Airway Clearance Assessment CF Parent AIRWAY CLEARANCE ASSESSMENTThere are no right or wrong answers to this assessment. Please answer as truthfully as possible so that we can work together to find the best airway clearance treatment(s) for you and your child's lifestyle.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. To what extent is each statement true for you?Check the box that applies to each statement.I can explain the benefits of airway clearance.*Not at all trueA bit trueTrueVery trueI think airway clearance is an important part of my child’s care and makes him/her healthier.*Not at all trueA bit trueTrueVery trueI know about all of the airway clearance options that are available to my child.*Not at all trueA bit trueTrueVery trueI know the correct order in which to do pulmonary treatments, including airway clearance.*Not at all trueA bit trueTrueVery trueMy child consistently does his/her airway clearance routine each day.*Not at all trueA bit trueTrueVery trueMy child does their airway clearance routine when we travel.*Not at all trueA bit trueTrueVery trueWe set aside time each day for my child to perform his/her airway clearance.*Not at all trueA bit trueTrueVery trueI am confident my child knows how to do his/her airway clearance correctly.*Not at all trueA bit trueTrueVery trueI am confident I know how to clean/disinfect my child’s airway clearance equipment.*Not at all trueA bit trueTrueVery trueMy child is comfortable doing airway clearance in front of friends/family.*Not at all trueA bit trueTrueVery trueI am satisfied with my child’s current airway clearance routine.*Not at all trueA bit trueTrueVery true3. Which of the following might get in the way of doing your current airway clearance routine or adding a new airway clearance option?Check all items that apply to your situation.* I don’t think it helps It takes too much time Not a priority I’m not sure why they should do it Normal routine is disrupted It’s too heavy/complicated Child forgets I don’t think it’s necessary Travel with it is difficult Issues cleaning/ disinfecting Child is embarrassed It worsens child’s cough Child prefers to exercise/play sports I‘m not sure about the settings Child finds it boring Child is uncomfortable/it hurts Gets in the way of social time/activities Child doesn't feel well enough High out-of-pocket cost Child feels good, doesn’t have symptoms Child is on a modulator, doesn’t need it Other 4. Use this space to add any thoughts not addressed in the sections above 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
