Airway Clearance Assessment CF Teen AIRWAY CLEARANCE ASSESSMENTThere are no right or wrong answers to this survey. Please answer as truthfully as possible so we can work together to find the best airway clearance treatment(s) for you and your lifestyle.First Name Last Name Physician* Name of Clinic* 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 Bronchodilators Hypertonic 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 Thinners Airway 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 OPEP Vest 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. How true are the following statements for you?Check the box that most closely describes how you feel.I can explain the benefits of airway clearance.* Not at all true Somewhat true True Very true I am confident I know how to do my airway clearance correctly* Not at all true Somewhat true True Very true I am satisfied with my current airway clearance routine* Not at all true Somewhat true True Very true I know about all of the airway clearance options that are available to me* Not at all true Somewhat true True Very true I do my airway clearance routine every day* Not at all true Somewhat true True Very true I do my airway clearance routine when I am away from home* Not at all true Somewhat true True Very true I know the correct order in which to do my respiratory treatments, including airway clearance* Not at all true Somewhat true True Very true I know how to clean/disinfect my airway clearance equipment* Not at all true Somewhat true True Very true I am comfortable doing airway clearance in front of friends/family* Not at all true Somewhat true True Very true 3. Which of the following might get in the way of doing your current airway clearance routine or adding a new airway clearance option?Which of these might get in the way of doing your current airway clearance therapy (ACT) and/or might prevent you from adding a new ACT?* I don’t think it helps I don’t think I need it I’m not producing sputum It takes too much time It disrupts my daily life It gets in the way of time with friends I would rather play sports/exercise It makes my cough worse It’s uncomfortable/hurts The equipment is difficult to set up I have issues with cleaning/disinfecting I’m not sure about the settings I forget to do it It reminds me of my CF It’s embarrassing I don’t want to do it when I’m away from home Check all that apply4. 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
