From the Guidelines
Pulmozyme (dornase alfa) should be administered before chest physiotherapy for optimal effectiveness, with bronchodilators like Xopenex given first, followed by Pulmozyme, then anti-inflammatory medications like Budesonide, and finally chest physiotherapy. When using multiple nebulized medications, this sequence is recommended to maximize therapeutic benefit. The bronchodilator helps open airways for better medication deposition, Pulmozyme breaks down DNA in thick mucus making it easier to clear during chest physiotherapy, and Budesonide is given last to reduce inflammation without being cleared by the chest physiotherapy 1.
The most recent and highest quality study, from 2017, suggests using bronchodilators before physiotherapy, including inhaled mucoactive drugs, as well as before inhaled antibiotics, to increase tolerability and optimize pulmonary deposition in diseased areas of the lungs 1. Although there is no direct evidence on the optimal sequence of Pulmozyme, Xopenex, and Budesonide, the general principle of using bronchodilators first, followed by mucoactive agents, and then anti-inflammatory medications, can be applied.
It is essential to allow adequate time between medications (at least 15 minutes) for optimal absorption and effect of each medication. This sequence and timing can help improve the effectiveness of chest physiotherapy and reduce the burden of treatment on patients. The European Respiratory Society guidelines also suggest that patients with chronic productive cough or difficulty expectorating sputum should be taught an airway clearance technique by a trained respiratory physiotherapist to perform once or twice daily 1.
In patients with cystic fibrosis, nebulized therapy should be evaluated and re-assessed regularly, considering outcomes such as weight gain, reduced exacerbation frequency, improved physical function, and quality of life 1. The choice of an appropriate nebulizer system is also crucial for the quality of the aerosol produced and the drug output 1.
Overall, the recommended sequence of Pulmozyme, Xopenex, and Budesonide, followed by chest physiotherapy, is based on the principles of optimizing medication deposition, reducing inflammation, and improving airway clearance, with the goal of maximizing therapeutic benefit and improving patient outcomes.
From the Research
Administration of Pulmozyme
- The optimal timing of Pulmozyme (dornase alfa) administration in relation to chest physiotherapy is unknown, but a study suggests that a longer time interval between Pulmozyme nebulization and chest physiotherapy may be more efficacious 2.
- The study found that a longer time interval (>6 hours) between Pulmozyme administration and chest physiotherapy improved clinical outcomes, including forced expiratory flow (FEF) and cystic fibrosis-specific quality of life, compared to a shorter time interval (< or =6 hours) 2.
Combination with Xopenex and Budesonide Nebulizers
- There is no direct evidence on the optimal timing of Pulmozyme administration in relation to chest physiotherapy when combined with Xopenex and budesonide nebulizers.
- However, the study on Pulmozyme administration timing suggests that a longer time interval between Pulmozyme nebulization and chest physiotherapy may be beneficial, regardless of other concurrent treatments 2.
Chest Physiotherapy Efficacy
- Chest physiotherapy may have little to no effect on improving mortality and cure rate in adults with pneumonia, but some physiotherapies may slightly shorten hospital stays, fever duration, and ICU stays 3.
- The use of dornase alpha, a mucolytic agent, has been shown to be effective in managing pulmonary atelectasis after congenital heart surgery 4.
- Chest physiotherapy, including postural drainage, percussion, and vibration, may improve pulmonary function in patients with large sputum volumes, but its effectiveness in other conditions, such as chronic bronchitis, is uncertain 5.