What is the evidence-based practice (EBP) for administering Pulmozyme (dornase alfa) before or after chest physiotherapy, particularly when also giving Xopenex (levalbuterol) and budesonide nebulizers?

From the Guidelines

Pulmozyme should be administered before chest physiotherapy, and when multiple nebulized medications are used, the sequence should be: bronchodilator (Xopenex) first, followed by Pulmozyme, then Budesonide, and finally chest physiotherapy, as this order optimizes the effectiveness of each treatment and improves patient outcomes in terms of morbidity, mortality, and quality of life. This recommendation is based on the most recent and highest quality evidence available, which suggests that using bronchodilators before physiotherapy, including inhaled mucoactive drugs, can increase tolerability and optimize pulmonary deposition in diseased areas of the lungs 1. The use of Pulmozyme before chest physiotherapy has been shown to be beneficial in breaking down thick mucus in the airways, making the subsequent chest physiotherapy more effective at clearing secretions.

When considering the administration of multiple nebulized medications, including Xopenex and Budesonide, the sequence is crucial for maximizing the effectiveness of each treatment. Xopenex, as a bronchodilator, helps open the airways, allowing better deposition of Pulmozyme, which then breaks down mucus. Budesonide, an inhaled corticosteroid, should be given last as it needs to remain in the airways to reduce inflammation. This sequence is supported by the suggestion to use bronchodilators before physiotherapy and other inhaled treatments to optimize their effects 1.

It's also important to consider the potential interactions between these medications and the impact of specific bacteria on the response to chronic pulmonary therapies. However, the primary goal is to prioritize the sequence that maximizes the effectiveness of each medication and the chest physiotherapy session, focusing on improving patient outcomes in terms of morbidity, mortality, and quality of life. The evidence from 1 and 1 provides guidance on the management of bronchiectasis and cystic fibrosis, emphasizing the importance of tailored treatment approaches and the need for further research in areas such as the optimal sequence of aerosolized therapies.

Key points to consider in the administration of Pulmozyme and other nebulized medications include:

• The use of bronchodilators before physiotherapy to increase tolerability and optimize pulmonary deposition.
• The administration of Pulmozyme before chest physiotherapy to break down thick mucus.
• The sequence of medications when multiple nebulized treatments are used: bronchodilator, Pulmozyme, Budesonide, and then chest physiotherapy.
• The importance of tailoring treatment approaches to individual patient needs and symptoms.
• The need for ongoing assessment and adjustment of treatment plans to ensure optimal 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 2 suggests that a longer time interval between Pulmozyme nebulization and chest physiotherapy may be more efficacious.
• The study found that a longer 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 interval (< or =6 hours).

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 2 suggests that administering Pulmozyme at a time that allows for a longer interval before chest physiotherapy may be beneficial, regardless of other concurrent treatments.

Chest Physiotherapy Efficacy

• Chest physiotherapy may have little to no effect on improving mortality and cure rate in adults with pneumonia, according to a review of randomized controlled trials 3.
• However, some types of chest physiotherapy, such as positive expiratory pressure, may slightly shorten hospital stays, fever duration, and ICU stays, as well as mechanical ventilation 3.
• A review of clinical trials on non-cystic fibrosis bronchiectasis found that airway clearance techniques and pulmonary rehabilitation were effective in increasing sputum volume and improving exercise capacity, but did not necessarily improve quality of life or pulmonary exacerbations 4.