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Fall 2017 – Issue 03

An official publication of the Ontario Respiratory Care Society, a section of
The Lung Association – Ontario.

intensive care image

A Case in the Intensive Care Unit: A Physiotherapy Perspective

Chris Farley, BHSc, MScPT

The Intensive Care Unit (ICU) is a fast-paced environment with a diverse team of staff. Physicians, nurses, respiratory therapists, physiotherapists, dietitians and pharmacists, among others, each with their own scope of practice to care for patients with critical illnesses.

It is an unfortunate reality in health care, particularly in intensive care, that there are sad and unsuccessful stories. To maintain a good outlook, it is important to remember the positive impact we, as health professionals, have and recall our success stories.

One of my favourite success stories involved a former patient who we will call Jennifer. She presented to the emergency department with progressive weakness, longstanding difficulty swallowing and overall fatigue. Jenn developed respiratory failure which required intubation and was then transferred to ICU.

Upon Jennifer’s arrival to the ICU on day one, physicians, nurses and respiratory therapists worked to monitor and stabilize her using various intravenous medications and cardiac monitoring. After a brief discussion with the medical team, it seemed they were unsure of what was causing her progressive weakness and respiratory failure.

On day two, we received an order for physiotherapy to assess Jenn. Upon reviewing the patient’s chart, it seemed the medical team was considering her illness to be neurological, with Guillain Barre syndrome and myasthenia gravis being two potential diagnoses among other neurological conditions.

We arrived to assess Jenn and found her husband, Jim at her side. With Jim present and able to communicate for the patient, we were able to get a sense of what Jenn’s life looked like before she ended up with us. She was an active 68-year-old lady with two adult children, both of whom lived outside of the province. She had enjoyed gardening, traveling and exercising at the gym.

At this time, Jenn was intubated, rousing minimally and not following commands. Our treatment mainly focused on maintaining her joint range of motion, monitoring her respiratory status to ensure she wasn’t retaining secretions and repositioning to maintain skin integrity.

The next day, Jenn was starting to rouse more but wasn’t able to consistently follow commands. Our treatment continued to focus on maintaining her respiratory status and skin integrity with repositioning. She was able to participate with her bed exercises with active assisted range of motion to initiate muscle activation.

By day four, Jenn was fully roused. She was assisting nursing staff with turning and consistently participating actively with bed exercises. Her treatment needed to be progressed. I had been in to speak with Jenn and Jim earlier in the day and mentioned that today may be the day we try sitting on the side of the bed and perhaps even stand.

Later that day, the nurse and I arrived to find Jennifer poised to carry out our plan. With the intravenous lines, drains and the ventilator tubing being organized and managed by myself and the nurse, Jenn was able to make her way towards the side of the bed. Today, she needed assistance from both of us to move her legs and torso to sit at the edge. Fortunately, once she was settled at the edge, Jenn was able to maintain her sitting balance by herself while her feet were firmly on the floor. Jenn tolerated the session well, with her vital signs remaining stable throughout.

Jenn remained mechanically ventilated through the endotracheal tube for the next several days. We continued to challenge her endurance and strength by asking her to sit for longer periods and by progressing to standing with assistance. She had also started and was able to complete more repetitions of basic lower and upper extremity exercises.

By day 15, Jenn was still ventilator dependent. The team had opted to insert a PEG tube to feed her and perform a tracheostomy to continue to mechanically ventilate her. Jenn was left to rest on the day her PEG and tracheostomy were inserted.

On day 20, Jenn had progressed well with her sitting and standing tolerance. Her standing tolerance had improved so well with the walker that she was able to side step up the bed and towards her chair at the bedside. By this time, she was sitting up in the chair for up to an hour, twice a day. We had reached a plateau. Jenn’s balance and strength had improved, but her endurance during transitional movements and stepping was still poor.

Over the three weeks we had been seeing her, we had learned more about her. Not only did she enjoy exercising, more specifically she was an avid cycler years ago. At this time, our hospital was involved in a study looking at the feasibility of in-bed cycling for mechanically ventilated patients. Although Jenn didn’t meet the inclusion criteria for the study, she was a perfect candidate for us to try the cycle. For the next two weeks, we set up an alternating program of in-bed cycling and functional mobility. Two days per week Jenn would complete fifteen to thirty minutes of in-bed cycling. The mechanics of the bike allowed for patients to cycle actively as much as they could, while allowing for passive movement for recovery periods. Jenn had already been one of the most motivated patients I had ever treated, but using the bike got her more focused on her recovery than ever.

The focus of the other three days of the week was functional mobility. We had started marching on the spot with a walker and taking short walks away from and back towards her bed. Jenn’s bed to chair transfers had improved to a level that nursing staff were able to transfer her to the chair three times per day in addition to her physiotherapy treatment sessions.

By day 30, Jenn was walking short distances with her rollator walker. She had begun weaning off the ventilator with tracheostomy mask trials; however she still required the added support from the ventilator to ambulate. Setup for Jenn to walk on the ventilator required the most collaboration with the team. The respiratory therapist would transfer her from the ventilator in the room to the portable ventilator and then monitor the ventilator throughout the treatment. The nurse would ensure that all her lines were secured and locked off. The nurse would also be secondary support for the patient during the actual ambulation task, in case she lost her balance or needed hands on assistance of two people. I would provide primary support for Jenn as she ambulated around our unit with her walker while closely monitoring her oxygen saturation and heart rate. The final member of our mobility team was Jenn’s husband. Jim’s main responsibility involved managing the wheelchair that would allow her to take her sitting rests.

With the combined cycling and ambulation training, Jenn’s endurance improved very rapidly. Our unit is a large square of approximately 100 metres around. In the next two weeks, Jenn was able to walk between six and ten laps per physiotherapy session with a sitting rest between each lap.

Soon cycling no longer posed a challenge to Jenn. Her weaning continued to improve such that she didn’t need to be on the ventilator during her physiotherapy treatment anymore. To continue to improve her functional strength, we continued to progress her ambulation distance with fewer rests. We started to alternate between ambulation training one day and stair training the next. Within the next few weeks, Jenn was completing two to three laps of the unit between each rest. Her endurance had improved such that she was ascending and descending our eight-stair flight twice between each rest.

Although she continued to have fairly steady improvements with her progress with physiotherapy, Jenn did experience medical setbacks every few weeks. Along with her functional mobility training, we would intermittently need to use manual secretion mobilization techniques like percussion, vibrations and facilitated deep breathing to promote secretion clearance. Urinary tract infections and new pneumonia symptoms at times dictated her ability to participate. Luckily, her participation would only be limited for one or two days, and she would quickly return to the functional mobility level she had achieved days earlier.

Finally, after four months, Jenn was consistently remaining off the ventilator during the night. Her tracheostomy had been corked and she was consistently on room air. She had reached her goals for discharge from the ICU and she was nearing her physiotherapy goals for discharge from the hospital.
Jenn was signed out to medicine and she left our ICU. Often when someone has had a four month stay in the ICU they require some sort of rehabilitation program prior to discharge back to independent living. Having been able to participate in and tolerate such a high level of functional training supported by the ICU interdisciplinary team, Jenn was discharged back home with Jim just 10 days after her transfer to the medical floor.


Helping patients with COPD develop a deeper understanding of symptom management

patient education

“Why are you telling me to exercise when I’m already short of breath?” – Helping patients with COPD develop a deeper understanding of symptom management

Karen M. Zhang, PhD
Psychology Resident
Supervised by Dr. Joe Pellizzari, C. Psych

A patient with chronic obstructive pulmonary disease (COPD) once described her illness experience as trying to breathe through a straw under a wet cloth that is covering the face. She was making a point that exercise is the last thing someone with shortness of breath would want to do. She even emphasized that the idea sounds absolutely ludicrous. This belief is not uncommon among patients, considering that many individuals with COPD perceive exercise to be aversive, and/or even impossible (Katajisto et al., 2012).

However, from the perspective of healthcare professionals, it is undisputed that regular physical activity is highly effective for improving lung capacity and quality of life for COPD patients (Vestbo et al., 2013). There is well-established evidence that participation in exercise-based programs, such as respiratory rehabilitation, can help reduce illness exacerbations, minimize re-hospitalizations, and increase patients’ functioning and wellbeing. The question then is how do we transfer this knowledge to patients so that they understand and view regular exercise as important and vital for COPD symptom management?

Providing more effective delivery of patient education may be the most obvious solution for improving patient-provider communication and increasing patient knowledge around the need for exercise. Yet, little is known about the best way to optimize patient understanding. Part of the problem is that patient education interventions are often poorly described in the literature (Smith et al., 2011). In a systematic review of 360 studies evaluating the effectiveness of patient education for chronic disease management, only 27% of these studies described the pedagogical features in the interventions (Lagger, 2010). This suggests that before we can start loading COPD patients with educational materials, we need to first determine how we can explain the information so that it makes sense.

Different Levels of Knowledge 

According to research in cognitive psychology, the depth at which an individual learns about a concept affects how well the information subsequently can be retrieved and used (Minda, 2015; Tulving, 2002). Shallow processing refers to learning at the surface level, typically in a rote manner. This type of processing enables acquisition of factual knowledge, which is associated with recalling facts verbatim (Mayer, 2002). In contrast, deep processing, based on knowledge of conceptual information about the subject matter is a more useful form of learning. Individuals who process information at a deep level (e.g., experts) can better apply their knowledge to solve problems (Chi et al., 1981; Devantier et al., 2009). These two types of information processing may make more sense when we think about how educators test students to determine those who really understood the course materials and apply it (deep knowledge) versus those who simply crammed the information the night before (factual knowledge). While both types of students can recall facts about the subject matter, only those who have processed the course information more deeply can generalize and use the information in different situations.

In a similar way, it could be that the depth to which COPD patients process information about their condition and its management might influence how they perceive the need for exercise. That is, patients who have a deeper conceptual knowledge of their COPD may be more likely to understand the seemingly counterintuitive information that increased physical activity can help with breathlessness. Recent research suggests that one way to help patients develop deeper understanding of their chronic condition and its management is to explicitly explain to them WHY a specific therapy or recommendation is effective.

“If you tell me WHY, I might comply”

Explanations about why an effect occurs or how things work are referred to as causal explanations in the cognitive science literature (Keil, 2011). This method of explaining a concept has been shown to facilitate deeper knowledge in a medical education context. In one study, students received either standard information about how to perform a percussive respiratory exam or standard information with additional causal information about why physical sounds occurred during the medical test (Goldszmidt et al., 2012). Results showed that those who received the causal explanations were better able to interpret the examination results. This study, along with others (Woods, Brooks & Norman, 2005), indicated that causal information helps to enhance deeper understanding and better application of medical information. Would this approach then be effective in a patient education context?

In our recent experimental study, we looked at whether integrating causal information into a health education booklet would help participants better understand illness management (Zhang et al., 2017). Participants received one of two versions (causal vs. non-causal) of a patient education booklet about a hypothetical disease. We used a hypothetical disease to control for any prior knowledge of the illness condition. Individuals in the causal explanation condition learned about how illness management behaviours, illness pathophysiology and symptom reduction are causally linked (see Figure 1). In other words, the causal information highlighted how health behaviours, such as exercise, are directly affecting their bodily functions and symptoms. The non-causal group also received the same information but it was presented in a segmented fashion. Our findings showed that individuals who received the causal information in the education booklet were better able to apply their knowledge to answer questions about managing symptom flare-up than the comparison group. It appears that causal information helps individuals link otherwise fragmented information; thereby, making the information more easily accessible to solve problems.

We are currently investigating the effectiveness of integrating causal information in a patient education session at cardiac rehabilitation. More specifically, the causal information highlights the cause-and-effect of behavioural intervention on cardiovascular pathophysiology (see Figure 2 for an example). Although the results are still pending, it has been observed clinically that patients perceive exercise recommendations to be more credible when they are told why they need to do it.

How can causal information help with patient education for individuals with COPD?

Considering the growing research evidence and clinical observations that explaining ‘why’ could improve understanding of illness management, the use of causal information might be a promising approach for COPD patient education. For example, it might be helpful for patients to understand how exercise can improve their lungs’ endurance and ability to use oxygen more efficiently. Drawing explicit connections between physical activity and the strengthening of limb muscles may help patients formulate a deeper understanding of the need for regular exercise. Additionally, causal information can be used to explain the rationale for different types of exercises (e.g., strengthening, aerobic and breathing exercises) and other COPD management strategies. The use of causal explanations can be easily adapted into a variety of modalities, including visual displays, written information and other multimedia formats to optimize patients’ attentiveness to the information.

It is also possible that a deeper understanding of COPD management may lead to better adherence to exercise recommendations. However, it is important to note that knowledge alone does not drive behavioural change (Lagger, 2010). The use of causal information can be combined with other patient education strategies, such interventions to leverage self-efficacy, to help COPD patients better engage in exercise programs.


Helping patient understand why exercise is important for illness management, rather than simply telling them what to do, can help improve patient-provider partnerships in COPD management. It is critical to acknowledge that COPD patients are experts of their experience and it can be difficult for them to adopt behaviours that seem to be counterintuitive. Providing more in depth information about how exercise affects pathophysiology may help patients make more informed decisions about their health care, and understand that exercise recommendations are not meant to subject them to more suffering. Viewing patients as capable learners is a step towards more patient-centred care.


Back to Front Page


    1. Brown, J. P., Clark, A. M., Dalal, H., Welch, K., & Taylor, R. S. (2013). Effect of patient education in the management of coronary heart disease: a systematic review and meta-analysis of randomized controlled trials. Eur J Prev Cardiol, 20(4), 701–714. https://doi.org/10.1177/2047487312449308
    2. Chi, M. T. H., Feltovich, P. J., & Glaser, R. (1981). Categorization and representation of physics problems by experts and novices. Cognitive Science, 5, 121–152. https://doi.org/10.1207/s15516709cog0502_2
    3. Devantier, S. L., Minda, J. P., Goldszmidt, M., & Haddara, W. (2009). Categorizing patients in a forced-choice triad task: The integration of context in patient management. PLoS ONE, 4(6). https://doi.org/10.1371/journal.pone.0005881
    4. Goldszmidt, M., Minda, J. P., Devantier, S. L., Skye, A. L., & Woods, N. N. (2012). Expanding the basic science debate: The role of physics knowledge in interpreting clinical findings. Advances in Health Sciences Education, 17(4), 547–555. https://doi.org/10.1007/s10459-011-9331-2
    5. Katajisto, M., Kupiainen, H. Rantanen, P., Lindqvist, A., Kilpelainen, M., Tikkanen, H., & Laitinen, T. (2012). Physical inactivity in COPD and increased patient perception of dyspnea. International Journal of COPD, 7, 743-755.
    6. Keil, F. C. (2011). Explanation and Understanding. Annual Review of Psychology, 57(Salmon 1989), 227–254. https://doi.org/10.1146/annurev.psych.57.102904.190100. Explanation
    7. Lagger, G., Pataky, Z., & Golay, A. (2010). Efficacy of therapeutic patient education in chronic diseases and obesity. Patient Education and Counseling, 79(3), 283–6. https://doi.org/10.1016/j.pec.2010.03.015
    8. Mayer, R. E. (2002). Rote Versus Meaningful Learning. Theory Into Practice, 41(4), 226–232. https://doi.org/10.1207/s15430421tip4104_4
    9. Minda, J. P. (2015). The psychology of thinking: Reasoning, decision-making and problem-solving. London, UK: UK: SAGE Publications, Ltd.
    10. Smith, S., Mitchell, C., & Bowler, S. (2007). Patient-Centered Education: Applying Learner-Centered Concepts to Asthma Education. Journal of Asthma, 44(10), 799–804. https://doi.org/10.1080/02770900701645256
    11. Tulving, E. (2002). Episodic memory: from mind to brain. Annual Review of Psychology, 53(1), 1–25. https://doi.org/10.1146/annurev.psych.53.100901.135114
    12. Vestbo, J., Hurd, S., Agusti, A. G., Jones, P. W., Vogelmeier, C., Anzueto, A. et al. (2013). Global strategy for diagnosis, management, and prevention of chronic obstructive pulmonary disease. American Journal of Respiratory Critical Care Medicine, 187(4), 347-365. DOI: 10.1164/rccm.201204-0596pp
    13. Woods, N. N., Brooks, L. R., & Norman, G. R. (2005). The value of basic science in clinical diagnosis: Creating coherence among signs and symptoms. Medical Education, 39(1), 107–112. https://doi.org/10.1111/j.1365-2929.2004.02036.x
    14. Zhang, K. M., Swartzman, L. C., Petrella, R. J., Gill, D. P., & Minda, J. P. (2017). Explaining the causal links between illness management and symptom reduction: Development of an evidence-based patient education strategy. Patient Education & Counseling. doi: 10.1016/j.pec.2017.01.009


Sample Causal Information


(presented on one page):


How Can I Manage the Symptoms and Complications of Alphabet Disease?


Feeling Tired (fatigued)


What to do: Consume 3-4 glasses of high carbohydrate drinks each day Why: Alphabet disease makes it difficult for your body to produce essential fats and carbohydrates that give you energy. Consuming high carbohydrate drinks will supply you with the energy you need.

Sample Non-Causal Information


(presented on separate pages):


What is Alphabet Disease?

Alphabet disease occurs when your liver has difficulty breaking down Alphabetin into vitamin ABC. Your body needs vitamin ABC to metabolize proteins, keep your immune system strong and produce fats and carbohydrates. As a result, individuals with Alphabet disease have a build up of proteins and not enough fats and carbohydrates.

What are the Symptoms and Complications?

Feeling tired (fatigued)


How Can I Manage My Alphabet Disease?

High Carbohydrate Drinks

Consume 3-4 glasses of natural juices and energy drinks each day.

Figure 1: This figure shows an example of how the learning material was presented in a causal and non-causal way. The dotted line represents information that was shown on a separate page in the booklet.


“When you exercise, your muscles require increased flow of blood and your heart would work harder to pump that blood. Increased blood flow tugs at and stimulates the inner lining of your coronary arteries, also called the endothelium. This gradually reconditions the endothelium to enhance its ability to create and release nitric oxide. As you have learned earlier, the release of nitric oxide allows the artery to expand in response to physical activity. Therefore, with regular exercise, you will begin to experience fewer angina symptoms and your artery will begin to restore its health. When this happens, there is fewer plaque build-up which then means you’ll have a lower chance of future heart problems”


Figure 2: This is an example of an explanation that includes causal information about the linkage between flow-mediate dilatation, cardiac risk factors, symptoms and health behaviours.

Chair’s Message

I hope that everyone had a wonderful summer! Despite the lazy days of summer, things have been moving right along at The Lung Association. The planning for Better Breathing 2018 is almost complete! Save the date, January 25 – 27, 2018, and plan to attend Canada’s premier respiratory conference hosted by the Ontario Thoracic Society (OTS), the Ontario Respiratory Care Society (ORCS) and The Lung Association – Ontario. Topics and speakers have been selected to appeal to a variety of professions working in all areas of respiratory health. This year’s line-up includes sessions on Transplant Innovations, the Use of Apps and New Technology in Sleep Medicine, Compassion Fatigue for Health-care Workers and a debate on pulmonary rehabilitation versus general rehabilitation when treating COPD, to name a few.

The goal of The Lung Association’s Better Breathing Conference is to provide a forum for professional education and to formulate, disseminate and implement strategies for achieving optimal respiratory health for Ontario. The conference goal will be achieved through plenary sessions, workshop sessions and poster presentations. On behalf of the ORCS Education and the Research and Fellowship Committees and the RTSO Research Committee, I invite you to submit an abstract for a poster presentation at the conference. The abstract review committee will finalize selection of abstracts after the deadline date of Monday, November 13, 2017. For more information please see the Call for Abstracts on the Better Breathing website.

We are eager to continue to enhance the benefits of your ORCS membership! A survey was deployed this summer to gain your thoughts on the Better Breathing Conference and what you value about membership in the ORCS. More than 100 people responded – a response rate of an impressive 14.5 per cent, which demonstrates our members care about the Society.

And finally, The Lung Association continues to work on a new membership portal that will greatly improve the ORCS registration process for returning and new members, allow members to have their own profile page, and streamline BBC and other event registrations. Stay tuned for its expected roll out in the coming months.

I am always available to discuss any comments or suggestions that you may have.  I am available by email dina.brooks@utoronto.ca or by phone at 4l6-978-1739.

Respectfully submitted,

Dina Brooks, BScPT, MSc, PhD
Chair, Ontario Respiratory Care Society

Editor’s Message

Greetings everyone. We are excited to bring you the third edition of the joint ORCS/RHEIG publication which now bears the new title Update on Respiratory Health, Research and Education. We truly feel this new title incorporates the essential elements of both previous publications and is a resource which will provide you with a wide range of information to enhance your knowledge and practice.

In this edition, we are pleased to cover a wide range of topics. The two Feature Articles discuss Mobility in the ICU and Causal Information in Patient Education. The Eye On section highlights the work being done by the Caring for My COPD program at NHCHC. The Toolbox reminds us of the importance of teaching and reinforcing correct inhaler technique.

The Respiratory Articles of Interest section summarizes three articles which focus on the effects of oxygen therapy in a variety of scenarios. The poster winners from Better Breathing 2017 are featured in In The Spotlight.

As you read this, we are only a few months away from Better Breathing 2018. We encourage all members to attend this exciting and informative conference and to bring along your colleagues who have perhaps never attended a Better Breathing conference.

The Respiratory Health Educators Group (RHEIG) has been busy planning their sponsored afternoon on Thursday, January 25, 2017. Broad topics being investigated at present include: ethical issues surrounding end-of-life care and assisted suicide, how to effectively communicate with your patients dealing with lung cancer, brief action planning with your patients around behavior change, new respiratory medications in COPD and asthma, and how to help you and your patients recognize “fake news”.
The ORCS Editorial Board and the RHEIG have continued to work on Terms of Reference, and the integration of these two groups to provide this joint publication. Continued thanks to all who have helped and continue to help facilitate this process.

As we continue to enhance and improve this new joint electronic venture, we are very interested in your feedback, both positive and negative. We want this publication to meet your needs so please let us know what you think!
Mark January 25 to 27, 2018 on your calendar and we look forward to seeing many of you in Toronto at Better Breathing 2018.


Lorelei Samis
Co-chair RHEIG Executive Team
Editorial Board


Short-term Effects of Supplemental Oxygen on 6-Min Walk Test Outcomes in Patients With COPD: A Randomized, Placebo-Controlled, Single-blind, Crossover Trial

Submitted by Priscila Robles 

Jarosch I, Gloeckl R, Damm E, Schwedhelm AL, Buhrow D, Jerrentrup A, et al. Short-term Effects of Supplemental Oxygen on 6-Min Walk Test Outcomes in Patients With COPD: A Randomized, Placebo-Controlled, Single-blind, Crossover Trial. Chest. 2017;151(4):795-803.

Providing oxygen supplement (O2_suppl.) to patients with Chronic Obstructive Pulmonary Disease (COPD) who would benefit from this intervention is clinically important.  Identification of those with a high “oxygen response” is also important as there appear to be subgroups with different levels of oxygenation. A total of 124 severe to very severe COPD patients underwent one 6-min walk test on supplemental oxygen, and one 6-min walk test on room air after a practice 6-min walk test in a prospective, randomized, placebo-controlled, single-blind, crossover fashion. Three subgroups were identified through a post-hoc approach: HYX= hypoxemia at rest and following exercise, EIH= exercise-induced hypoxemia; and NOX= normoxemia at rest and during exercise. Results showed significant improvements from O2_suppl. in hypoxemic patients: i) 42% of patients with HYX and 47% with EIH had ≥ 30 metres increase in 6MWD; ii) oxygen saturation (SpO2) improved by 8.5% (HYX) and 5.4% (EIH), and iii) 24% of patients with HYX and 19% with EIH had a reduction in end-exercise dyspnea scores of ≥ 1 Borg point. In normoxemic patients with COPD, oxygen-related effects were not of clinical relevance. O2_suppl. generally improved exercise capacity and oxygenation in COPD patients with HYX as well as EIH; however, final sample size may opaque clinically relevant differences in the characteristic of oxygen responders and nonresponders among those subgroups.

A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation

Submitted by Priscilla Robles

Long-Term Oxygen Treatment Trial Research G, Albert RK, Au DH, Blackford AL, Casaburi R, Cooper JA, Jr., et al. A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation. N Engl J Med. 2016;375(17):1617-27.

The Long-Term Oxygen Treatment Trial (LOTT) is a parallel-group, randomized, multi-centre study of long-term supplemental oxygen in patients with COPD and moderate resting desaturation. The trial was originally designed to test whether the use of supplemental oxygen would result in a longer time to death than no supplemental oxygen among these patients. To meet recruitment goals, the investigators further included patients with exercise-induced desaturation and incorporated the secondary outcome of hospitalization for any cause. Other health outcomes were also assessed. Three hundred and sixty eight patients were assigned to supplemental-oxygen and 370 to no-supplemental-oxygen groups, and were then followed for 1 to 6 years. The prescription of supplemental oxygen (either for resting or exercise-induced desaturation) did not affect the time to death or first hospitalization, time to death, time to first hospitalization, time to first COPD exacerbation, time to first hospitalization for a COPD exacerbation, the rate of all hospitalizations, the rate of all COPD exacerbations, or changes in measures of quality of life, depression, anxiety, or functional status. There was no effect on the primary outcome in subgroups defined according oxygen prescription. The investigators concluded that long-term supplemental oxygen in patients with stable COPD and resting or exercise-induced moderate desaturation has no benefit with regard to the multiple outcomes measured.

Clinical Usefulness of Long-Term Oxygen Therapy in Adults

Submitted by Priscilla Robles

Ekstrom M. Clinical Usefulness of Long-Term Oxygen Therapy in Adults. N Engl J Med. 2016;375(17):1683-4.

Whether long-term oxygen therapy is beneficial in moderate hypoxemia is a question no more, according to this NEJM editorial on the Long-Term Oxygen Treatment Trial (LOTT) published in the same issue. The Editorial highlights the lack of quality evidence regarding clinical usefulness of long-term oxygen treatment in patients with COPD and moderate hypoxemia despite frequent prescription, relatively high costs, and the potential burden on patients. The Editor tackles the fact that indication and eligibility criteria have been based on two classic papers that included patients whose characteristics may not adequately reflect characteristics of patients being prescribed such therapy in current practice. Moreover, survival benefit in mild to moderate hypoxemia has not been confirmed in subsequent studies and evidence of efficacy on symptoms and health-related quality of life is also limited. The LOTT study then represents a groundbreaking contribution to the scarce literature on long-term oxygen therapy that includes the largest patient cohort to date, patient-centred outcomes, clinically relevant subgroups with moderate desaturation (at rest and during exercise) and treatment strategies for which evidence is needed. Based on the lack of effect observed in the LOTT, the Editor understands that long-term oxygen therapy should be reserved for those with severe resting hypoxemia to prolong survival, and should not be routinely prescribed for those with mild to moderate hypoxemia.


Caring for my COPD program

Reena De Groot, RN, CRE

Caring for My COPD is a free community-based program that began in February 2014. The program was designed to enhance the quality of life for people with Chronic Obstructive Pulmonary Disease (COPD). The Hamilton Niagara Halton Brant Local Integrated Health Network (HNHBLHIN) funded program is offered in four locations: North Hamilton Community Health Centre in Hamilton, Grand River Community Health Centre in Brantford, Niagara Falls Community Health Centre in Niagara Falls, and Centre de santé communautaire in Welland.
The design of the program is to help clients learn to better self-manage their COPD. A secondary goal of the program is to decrease COPD-related emergency room visits, hospitalizations, and hospital readmissions within 30 days of discharge. Ultimately the goal of the program is to improve clients’ quality of life by providing them with the tools to self-manage, engage in meaningful peer support and participate in exercise and activities that will enable them to remain healthy for longer.

The original program model allowed only hospital physicians to refer to the program; the aim was to target those clients who had recently been hospitalized or were at risk of re-hospitalization. The program has evolved to meet the needs of the communities they serve and now also accepts referrals from primary care providers with clients who have a confirmed diagnosis of COPD. Clients who are medically unstable or live in long-term care facilities are not eligible for the program.
The Caring for My COPD program offers a bundle of services using the principles of the Chronic Disease Management Model. Caring for My COPD provides the following services:

  • Case Management by a Certified Respiratory Educator (CRE) trained coordinator who collaborates with clients’ primary care providers and respirologists
  • Spirometry and 6-minute walk testing
  • Review and assessment of personalized COPD Action Plans
  • Group and individual COPD education
  • Peer support
  • Supervised and personalized exercise programs
  • Individual counseling and spiritual support
  • Education sessions for families and caregivers to support individuals with COPD
  • Caregiver support

The Caring for My COPD program staff includes a Certified Respiratory Educator (CRE), kinesiologist, physiotherapist, occupational therapist, social worker, dietitian, psychologist and admin support. The team works together with participants to help improve their ability to not only manage their COPD but to live life fully.

The program is a 10-week intensive program that involves once-weekly education sessions and a minimum of twice-weekly exercise sessions. Education sessions cover topics such as breathing and coughing, medications, stress and anxiety, falls prevention, healthy eating and COPD exacerbations and action plans. The exercise part of the program is targeted to meet the individual’s needs and all sites offer group or 1:1 options.

The four program locations have evolved over the years to include graduate peer support groups. There is compelling evidence in the medical literature that peer support is key in assisting people to successfully self-manage a chronic health condition. Peers understand the physical, emotional, and spiritual challenges of living with an illness like COPD and can assist one another in continuing to find meaning and joy in daily living. Peer support groups can enrich programming and contribute greatly to helping people live longer and more satisfying lives despite their illness.

North Hamilton Community Health Centre’s Take a Breath (TAB) Club has been offered since 2014. This group was formed for graduates of the Caring for My COPD Program to provide participants with the opportunity to enhance self-management skills and participate in regular exercise in a supportive and caring environment. The group meets weekly for peer support and then has the opportunity to exercise with the kinesiologist and physiotherapist two times a week. The group typically welcomes between 25 and 30 members each week. Additionally, the TAB Choir was formed in 2015 as an innovative way to improve lung function while engaging in a joyful group activity. As well as TV and radio appearances, the choir has sung at a variety of venues, including Hamilton Town Hall and St. Joseph’s Hospital.

The Grand River Community Health Centre (GRCHC) offers a peer support group monthly called LUNGevity. This group is open to all program graduates and is an opportunity for graduates to be a part of a community of shared experiences and shared resources. At the LUNGevity group, participants typically engage in cooking with the program’s dietitian during the first half of the session. They then enjoy the food they have prepared while having an informal supportive dialogue with the program’s social worker, who helps facilitate the discussion as needed. Although the goals of the group are to provide supportive care and build a community for participants, the activities used to help attain these goals remain fluid and are driven by the needs and interests of those participating. In addition to the LUNGevity group, the Brantford Caring for My COPD program also has plans to offer a graduate exercise program for those that are medically cleared to participate. This will allow program grads who are cleared to exercise with another option to stay active post-program in an environment that they are already familiar with.

Centre de santé communautaire Hamilton Niagara offers a twice-monthly group that allows a time for past participants to enjoy coffee, games and socializing in a supportive environment. Graduates of the program have the opportunity to attend open gym times and exercise with the kinesiologist. Graduates are also invited to stay on as volunteers assisting staff and supporting new clients as they work through the program.

If you have a client with COPD, know someone who would benefit from the program or would like more information please contact the program coordinator.

Centre de santé communautaire Welland – 905-714-9935 ext. 2285

Grand River CHC Brantford – 519-754-0777 ext.235

Niagara Falls CHC – 905-356-6666

North Hamilton CHC – 905-523-1184


BBC 2017 Poster Winners

In the Spotlight this month are the poster winners from the ORCS Poster Session at the Better Breathing Conference 2017, which was held January 26-28 at the Toronto Marriot Downtown Eaton Centre.

The winner of the Margaret Fitch award for best poster was Lisa Wickersonfrom the University of Toronto for her poster “Exertional Oxygen Requirements, Exercise Capacity and Aerobic Training in Advanced Interstitial Lung Disease.” Co-authors on the study were Lisa Wickerson, Dina Brooks, Darlene Reid, Lianne G. Singer and Sunita Mathur.

The Lisa Cicutto award for best poster by a student was presented to John Odame of Ryerson University for his poster “Recruitment Limitations of Pharmacist Led Asthma-Specific Intervention Program.” His co-authors were Pria Nippak, Lee Verweel and Zahava Rosenburg-Yunger.

Finally, the winner of the inaugural Sheila Gordon-Dillane award was Jessica Schooley of Kingston General Hospital and Queen’s University for “An Electronic Asthma Performance Indicator Reporting System: Use of Standardized Electronic Medical Record Data at the Point of Care.” Co-authors on this poster were David Barber, Karen Hall-Barber, Teresa To and Diane Lougheed.

In 2018, the Better Breathing Poster Session will be a collaboration between the ORCS and the Respiratory Therapy Society of Ontario (RTSO). To submit an abstract for this session, download the form here and submit to orcs@lungontario.ca by Nov 13, 2017.

We look forward to seeing you all at Better Breathing 2018! Registration will open soon, so keep an eye on your inbox for more information!




Ontario Respiratory Care Society Research and Fellowship Awards

Mika Nonoyama, Chair, ORCS Research and Fellowship CommitteeThe ORCS Research and Fellowship committee is pleased to announce The Lung Association – Ontario funding of $83,500 for the following Awards for the year 2017-18. We congratulate all the successful winners and sincerely appreciate your dedication to lung health.


Pictured at right: Mika Nonoyama, FCSRT, RRT, PhD, Chair, ORCS Research and Fellowship Committee



Is dual tasking compromised in people with COPD?
Principal Investigator: Darlene Reid, BMR (PT), PhD, University of Toronto, Toronto

 Patient and family centred performance measures focused on actionable processes of care for persistent or chronic critical illness
Principal Investigator: Louise Rose, RN, PhD, University of Toronto, Toronto

 High intensity interval versus moderate intensity continuous exercise in individuals with advanced interstitial lung disease
Principal Co-Investigators: Sunita Mathur, BScPT, MSc, PhD & Lisa Wickerson, BScPT, MSc, PhD, University of Toronto, Toronto


Candidate: Justine Horne, RD, London
Program: PhD, Health & Rehabilitation Sciences, Western University

Candidate: Sylvia Rinaldi, RD, London
Program: PhD, Health & Rehabilitation Sciences, Western University

Candidate: Kenneth Wu, PT, Toronto
Program: MSc, Rehabilitation Science, University of Toronto

Candidate: Sachi O’Hoski, PT, Hamilton
Program: PhD, Rehabilitation Science, McMaster University


The deadline for applications for the 2018-19 funding year is February 1, 2018 for all streams of the program: Research Grants, and Fellowship Awards. Visit lungontario.ca later in 2017 to download the 2018-19 application forms and program guidelines.

ORCS Members are also welcome to apply for Ontario Thoracic Society (OTS) grants-in-aid (GIA), which are allocated to individual researchers in support of research in topics related to respiratory medicine in Ontario. To learn more, visit www.lung.ca/lung-research/apply-funding



Continuing need to review inhaler use technique

Jane Lindsay, BScPT, CRE

If you think that your patients have trouble with correct inhaler technique, you’re right. A review study, published in Chest in 2016, has concluded that “incorrect inhaler technique is unacceptably frequent and has not improved over the past 40 years, pointing to an urgent need for new approaches to education and drug delivery.” [1]

The authors state: “The most frequent metered-dose inhaler (MDI) errors were in coordination (45%; 95% CI, 41%-49%), speed and/or depth of inspiration (44%; 40%-47%), and no postinhalation breath-hold (46%; 42%-49%). Frequent dry powder inhalers (DPI) errors were incorrect preparation in 29% (26%-33%), no full expiration before inhalation in 46% (42%-50%), and no postinhalation breath-hold in 37% (33%-40%). The overall prevalence of correct technique was 31% (28%-35%); of acceptable, 41% (36%-47%); and of poor, 31% (27%-36%). There were no significant differences between the first and second 20-year periods of scrutiny.” [1]

While this doesn’t come a surprise to respiratory educators, it reinforces the need to review inhaler technique, and to provide effective education when errors are found.

A list of proper instructions for inhaler technique are an important part of your toolbox, whether your patient population is pediatric or adult, acute or chronic. The authors have provided a table outlining “Essential Inhalation Maneuver Steps” which is available in the open-access full text article (see links below).

The Lung Association – Ontario also provides patient-friendly information on inhalation techniques, and provides an array of educational videos for the different devices.

1. Sanchis, J., Gich, I., Pedersen, S. Systematic review of errors ininhaler use: Has patient technique improved over time? Chest. 2016;150(2):394-406. doi: 10.1016/j.chest.2016.03.041. [PubMed].


Jocelyn Carr, BScPT, MSc
Lorelei Samis, BScPT

Yvonne Drasovean, RRT
Elizabeth Gartner, BScOT
Therese Hawn, BScPT
Lawrence Jackson, BScPhm
Priscila Robles, BScPT, MSc, PhD

Dina Brooks, BScPT, MSc, PhD

George Habib, BA, BEd, CAE

Sherry Zarins

OTS/ORCS Coordinator
Natalie Bennett

RHEIG Executive Team

Jane Lindsay, BScPT, CRE
Lorelei Samis, BScPT

Cassy Bernard, RN
Lana Biro, RRT, CRE
Karen Brooks, RN, BSc, CRE, CTE
Michael Callihoo, RRT, CRE
Rose-Marie Dolinar, RN(EC), MScN, PhD student
Diane Feldman, RRT, CRE
Olivia Ng, BScPhm, RPh, PharmD (Candidate)
Maria Willms, RN, CRE
Rebecca Whiting, RRT, CRE



An official publication of the Ontario Respiratory Care Society, a section of The Lung Association.