Order of treatments?

Bit of a basic question but when it comes to inhaled treatments, I know the order is supposed to be:

bronchodilator

mucoactive treatments

chest clearance

steroids etc.

I’ve been on the same regimen for a while but I’m a bit confused because my steroid inhaler is a combination inhaler so it’s a steroid AND a long-acting bronchodilator. If I do this before my chest clearance, I won’t be getting the most out of the steroid: if I do it after, I would need to use salbutamol before my chest clearance in order to prevent the bit of constriction I can get with my nebulised saline, but then that affects how much of the long-acting bronchodilator works in the lungs.

Any ideas? My respiratory consultant has kind of given up on me and is impossible to reach at the best of times: I haven’t heard a thing from him since my last appointment in January where I clearly was still having issues but he said he didn’t see why he needed to see me before I came back to uni in September. Not so much as a welfare call throughout the pandemic either despite me shielding so that’s why I’m asking here

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I take two inhalers when I wake up. Spiriva which is a long acting broncho dilater and after a few minutes, fostair, which is steroid and bronchodilater. I then have cereal and acup of tea. This gives time for the steroid as well as the broncho dilater to work.

After about 30-40 mins I ventolin,followed by saline.

I do my clearance about two hours later or when it suits me.

As we are all different this would be up to you.

This routine works well for me.

I hope this helped.

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I nebulise ventolin and saline

[Bkin]

My instruction was do the exercises - clearance technique in the morning on rising and before bed (especially with lung infection)

You could think of it another way, the inhaler medicine will help open up the airways for easier breathing to achieve clearance better.

I take inhaler meds, in the morning and at night (broncho dilaters and steroid inhaler)

I have both emphysema and bronchiectasis. I don't nebulize.

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When my daughter was taking a combined inhaler, the advice about order was always to take salbutamol first, then saline neb, do clearance, any antibiotic nebs, then any steroid or combined inhaler right at the end. She literally only uses salbutamol pre physio both to aid deeper clearance but also prevent the small amount of tightness she gets from saline, she doesn’t actually need it otherwise when well.

[Hidden in reply to Hidden]

This sounds most like my routine with the combination inhaler and the saline and airway clearance so I think I’ll go with this! If it doesn’t seem that much of an issue in terms of the salbutamol preventing the long-acting reliever from being as effective then that’s all good ^_^

[Hidden in reply to Hidden]

Glad I could help 👍 With regards to concurrent use, we never had any problems, and my understanding is that although all beta2-agonists, the two main immediate relievers available and the LABAs do have different pharmacological profiles linked to how they favour different substances in the body (salbutamol and terbutaline are hydrophilic, the LABAs are all lipophilic, meaning they both bind to receptors and react in slightly different ways), so they are able to be used side by side without any issues around loss of efficacy or interaction as a result.

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I've been advised to use my blue inhaler before chest physio and wait half an hour before doing chest clearance.

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Thank you everyone! I think Charlie_G’s comment sounds most similar to my situation so I think I’ll keep doing that ^_^ think I’ll get that Wythenshawe referral sorted as well, it’s just pretty awful how I’ve had absolutely 0 contact with my current respiratory team for the entire pandemic given my risk category so it’s the final straw