What is the evidence-based practice (EBP) for administering Pulmozyme (dornapine) before or after chest physiotherapy, and is it safe to administer concurrently with Xopenex (levalbuterol) and budesonide nebulizers?

From the Guidelines

Pulmozyme (dornase alfa) should be administered before chest physiotherapy for optimal effectiveness, with bronchodilators like Xopenex/levalbuterol given first, followed by Pulmozyme, then inhaled steroids like budesonide, and finally chest physiotherapy. The recommended sequence is based on the principle of maximizing airway clearance and minimizing potential interactions between medications 1. When using multiple respiratory medications, it is essential to allow sufficient time between each medication to optimize their effectiveness.

• The sequence of administration is crucial, as bronchodilators help open airways, Pulmozyme breaks down mucus, and chest physiotherapy clears the loosened secretions.
• Waiting 15-30 minutes after Pulmozyme administration before starting chest physiotherapy allows the enzyme to work on the mucus, making it less viscous and easier to clear.
• Administering Pulmozyme during chest physiotherapy may be less effective, as the medication needs time to break down DNA in the mucus.
• When using Xopenex and budesonide nebulizers, allowing 5-10 minutes between medications helps minimize potential interactions and optimize their effectiveness.
• The European Respiratory Society guidelines suggest 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.

It is essential to note that the guidelines recommend against offering recombinant human DNase to adult patients with bronchiectasis, but this does not apply to patients with cystic fibrosis, who may still benefit from Pulmozyme therapy 1. Overall, the recommended sequence and timing of medication administration can help maximize the effectiveness of Pulmozyme and other respiratory medications, improving patient outcomes and quality of life.

From the FDA Drug Label

The recommended dosage, in most cystic fibrosis patients, is 2.5 mg (one single-dose ampule) inhaled once daily using a recommended jet nebulizer connected to an air compressor system or via a vibrating mesh nebulizer Do not dilute or mix PULMOZYME with other drugs in the nebulizer. Mixing of PULMOZYME with other drugs could lead to adverse physicochemical and/or functional changes in PULMOZYME or the admixed compound.

The optimal timing of Pulmozyme administration in relation to chest physiotherapy is not specified in the drug label.

• It is recommended to avoid mixing Pulmozyme with other drugs, such as Xopenex and budesonide, in the nebulizer.
• There is no information that suggests it is bad to give Pulmozyme while giving chest physiotherapy, but the label does not provide guidance on concurrent administration. 2

From the Research

Administration of Pulmozyme

• The optimal timing of Pulmozyme administration in relation to chest physiotherapy is unknown, but a study suggests that a longer time interval between Pulmozyme nebulization and chest physiotherapy may improve clinical outcomes in patients with cystic fibrosis 3.
• Pulmozyme can be administered before or after chest physiotherapy, but the study found that a longer interval (>6 hours) between Pulmozyme administration and chest physiotherapy resulted in significant improvements in FEF(25-75%) and CF-specific quality of life compared to a shorter interval (< or =6 hours) 3.

Co-Administration with Other Nebulizers

• There is evidence that Pulmozyme can be co-administered with other nebulizers, such as albuterol, in mechanically ventilated patients with COVID-19 4.
• However, the study did not specifically investigate the co-administration of Pulmozyme with Xopenex and budesonide nebulizers.
• The safety and efficacy of co-administering Pulmozyme with other nebulizers should be considered on a case-by-case basis, taking into account the individual patient's condition and medical history.

Administration During Chest Physiotherapy

• There is no evidence to suggest that it is bad to give Pulmozyme while giving chest physiotherapy, but the optimal timing of administration is still unknown 3.
• Chest physiotherapy, including postural drainage, percussion, and vibration, can help improve mucociliary clearance and pulmonary function in patients with excessive tracheobronchial secretions 5.
• The use of Pulmozyme, a mucolytic agent, can help reduce the viscosity of sputum and improve lung function in patients with cystic fibrosis and other respiratory conditions 6, 7.