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Spring 2018 – Issue 05

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

Chair’s Message

The ORCS is growing and with that comes the expanded reach and impact of lung health programs across the province.  By the end of fiscal 2017-18 membership was more than 800 strong! If you haven’t renewed your membership for this year, don’t delay, renew today: https://lungontario.ca/for-health-professionals/ontario-respiratory-care-society/.

Last year, the seven Regional Planning Committees of ORCS planned and implemented six events that included 15 speakers and topics and were attended by more than 180 participants. This year, to create efficiencies and better align with The Lung Association’s regions, some ORCS regions have been amalgamated. Essex/Kent and Southwestern Planning Committees merged to become Western Ontario.  Greater Toronto and South Central Ontario merged to become Central Ontario.

Are you involved in research? The ORCS Research Grants and Fellowship Awards support research and graduate study by health-care providers in the field of respiratory care regarding any field of acute or chronic lung disease. This may include investigation of any phenomenon pertinent to illness assessment, management, or patient response, or may be aimed at health promotion, education and prevention issues. Last year, approximately $83,000 was invested to fund three ORCS Research Grants and five Fellowship Awards. The applications for 2018-19 funding are currently going through the ORCS review process with a recommendation expected to be ready for the June meeting of The Lung Association Board of Directors.

And what about education? We have that covered as well. Falling under the umbrella of the ORCS is the Respiratory Health Educators Interest Group (RHEIG).  RHEIG is a multi-disciplinary group that promotes and advances the field of respiratory patient education, with a specific interest in applying theory in a practical way. RHEIG members are responsible for education-related content in this publication, represent RHEIG interests on the Editorial Board and Education Committees, and generate ideas for speakers and topics for the annual Better Breathing Conference. If this is an area where you have an interest, please let us know on your membership profile.

And we’re super happy about Member 365, the new ORCS and OTS membership portal that launched in the fall. The new portal is a system that puts membership management, communications and events all in one place. It greatly improved the registration process for the Better Breathing conference in January as well as the sign ups and renewals of ORCS membership for this coming fiscal year. If you haven’t already set up your profile, please visit https://lungontario.ca/for-health-professionals/ontario-respiratory-care-society/ today!

I am always available to discuss any comments or suggestions that you may have. Feel free to contact me by email dina.brooks@utoronto.ca or by phone 416-978-1739.

Don’t forget to save the date for Better Breathing 2019! January 24 – 26, 2019.

Respectfully submitted,

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

Editor’s Message

Editor Lorelei

Spring is traditionally thought of as a time of renewal, re-birth, and change.  We too at the ORCS continue to navigate change and renewal both within The Lung Association (TLA) and within our own society.

Jane Lindsay’s Eye On article on the history and evolution of the Respiratory Health Educators Interest Group (RHEIG) and proposed changes to the structure of the group, are one example of some the changes within the ORCS in the past couple of years.  Although the group will look slightly different than before, these changes will continue to promote the importance of respiratory health education and educators.

 

A big shout-out to McMaster University for becoming the first 100 per cent smoke-free campus in Ontario, as described in the article by Rachel McLay.

In this edition, we are pleased to cover a wide variety of topics in the area of respiratory disease and health that range from research, to educational tools and community programs. The Feature Articles include a look at the oxygen status of muscles during exercise in patients with Interstitial Lung Disease, the status of Tuberculosis in Canada and the work of the Breathe Easy Support Team (B.E.S.T) in setting up community-based support groups across Ontario.  The Respiratory Articles of Interest section summarizes articles which focus on the Canadian Thoracic Society’s position statements on recognizing and managing severe asthma, and an update on the pharmacological treatment of patients with COPD. The Toolbox highlights a website called Choosing Wisely Canada which promotes conversation between patients and their physicians to prevent unnecessary tests and treatments while the poster winners from Better Breathing 2018 are featured in In The Spotlight. Information has also been provided on the Motivational Interviewing Workshops which are being offered through TLA.

The ORCS Editorial Board and the RHEIG continue to work on the integration of these two groups to provide this joint publication.  We are always looking for new people interested in helping with either (or both!) of these groups.  Contact TLA and ask how you can help!

Stay tuned for the Fall Edition of Update on Respiratory Health, Research & Education, where you will begin to see promotion of Better Breathing 2019 and the amazing topics which will be presented there.

Sincerely,

Lorelei Samis
Co-chair Editorial Board
Co-chair RHEIG Executive Team

Legislative Assembly of Ontario

After ten years of work by The Lung Association and its many Breathing partners and stakeholders across the province, on December 12, 2017 Bill 71 was passed by unanimous consent in the Ontario Legislature.  And, on December 14th the Bill received Royal Assent from the Lieutenant Governor, officially enacting into law The Ontario Lung Health Advisory Council.

This group will be dedicated to providing provincially-based advice and recommendations on lung health to the Minister of Health and Long-Term Care to make improvements in lung health awareness, diagnosis, treatment and care. Its goal will be to work towards the development and implementation of an Ontario Lung Health Action Plan that will provide a coordinated approach to prevent lung disease, improve patient outcomes and reduce health-care spending.

Since the passing of the Lung Health Act, The Lung Association has continued to work with the Ministry of Health and Long-Term Care on recommendations for candidates to fill the various positions on the Council. A final decision on the membership will be made by the Minister of Health and Long-Term Care, with formal approval by the Executive Council of Ontario.

While we don’t yet know the final membership of the Council, we do know that we will need a broad base of expertise and support to complement its efforts. With that in mind, we anticipate additional opportunities to contribute through working groups and project-based initiatives. Additional information on volunteer opportunities such as these will be forthcoming.

Thank you to the members of the Lung Health Caucus, members of our professional societies, our donors, partners, volunteers and staff for all of your support in getting us to where we are today. With you by our side, we are helping even more Ontarians breathe.

McMaster University Leading Change – Ontario’s First 100% Tobacco and Smoke-Free Campus

By: Rachel McLay.  As of January 1st, 2018, McMaster University in Hamilton, Ontario became the first post-secondary institution in the province, and the 14th in the country, to implement a tobacco and smoke-free policy across campus. This policy supports improving the health and wellness of the community, whether through minimizing exposure to tobacco and smoking products, or encouraging people to quit.

Given that 1 in 10 Canadians smoked regularly or occasionally in 2015, with young adults being the most likely to smoke compared to other age groups, eliminating tobacco and smoking from campuses is a step in the right direction towards meaningful change. The Lung Association – Ontario would like to congratulate McMaster on being a leader in this movement and for contributing towards the prevention of the many serious and chronic conditions linked to tobacco-use and smoking.

Breathe Easy Support Team

Maha Alrimali, RPh, CRE, The Lung Association – Ontario

The Breathe Easy Support Team (B.E.S.T.), launched by The Lung Association-Ontario (TLA) in January 2017, is a community-based support group that brings together patients and their caregivers. Members include patients who have chronic obstructive pulmonary disease (COPD), idiopathic pulmonary fibrosis (IPF), as well as those undergoing a lung transplant.

Patients can self-refer or be referred by their health-care provider. The support group meets monthly at the Real Canadian Superstore® across the street from our provincial office (located near Don Mills and Eglinton in Toronto).  B.E.S.T. is supported by a Registered Pharmacist/Certified Respiratory Educator from our provincial office.  Meetings are scheduled for 10:30-11:30am on the first Thursday of every month (except July and August). Parking is available at no cost and light snacks and refreshments are provided. The meeting location is on the ground floor of the supermarket and is easily accessible for those with mobility challenges.

Over the past 14 months, TLA has worked with the support group members to promote lung health as well as disease self-management. Along with providing education on various lung health topics, B.E.S.T. gatherings are also for sharing personal experiences and expectations. Members often discuss their own journey of living with a chronic lung disease and how it has affected their lives. Members have brought items to the meetings, such as their oximeters, portable oxygen tanks, and pulmonary rehabilitation CDs. These items have provided the subject for useful discussions. B.E.S.T has invited a number of guests from different disciplines to speak about their areas of expertise related to managing lung disease. Guest speakers to date have included a dietitian, a kinesiologist, a yoga instructor and a respiratory therapist. The topics discussed at these meetings have helped bridge the gap between patient knowledge and their perception of lung disease, and the science provided by clinical research along with the recommendations in the Canadian guidelines.

We know the proven benefits from pulmonary rehabilitation and self-management education programs and support groups.  B.E.S.T. is one of many Lung Association initiatives that engage patients with lung disease.

If you are interested in starting a support group, please contact Jody Hamilton, Manager Patient Engagement & Community Programs, The Lung Association-Ontario, jhamilton@lungontario.ca.

Below is a list of other support groups in Ontario. If you know of a patient and or caregiver who might benefit from attending a support group please call 1-888-344-5864 (LUNG) or email info@lungontario.ca (TLA keeps a data-base of support groups across Ontario).

  • LHIN 1 – Erie St. Clair has four support groups in Sarnia, Windsor, and Chatham.
  • LHIN 2 – South West has one support group in London.
  • LHIN 3 – Waterloo Willington has one support group in Cambridge.
  • LHIN 4 – Hamilton and Niagara has five support groups in St. Catharines, Hamilton, Brantford and Niagara-on-the-Lake.
  • LHIN 5 – Central West has no support groups.
  • LHIN 6 – Mississauga Halton has two support groups in Mississauga.
  • LHIN 7 – Toronto Central has four support groups in Toronto.
  • LHIN 8 – Central has two support groups in Newmarket and Markham.
  • LHIN 9 – Central East has one support group in Whitby.
  • LHIN 10 – South East has no support groups.
  • LHIN 11 – Champlain has one support group in Ottawa.
  • LHIN 12 – North Simcoe has no support groups.
  • LHIN 13 – North East has two support groups in Sudbury and North Bay.
  • LHIN 14 – North West has one support group in Thunder Bay.

When you can’t breathe, nothing else matters”.

The Respiratory Health Education Interest Group (RHEIG) is a multi-disciplinary group of ORCS members who promote and advance the field of respiratory education, with a specific interest in applying theory in a practical way.

A Closer look at Tuberculosis in Canada

Dr. Ian Kitai, MB, BCh, FRCP is a tuberculosis specialist and Staff Physician in Infectious Diseases at SickKids and Associate Professor in the Department of Paediatrics at the University of Toronto.

March 24th is World TB Day.   This commemorates the announcement in 1882 by Dr. Robert Koch of the discovery of the bacillus that causes tuberculosis (TB) disease. If Mycobacterium tuberculosis had a consciousness and could talk, it might say it’s doing fine despite some scientific advances. In 2016, TB surpassed HIV as the leading cause of infectious disease-related deaths globally.

It’s been estimated that in 2016, 10.4 million people fell ill with TB, and there were 1.36 million TB-related deaths in the world.1 There were at least 490,000 new cases of multi-drug resistant TB, a form that is difficult and expensive to treat, and where treatment sometimes fails.1

In 2016, Canada had approximately 4.8 cases of TB per 100,000 people (a slight increase from 2015) and compares with the global incidence rate of about 137 per 100,000. 2 While it may appear that TB is rare in Canada, in fact, the incidence is high in some indigenous communities, as well as in areas where there are large populations of new Canadians. Rates in Nunavut in 2016 were 149 per 100,000, and Toronto and Peel regions have rates above nine cases per 100,000. 2,3

TB disease in children is different from that in adults. In adults, the diagnosis of TB is usually made by examining and culturing their sputum, but children don’t often cough up sputum.  Pediatric TB disease less often involves lung tissue than in adults, but involves other parts of the chest and body.  So, diagnosis of TB in children is more difficult and the disease may be much more damaging.  We don’t really know how much childhood TB there is in the world, but we know it is really under recognised in high TB-burden countries and is a major concealed cause of childhood deaths. In 2012, the World Health Organisation estimated that 500,000 (5.6%) of the 9 million new TB cases were children; for 2016, the estimate is 11% of the 10.4 million cases – that is 1.14 million children. 1

It’s difficult to grasp what these numbers mean, especially when most health-care professionals in Toronto don’t often see TB. Most children and adults diagnosed here are treated and fully cured; in other parts of the world many people die for want of access to diagnosis and inexpensive drugs. But, TB is often not that easy: TB meningitis, the most devastating form, is much more common in young children, begins with vague and nonspecific symptoms, and is often diagnosed late. Even with early diagnosis and treatment, most children do not survive TB meningitis undamaged. In Africa, but also occasionally here in Canada, I have seen too many children who went from normal development to now being unable to walk, see or hear well; who suffered a devastating stroke a few days into treatment; or who died.  TB elimination by 2015, a post-millennial goal4, is a very important aim toward which we should continue to work.

William Osler taught that “TB is a social disease with a medical aspect.”5 It can cause disease in anyone, but the poor and marginalised – not only in high-burden countries, but also here in Canada – are most often affected. It is unacceptable that TB so disproportionately affects indigenous Canadians; its elimination from these communities will require markedly improved housing and living conditions, as well as strengthened health systems in remote areas, and must be our first priority. It’s unacceptable that this disease disproportionately affects the foreign born; its elimination will require improved targeted and compassionate screening, better diagnostic tests, better treatment for infection, and most importantly, marked reduction in the very unevenly distributed global burden of TB.

In addition to indigenous Canadians, new Canadians have made this country what it is. We must understand that participating in the global struggle to end TB is not only right – it is in our own immediate and long-term interests.

  1. Global tuberculosis report 2017. Geneva: World Health Organization; 2017. Licence: CC BY-NCSA 3.0 IGO. Available at http://www.who.int/tb/publications/global_report/en/ accessed April 23 2018
  2. Vachon J, Gallant V, Siu W. Tuberculosis in Canada, 2016. Can Commun Dis Rep. 2018; 44(3/4):75-81. https://doi.org/10.14745/ccdr.v44i03a01.
  3. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Tuberculosis: Ontario Provincial Report, 2012. Toronto, ON: Queen’s Printer for Ontario; 2015.
  4. Wejse, Christian. Tuberculosis elimination in the post Millennium Development Goals era. International Journal of Infectious Diseases, 2015; 152-155
  5. Grzybowski S; Allen EA. Tuberculosis: 2. History of the disease in Canada CMAJ • APR. 6, 1999; 160: 1025-8

About the SickKids TB program

For the past 14 years, SickKids staff have led the development of national guidelines for the diagnosis and management of pediatric TB in Canada. SickKids has a multidisciplinary TB clinic that includes physicians, a nurse practitioner and nurses with support from social work and interpreter services. The clinic is closely integrated with public health units and always includes staff from Toronto Public Health. The clinic is one of the only paediatric TB clinics in the world to have high air flow and negative pressure rooms for patient and staff safety. The clinic has more than 1,100 patient visits per year and is the main referral centre for paediatric TB in the Greater Toronto Area.  Patients may be referred to the SickKids TB clinic by family physicians, specialist physicians, public health nurses, frontline health care workers or health agency personnel. We also assist with clinical queries related to paediatric TB from other jurisdictions.

SAVE THE DATE: NOVEMBER 19 – 21, 2018

Oxygen status of muscle during exercise in patients with interstitial lung disease – How much exercise is too much?

Submitted by Darlene Reid, BMR (PT), PhD

Background – Exercise is good but is it safe?

People with interstitial lung disease (ILD) have greatly reduced exercise capacity reflected by a 6-minute walk distance that is about 50 per cent lower and physical activity levels that are about one-third of those attained in healthy people.1-3 Pulmonary rehabilitation is an intervention recommended to individuals with chronic lung disease to improve symptoms, exercise capacity and health-related quality of life primarily through exercise training.4,5 Prescription of exercise for people living with ILD is often based on evidence derived from pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD).  However, physiologic impairments appear to limit exercise to a greater extent in persons with ILD compared to those with COPD.6,7 For example, the exercise response in ILD is characterized by marked oxygen desaturation during relatively low levels of exercise.  Consequently, supplemental oxygen, especially during exertion, is more common and prescribed at higher flow rates in ILD compared to other chronic lung diseases.  We need to have a better understanding of how exercise impacts the oxygen status of muscle in ILD, especially in those with severe disease, in order to tailor recommendations for oxygen and exercise prescriptions.

What is the clinical problem?

A pulse oximeter estimates oxygen saturation in the peripheral circulating blood (SpO2). This information is used to titrate supplemental oxygen delivery to maintain an adequate level of oxygenation during exercise and determine the “safe” level of exercise intensity; however it provides no information about regional oxygenation of exercising muscle.  Near infrared spectroscopy (NIRS) is a non-invasive device that evaluates capillary oxygenation of the blood supplying underlying muscle tissue, a mix of venule and arteriole oxygenation.8,9  “NIRS is like an oximeter for muscle.”  Infrared light emitted from the device is absorbed by either oxy- or deoxy- hemoglobin and evaluation of this absorbance provides a measure of these two values.  Adding the two together provides an estimate of the total amount of hemoglobin and hence the total amount of blood (and oxygen) in the muscle beneath the NIRS device.  Using NIRS, we have shown that incremental loading of the biceps or the sternomastoid in stable COPD patients (none of whom were on supplemental oxygen) results in marked deoxygenation of the these two muscles.10  This pattern is quite different than that shown in healthy men where sternomastoid oxygenation status was maintained during incremental inspiratory threshold loading.11

How we began studying the problem?

With the support of funding from the Ontario Respiratory Care Society, a group of colleagues affiliated with the University of Toronto and Toronto General Hospital performed a study to examine the oxygen status of the muscles that are recruited during arm and leg exercise in people with mild ILD, severe (oxygen dependent) ILD and healthy people.  This study was led by Dr Darlene Reid (Principal Investigator), and co-investigators, Sunita Mathur, Lianne Singer and Lisa Wickerson.  However, Lisa Wickerson and Leandro Bonetti did all of the hard work of refining the methodology, recruiting participants, and collecting and analyzing the data.  Lisa performed this project as part of her PhD in the Rehabilitation Sciences Institute and Leandro Bonetti was a visiting scientist from Universidade de Caxias do Sul in Brazil.

The main exercises performed by study participants were incremental loading of the elbow flexors and the knee extensors on an isokinetic dynamometer, which is a computerized weight lifting device that can be programmed for specific types of exercise programs (see top pictures).  For both the elbow flexor and the knee extensor exercise, participants began at a very low level of intensity and then worked against higher and higher loads until they could no longer continue or were unable to do the exercise well.  NIRS devices were attached over the muscle that was doing the most work (see white arrows in pictures).  During this type of repetitive exercise, the NIRS device measures oxy-, deoxy- and total hemoglobin and estimates the saturation of oxygen in muscle, termed the SmO2.  The computer monitor displays SmO2 data (tracing) generated from an NIRS device during repetitive exercise, as shown on the right.  With repetitive muscle contraction the percentage of SmO2 in the vastus lateralis declines over time. The oscillations of the SmO2 tracing coincides with each muscle contraction.  The SmO2 begins at 68 per cent and drops to 54 per cent (number in the bottom left) after several contractions.  This value is lower than the usual resting SmO2 in muscle but further research is required to determine when this would be of concern, especially if the low value recovers within a short period of rest.  In other words, the dose response that causes injury is not known and likely relies on many other factors.

What did we discover?

Preliminary analysis of study findings is very interesting.  SmO2 decreased in participants with and without ILD but it dropped to a very low level at a much lower workload in those with severe ILD.  The workloads for both arm and leg exercise in IDL subjects was only about 50 per cent of the maximum workload attained in healthy people.  From a functional perspective, these results infer that SmO2 in people with severe ILD has a much higher probability of dropping to low levels during daily activities than in healthy people.  One of the next steps is to determine if the muscle has a good store of anti-oxidants eg. vitamin E, to sop up the oxidative stress imposed by low levels of  SmO2.  Persistent oxidative stress can increase reactive oxygen species that can damage cell membranes, increase oxidation of proteins and alter gene expression.12,13  In particular, activation of Hypoxia-Inducible-Factor-α can promote apoptosis, which is considered to be a primary contributor to muscle atrophy in people who live at high altitude and possibly in diseases that result in chronic hypoxemia.12 Thus, low SmO2 will not only reduce the workload that can be achieved but could result in oxidative stress that can trigger metabolic changes resulting in damage to  the muscle.

Another important finding of our study was that the SmO2 was not related to the SpO2 reading from the oximeter.  The clinical implication of this finding is that if one would like to know the oxygen status of muscle, NIRS monitoring will provide a more accurate evaluation than an oximeter.

Did we answer the big question – How much exercise is too much?

In the end, can we answer the question about how much exercise is too much? The short answer is “Not yet”.  Exercise training in pulmonary rehabilitation programs can definitely improve function and quality of life in people with ILD.  However, more work needs to be done to determine the most appropriate type and intensity of exercise, and whether supplemental oxygen and other interventions will temper the oxidative stress that occurs in muscle during exercise in people with ILD and other chronic lung diseases. The story continues.

The contribution of ORCS research funding to this study is gratefully acknowledged.

References

  1. Flaherty KR. IPF. Prognostic value of changes in physiology and 6 minute-walk test. Am J Respir Crit Care Med 2006; 174:803.
  2. Wallaert B, Monge E, Le Rouzic O, Wemeau-Stervinou L, Salleron J, Grosbois JM. Physical activity in daily life of patients with fibrotic idiopathic interstitial pneumonia. Chest 2013;144:1652–8.
  3. Wickerson L, Mathur S, Helm D, Singer L, Brooks D. Physical activity profile of lung transplant candidates with interstitial lung disease.  J Cardiopul Rehab Prevent 2013; 33(2):106-112.
  4. Spruit M, Singh S, Garvey C et al. An official ATS/ERS statement: key concepts and advances in pulmonary rehabilitation. Am J Resp Crit Care Med 2013;188:e13-e64.
  5. Dowman L. Hill CJ, Holland AE. Pulmonary rehabilitation for interstitial lung disease. Cochrane Database Syst Rev 2014;10:CD006322.
  6. Markovitz GH, Cooper CB. Exercise and interstitial lung disease. Curr Opin Pulm Med 1998;4:272-280.
  7. Hansen JE, Wasserman K. Pathophysiology of activity limitation in patients with interstitial lung disease. Chest 1996;109:1566-1576.
  8. Boushel R, Langberg H, Olesen J, Gonzales-Alonzo J, Bulow J, Kjaer M. Monitoring tissue oxygen availability with near infrared spectroscopy (NIRS) in health and disease. Scand J Med Sci Sports 2001;11:213-22.
  9. Ferrari M, Mottola L, and Quaresima V. Principles, techniques, and limitations of near infrared spectroscopy. Can J Appl Physiol 2004;29(4):463-487.
  10. Reid WD, Sheel AW, Shadgan B, Garland SJ, Road JD. Recruitment and deoxygenation of sternocleidomastoid and biceps during incremental loading in stable COPD patients. J Cardiopul Rehab Prevent 201
  11. Shadgan B, Guenette JA, Sheel AW, Reid WD. Sternocleidomastoid muscle deoxygenation in response to incremental inspiratory threshold loading measured by near infrared spectroscopy.  Respir Physiol Neuro 2011;178:202-209.
  12. Favier FB, Britto FA, Freyssenet DG, Bigard XA, Benoit H. HIF-1-driven skeletal muscle adaptations to chronic hypoxia.  Molecular insights into muscle physiology.   Cell Mol Life Sci 2015:72:4681–4696. DOI 10.1007/s00018-015-2025-9.
  13. Eliason JL, Wakefield TW. Metabolic consequences of acute limb ischemia and their clinical implications. Semin Vasc Surg 2009; 22:29-33.

Acknowledgement

We are grateful to the ORCS of The Lung Association – Ontario that provided funding in 2016 to perform this study.  We also very much appreciate the contributions of the participants who devoted their time in performing this study.

Darlene Reid, a member of ORCS, is a physiotherapist and professor in the Department of Physical Therapy at the University of Toronto.

 

What’s new in the pharmacotherapy management in COPD? CTS position statement: Pharmacotherapy in patients with COPD-an update

Bourbeau J, Bhutani M, Hernandez P, Marciniuk DD, Aaron SD, Balter M, et al. CTS position statement: Pharmacotherapy in patients with COPD-an update. Canadian Journal of Respiratory, Critical Care and Sleep Medicine. 2017; 1(4): 222-241.

Submitted by Shirley Quach

From the last Canadian Thoracic Society (CTS) COPD guideline update in 2008, new clinical evidence and pharmacotherapies have been challenging the treatments for COPD. The objective of this CTS position statement is to review the available pharmacotherapies and to provide clinical guidance in the treatment and management of stable COPD.

The new CTS statement elaborates on the following points:

1- Guidelines for choosing appropriate maintenance pharmacotherapies to help Improve symptoms, exercise tolerance, and health status in stable COPD

2- Guidelines for choosing appropriate pharmacotherapies for preventing and reducing the frequency of acute exacerbations in stable COPD

3- Guidelines to treating patients who have Asthma and COPD overlap (ACO)

The CTS position paper is advocating for personalized pharmacotherapy treatments compared to previous COPD guidelines. CTS is encouraging clinicians to prescribe therapies to patients with the intention to alleviate symptom burden, decrease the risk of exacerbations and improve quality of life, and to not simply treat the degree of airflow obstruction.

There is growing evidence to demonstrate improved clinical outcomes with combined inhaled therapies, and if required, “step up” therapies should be considered. Individuals with COPD should have maintenance therapy of LAMA or LABA monotherapy, and LAMA/LABA dual therapy should be prescribed if symptoms and exacerbations persist. ICS can be added if LAMA/LABA dual therapy is not effective in minimizing exacerbation frequency and symptom burden; however, there is no evidence to demonstrate ICS/LABA/LAMA triple therapy is superior than LABA/LAMA dual therapy. While “step down” of treatments should be exercised with caution, this can be considered and applied to patients who exhibit more risks than benefits in the prescribed therapy.


Severe Asthma CTS Position Statement 2017

Fitzgerald JM, Lemiere C, Lougheed MD, Ducharme FM, Dell SD, Ramsey C, et al. Recognition and management of severe asthma: A Canadian Thoracic Society position statement. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine. 2017Feb;1(4):199–221.

Submitted by Priscila Robles

Severe asthma is defined as requiring treatment with high-dose inhaled corticosteroid (ICS) and a second controller for the previous year, or systemic corticosteroids for 50 per cent of the previous year to prevent it from becoming “uncontrolled”, or which remains “uncontrolled” despite this therapy.

This Canadian Thoracic Society position statement clearly distinguishes severe asthma from uncontrolled asthma – the latter being mostly commonly due to inadequate asthma management. The role of new and emerging therapies in severe asthma and the identification of potential responders are discussed and a revised treatment algorithm is provided accordingly. Adherence to treatment, inhalation technique, domestic/work environment, co-morbidities, a written action plan and referral to educators/specialists should all be verified carefully before establishing a diagnosis of severe asthma. Individuals with confirmed severe asthma are phenotyped using total IgE, peripheral eosinophil count, sputum eosinophils and FeNO testing to inform add-on therapies: i) anti-IgE therapy to reduce asthma exacerbations in children (≥6 yrs) and adults who are sensitized to at least one perennial allergen and poorly controlled despite high doses of ICS and second controller therapy; ii) Anti-IL5 therapies for adults with severe eosinophilic asthma who experience recurrent asthma exacerbations despite optimal management; iii) addition of omalizumab for children and adolescents with poor control when therapy is stepped down; iv) addition of tiotropium bromide inhalation for individuals aged ≥ 12 yrs with severe asthma uncontrolled; v) macrolides considered independently to a specific phenotype. This position paper offers health-care practitioners an objective approach for the recognition and management of severe asthma in Canada.

Choosing wisely: The Canadian Thoracic Society’s list of six things that physicians and patients should question

Gupta S, Goodridge D, Pakhalé S, McIntyre K & Pendharkar SR. Choosing wisely: The Canadian Thoracic Society’s list of six things that physicians and patients should question, Canadian Journal of Respiratory, Critical Care and Sleep Medicine. 2017; 1(2): 54-61, DOI: 10.1080/24745332.2017.1331666

Submitted by Jane Lindsay

In an effort to help improve quality while reducing waste in healthcare, the Canadian Thoracic Society (CTS) is using the “Choosing Wisely” campaign. This initiative assists both patients and clinicians as they discuss options for care, with the goal of reducing unnecessary tests, treatments and referrals.

In order to generate their list of recommendations, the CTS appointed a 5-member Choosing Wisely Task Force, consisting of four respirologists and one nurse/PhD scientist from four cities across Alberta, Saskatchewan and Ontario. Their initial list used existing Canadian and US Choosing Wisely recommendations, Canadian Medical Association (CMA) Patient-Oriented Evidence that matters, and suggestions from CTS content experts. This initial list was reduced by voting members of the CTS and the Task Force in three electronic Delphi processes in online polls. Evidence reviews, which are explained in the article, were used to reduce the top ten recommendations to the “Choosing Wisely Top 6” list.
The six items on the list will probably not be surprises to ORCS members, but this will provide a useful tool during patient conversations. The list of six “don’ts” includes recommendations on the use (or not) of maintenance inhalers for stable COPD patients, CT screening for cancer in low-risk patients, CT and VQ scans to evaluate some patients for pulmonary embolus, antibiotics for adult cough, medications for asthma patients under six years old, and antibiotics during asthma exacerbation.

The authors acknowledge that creation of the current list is only the first step, and there will be challenges in the ‘de-implementation’ of several current practices. For example, in order to de-implement some treatments, items one and five call for an increase in the use of spirometry – the underuse of which is a much bigger problem in primary care than in respirology. ORCS members can hopefully act as change agents to help with the dissemination and implementation of these recommendations.

Respiratory Health Educators Interest Group (RHEIG)

Submitted by Jane Lindsay.

Everyone who works in health care knows that ‘life is change’ and everyone who has watched The Lung Association evolve knows that we are not immune.

 

The Lung Association – Ontario (TLA), the Ontario Respiratory Care Society (ORCS), and the Respiratory Health Educators Interest Group (RHEIG) have all undergone significant change in the past year or two.  With the re-branding of the Lung Association, and the launch of the revised website, these changes have become more noticeable.

With regards to the RHEIG, the changes are quite significant, in a positive fashion.  To see the continuous evolvement, it may be insightful to see where we have been.  The following brief summary was supplied by Sheila Gordon-Dillane, who was instrumental in developing and leading RHEIG throughout its history:

The RHEIG originated as the Ontario Asthma Educators Association (OAEA) in the mid-1990s when the idea of certifying asthma educators began and the national Asthma Education Conferences started (Canadian Network for Asthma Care or CNAC held bi-annual conferences and developed the national certification system and exam). The Michener Institute of Education at University Health Network (UHN), formerly known as the Michener Institute of Applied Sciences, developed an asthma educator post-graduate course to prepare health professionals to write the national exam to become a Certified Asthma Educator.

The OAEA ran as a volunteer group for about five years. They charged $35 for a membership, created a newsletter and added a half day seminar after Better Breathing. The founding members included Ann Bartlett, Nancy Garvey, Paula Burns, Andrea White Markham, Karen Zalan and several others, many of whom have retired. Glaxo sponsored the newsletter for many years and AZ sponsored the seminar. By 2001, the original volunteers were burning out and they approached Cindy Shcherban and Sheila Gordon-Dillane about becoming an interest group of the ORCS so they could have administrative support. This made sense because there was a lot of overlapping membership. ORCS decided to add on an optional $15 to the ORCS annual membership fee and their Executive Team was elected annually and planned the content of the newsletter and a lecture and workshops on Thursday afternoon (rather than Saturday afternoon) at Better Breathing.

After two or three years as the Ontario Asthma Educators Interest Group of ORCS, there began to be interest in certification of COPD Educators. Since many people did both, it did not make sense to have two interest groups so the name was changed to Respiratory Health Educators Interest Group. This opened it up to COPD Educators, many of whom were physiotherapists and The Michener Institute developed a course for COPD Educators as well and eventually the certification was changed to Certified Respiratory Educator (CRE). The COPD Alliance conferences began in the late 1990s with broad support nationally from respirologists and pharmaceutical companies as well as the nurses, PTs and RRTs.

Since the times described in Sheila’s summary, the RHEIG executive team has continued to be responsible for the development of an educator-oriented session at the annual Better Breathing Conference. In addition, the newsletter “Connections” was published three times per year, and contained a Feature Article relevant to educators, an ‘Eye On’ article featuring the work of a specific person or group particularly relevant to respiratory educators, and a ‘Toolbox’ article, which focused on hands-on or practical information. RHEIG members paid an extra fee in addition to their ORCS membership, in order to receive the newsletter.

Most RHEIG members have obtained training and/or certification as Respiratory, Asthma or COPD Educators.  Of course, many (if not all) members of the ORCS are ‘educators’ whether they have gone through a formal certification process or not.  While certification was in the early stages, it was extremely helpful to have a group that recognized this unique and growing sub-set of health professionals.  However, with the current evolution of The Lung Association, and the increasingly widespread training and certification of respiratory educators, the time has come to recognize that all ORCS members are educators, so we are changing the membership structure to eliminate the extra fee associated with RHEIG membership.  In addition, the content from the RHEIG newsletter, Connections, has been incorporated in the new combined ORCS-RHEIG newsletter “Update on Respiratory Health, Research and Education.”  This fully electronic publication still contains the three main article types that are particularly reflective of an educator’s practice. Now all ORCS members receive the full publication. The RHEIG executive will continue to function as a sub-committee of the ORCS, planning the content for the publication and for a half day of the Better Breathing conference.  This sub-committee always welcomes new members, so if you are interested in helping the ORCS continue to develop educators’ expertise, please contact Sherry Zarins or one of the members of the Executive Committee.

The Respiratory Health Education Interest Group (RHEIG) is a multi-disciplinary group of ORCS members who promote and advance the field of respiratory education, with a specific interest in applying theory in a practical way.

BBC 2018 Poster Winners

In the Spotlight this month features the poster winners from the Poster Session at the Better Breathing Conference 2018, which was held January 25 – 27 at the Toronto Marriot Downtown Eaton Centre.

The winner of the Margaret Fitch award for best poster was Sunita Mathur from the University of Toronto for her poster “Evaluation of quadriceps muscle strength and power in people with COPD.” Co-authors on the study were Nathalia Maia, Kim-Ly Bui, Anna Michalski and Didier Saey.

The Lisa Cicutto award for best poster by a student was presented to Sachi O’Hoski of McMaster University for her poster “Barriers to and facilitators of community participation from the perspective of people with COPD.” Her co-author was Marla Beauchamp.

The winners of the Sheila Gordon-Dillane award for best poster on evaluation were co-authors Tony Raso & Robyn Klages of William Osler Health System and Brampton Memorial Hospital for “A traffic light algorithm based approach to managing difficult airways.”

In 2018, the Better Breathing Poster Session was, for the first time, a collaboration between the ORCS and the Respiratory Therapy Society of Ontario (RTSO).  RTSO Poster Awards were presented as follows: Best Research poster by co-authors Sara Han, Diane Feldman, Carole Madeley for “Utilization of the health equity impact assessment to ensure equitable delivery of a primary care respiratory program,” the best Program poster went to Tony Raso & Robyn Klages for “A traffic light algorithm based approach to managing difficult airways,” and the best RTSO Student award went to Shirley Quach for “Asthma care APPs in the patient’s pocket:  What does the literature report?”

We look forward to seeing you all at Better Breathing 2019!
Mark your calendars for January 24 – 26, 2019.

Get Involved

 

Ontario Respiratory Care Society (ORCS) Committees

Provincial Committee
The Provincial Committee provides leadership to the ORCS and is comprised of the ORCS Chair, a Chair-Elect or Past Chair in alternate years, the Chairs of the five standing committees, the Chairs of the regional planning committees and a member of The Lung Association Board of Directors.

Editorial Board
Produce an electronic publication for the Ontario Respiratory Care Society (ORCS) members; provide academic content for the publication.

Respiratory Health Educators Interest Group (RHEIG)
Provide respiratory education and a half-day session at the Better Breathing Conference; provide patient education content for the ORCS publication.

Membership Engagement Committee
Recruit and build membership for the Society.

Education Committee
Session planning for the Better Breathing Conference.

Research and Fellowship Committee
Manage the funding process including Grant and Fellowship application review and funding allocation.

Regional Planning Committees
Regional Planning Committees plan educational events in their respective regions. The Regions include:
Northeastern Region
Northwestern Region
Eastern Region
Central Region
Western Region

Choosing Wisely Canada

“Choosing Wisely Canada is a campaign to help clinicians and patients engage in conversations about unnecessary tests and treatments, and make smart and effective care choices”.

The site provides links to lists, usually less than 10 items long, of things that clinicians and patients should question, in more than 40 diseases or clinical situations, including the CTS recommendations described in the article summarized in this edition of Update on Respiratory Health, Research & Education.  Since, according to that CTS article, physicians’ decisions are responsible for 80 per cent of health-care expenditures, the site’s information is geared largely to physicians.  However, it includes valuable information for conversations between patients and all members of the health-care team.  While only a small proportion is directly applicable to respiratory practice, the multiple co-morbidities that affect our patients means that many other items will be of interest or assistance.

A few of examples of relevant co-morbidity information are:

  • ‘Don’t use oxygen to treat non-hypoxic dyspnea’ from the ‘palliative care’ list
  • A link to the ‘Antibiotic Wisely’ campaign, found in several sections including the ‘nursing’ section.
  • Patient-oriented handouts, such as ‘Common tests, treatments and Procedures You May Think You Need: Let’s think again’ found in several sections, including the ‘nurse practitioner’ section.

The site also provides a link to “Perspectives: A digital magazine exploring the unnecessary care phenomenon and what people are doing about it.” In the ‘Around the World’ section a variety of information can be found from Australia, including videos such as “How would you feel if your doctor said ‘it’s best to do nothing?” and “If a doctor recommends a test or procedure, would you ask them about risk?”

Access this website at https://choosingwiselycanada.org/

The Respiratory Health Education Interest Group (RHEIG) is a multi-disciplinary group of ORCS members who promote and advance the field of respiratory education, with a specific interest in applying theory in a practical way.

Dyspnea from the Larynx also known as vocal cord dysfunction

Submitted by Jennifer Anderson, MD MSc FRCS(C)

Case Presentation
A 46 year old woman who was a housekeeper at a regional Ontario hospital for 17 years presented with recurrent episodic shortness of breath. These episodes would occur while in the workplace after exposure to cleaning products. The most troublesome product was Lemon Quat, a cleaning product used on the obstetrical unit.

Within seconds of exposure, the patient complained of chest tightness, shortness of breath, throat clearing, dry cough and husky voice. At the time of the first episode she was taken to the emergency department and treated with nebulized bronchodilator, intravenous steroids and antihistamines. Her symptoms resolved over several hours.

The patient returned to work after a week but continued to experience similar symptoms to varying degrees. Over the following few months, exposure to perfume, second-hand smoke, other cleaning products and exhaust fumes also provoked similar symptoms. Symptoms could last minutes to hours depending on the degree of exposure.

Her past medical history was significant for a history of gastroesophageal reflux (treated with proton-pump inhibitor) and a remote history of smoking (5 pack-year history).

The patient was started on bronchodilators by her family doctor and referred to a local respirologist. The work up revealed normal spirometry and a mildly positive methacholine challenge. The patient was tried on various bronchodilators and inhaled corticoid steroid without benefit. Extensive allergy testing was entirely negative.

Subsequent referral was made to a tertiary centre, the Voice Disorders Clinic, at St. Michael’s Hospital for multidisciplinary consultation and provocation testing.

After a detailed history regarding the initial onset, triggers, symptoms, review of prior test results and response to treatment was collected, the patient was examined with a routine otolaryngology exam. The upper airway was further assessed using video-endoscopy with provocation testing.

The detailed history revealed that the symptoms first occurred after an accidental exposure to the cleaning fluid which contained respiratory irritants (ammonium chloride, dimethyl-amine oxide and ethylenediamine) at a tenfold increased concentration than usual in an enclosed space.

Provocation testing during laryngeal endoscopy showed that after exposure, the patient showed increased laryngeal tension with supraglottic partial constriction, partial adduction (closure) of the vocal folds along with onset of dry cough within seconds of exposure to perfume, hand sanitizer and cologne. The voice quality also drastically altered and became strained, husky and dysphonic. The patient was diagnosed with irritable larynx syndrome (ILS) synonymous with the term irritant-associated vocal cord dysfunction (VCD).

This breathing disorder is clinically diagnosed based on episodic shortness of breath due to laryngeal/vocal cord adduction causing dyspnea and noisy breathing. Other common symptoms are voice change (dysphonia) and cough.

Morris and Kent reviewed 355 published reports concerning VCD and described their classification system in 20101. Broadly, the authors subcategorized VCD into Irritant Associated, Psychogenic and Exertional. In general, these three patterns are often seen in patients with a symptom complex consistent with episodic upper airway obstruction and reflect our 20-year experience at the Voice Disorders Clinic at St. Michael’s Hospital, a tertiary referral centre at the University of Toronto.

The etiology of VCD has several theories including Irritant Associated causes and neurogenic via altered sensorimotor pathways resulting in laryngeal hyper-responsiveness after exposure to airborne irritants. VCD is commonly diagnosed in patients who have other central hypersensitivity disorders such as irritable bowel syndrome and fibromyalgia2.

Psychogenic causes have also been postulated in VCD. A recent study3 described formal psychological testing in newly diagnosed VCD patients and demonstrated that VCD patients show elevated scores on hypochondriasis and hysteria compared to normal population on the MMP-2 (validated personality questionnaire). Also, female patients had higher levels of negative stress. Interestingly, approximately 27% of VCD patients had normal results on the psychological testing. In another report4, up to 73% of VCD patients will have a previous or current psychiatric diagnosis.

Exertional VCD may be associated with structural pathology in some patients wherein the supraglottis (epiglottis and aryepiglottic folds approximating) shows partial collapse during maximal exertion and is more commonly identified in young female athletes5. The European Laryngological Society formed a consensus group and has described this as exertional induced laryngeal obstruction (EILO). Flexible nasendoscopy performed during exercise shows laryngeal airflow obstruction observed at the supraglottis during maximal inhalational effort. Behavioural therapy or respiratory retraining is often beneficial with a smaller subset showing improvement after a surgery (supraglottoplasty)5 to reduce collapse of the epiglottis.

Other associated morbidities include asthma (up to 30%) rhinitis/sinusitis (post-nasal drip), gastroesophageal reflux (20-50%) and migraine headache.

The investigations performed in the patient group are the common respiratory assessment tools since most patients are initially treated for possible reactive airway disease. Spirometry, methacholine challenge, allergy testing and occasionally chest Computerized Tomography (CT) scan are done in this patient population, usually prior to being evaluated by a laryngoscopy provocation test.

Other useful investigations include CT of the sinuses in those with prominent rhinosinusitis, and sputum analysis and/or serum for Immunoglobulin E (IgE).

The majority of patients diagnosed and treated at our centre are ILS or irritant-associated VCD after asthma has either been excluded or treated without sufficient improvement.

The principles for management include:

Level 1: Minimize sensory stimuli:

  • Engineering change at workplace
  • Personal protective equipment
  • ‘Scent-free’ policy

Level 2: Behavioural:

  • Redirect mal-habituated central response
  • Cognitive reframing
  • Voice therapy, relaxation, mindfulness
  • Specific exercise, daily home program

Level 3: Medical:

  • Reflux appropriately treated
  • Neuro-psychotropic medication
    • Antidepressants (Amitriptyline)
    • Neural Modifiers (Pregabalin)
    • Antispasmodic (Baclofen)
  • Counseling/Psychiatric referral

Prognosis

In general, with the treatment of comorbidities and the management principles above applied, it is our experience that in compliant patients the majority of individuals improve, but rarely do the symptoms entirely resolve. Behavioural therapy has been a keystone for treatment wherein the patient gains understanding of their symptoms and contributing factors. Therapy focuses on awareness, exercises and strategies to reduce frequency and severity of symptoms. This typically reduces isolation and anxiety around their triggers. If the patient has not been working due this condition, 75% of our patients diagnosed with ILS/VCD have been able to return to work, although commonly there have been modifications to the workplace.

Figure 1. Widely abducted vocal cords during inspiration

Figure 2. Partial adduction of vocal folds during inspiration while undergoing provocation testing with perfume.

References

  1. Morris, M and Kent C. Diagnostic Criteria for Classification of Vocal Cord Dysfunction. Chest. 2010; 138(5):1213-1223.
  2. Morrison M, Rammage L and Emami AJ. Irritable Larynx Syndrome. J of Voice . 1999; Sep:13(3):447-55.
  3. Hussein OF, Husein TN, Gardner R et al. Formal Psychological Testing in Patients with paradoxical Vocal Fold Dysfunction. The Laryngoscope. 2008;118:-747.
  4. Newman KB, Mason UG, Schmaling KB. Clinical features of vocal cords dysfunction. A< J of Respir Cri Care Med. 1995;152(4):1382-1386.
  5. Ruksing OD, Heimdal JH, Oloffson J et al. Larynx during exercise: the unexplored bottleneck of the airways. Eur Arch Otorhinolaryngol. 2014; DIO 10.1007/s00405-014-3159-3.

The Respiratory Health Education Interest Group (RHEIG) is a multi-disciplinary group of ORCS members who promote and advance the field of respiratory education, with a specific interest in applying theory in a practical way.

Upcoming Events Listings

May 26-27, 2018
Toronto
RESPTREC™ COPD Module plus education
RESPTREC™ offers courses for those who wish to pursue their Certified Respiratory Educator designation. The Education module remains the foundation for learning how to engage patients in self-management. Learners will learn how to apply educational theory to practice. The Asthma and COPD modules are disease-specific courses based upon the most recent evidence-based published guidelines and references for disease management.
For more information and to register, please visit resptrec.org

May 31, 2018
Respiratory Medications & COPD Workshop
The Lung Association – Ontario’s Provider Education Program will be running a COPD workshop in Oshawa. For more information and to register, please visit olapep.ca.

June 1, 2018
2018 Annual Golf Classic
The Annual Golf Classic will be held at Glencairn Golf Club from 7am to 4pm. Please join us for a round of golf in support of life-saving lung research. By coming together The Lung Association – Ontario can continue to fund the brightest scientists and clinical researchers in their cutting edge lung research. For more information or to buy tickets, please visit
https://lungontario.ca/site/Calendar?id=100221&view=Detail

June 2 – 3, 2018
Toronto

RESPTREC™ Asthma Module
RESPTREC™ offers courses for those who wish to pursue their Certified Respiratory Educator designation. The Education module remains the foundation for learning how to engage patients in self-management. Learners will learn how to apply educational theory to practice. The Asthma and COPD modules are disease-specific courses based upon the most recent evidence-based published guidelines and references for disease management. For more information and to register, please visit resptrec.org

June 5, 2018
COPD Workshop

The Lung Association – Ontario’s Provider Education Program will be running a COPD workshop in Hamilton. For more information and to register, please visit olapep.ca.

June 20, 2018
Spirometry Workshop

The Lung Association – Ontario’s Provider Education Program will be running a COPD workshop in Toronto. For more information and to register, please visit olapep.ca.

November 19 – 21, 2018
TB Conference 2018
Save the date!
The biennial TB Conference 2018 will be held at the Chelsea Hotel, Toronto. The goal of the TB Conference is to provide advanced information to health-care providers on the challenges of TB elimination in the local, national and global context. For more information as it become available, please visit https://lungontario.ca/for-health-professionals/educational-opportunities/tb-conference/

January 24 – 26, 2018
Better Breathing Conference 2019

Save the date!
Better Breathing 2019 will be held at the Marriott Toronto Downtown Eaton Centre Hotel, presented by two professional societies: Ontario Thoracic Society (OTS) & Ontario Respiratory Care Society (ORCS). www.betterbreathing.ca

 

EDITORIAL Committee

CO-CHAIRS
Jocelyn Carr, BScPT, MSc
Lorelei Samis, BScPT

MEMBERS
Julie Duff Cloutier, RN, MSc, CAE
Yvonne Drasovean, RRT
Elizabeth Gartner, BScOT
Lawrence Jackson, BScPhm
Rachel McLay, HBSc (Kinesiology)
Shirley Quach, HBsc, RRT
Priscila Robles, BScPT, MSc, PhD
Lily Spanjevic, RN, BScN, MN, GNC(C), CRN(C), CMSN(C)

CHAIR, ONTARIO RESPIRATORY CARE SOCIETY
Dina Brooks, BScPT, MSc, PhD

PRESIDENT & CEO, THE LUNG ASSOCIATION – ONTARIO
George Habib, BA, BEd, CAE

DIRECTOR, ONTARIO RESPIRATORY CARE SOCIETY
Sherry Zarins

OTS/ORCS Coordinator
Natalie Bennett

RHEIG Executive Team

CO-CHAIRS
Jane Lindsay, BScPT, CRE
Lorelei Samis, BScPT

MEMBERS
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

 

 

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