Inhalation, in what order?

Question

My daughter (7 months old, CF) has to inhale a number of different drugs.

What order would be best for this?

At the moment, she inhales the following drugs in the morning and evening:
1. salbutamol and Atrovent® (ipatropium bromide)
2. Mucoclear® (NaCl) 3%
3. Pulmicort® (budesonide)

In between, twice a day:
1. salbutamol and ipatropium bromide
2. NaCl 3%

Ist his order okay?

Additionally, there is half a vial of Pulmozyme® (dornase alfa). Where can we fit this in best?

Answer

Hello,

First of all: this is a really difficult question.

Generally, one can say that those drugs that open the airways should be inhaled first. For you, this seems to be the case with salbutamol and Atrovent® (ipatropium bromide), which you probably inhale with a metered-dose inhaler and a spacer. Following these are the mucolytic drugs such as Mucoclear® (NaCl) and Pulmozyme® (dornase alfa). Those drugs that are supposed to act on the cleaned mucus membranes should be inhaled last, such as Pulmicort® (budesonide) or antibiotics (not relevant in your case). Inhaling dornase alfa and NaCl simultaneously or back-to-back is very uncommon and, in my opinion, does not make much sense.

It would therefore be one option for you to find a fifth time during the day to inhale dornase alfa separately or to skip one NaCl inhalation and substitute dornase alfa for it.

There is a general recommendation not to inhale dornase alfa too late in the evening in order to support its mucolytic effect through movement, which naturally one is more likely to have during the day than at night.

Do talk to your treating doctor about which inhalation regime suits your daughter best, also regarding the frequency of humid inhalation and a potentially suboptimal toleration with your daughter.

I hope I could help you with this answer.

Kind regards,
Birgit Dittmar
Physiotherapist

30.08.2011