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Sheers NL, Howard ME, Rochford PD, Rautela L, Chao C, McKim DA, Berlowitz DJ. A Randomized Controlled Clinical Trial of Lung Volume Recruitment in Adults with Neuromuscular Disease. Ann Am Thorac Soc 2023; 20:1445-1455. [PMID: 37390359 PMCID: PMC10559144 DOI: 10.1513/annalsats.202212-1062oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 06/30/2023] [Indexed: 07/02/2023] Open
Abstract
Rationale: Clinical care guidelines advise that lung volume recruitment (LVR) be performed routinely by people with neuromuscular disease (NMD) to maintain lung and chest wall flexibility and slow lung function decline. However, the evidence base is limited, and no randomized controlled trials of regular LVR in adults have been published. Objectives: To evaluate the effect of regular LVR on respiratory function and quality of life in adults with NMD. Methods: A randomized controlled trial with assessor blinding was conducted between September 2015 and May 2019. People (>14 years old) with NMD and vital capacity <80% predicted were eligible, stratified by disease subgroup (amyotrophic lateral sclerosis/motor neuron disease or other NMDs), and randomized to 3 months of twice-daily LVR or breathing exercises. The primary outcome was change in maximum insufflation capacity (MIC) from baseline to 3 months, analyzed using a linear mixed model approach. Results: Seventy-six participants (47% woman; median age, 57 [31-68] years; mean baseline vital capacity, 40 ± 18% predicted) were randomized (LVR, n = 37). Seventy-three participants completed the study. There was a statistically significant difference in MIC between groups (linear model interaction effect P = 0.002, observed mean difference, 0.19 [0.00-0.39] L). MIC increased by 0.13 (0.01-0.25) L in the LVR group, predominantly within the first month. No interaction or treatment effects were observed in secondary outcomes of lung volumes, respiratory system compliance, and quality of life. No adverse events were reported. Conclusions: Regular LVR increased MIC in a sample of LVR-naive participants with NMD. We found no direct evidence that regular LVR modifies respiratory mechanics or slows the rate of lung volume decline. The implications of increasing MIC are unclear, and the change in MIC may represent practice. Prospective long-term clinical cohorts with comprehensive follow-up, objective LVR use, and clinically meaningful outcome data are needed. Clinical trial registered with anzctr.org.au (ACTRN12615000565549).
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Affiliation(s)
- Nicole L. Sheers
- Department of Respiratory and Sleep Medicine and
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
| | - Mark E. Howard
- Department of Respiratory and Sleep Medicine and
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
- Turner Institute of Brain and Mental Health, Monash University, Clayton, Victoria, Australia
| | | | - Linda Rautela
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Caroline Chao
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - Douglas A. McKim
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; and
- CANVent Respiratory Rehabilitation Services, Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada
| | - David J. Berlowitz
- Department of Respiratory and Sleep Medicine and
- Department of Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
- The University of Melbourne, Parkville, Victoria, Australia
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2
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Katz SL, Blinder H, Newhook D, Bmus LA, Nicholls S, McMillan HJ, Mah JK, Campbell C, McAdam LC, Zielinski D, Toupin-April K, Momoli F, McKim DA. Understanding the experiences of lung volume recruitment among boys with Duchenne muscular dystrophy: A multicenter qualitative study. Pediatr Pulmonol 2023; 58:46-54. [PMID: 36102618 DOI: 10.1002/ppul.26154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/22/2022] [Accepted: 09/08/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Despite recommendations for regular lung volume recruitment (LVR) use in clinical practice guidelines for children with neuromuscular disease, adherence to LVR is poor. We aimed to describe the experience of LVR by boys with Duchenne muscular dystrophy (DMD), their families, and healthcare providers (HCPs), as well as to identify the barriers and facilitators to LVR use. METHODS This multicenter, qualitative study evaluated boys with DMD (n = 11) who used twice-daily LVR as part of a randomized controlled trial, as well as their parents (n = 11), and HCPs involved in the clinical use of LVR (n = 9). Semistructured interviews were conducted to identify participants' understanding of LVR therapy and their beliefs, barriers and facilitators to its use. Thematic analysis was conducted using an inductive approach. A subanalysis compared adherent and nonadherent children. RESULTS Seven themes were identified related to participants' beliefs and experiences with LVR: emotional impact, adaptation to LVR, perceived benefits of LVR, routine, family engagement, clinical resources, and equipment-related factors. Strategies to improve adherence were also identified, including education, reinforcement and demonstration of LVR benefit, as well as clinician support. There were no thematic differences between adherent and nonadherent children. DISCUSSION Despite the benefits of LVR and positive experiences with it by many families, there remain barriers to adherence to treatment. HCPs need to balance the need for early introduction to give families time to adapt to LVR while ensuring that the benefit of LVR outweighs the burden. Clinician support is important for family engagement.
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Affiliation(s)
- Sherri L Katz
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Henrietta Blinder
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Dennis Newhook
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Leana Azerrad Bmus
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Stuart Nicholls
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Hugh J McMillan
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jean K Mah
- Department of Pediatrics and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada.,Division of Pediatric Neurology, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Craig Campbell
- Pediatrics, Epidemiology and Clinical Neurological Sciences, University of Western Ontario, London, Ontario, Canada.,Department of Paediatrics, Children's Hospital London Health Sciences Centre, London, Ontario, Canada
| | - Laura C McAdam
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - David Zielinski
- Montreal Children's Hospital, Montreal, Quebec, Canada.,Research Institute of McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Karine Toupin-April
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Douglas A McKim
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,CANVent Respiratory Rehabilitation Services, The Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada
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Birnkrant DJ, Bello L, Butterfield RJ, Carter JC, Cripe LH, Cripe TP, McKim DA, Nandi D, Pegoraro E. Cardiorespiratory management of Duchenne muscular dystrophy: emerging therapies, neuromuscular genetics, and new clinical challenges. The Lancet Respiratory Medicine 2022; 10:403-420. [DOI: 10.1016/s2213-2600(21)00581-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 11/01/2021] [Accepted: 12/14/2021] [Indexed: 01/06/2023]
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4
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Wasilewski MB, Kokorelias KM, Nonoyama M, Dale C, McKim DA, Road J, Leasa D, Tandon A, Goldstein R, Rose L. The experience of family caregivers of ventilator-assisted individuals who participated in a pilot web-based peer support program: A qualitative study. Digit Health 2022; 8:20552076221134964. [DOI: 10.1177/20552076221134964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/05/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Family caregivers play an important role supporting the day-to-day needs of ventilator-assisted individuals (VAIs) living at home. Peer-to-peer communication can help support these caregivers and help them sustain caregiving in the community. Online peer-support has been suggested as a way to help meet caregivers’ support needs. Methods A qualitative descriptive approach was used to elicit the perspectives of support received from caregivers who participated in a pilot web-based peer support program from October to December 2018. Data were collected through the transcripts of weekly online peer-to-peer group chats. Data were analyzed using an integration of thematic and framework analysis. Results In total, eight caregivers and five peer mentors participated in the pilot. All five mentors and four of the caregivers participated in the weekly chats. We identified three themes, a) The experience of caregivers is characterized by unique challenges related to the complexity of VAI care including technology; b) Mentors and caregiver participants reciprocally share support; c) Despite hardships, there are things that make caregiving easier and joyful. Discussion Our results add to the growing body of evidence pointing to the importance of online communities for supporting vulnerable caregivers. The reciprocal element of peer support, where trained mentors and untrained participants both benefit from support, can help sustain peer-support interventions. Despite the challenges of providing care to a VAI, there are facilitators that may help ease the caregiving experience and caregivers can benefit from ongoing support that is tailored to their needs along the caregiving trajectory.
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Affiliation(s)
- Marina B. Wasilewski
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kristina M. Kokorelias
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Mika Nonoyama
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Craig Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Douglas A McKim
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jeremy Road
- Division of Respiratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Leasa
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Anu Tandon
- Division of Respiratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Roger Goldstein
- Respiratory Medicine, West Park Healthcare Centre, Toronto, Ontario, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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Gotesman RD, Lalonde E, McKim DA, Bourque PR, Warman-Chardon J, Zwicker J, Breiner A. Laryngospasm in amyotrophic lateral sclerosis. Muscle Nerve 2021; 65:400-404. [PMID: 34817079 DOI: 10.1002/mus.27466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Laryngospasm is an involuntary, sustained closure of sphincter musculature that leads to an unpleasant subjective experience of dyspnea and choking. It is an underreported symptom in amyotrophic lateral sclerosis (ALS). In this study we aimed to better characterize the prevalence and clinical characteristics of laryngospasm in ALS patients. METHODS The medical records of 571 patients with ALS followed between 2008 and 2018 were searched for evidence of laryngospasm. A total of 23 patients with laryngospasm were identified and the data related to patient and laryngospasm characteristics were extracted. RESULTS Laryngospasm was reported in 4% of ALS patients. Females comprised 57% of patients and their mean age was 63.4 years. Laryngospasm frequently manifested in patients with moderate bulbar dysfunction and seemed independent of respiratory function. Among laryngospasm patients, 26% were cigarette smokers and 13% had a history of gastroesophageal reflux. The most common reported trigger was excessive saliva irritating the vocal cords (35%) followed by eating a meal (17%). There was significant variation in laryngospasm frequency (up to 5 per hour) and duration (seconds to minutes). Most patients could not identify an effective coping mechanism, although 13% reported that drinking water was effective. DISCUSSION Despite its low prevalence in ALS, laryngospasm should be included in the symptom inquiry. The present findings may improve patient care through increased recognition of the clinical features of laryngospasm in ALS patients, identifying a link between laryngospasm and moderate bulbar dysfunction, and highlighting trigger avoidance as a management strategy. Additional research is required to understand the pathophysiology and optimal treatment.
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Affiliation(s)
- Ryan D Gotesman
- Department of Medicine (Neurology), The Ottawa Hospital, and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Eric Poulin Centre for Neuromuscular Disease, University of Ottawa, Ottawa, Ontario, Canada
| | - Emilie Lalonde
- Eric Poulin Centre for Neuromuscular Disease, University of Ottawa, Ottawa, Ontario, Canada
| | - Douglas A McKim
- Division of Respiratory Medicine, CANVent Respiratory Rehabilitation Services, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Pierre R Bourque
- Department of Medicine (Neurology), The Ottawa Hospital, and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Eric Poulin Centre for Neuromuscular Disease, University of Ottawa, Ottawa, Ontario, Canada
| | - Jodi Warman-Chardon
- Department of Medicine (Neurology), The Ottawa Hospital, and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Eric Poulin Centre for Neuromuscular Disease, University of Ottawa, Ottawa, Ontario, Canada
| | - Jocelyn Zwicker
- Department of Medicine (Neurology), The Ottawa Hospital, and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Eric Poulin Centre for Neuromuscular Disease, University of Ottawa, Ottawa, Ontario, Canada
| | - Ari Breiner
- Department of Medicine (Neurology), The Ottawa Hospital, and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Eric Poulin Centre for Neuromuscular Disease, University of Ottawa, Ottawa, Ontario, Canada
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Naughton PE, Sheers N, Berlowitz DJ, Howard ME, McKim DA, Katz SL. Objective measurement of lung volume recruitment therapy: laboratory and clinical validation. BMJ Open Respir Res 2021; 8:8/1/e000918. [PMID: 34326156 PMCID: PMC8323364 DOI: 10.1136/bmjresp-2021-000918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/11/2021] [Indexed: 11/29/2022] Open
Abstract
Lung volume recruitment manoeuvres are often prescribed to maintain respiratory health in neuromuscular disease. Unfortunately, no current system accurately records delivered dose. This study determined the performance characteristics of a novel, objective, manual lung volume recruitment bag counter (‘the counter’) with bench and healthy volunteer testing, as well as in individuals with neuromuscular disease. We undertook (1) bench test determination of activation threshold, (2) bench and healthy volunteer fidelity testing during simulated patient interface leak and different pressure compressions and (3) comparisons with self-report in individuals with neuromuscular disease. The data are reported as summary statistics, compression counts, percentage of recorded versus delivered compressions and concordance (Cohen’s kappa (K) and absolute agreement).
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Affiliation(s)
- Phoebe E Naughton
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Physiotherapy, Austin Health, Heidelberg, Victoria, Australia
| | - Nicole Sheers
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - David J Berlowitz
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia .,Physiotherapy, Austin Health, Heidelberg, Victoria, Australia.,Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia.,Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Mark E Howard
- Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia
| | - Douglas A McKim
- Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Respiratory Medicine, Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sherri L Katz
- Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Respiratory Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
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Kaminska M, Rimmer KP, McKim DA, Nonoyama M, Giannouli E, Morrison D, O’Connell C, Petrof BJ, Maltais F. Long-term non-invasive ventilation in patients with chronic obstructive pulmonary disease (COPD): 2021 Canadian Thoracic Society Clinical Practice Guideline update. Canadian Journal of Respiratory, Critical Care, and Sleep Medicine 2021. [DOI: 10.1080/24745332.2021.1911218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Marta Kaminska
- Research Institute of the McGill University Health Centre, Meakins-Christie Laboratories, Montréal, Québec
| | - Karen P. Rimmer
- Division of Respiratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Douglas A. McKim
- Division of Respirology, University of Ottawa and The Ottawa Hospital Research Institute, CANVent Respiratory Services, Ottawa, Ontario, Canada
| | - Mika Nonoyama
- University of Ontario Institute of Technology, Oshawa, Ontario, Canada
| | - Eleni Giannouli
- Division of Respiratory Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Debra L. Morrison
- Division of Respirology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Colleen O’Connell
- Stan Cassidy Centre for Rehabilitation, Fredericton, New Brunswick, Canada
| | - Basil J. Petrof
- Research Institute of the McGill University Health Centre, Meakins-Christie Laboratories, Montréal, Québec
| | - François Maltais
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
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McKim DA, Cripe TP, Cripe LH. The effect of emerging molecular and genetic therapies on cardiopulmonary disease in Duchenne muscular dystrophy. Pediatr Pulmonol 2021; 56:729-737. [PMID: 33142052 DOI: 10.1002/ppul.25079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/27/2020] [Accepted: 08/28/2020] [Indexed: 01/22/2023]
Abstract
Gene therapy is an attractive approach being intensively studied to prevent muscle deterioration in patients with Duchenne muscular dystrophy. While clinical trials are only in early stages, initial reports are promising for its effects on ambulation. Cardiopulmonary failure, however, is the most common cause of mortality in Duchenne muscular dystrophy (DMD) patients, and little is known regarding the prospects for gene therapy on alleviating DMD-associated cardiomyopathy and respiratory failure. Here we review current knowledge regarding effects of gene therapy on DMD cardiomyopathy and discuss respiratory endpoints that should be considered as outcome measures in future clinical trials.
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Affiliation(s)
- Douglas A McKim
- Division of Respiratory Medicine, CANVent Respiratory Rehabilitation Services, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Timothy P Cripe
- Division of Pediatric Hematology, Oncology, Blood and Marrow Transplant, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Linda H Cripe
- Division of Pediatric Cardiology, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio, USA
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Nonoyama ML, Katz SL, Amin R, McKim DA, Guerriere D, Coyte PC, Wasilewski M, Zagorski B, Rose L. Healthcare utilization and costs of pediatric home mechanical ventilation in Canada. Pediatr Pulmonol 2020; 55:2368-2376. [PMID: 32579273 DOI: 10.1002/ppul.24923] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 06/13/2020] [Accepted: 06/23/2020] [Indexed: 11/12/2022]
Abstract
BACKGROUND Children using home mechanical ventilation (HMV) live at home with better quality of life, despite financial burden for their family. Previous studies of healthcare utilization and costs have not considered public and private expenditures, including family caregiver time. Our objective was to examine public and private healthcare utilization and costs for children using HMV, and variables associated with highest costs. METHODS Longitudinal, prospective, observational cost analysis study (2012-2014) collecting data on public and private (out-of-pocket, third-party insurance, and caregiving) costs every 2 weeks for 6 months using the Ambulatory Home Care Record. Functional Independence Measure (FIM), WeeFIM, and Caregiving Impact Scale (CIS) were measured at baseline and study completion. Regression modeling examined a priori selected variables associated with monthly costs using Andersen and Newman's framework for healthcare utilization, relevant literature, and clinical expertise. Data are reported in 2015 Canadian dollars ($1CAD = $0.78USD). RESULTS Forty two children and their caregivers were enrolled. Overall median (interquartile range) monthly healthcare cost was $12 131 ($8159-$15 958) comprising $9929 (89%) family caregiving hours, $996 (9%) publicly funded, and $252 (2%) out-of-pocket (<1% third-party insurance) costs. With higher FIM score (lower dependency), median costs were reduced by 4.5% (95% confidence interval: 8.3%-0.5%), adjusted for age, sex, tracheostomy, and daily ventilation duration. Note: since the three cost categories did not sum to the total statistically derived median cost, the percentage of each category used the sum of median public + caregiver lost time + private out-of-pocket + third-party insurance as the denominator. CONCLUSIONS For HMV children, most healthcare costs were due to family caregiving costs. More dependent children incur highest costs. The financial burden to family caregivers is substantial and needs to considered in future policy decisions related to pediatric HMV.
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Affiliation(s)
- Mika L Nonoyama
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada.,Department of Respiratory Therapy, The Hospital for Sick Children, Toronto, Canada
| | - Sherri L Katz
- Division of Respirology, CHEO, University of Ottawa, Ottawa, Canada.,Clinical Research Unit, CHEO Research Institute, Ottawa, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Douglas A McKim
- Division of Respiratory Medicine, The Ottawa Hospital, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada
| | - Denise Guerriere
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Canadian Centre for Health Economics, Toronto, Canada
| | - Peter C Coyte
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Marina Wasilewski
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, Canada
| | - Brandon Zagorski
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Louise Rose
- Department of Medicine, University of Toronto, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, England.,Lawrence S. Bloomberg Faculty of Nursing and Faculty of Medicine, University of Toronto, Toronto, Canada
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Cazzolli PA, Brooks BR, Nakayama Y, Lewarski JS, McKim DA, Holt SL, Chatburn RL. The Oral Secretion Scale and Prognostic Factors for Survival in Subjects With Amyotrophic Lateral Sclerosis. Respir Care 2020; 65:1063-1076. [PMID: 32127413 DOI: 10.4187/respcare.07005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Noninvasive ventilation (NIV) can be tolerated in patients with amyotrophic lateral sclerosis (ALS), unless bulbar impairment becomes severe. Excessive oral secretions may result in NIV intolerance and insufficient ventilation. OBJECTIVE To assess the reliability of the Oral Secretion Scale (OSS) for predicting the tolerance of NIV, when to initiate hospice or transition to tracheostomy, and prognostic factors for survival of users of NIV. METHODS A validated OSS was developed to measure oral secretions in correlation with the ability to swallow saliva and clear the upper airway: OSS score of 4 = normal (automatic swallow); OSS score of 3 = infrequent secretions (automatic swallow decreased); OSS score of 2 = occasional drooling and/or pooling (conscious swallow required); OSS score of 1 = severe, frequent drooling and/or pooling (conscious swallow difficult); OSS score of 0 = most severe, constant drooling/pooling (conscious swallow impossible). A total of 137 subjects were followed up prospectively during ongoing patient visits from NIV initiation until death or tracheostomy. Survival was calculated by using Kaplan-Meier analysis. OSS scores when NIV became intolerable were determined. Uni- and/or multivariate Cox-regression analyses showed prognostic factors that affect survival. RESULTS The median months of survival from NIV initiation were the following: 11 (95% CI 7.3-14.0), 5 (95% CI 3.1-6.1), and 1 (95% CI 1.1-1.5) stratified by OSS scores of 4, 3-2, and 1, respectively; and 21 (95% CI 8.6-33.2), 8 (95% CI 3.4-11.5), 6 (95% CI 4.2-8.2), and 2 (95% CI 1.5-2.7) stratified by 24, 17-23, 4-16, and <4 h/d of NIV use, respectively. Survival was significantly (P < .001) longer with an OSS score of 4 than an OSS score of 1 at NIV initiation; and significantly (P < .001) longer when NIV used 24 h/d than <24 h/d. In the subjects unable to tolerate NIV, ≥80% had OSS score of 1 or 0. Univariate and multivariate analyses hazard ratio 4.91, 95% CI 2.98-8.09, P < .001, and hazard ratio 4.60, 95% CI 2.66-7.96, P < .001), respectively, showed hours per day of NIV use was a significant factor associated with survival. CONCLUSIONS The subjects with an OSS score of 4 tolerated NIV and survived significantly longer than subjects with an OSS score of <4. An OSS score of 1 signaled NIV intolerance and the need for hospice or transition to planned tracheostomy. Use of OSS can help guide NIV management decisions.
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Affiliation(s)
| | - Benjamin Rix Brooks
- Carolinas Neuromuscular/ALS-MDA Care Center, Atrium Health Neurosciences Institute, Department of Neurology, Carolinas Medical Center, University of North Carolina School of Medicine - Charlotte Campus, Charlotte, North Carolina
| | | | | | - Douglas A McKim
- University of Ottawa, CANVent Respiratory Rehabilitation Services, The Ottawa Rehabilitation Centre, and The Ottawa Hospital Sleep Centre, Ottawa, Canada, Ottawa Hospital Research Institute
| | - Sheryl L Holt
- Physical Therapy Department, University of Mount Union, Alliance, Ohio, ALS Care Project Canton, Ohio
| | - Robert L Chatburn
- Respiratory Institute, Cleveland Clinic Foundation, Department of Medicine, Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
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11
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Wasilewski MB, Nonoyama M, Dale C, McKim DA, Road J, Leasa D, Goldstein R, Rose L. Development of a Web-Based Peer Support Program for Family Caregivers of Ventilator-Assisted Individuals Living in the Community: Protocol for a Pilot Randomized Controlled Trial. JMIR Res Protoc 2019; 8:e11827. [PMID: 30724737 PMCID: PMC6386648 DOI: 10.2196/11827] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/24/2018] [Accepted: 11/01/2018] [Indexed: 01/27/2023] Open
Abstract
Background Across Europe, Canada, Australia, and the United States, the prevalence of home mechanical ventilation (HMV) prevalence is 6.6-12.9 per 100,000. At-home ventilator-assisted individuals (VAIs) are often vulnerable and highly comorbid, requiring complex care. In Canada, most VAI care is provided by family, leading to poor health-related quality of life and increased caregiver burden. No supportive interventions or peer support programs are tailored to VAI caregivers. Owing to the financial, geographic, and time limitations, Web-based support delivery may especially meet VAI family caregiver needs. We have developed a peer mentor training and Web-based peer support program for VAI caregivers including information-sharing, peer-to-peer communication, and peer mentorship. Objective Study Stage 1 aims to (1) evaluate the face and content validity of the peer mentor training program and (2) investigate participant satisfaction. Study Stage 2 aims to evaluate (1) the feasibility of participant recruitment and Web-based program delivery; (2) acceptability, usability, and satisfactoriness; (3) experiences of caregivers and peer mentors with the Web-based peer support program; and (4) effect of the Web-based peer support program on caregiver health outcomes. Methods Study Stage 1: We will train 7 caregivers to act as peer mentors for the Web-based peer support program trial; they will complete questionnaires rating the utility of individual training sessions and the training program overall. Study Stage 2: We will recruit 30 caregiver peers for a pilot randomized controlled trial of the 12-week Web-based peer support program using a waitlist control; the program includes private chat, a public discussion forum, and weekly moderated chats. Caregiver peers will be randomized to the intervention or waitlist control group using a 1:1 ratio using Randomize.net. Both groups will complete pre- and postintervention health outcome questionnaires (ie, caregiving impact, mastery, coping, personal gain, positive affect, and depression). Caregiver peers in the intervention arm will only complete a program evaluation and will be invited to participate in an interview to provide insight into their experience. Peer mentors will be invited to participate in a Web-based focus group to provide insight into their experience as mentors. We will judge the feasibility per the number of recruitment and program delivery goals met, use analysis of covariance to compare health outcomes between intervention and control groups, and analyze qualitative data thematically. Results Peer mentor training was completed with 5 caregivers in July 2018. To date, 2 caregivers have beta-tested the website, and the Web-based peer support program trial will commence in September 2018. Results are expected by early 2019. Conclusions This study will result in the production and initial evaluation of a rigorously developed, evidence- and stakeholder-informed Web-based peer training and peer support program for caregivers of VAIs residing at home. International Registered Report Identifier (IRRID) PRR1-10.2196/11827
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Affiliation(s)
- Marina B Wasilewski
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Mika Nonoyama
- Faculty of Health Sciences, University of the Ontario Institute of Technology, Oshawa, ON, Canada
| | - Craig Dale
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Douglas A McKim
- Rehabilitation and Sleep Laboratory, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jeremy Road
- The Lung Centre, Vancouver General Hospital, Vancouver, BC, Canada
| | - David Leasa
- London Health Sciences Centre, London, ON, Canada
| | | | - Louise Rose
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.,Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, United Kingdom.,Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Prolonged Ventilation Weaning Centre, Michael Garron Hospital, Toronto, ON, Canada
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Nonoyama ML, McKim DA, Road J, Guerriere D, Coyte PC, Wasilewski M, Avendano M, Katz SL, Amin R, Goldstein R, Zagorski B, Rose L. Healthcare utilisation and costs of home mechanical ventilation. Thorax 2018; 73:thoraxjnl-2017-211138. [PMID: 29374088 DOI: 10.1136/thoraxjnl-2017-211138] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 11/23/2017] [Accepted: 12/11/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Individuals using home mechanical ventilation (HMV) frequently choose to live at home for quality of life, despite financial burden. Previous studies of healthcare utilisation and costs do not consider public and private expenditures, including caregiver time. OBJECTIVES To determine public and private healthcare utilisation and costs for HMV users living at home in two Canadian provinces, and examine factors associated with higher costs. METHODS Longitudinal, prospective observational cost analysis study (April 2012 to August 2015) collecting data on public and private (out-of-pocket, third-party insurance, caregiving) costs every 2 weeks for 6 months using the Ambulatory and Home Care Record. Functional Independence Measure (FIM) was used at baseline and study completion. Regression models examined variables associated with total monthly costs selected a priori using Andersen and Newman's framework for healthcare utilisation, relevant literature, and clinical expertise. Data are reported in 2015 Canadian dollars ($C1=US$0.78=₤0.51=€0.71). RESULTS We enrolled 134 HMV users; 95 with family caregivers. Overall median (IQR) monthly healthcare cost was $5275 ($2291-$10 181) with $2410 (58%) publicly funded; $1609 (39%) family caregiving; and $141 (3%) out-of-pocket (<1% third-party insurance). Median healthcare costs were $8733 ($5868-$15 274) for those invasively ventilated and $3925 ($1212-$7390) for non-invasive ventilation. Variables associated with highest monthly costs were amyotrophic lateral sclerosis (1.88, 95% CI 1.09 to 3.26, P<0.03) and lower FIM quintiles (higher dependency) (up to 6.98, 95% CI 3.88 to 12.55, P<0.0001) adjusting for age, sex, tracheostomy and ventilation duration. CONCLUSIONS For HMV users, most healthcare costs were publicly supported or associated with family caregiving. Highest costs were incurred by the most dependent users. Understanding healthcare costs for HMV users will inform policy decisions to optimise resource allocation, helping individuals live at home while minimising caregiver burden.
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Affiliation(s)
- Mika L Nonoyama
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada
- Department of Respiratory Therapy, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Douglas A McKim
- Division of Respiratory Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | - Denise Guerriere
- Division of Respirology, Department of Medicine, Institute for Heart and Lung Health, University of British Columbia, Vancouver, British Columbia, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Canadian Centre for Health Economics, Toronto, Ontario, Canada
| | - Peter C Coyte
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Marina Wasilewski
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Monica Avendano
- Respiratory Medicine, West Park Healthcare Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sherri L Katz
- Division of Respirology, Department of Pediatrics, CHEO, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Research Unit, CHEO Research Institute, Ottawa, Ontario, Canada
| | - Reshma Amin
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Roger Goldstein
- Respiratory Medicine, West Park Healthcare Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brandon Zagorski
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Louise Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Molgat-Seon Y, Hannan LM, Dominelli PB, Peters CM, Fougere RJ, McKim DA, Sheel AW, Road JD. Lung volume recruitment acutely increases respiratory system compliance in individuals with severe respiratory muscle weakness. ERJ Open Res 2017; 3:00135-2016. [PMID: 28326313 PMCID: PMC5349097 DOI: 10.1183/23120541.00135-2016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 12/23/2016] [Indexed: 12/13/2022] Open
Abstract
The aim of the present study was to determine whether lung volume recruitment (LVR) acutely increases respiratory system compliance (Crs) in individuals with severe respiratory muscle weakness (RMW). Individuals with RMW resulting from neuromuscular disease or quadriplegia (n=12) and healthy controls (n=12) underwent pulmonary function testing and the measurement of Crs at baseline, immediately after, 1 h after and 2 h after a single standardised session of LVR. The LVR session involved 10 consecutive supramaximal lung inflations with a manual resuscitation bag to the highest tolerable mouth pressure or a maximum of 50 cmH2O. Each LVR inflation was followed by brief breath-hold and a maximal expiration to residual volume. At baseline, individuals with RMW had lower Crs than controls (37±5 cmH2O versus 109±10 mL·cmH2O−1, p<0.001). Immediately after LVR, Crs increased by 39.5±9.8% to 50±7 mL·cmH2O−1 in individuals with RMW (p<0.05), while no significant change occurred in controls (p=0.23). At 1 h and 2 h post-treatment, there were no within-group differences in Crs compared to baseline (all p>0.05). LVR had no significant effect on measures of pulmonary function at any time point in either group (all p>0.05). During inflations, mean arterial pressure decreased significantly relative to baseline by 10.4±2.8 mmHg and 17.3±3.0 mmHg in individuals with RMW and controls, respectively (both p<0.05). LVR acutely increases Crs in individuals with RMW. However, the high airway pressures during inflations cause reductions in mean arterial pressure that should be considered when applying this technique. Acute changes following lung volume recruitmenthttp://ow.ly/2dqE308g3oG
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Affiliation(s)
| | - Liam M Hannan
- Institute for Breathing and Sleep, Austin Hospital, Heidelberg, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Australia
| | - Paolo B Dominelli
- School of Kinesiology, University of British Columbia, Vancouver, Canada
| | - Carli M Peters
- School of Kinesiology, University of British Columbia, Vancouver, Canada
| | - Renee J Fougere
- Faculty of Nursing, University of Toronto, Toronto, Canada; Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Douglas A McKim
- Division of Respiratory Medicine, The Ottawa Hospital, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| | - A William Sheel
- School of Kinesiology, University of British Columbia, Vancouver, Canada
| | - Jeremy D Road
- Faculty of Medicine, University of British Columbia, Vancouver, Canada; Division of Respiratory Medicine, Vancouver General Hospital, Vancouver, Canada
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Bédard ME, McKim DA. Continuous Mouthpiece Daytime Amyotrophic Lateral Sclerosis in Noninvasive Ventilation: Definitive Solid Therapy?-Reply. Respir Care 2017; 62:387-388. [PMID: 28246284 DOI: 10.4187/respcare.05453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
BACKGROUND Critically ill mechanically ventilated patients experience impaired airway clearance due to ineffective cough and impaired secretion mobilization. Cough augmentation techniques, including mechanical insufflation-exsufflation (MI-E), manually assisted cough, and lung volume recruitment, improve cough efficiency. Our objective was to describe use, indications, contraindications, interfaces, settings, complications, and barriers to use across Canada. METHODS An e-mail survey was sent to nominated local survey champions in eligible Canadian units (ICUs, weaning centers, and intermediate care units) with 4 telephone/e-mail reminders. RESULTS The survey response rate was 157 of 238 (66%); 78 of 157 units (50%) used cough augmentation, with 50 (64%) using MI-E, 53 (68%) using manually assisted cough, and 62 (79%) using lung volume recruitment. Secretion clearance was the most common indication (MI-E, 92%; manually assisted cough, 88%; lung volume recruitment, 76%), although the most common units (44%) used it <50% of the time. Use during weaning from invasive (MI-E, 21%; manually assisted cough, 39%; lung volume recruitment, 3%) and noninvasive ventilation (MI-E, 21%; manually assisted cough, 33%; lung volume recruitment, 21%) was infrequent. The most common diagnoses were neuromuscular disease (97%) and spinal cord injury (83%). Pneumothorax was the most frequently identified absolute contraindication for MI-E (93%) and lung volume recruitment (83%); rib fracture was most frequently identified for manually assisted cough (69%). MI-E mean inspiratory pressure was 31 cm H2O, and expiratory pressure was -32 cm H2O. Mucus plugging requiring tracheostomy inner change was the most frequent complication for MI-E (23%), chest pain for manually assisted cough (36%), and hypotension for lung volume recruitment (17%). The most commonly cited barriers were lack of expertise (70%), knowledge (65%), and resources (52%). CONCLUSIONS We found moderate adoption of cough augmentation techniques, particularly for secretion management. Lack of expertise and knowledge are potentially modifiable barriers addressed with educational interventions.
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Affiliation(s)
- Louise Rose
- Sunnybrook Health Sciences Centre; the Lawrence S Bloomberg Faculty of Nursing, University of Toronto; the Provincial Centre of Weaning Excellence/Prolonged Ventilation Weaning Centre, Toronto East General Hospital; Mount Sinai Hospital; the Li Ka Shing Knowledge Institute, St. Michael's Hospital; and the West Park Healthcare Centre, Toronto, Ontario, Canada.
| | - Neill K Adhikari
- Sunnybrook Health Sciences Centre, Interdivisional Department of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Joseph Poon
- Faculty of Medicine, University of Sydney, Sydney, New South Wales, Australia
| | - David Leasa
- Critical Care Western and London Health Sciences Centre and Western University, London, Ontario, Canada
| | - Douglas A McKim
- Ottawa Hospital Respiratory Rehabilitation Center, the Ottawa Hospital Sleep Centre, and the University of Ottawa, Ottawa, Ontario, Canada
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Abstract
BACKGROUND Noninvasive ventilation (NIV) is commonly used to provide ventilatory support for individuals with amyotrophic lateral sclerosis (ALS). Once 24-h ventilation is required, the decision between invasive tracheostomy ventilation and palliation is often faced. This study describes the use and outcomes of daytime mouthpiece ventilation added to nighttime mask ventilation for continuous NIV in subjects with ALS as an effective alternative. METHODS This was a retrospective study of 39 subjects with ALS using daytime mouthpiece ventilation over a 17-y period. RESULTS Thirty-one subjects were successful with mouthpiece ventilation, 2 were excluded, 2 stopped because of lack of motivation, and 4 with bulbar subscores of the Revised Amyotrophic Lateral Sclerosis Functional Rating Scale (b-ALSFRS-R) between 0 and 3 physically failed to use it consistently. No subject in the successful group had a b-ALSFRS-R score of <6. Thirty of the successful subjects were able to generate a maximum insufflation capacity - vital capacity difference with lung volume recruitment. The median (range) survival to tracheostomy or death from initiation of nocturnal NIV and mouthpiece ventilation were 648 (176-2,188) and 286 (41-1,769) d, respectively. Peak cough flow with lung-volume recruitment >180 L/min at initiation of mouthpiece ventilation was associated with a longer survival (637 ± 468 vs 240 ± 158 d (P = .01). CONCLUSIONS Mouthpiece ventilation provides effective ventilation and prolonged survival for individuals with ALS requiring full-time ventilatory support and maintaining adequate bulbar function.
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Affiliation(s)
- Marie-Eve Bédard
- Canadian Alternatives in Noninvasive Ventilation (CANVent) Program, Ottawa Hospital Rehabilitation Centre, Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Douglas A McKim
- Canadian Alternatives in Noninvasive Ventilation (CANVent) Program, Ottawa Hospital Rehabilitation Centre, Division of Respirology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Solomon BK, Wilson KG, Henderson PR, Poulin PA, Kowal J, McKim DA. Loss of Dignity in Severe Chronic Obstructive Pulmonary Disease. J Pain Symptom Manage 2016; 51:529-37. [PMID: 26620235 DOI: 10.1016/j.jpainsymman.2015.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 11/05/2015] [Accepted: 11/09/2015] [Indexed: 02/02/2023]
Abstract
CONTEXT The maintenance of dignity is an important concept in palliative care, and the loss of dignity is a significant concern among patients with advanced cancer. OBJECTIVES The goals of this study were to examine whether loss of dignity is also a concern for patients receiving interdisciplinary rehabilitation for Stage III or IV chronic obstructive pulmonary disease. We examined the prevalence and correlates of loss of dignity and determined whether it improves with treatment. METHODS Inpatients underwent a structured interview inquiry around their sense of dignity and completed measures of pulmonary, physical, and psychological function at admission (n = 195) and discharge (n = 162). RESULTS Loss of dignity was identified as a prominent ongoing concern for 13% of patients. It was correlated with measures of depression and anxiety sensitivity, but not with pulmonary capacity or functional performance. A robust improvement in loss of dignity was demonstrated, with 88% of those who reported a significant problem at admission no longer reporting one at discharge. CONCLUSION The prevalence of a problematic loss of dignity among patients with severe chronic obstructive pulmonary disease is at least as high as among those receiving palliative cancer care. Loss of dignity may represent a concern among people with medical illnesses more broadly, and not just in the context of "death with dignity" at the end of life. Furthermore, interdisciplinary care may help to restore a sense of dignity to those individuals who are able to participate in rehabilitation.
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Affiliation(s)
- Brahm K Solomon
- School of Psychology, University of Ottawa, Ottawa, Ontario, Canada.
| | - Keith G Wilson
- Department of Psychology, The Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada
| | - Peter R Henderson
- Department of Psychology, The Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada
| | - Patricia A Poulin
- Department of Psychology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - John Kowal
- Department of Psychology, The Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada
| | - Douglas A McKim
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Solomon BK, Wilson KG, Henderson PR, Poulin PA, Kowal J, McKim DA. A Breathlessness Catastrophizing Scale for chronic obstructive pulmonary disease. J Psychosom Res 2015; 79:62-8. [PMID: 25498317 DOI: 10.1016/j.jpsychores.2014.11.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 11/22/2014] [Accepted: 11/25/2014] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Catastrophizing about breathlessness may be related to disability in patients with chronic obstructive pulmonary disease (COPD), but assessment options are limited. This study reports the initial validation of a 13-item Breathlessness Catastrophizing Scale (BCS). METHOD Pulmonary rehabilitation inpatients completed spirometric, functional performance and questionnaire assessments at admission (N=242) and discharge (n=186). RESULTS The BCS comprised a unifactorial scale that demonstrated excellent internal consistency (Cronbach's alpha=.96) and correlated with measures of anxiety sensitivity, depression, and self-efficacy, but not with performance on walk and stair-climbing tests. BCS scores improved robustly with rehabilitation, approaching a medium effect size (d=.43), and demonstrated a modest association with enhanced performance in a stair-climbing test of exercise tolerance. CONCLUSION The BCS is a reliable measure of catastrophizing in severe COPD that has good convergent validity and sensitivity to change. Its association with functional performance requires further investigation. However, it appears that a high level of catastrophizing about breathlessness is not a barrier to functional improvement with inpatient pulmonary rehabilitation.
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Affiliation(s)
| | - Keith G Wilson
- Department of Psychology, The Ottawa Hospital Rehabilitation Centre, Canada
| | - Peter R Henderson
- Department of Psychology, The Ottawa Hospital Rehabilitation Centre, Canada
| | | | - John Kowal
- Department of Psychology, The Ottawa Hospital Rehabilitation Centre, Canada
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Abstract
BACKGROUND No comprehensive Canadian national data describe the prevalence of and service provision for ventilator-assisted individuals living at home, data critical to health-care system planning for appropriate resourcing. Our objective was to generate national data profiling service providers, users, types of services, criteria for initiation and monitoring, ventilator servicing arrangements, education, and barriers to home transition. METHODS Eligible providers delivering services to ventilator-assisted individuals (adult and pediatric) living at home were identified by our national provider inventory and referrals from other providers. The survey was administered via a web link from August 2012 to April 2013. RESULTS The survey response rate was 152/171 (89%). We identified 4,334 ventilator-assisted individuals: an estimated prevalence of 12.9/100,000 population, with 73% receiving noninvasive ventilation (NIV) and 18% receiving intermittent mandatory ventilation (9% not reported). Services were delivered by 39 institutional providers and 113 community providers. We identified variation in initiation criteria for NIV, with polysomnography demonstrating nocturnal hypoventilation (57%), daytime hypercapnia (38%), and nocturnal hypercapnia (32%) as the most common criteria. Various models of ventilator servicing were reported. Most providers (64%) stated that caregiver competency was a prerequisite for home discharge; however, repeated competency assessment and retraining were offered by only 45%. Important barriers to home transition were: insufficient funding for paid caregivers, equipment, and supplies; a shortage of paid caregivers; and negotiating public funding arrangements. CONCLUSIONS Ventilatory support in the community appears well-established, with most individuals managed with NIV. Although caregiver competency is a prerequisite to discharge, ongoing assessment and retraining were infrequent. Funding and caregiver availability were important barriers to home transition.
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Affiliation(s)
- Louise Rose
- Department of Critical Care and Research Institute, Sunnybrook Health Sciences Centre; the Lawrence S Bloomberg Faculty of Nursing, University of Toronto; the Provincial Centre of Weaning Excellence/Prolonged Ventilation Weaning Centre, Toronto East General Hospital; Mt Sinai Hospital; Li Ka Shing Knowledge Institute, St Michael's Hospital; and West Park Healthcare Centre, Toronto, Ontario, Canada.
| | - Douglas A McKim
- Respiratory Rehabilitation and the Sleep Centre, The Ottawa Hospital, and the Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sherri L Katz
- Children's Hospital of Eastern Ontario (CHEO), the CHEO Research Institute, and the University of Ottawa, Ottawa, Ontario, Canada
| | - David Leasa
- London Health Sciences Centre and the Department of Medicine, University of Western Ontario, London, Ontario, Canada
| | - Mika Nonoyama
- University of Ontario Institute of Technology, Oshawa, Ontario, Canada
| | - Cheryl Pedersen
- Centre for Research in Inner City Health, Li Ka Shing Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Roger S Goldstein
- West Park Healthcare Centre and the Departments of Medicine and Physical Therapy, University of Toronto, Toronto, Ontario, Canada
| | - Jeremy D Road
- Vancouver General Hospital; the Provincial Respiratory Outreach Program, Vancouver Coastal Health; and the University of British Columbia, Vancouver, British Columbia, Canada
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Sandoz JS, LeBlanc C, McKim DA. Data downloads for effective noninvasive ventilation in patients with neuromuscular respiratory failure. Respir Care 2013; 59:e35-40. [PMID: 23942753 DOI: 10.4187/respcare.02153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jacqueline S Sandoz
- Canadian Alternatives in Noninvasive Ventilation (CANVent) program, Ottawa Hospital Rehabilitation Centre, Division of Respiratory Medicine, Ottawa Hospital, Ontario, Canada
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McKim DA, Katz SL, Barrowman N, Ni A, LeBlanc C. Lung Volume Recruitment Slows Pulmonary Function Decline in Duchenne Muscular Dystrophy. Arch Phys Med Rehabil 2012; 93:1117-22. [DOI: 10.1016/j.apmr.2012.02.024] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 01/21/2012] [Accepted: 02/02/2012] [Indexed: 02/07/2023]
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McKim DA, King J, Walker K, Leblanc C, Timpson D, Wilson KG, Marks M, Curran D, Woolnough A. Formal ventilation patient education for ALS predicts real-life choices. ACTA ACUST UNITED AC 2012; 13:59-65. [PMID: 22214354 DOI: 10.3109/17482968.2011.626053] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Our objective was to evaluate a single-session, hands-on education programme on mechanical ventilation for ALS patients and caregivers in terms of knowledge, change in affect and to determine whether ventilator decisions made after the education sessions predict those made later in life. Questionnaires were administered to 26 patients and 26 caregivers on four separate occasions. The questionnaires assessed knowledge of ventilatory support, feedback on the nature of the education programme, as well as self-reported emotional well-being. All patients were followed until their death or until initiation of invasive ventilation. Both groups demonstrated significant improvements in knowledge as a result of the education session which was retained after one month. There was no change in patient or caregiver reports' self-reported emotional well-being. The choices of ventilatory support expressed at one month (T4) accurately predicted the real-life clinical choices made by 76% of patients. Any difference resulted from choosing palliative care. Hands-on patient and caregiver education results in improved knowledge, assists in decision-making with respect to ventilatory support, and is not associated with a worsening of affect. It also provides for an accurate prediction of real-life choices and avoids undesired life support interventions and critical care admissions.
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Affiliation(s)
- Douglas A McKim
- Respiratory Rehabilitation Services and The Ottawa Hospital Sleep Centre, Department of Medicine, University of Ottawa, 1201-505 Smyth Road, Ottawa, Ontario, Canada.
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McKim DA, Road J, Avendano M, Abdool S, Côté F, Duguid N, Fraser J, Maltais F, Morrison DL, O’Connell C, Petrof BJ, Rimmer K, Skomro R. Home mechanical ventilation: a Canadian Thoracic Society clinical practice guideline. Can Respir J 2011; 18:197-215. [PMID: 22059178 PMCID: PMC3205101 DOI: 10.1155/2011/139769] [Citation(s) in RCA: 121] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Increasing numbers of patients are surviving episodes of prolonged mechanical ventilation or benefitting from the recent availability of userfriendly noninvasive ventilators. Although many publications pertaining to specific aspects of home mechanical ventilation (HMV) exist, very few comprehensive guidelines that bring together all of the current literature on patients at risk for or using mechanical ventilatory support are available. The Canadian Thoracic Society HMV Guideline Committee has reviewed the available English literature on topics related to HMV in adults, and completed a detailed guideline that will help standardize and improve the assessment and management of individuals requiring noninvasive or invasive HMV. The guideline provides a disease-specific review of illnesses including amyotrophic lateral sclerosis, spinal cord injury, muscular dystrophies, myotonic dystrophy, kyphoscoliosis, post-polio syndrome, central hypoventilation syndrome, obesity hypoventilation syndrome, and chronic obstructive pulmonary disease as well as important common themes such as airway clearance and the process of transition to home. The guidelines have been extensively reviewed by international experts, allied health professionals and target audiences. They will be updated on a regular basis to incorporate any new information.
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Affiliation(s)
- Douglas A McKim
- Division of Respirology, University of Ottawa, and Respiratory Rehabilitation Services, Ottawa Hospital Sleep Centre, Ottawa, Ontario
| | - Jeremy Road
- Division of Respiratory Medicine and The Lung Centre, University of British Columbia, Provincial Respiratory Outreach Program, Vancouver, British Columbia
| | - Monica Avendano
- Respiratory Medicine, West Park Healthcare Centre, University of Toronto
| | - Steve Abdool
- Respiratory Medicine, West Park Healthcare Centre, University of Toronto
- Centre for Clinical Ethics at St Michael’s Hospital, West Park Healthcare Centre, and University of Toronto, Toronto, Ontario
| | | | - Nigel Duguid
- Eastern Health, Memorial University, St John’s, Newfoundland and Labrador
| | - Janet Fraser
- Respiratory Therapy Services, West Park Healthcare Centre, Toronto, Ontario
| | - François Maltais
- Research Centre, University Institute of Cardiology and Lung Health for Québec, Laval University, Québec, Québec
| | - Debra L Morrison
- Sleep Clinic and Laboratory, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia
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Griller N, LeBlanc C, McKim DA. 24-HOUR NONINVASIVE VENTILATION IN DUCHENNE MUSCULAR DYSTROPHY. Chest 2008. [DOI: 10.1378/chest.134.4_meetingabstracts.s66003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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25
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McKim DA, LeBlanc C. Maintaining an "oral tradition": specific equipment requirements for mouthpiece ventilation instead of tracheostomy for neuromuscular disease. Respir Care 2006; 51:297-8. [PMID: 16544438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
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Wilson KG, Aaron SD, Vandemheen KL, Hébert PC, McKim DA, Fiset V, Graham ID, Sevigny E, O'Connor AM. Evaluation of a decision aid for making choices about intubation and mechanical ventilation in chronic obstructive pulmonary disease. Patient Educ Couns 2005; 57:88-95. [PMID: 15797156 DOI: 10.1016/j.pec.2004.04.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2003] [Revised: 03/22/2004] [Accepted: 04/19/2004] [Indexed: 05/24/2023]
Abstract
To assist patients with chronic obstructive pulmonary disease (COPD) in advance planning for life-threatening exacerbations, we developed a structured decision aid that describes the process, risks, and outcomes of intubation and mechanical ventilation (MV). Thirty-three patients with severe COPD took part in a before-after evaluation study. At baseline, only two participants (6%) reported that they had already made an advance decision about MV. After reviewing the decision aid, 31 participants (94%) reported that they had made a choice, which in 23 cases (74% of those deciding) was to forego MV. These choices were associated with more accurate expectations of MV outcome, and reduced decisional conflict. Qualitatively, participants who would accept MV emphasized their wish to prolong life, whereas those who would forego MV were more influenced by the burdens of treatment and the perception of a poor long-term outcome. However, there was evidence that 24% of participants did not completely comprehend the decision aid and 27% found the experience to be stressful. These findings indicate that a decision aid for MV helps patients plan for life-threatening exacerbations, and may be a useful adjunct to counseling for some patients with severe COPD.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Attitude to Health
- Choice Behavior
- Conflict, Psychological
- Decision Support Techniques
- Female
- Health Knowledge, Attitudes, Practice
- Humans
- Informed Consent
- Intubation, Intratracheal/psychology
- Male
- Middle Aged
- Ontario
- Outcome and Process Assessment, Health Care
- Patient Education as Topic/methods
- Patient Education as Topic/standards
- Patient Selection
- Pulmonary Disease, Chronic Obstructive/psychology
- Pulmonary Disease, Chronic Obstructive/therapy
- Qualitative Research
- Respiration, Artificial/psychology
- Risk Assessment
- Social Support
- Stress, Psychological/psychology
- Surveys and Questionnaires
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Affiliation(s)
- Keith G Wilson
- The Rehabilitation Centre, Ottawa, Ont., Canada K1H 8M2.
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27
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Guyatt GH, McKim DA, Weaver B, Austin PA, Bryan RE, Walter SD, Nonoyama ML, Ferreira IM, Goldstein RS. Development and testing of formal protocols for oxygen prescribing. Am J Respir Crit Care Med 2001; 163:942-6. [PMID: 11282770 DOI: 10.1164/ajrccm.163.4.2002135] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The absence of standardized assessment protocols with well- defined measurement properties limits comparison of outcomes among those receiving long-term oxygen therapy (LTOT). We describe simple protocols for a hospital test, a simulated home test, and an actual home test, their reliability and relationship to each other. Stable patients with exercise hypoxemia participated. In 74 patients who completed four exercise tests, correlations between tests ranged from 0.85 to 0.78. Of these 27.0% had the same prescription from all four tests. In 46% prescriptions were within 1 L/ min and in 27% within 2 L/min. During exercise the hospital tests suggested slightly higher oxygen prescriptions than did the simulated home tests (2.5 L/min versus 2.0 L/min, p < 0.001). In 23 patients who participated in actual home assessments, the correlations between the home test, the hospital, and the simulated home tests were 0.22 (95% CI -0.24 to 0.67) and 0.27 (95% CI -0.18 to 0.72). In conclusion, standardizing tests for the assessment of LTOT is important. We describe simple hospital and simulated home tests that are reproducible, easy to carry out, and correlate well with each other.
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Affiliation(s)
- G H Guyatt
- Department of Clinical Epidemiology and Biostatistics and Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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28
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Abstract
OBJECTIVE Almost every country in the developed world has a domiciliary oxygen program. Whether recipients meet program criteria has not been rigorously studied. DESIGN Cross-sectional survey. PARTICIPANTS Two hundred thirty-seven patients receiving domiciliary oxygen in the Ontario Ministry of Health Home Oxygen Program (HOP). METHODS A respiratory therapist visited the patients' homes and administered questionnaires, obtained resting arterial blood gas measurements, and conducted a standardized home exercise test while monitoring oxygen saturation using an oximeter. MEASURES OF OUTCOME We evaluated the extent to which patients met HOP criteria that are based on the inclusion criteria of randomized trials showing the life-prolonging effects of domiciliary oxygen. We also assessed the extent to which the patients' oxygen prescription was consistent with the results of rest and exercise testing. RESULTS Ninety-six of 237 participants (40.5%; 95% confidence interval, 34.3 to 46.8) did not meet criteria for home oxygen. Patients aged < or = 70 years were more likely to meet criteria (71 of 105 patients; 67.9%) than those > 70 years old (70 of 132 patients; 53.0%). The proportion of patients meeting criteria was similar whether the referring physician was a specialist (71 of 112 patients; 62.5%) or a primary-care physician (69 of 123 patients; 56. 1%). A very important health benefit from oxygen was identified among 82% of those who met criteria and 88% of those who did not. Patients received higher flow rates than our criteria suggested were appropriate. Agreement between the independently assessed oxygen prescription at rest and the patients' report of oxygen use was extremely poor (chance-corrected agreement [kappa], 0.17), as was agreement concerning optimal exercise flow rates (kappa, 0.26). CONCLUSIONS Current procedures for administration and reimbursement of home oxygen result in a large proportion of recipients not meeting criteria, as well as the prescription of excessive oxygen flow rates. These results are likely to apply to many jurisdictions and suggest a large potential for more efficient resource allocation.
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Affiliation(s)
- G H Guyatt
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Mahon JL, Laupacis A, Hodder RV, McKim DA, Paterson NA, Wood TE, Donner A. Theophylline for irreversible chronic airflow limitation: a randomized study comparing n of 1 trials to standard practice. Chest 1999; 115:38-48. [PMID: 9925061 DOI: 10.1378/chest.115.1.38] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE To compare quality of life and exercise capacity (primary aim), and drug usage (secondary aim), between groups of patients with irreversible chronic airflow limitation (CAL) who were undergoing theophylline Theo-Dur; Key Pharmaceuticals; Kenilworth, NJ) therapy guided by n of 1 trials or standard practice. DESIGN Randomized study of n of 1 trials vs standard practice. SETTING Outpatient departments in two tertiary care centers. PATIENTS Sixty-eight patients with irreversible CAL who were symptomatic despite the use of inhaled bronchodilators, and who were unsure whether theophylline was helping them following open treatment, were randomized into n of 1 trials (N=34) or standard practice. INTERVENTIONS The n of 1 trials (single-patient, randomized, double-blind, multiple crossover comparisons of the effect on dyspnea of theophylline vs a placebo) followed published guidelines. Standard practice patients stopped taking theophylline but resumed it if their dyspnea worsened. If their dyspnea then improved, theophylline was continued. In both groups, a decision about continuing or stopping the use of theophylline was made within 3 months of randomization. MEASUREMENTS AND RESULTS The primary outcomes (the chronic respiratory disease questionnaire [CRQ] and 6-min walk) were measured at baseline, 6 months, and 12 months by personnel blinded to treatment group allocation. No between-group differences (n of 1 minus standard practice) were seen in within-group changes over time (1 year minus baseline) in the CRQ Physical Function score (point estimate on the difference, -2.8; 95% confidence limits [CLs], -8.2, 2.5), CRQ Emotional Function score (point estimate on the difference, 0.5; 95% CLs, -4.7, 5.7), or 6-min walk (point estimate on the difference, 8 m; 95% CLs, -26, 44 m). No differences between groups were seen in the secondary outcome of the proportion of patients taking theophylline at 6 and 12 months. In 7 of 34 n of 1 trial patients (21%), dyspnea improved during theophylline treatment compared with placebo treatment. CONCLUSIONS Using n of 1 trials to guide theophylline therapy in patients with irreversible CAL did not improve their quality of life or exercise capacity, or reduce drug usa e, over 1 year compared to standard practice. Under the objective conditions of an n of 1 trial, 21% of patients with CAL responded to theophylline. There remains a rationale for considering theophylline in patients with irreversible CAL who remain symptomatic despite the use of inhaled bronchodilators, but the use of n of 1 trials to guide this decision did not yield clinically important advantages over standard practice.
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Affiliation(s)
- J L Mahon
- Department of Medicine, University of Western Ontario, Canada.
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Chow BJ, McKim DA, Shennib H, Dales RE. Superior vena cava obstruction secondary to mediastinal lymphadenopathy in a patient with cystic fibrosis. Chest 1997; 112:1438-41. [PMID: 9367491 DOI: 10.1378/chest.112.5.1438] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Superior vena cava (SVC) obstruction most often is a complication of malignant tumors such as lung cancer or lymphoma. The common use of long-term indwelling central venous catheters also has added to the prevalence of SVC obstruction. This report describes the first case of SVC obstruction in a patient with cystic fibrosis due to extrinsic compression from benign reactive mediastinal lymphadenopathy. Although in these circumstances intravascular thrombosis should be ruled out, extrinsic compression from mediastinal lymphadenopathy should be considered.
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Affiliation(s)
- B J Chow
- Department of Medicine and Respirology, University of Ottawa, Ontario, Canada
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McKim DA, Dales RE, Lefebvre GG, Proulx M. Nocturnal positive-pressure nasal ventilation for respiratory failure during pregnancy. CMAJ 1988; 139:1069-71. [PMID: 3056601 PMCID: PMC1268443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- D A McKim
- Department of Medicine, Ottawa General Hospital, Ont
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