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 NameNumber of puffs or minutesTimes a day?Days a week?BronchodilatorsSelectProventil®ProAir®Ventolin®Xopenex®OtherHow many times a day?How long each time?How many times a week?Other Inhaled BronchodilatorsHypertonic SalineSelectHypersal®Pulmosal®Sodium Chloride3 %3.5 %7 %How many times a day?How long each time?How many times a week?Mucolytics (Mucus Thinners)SelectMucomyst®Bronchitol®Pulmozyme®OtherHow many times a day?How long each time?How many times a week?Other Mucolytics/Mucus ThinnersAirway Clearance TechniquesTreatment NameNumber of puffs or minutesTimes a day?Days a week?Positive Expiratory Pressure (PEP)SelectResistex PEP MaskTheraPEP®How many times a day?How long each time?How many times a week?Oscillating Positive Expiratory Pressure (OPEP)SelectAcapella Choice®Aerobika®Flutter®Lung Flute®RC-Cornet®OtherHow many times a day?How long each time?How many times a week?Other OPEPVest Therapy (Mobile)SelectAffloVest®Monarch®How many times a day?How long each time?How many times a week?Vest Therapy (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®Colistin®How many times a day?How long each time?How many times a week?Inhaled CorticosteroidsSelectFlovent®Pulmicort®QVar®How many times a day?How long each time?How many times a week?2. To what extent is each statement true for you?To what extent is each statement true for your child?Check the box that best describes how closely each statement describes your or your child's experience.I can explain the benefits of airway clearance.*Not at all trueSomewhat trueTrueVery trueI am confident my child knows how to do their airway clearance correctly*Not at all trueSomewhat trueTrueVery trueI am satisfied with my child‘s current airway clearance routine*Not at all trueSomewhat trueTrueVery trueI know about all of the airway clearance options that are available to my child*Not at all trueSomewhat trueTrueVery trueMy child does their airway clearance routine every day*Not at all trueSomewhat trueTrueVery trueMy child does their airway clearance routine when away from home*Not at all trueSomewhat trueTrueVery trueI know the correct order in which to do my child‘s respiratory treatments, including airway clearance*Not at all trueSomewhat trueTrueVery trueI know how to clean/disinfect my child’s airway clearance equipment*Not at all trueSomewhat trueTrueVery trueMy child is comfortable doing airway clearance in front of friends/family*Not at all trueSomewhat trueTrueVery true3. Which of these might get in the way of your child doing their current airway clearance therapy (ACT) and/or might prevent your child from adding a new ACT?Select all that applyCheck all items that apply to your situation.* I and/or my child don't think it helps I and/or my child don’t think they need it My child is not producing sputum It takes too much time It disrupts my child‘s daily life It gets in the way of my child‘s time with friends My child would rather play sports/exercise It makes my child‘s cough worse It’s uncomfortable/hurts The equipment is difficult to set up I or my child have issues with cleaning/disinfecting I or my child aren't sure about the settings I forget to do tell my child to do it It reminds my child of their CF It’s embarrassing My child doesn’t want to do it when away from home 4. 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