I use the inhaler, then neb saline. If ill, I neb a combo, then saline. But I confess I neither rinse the neb nor switch cups between. The reason I do them first and second is that by the time I start nebbing instead of inhaling levalbuterol, my breathing is usually pretty bad, and I need to get theiairways open. When I asked about it in the hospital (I was seen by the RT after unrelated surgery because of the MAC) he said it would be perfectly reasonable to do together. They don't do it in the hospital because they aren't familiar with the patient, and want to know what is causing the problem if there is a reaction.
Sue