What is the evidence-based practice (EBP) to administer Pulmozyme (dornap alpha) before or after chest physiotherapy (chest physical therapy)?

From the Guidelines

The evidence-based practice (EBP) recommendation is to administer Pulmozyme (dornase alfa) approximately 30 minutes before chest physiotherapy. This timing allows the medication to begin breaking down the thick, sticky mucus in the airways of patients with cystic fibrosis or other pulmonary conditions, making the subsequent chest physiotherapy more effective at clearing secretions. Pulmozyme works by cleaving extracellular DNA in the sputum, reducing its viscosity and elasticity, as noted in the British Thoracic Society guideline for bronchiectasis in adults 1. When administered before chest physiotherapy, the medication has time to start this enzymatic action, which then enhances the mechanical clearance achieved during physiotherapy techniques such as percussion, vibration, and postural drainage. The standard dose of Pulmozyme is 2.5 mg (one ampule) inhaled once daily using a recommended nebulizer, as this dose has been studied in clinical trials, including a multi-centre study in 349 patients with idiopathic bronchiectasis 1. Some patients may benefit from twice-daily administration, but the evidence for this is less clear. It's also important to consider the use of chest physiotherapy in conjunction with Pulmozyme, as outlined in the ACCP evidence-based clinical practice guidelines for nonpharmacologic airway clearance therapies 1, which suggests that chest physiotherapy can be beneficial in patients with cystic fibrosis and other pulmonary conditions, particularly those who produce significant amounts of mucus. Patients should complete their full prescribed physiotherapy regimen following Pulmozyme administration to maximize the benefits of both treatments. Key points to consider include:

• The timing of Pulmozyme administration in relation to chest physiotherapy
• The dose and administration of Pulmozyme
• The benefits and limitations of chest physiotherapy in various pulmonary conditions
• The importance of individualizing treatment based on patient needs and response to therapy, as the evidence is not always clear-cut, and some studies have shown mixed results, such as the study on bromhexine hydrochloride 1.

From the Research

Administration Timing of Pulmozyme

The optimal timing of Pulmozyme administration in relation to chest physiotherapy is a topic of interest.

• A study published in 2007 2 investigated the effect of a longer time interval between dornase alfa (Pulmozyme) nebulization and chest physiotherapy on clinical outcomes in patients with cystic fibrosis.
• The results showed that a longer time interval (>6 hours) between Pulmozyme administration and chest physiotherapy improved forced expiratory flow (FEF) and cystic fibrosis-specific quality of life compared to a shorter time interval (< or =6 hours).
• However, other studies do not provide direct evidence on the optimal timing of Pulmozyme administration in relation to chest physiotherapy.

Pulmozyme and Chest Physiotherapy

Pulmozyme is used to aid sputum clearance in patients with cystic fibrosis.

• A review published in 2014 3 discussed the evidence for the use of agents that improve sputum clearance, including Pulmozyme, and suggested that a combination of a hyperosmolar agent and a mucolytic agent, such as Pulmozyme, may provide the most logical approach to improving lung function and reducing exacerbations.
• Another study published in 2022 4 used Pulmozyme in combination with intrapleural alteplase to manage complex pleural infection, but did not investigate the timing of Pulmozyme administration in relation to chest physiotherapy.

Other Uses of Pulmozyme

Pulmozyme has been investigated for its potential use in other conditions, such as pulmonary fibrosis.

• A study published in 2025 5 found that Pulmozyme ameliorated lipopolysaccharide-induced lung fibrosis in mice, but provoked residual inflammation by modulating cell-free DNA composition and controlling neutrophil phenotype.
• However, this study did not investigate the timing of Pulmozyme administration in relation to chest physiotherapy.

Chest Physiotherapy

Chest physiotherapy has been widely used as an adjunctive treatment for various respiratory conditions, including pneumonia.

• A review published in 2022 6 found that the current evidence is very uncertain about the effect of chest physiotherapy on improving mortality and cure rate in adults with pneumonia, and that some physiotherapies may slightly shorten hospital stays, fever duration, and ICU stays, but the certainty of evidence is very low.