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Children's Hospital at Dartmouth Hitchcock (CHad)
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Order of Nebulizer Treatment

Patients with cystic fibrosis should always take their medications, and use airway clearance techniques, in a specific order. This is important because each medication achieves a different result.

Not all patients will be on the same medications, but the order listed here should be followed for any combination of medications.

Albuterol (or any bronchodilator) should be given first. A bronchodilator helps open the airways that move air to or from the lungs. Not all people with cystic fibrosis will respond to bronchodilators, so they may not be ordered. Any type of nebulizer may be used with this medication.

Pulmozyme, a mucolytic, will break down the DNA structure of the mucus produced by people with cystic fibrosis. This helps them cough out the thick secretions. This drug may be given using a Pari or a sidestream nebulizer.

Airway clearance techniques

  • Coughing or huffing (a gentle cough)
  • Chest physical therapy (CPT), which involves lying in various positions and clapping on the chest
  • Using a positive expiratory pressure (PEP) device, which is often a mask or a mouthpiece attached to a special machine. An acapella valve is one type of PEP device.
  • Breathing out through a flutter device (also known as oscillating positive expiratory pressure)
  • Wearing a special vest that is attached to a machine that vibrates at a high frequency. Albuterol and Pulmozyme may be given during this type of treatment, but not inhaled antibiotics.
  • Autogenic drainage, or drainage controlled by the person with cystic fibrosis. This is often hard for young children to perform.

Inhaled antibiotics such as Tobi and Tobramycin should be given last. The object of inhaled antibiotics is to attack the bacteria within the lungs. The airways should be open and cleared of as much mucus as possible before receiving this therapy. Only Pari nebulizers can be used with this medication.

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