way 3 CF centers in Ohio have us do it but as previously stated by other people, it doesn't make a difference and do what works best for you.

 

[stephen]

A number of years ago I read that it took Pulmozyme about 30 minutes to break down the mucus. Therefore, nothing should be nebulized for 30 minutes following Pulmozyme to realize its full benefit.

 

[ethan508]

Therefore, nothing should be nebulized for 30 minutes following Pulmozyme to realize its full benefit.

I want a doctor/pharmacist (or at least a direct quote from one) to support a claims like "Nothing should be nebulized" on top of Pulmozyme. Not all drugs interact with each other in a neutralizing way. Even if it takes 30 minutes for pulmozyme to fully work, why does that mean I don't way an antibiotic in there suppressing bacteria growth when the mucus starts breaking down.

Secondly there has to be a bit of practicality in how we do our treatments. If the science hasn't demonstrated the best methods then we need to find the methods that will help us be more compliant. Stretching out treatments across the entire day, and spending the bulk of our free time chained to the vest/nebuilzer isn't going to lead to high compliance or high quality of life. The shorter and less time intrusive I can keep my treatments the more likely I will stay compliant. I became vastly more compliant with airway clearance once I could do it concurrent with the nebulizer (i.e. once I got a vest).

 

[stephen]

ethhan508,

I agree that not all drugs react with each other in a neutralizing way. However the reason to wait before nebulizing antibiotics after using Pulmozyme is to allow it to break down and clear out the thick mucus so that the antibiotics can reach the lung tissue where they can be most effective. It could take 30 minutes for Pulmozyme to work.

I also agree that practicality can play a very important rolein being compliant. When time does not permit following the ideal treatment regimen, it’s better to do what is convenient rather than ship treatments altogether.

One of the sources suggesting the 30 minute wait after using Pulmozyme was an article in:

Journal of Cystic Fibrosis Volume 8Suppl 1 (2009) S6–S9

Does the timing of inhaled dornase alfamatter? ✩
Lianne van der Giessen *
Erasmus Medical Centre – Sophia Children’sHospital, Rotterdam, Netherlands

Abstract
In CF patients with mild or moderate lung disease, the most sensitive spirometric measure of response to dornase alfa is peripheral airflow. Cross-over studies in patients, already stabilised on dornase alfa, indicate that peripheral airflow shows greater improvement when it is administered 30 minutes before airway clearance therapy (ACT) rather than shortly after ACT. These results are consistent with the hypothesis that the major role of dornase alfa is to facilitate expectoration of sputum during ACT.When ACT is performed in the morning, efficacy and safety are similar when dornasealfa is inhaled before bedtime or upon awakening. Most patients may therefore choose the most convenient time of day to inhale dornase alfa provided that they wait at least 30 minutes before performing ACT. Further research is necessary to establish the optimum regimen in patients with more advanced lung disease.

© 2009 European Cystic Fibrosis Society.Published by Elsevier B.V. All rights reserved.

https://www.sciencedirect.com/science/article/pii/S1569199309600047


I personally stopped using Pulmozyme and The Vest in 2014 when I started Kalydeco. Kalydeco just about eliminated the thick sticky mucus from my lungs. Before that however my regimen was:

• Bronchodilator
• Hypertonic Saline - and start The Vest about half way through
• Pulmozyme
• Wait 20 Minutes plus, then The vest
• Antibiotic (Cayston)
• Advair

The reasoning for this sequence was:
First open the airways with a Bronchodilator so the Hypertonic Saline and Pulmozyme can get in to loosen and break-down the thick mucus. Allow about 30 minutes for the Pulmozyme to work. Then The Vest can be more effective in shaking the mucus loose so it can be coughed up. Once the airways are open and cleared the medications, e.g. antibiotics and Advair, can better reach the areas they are intended to treat.

If you find that Pulmozyme is not very affective, perhaps it's because you're not giving it enough time to work properly.

 

[Starfall99]

Was just logging in to post this exact question, so thanks outofthisworld! I've been doing Pulmozyme after airway clearance, because my previous CF doctor said it was better to give it a chance to stay in your lungs instead of coughing it right out during airway clearance. But what I've found online seems to recommend doing it after airway clearance. Maybe I'll trial switching the order and see how it goes.

I also didn't realize that steroids were recommended to be done last. I've been doing them after the bronchidilators under the assumption that steroids also open up the airways. Good to know!

One thing about waiting post-Pulmozyme: part of why my doctor told me to do hypertonic saline before airway clearance, and Pulmozyme after, is that hypertonic saline is short-acting whereas Pulmozyme is longer-acting. So if you do hypertonic saline, then Pulmozyme, then wait, you're gaining the effect of the Pulmozyme but losing the effect of the hypertonic saline. If you're using both, and waiting after Pulmozyme, maybe it would be better to do the hypertonic saline after the Pulmozyme, right before starting airway clearance?

 

[LittleLab4CF]

I'm not going to be able to answer your question about Xopenex. I did a "Search" of Xopenex and there are in excess of 500 references in over 500 posts. Hopefully you will be able to get some answers.

Hope this helps,

LL

 

[ethan508]

Journal of Cystic Fibrosis Volume 8Suppl 1 (2009) S6–S9

Does the timing of inhaled dornase alfamatter? ✩
Lianne van der Giessen *
Erasmus Medical Centre – Sophia Children’sHospital, Rotterdam, Netherlands

Thanks for posting that study Stephan, very interesting.