Pulmonology focuses on diagnosing and treating lung and airway conditions such as asthma, COPD, and pneumonia, as well as overall respiratory health.

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The Pillars of Daily Care

Managing cystic fibrosis takes a lot of effort and is a lifelong process. The main goal is to prevent damage before it happens, not just treat problems as they arise. Treatment can take 2 to 4 hours each day. At Liv Hospital, our team helps patients fit these treatments into their daily lives to get the best results. The main areas of care are clearing the airways, supporting nutrition, controlling infections, and treating the genetic problem.

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Airway Clearance Therapies (ACTs)

Mechanical clearance of mucus is essential to prevent infection. ACTs are performed daily, typically twice a day when well and up to four times a day when sick.

  • High-Frequency Chest Wall Oscillation (The Vest): This is the most common method in many countries. The patient wears an inflatable vest connected to an air pulse generator. The machine rapidly inflates and deflates the vest, creating high-frequency oscillations that shear mucus off the bronchial walls and mobilize it into the central airways for coughing out.
  • Positive Expiratory Pressure (PEP): The patient breathes through a device (mask or mouthpiece) against resistance. This builds pressure behind the mucus, splinting the airways open and pushing secretions upward.
  • Active Cycle of Breathing Techniques (ACBT): A cycle of deep breathing, breath-holding, and huffing to mobilize secretions without equipment.
  • Autogenic Drainage: A controlled breathing technique that uses different lung volumes to move mucus from small to large airways.
  • Exercise: Aerobic exercise is increasingly prescribed as a formal part of airway clearance because increased ventilation helps mobilize secretions.
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Inhaled Mucoactive Agents

To make airway clearance effective, inhaled medications are used to alter the properties of the mucus. These are typically taken via nebulizer before or during ACTs.

  • Bronchodilators (Albuterol/Levalbuterol): These open the airways, allowing better penetration of other meds and preventing bronchospasm.
  • Hypertonic Saline (7%): This strong salt solution creates an osmotic gradient that draws water from the airway tissue into the mucus layer. This rehydrates the ASL and mucus, making it easier to clear.
  • Dornase Alfa (Pulmozyme): This enzyme (DNase) targets the DNA released by dying neutrophils. This extracellular DNA makes CF mucus extremely viscous and stringy. Pulmozyme “cuts” these DNA strands, significantly thinning the mucus.

CFTR Modulator Therapy

CFTR modulators are small-molecule drugs that target the root cause of the disease, the defective protein, rather than just the symptoms. They have transformed the landscape of CF care.

  • Potentiators (Ivacaftor): These drugs help the CFTR channel “gate” open. They are used for gating mutations (Class III) where the protein is at the surface but acts like a locked door. Ivacaftor acts as the key.
  • Correctors (Lumacaftor, Tezacaftor, Elexacaftor): These drugs act as chaperones, helping the misfolded CFTR protein (Class II) assume its correct shape so it can traffic to the cell surface rather than be degraded.
  • Triple Combination Therapy (Trikafta/Kaftrio): This combines two correctors (Elexacaftor and Tezacaftor) with a potentiator (Ivacaftor). It is effective for patients with at least one F508del mutation (approx. 90% of the CF population). It significantly improves lung function (FEV1), reduces sweat chloride, and decreases exacerbations.

Anti-Infective Strategies

Controlling the bacterial load is critical.

  • Eradication Protocols: When a new pathogen, such as Pseudomonas aeruginosa, is first cultured, an aggressive eradication protocol is initiated (usually inhaled tobramycin + oral ciprofloxacin) to kill the bacteria before it establishes a biofilm.
  • Chronic Suppression: For patients with chronic colonization, inhaled antibiotics (Tobramycin, Aztreonam, Colistimethate) are used in cycling monthly regimens (28 days on, 28 days off) to keep the bacterial load low and reduce inflammation.
  • Macrolides (Azithromycin): Used not as an antibiotic but as an anti-inflammatory and anti-biofilm agent. Taken three times a week, it improves lung function and reduces exacerbations.
  • IV Antibiotics: For severe pulmonary exacerbations, hospitalization for 14-21 days of intravenous antibiotics is often required. This allows for higher drug concentrations and intensive clearance therapy.

Nutritional Management and Pancreatic Enzyme Replacement

Good nutrition is directly correlated with better lung function.

  • Pancreatic Enzyme Replacement Therapy (PERT): Patients with pancreatic insufficiency must take enzyme capsules (containing lipase, protease, and amylase) with every meal and snack to aid the digestion of fat and protein. Dosing is individualized based on fat content.
  • High-Calorie Diet: The energy demand of breathing and chronic infection, combined with malabsorption, means patients need 110-200% of the recommended daily caloric intake. A diet high in healthy fats, salt, and protein is encouraged.
  • Fat-Soluble Vitamins: Special CF-specific multivitamins containing water-miscible forms of Vitamins A, D, E, and K are prescribed to prevent deficiency.
  • Enteral Feeding: If oral intake cannot maintain BMI, a gastrostomy tube (G-tube) may be placed for nocturnal supplemental feeding.

Managing Comorbidities

  • CFRD Management: Treated with insulin regimens. Oral hypoglycemics are generally not effective. Continuous glucose monitoring is becoming standard.
  • Liver Disease: Ursodeoxycholic acid (Ursodiol) improves bile flow and may protect the liver. Management of portal hypertension may require endoscopic procedures.
  • Mental Health: Regular screening for anxiety and depression is integrated into care, with referrals to psychologists familiar with chronic illness.

Lung Transplantation

For patients with end-stage lung disease (FEV1 < 30%, rapid decline, or massive hemoptysis) who have exhausted medical options, double lung transplantation is the final therapeutic consideration. While it exchanges the chronic lung disease for the risks of immunosuppression and rejection, it can offer a dramatic improvement in quality of life and survival. Post-transplant care is complex, but the CF defect is removed from the respiratory system.

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Assoc. Prof. MD. Engin Aynacı Assoc. Prof. MD. Engin Aynacı Pulmonology Overview and Definition
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FREQUENTLY ASKED QUESTIONS

Do the modulator drugs cure CF?

They are not a cure because if you stop taking them, the protein dysfunction returns. However, they are highly effective functional treatments that treat the underlying cause.

Any food containing fat or protein requires enzymes for digestion. If you skip enzymes with snacks, you will not absorb those calories and may experience stomach pain and bloating.

No, airway clearance is preventative. Even when you feel well, mucus is being produced. Clearing it daily prevents it from building up and becoming infected.

Cycling (e.g., one month on, one month off) helps prevent the bacteria from developing resistance to the drug while still keeping the bacterial population suppressed.

Hypertonic saline draws water back into the airway surface liquid, rehydrating the dried-out mucus so the cilia can move it more effectively; it’s like watering a dry slide.

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