A Breath of Fresh Air 2015 / Une Boufée D’air Frais 2015

Can Respir J. 2015 Apr;22(Suppl A):7A.

01 • CRC2015-059: Objective Measures of Asthma, Subjective Distress, and Physiological Responses of Asthma Patients With and Without Panic Disorder During Methacholine Challenge

SL Bacon ^1,², M Boudreau ^1,³, KL Lavoie ^1,³, A Elhalwi ^1,², J Sayegh-Smith ^1,⁴, C Lemiere ^1,⁴, K Maghni ^1,⁴

Abstract

RATIONALE:

Panic disorder (PD) has been shown to be associated with worse asthma outcomes in individuals with asthma, but the psychophysiological mechanisms underlying this association remain unclear. Some theories suggest that asthmatics with PD have worse underlying asthma severity and some argue that they simply report more symptoms based on their tendency to catastrophize bodily sensations.

METHODS:

A total of 39 patients (19 with and 20 without PD) with physician-diagnosed asthma underwent standard metacholine challenge testing (MCT). Demographic and medical/asthma history information was collected at baseline. Pre and post MCT patients completed the Panic symptom scale (PSS), the Modified Borg Scale (MBS), and the Subjective distress visual analogue scale (SD-VAS). Heart rate (HR), systolic, and diastolic blood pressure (SBP/DBP) were recorded pre, during, and post MCT.

RESULTS:

There were no differences in PC20 values between asthmatics with and without PD (F=0.21, p=0.652). PD patients had a higher number of panic symptoms (from the PSS) at post-test compared to those without PD ([M (SD)] PD pre = 2.21 (2.42), PD post = 5.00 (3.32); non-PD pre = 0.75 (1.07), non-PD post = 2.25 (1.89): F=5.05, p=0.031). There were no differences in MBS (F=0.70, p=0.407), SD-VAS anxiety (F=0.36, p=0.554), SD-VAS worry (F=0.84, p=0.366), HR (F=0.06, p=0.805), SBP (F=0.49, p=0.487), or DBP (F=0.01, p=0.942) between PD and non-PD patients.

CONCLUSIONS:

Results suggest that having PD is associated with increased subjective responses during MCT, with no impact on objective measures of asthma. Future research should focus on the potential impact of these increased panic attack-like symptoms on long-term asthma care and if intervening on them influences outcomes such as emergency room visits.

Footnotes

Financial Support: SLB and KLL were supported by CIHR and FRQS salary awards.

Can Respir J. 2015 Apr;22(Suppl A):7A.

02 • CRC2015-051: The Impact of Health Care Use on the Development of Mood Disorders in Patients with Asthma

M Béland ^1,^2,³, SL Bacon ^1,^2,³, KL Lavoie ^2,^3,⁴

Abstract

RATIONALE:

Studies have shown that the prevalence of mood disorders (MD) is higher in asthmatics than the general population. A recent study has looked at what factors predict the development of MD in people with asthma and found that non-asthma hospitalization was a significant predictor. The aim of this study was to further investigate the impact of health care use on the development of MD in patients with asthma.

METHODS:

495 adults with confirmed asthma and no baseline MD were recruited. Patients completed a questionnaire pack including sociodemographic, medical history, and psychological measures, followed by a brief psychiatric interview. After an average of 4.3 years, the psychiatric interview was re-administered. Univariate logistic regressions were conducted for each potential predictor (ie, non-asthma hospitalization, asthma hospitalizations, asthma emergency visits) and those with a p<0.15 for the Wald-test were included in a final multivariate logistic regression.

RESULTS:

The two hospitalization variables were included in the final model, though only 1 predictor remained significant. Patients who were hospitalized for a non-asthma event during the 12 months prior to baseline were two times more likely to have a MD at follow-up (OR=2.16; 95% CI = 0.02–2.16) than those who were not hospitalized.

CONCLUSION:

These findings reinforce the idea that non-asthma hospitalizations have a long term impact on the development of MD in asthma patients. One possible explanation for these findings is that prior hospitalization could be the beginning of more hospitalizations in the future, which could in turn lead to, or facilitate, the development of an MD.

Footnotes

Financial Support: Project funded by SSHRC. Drs Bacon and Lavoie also received salary support from CIHR and FRQS.

Can Respir J. 2015 Apr;22(Suppl A):7A–8A.

03 • CRC2015-026: Airway Responsiveness to Mannitol Decreases 24 Hours after Allergen Inhalation Challenge

BE Davis ^1,², DO Amakye ², DW Cockcroft ^1,²

Abstract

RATIONALE :

Airway responsiveness to indirect stimuli correlates positively with airway inflammation. Allergen inhalation challenge is associated with an influx of inflammatory cells and an increase in bronchial airway response sensitivity to methacholine at 3 hours and 24 hours post allergen challenge. We recently documented a loss in airway responsiveness to mannitol 3 hours after allergen challenge which may have been due to cross refractoriness. We hypothesized that airway responsiveness to mannitol would increase 24 hours after allergen challenge.

METHODS:

Eleven individuals with mild atopic asthma completed standardized allergen bronchoprovocation testing on two separate occasions separated by at least two weeks. In random order, methacholine or mannitol challenges were performed 24 hours pre and 24 hours post allergen challenge. Levels of fractional exhaled nitric oxide (FeNO) were also measured pre and post allergen challenge.

RESULTS:

Airway responsiveness to methacholine increased 24 hours post allergen challenge; the geometric mean methacholine PC20 decreased from 5.9 mg/mL to 2.2 mg/mL (p=0.011). FeNO levels were significantly increased at this same time-point (p=0.01). Conversely, allergen exposure decreased airway responsiveness to mannitol; geometric mean dose response ratio was significantly higher after allergen exposure (57mg/%fall to 147mg/%fall; p=0.028). FeNO levels were also increased but not significantly (p=0.05) (Figure 1).

CONCLUSIONS:

Allergen induced changes in airway responsiveness to direct and indirect stimuli are markedly different. The loss in responsiveness to mannitol is likely not explainable by a refractory state. The effect(s) of allergen exposure on airway responsiveness to indirect acting stimuli requires further investigation.

Figure 1) — Allergen induced changes in airway responsiveness to methacholine (left) and mannitol (right) at 24 hours post allergen inhalation challenge

CONCLUSIONS:

In pts with GOLD 3–4 COPD receiving dual bronchodilation, exacerbation risk is non-inferior with ICS withdrawal compared to ICS therapy.

Footnotes

Financial Support: Boehringer Ingelheim. Previously presented at ERS 2014 in Munich, Germany.

Can Respir J. 2015 Apr;22(Suppl A):10A.

10 • CRC2015-033: Effects of 12 Weeks of Once-Daily Tiotropium and Olodaterol Fixed-Dose Combination on Exercise Endurance in Patients with COPD

L Guo, presenting on behalf of F Maltais^1,², JBG Iturri ³, A Kirsten ⁴, D Singh ⁵, A Hamilton ⁶, K Tetzlaff ^7,⁸, Y Zhao ⁹, R Casaburi ¹⁰

Abstract

BACKGROUND:

Both tiotropium (T) and olodaterol (O) monotherapies improve exercise endurance in patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVE:

To evaluate the effects of T+O fixed-dose combination on exercise endurance in patients with GOLD 2–3 COPD after 12 weeks.

METHODS:

TORRACTO (NCT01525615) was a 12-week, double-blind, parallel-group, placebo-controlled, Phase III study. Patients with GOLD 2–3 COPD received T+O (5/5 or 2.5/5 μg) once daily via Respimat Soft Mist inhaler, or placebo. Primary end point was endurance time (ET) during constant work-rate cycle ergometry to symptom limitation after 12 weeks. ET during endurance shuttle walking (ESW) to symptom limitation after 12 weeks was also assessed in a subset of 165 patients. Other end points included pre-exercise inspiratory capacity (IC).

RESULTS:

404 patients (269 men) were randomised (full analysis set n=385). Mean post-bronchodilator FEV₁ was 1.66 L (58.6% predicted). After 12 weeks, geometric mean ET during constant work rate cycle ergometry increased by 14% with T+O FDC 5/5 μg versus placebo (p=0.02) and by 9% with T+O FDC 2.5/5 μg (p=0.14) versus placebo. In the ESW subset (n=165), increases in ET during ESW were observed for both T+O doses vs placebo after 12 weeks (21% increase, nominal p=0.06 for each dose). Both T+O doses increased pre-exercise IC vs placebo (nominal p<0.0005) after 12 weeks. No safety concerns were identified.

CONCLUSIONS:

T+O 5/5 μg improved ET during cycle ergometry vs placebo.

Footnotes

Study supported by Boehringer Ingelheim. Previously presented at ERS 2014 in Munich, Germany.

Financial Support: Boehringer Ingelheim. Previously presented at ERS 2014 in Munich, Germany

Can Respir J. 2015 Apr;22(Suppl A):10A.

11 • CRC2015-032: Once-Daily Tiotropium and Olodaterol Fixed-Dose Combination Via the Respimat Improves Outcomes vs Mono-Components in COPD in Two 1-Year Studies

A Hamilton ¹, R Buhl ², E Derom ³, G Ferguson ⁴, F Maltais ⁵, E Pizzichini ⁶, J Reid ⁷, H Watz ⁸, L Groenke ⁹, Kay Tetzlaff ¹⁰, L Korducki ¹¹, H Huisman ¹², S Waitere-Wijker ¹², E Bateman ¹³

Abstract

INTRODUCTION:

Tiotropium (T), a once-daily long-acting muscarinic antagonist, is a well-established first-line maintenance treatment in chronic obstructive pulmonary disease (COPD); olodaterol (O) is a once-daily long-acting β2-agonist that has recently gained approval in several countries. Two Phase III replicate pivotal studies assessed the efficacy and safety of fixed-dose combinations of T and O (T+O) delivered via Respimat Soft Mist inhaler in patients with GOLD Stage 2–4 COPD.

METHODS:

Two 52-week, double-blind, parallel-group studies randomised 5162 patients to O 5 μg, T 2.5 μg, T 5 μg, T+O 2.5/5 μg or T+O 5/5 μg. Primary efficacy end points were trough FEV1 response (ie change from baseline), FEV1 area under the curve from 0–3 hours response and SGRQ total score after 24 weeks. Pooled data from the two studies are presented here; lung function from the individual studies will subsequently be provided.

RESULTS:

All treatments resulted in clinically relevant improvements in lung function, with significant increases with both T+O doses over the individual components (p<0.001 for each study). Trough FEV₁ responses were 0.055 L (O 5 μg), 0.073 L (T 2.5 μg), 0.080 L (T 5 μg), 0.118 L (T+O 2.5/5 μg) and 0.140 L (T+O 5/5 μg). SGRQ total scores improved by 5.1 (O 5 μg), 5.7 (T 2.5 μg), 5.6 (T 5 μg), 6.2 (T+O 2.5/5 μg) and 6.8 points (T+O 5/5 μg); differences between T+O 5/5 μg and O 5 μg and T 5 μg were statistically significant (p<0.05 in both cases). All treatments were well tolerated.

CONCLUSIONS:

T+O 5/5 μg significantly improved lung function and provided symptomatic benefit over O 5 μg and T 5 μg.

Footnotes

Financial Support: Boehringer Ingelheim. Previously presented at ERS 2014 in Munich.

Can Respir J. 2015 Apr;22(Suppl A):10A–11A.

12 • CRC2015-018: Survey of Patients Using an Oscillating Positive Expiratory Pressure Device Indicates Improvement in Well-Being and Compliance to Therapy

H Harkness ¹, C Patrick ¹, J Lefebvre ¹

Abstract

BACKGROUND:

Chronic obstructive pulmonary disease (COPD) is characterized by a number of interrelated physiological changes in the lungs, resulting in airflow limitation and chronic inflammatory response which creates excess mucus within the airways. Due to airway damage there is an inability of the lungs to clear excess mucus. Pharmacological treatments have little impact on mucus clearance.

OBJECTIVE:

A survey was to be undertaken with patients using a novel device, the Aerobika* Oscillating PEP to determine whether use of the device had any impact on the well-being and quality of life.

RESULTS:

812 surveys were collected. 90% of patients had COPD; others patients had bronchiectasis (8%) and cystic fibrosis (2%). After approximately 4 weeks use, patients were asked to identify the benefits they experienced from using the device. The following were ranked in terms of priority: easier to clear mucus from lungs, could breathe more deeply, didn’t cough as much, overall felt better, not as breathless, better sleep, able to walk easier/farther, and had more energy. The questionnaire demonstrated a high degree of satisfaction with the Aerobika* OPEP by patients, specifically in assisting with mucus clearance and decreased breathlessness which reinforced the findings of a recently presented clinical study (1). In addition, 97% indicated they would continue to use the device – an exceptionally high acceptance rating leading to better compliance and therapeutic benefit.

CONCLUSION:

The results from this patient feedback survey indicate that the Aerobika* OPEP has a high degree of acceptance within the COPD population because it is easy to use, helps clear mucus and reduces feelings of breathlessness.

Footnotes

Financial Support: Trudell Medical International.

REFERENCE:

1.Svenningsen S, et al. Oscillating positive expiratory pressure therapy in chronic obstructive pulmonary disease and bronchiectasis. Presented at ERS 2014; Munich, Germany. [Google Scholar]

Can Respir J. 2015 Apr;22(Suppl A):11A.

13 • CRC2015-003: Self-Conscious Emotions in Patients with Chronic Obstructive Pulmonary Disease (COPD)

SL Harrison ^1,², N Robertson ³, R Goldstein ¹, D Brooks ^1,²

Abstract

RATIONALE:

Symptoms of anxiety and depression are elevated in patients with COPD. Self-conscious emotions have been documented in patient narratives which appear to negatively impact on psychological morbidity. There is a need to understand the extent to which self-conscious emotions are expressed in patients with COPD.

METHODS:

15 patients with COPD participated in individual interviews exploring self-conscious emotions. Data were coded independently by two researchers and constructs elicited via inductive thematic analysis.

FINDINGS:

6 overarching themes were abstracted: Spectrum of blame – accepting personal responsibility for the disease, attempting to justify smoking behaviour and attributing disease to external factors. Concern about the view of others – associated with the visibility of the disease. Minimisation – dismissal of self, related to judgements about self-worth and aging, and dismissal from others. Silence – stoicism and suppression. Worry about the future – related to the progressive nature of COPD and catastrophic cognitions. Grief – loss of the anticipated future and the lifestyle once had.

CONCLUSIONS:

Patients recognise COPD to be self-inflicted provoking painful emotions. Embarrassment and shame are coupled with feelings of guilt associated with not wanting to emotionally burden others; yet, patients express desire for compassion and understanding. Reflection on the past and anticipation about the future elicit feelings of grief, frustration and anxiety. Mindfulness therapies which encourage patients to be nonjudgmental about their smoking behavior and draw focus back to the ‘current’ may be beneficial in promoting acceptance and control and reducing elaboration and anxiety.

Footnotes

Financial Support: Funded by the Canadian Respiratory Health Professionals (CRHP) and DB was supported by the Canadian Research Chair.

Can Respir J. 2015 Apr;22(Suppl A):11A.

14 • CRC2015-054: The Economic Burden of COPD in British Columbia from 2001 to 2010: A Population Based Study

R Khakban ¹, D Sin ², R Ng ², Z Zafari ², B McManus ², Z Hollander ², M Sadatsafavi ^3,⁴, J Mark FitzGerald ⁴, C Marra ⁵

Abstract

RATIONALE:

The burden of a disease is a complex function of its prevalence, environmental factors, influx of new technologies, and real-world practice patterns. In this ever-changing landscape, up-to-date estimates are required for evidence-informed policy making. The objective of this study was to evaluate the excess cost of COPD and its trends from 2001 to 2010 in British Columbia (BC).

METHODS:

We used BC’s administrative health data to create a cohort of patients with COPD based on validated case definitions. Patients were matched to a comparison cohort of non-COPD subjects with respect to sex, birth year, local health area, and socio-economic characteristics. Direct medical costs (inflation-adjusted to $CAD 2010) for COPD and comparison cohorts were calculated based on billing records, and excess costs were estimated by subtracting costs of the comparison group from the COPD group. Costs were categorized as inpatient, outpatient, medication, and community care.

RESULTS:

194,001 and 314,519 individuals constituted the COPD and comparison cohorts, respectively (mean age at entry 69.1, 47.5% female); average follow-up time was 8.5 years. The excess cost of COPD was $6,828 per patient/year. Inpatient, outpatient, medication, and community care costs were responsible for 59%, 16%, 22%, and 2% of the excess costs, respectively. The relative share of these cost components remained relatively constant over the last six year of follow-up. Excess costs increased by $20.0 million/year (P<0.01) and per-person costs increased by $200/year (P<0.01).

CONCLUSIONS:

The direct economic burden of COPD has increased significantly between 2001 and 2010 owing to increased prevalence and increased per-patient costs over and beyond the health-care costs of the general population. This should prompt policy makers and researchers to investigate the underlying reasons.

Footnotes

Financial Support: Genome Canada, Genome British Columbia, Genome Quebec, Canadian Institutes of Health Research, Canadian Respiratory Research Network, St Paul’s Hospital Foundation & the PROOF Center of Excellence.

Funding: None.

Can Respir J. 2015 Apr;22(Suppl A):11A–12A.

15 • CRC2015-047: The Impact of Anxiety and Mood Disorders on Chronic Obstructive Pulmonary Disease Development

A Moga ^1,², K Lavoie ^1,³, A Yohannes ⁴, R Pelletier ^1,⁵, SL Bacon ^1,⁶

Abstract

BACKGROUND:

Abstract

BACKGROUND:

Nintedanib, an intracellular inhibitor of tyrosine kinases, is in development for the treatment of idiopathic pulmonary fibrosis (IPF). The INPULSIS™ trials were two replicate randomized, double-blind, placebo-controlled, 52-week Phase III trials that assessed the efficacy and safety of nintedanib 150 mg twice daily in patients with IPF. The primary endpoint was the annual rate of decline in forced vital capacity (FVC), which was significantly reduced in the nintedanib group compared with placebo in both trials.

AIM:

To assess the impact of baseline FVC on the effect of nintedanib on rate of decline in FVC.

METHODS:

A pre-specified subgroup analysis of patients with baseline FVC >70% versus ≤70% of predicted value was undertaken using pooled data from both trials.

RESULTS:

700 patients (nintedanib 431, placebo 269) had baseline FVC >70% predicted and 361 patients (nintedanib 207, placebo 154) had baseline FVC ≤70% predicted. For patients with a baseline FVC >70% predicted, mean age was 67.4 years, 76.9% were male, 55.7% were White and mean carbon monoxide diffusion capacity (DLCO) was 4.0 mmol/min/kPa. For patients with a baseline FVC ≤70% predicted, mean age was 65.5 years, 83.9% were male, 60.4% were White and mean DLCO was 3.6 mmol/min/kPa. There was no significant treatment by subgroup interaction: the difference in adjusted annual rate of decline in FVC between the nintedanib and placebo groups was comparable in both subgroups.

CONCLUSION:

A subgroup analysis of pooled data from the INPULSIS™ trials showed that nintedanib 150 mg twice daily slowed the decline in lung function in patients with IPF, independent of severity of lung function impairment at baseline.

Footnotes

Financial Support: Boehringer Ingelheim. Previously presented at ERS 2014 in Munich, Germany.

Can Respir J. 2015 Apr;22(Suppl A):13A–14A.

21 • CRC2015-057: Comparative Studies of Asbestos Phagocytosis in Murine and Human Macrophages

IS Khan ¹, A Brahmendra ¹, A Prashar ¹, MR Terebiznik ¹

Abstract

RATIONALE:

Asbestos is a group of fibrous silicate minerals that causes pulmonary diseases, including malignant mesothelioma and bronchogenic carcinoma. According to fibre toxicology, the pathogenicity of asbestos and other respirable fibres is due to the frustrated phagocytosis of fibres exceeding 15 μm in length, which results in the stimulation of cells to release inflammatory mediators and contributes to fibrosis. The cellular mechanisms that cause frustrated phagocytosis are unknown, largely due to a lack of techniques to study the internalization of these fibres by macrophages. Investigating these mechanisms is critical given the continued use of asbestos and other fibres worldwide, and the increasing use of newly-developed nanofibres, which are proposed to elicit similar responses. We developed immunofluorescence and indirect opsonization methods that allowed us to investigate the phagocytosis of asbestos fibres using confocal microscopy in cultured murine and human macrophages.

RESULTS:

Our findings indicate key differences in the phagosomal uptake and maturation of asbestos fibres between these cell types. RAW 264.7 murine macrophages can internalize long asbestos fibres, albeit through a process which deviates from the canonical phagocytic pathway. However, internalization in U937 human macrophages is arrested at the cup stage. Interestingly, indirect opsonization of fibres with IgG, which directs uptake via Fcg receptors, restores phagocytosis, likely due to the engagement of more receptors. Regardless of the uptake process, phagosomes containing asbestos fibres in both cell types fail to acidify, suggesting a deviation from the canonical phagosomal maturation pathway, possibly contributing to pathogenicity.

CONCLUSIONS:

Altogether, our results suggest that along with fibre length, a deficiency in receptors for asbestos recognition could contribute to an anomalous phagocytic uptake process. Our techniques allow us to follow the phagocytosis of asbestos fibres and study the contribution of frustrated phagocytosis towards disease, as well as identify other points to be explored to explain the toxicity of these fibres.

Footnotes

Financial Support: NSERC Discovery Grants Program.

Can Respir J. 2015 Apr;22(Suppl A):14A.

22 • CRC2015-016: Utility of the Trans-Esophageal Contrast Echocardiogram as an Additional Screening Tool for Cardio-Pulmonary Shunt Assessments in Hereditary Hemorrhagic Telangiectasia

H Mann ¹, M Shanks ², J Choy ², U Geisthoff ³, H-W Angenedt ⁴, S Weise ⁴, D Vethanayagam ²

Abstract

INTRODUCTION:

Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant disorder characterized by abnormal vascular maturation, resulting in the development muco-cutaneous telangiectasias and arterio-venous malformations (AVMs). Pulmonary AVMs (PAVMs), seen in 35–40% of HHT patients, can have significant clinical consequences due to the right-to-left shunt created.

RATIONALE:

Transthoracic contrast echocardiography (TTCE) paired with chest radiography has been utilized at HHT Centers to optimize detection of shunts. However, TTCE cannot always delineate the nature and location of the noted shunt; the utility of more invasive screening with trans-esophageal contrast echocardiogram (TECE) has been explored.

METHODS:

We sought to assess the proportion of HHT patients seen at the Edmonton and Germany HHT Centers where TECE was performed following TTCE for better delineation of the identity of a shunt. Inclusion criteria included either possible or definite HHT subjects who had undergone TTCE and/or TECE screening.

RESULTS:

257 subjects who had undergone TTCE and/or TECE screening were studied. In 92 of the 141 (54.9%) cases where both TTCE and CT were performed, the results of the screenings conflicted in regards to the presence of a shunt. Of the 43 subjects (out of 45) positive for both TTCE and TECE, 11 (26.2%) saw a reclassification in the shunt type and 1 subject (2.4%) saw the discovery of a new shunt altogether.

CONCLUSIONS:

The results of this study show potential benefits for adapting TECE to the normal screening protocol for a limited subset of HHT patients with unclear shunt identities. Clarity in intrathoracic shunt location can have important implications for diagnosis and management of HHT (possible vs. definite HHT). This may secondarily positively impact overall health care utilization and cost to the health care system if used in HHT Centers.

Footnotes

Financial Support: None.

Can Respir J. 2015 Apr;22(Suppl A):14A.

23 • CRC2015-060: Quality of Life According to Cancer Type in Patients with Malignant Pleural Effusion Treated with Indwelling Pleural Catheter or Talc Pleurodesis

JAP Olfert ¹, ED Penz ¹, EK Mishra ², HE Davies ³, BJ Manns ⁴, RF Miller ⁵, NM Rahman ²

Abstract

RATIONALE:

The Second Therapeutic Intervention in Malignant Effusion Trial (TIME2)¹, compared indwelling pleural catheter (IPC) with talc pleurodesis (Talc) for treatment of malignant pleural effusion. Various clinical and economic outcomes have been published previously.^1,2 Quality of life according to cancer type has yet to be described.

METHODS:

106 patients at 7 centers across the UK were randomized to either indwelling pleural catheter or Talc and followed for one year or until death. Dyspnea and chest pain were assessed using a 100-mm line visual analog scale. Quality of life was assessed by EORTC-QLQ 30 and EQ-5D questionnaires. Quality-adjusted life-years (QALYs) gained were determined by area under the curve methodology using utility weights obtained from EQ-5D questionnaire. Analysis was performed according to cancer type and treatment modality.

RESULTS:

Baseline utility scores for IPC and Talc groups by cancer type were: breast (0.637 versus 0.634), lung (0.553 versus 0.553), mesothelioma (0.634 versus 0.816), and other (0.566 versus 0.588). Mean QALY observed during the trial by cancer type was: breast (0.407), lung (0.252), mesothelioma (0.573) and other (0.298). The difference in mean QALY between IPC and Talc was not significant among different cancer types.

CONCLUSION:

There was no significant difference in QALYs gained with IPC compared to Talc when stratified by cancer type. Mesothelioma was associated with the highest QALYs; however, baseline utility scores were highest in this group. Power to detect a difference in QALYs by cancer type may have been limited by small sample size.

Footnotes

Financial Support: The TIME2 trial was supported with an unrestricted education grant from the British Lung Foundation and the Robert Luff Foundation, London, England. The University of Oxford sponsored the TIME2 trial. The IPCs and drainage bottles were provided by Rocket Medical, Washington, England. An Alberta Innovates Health Solutions Clinician Fellowship award supported Dr. Penz during her involvement in the analysis and preparation of the manuscript. Dr. Manns is supported by Alberta Innovates – Health Solutions salary award and by an alternative funding plan from the Government of Alberta and Universities of Alberta and Calgary. No additional funding was provided for this study.

Conflicts of Interest: Dr Miller reported receiving support for lectures on HIV infection from Merck and Gilead. Dr Rahman reported that he acts as a consultant to Rocket Medical for device development. No other conflicts of interest were reported.

Can Respir J. 2015 Apr;22(Suppl A):14A–15A.

24 • CRC2015-020: Transbronchial Biopsies in Lung Cancer: Retrospective Review of 116 Patients

PS Zhu ¹, CD Poirier ¹, M Gagnon ¹, T Vandemoortele ¹

Abstract

RATIONALE:

Bronchoscopy with transbronchial biopsy (TBB) is an interesting tool in the investigation of lung cancer. We aimed to describe the yield and safety of TBB in the evaluation of pulmonary malignancy.

METHODS:

We retrospectively reviewed the data of 116 TBB performed to assess lung lesions executed between January 2013 and December 2013 at a tertiary center. We evaluated these procedures in terms of diagnostic yield for neoplasia and complications.

RESULTS:

The mean age of the patients was 66 years old (range 26–88), with 55 male (48.9%). The mean number of biopsies was 4.28 (±1.46). Diagnostic yield from TBB alone for lung cancer was 37.9% (44/116), while when combined with other sampling procedures (such as bronchial biopsy, bronchoalveolar lavage or brush), it improved to 43.1% (50/116). When endobronchial ultrasound-transbronchial needle aspiration (EBUSTBNA) was also performed, diagnostic yield further increased to 58.6% (68/116). A higher number of biopsies improved the diagnostic yield (72.7% with >5 biopsies vs 36.7% with 3–5 biopsies vs 0% with 1–2 biopsies; p=0.015). Diagnostic yield was higher when lesions measured ≥30 mm (46.3%; 31/67) compared with nodules <30 mm in diameter (25.6%; 10/39) [p=0.041]. Adjuncts such as radial EBUS (8/116), electromagnetic navigation (19/116), fluoroscopy (17/116) and cryoprobe (4/116) were used in 29 TBB (25%), with no significant effect on performance (p=0.659). Only one patient suffered from a small pneumothorax (0.9%) that did not require chest drainage. Number of biopsies did not influence the risk of complications.

CONCLUSIONS:

Efficacy of TBB for the diagnosis of lung cancer is optimized when performed in conjunction with EBUS-TBNA, >5 biopsies and lesions ≥30 mm. TBB appears to be a relatively safe procedure, with no significant rise in risk of complications with higher number of biopsies.

Can Respir J. 2015 Apr;22(Suppl A):15A.

25 • CRC2015-004: The Patient Who Couldn’t Quite Catch Her Breath: Interstitial Lung Disease Complicated by Hepatopulmonary Syndrome

N Sitzer ¹, R Mathew ¹, J Gelberg ^1,²

Abstract

RATIONALE:

Hepatopulmonary syndrome (HPS) is a triad of liver disease, impaired oxygenation and intrapulmonary vascular dilatations. While dyspnea is the predominant presenting symptom, platypnea and orthodeoxia are highly suggestive of HPS in the setting of chronic liver disease. A delay in diagnosis is common as dyspnea in cirrhotic patients is often attributed to ascites, anemia, muscle wasting or portopulmonary hypertension. The clinical picture is further complicated in patients with underlying lung pathology and baseline dyspnea.

METHODS:

A 56-year-old female with rapidly progressive idiopathic pulmonary fibrosis and alcoholic liver disease presented to the Emergency Department with worsening dyspnea and increased oxygen requirements. She was empirically treated for a respiratory infection with ceftazadime, levofloxacin and oseltamivir. CT chest revealed worsening pulmonary fibrosis, but no etiology for her acute deterioration. While in hospital she was noted to have orthodeoxia and platypnea suggestive of HPS. Echocardiogram with agitated saline contrast revealed a patent foramen ovale with bidirectional shunting and large inflow of contrast from the pulmonary veins, worse in the upright position compared to the supine position. These findings were consistent with a large intrapulmonary shunt and a preliminary diagnosis of HPS. She is currently under review by the transplant board in Toronto for a combined liver and lung transplant.

CONCLUSION:

In patients with interstitial lung disease, worsening dyspnea is often attributed to infection, congestive heart failure, pulmonary embolus or progression of underlying fibrosis. Our case highlights the importance of considering a broad range of differential diagnoses in patients presenting with progressive dyspnea, especially in the setting of in underlying chronic liver disease. Early recognition of HPS can lead to referral for definitive treatment with liver transplant.

Can Respir J. 2015 Apr;22(Suppl A):15A.

26 • CRC2015-024: A Multi-Specialty Thoracic Oncology Clinic for Individualizing the Care of High-Risk Patients

C-A Vallée ¹, A Bujold ², S Carignan ³, G Rakovich ¹

Abstract

RATIONALE:

There are several options available for treating early stage lung cancer. Although lobectomy remains the standard of care, sub-lobar resection, stereotactic radiotherapy and radio-frequency ablation may be appropriate in high risk patients. Direct evidence comparing these methods is lacking and thus therapeutic decisions are often deferred to an institutional “multidisciplinary tumor committee”. We hypothesized that a multispecialty thoracic oncology clinic could streamline patient evaluation as well as improve outcomes by fine tuning therapeutic decisions based on specific patient and tumour characteristics.

METHODS:

The proposed clinic was held jointly by a thoracic surgeon, radiation oncologist and interventional radiologist, beginning in March 2013. After 18 months, data were reviewed.

RESULTS:

A total of 36 patients were evaluated. Mean age was 69±11.7 years. Mean FEV₁ was 1.83±0.59 L. 14 patients had been treated for at least one distinct lung cancer in the past. 24 patients now had new single lesions, while 7 patients had multiple synchronous lesions. All had early stage tumors. An additional 5 patients had pulmonary metastases. After evaluation, 26 patients were referred for non-operative treatment: 16 because of co-morbidities and 10 because of patient preference. Eighteen patients had radiotherapy and 8 had ablation. Three patients had surgical resection, and 1 had combined resection and radiotherapy for synchronous tumors. Six patients with suspicious lesions were observed. There were 2 cancer related deaths and 2 distant metastasic recurrences during the study period. There were no treatment related adverse events.

CONCLUSION:

The main indications for referral were a complex onco-logic history and multiple tumors. Our approach facilitates individualized care and active participation of patients in decision-making. It also offers the potential for avoiding multiple specialty referrals and delays. Although follow-up is limited, patient outcomes were satisfactory and morbidity was minimal. Referral criteria and treatment options still need to be further refined.

Footnotes

Financial Support: None.

Can Respir J. 2015 Apr;22(Suppl A):15A.

27 • CRC2015-049: Collaborative Care in OSA: A New Paradigm

ME Fenton ¹, SA Stewart ², RP Skomro ¹, JA Gjevre ¹, S McCrae ³

Abstract

BACKGROUND:

Obstructive sleep apnea (OSA) is a prevalent disorder with a quarter of the Canadian population at high risk, that has traditionally been investigated and managed by specialists. There are two bottlenecks in the path of a patient seeking investigation and treatment of OSA – a specialist waitlist and sleep laboratory waitlist. Our centre has been providing level 3 testing since 2006, reducing the sleep-lab waitlist. To address the specialist bottleneck, we developed a new care-pathway providing testing and treatment directly from primary care. This model investigates the effect of this direct access (DA) program on patient wait-times and OSA diagnosis rates.

METHODS:

Patients with a high pretest probability of OSA without significant comorbidities were referred directly to level 3 testing at the Sleep Disorders Centre. After review of the data by a sleep specialist, patients with a positive study were sent for education and auto-CPAP titration to determine fixed pressure CPAP settings. Indeterminate and complex findings were sent for polysomnography. We surveyed wait-times in 5 sleep specialist clinics in the Saskatoon Health Region (SHR) for comparison.

RESULTS:

A total of 647 patients (53% male) were referred for direct testing. The median time from family physician referral to level III testing was 30 days for direct access (DA) patients, compared to 265 days for those seen by specialists (HR=4.8, P<0.0001). 71.6% of DA patients were diagnosed with OSA, compared to 79.2% in the specialist group (8.6% difference, P<0.0001).

DISCUSSION:

Using this DA model, the time to diagnosis for patients with OSA was significantly decreased. The diagnostic rate of 71% by level 3 for DA is below the specialist arm but is acceptable. This study demonstrates the potential for direct to level III referral to significantly reduce wait times and improve time to treatment.

Can Respir J. 2015 Apr;22(Suppl A):16A.

28 • CRC2015-040: A Multi-Stakeholder Collaboration to Improve Outcomes in Patients with Chronic Obstructive Pulmonary Disease (COPD) in Ontario: Value Demonstrating Initiative (VDI) on COPD

C Madeley ¹, A Barlett ², D Brooks ³, J Cafazzo ⁴, C Faulds ⁵, A Gershon ⁶, J Glennie ⁷, M Hillmer ⁸, C Hay ⁹, A Hayes ¹⁰, A Kaplan ¹¹, L LeBlanc ¹², C Licskai ¹³, M Lundie ¹⁴, K McIntyre ¹⁵, J Plaxton ¹⁶, J Pringle ¹⁷, R Maleki-Yazdi ¹⁸

Abstract

RATIONALE:

COPD affects 12% of Ontarians and prevalence is increasing. COPD patients are among the high health care users. In order to improve their quality of life and increase the effectiveness of the health care system, an innovative collaboration between the Ministry of Health and Long-Term Care, the Ontario Lung Association, and Canada’s Research-Based Pharmaceutical Companies (Rx&D) began in 2013. They worked together to translate existing knowledge and evidence into practice.

METHODS:

An expert panel comprised of representatives from the collaborating organizations, respirologists, family physicians, pharmacists, respiratory therapists, researchers, and a patient representative provided evidence-based advice on the design, implementation, and evaluation of integrated multidisciplinary COPD care for patients at high risk of hospitalization. With the support of a secretariat based at the Ministry of Health and Long-Term Care, the Panel reviewed evidence and leading practices, and leveraged the recommendations of the Ontario Health Technology Advisory Committee (OHTAC) and Health Quality Ontario (HQO) to provide advice on:

Intervention design (eg, eligibility criteria, approaches to care coordination) Implementation considerations (e.g., care delivery, training)
Monitoring and evaluation (e.g., approaches to evaluating implementation, maintenance of intervention).

RESULTS:

RESULTS:

We recruited 11 mentors and 47 mentees. Spirometry knowledge scores increased significantly [(21.4±3.1 to 27.3±3.5 (p<0.01)]. Spirometric acceptability and repeatability criteria were met by 59/191 (30.9%) spirometry tracings pre-intervention and 86/193 (44.6%) post-intervention [odds ratio 1.72 (1.27, 2.34)]. Finally, spirometry was ordered in 75/512 (14.6%) and 129/336 (38.4%) of respiratory visits (p<0.01) pre and post-intervention, respectively.

CONCLUSION:

A mentorship-based intervention involving both primary care physicians and allied health practitioners can enhance knowledge, technical competence, and actual use of spirometry in eclectic, real world primary care settings.

Can Respir J. 2015 Apr;22(Suppl A):17A.

32 • CRC2015-056: Innovations in Treating Chronic Obstructive Pulmonary Disease (COPD) Exacerbations Using New Technology

M Sedeno ¹, P-Z Li ¹, A Joubert ¹, I Drouin ¹, R Abimaroun ¹, I Ouellet ¹, D Beaucage ¹, M Patel ¹, J Bourbeau ¹

Abstract

INTRODUCTION:

We conducted a pilot study evaluating the feasibility and potential benefits of a novel approach of COPD self-management that includes an interactive phone assessment/reporting system (COPDTelesystem) in addition to a written action plan and a nurse case manager support to improve patients’ adherence to prompt COPD treatment in those at risk for exacerbations.

METHODS:

Prospective cohort of COPD patients (GOLD 2+) with ≥1 exacerbations requiring antibiotic or prednisone in the past year. Patients received scheduled calls from the COPD-Telesystem at 2 weeks and months 1–6 to evaluate the presence of an exacerbation and remind them to follow their action plan; they could also call the COPDTelesystem to report changes or new respiratory symptoms. The case manager received an alarm in case of exacerbation and called back patients for follow-up. Outcomes evaluation by monthly phone interview for 12 months included patients’ use of rescue bronchodilators, antibiotics and/or prednisone in response to exacerbation symptoms and use of healthcare resources.

RESULTS:

Twenty-four COPD patients were recruited and 16 experienced exacerbations. A total of 39 exacerbations were recorded. Although 36 exacerbations presented increased shortness of breath, only 2 increased rescue bronchodilators, and 2 took prednisone. Antibiotics were used in 4 out of 26 exacerbations presenting changes in sputum. There were 14 severe exacerbations (requiring either a doctor or ER visit or hospitalization), and these lasted longer than non severe (21.9 versus 9.1 days).

CONCLUSIONS:

To date, patients have not demonstrated adherence to the action plan directives in case of a COPD exacerbation. This calls for a more intensive follow-up from the nurse case manager to support the use of the COPD-Telesystem for reporting and the action plan.

Footnotes

Financial Support: Investigator-initiated study funded by GlaxoSmithKline.

Can Respir J. 2015 Apr;22(Suppl A):17A.

33 • CRC2015-046: Spontaneous Pneumomediastinum in a Healthy Newborn

S Bin-Hasan ¹, R Amin ¹

Abstract

BACKGROUND:

Spontaneous pneumomediastinum (PM) is an uncommon phenomenon in healthy, term newborns as it is estimated to occur in 0.1% to 0.2% of all live births. The pathophysiology is related to over distension and rupture of alveoli, with the escaped air following the path of the least resistance towards the hilum and the mediastinum. From the literature, management of asymptomatic PM varies from conservative management to application of 100% oxygen with similar outcomes.

CLINICAL CASE DESCRIPTION:

A female infant was born at term via spontaneous vaginal delivery to a healthy mother with unremarkable antenatal history. Mom was Group B Strep (GBS) positive and received appropriate antenatal antibiotics. Because of an elevated white cell count of 32.6, the infant was started on Ampicillin and Gentamicin. The antibiotics therapy were discontinued 48 hours later when the blood cultures were negative. On clinical examination, the heart sounds were decreased over the upper anterior chest. The oxygen saturations were 100% in room air, there was no tachypnea or respiratory distress. A chest radiograph demonstrated a cystic abnormality in the left hemithorax. The differential diagnosis included a cystic lesion communicating with the airways versus a loculated PM. Chest CT scan confirmed the diagnosis of a loculated PM. The baby was discharged home and at the one month follow up visit, the repeat chest radiograph showed complete resolution of the PM.

CONCLUSION:

Unlike other air-leak syndromes in the neonatal population, spontaneous PM is much less common especially in the absence of a barotrauma. The clinical assessment is very important to identify the subtle clues as presented in the case, as well as, a proper radiological assessment to confirm the diagnosis.

Following the patient clinically is essential to confirm the diagnosis as PM will resolve spontaneously without additional sequelae.

Footnotes

Financial Support: None.

Can Respir J. 2015 Apr;22(Suppl A):18A.

34 • CRC2015-035: 1-Year Efficacy and Safety Study of Tiotropium Respimat Add-On to ICS in Adolescent Patients with Symptomatic Asthma

M-A Caron, presenting on behalf of E Hamelmann^1,², A Boner ³, J Bernstein ⁴, P Moroni-Zentgraf ⁵, M Engel ⁵, M Avis ⁶, A Unseld ⁷, M Vandewalker ⁸

Abstract

BACKGROUND:

Tiotropium Respimat (tioR) add-on to ICS therapy improves lung function in adult patients. Here we examine the efficacy and safety of tioR in adolescents.

METHODS:

48-wk Phase III, randomised, double-blind, placebo-controlled, parallel-group trial (NCT01257230) in asthmatic adolescents (12–17 yrs). Inclusion criteria: =3-month asthma history; pre-bronchodilator FEV1 =60% and =90% of predicted; screening ACQ-7=1.5. Patients were randomised to once-daily tioR 5μg, tioR 2.5μg or placebo Respimat (pboR) add-on to ICS (12–14 yrs: 200–400 μg; >14 yrs: 400–800 μg budesonide or equivalent). Primary end point at wk 24: peak FEV₁ (0–3 h). Additional end points: trough FEV1 and PEFam/pm (wks 24 and 48), and AE data.

RESULTS:

397 patients treated. Mean age: 14.3 yrs (range 11–17 yrs); 65% male; mean FEV₁ % predicted at baseline: 82.8. TioR 5 μg significantly improved all end points vs pboR at 24 and 48 wks; tioR 2.5 μg significantly improved some end points, eg peak FEV₁ (0–3h) at 24 and 48 wks and trough FEV₁ at 48 wks. AEs were comparable across all treatment groups; a small number of drug-related AEs (tioR 5 μg=4, tioR 2.5 μg=1, pboR=1) and no fatal AEs were reported.

CONCLUSION:

Tiotropium Respimat add-on to ICS significantly improves lung function, has a safety profile comparable with placebo and is well tolerated in adolescent patients with symptomatic asthma.

Footnotes

Financial Support: Boehringer Ingelheim. Previously presented at ERS 2014 in Munich, Germany.

Can Respir J. 2015 Apr;22(Suppl A):18A.

35 • CRC2015-058: The Influence of Socioeconomic Inequity on the Long-Term Healthcare Costs of Asthma Under Universal Health Insurance

W Chen ¹, LD Lynd ^1,², JM FitzGerald ^3,⁴, M Sadatsafavi ^3,⁴

Abstract

RATIONALE:

In asthma low-socioeconomic status (SES) tends to contribute excess health-care burden, but its impact on asthma costs in a universal health-care system is unknown. This study examined the extent of SES-related disparities in the long-term direct medical costs of asthma and trends over time.

METHODS:

Using BC’s administrative data, between January 1997 and March 2013, asthma patients were identified using a validated case definition. Index date was defined as the first day after the first asthma diagnosis. Each asthmatic was matched to a non-asthmatic based on age and sex, the latter was assigned the same index date. Participants aged 18 to 45 years on the index date were included in the final analysis. SES was defined by median neighborhood household income quintile in the index year. Excess health-care costs were reported in 2013 Canadian dollars, including all-cause inpatient episodes, outpatient visits and medications from the billing records. A survival-adjusted, multipart generalized linear model was used to model the 15-year healthcare costs, accounting for death and early withdrawal. The impact of SES was assessed in participants with and without asthma, adjusting for age, sex and the year of asthma onset. The excess costs of asthma were determined by contrasting the predicted costs of asthmatics and non-asthmatics.

RESULTS:

The sample included 53,988 asthma cases and non-asthma controls, respectively (both groups: mean age 33 years, 61% female). People in the lowest SES quintile were expected to incur $3,243 more covariate-adjusted excess costs of asthma over 15 years compared with the highest quintile ($19,772 vs. $16,529, p<0.001). Overall, lower SES was associated with greater 15-year asthma costs than higher SES (trend test: p<0.001). The gap of SES-related disparities in asthma costs widened over time.

CONCLUSIONS:

Lower SES at onset of asthma is associated with greater medical costs over the long term.

Footnotes

Financial Support: This work was supported by AllerGen National Center of Excellence as part of the project “Platform for Outcomes Research and Translation in Asthma and Allergy (PORTAL)”.

Conflict of Interest: The authors declare no conflict of interests.

Can Respir J. 2015 Apr;22(Suppl A):18A.

36 • CRC2015-009: Primary Ciliary Dyskinesia and Neonatal Respiratory Distress

T Mullowney ^1,², D Manson ^3,⁴, R Kim ^2,⁵, D Stephens ⁶, V Shah ^7,^8,⁹, S Dell ^1,^6,^8,⁹

Abstract

ABSTRACT NOT PUBLISHED AT AUTHORS’ REQUEST

Can Respir J. 2015 Apr;22(Suppl A):19A.

37 • CRC2015-010: : Audit of Influenza Vaccination in the Regional Paediatric Asthma Clinic (RPAC) with Comparisons of Outcomes Over the Influenza Season

N Snow ¹, K Downey ², WG Smith ^1,²

Abstract

PURPOSE:

To audit the compliance of paediatric asthma patients with Influenza Vaccination during the 2013–2014 influenza season, where vaccinations was made available and assess relevant asthma related outcomes such as increased rate of unscheduled visits, antibiotic use and prednisone rescue, in asthmatic children who were not immunized for Influenza vs. those immunized.

METHODS:

An audit of consecutive patients during the two influenza seasons was undertaken.

RESULTS:

For the 2012–2013 influenza season, a total of 193 patients were audited. Of the total, 24% received the influenza vaccination. The 2013–2014 year audit indicated that 383 children were offered immunization and 268 agreed for a rate of 59%.

The only variable changed during this second year of audit was the availability of the influenza immunization given by the RRT (CAE) at the clinic at the time of the visit.

CONCLUSIONS:

By addressing the potential barriers to influenza immunization and offering immunization at the clinic, there was an increased uptake of the vaccine from 24% in 2012–2013 to 59% in 2013–2014. We also documented the increased rate of unscheduled visits, antibiotic use and prednisone rescue, in asthmatic children who were not immunized for Influenza.

In the 2012–2013 audit year, 193 children were offered the influenza Vaccine at the clinic; 46 (23.6%) said “Yes”. In the 2013–2014 audit, 89 of the same children were back for follow- up visits for their asthma and 79 (88.8%) said “Yes”, when vaccination was made available at their clinic visit.

Footnotes

Conflicts of Interest: All cost was assumed by the Regional Paediatric Asthma Clinic, there are no conflicts of interest to declare.

Can Respir J. 2015 Apr;22(Suppl A):19A–20A.

38 • CRC2015-053: Plastic Bronchitis: A Sticky Situation

MFA Wright ¹, A Kapur ¹, DF Wensley ¹

Abstract

RATIONALE:

Plastic bronchitis is a rare condition characterised by formation of casts that can cause life-threatening airway obstruction. Associations include congenital heart disease and infective or inflammatory respiratory disorders. We describe a case of plastic bronchitis in a child with acute severe asthma, and discuss options for management.

METHODS:

A previously well 18-month old girl was admitted to hospital with respiratory distress and wheeze secondary to rhinovirus infection. Following initial response to conventional asthma management she acutely deteriorated with increased respiratory distress, hypoxia and acidosis. Despite use of intravenous bronchodilators she required intubation and mechanical ventilation. Ventilation was difficult and she developed a worsening respiratory acidosis (pH 7.05, PCO₂ 95 mmHg). Repeat x-ray showed complete collapse of the left lung and right upper lobe.Emergency bronchoscopy was performed, at which a tenacious mucus plug was found to be obstructing the left main bronchus, and was successfully extracted. Post-procedural x-ray showed improved aeration bilaterally, associated with a marked improvement in acid-base status and ventilatory requirements. The child was extubated the next day and made a complete recovery.

RESULTS:

Bronchoscopy is the mainstay of diagnosis and management in acute episodes of plastic bronchitis, and can be life-saving. However, casts may be too friable to be removed by forceps or too thick to be removed by suction. Cast fragmentation using mucolytic or fibrinolytic agents, either by endotracheal instillation or inhalation, can be effective in such circumstances. Recurrence rates are high amongst successfully treated cases. Long-term management options that have been described with variable success include azithromycin, inhaled mucolytics, and thoracic duct ligation.

CONCLUSION:

Plastic bronchitis should be considered in cases of infective or inflammatory respiratory illnesses with acute clinical or radiological deterioration. Timely cast removal can be life-saving. Optimising control of the underlying disease is essential in order to minimise recurrence risk.

Figure 2) — Post-bronchoscopy chest x-ray

Financial Support: This work was supported by operating grants from the Fonds de recherche du Québec – Santé (FRQ-S) [grant number 12505] and the Canadian Lung Association – Canadian Respiratory Health Professionals [no assigned grant number].

Can Respir J. 2015 Apr;22(Suppl A):21A.

43 • CRC2015-038: Relationship Between Anxiety, Depression, Illness Perceptions and Outcomes of Pulmonary Rehabilitation for Individuals with Chronic Obstructive Pulmonary Disease

KJ Horvey ¹, S Butcher ¹, D Marciniuk ¹, D Goodridge ¹, L Brawley ¹

Electrical muscle stimulation (EMS) may preserve muscle mass during critical illness. This study aimed to determine feasibility of 1) administering EMS: number of sessions completed, proportion of dropouts, level of muscle contraction achieved and adverse events; and 2) obtaining ultrasound images of muscle thickness.

METHODS:

Randomized controlled trial comparing EMS to sham treatment in critically ill patients, mechanically ventilated for >7 days. EMS was delivered to the quadriceps and gluteals, twice per day (30 min/session) 5 days/week for 4 weeks. The primary outcome was ultrasound imaging to assess muscle thickness of the quadriceps at baseline, 2 and 4 weeks.

RESULTS:

Twenty-four subjects were enrolled between July 2012 and Oct 2013 (16 male; 51±18 years). Baseline assessment and randomization occurred a mean (SD) 16±9 days from ICU admission. 50% of subjects completed 2 weeks of treatment and 5 additional subjects completed 4 weeks. Reasons for dropout prior to 2 weeks were death (n=2), transfer out of ICU (n=4) and skin breakdown unrelated to EMS (n=1). On average, subjects completed 22±11 sessions of EMS (range 4 to 39 sessions). The amplitude of EMS varied per session and ranged from minimal dosage (11mA) to maximal output of the stimulator (160 mA). The majority of subjects experienced small muscle contractions (ratings= 1–2 on a 5 point scale; 0 = no visible contraction and 5 = strong contraction). There were no adverse events. 88% of ultrasound images had adequate quality for analysis.

CONCLUSIONS:

EMS appears to be feasible to apply in a long-term, mechanically ventilated population however mortality and early ICU discharge affected protocol completion. Ultrasound imaging is a quantitative outcome for EMS trials and was found to have sufficient quality for analysis. Future studies should examining factors which affect muscle contractility in critically ill patients.

Footnotes

Financial Support: Allied Health Research Grant (University Health Network), Canadian Respiratory Health Professional Research Grant (The Lung Association).

Can Respir J. 2015 Apr;22(Suppl A):22A.

47 • CRC2015-013: Cardiopulmonary Responses to Short Bouts of Strength Exercises in People with COPD: A Comparison of Exercise Intensities

P Robles ^1,², T Araujo ¹, T Janaudis-Ferreira ¹, K Zabjek ², D Brooks ^1,², Sunita Mathur ^1,², Susan Marzolini ³

Abstract

Abstract

BACKGROUND:

Cornelia de Lange Syndrome (CdLS) is a rare genetic disorder with an incidence of 1:10000 to 1:50000. Sleep disturbances in CdLS have been reported in previous studies with a prevalence of 12 to 80% based on sleep questionnaires. However, PSG findings to confirm suspected SDB have not been previously reported in CdLS.

CASE REPORT:

We present a 15 month old boy with CdLS who was referred to our institution for a second opinion due to recurrent episodes of acute respiratory failure requiring intermittent invasive mechanical ventilation over the preceding 6 months. His past medical history was significant for a cleft palate, previous supraglottoplasty for laryngomalacia, gastroesophageal reflux disease requiring fundoplication and an atrial septal defect (ASD). He had been on continuous supplemental oxygen by nasal prongs since the age of 8 months. A diagnostic workup was performed showing a normal barium swallow, Chest CT showing no parenchymal disease and an echocardiographically confirmed ASD. A brain MRI demonstrated cerebral parenchymal atrophy and hypoplasia in the bilateral frontal parietal regions and brainstem. There was no adenotonsillar hyper-trophy on upper airway endoscopy. An overnight oximetry study on room air showed a desaturation index of 54.4/hr. On the polysomnogram (PSG), CSA (central apnea-hypopnea index of 19/hour) and nocturnal hypoventilation (transcutaneous CO2 >50mmHg for 53% of the night) were found in the absence of obstructive events. In consideration of the PSG findings non-invasive positive pressure ventilation was initiated and resulted in a significant improvement in the child’s clinical status.

CONCLUSION:

Children with CdLS and recurrent respiratory exacerbations and/or unexplained nocturnal oxygen desaturations should be screened for sleep disordered breathing. In the case of central sleep apnea, long-term ventilation should be discussed with the family because of the opportunity for early intervention to decrease morbidity and improve the quality of life of these children.

Can Respir J. 2015 Apr;22(Suppl A):23A–24A.

51 • CRC2015-014: Access to Zzz’s: A Quality Improvement Journey

C Byblow ¹, K Ward ², B Pawlak ¹, PJ Hanly ^1,³, J Warren ⁴, SR Pendharkar ^1,^3,⁵

Advances in health care including long-term mechanical ventilation (LTMV) have translated into more children with chronic health conditions or disabilities reaching adulthood. Successful transition from paediatric to adult health services is vital to long-term health and psychosocial outcomes. International research has identified important deficits in health transition experiences. The goal of this descriptive qualitative study was to explore paediatric to adult transitional experiences of domiciliary LTMV patients and family caregivers in Canada.

METHODS:

Participants representing 14 paediatric to adult transitions were recruited through hospital and community respiratory clinics in British Columbia and Ontario. Semi-structured interviews were conducted with 13 family caregivers and 5 young adults (ages 17–21) receiving domiciliary LTMV. Interviews were transcribed verbatim and explored through qualitative methods to elucidate key elements of the transition experience.

RESULTS:

Availability of adult health services was a central determinant of the transition experience. In some cases, there was no identified specialty provider to whom care could be transitioned thus inhibiting continuity of health services. Gaps in home care funding, communication, and trained community providers were cited as major transitional barriers. Service shortfalls intensified caregiver burden and a sense of social isolation in transition. Strategies to facilitate transition included team meetings, written care plans, and a central point of contact for health information.

CONCLUSIONS:

Despite existing programs and models, transition from paediatric to adult health services remains challenging. Transition for those requiring domiciliary LTMV may be characterized by health service gaps. Improved health self-efficacy and satisfaction may be enhanced through a central point of contact whereby lay or professional navigators could assist individuals and families to identify transitional resources and information enabling informed decisions. Better understanding of effective transition programs is required to bridge the gap between paediatric and adult services and improve transition experiences in Canada.

Footnotes

Financial Support: CIHR.

Conflict of Interest: There are no conflicts of interest from any of the authors of this study.

Can Respir J. 2015 Apr;22(Suppl A):25A.

55 • CRC2015-028: Ventilator Settings Associated with Average Volume-Assured Pressure Support (AVAPS) Tolerance in ALS

M Kaminska ^1,², R Troini ¹, V Adam ¹

Abstract

RATIONALE:

The average volume-assured pressure support (AVAPS) mode of non-invasive ventilation (NIV) is a barometric mode that auto-adjusts the delivered inspiratory pressure (IPAP) to maintain a pre-specified tidal volume, potentially with greater stability of ventilation compared to the spontaneous–timed (ST) mode. Our aim was to assess tolerance to AVAPS in patients with amyotrophic lateral sclerosis (ALS) already on NIV in ST, and to identify ventilator settings associated with AVAPS intolerance.

METHODS:

Ten ALS patients were switched from ST to AVAPS. The expiratory pressure (EPAP) was unchanged. The initial IPAPAVAPS range and target tidal volume (VT) were based on, respectively, the IPAPST and the mean VT attained in ST. Whenever needed, adjustments were made to maximize comfort. Mean and maximal IPAPAVAPS were obtained from the ventilator download after 2–4 weeks.

RESULTS:

Three of 10 patients did not tolerate AVAPS due to excessive pressure; one had bulbar dysfunction. Target VT in six of the seven tolerant patients were ≤6 cc/kg ideal body weight, whereas in intolerant patients, VT was >6 cc/kg. The mean difference between the mean IPAPAVAPS and the set IPAPST was −0.2 cmH₂O (range −1.8 to 2.3) in tolerant patients, and 1.4 cmH₂O (−1.1 to 3.4) in intolerant patients. The mean difference between the maximal IPAPAVAPS and the IPAPST was 1.8 cmH₂O (0 to 4.0) in tolerant patients, and 3.6 cmH₂O (2.2 to 5.0) in intolerant patients.

CONCLUSION:

AVAPS is well tolerated in most ALS patients, using target VT ≤6 cc/kg ideal body weight. Intolerance appears to result from high IPAPAVAPS required to maintain a higher target VT. Intolerance may occur despite a mean IPAPAVAPS lower than IPAPST, if maximal IPAPAVAPS is higher. Additional studies will be needed to assess whether AVAPS might provide more stable ventilation throughout all sleep phases and as disease progresses in ALS.

Footnotes

Financial Support: None.

Can Respir J. 2015 Apr;22(Suppl A):25A.

56 • CRC2015-041: Transitioning from Hospital to Home: The Experiences of Adults Requiring Long Term Mechanical Ventilation (LTMV) and their Family Caregivers

J King ¹, C Dale ², M Nonoyama ³, D McKim ⁴, J Road ⁵, L Rose, on behalf of CANuVENT group⁶

Abstract

RATIONALE:

Advanced life support technologies have contributed to a growing population dependent on long term mechanical ventilation (LTMV). Although people receiving LTMV are increasingly discharged from hospital to home, little is known about this transition. The goal of this descriptive qualitative study was to elucidate the transitional experiences of people receiving LTMV and their family caregivers.

METHODS:

Recruitment of participants occurred through hospital and community respiratory clinicians in Alberta, British Columbia, Ontario and Saskatchewan. Semi-structured telephone or home interviews were conducted with 20 adults receiving LTMV and 13 family caregivers. To foster reflexivity in analysis, regular team meetings were recorded, transcribed and reviewed to reach agreement on the developing themes.

RESULTS:

Preliminary descriptive themes that have emerged include ‘Mixed Expectations’, ‘Home as Hospital’, ‘Changing Roles and Responsibilities’ and ‘Social and Geographic Isolation’. From the perspective of adults receiving LTMV and their caregivers, there are not one but multiple transitions. For the adult receiving LTMV the more profound transition home on LTMV is conditioned by uncertainty in identity and supportive resources for daily living. While for family members, the more profound transition is moving from being a family member to primary caregiver. Participants described early uncertainties regarding their home management capacities and varying degrees of isolation in their transition.

CONCLUSIONS:

Healthcare professionals may use these findings to improve sensitivity, understanding and opportunities for improving transition in a growing LTMV population. Potential resources warranting inquiry include the development of peer support for people receiving LTMV and their families, in addition to community outreach, to more effectively bridge clinical and domiciliary environments.

Footnotes

Financial Support: CIHR.

Conflict of Interest: None to report.

Can Respir J. 2015 Apr;22(Suppl A):25A–26A.

57 • CRC2015-017: Pneumothorax in Ventilated Neuromuscular Patients

AHS Loewen ^1,^2,^3,^4,⁵, R Tye ^1,², L Howie ³, KL Fraser ^4,⁵, KP Rimmer ^1,^2,^3,⁴

Abstract

RATIONALE:

In neuromuscular patients positive airway pressure ventilation and cough assistance are utilized routinely and may place patients at risk of pneumothorax.

METHODS:

Retrospective chart review of six cases of pneumothorax in ventilated neuromuscular patients between the years 2011 to 2014

RESULTS:

Six neuromuscular patients (diagnosis of ALS, limb girdle dystrophy, myotonic dystrophy, CAP myopathy and collagen 6-related myopathy) were reviewed. Mean FVC 1.3 L (35% predicted), mean BMI 17. One patient was ventilated with tracheostomy, the remaining 5 noninvasively. Mean duration of positive pressure ventilation at time of the pneumothorax was 1.25 years. The invasively ventilated patient was on volume assist control, tidal volume 500 mL, with peak inspiratory pressure 20 mmHg, PEEP 4, and was using mechanical insufflation-exsufflation. The remaining noninvasively ventilated patients had a mean IPAP of 19 cmH₂O, mean EPAP 7 cmH₂O, back up rate of 15. These patients used lung volume recruitment for airway clearance (3 patients). 5 of 6 patients required chest tube placement and 4 of 6 had recurrent pneumothoraces. Two of these received chemical pleurodesis.

CONCLUSION:

Although seldom reported pneumothorax occurs in neuromuscular patients receiving chronic positive pressure ventilation and cough assistance techniques. This raises the question of whether barotrauma or volutrauma can occur in patients with presumably normal lung compliance. Commonly decreased lung compliance is associated with risk of pneumothorax in ventilated patients. The overall BMI of these patients was low, it is possible that nutritional status can be associated with risk of pneumothorax. In one patient a collagen disorder was subsequently diagnosed, and this raises the interesting possibility of connective tissue disorders associated with neuromuscular disease.

Footnotes

Financial Support: None.

Can Respir J. 2015 Apr;22(Suppl A):26A.

58 • CRC2015-044: Ventilatory Responses During Stage I Exercise Tests do not Correlate to PHOX2B Genotype in Children with Congenital Central Hypoventilation Syndrome (CCHS)

WTH To ^1,², T Moraes ^1,^2,³, JE Schneiderman ^1,^3,⁵, R Amin ^1,^2,⁴

Abstract

BACKGROUND:

Congenital central hypoventilation syndrome (CCHS) is a genetic disorder affecting the PHOX2B gene characterized by alveolar hypoventilation. Our aim was to determine if there is a genotype-phenotype correlation between mutation type and ventilatory responses to exercise.

METHODS:

Patients less than 18 years of age diagnosed with CCHS (PHOX2B positive) that had undergone a Stage 1 exercise test according to the Godfrey protocol, in the Cardiopulmonary Exercise Laboratory at the Hospital for Sick Children, in Toronto, Canada between September 2013 and March 2014 were included. The tests were performed on a Corival (Lode, BV, Netherlands) cycle ergometer with a VMAX V229 (VIASYS, CareFusion, San Diego, CA) oxygen consumption cart. A priori criteria for stopping the test included an end tidal CO₂ of 55–60 mmHg, oxygen saturation of 85%, cardiac arrhythmia, chest pain, or inability to maintain cycling cadence.

RESULTS:

Eight children were included (4 female). Five (63%) had a non polyalanine repeat mutation (NPARM). All three PARM mutations were 20/25. The median (IQR) age at the time of exercise testing was 10.1 (8.3–12.9) years. Four children (50%) presented within the first year of life. All participants are managed with nocturnal noninvasive positive pressure ventilation (NiPPV). Stage 1 exercise tests were abnormal in 2 (25%) identical twin boys with 20/25 mutations whom presented in the first year of life. Their peak exercise end tidal CO₂ values were 59 mmHg and 53 mmHg. This represented a 48% and 25% respectively, increase at peak exercise as compared to baseline.

CONCLUSIONS:

Ventilatory responses during Stage 1 exercise tests did not correlate with PHOX2B genotype or age of presentation in our cohort, suggesting the need for surveillance exercise testing in all children with CCHS. Further research is needed to determine whether there is any change in ventilatory responses to exercise over time.

[b1-crj-22a-7] 1.Svenningsen S, et al. Oscillating positive expiratory pressure therapy in chronic obstructive pulmonary disease and bronchiectasis. Presented at ERS 2014; Munich, Germany. [Google Scholar]

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A Breath of Fresh Air 2015 / Une Boufée D’air Frais 2015

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