Action Plan CF AIRWAY CLEARANCE ACTION PLANA copy of this Action Plan should be provided at the conclusion of the clinic visit for reference at home. Clinicians should retain a copy in the patient’s chart for review during the next visit.First NameLast NamePhysician*Name of Clinic*Phone # (optional)Email* 1. Which treatment methods are you currently using?Please select the devices/methods you use from the drop downs and indicate how frequently you use them.Treatment NameHow Long?Times a day?Times a week?BronchodilatorsSelectProventil®ProAir®Ventolin®Xopenex®Serevent®Spiriva®OtherHow many times a day?How long each time?How many times a week?Other Inhaled BronchodilatorsHypertonic SalineSelectHypersal®Pulmosal®3 %7 %How many times a day?How long each time?How many times a week?Mucolytics (Mucus Thinners)SelectPulmozyme®Mucomyst®OtherHow many times a day?How long each time?How many times a week?Other Mucolytics/Mucus ThinnersAirway Clearance TechniquesTreatment NameHow Long?Times a day?Times a week?Positive Expiratory Pressure (PEP)SelectPEP ValvePEP MaskFlutterHow many times a day?How long each time?How many times a week?Oscillating Positive Expiratory Pressure (OPEP)SelectAcapella Choice®Aerobika®Lung Flute®OtherHow many times a day?How long each time?How many times a week?Other OPEPHigh-Frequency Chest Wall Oscillation (Mobile)SelectAffloVest®Monarch®How many times a day?How long each time?How many times a week?High-Frequency Chest Wall Oscillation (Stationary)SelectThe Vest®InCourage®SmartVest®How many times a day?How long each time?How many times a week?Huff CoughingHow many times a day?How long each time?How many times a week?Percussion and Postural DrainageHow many times a day?How long each time?How many times a week?Active Cycle of Breathing Techniques (ACBT)How many times a day?How long each time?How many times a week?Autogenic DrainageHow many times a day?How long each time?How many times a week?Intrapulmonary Percussive Ventilation (IPV)How many times a day?How long each time?How many times a week?Other:How many times a day?How long each time?How many times a week?Exercise: Please specify which type:How many times a day?How long each time?How many times a week?Inhaled AntibioticsSelectCayston®TOBI®TOBI Podhaler®Bethkis®How many times a day?How long each time?How many times a week?Inhaled CorticosteroidsSelectPulmicort®QVar®Flovent®How many times a day?How long each time?How many times a week?2. Your care team also recommends that you explore the following educational resources about Airway Clearance Therapies:Check all items that apply About Airway Clearance Prioritizing Airway Clearance Order of therapies Talking to friends Benefits of Airway Clearance Fitting Airway Clearance into a busy day Cleaning and disinfecting equipment Support systems Airway Clearance techniques Doing Airway Clearance while ‘on the go’ How to recognize when I’m sick and what to do Using reminders to help with adherence How Airway Clearance improves overall well-being Doing Airway Clearance while on vacation Download your PDF Now review the form below to verify that it is complete and accurate, if necessary scroll back up to correct information. The preview should automatically load your information, if it does not click the reload icon below to reload it. Once you have verified all your information, click the Download PDF button to save the form to your computer. To protect your privacy we do not save your information, so be sure to move your file to a secure, accessible location after downloading. Your PDF
