Page 1 of 2 12 LastLast
Results 1 to 10 of 12

Thread: Question about order

  1. #1

    Question about order

    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.
    Last edited by outofthisworld156; 06-07-2018 at 07:40 AM.

  2. #2
    Senior Member
    Join Date
    Sep 2016
    Posts
    165
    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.
    Last edited by kenna2; 06-01-2018 at 09:23 AM.

  3. #3
    Senior Member
    Join Date
    Jan 2015
    Posts
    279
    I second kenna's response with one exception. I do airway clearance (vest) concurrent with my nebulized medicines, stopping to huff cough as needed.
    Thirtysomething Dad of three (IVFw/ICSI), Mormon, Engineer in Utah.
    I was dx at 1 yr (failure to thrive), D▲F508, FEV1~94%, PA and MSSA, PI.
    2 brothers w/CF, 3 siblings w/out. My wife and parents are saints.

  4. #4
    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

  5. #5
    Super Moderator
    Join Date
    Apr 2006
    Posts
    20,898
    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.
    Parent to a child wcf double delta f508.

    Started Orkambi July 2015
    Began Symdeko August 2018

  6. #6
    Senior Member
    Join Date
    Sep 2016
    Posts
    165
    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.

  7. #7
    Super Moderator
    Join Date
    Aug 2016
    Posts
    39
    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.
    76 Y/O with CF (D1152H and G542X) and Broncheiectesis.
    FEV1 Low 40s%.
    Started Kalydeco March 2014, Switched to Symdeko March 2018. Doing very well!

  8. #8
    Senior Member
    Join Date
    Jan 2015
    Posts
    279
    Quote Originally Posted by stephen View Post
    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).
    Thirtysomething Dad of three (IVFw/ICSI), Mormon, Engineer in Utah.
    I was dx at 1 yr (failure to thrive), D▲F508, FEV1~94%, PA and MSSA, PI.
    2 brothers w/CF, 3 siblings w/out. My wife and parents are saints.

  9. #9
    Super Moderator
    Join Date
    Aug 2016
    Posts
    39
    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.
    Last edited by stephen; 06-10-2018 at 09:06 PM. Reason: Forematting
    76 Y/O with CF (D1152H and G542X) and Broncheiectesis.
    FEV1 Low 40s%.
    Started Kalydeco March 2014, Switched to Symdeko March 2018. Doing very well!

  10. #10
    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?
    39 year old female with CF

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •