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This position statement aims to provide guidance for resumption of pulmonary rehabilitation (PR) services during the post-peak phase of the COVID-19 pandemic (ie, period of low community prevalence...

RATIONALE: Pulmonary rehabilitation (PR) is recommended in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) to reduce the risk of future exacerbations. Previous r...

BACKGROUND: Optimal chronic obstructive pulmonary disease (COPD) management includes both pharmacologic therapy and non-pharmacologic interventions including smoking cessation, vaccination, patient...

In this guideline update, we highlight important and new findings related to pharmacological therapy of chronic obstructive pulmonary disease (COPD) that should change clinical practice and improve...

RATIONALE: Delivery of pulmonary rehabilitation (PR) varies widely across Canada. There is a need for evidence-based quality indicators (QI) that can be used to identify variations in the quality o...

Exercise intolerance is a hallmark feature in heart failure with preserved ejection fraction (HFpEF). Prior heavy exercise (“priming exercise”) speeds pulmonary oxygen uptake (V̇o2p) kinetics in older adults through increased muscle oxygen delivery and/or alterations in mitochondrial metabolic activity. We tested the hypothesis that priming exercise would speed V̇o2pon-kinetics in patients with HFpEF because of acute improvements in muscle oxygen delivery. Seven patients with HFpEF performed three bouts of two exercise transitions: MOD1, rest to 4-min moderate-intensity cycling and MOD2, MOD1 preceded by heavy-intensity cycling. V̇o2p, heart rate (HR), total peripheral resistance (TPR), and vastus lateralis tissue oxygenation index (TOI; near-infrared spectroscopy) were measured, interpolated, time-aligned, and averaged. V̇o2pand HR were monoexponentially curve-fitted. TPR and TOI levels were analyzed as repeated measures between pretransition baseline, minimum value, and steady state. Significance was P < 0.05. Time constant (τ; tau) V̇o2p(MOD1 49 ± 16 s) was significantly faster after priming (41 ± 14 s; P = 0.002), and the effective HR τ was slower following priming (41 ± 27 vs. 51 ± 32 s; P = 0.025). TPR in both conditions decreased from baseline to minimum TPR ( P < 0.001), increased from minimum to steady state ( P = 0.041) but remained below baseline throughout ( P = 0.001). Priming increased baseline ( P = 0.003) and minimum TOI ( P = 0.002) and decreased the TOI muscle deoxygenation overshoot ( P = 0.041). Priming may speed the slow V̇o2pon-kinetics in HFpEF and increase muscle oxygen delivery (TOI) at the onset of and throughout exercise. Microvascular muscle oxygen delivery may limit exercise tolerance in HFpEF.

Studies assessing dyspnoea and health-related quality of life (HRQoL) in chronic obstructive pulmonary disease (COPD) have focussed on patients in clinical settings, not the general population. The aim of this analysis was to compare the prevalence and severity of dyspnoea and impaired HRQoL in individuals with and without COPD from the general population, focussing on mild–moderate COPD. Analysis of the 3-year Canadian Cohort Obstructive Lung Disease (CanCOLD) study included four subgroups: mild COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) 1); moderate COPD (GOLD 2); non-COPD smokers; and non-COPD never-smokers. The primary outcome was dyspnoea (Medical Research Council (MRC) scale), and the secondary outcome was HRQoL (COPD Assessment Test (CAT) score; Saint George's Respiratory Questionnaire (SGRQ) score). Subgroups were analysed by sex, physician-diagnosed COPD status and exacerbations. 1443 participants (mild COPD (n=397); moderate COPD (n=262(; smokers (n=449) and never-smokers (n=335)) were studied. People with mild COPD were more likely to report more severe dyspnoea (MRC 2 versus 1) than those without COPD (OR (95% CI) 1.42 (1.05–1.91)), and non-COPD never-smokers (OR (95%CI) 1.64 (1.07–2.52)). Among people with mild COPD, more severe dyspnoea was reported in women versus men (MRC2 versus 1; OR (95% CI) 3.70 (2.23–6.14)); people with, versus without, physician-diagnosed COPD (MRC2 versus 1; OR (95% CI) 3.27 (1.71–6.23)), and people with versus without recent exacerbations (MRC2 versus 1; ≥2 versus 0 exacerbations: OR (95% CI) 3.62 (1.02–12.86); MRC ≥3 versus 1; 1 versus 0 exacerbation: OR (95% CI): 9.24 (2.01–42.42)). Similar between-group differences were obtained for CAT and SGRQ scores. Careful assessment of dyspnoea and HRQoL could help identify individuals for earlier diagnosis and treatment., Individuals from a population-based study with mild COPD are more symptomatic than non-COPD peers. Worse dyspnoea and quality of life was reported by people with mild COPD who are female, or have a physician diagnosis of COPD or recent exacerbations. https://bit.ly/2XE2B6S

Clarus Leung,1 Jean Bourbeau,2 Don D Sin,1 Shawn D Aaron,3 J Mark FitzGerald,4 François Maltais,5 Darcy D Marciniuk,6 Denis O’Donnell,7 Paul Hernandez,8 Kenneth R Chapman,9 Brandie Walker,10 Jeremy D Road,4 Liyun Zheng,1 Carl Zou,1 James C Hogg,1 Wan C Tan1 On behalf of the CanCOLD Collaborative Research Group1Centre for Heart Lung Innovation, St Pauls Hospital, The University of British Columbia, Vancouver, BC, Canada; 2Research Institute McGill University Health Centre, McGill University, Montreal, Quebec, Canada; 3The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada; 4Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, Canada; 5Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada; 6Respiratory Research Centre, University of Saskatchewan, Saskatoon, Canada; 7Department of Medicine, Queen’s University, Kingston, Canada; 8Department of Medicine, Dalhousie University, Halifax, Canada; 9Toronto General Hospital Research Institute, University of Toronto, Toronto, Canada; 10Department of Medicine, University of Calgary (BW), Alberta, CanadaCorrespondence: Wan C TanCentre for Heart Lung Innovation, St. Paul’s Hospital, University of British Columbia, Rm 166, 1081 Burrard Street, Vancouver, B.C, V6Z 1Y6, CanadaTel +1-604-682-2344 ext 62749Fax +1-604-806-9274Email wan.tan@hli.ubc.caPurpose: To determine the spirometric-based prevalence of COPD across different regions in Canada and to evaluate the site heterogeneity of risk factors.Patients and Methods: In this cross-sectional, population-based study, random samples of non-institutionalized adults aged ≥ 40 years were generated by random digit dialling. Participants answered an interviewer-administered questionnaire and performed spirometry before and after bronchodilator administration. COPD was defined as post-bronchodilator FEV1/FVC < 0.70 (fixed ratio, FR) and as FEV1/FVC < 5th percentile (lower limits of normal, LLN). Separate logistic regression models were used to compute the risk (adjusted odds ratio, aOR) for COPD. I2 and Tau2 analyses were used to evaluate heterogeneity.Results: Out of 5176 (95%) participants, 4893 (47% male with mean age 56.6 years (95% confidence interval, 56.0– 57.2)) had spirometry that satisfied ATS criteria. The population prevalence of COPD was 16.2% (95% CI, 14.5– 17.8) by FR and 11.2% (95% CI, 9.7– 12.6) by LLN. Male predominance in prevalence was shown by FR but not by LLN criteria. Patient characteristics associated with an increased risk of COPD included: age (OR 1.56; 95% CI 1.33– 1.84); history of physician-diagnosed asthma (OR 3.30; 95% CI 2.42– 4.49); and childhood hospitalization for respiratory illness (OR 1.81; 95% CI 1.17– 2.80). In terms of smoking-related risk factors, current smoking status had the highest odds ratio (OR 3.49; 95% CI 2.55– 4.80). Variance in prevalence among sites was significantly reduced by adjusting for risk factors in Tau2 analyses. Higher odds of exposure for each risk factor was found in more severe COPD, suggesting that a higher risk could be linked to the development of severe disease.Conclusion: This study reports the population prevalence of COPD in nine urban cities which collectively represent the majority of the Canadian population and demonstrates that heterogeneity in prevalence among sites is substantially explained by variation in associated risk factors for COPD.Keywords: prevalence, heterogeneity, COPD

BACKGROUND: Physiologic and symptom responses at the ventilatory threshold (Tvent) during incremental cardiopulmonary exercise testing (CPET) can provide important prognostic information. RESEARCH QUESTION: This study aimed to develop an updated normative reference set for physiologic and symptom responses at Tvent during cycle CPET (primary aim) and to evaluate previously recommended reference equations from a 1985 study for predicting Tvent responses (secondary aim). STUDY DESIGN AND METHODS: Participants were adults 40 to 80 years of age who were free of clinically relevant disease from the Canadian Cohort Obstructive Lung Disease. Rate of oxygen consumption ([Formula: see text] O(2)) at Tvent was identified by two independent raters; physiologic and symptom responses corresponding to [Formula: see text] O(2) at Tvent were identified by linear interpolation. Reference ranges (5th-95th percentiles) for responses at Tvent were calculated according to participant sex and age for 29 and eight variables, respectively. Prediction models were developed for nine variables (oxygen pulse, [Formula: see text] O(2), rate of CO(2) production, minute ventilation, tidal volume, inspiratory capacity, end-inspiratory lung volume [in liters and as percentage of total lung capacity], and end-expiratory lung volume) using quantile regression, estimating the 5th (lower limit of normal), 50th (normal), and 95th (upper limit of normal) percentiles based on readily available participant characteristics. The two one-sided test of equivalence for paired samples evaluated the measured and 1985-predicted [Formula: see text] O(2) at Tvent for equivalence. RESULTS: Reference ranges and equations were developed based on 96 participants (49% men) with a mean ± SD age of 63 ± 9 years. Mean [Formula: see text] O(2) at Tvent was 50% of measured [Formula: see text] O(2) peak; the normal range was 33% to 66%. The 1985 reference equations overpredicted [Formula: see text] O(2) at Tvent: mean difference in men, −0.17 L/min (95% CI, −0.25 to −0.09 L/min); mean difference in women, −0.19 L/min (95% CI, −0.27 to −0.12 L/min). INTERPRETATION: A contemporary reference set of CPET responses at Tvent from Canadian adults 40 to 80 years of age is presented that differs from the previously recommended and often used reference set from 1985. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00920348; URL: www.clinicaltrials.gov

To understand the role of case complexity in the learning curve for robotic colorectal surgery.Sixty-two patients who underwent robot-assisted colorectal surgery were retrospectively reviewed. Each case was assigned a category of complexity ranging from I to IV. Overall, groups and categories of segmental colectomy, rectopexy, and proctectomy for cancer were analyzed according to case volume. Forty-eight patients who underwent similar laparoscopic cases during the same period were also reviewed for comparison.Level I complexity cases were identified in 30% of the first 15 cases compared to 3% after the first 15 cases (P .01). Level IV complexity cases were identified in 10% of the first 15 cases and 34% after 15 cases (P = .03). Mean operative time for the overall group was 426 minutes (range 178-766, standard deviation [SD] = 152) in the first 15 cases and 373 minutes (range 190-593, SD = 109) after more than 15 cases (P = NS). Mean operative time for rectal cancer procedures decreased from 518 minutes (range 425-752, SD = 88) to 410 minutes (range 220-593, SD = 98) after 15 cases (P = .02). Mean operative time for rectopexy decreased from 361 minutes (range 276-520, SD = 85) to 258 minutes (range 215-318, SD = 34) after 15 cases (P = .03). Overall complications were reduced after 15 cases (6.3%) compared with the first 15 cases (27%) (P = .04). When comparing laparoscopic and open cases, laparoscopic cases were associated with a significant shorter operative time (P = .00001) as well as overall cost (P = .00001).Complex robotic colorectal surgery can be performed early in the experience, with reduced operative time. Overall complications are reduced after 15 robotic cases. This study shows that improvement in robotic surgery operating time and surgical outcomes occur along with application of the technology to more difficult cases, not as a function of choosing less complex cases.

RATIONALE: Since the last published Canadian Thoracic Society (CTS) COPD guideline in 2007 and the 2008 update – highlights for primary care, many new clinical trials have challenged COPD treatment...

Background The COPD Assessment Test (CAT) is a valid disease-specific questionnaire measuring health status. However, knowledge concerning its use regarding patient and disease characteristics remains limited. Our main objective was to assess the degree to which the CAT score varies and can discriminate between specific patient population groups. Methods The Canadian Cohort Obstructive Lung Disease (CanCOLD) is a random-sampled, population-based, multicenter, prospective cohort that includes subjects with COPD (Global Initiative for Chronic Obstructive Lung Disease [GOLD] classifications 1 to 3). The CAT questionnaire was administered at three visits (baseline, 1.5 years, and 3 years). The CAT total score was determined for sex, age groups, smoking status, GOLD classification, exacerbations, and comorbidities. Results A total of 716 subjects with COPD were included in the analysis. The majority of subjects (72.5%) were not previously diagnosed with COPD. The mean FEV 1 /FVC ratio was 61.1 ± 8.1%, with a mean FEV 1 % predicted of 82.3 ± 19.3%. The mean CAT scores were 5.8 ± 5.0, 9.6 ± 6.7, and 16.1 ± 10.0 for GOLD 1, 2, and 3+ classifications, respectively. Higher CAT scores were observed in women, current smokers, ever-smokers, and subjects with a previous diagnosis of COPD. The CAT was also able to distinguish between subjects who experience exacerbations vs those who had no exacerbation. Conclusions These results suggest that the CAT, originally designed for use in clinically symptomatic patients with COPD, can also be used in individuals with mild airflow obstruction and newly diagnosed COPD. In addition, the CAT was able to discriminate between sexes and subjects who experience frequent and infrequent exacerbations. Trial Registry ClinicalTrials.gov; No.: NCT00920348; Study ID No.: IRO-93326.

Background and objective Lack of consensus on diagnosis of ACO limits our understanding of the impact, management and outcomes of ACO. The present observational study aims to describe the prevalence, clinical characteristics and course of individuals with ACO based on various definitions used in clinical practice. Methods We included individuals with COPD from the prospective, multisite CanCOLD study and defined subjects with ACO using seven definitions commonly used in the literature. Results Data including questionnaires, lung function and CT scans were analysed from 522 individuals with COPD who were randomly recruited from the population. Among them, 264 fulfilled at least one of the seven definitions of ACO. Prevalence of ACO varied from 3.8% to 31%. Regardless of the definition, individuals with ACO had worse outcomes (lung function and higher percentage of fast decliners, symptoms and exacerbations, health-related quality of life and comorbidities) than the remaining patients with COPD. Conversely, patients with non-ACO had higher emphysema and bronchiolitis scores. The three definitions that included atopy and/or physician diagnosis of asthma identified subjects who differed significantly from patients with COPD. The two ACO definitions with post-bronchodilator reversibility were concordant with COPD and were the least stable, with less than 50% of the patients from each group maintaining reversibility over visits. Conclusion Atopy and physician-diagnosed asthma are more distinguishing characteristics to identify ACO. This finding needs to be validated using measures of airway inflammation and other specific biomarkers.

Chronic obstructive pulmonary disease (COPD) is a common multisystem inflammatory disease with ramifications involving essentially all organ systems. Pulmonary rehabilitation is a comprehensive program designed to prevent and mitigate these disparate systemic effects and improve patient quality of life, functional status, and social functioning. Although initial patient assessment is a prominent component of any pulmonary rehabilitation (PR) program, cardiopulmonary exercise testing (CPET) is not regularly performed as a screening physiologic test prior to PR in COPD patients. Further, CPET is not often used to assess or document the improvement in exercise capacity related to completion of PR. In this review we will describe the classic physiologic abnormalities related to COPD on CPET parameters, the role of CPET in Risk Stratification/Safety prior to PR, the physiologic changes that occur in CPET parameters with PR, and the literature regarding the use of CPET to assess PR results. Finally, we will compare CPET to 6MW in COPD PR, the common minimal clinically important difference (MCID) is associated with CPET, and the potential future roles of CPET in PR and Research.

This article provides an update on progress toward establishing pulmonary and critical care medicine (PCCM) fellowship training as one of the first four subspecialties to be recognized and supported by the Chinese government. Designed and implemented throughout 2013 and 2014 by a collaborative effort of the Chinese Thoracic Society (CTS) and the American College of Chest Physicians (CHEST), 12 leading Chinese hospitals enrolled a total of 64 fellows into standardized PCCM training programs with common curricula, educational activities, and assessment measures. Supplemental educational materials, online assessment tools, and institutional site visits designed to evaluate and provide feedback on the programs' progress are being provided by CHEST. As a result of this initial progress, the Chinese government, through the Chinese Medical Doctor's Association, endorsed the concept of subspecialty fellowship training in China, with PCCM as one of the four pilot subspecialties to be operationalized nationwide in 2016, followed by implementation across other subspecialties by 2020. This article also reflects on the achievements of the training sites and the challenges they face and outlines plans to enhance and expand PCCM training and practice in China.

IntroductionVery-low birthweight (VLBW, Methods and analysisThis trial tests whether adding bovine lactoferrin (bLF) to feeds in VLBW infants improves (1) survival to hospital discharge free from brain injury, late-onset sepsis, NEC and treated retinopathy of prematurity (primary composite end point); (2) each component of the primary composite end point and (3) time to reach full enteral feeds, number of blood transfusions, chronic lung disease and length of hospital stay. It includes a cost-effectiveness analysis of bLF in improving survival free from major morbidity, and evaluates the effect of bLF on survival and developmental outcomes at 24 to 36 months corrected gestational age.This is a multicentre, two-arm, randomised trial comparing the treatment group receiving bLF added to breast milk or formula milk daily (up to 250 mg/kg/day bLF) versus the control group receiving no bLF supplementation. The intervention is administered until 34 completed weeks corrected gestation or for 2 weeks, whichever is longer, or until discharge home, if earlier. The target sample size of 1500 participants yields 85% power, at the two-sided 5% level significance, to detect a difference in proportions meeting the primary outcome assuming the true probability is 74% in controls and 80.5% in the bLF group.Ethics and disseminationThis protocol was approved by Northern Sydney Local Human Research Ethics Committee in January 2017 (Version 2.0, Reference 1003-118M) and other relevant ethics committees. The findings of the trial will be disseminated through peer-reviewed journals and conference presentations.Trial registration numberACTRN12611000247976; Pre-results.

COPD is a common disease with substantial associated morbidity and mortality. Patients with COPD usually have a progression of airflow obstruction that is not fully reversible and can lead to a history of progressively worsening breathlessness, affecting daily activities and health-related quality of life.1-3 COPD is the fourth leading cause of death in Canada4 and the third leading cause of death in the United States where it claimed 133,965 lives in 2009.5 In 2011, 12.7 million US adults were estimated to have COPD.6 However, approximately 24 million US adults have evidence of impaired lung function, indicating an underdiagnosis of COPD.7 Although 4% of Canadians aged 35 to 79 years self-reported having been given a diagnosis of COPD, direct measurements of lung function from the Canadian Health Measures Survey indicate that 13% of Canadians have a lung function score indicative of COPD.4 COPD is also costly. In 2009, COPD caused 8 million office visits, 1.5 million ED visits, 715,000 hospitalizations, and 133,965 deaths in the United States.8 In 2010, US costs for COPD were projected to be approximately $49.9 billion, including $29.5 billion in direct health-care expenditures, $8.0 billion in indirect morbidity costs, and $12.4 billion in indirect mortality costs.9 Exacerbations account for most of the morbidity, mortality, and costs associated with COPD. The economic burden associated with moderate and severe exacerbations in Canada has been estimated to be in the range of $646 million to $736 million per annum.10 This value may be an underestimate given that the prevalence of moderate exacerbations is not well documented, COPD is underdiagnosed, and the rate of hospitalization due to COPD is increasing.11 Exacerbations are to COPD what myocardial infarctions are to coronary artery disease: They are acute, trajectory-changing, and often deadly manifestations of a chronic disease. Exacerbations cause frequent hospital admissions, relapses, and readmissions12; contribute to death during hospitalization or shortly thereafter12; reduce quality of life dramatically12,13; consume financial resources12,14; and hasten a progressive decline in pulmonary function, a cardinal feature of COPD. Hospitalization due to exacerbations accounts for > 50% of the cost of managing COPD in North America and Europe.15,16 COPD exacerbation has been defined as an event in the natural course of the disease characterized by a baseline change in the patient’s dyspnea, cough, and/or sputum that is beyond the normal day-to-day variations, is acute in onset, and may warrant a change in regular medication in a patient with underlying COPD.17,18 Exacerbation in clinical trials has been defined for operational reasons on the basis of whether an increase in treatment beyond regular or urgent care is required in an ED or a hospital. Exacerbation treatment in clinical trials usually is defined by the use of antibiotics, systemic corticosteroids, or both.19 The severity of the exacerbation is then ranked or stratified according to the outcome: mild, when the clinical symptoms are present but no change in treatment or outcome is recorded; moderate, when the event results in a change in medication, such as the use of antibiotics and systemic corticosteroids; or severe, when the event leads to a hospitalization.1 Two-thirds of exacerbations are associated with respiratory tract infections or air pollution, but one-third present without an identifiable cause.17 Exacerbations remain poorly understood in terms of not only cause but also treatment and prevention. Although the management of an acute exacerbation has been the primary focus of clinical trials, the prevention of acute exacerbations has not been a major focus until recently. Most current COPD guidelines focus on the general diagnosis and evaluation of the patient with COPD, the management of stable disease, and the diagnosis and management of acute exacerbations.1,20 Although current COPD guidelines state that prevention of exacerbations is possible, little guidance is provided to the clinician regarding current available therapies for the prevention of COPD exacerbations.1,20 Moreover, new therapies have promise in preventing acute exacerbations of COPD (AECOPD) and would benefit from critical review of their efficacy in the exacerbation prevention management.21-23 The American College of Chest Physicians (CHEST) and Canadian Thoracic Society (CTS) jointly commissioned this evidence-based guideline on the prevention of COPD exacerbations to fill this important void in COPD management. The overall objective of this CHEST and CTS joint evidence-based guideline (AECOPD Guideline) was to create a practical, clinically useful document describing the current state of knowledge regarding the prevention of AECOPD according to major categories of prevention therapies. We accomplished this by using recognized document evaluation tools to assess and choose the most appropriate studies and evidence to extract meaningful data and to grade the level of evidence supporting the recommendations in a balanced and unbiased fashion. The AECOPD Guideline is unique not only for its topic but also for the first-in-kind partnership between two of the largest thoracic societies in North America. The CHEST Guidelines Oversight Committee in partnership with the CTS COPD Clinical Assembly launched this project with the objective that a systematic review and critical evaluation of the published literature by clinical experts and researchers in the field of COPD would lead to a series of recommendations to assist clinicians in their management of the patient with COPD. This guideline is unique because a group of interdisciplinary clinicians who have special expertise in COPD clinical research and care led the development of the guideline process with the assistance of methodologists.

BACKGROUND:COPD is a major cause of morbidity and mortality in the United States as well as throughout the rest of the world. An exacerbation of COPD (periodic escalations of symptoms of cough, dyspnea, and sputum production) is a major contributor to worsening lung function, impairment in quality of life, need for urgent care or hospitalization, and cost of care in COPD. Research conducted over the past decade has contributed much to our current understanding of the pathogenesis and treatment of COPD. Additionally, an evolving literature has accumulated about the prevention of acute exacerbations. METHODS:In recognition of the importance of preventing exacerbations in patients with COPD, the American College of Chest Physicians (CHEST) and Canadian Thoracic Society (CTS) joint evidence-based guideline (AECOPD Guideline) was developed to provide a practical, clinically useful document to describe the current state of knowledge regarding the prevention of acute exacerbations according to major categories of prevention therapies. Three key clinical questions developed using the PICO (population, intervention, comparator, and outcome) format addressed the prevention of acute exacerbations of COPD: nonpharmacologic therapies, inhaled therapies, and oral therapies. We used recognized document evaluation tools to assess and choose the most appropriate studies and to extract meaningful data and grade the level of evidence to support the recommendations in each PICO question in a balanced and unbiased fashion. RESULTS:The AECOPD Guideline is unique not only for its topic, the prevention of acute exacerbations of COPD, but also for the first-in-kind partnership between two of the largest thoracic societies in North America. The CHEST Guidelines Oversight Committee in partnership with the CTS COPD Clinical Assembly launched this project with the objective that a systematic review and critical evaluation of the published literature by clinical experts and researchers in the field of COPD would lead to a series of recommendations to assist clinicians in their management of the patient with COPD. CONCLUSIONS:This guideline is unique because it provides an up-to-date, rigorous, evidence-based analysis of current randomized controlled trial data regarding the prevention of COPD exacerbations.

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.

BackgroundPrevious studies have associated marijuana exposure with increased respiratory symptoms and chronic bronchitis among long-term cannabis smokers. The long-term effects of smoked marijuana on lung function remain unclear.MethodsWe determined the association of marijuana smoking with the risk of spirometrically defined chronic obstructive pulmonary disease (COPD) (post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity ratio 1in a subset of 1285 males and females, aged ≥40 years, who self-reported use (or non-use) of marijuana and tobacco cigarettes and performed spirometry before and after inhaled bronchodilator on multiple occasions. Analysis for the decline in FEV1was performed using random mixed effects regression models adjusted for age, sex and body mass index. Heavy tobacco smoking and marijunana smoking was defined as >20 pack-years and >20 joint-years, respectively.Results∼20% of participants had been or were current marijuana smokers with most having smoked tobacco cigarettes in addition (83%). Among heavy marijuana users, the risk of COPD was significantly increased (adjusted OR 2.45, 95% CI 1.55–3.88). Compared to never-smokers of marijuana and tobacco, heavy marijuana smokers and heavy tobacco smokers experienced a faster decline in FEV1by 29.5 mL·year−1(p=0.0007) and 21.1 mL·year−1(p−1(pInterpretationHeavy marijuana smoking increases the risk of COPD and accelerates FEV1decline in concomitant tobacco smokers beyond that observed with tobacco alone.

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.

Background: Dyspnea that is refractory to conventional treatments affects up to 50% of patients with advanced chronic obstructive pulmonary disease (COPD). Although professional societies recommend opioids in this setting, evidence supporting their use over months is limited. We conducted a multicentre mixed-methods study to understand patients’ experiences when opioids are added to optimized conventional treatments for advanced COPD. Methods: A total of 44 patients (median age 74, range 51‐89 years) agreed to participate in this 6-month study. After baseline assessments, immediate-release morphine sulfate syrup (initially 0.5 mg twice daily) was slowly titrated upward based on weekly assessments of symptoms. We conducted semistructured interviews and collected contemporaneous measures of health-related quality of life, severity of dyspnea, anxiety, depression, global ratings of opioid “helpfulness” and adverse effects before, at 2 months and at 4‐6 months after opioids were started. Results: Of the 44 patients, 32 (73%) completed the trial; 27 (90%) of 30 patients reported the opioid treatment as very (43%) or somewhat (47%) helpful. Three main themes emerged from the patients’ overall positive experiences: small gains have big impact; realign hopes with reality; and “try it.” Significant improvements were observed in median (interquartile range) scores between base line and 4‐6 months’ assessment for health-related quality of life (Chronic Respiratory Questionnaire: 3.5 [2.8‐4.0] v. 4.2 [3.6‐4.8]; and Chronic Respiratory Questionnaire‐Dyspnea domain: 2.8 [2.3‐3.6] v. 3.9 [2.8‐4.5]) and decreases in severity of dyspnea (numerical rating scale: 7.0 [5.0‐8.0] v. 5.0 [4.0‐6.0]). Adverse effects were minimal for most patients. Interpretation: Opioids were a helpful and acceptable intervention for refractory dyspnea in patients with advanced COPD. Many of the patients experienced sustained benefits over months, which supports recent recommendations to consider opioids in this setting. Trial registration: ClinicalTrial.gov, no. NCT00982891

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.

Background The purpose of this randomised double-blind double-dummy placebo-controlled trial was to investigate whether etanercept, a tumour necrosis factor α (TNFα) antagonist, would provide more effective anti-inflammatory treatment for acute exacerbations of chronic obstructive pulmonary disease (COPD) than prednisone. Methods We enrolled 81 patients with acute exacerbations of COPD and randomly assigned them to treatment with either 40 mg oral prednisone given daily for 10 days or to 50 mg etanercept given subcutaneously at randomisation and 1 week later. Both groups received levofloxacin for 10 days plus inhaled bronchodilators. The primary endpoint was the change in the patient9s forced expiratory volume in 1 s (FEV 1 ) 14 days after randomisation. Secondary endpoints included 90-day treatment failure rates and dyspnoea and quality of life. Results At 14 days the mean±SE change in FEV 1 from baseline was 20.1±5.0% and 15.2±5.7% for the prednisone and etanercept groups, respectively. The mean between-treatment difference was 4.9% (95% CI −10.3% to 20.2%), p=0.52. Rates of treatment failure at 90 days were similar in the prednisone and etanercept groups (32% vs 40%, p=0.44), as were measures of dyspnoea and quality of life. Subgroup analysis revealed that patients with serum eosinophils >2% at exacerbation tended to experience fewer treatment failures if treated with prednisone compared with etanercept (22% vs 50%, p=0.08). Conclusions Etanercept was not more effective than prednisone for treatment of acute exacerbations of COPD. Efficacy of prednisone was most apparent in patients who presented with serum eosinophils >2%. Clinical Trials gov number NCT 00789997.

Background Chronic obstructive pulmonary disease (COPD) is a respiratory syndrome characterized by progressive, partially reversible airway obstruction and lung hyperinflation. COPD has a substantial burden which is seen in both patient quality of life and healthcare costs. One proposed method of minimizing this burden is the implementation of clinical pathways (CPWs). CPWs aim to guide evidence-based practice and improve the interaction between health services. They bring the best available evidence to a range of healthcare professionals by adapting evidence-based clinical guidelines to a local context and detailing the essential steps in the assessment and care of patients. Methods The aim of this systematic review is to synthesize existing literature on the effects of CPWs for the treatment or management of COPD. We will screen search hits from search strategies developed for a Cochrane Effective Practice and Organisation of Care (EPOC) systematic review on the use of CPWs in primary care and a Cochrane EPOC review on the use of CPWs in hospitals. These searches were run in a range of databases. Studies will be screened independently by two reviewers. All studies identified by our search strategy will be considered regardless of study design as long as they meet the operational definition for clinical pathways developed by Kinsman et al. (BMC Medicine 8, 2010) and focus on the treatment or management of COPD. All included studies will be evaluated for risk of bias utilizing methodologies set out by the Cochrane collaboration. Data regarding patient, professional and systems outcomes will be extracted from all included studies. Data will be presented in both narrative and tabular form. Discussion The systematic review outlined in this protocol aims to identify, assess and synthesise all available evidence on the effects of CPWs regarding the treatment and management of COPD. As a result, this review will provide an evidence base for decision makers regarding the practicality, cost effectiveness, patient benefit and best practices regarding the implementation of CPWs for the care of COPD. Electronic supplementary material The online version of this article (doi:10.1186/s13643-016-0311-8) contains supplementary material, which is available to authorized users.

Chronic obstructive pulmonary disease (COPD) remains undiagnosed in many individuals with persistent airflow limitation. These individuals may be susceptible to exacerbation-like respiratory events that consume health care resources.To compare exacerbation-like respiratory events, event prevalence, and differences in the odds of using medication and/or health services between subjects with diagnosed and undiagnosed COPD.Subjects sampled from the general population participating in the CanCOLD (Canadian Cohort Obstructive Lung Disease) study, with at least 12 months of exacerbation-event follow-up who were classified as having physician-diagnosed or undiagnosed COPD were assessed. Exacerbation-like respiratory events were captured using a questionnaire administered every 3 months.A total of 355 subjects were undiagnosed and 150 were diagnosed with COPD. Undiagnosed subjects were less symptomatic and functionally impaired, had been prescribed fewer respiratory medications, and had better health status. The incidence of reported exacerbation-like events was higher in diagnosed subjects and increased in both groups with the severity of airflow obstruction. Although subjects with diagnosed COPD were more often prescribed medication for exacerbation events, health service use for exacerbation events was similar in both groups.Most subjects with COPD in Canada remain undiagnosed. These subjects are less symptomatic and impaired, which may partly explain lack of diagnosis. Although patients with undiagnosed COPD experience fewer exacerbations than those with diagnosed COPD, they use a similar amount of health services for exacerbation events; thus, the overall health system burden of exacerbations in those with undiagnosed COPD is considerable.

RATIONALE: Pulmonary rehabilitation (PR) has demonstrated physiological, symptom-reducing, psychosocial, and health economic benefits for patients with chronic respiratory diseases, yet it is underutilized worldwide. Insufficient funding, resources, and reimbursement; lack of healthcare professional, payer, and patient awareness and knowledge; and additional patient-related barriers all contribute to the gap between the knowledge of the science and benefits of PR and the actual delivery of PR services to suitable patients.OBJECTIVES: The objectives of this document are to enhance implementation, use, and delivery of pulmonary rehabilitation to suitable individuals worldwide.METHODS: Members of the American Thoracic Society (ATS) Pulmonary Rehabilitation Assembly and the European Respiratory Society (ERS) Rehabilitation and Chronic Care Group established a Task Force and writing committee to develop a policy statement on PR. The document was modified based on feedback from expert peer reviewers. After cycles of review and revisions, the statement was reviewed and formally approved by the Board of Directors of the ATS and the Science Council and Executive Committee of the ERS.MAIN RESULTS: This document articulates policy recommendations for advancing healthcare professional, payer, and patient awareness and knowledge of PR, increasing patient access to PR, and ensuring quality of PR programs. It also recommends areas of future research to establish evidence to support the development of an updated funding and reimbursement policy regarding PR.CONCLUSIONS: The ATS and ERS commit to undertake actions that will improve access to and delivery of PR services for suitable patients. They call on their members and other health professional societies, payers, patients, and patient advocacy groups to join in this commitment.

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.

This commentary heralds the recognition in China of a new subspecialty, Pulmonary and Critical Care Medicine, and the first national fellowship training pathway in any medical specialty. Because of striking environmental health-care similarities that existed in the United States, the Chinese medical community decided to model the specialty after that in the United States. Because of its expertise in educating pulmonary and critical care physicians in the United States, the American College of Chest Physicians was chosen by the Chinese Thoracic Society, with the approval of the Chinese government, to help with the transformation of this new specialty. A work group representing the two societies is collaborating to reorganize ICUs within a select group of large teaching hospitals in China and to introduce standardized and rigorous training in pulmonary and critical care medicine as a national program.

Cindy J Wong1, Donna Goodridge1, Darcy D Marciniuk2, Donna Rennie1,31College of Nursing, 2College of Medicine, 3Canadian Centre for Health and Safety in Agriculture, University of Saskatchewan, Saskatoon, CanadaBackground: Fatigue is a distressing, complex, multidimensional sensation common in individuals with chronic obstructive pulmonary disease (COPD). While fatigue negatively impacts functional performance and quality of life, there has been little study of the fatigue that affects participants in pulmonary rehabilitation programs. The purpose of this study was to examine the emotional, behavioral, cognitive, and physical dimensions of fatigue and their relationships to dyspnea, mental health, sleep, and physiologic factors.Patients and methods: A convenience sample of 42 pulmonary rehabilitation participants with COPD completed self-report questionnaires which measured dimensions of fatigue using the Multidimensional Fatigue Inventory, anxiety and depression using the Hospital Anxiety and Depression Scale, and sleep quality using the Pittsburgh Sleep Quality Index. Data on other clinical variables were abstracted from pulmonary rehabilitation program health records.Results: Almost all (95.3%) participants experienced high levels of physical fatigue. High levels of fatigue were also reported for the dimensions of reduced activity (88.1%), reduced motivation (83.3%), mental fatigue (69.9%), and general fatigue (54.5%). Close to half (42.9%) of participants reported symptoms of anxiety, while almost one quarter (21.4%) reported depressive symptoms. Age was related to the fatigue dimensions of reduced activity (ρ = 0.43, P < 0.01) and reduced motivation (ρ = 0.31, P < 0.05). Anxiety was related to reduced motivation (ρ = -0.47, P < 0.01). Fatigue was not associated with symptoms of depression, sleep quality, gender, supplemental oxygen use, smoking status, or Medical Research Council dyspnea scores.Conclusions: Fatigue (particularly the physical and reduced motivation dimensions of fatigue) was experienced by almost all participants with COPD attending this pulmonary rehabilitation program. Fatigue affected greater proportions of participants than either anxiety or depression. The high prevalence of fatigue may impact on enrolment, participation, and attrition in pulmonary rehabilitation programs. Further investigation of the nature, correlates, and impact of fatigue in this population is required.Keywords: COPD, fatigue, pulmonary rehabilitation, anxiety, depression, sleep quality

IntroductionHospital and emergency department discharge for patients with chronic obstructive pulmonary disease (COPD) is often poorly organised. We developed a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbations of COPD.MethodsA purposeful sample of clinicians and patients were invited to participate in a two-round Delphi study (July–November 2015). In round 1, participants rated on a seven-point Likert scale (1=not at all important; 7=extremely important) the importance of 29 unique COPD care actions. Round 2 comprised items selected from round 1 based on consensus (>80% endorsement for Likert values 5–7). A list of 18 care items from round 2 was discussed in a face-to-face nominal group meeting.ResultsSeven care items were included in the COPD discharge bundle based on clinician and patient input: (1) ensure adequate inhaler technique is demonstrated; (2) send discharge summary to family physician and arrange follow-up; (3) optimise and reconcile prescription of respiratory medications; (4) provide a written discharge management plan and assess patient’s and caregiver’s comprehension of discharge instructions; (5) refer to pulmonary rehabilitation; (6) screen for frailty and comorbidities; and (7) assess smoking status, provide counselling and refer to smoking cessation programme.ConclusionWe present a seven-item, patient-centred, evidence-based and consensus-based discharge bundle for patients with acute exacerbations of COPD. Alignment with clinical practice guidelines and feasibility of local adaptations of the bundle should be explored to facilitate wide applicability and evaluation of the effectiveness of the COPD discharge bundle.

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.

Small studies have suggested that inhaled corticosteroids can suppress systemic inflammation in chronic obstructive pulmonary disease (COPD).To determine the effect of inhaled corticosteroids with or without long-acting beta(2)-adrenergic agonist on systemic biomarkers of inflammation.We conducted a double-blind randomized placebo-controlled trial across 11 centers (n = 289 patients with FEV(1) of 47.8 +/- 16.2% of predicted) to compare the effects of inhaled fluticasone alone or in combination with salmeterol against placebo on circulating biomarkers of systemic inflammation over 4 weeks. The primary endpoint was C-reactive protein (CRP) level. Secondary molecules of interest were IL-6 and surfactant protein D (SP-D).Neither fluticasone nor the combination of fluticasone/salmeterol had a significant effect on CRP or IL-6 levels. There was, however, a significant reduction in SP-D levels with fluticasone and fluticasone/salmeterol compared with placebo (P = 0.002). Health status also improved significantly in both the fluticasone and fluticasone/salmeterol groups compared with placebo, driven mostly by improvements in the symptom scores. Changes in the circulating SP-D levels were related to changes in health status scores. FEV(1) improved significantly only in the fluticasone/salmeterol group compared with placebo.ICS in conjunction with long-acting beta(2)-adrenergic agonist do not reduce CRP or IL-6 levels in serum of patients with COPD over 4 weeks. They do, however, significantly reduce serum SP-D levels. These data suggest that these drugs reduce lung-specific but not generalized biomarkers of systemic inflammation in COPD.

SummaryBackgroundPrevious studies have documented similar levels of end-of-life symptom burden for lung cancer and chronic obstructive pulmonary disease (COPD) patients, yet there has been little comparison of health care utilization during this period. This study contrasts health care utilization by people with COPD and those with lung cancer in the 12 months prior to death.MethodsWe performed a retrospective cohort study of 1098 patients who died in 2004 with a cause of death recorded as COPD or lung cancer using administrative health data. Our outcomes of interest included acute, long-term and home care service utilization.ResultsThe study population was 42% female with a mean age of 77 years (S.D.=11). In the last 12 months of life, decedents with COPD were more likely to be institutionalized in a LTC setting (41% vs. 12.5%, p

Background We hypothesized that breathing helium-hyperoxia (HeO 2 ) would significantly improve 6-min walking test (6MWT) distance in COPD subjects. Methods This was a blinded, randomized crossover study. At visit 1, we assessed pulmonary function, exercise capacity, and 6MWT distance. Visits 2 and 3 consisted of four 6MWTs in which the following different inspired gases were used: room air (RA) by mask; 100% O 2 by mask (mask O 2 ); 100% O 2 by nasal prongs (nasal O 2 ); and 70% He/30% O 2 by mask (HeO 2 ). Walking distance, shortness of breath, leg fatigue, O 2 saturation, and heart rate (HR) were assessed. Results Sixteen COPD subjects participated (mean FEV 1 /FVC ratio [± SD], 48 ± 8%; mean FEV 1 , 55 ± 13% predicted). Subjects walked farther when breathing HeO 2 (564 m) compared to RA (497 m; p 2 (520 m; p 2 (528 m; p 2 , there was no increase in shortness of breath or leg fatigue. There was desaturation when breathing RA (8%; p 2 (5%; p 2 (3%; difference not significant) and mask O 2 (0%; difference not significant). There were no significant differences in HR in the four 6MWTs. Conclusions The use of HeO 2 increased 6MWT distance in COPD subjects more than either mask O 2 or nasal O 2 compared to RA. The increased walking distance was not associated with increased shortness of breath or leg fatigue. The results suggest that clinical benefit would be obtained by administering HeO 2 during exercise, which may have significant clinical implications for the management of COPD patients.

BACKGROUND: Saskatchewan Aboriginal people are experiencing epidemics of both type 2 diabetes (T2DM) and tuberculosis (TB). The purpose of this study was to determine if a relationship exists between diabetes and TB in Saskatchewan and to establish whether there is a difference in the degree of any association between Aboriginal and non- Aboriginal people. METHODS: Utilizing Saskatchewan Health databases, TB incidence (cases identified from 1986–2001) was compared between four subpopulations identified from 1991–1995: Registered Indians (RI) with and without diabetes, and other Saskatchewan people (OSKP) with and without diabetes. RESULTS: Diabetic women aged 20–59 years had higher average annual incidence rates of TB than non-diabetic women, but within-population rate ratios of TB in diabetic versus non-diabetic women were only significant in those aged 50–59 (2.7 [CI 1.28, 5.72] in RI and 3.9 [CI 1.58, 9.67] in OSKP). No other within-population diabetic subgroup had significantly higher rates of TB. The only male diabetic group that had a higher rate of TB were RI plus OSKP men aged 50–59 years. Overall, diabetes preceded TB in 87/111 individuals with both diseases (p

Background Exercise is recommended for people with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), yet there is little information to guide safe and effective mobilization and exercise for these patients. Objectives The purpose of this study was to develop a clinical decision-making tool to guide health care professionals in the assessment, prescription, monitoring, and progression of mobilization and therapeutic exercise for patients with AECOPD. Design and Methods A 3-round interdisciplinary Delphi panel identified and selected items based on a preselected consensus of 80%. These items were summarized in a paper-based tool titled Mobilization in Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD-Mob). Focus groups and questionnaires were subsequently used to conduct a sensibility evaluation of the tool. Results Nine researchers, 13 clinicians, and 7 individuals with COPD identified and approved 110 parameters for safe and effective exercise in AECOPD. These parameters were grouped into 5 categories: (1) “What to Assess Prior to Mobilization,” (2) “When to Consider Not Mobilizing or to Discontinue Mobilization,” (3) “What to Monitor During Mobilization for Patient Safety,” (4) “How to Progress Mobilization to Enhance Effectiveness,” and (5) “What to Confirm Prior to Discharge.” The tool was evaluated in 4 focus groups of 18 health care professionals, 90% of whom reported the tool was easy to use, was concise, and would guide a health care professional who is new to the acute care setting and working with patients with AECOPD. Limitations The tool was developed based on published evidence and expert opinion, so the applicability of the items to patients in all settings cannot be guaranteed. The Delphi panel consisted of health care professionals from Canada, so items may not be generalizable to other jurisdictions. Conclusions The AECOPD-Mob provides practical and concise information on safe and effective exercise for the AECOPD population for use by the new graduate or novice acute care practitioner.

Little is known about longitudinal trends in objectively measured physical activity (PA) during and after pulmonary rehabilitation (PR) for individuals with Chronic Obstructive Pulmonary Disease (COPD). The purpose of this study was to examine the PA trajectories of patients with COPD during and after PR and whether demographic, clinical, or program characteristics differed across these trajectories. The study was approved by Research Ethics Boards at all participating institutions, and written informed consent was obtained from each participant prior to study inclusion. COPD patients (N = 190) completed a questionnaire and wore a pedometer for 7 days at baseline, end of PR, and 3 and 9 months after completing PR. Latent class growth analyses showed that two distinct PA trajectories emerged. Active Maintainers averaged 9177 steps/day at baseline, and maintained this level throughout the assessment and post rehabilitation period. In contrast, Inactive Maintainers averaged 3133 steps/day at baseline, which also remained stable during and after PR. Follow-up analyses showed the Inactive Maintainers were more likely to be retired from work and have lower baseline scores for their stress tests and 6-minute walk tests compared to Active Maintainers (all p < 0.05). These results suggest that two distinct steps/day trajectories exist for COPD patients during and after completing PR that are partially explained by specific demographic and clinical characteristics.

We treated a 23-year-old aboriginal woman with drug-resistant pulmonary tuberculosis (TB). She experienced intolerance to her oral anti-TB medications, had subtherapeutic drug levels, and failed to respond to treatment. She then was effectively treated with percutaneous gastrojejunostomy tube (PGJT) administration of drugs. We present our data on the serum drug levels of rifampin, para-aminosalicylic acid, and levofloxacin after PGJT administration, and compare these values to published levels for oral administration of these drugs. In our patient, serum drug levels peaked and began to decline earlier than in the published data for oral administration of the same drugs.

COPD patients with high symptom burden or CAT ≥10 have an increased likelihood of experiencing work productivity losshttp://ow.ly/FnG030e6uaY