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BACKGROUND: Pulmonary rehabilitation (PR) is a recommended intervention in the management of individuals with chronic lung disease. It is important to study the characteristics and capacity of programs in Canada to confirm best practices and identify future areas of program improvement and research.OBJECTIVE: To identify all Canadian PR programs, regardless of setting, and to comprehensively describe all aspects of PR program delivery. The present article reports the results of the survey related to type of program, capacity and program characteristics.METHODS: All hospitals in Canada were contacted to identify PR programs. A representative from each program completed a 175-item online survey encompassing 16 domains, 10 of which are reported in the present article.RESULTS: A total of 155 facilities in Canada offered PR, of which 129 returned surveys (83% response rate). PR programs were located in all provinces, but none in the three territories. Most (60%) programs were located in hospital settings, 24% were in public health units and 8% in recreation centres. The national capacity of programs was estimated to be 10,280 patients per year, resulting in 0.4% of all Canadians with chronic obstructive pulmonary disease (COPD) and 0.8% of Canadians with moderate to severe COPD having access to PR. COPD, interstitial lung disease, and asthma were the most common diagnoses of patients. The majority of programs had at least four health care professionals involved; 9% had only one health care professional involved.CONCLUSION: The present comprehensive survey of PR in Canada reports an increase in the number of programs and the total number of patients enrolled since the previous survey in 2005. However, PR capacity has not kept pace with demand, with only 0.4% of Canadians with COPD having access.

This study compared physiological responses and work performed during a supramaximal high-intensity interval exercise training session (HIIT) and a constant work rate (CWR) exercise session. Fourteen patients with COPD (mean FEV1 53±13% predicted (±SD)) completed an incremental cardiopulmonary exercise test (CPET) and a steep ramp anaerobic test (SRAT) and then two exercise bouts to symptom limitation on separate days, in random order: (1) a CWR trial at 80% of CPET peak work rate (mean 63±15 W) and (2) a HIIT trial using repeats of 30 s at 70% of SRAT peak work rate (mean 112±29 W) followed by 90 s at 20% of CPET peak work rate. Subjects ceased exercise primarily due to dyspnea for both HIIT and CWR (64% vs. 57%, resp.). End-exercise VE, HR, dyspnea, and leg fatigue were similar between the two exercise protocols. Average work rate was lower in HIIT than CWR (32 vs. 63 W, P<0.05); however, subjects performed HIIT longer (542 vs. 202 s, P<0.05) and for greater total work (23.3 vs. 12.0 kJ, P<0.05). The supramaximal HIIT protocol was well tolerated and demonstrated similar maximal physiologic responses to constant work rate exercise, but with greater leg muscle work performed and greater peak exercise intensity.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a common respiratory condition and the fourth leading cause of death in Canada. Optimal COPD management requires patients to participate in their care and physician knowledge of patients’ perceptions of their disease.METHODS: A prospective study in which respiratory specialist physicians completed a practice assessment questionnaire and patient assessments for 15 to 20 consecutive patients with COPD. Patients also completed a questionnaire regarding their perceptions of COPD and its management.RESULTS: A total of 58 respiratory specialist physicians from across Canada completed practice assessments and 931 patient assessments. A total of 640 patients with COPD (96% with moderate, severe or very severe disease) completed questionnaires. Symptom burden was high and most patients had experienced a recent exacerbation. Potential COPD care gaps were identified with respect to appropriate medication prescription, lack of an action plan, and access to COPD educators and pulmonary rehabilitation. Perceived knowledge needs and gaps differed between physicians and patients.CONCLUSIONS: Despite the dissemination of Canadian and international COPD clinical practice guidelines for more than a decade, potential care gaps remain among patients seen by respiratory specialist physicians. Differing perceptions regarding many aspects of COPD among physicians and patients may contribute to these care gaps.

Dyspnea is a cardinal symptom of chronic obstructive pulmonary disease (COPD), and its severity and magnitude increases as the disease progresses, leading to significant disability and a negative effect on quality of life. Refractory dyspnea is a common and difficult symptom to treat in patients with advanced COPD. There are many questions concerning optimal management and, specifically, whether various therapies are effective in this setting. The present document was compiled to address these important clinical issues using an evidence-based systematic review process led by a representative interprofessional panel of experts.The evidence supports the benefits of oral opioids, neuromuscular electrical stimulation, chest wall vibration, walking aids and pursed-lip breathing in the management of dyspnea in the individual patient with advanced COPD. Oxygen is recommended for COPD patients with resting hypoxemia, but its use for the targeted management of dyspnea in this setting should be reserved for patients who receive symptomatic benefit. There is insufficient evidence to support the routine use of anxiolytic medications, nebulized opioids, acupuncture, acupressure, distractive auditory stimuli (music), relaxation, hand-held fans, counselling programs or psychotherapy. There is also no evidence to support the use of supplemental oxygen to reduce dyspnea in nonhypoxemic patients with advanced COPD.Recognizing the current unfamiliarity with prescribing and dosing of opioid therapy in this setting, a potential approach for their use is illustrated. The role of opioid and other effective therapies in the comprehensive management of refractory dyspnea in patients with advanced COPD is discussed.

BACKGROUND: Currently, no reference or normative values for spirometry based on a randomly selected Canadian population exist.OBJECTIVE: The aim of the present analysis was to construct spirometric reference values for Canadian adults 20 to 90 years of age by combining data collected from healthy lifelong nonsmokers in two population-based studies.METHOD: Both studies similarly used random population sampling, conducted using validated epidemiological protocols in the Canadian Obstructive Lung Disease study, and the Lung Health Canadian Environment study. Spirometric lung function data were available from 3042 subjects in the COLD study, which was completed in 2009, and from 2571 subjects in the LHCE study completed in 1995. A total of 844 subjects 40 to 90 years of age, and 812 subjects 20 to 44 years of age, were identified as healthy, asymptomatic, lifelong nonsmokers, and provided normative reference values for spirometry. Multiple regression models were constructed separately for Caucasian men and women for the following spirometric parameters: forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC) and FEV1/FVC ratio, with covariates of height, sex and age. Comparison with published regression equations showed that the best agreement was obtained from data derived from random populations.RESULTS: The best-fitting regression models for healthy, never-smoking, asymptomatic European-Canadian men and women 20 to 90 years of age were constructed. When age- and height-corrected FEV1, FVC and FEV1/FVC ratio were compared with other spirometry reference studies, mean values were similar, with the closest being derived from population-based studies.CONCLUSION: These spirometry reference equations, derived from randomly selected population-based cohorts with stringently monitored lung function measurements, provide data currently lacking in Canada.

Pulmonary rehabilitation (PR) participation is the standard of care for patients with chronic obstructive pulmonary disease (COPD) who remain symptomatic despite bronchodilator therapies. However, there are questions about specific aspects of PR programming including optimal site of rehabilitation delivery, components of rehabilitation programming, duration of rehabilitation, target populations and timing of rehabilitation. The present document was compiled to specifically address these important clinical issues, using an evidence-based, systematic review process led by a representative interprofessional panel of experts.The evidence reveals there are no differences in major patient-related outcomes of PR between nonhospital- (community or home sites) or hospital-based sites. There is strong support to recommend that COPD patients initiate PR within one month following an acute exacerbation due to benefits of improved dyspnea, exercise tolerance and health-related quality of life relative to usual care. Moreover, the benefits of PR are evident in both men and women, and in patients with moderate, severe and very severe COPD. The current review also suggests that longer PR programs, beyond six to eight weeks duration, be provided for COPD patients, and that while aerobic training is the foundation of PR, endurance and functional ability may be further improved with both aerobic and resistance training.

Denis E O’Donnell MD*‡, Paul Hernandez MD†‡, Shawn Aaron MD‡, Jean Bourbeau MD‡, Darcy Marciniuk MD‡, Rick Hodder MD‡, Meyer Balter MD, Gordon Ford MD, Andre Gervais MD, Roger Goldstein MD, Francois Maltais MD, Jeremy Road MD, Valoree McKay§, Jennifer Schenkel§ *President, comite d’elaboration des lignes directrices de la SCT au sujet de la BPCO; †President, comite de mise en œuvre et de diffusion; ‡Comite de redaction; §Personnel administratif de l’Association pulmonaire du Canada

Endemic tuberculosis (TB) was almost certainly present in Canadian aboriginal people (aboriginal Canadians denotes status Indians, Inuit, nonstatus Indians and metis as reported by Statistics Canada) before the Old World traders arrived. However, the social changes that resulted from contact with these traders created the conditions that converted endemic TB into epidemic TB. The incidence of TB varied inversely with the time interval from this cultural collision, which began on the east coast in the 16th century and ended in the Northern Territories in the 20th century. This relatively recent epidemic explains why the disease is more frequent in aboriginal children than in Canadian-born nonaboriginal people. Treatment plans must account for the socioeconomic conditions and cultural characteristics of the aboriginal people, especially healing models and language. Prevention includes bacillus Calmette-Guerin vaccination and chemoprophylaxis, and must account for community conditions, such as rates of suicide, which have exceeded the rate of TB. The control of TB requires a centralized program with specifically directed funding. It must include a program that works in partnership with aboriginal communities.

Cardiopulmonary exercise testing (CPET) allows the clinician to objectively evaluate symptoms and important functions. CPET also arms the investigator with a powerful tool to better understand the respiratory system role as an engaged participant of a fully integrated physiologic system in humans. The insights gained mean that CPET can aid in the assessment of activity limitation and dyspnea, in evaluating disability and disease severity, in judging risk and prognosis, and in considering the suitability for specific interventions such as transplantation. In the research laboratory, CPET can contribute to the complete evaluation of new therapeutic or management agents, provide physiologic understanding for various hypotheses and new-found research results, and aid in discovery to further our understanding of the complex behaviour and interaction of the human respiratory system. While these benefits are well known to those working closely in the field, the need for greater and more effective dissemination of these benefits is required. Hence, this special issue focuses on cardiopulmonary exercise testing. We begin with M. K. Stickland et al. reviewing normal exercise physiology, as well as providing guidelines for the understanding of cardiopulmonary exercise test results. Techniques to ensure valid measurements of inspiratory capacity permitting a learned assessment of ventilatory constraint are outlined by J. A. Guenette and colleagues, while R. Ramos and others review the clinical usefulness of rapid incremental testing protocols. J. C. da Silva et al. examine the best criteria to determine ramp exercise testing speed in their original research study. Meanwhile, I. Vogiatzis and colleagues undertake a detailed review of varied mechanisms contributing to activity limitation in chronic lung diseases. B. Borel et al. explore the responsiveness of different exercise testing protocols to therapeutic interventions in COPD. A. Apostolo et al. review the interaction and consequences for the lungs in the setting of chronic heart failure, while C. H. Kim and colleagues report original research assessing the validity of a new multivariate index for grading gas exchange severity in patients with pulmonary arterial hypertension and with heart failure. Finally, D. E. O'Donnell et al. review the respiratory consequences of obesity and its impact on exercise performance in both health and in COPD. We hope you find these articles both interesting and useful. We are confident that they will become meaningful resources in this field.

The cardiopulmonary exercise test (CPET) is an important physiological investigation that can aid clinicians in their evaluation of exercise intolerance and dyspnea. Maximal oxygen consumption (V˙O2max) is the gold-standard measure of aerobic fitness and is determined by the variables that define oxygen delivery in the Fick equation (V˙O2= cardiac output × arterial-venous O2content difference). In healthy subjects, of the variables involved in oxygen delivery, it is the limitations of the cardiovascular system that are most responsible for limiting exercise, as ventilation and gas exchange are sufficient to maintain arterial O2content up to peak exercise. Patients with lung disease can develop a pulmonary limitation to exercise which can contribute to exercise intolerance and dyspnea. In these patients, ventilation may be insufficient for metabolic demand, as demonstrated by an inadequate breathing reserve, expiratory flow limitation, dynamic hyperinflation, and/or retention of arterial CO2. Lung disease patients can also develop gas exchange impairments with exercise as demonstrated by an increased alveolar-to-arterial O2pressure difference. CPET testing data, when combined with other clinical/investigation studies, can provide the clinician with an objective method to evaluate cardiopulmonary physiology and determination of exercise intolerance.

Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is both preventable and treatable. Our understanding of the pathophysiology of this complex condition continues to grow and our ability to offer effective treatment to those who suffer from it has improved considerably. The purpose of the present educational initiative of the Canadian Thoracic Society (CTS) is to provide up to date information on new developments in the field so that patients with this condition will receive optimal care that is firmly based on scientific evidence. Since the previous CTS management recommendations were published in 2003, a wealth of new scientific information has become available. The implications of this new knowledge with respect to optimal clinical care have been carefully considered by the CTS Panel and the conclusions are presented in the current document. Highlights of this update include new epidemiological information on mortality and prevalence of COPD, which charts its emergence as a major health problem for women; a new section on common comorbidities in COPD; an increased emphasis on the meaningful benefits of combined pharmacological and nonpharmacological therapies; and a new discussion on the prevention of acute exacerbations. A revised stratification system for severity of airway obstruction is proposed, together with other suggestions on how best to clinically evaluate individual patients with this complex disease. The results of the largest randomized clinical trial ever undertaken in COPD have recently been published, enabling the Panel to make evidence-based recommendations on the role of modern pharmacotherapy. The Panel hopes that these new practice guidelines, which reflect a rigorous analysis of the recent literature, will assist caregivers in the diagnosis and management of this common condition.