A 24-year-old with cystic fibrosis is admitted with thick tenacious sputum, wheezing, and prior bronchospasm during mucolytic therapy, requiring daily dornase alfa and scheduled albuterol plus inhaled tobramycin for Pseudomonas colonization. Which aerosol medication sequence should the therapist select to deliver bronchodilators, mucolytics and antimicrobials?
Select an answer to reveal the explanation.
Short Explanation
You're juggling sticky mucus and twitchy airways at once. Opening the tubes first lets the sequence work like clearing a hallway before moving furniture through it.
Full Explanation
The correct sequence protects hyperreactive airways while maximizing deposition in cystic fibrosis with tenacious sputum and Pseudomonas colonization. Giving albuterol first reverses wheezing and prevents dornase alfa-induced bronchospasm, opening distal airways so the mucolytic given alone without admixture can deposit peripherally and liquefy extracellular DNA, and intervening airway clearance then removes mobilized mucus to reduce diffusion barrier and bacterial load so subsequently nebulized tobramycin achieves higher sputum concentrations. One plausible sequence nebulizes the agents back-to-back without interim clearance, which fails the clearance concept because liquefied but retained secretions dilute and obstruct antibiotic penetration despite correct bronchodilator-first order. Another plausible sequence gives dornase alfa before albuterol to thin mucus early, which fails the bronchoprotection concept because a potentially irritating mucolytic on constricted wheezing airways with prior reaction risks bronchospasm and poor peripheral deposition despite later clearance and correctly timed antibiotic. A third plausible sequence gives tobramycin right after albuterol and reserves dornase alfa until after clearance, which fails the deposition concept because antibiotic deposited on intact mucus plugs is expectorated and cannot benefit from mucolytic thinning. Exam caveat: when wheezing or prior bronchospasm is stated, bronchodilator precedes mucolytics, mucolytics are given alone before clearance, and inhaled antipseudomonals are last after clearance. Practical check: reassess wheeze after albuterol, complete the full dornase alfa dose plus timed huff, PEP or vest clearance before starting tobramycin, and monitor sputum volume, oximetry and bronchospasm symptoms throughout.