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Background The demand for physiotherapy clinical placements is rising which requires innovative approaches and an understanding of clinical placement models. Objective To determine physiotherapy student contribution to direct patient care activity during a collaborative clinical placement model. Secondary aims determined the impact of clinical area and clinical educator to student (CE:student) ratio and if a group of students could reach equivalent direct patient care activity of a junior or senior physiotherapist. Method Physiotherapy student, and junior and senior physiotherapist occasions of service (OOS) were collected from five Queensland Public Health Sector hospital information management systems from four physiotherapy clinical areas (i.e. cardiorespiratory, musculoskeletal, neurorehabilitation, and orthopedics). Number of days of clinical activity was recorded to provide average OOS/day. Results Across a 5-week clinical placement a group of physiotherapy students in a collaborative clinical placement model provided on average 10.6 OOS/day (95%CI 10.1-11.2). In three (75%) clinical areas, a group of students participating in higher CE:student ratios produced more OOS/day. Clinical area and CE:student ratio predicted 39% of the variance in student average OOS/day. On average a group of students reached the equivalent direct patient care activity of a junior and senior physiotherapist by week two of a 5-week clinical placement. Conclusion Physiotherapy students in a collaborative clinical placement model met or exceeded the direct patient care activity of a physiotherapist, irrespective of clinical area and CE:student ratio.

Background: Clinical placements offer students an opportunity to provide direct patient care and are essential to develop safe and effective practitioners. It is unknown what changes in direct patient care activities are required as students transition to graduate physiotherapists. Objective: To determine the change in direct patient care activity from physiotherapy student to new graduate. Methods: Five hospitals provided clinical activity data from 412 physiotherapy students and 50 new graduate physiotherapists working in four physiotherapy clinical areas. Main Outcome Measures: Percentage of day spent in direct patient care, average occasions of service (OOS) per day and average length of one OOS (LOOS) for physiotherapy students and new graduates. Results: Students spent less time during their day providing direct patient care (24%, 95% confidence interval (CI) 19 to 29), performed fewer OOS (4.4, 95%CI 4.0 to 4.8) and had longer LOOS (18 min, 95%CI 13 to 23) compared to new graduates. This was consistent across all clinical areas. Conclusions: Physiotherapy student caseload is half that of a new graduate physiotherapist, with students taking longer to complete an OOS. Given this disparity in workload, active stakeholder engagement is essential to implement strategies that support and optimize the transition from student to graduate.

Question(s)What is the impact of including an allied health assistant (AHA) role on physiotherapy service delivery in terms of service provision, scope of practice and skill mix changes in an acute respiratory service?DesignA pragmatic pre-post design study examined physiotherapy services across two three-month periods: current service delivery [P1] and current service delivery plus AHA [P2].Outcome measuresClinical and non-clinical activity contributing to physiotherapy services delivery quantified as number, type and duration (per day) of all staff activity, and categorised for skill level (AHA, junior, senior).ResultsOverall physiotherapy service delivery increased in P2 compared to P1 (n=4730 vs n=3048). Physiotherapists undertook fewer respiratory (p < 0.001) and exercise treatments (p < 0.001) but increased patient reviews for inpatients (p < 0.001) and at multidisciplinary clinics in P2 (56% vs 76%, p < 0.01). The AHA accounted for 20% of all service provision. AHA activity comprised mainly non-direct clinical care including oversight of respiratory equipment use (e.g. supply, set-up, cleaning, loan audits) and other patient related administrative tasks associated with delegation handovers, supervision and clinical documentation (72%) and delegated supervision of established respiratory (5%) and exercise treatments (10%) and delegated exercise tests (3%). The AHA completed most of the exercise tests (n = 25). AHA non-direct clinical tasks included departmental management activities such as statistics and ongoing training (11%). No adverse events were reported.ConclusionInclusion of an AHA in an acute respiratory care service changed physiotherapy service provision. The AHA completed delegated routine clinical and non-clinical tasks. Physiotherapists increased clinic activity and annual reviews. Including an AHA role offers safe and sustainable options for enhancing physiotherapy service provision in acute respiratory care services.

Background Increasing age, numbers, and complexity of care are potentially impacting physiotherapy service delivery for adults with cystic fibrosis (CF). Purpose This study aimed to describe physiotherapy service provision, scope of practice, and skill mix in a large tertiary adult CF center, and determine if services were meeting clinical practice recommendations. Methods A prospective cross-sectional study examined inpatient and outpatient physiotherapy care across a three-month period in a tertiary adult CF center. Physiotherapy services were described by number and skill level of physiotherapists, total hours of activity, and number, type, and duration of each physiotherapy activity. Results Twenty-two physiotherapists provided care. Respiratory (n = 1058, 38%), and exercise treatments (n = 338, 12%) were the most frequent. Exercise testing (n = 20, 1%), and detailed treatment reviews (n = 79, 3%) occurred infrequently. Time for research was limited. Junior physiotherapists undertook more exercise treatments per day (p < .01), with senior physiotherapists attending outpatient clinics (p < .01). Conclusion A large number of physiotherapists were involved in the delivery of services. Recommended respiratory and exercise treatments were frequently provided; however, other recommended activities occurred infrequently. The impact of increasing age, numbers of patients, and complexity of care may be contributing to demand exceeding supply for physiotherapy services. Future studies are required to determine innovative approaches to address the gaps in clinical practice recommendations.

Background: The transition from physiotherapy student to new graduate poses many challenges. In other health disciplines concerns have been raised about new graduate preparedness for practice.Objective: To explore the perspectives of new graduate and experienced physiotherapists on the transition from student to new graduate.Methods: Semi-structured interviews were conducted with 15 focus groups; nine new graduate groups and six experienced physiotherapist groups. Interviews were transcribed in preparation for thematic analysis whereby researchers examined transcripts independently and identified codes. Codes were compared and themes developed, discussed, and refined. Themes were reviewed by all authors.Results: Four themes emerged surrounding the transition from physiotherapy student to new graduate: 1) preparedness for practice; 2) protected practice; 3) independent and affirmation of practice; and 4) performance expectations. Both groups identified increased caseload volume and complexity were challenging, and that students were typically protected from realistic workloads. New graduates at times felt unprepared for their new roles and highlighted that coping with change in independence and managing expectations of themselves was difficult. Strategies identified that may assist the transition from student to new graduate included organizational, clinical placement experiences and building self-efficacy.Conclusions: Challenges are experienced during the transition from physiotherapy student to new graduate. To enhance this transition a multifactorial approach is required that includes all key stakeholders and strategically targets challenges associated with the student transition to new graduate.

Objective Pulmonary rehabilitation is recommended for people with chronic lung disease however access remains limited in rural and remote settings. The aim of this project was to explore the perspectives of rural and remote health care professionals regarding the establishment and delivery of pulmonary rehabilitation. Setting Rural (NSW) and remote (NT) Australian healthcare settings. Participants Health care professionals (n = 25) who attended a training program focussing on the delivery of pulmonary rehabilitation. Main outcome measure(s) Surveys with open written questions were completed by participants following the training program. Key informants also participated in face-to-face interviews. Thematic analysis was undertaken of data collected on participant opinions, attitudes and concerns regarding the establishment and delivery of pulmonary rehabilitation in their individual situation. Results Participating health care professionals (predominantly nurses and physiotherapists) identified a number of issues relating to establishing and delivering pulmonary rehabilitation; including staffing, time and case load constraints, patient and community attitudes, lack of professional knowledge and confidence and inability to ensure sustainability. The practicalities of delivering pulmonary rehabilitation, particularly exercise prescription and training, were also important concerns raised. Conclusions Lack of health care professional staffing, knowledge and confidence were reported to be factors impacting the establishment and delivery of pulmonary rehabilitation. This study has facilitated a greater understanding of the issues surrounding the establishment and delivery of pulmonary rehabilitation in rural and remote settings. Further research is required to investigate the contribution of health professional training and associated factors to improving the availability and delivery of pulmonary rehabilitation in rural and remote settings.

This prospective study investigated the validity of arterialised-venous blood gases (AVBG) for estimating arterial carbon dioxide P CO2, pH and bicarbonate (HCO3(-)) in people with obesity hypoventilation syndrome (OHS). AVBGs were obtained from an upper limb vein, after heating the skin at 42-46°C. Arterial blood gas (ABG) and AVBG samples were taken simultaneously and compared using Bland Altman analysis. Between-group differences were assessed with independent t-tests or Mann-Whitney U tests. Forty-two viable paired samples were analysed, including 27 paired samples from 15 OHS participants, and 15 paired samples from 16 controls. AVBG-ABG agreement was not different between groups, or between dorsal hand, forearm and antecubital AVBG sampling sites, and was clinically acceptable for P Co2: mean difference (MD) 0.4 mmHg (0.9%), limits of agreement (LOA) -2.7-3.6 mmHg (± 6.6%); pH: MD -0.008 (-0.1%), LOA -0.023-0.008 (± 0.2%); and HCO3(-): MD -0.3 mmol L(-1) (-1.0%), LOA -1.8-1.2 mmol L(-1) (± 5.3%). AVBG provides valid measures of [Formula: see text] , pH, and HCO3(-) in OHS.

Background and objective: To evaluate the impact of a chronic lung disease management training programme, Breathe Easy Walk Easy (BEWE), for rural and remote health-care practitioners. Methods: Quasi-experimental, before and after repeated measures design. Health-care practitioners (n = 33) from various professional backgrounds who attended the BEWE training workshop were eligible to participate. Breathe Easy Walk Easy, an interactive educational programme, consisted of a training workshop, access to online resources, provision of community awareness-raising materials and ongoing telephone/email support. Participant confidence, knowledge and attitudes were assessed via anonymous questionnaire before, immediately after and at 3 and 12 months following the BEWE workshop. At 12 months, local provision of pulmonary rehabilitation services and patient outcome data (6-min walk test results before and after pulmonary rehabilitation) were also recorded. Results: Measured knowledge (score out of 19) improved significantly after the workshop (mean difference 7.6 correct answers, 95% confidence interval: 5.8–9.3). Participants' self-rated confidence and knowledge also increased. At 12-month follow up, three locally run pulmonary rehabilitation programmes had been established. For completing patients, there was a significant increase in 6-min walk distance following rehabilitation of 48 m (95% confidence interval: 18–70 m). Conclusions: The BEWE programme increased rural and remote health-care practitioner knowledge and confidence in delivering management for people living with chronic lung disease and facilitated the establishment of effective pulmonary rehabilitation programmes in regional and remote Australian settings where access to such programmes is limited.

Objective: To investigate the existing experience, training, confidence and knowledge of rural/remote health care practitioners in providing management for people with chronic obstructive pulmonary disease (COPD). Design: Descriptive cross-sectional, observational survey design using a written anonymous questionnaire. This study formed part of a larger project evaluating the impact of breathe easy walk easy (BEWE), an interactive education and training program for rural and remote health care practitioners. Setting: Rural (n = 1, New South Wales) and remote (n = 1, Northern Territory) Australian health care services. Participants: Health care practitioners who registered to attend the BEWE training program (n = 31). Main outcome measures: Participant attitudes, objective knowledge and self-rated experience, training and confidence related to providing components of management for people with COPD. Results: Participants were from a variety of professional backgrounds (medical, nursing, allied health) but were predominantly nurses (n = 13) or physiotherapists (n = 9). Most participants reported that they had minimal or no experience or training in providing components of management for people with COPD. Confidence was also commonly rated by participants as low. Mean knowledge score (number of correct answers out of 19) was 8.5 (SD = 4.5). Questions relating to disease pathophysiology and diagnosis had higher correct response rates than those relating more specifically to pulmonary rehabilitation. Conclusion: The results of this study indicate that some rural and remote health care practitioners have low levels of experience, knowledge and confidence related to providing components of management for people with COPD and that education and training with an emphasis on pulmonary rehabilitation would be beneficial.

Background and Purpose. In theory, educational materials should reflect the underlying source and evidence base of the curricula. The purpose of the present study was to identify the levels of evidence represented within the cardiothoracic curricula in undergraduate (entry-level) physiotherapy programmes within Australia. Method. Using a retrospective document review, all tertiary institutions providing entry-level physiotherapy programmes were invited to submit paper copies of course materials used during 2003 to the Centre for Allied Health Evidence (CAHE), University of South Australia. A single independent reviewer collated all references cited within the teaching materials and ranked each reference according to a hierarchy of evidence where systematic reviews were regarded as the highest level of evidence and expert opinion or case studies as the lowest level. Results. A total of 974 references were cited within educational materials from the five participating universities. The number of references per university ranged from 71 to 256. Each ranking category was calculated as a percentage of the total number of references submitted by each university. All five universities demonstrated the same pattern of reference hierarchy where the lower levels of evidence represented approximately 70% of all references. Less than one per cent of all references were common to all five universities. Conclusions. Although auditing references cited within education material does not reflect educational process, the results from the present study provide a baseline from which to review and create strategies to strengthen the evidence base of the cardiothoracic curriculum. Copyright © 2005 Whurr Publishers Ltd.

Traditionally, manual hyperinflation has been performed using “rapid release” to promote a fast peak expiratory flow rate (PEFR) but rapid release has not been described. In addition, it has been demonstrated that different resuscitation circuits provide varying degrees of resistance to expiratory flow and it is known that a variety of circuits are used in Australia for manual hyperinflation. The aim of this study was to document current practice, the effect of rapid release, controlling inspiration, different volumes and circuit type on flow rates, and the inspiratory to expiratory flow rate (I:E) ratio during manual hyperinflation. Using a test lung model, 15 physiotherapists performed 11 trials using the Air Viva 2, a Mapleson-C and a Mapleson-F circuit, both with and without rapid release, and delivering two volumes. The order of the trials was randomised. Rapid release produced a faster PEFR irrespective of circuit type or volume delivered. The effect of rapid release, and the absolute PEFR, was less for the Air Viva 2 compared with the Mapleson circuits. Expiratory flow rate was faster for the larger volume. The theoretically optimal I:E ratio to move secretions was achieved delivering the lower target volume with the Mapleson circuits and using rapid release.

Validation of respiratory inductive plethysmography (LifeShirt system) (RIPLS) for tidal volume (VT), minute ventilation ( V ˙ E ) , and respiratory frequency (fB) was performed among people with untreated obesity hypoventilation syndrome (OHS) and controls. Measures were obtained simultaneously from RIPLS and a spirometer during two tests, and compared using Bland Altman analysis. Among 13 OHS participants (162 paired measures), RIPLS-spirometer agreement was unacceptable for VT: mean difference (MD) 3 mL (1%); limits of agreement (LOA) −216 to 220 mL (±36%); V ˙ E MD 0.1 L min−1 (2%); LOA −4.1 to 4.3 L min−1 (±36%); and fB: MD 0.2 br min−1 (2%); LOA −4.6 to 5.0 br min−1 (±27%). Among 13 controls (197 paired measures), RIPLS-spirometer agreement was acceptable for fB: MD −0.1 br min−1 (−1%); LOA −1.2 to 1.1 br min−1 (±12%), but unacceptable for VT: MD 5 mL (1%); LOA −160 to 169 mL (±20%) and V ˙ E : MD 0.1 L min−1 (1%); LOA −1.4 to 1.5 L min−1 (±20%). RIPLS produces valid measures of fB among controls but not OHS patients, and is not valid for quantifying respiratory volumes among either group.

Manual hyperinflation is used by physiotherapists to maintain or restore lung volume in the intubated patient. Volume restoration may be important in promoting secretion clearance, as airway closure is likely to result in a mechanical obstruction to the mucociliary apparatus. Studies have shown reversal of volume loss in this patient group using manual hyperinflation; however, the impact of volume restoration on secretion clearance has not been studied extensively. Manual hyperinflation is also used by physiotherapists to promote secretion clearance in intubated patients, with some suggesting that the technique mimics a cough. It has been proposed that the fast expiratory flows generated during cough clear secretions via mist flow, one type of two-phase gas-liquid flow. Expiratory flow rates generated during manual hyperinflation in the laboratory and clinical settings have been documented in the literature. These studies demonstrate that expiratory flow rates during manual hyperinflation are consistently...

Introduction In people with obesity hypoventilation syndrome (OHS), breathing 100% oxygen increases carbon dioxide (PCO 2 ), but its effect on pH is unknown. This study investigated the effects of moderate concentrations of supplemental oxygen on PCO 2 , pH, minute ventilation (V E ) and physiological dead space to tidal volume ratio (V D /V T ) among people with stable untreated OHS, with comparison to healthy controls. Methods In a double-blind randomised crossover study, participants breathed oxygen concentrations (F i O 2 ) 0.28 and 0.50, each for 20 min, separated by a 45 min washout period. Arterialised-venous PCO 2 (PavCO 2 ) and pH, V E and V D /V T were measured at baseline, then every 5 min. Data were analysed using general linear model analysis. Results 28 participants were recruited (14 OHS, 14 controls). Among OHS participants (mean±SD arterial PCO 2 6.7±0.5 kPa; arterial oxygen 8.9±1.4 kPa) F i O 2 0.28 and 0.50 maintained oxygen saturation 98–100%. After 20 min of F i O 2 0.28, PavCO 2 change (ΔPavCO 2 ) was 0.3±0.2 kPa (p=0.013), with minimal change in V E and rises in V D /V T of 1±5% (p=0.012). F i O 2 0.50 increased PavCO 2 by 0.5±0.4 kPa (p=0.012), induced acidaemia and increased V D /V T by 3±3% (p=0.012). V E fell by 1.2±2.1 L/min within 5 min then recovered individually to varying degrees. A negative correlation between ΔV E and ΔPavCO 2 (r=−0.60, p=0.024) suggested that ventilatory responses were the key determinant of PavCO 2 rises. Among controls, F i O 2 0.28 and 0.50 did not change PavCO 2 or pH, but F i O 2 0.50 significantly increased V E and V D /V T . Conclusion Commonly used oxygen concentrations caused hypoventilation, PavCO 2 rises and acidaemia among people with stable OHS. This highlights the potential dangers of this common intervention in this group.

Objective To determine the current structure and content of pulmonary rehabilitation programs in Australia. Design A cross sectional, observational design using a purpose designed anonymous written survey. Setting and participants The National database of Pulmonary Rehabilitation Programs maintained by the Australian Lung Foundation was used to identify all known programs in all states and territories of Australia (n = 193). All pulmonary rehabilitation programs listed on the database were included. Respondents were health professionals who coordinated programs. Results The response rate was 83% (161/193). Programs were coordinated by physiotherapists (75/147, 51%) and/or nurses (49/147, 33%), were hospital based (97/147, 66%) and ran for 8 weeks or longer (95/147, 65%). Pre (145/147, 99%) and post (137/147, 93%) program assessment was undertaken using a variety of measures. The Six Minute Walk Test (138/147, 94%) was the most commonly used test of exercise capacity. Exercise training was included in 145 programs (99%). Most patients attended at least two supervised exercise sessions per week (106/147, 72%) and exercised for at least 20 minutes (135/147, 92%). Lower limb endurance, upper limb endurance, strength training, and stretching/flexibility exercises were the most commonly included modes of exercise. Intensity prescription for exercise training was variable. Many respondents (93/147, 63%) indicated that they perceived a gap between their clinical practice and current evidence. Conclusions Pulmonary rehabilitation programs in Australia generally meet the broad recommendations for practice in terms of components, program length, assessment and exercise training. The prescription of exercise training intensity is an area requiring deeper exploration.

OBJECTIVE—To investigate sprint-training effects on muscle metabolism during exercise in subjects with (type 1 diabetic group) and without (control group) type 1 diabetes. RESEARCH DESIGN AND METHODS—Eight subjects with type 1 diabetes and seven control subjects, matched for age, BMI, and maximum oxygen uptake (V̇o2peak), undertook 7 weeks of sprint training. Pretraining, subjects cycled to exhaustion at 130% V̇o2peak. Posttraining subjects performed an identical test. Vastus lateralis biopsies at rest and immediately after exercise were assayed for metabolites, high-energy phosphates, and enzymes. Arterialized venous blood drawn at rest and after exercise was analyzed for lactate and [H+]. Respiratory measures were obtained on separate days during identical tests and during submaximal tests before and after training. RESULTS—Pretraining, maximal resting activities of hexokinase, citrate synthase, and pyruvate dehydrogenase did not differ between groups. Muscle lactate accumulation with exercise was higher in type 1 diabetic than nondiabetic subjects and corresponded to indexes of glycemia (A1C, fasting plasma glucose); however, glycogenolytic and glycolytic rates were similar. Posttraining, at rest, hexokinase activity increased in type 1 diabetic subjects; in both groups, citrate synthase activity increased and pyruvate dehydrogenase activity decreased; during submaximal exercise, fat oxidation was higher; and during intense exercise, peak ventilation and carbon dioxide output, plasma lactate and [H+], muscle lactate, glycogenolytic and glycolytic rates, and ATP degradation were lower in both groups. CONCLUSIONS—High-intensity exercise training was well tolerated, reduced metabolic destabilization (of lactate, H+, glycogenolysis/glycolysis, and ATP) during intense exercise, and enhanced muscle oxidative metabolism in young adults with type 1 diabetes. The latter may have clinically important health benefits.

Summary The aim of this prospective observational study was to document patterns of ventilation during manual hyperinflation by physiotherapists. Manual hyperinflation with a Mapleson-F system was performed on the same patients on two consecutive days. Patterns of ventilation were recorded using a heated pneumotachometer, pressure transducer and custom designed data acquisition and analysis systems. The mean (SE) results were: inspiratory time 1.45 (0.10) s; volume delivered 1.23 (0.07) l; peak inspiratory and expiratory flow rate 1.51 (0.06) l.s(-1) and 3.26 (0.30) l.s(-1), respectively and I : E flow rate ratio 0.63 (0.05). All the physiotherapists achieved an increase in volume which was delivered within a safe and effective pressure range and without cardiovascular compromise. Most (26 out of 34 sessions) performed the technique in the way recommended for enhancing secretion clearance. This is the first study to document comprehensively the pattern of ventilation during manual hyperinflation and provides the basis for further clinical trials evaluating its effectiveness for secretion clearance and volume restoration.

Manual hyperinflation (MHI) is used by physiotherapists as a treatment technique in intubated patients. This study investigated the effect of three different MHI techniques using a Mapleson-C circuit configuration with a CIG Medishield valve on volume delivered (Vt), peak inspiratory (PIFR) and expiratory flow rates (PEFR), and peak airway pressure (PAP) in a test lung model. The protocols differed in the degree of valve closure and inclusion of an inspiratory pause. For protocols 1, 2 and 3 the measures were Vt—1.33 (0.21), 2.74 (0.13), 3.55 (0.12) litres; PAP— 14.30 (0.82), 24.00 (0.47), 30.20 (0.92) cmH 2 O and PIFR—1.13 (0.05), 1.51 (0.15), 1.32 (0.09) l/s respectively. All pair comparisons were statistically significant except for PEFR (l/s), which was significantly lower for protocol 1 [1.62 (0.06)], compared to protocols 2 [2.01 (0.25)] and 3 [2.10 (0.19)] but not between protocols 2 and 3. Circuit and technique choice should be considered in relation to the specific therapeutic aim of treatment.

Objective Access to pulmonary rehabilitation (PR), an effective management strategy for people with chronic respiratory disease, is often limited particularly in rural and remote regions. Difficulties with establishment and maintenance of PR have been reported. Reasons may include a lack of adequately trained staff. There have been no published reports evaluating the impact of training programs on PR provision. The aim of this project was to evaluate the impact of an interactive training and support program for healthcare professionals (the Breathe Easy, Walk Easy (BEWE) program) on the delivery of PR in rural and remote regions. Methods The study was a quasi-experimental before–after design. Data were collected regarding the provision of PR services before and after delivery of the BEWE program and patient outcomes before and after PR. Results The BEWE program was delivered in one rural and one remote region. Neither region had active PR before the BEWE program delivery. At 12-month follow-up, three locally-run PR programs had been established. Audit and patient outcomes indicated that the PR programs established broadly met Australian practice recommendations and were being delivered effectively. In both regions PR was established with strong healthcare organisational support but without significant external funding, relying instead on the diversion of internal funding and/or in-kind support. Conclusions The BEWE program enabled the successful establishment of PR and improved patient outcomes in rural and remote regions. However, given the funding models used, the sustainability of these programs in the long term is unknown. Further research into the factors contributing to the ability of rural and remote sites to provide ongoing delivery of PR is required. What is known about the topic? PR including exercise training, education, and psychosocial support, is an effective and well evidenced management strategy for people with chronic obstructive pulmonary disease (COPD) that improves exercise capacity and quality of life, and reduces hospital admissions and length of stay. Despite the fact that participation in PR is seen as an essential component in the management of COPD, access remains limited, particularly in rural and remote regions. Difficulties with establishing and maintaining PR have been attributed to lack of physical and financial resources and adequately trained and skilled staff. There have been no published reports evaluating the impact of training programs for healthcare professionals in the provision of PR. What does this paper add? This paper is the first to demonstrate that the delivery of a well supported, interactive healthcare professional training program may facilitate the establishment of PR in rural and remote regions. Following delivery of the BEWE program, PR which broadly met the Australian recommendations for practice in terms of program content and structure, was established. Factors influencing the establishment of PR were related to the characteristics of the healthcare setting, such as remoteness, and to issues around staff retention. The settings where PR was not established were in less well-staffed, community-based, more remote settings. People with COPD who participated in these programs showed significant improvements in exercise capacity and quality of life. What are the implications for practitioners? One of the factors limiting the delivery of PR may be a lack of appropriately trained and skilled staff. Healthcare professionals’ participation in locally provided education and training programs targeted at developing skills for providing PR may enable effective PR programs to be established and maintained in rural and remote regions.

Operator performance during the expiratory phase of manual hyperinflation appears to vary between physiotherapists for Mapleson-B or C circuits. Some physiotherapists release the valve but maintain compression of the bag, whereas others release both the valve and the bag. The effect of this difference on peak expiratory flow rate (PEFR) has not been reported. The aim of this study was to document the effect of maintaining bag compression during expiration on PEFR and inspiratory to expiratory flow rate ratio (I:E). Six physiotherapists with experience using manual hyperinflation participated. A within-subjects repeated measures design was used. Subjects performed manual hyperinflation using a Mapleson-C circuit with 'rapid release', releasing the valve only, or releasing both the bag and the valve, during expiration in a test lung model. Inspiratory time was controlled using a metronome and flows were measured with a heated pneumotachometer. Maintaining bag compression significantly reduced PEFR (1.54 (0.08) vs 2.00 (0.07) l/sec, p = 0.008) and increased I:E flow rate ratio (0.65 (0.04) vs 0.50 (0.02), p = 0.02) for the Mapleson-C circuit at a 1.4 litre target volume. There were no significant differences for these measures between techniques when subjects emptied the bag. The effect needs to be confirmed in the clinical setting.