The Combination of Exercise and Respiratory Training Improves Respiratory Muscle Function in Pulmonary Hypertension

Purpose

Increased dyspnea and reduced exercise capacity in pulmonary arterial hypertension (PAH) can be partly attributed to impaired respiratory muscle function. This prospective study was designed to assess the impact of exercise and respiratory training on respiratory muscle strength and 6-min walking distance (6MWD) in PAH patients.

Methods

Patients with invasively confirmed PAH underwent 3 weeks of in-hospital exercise and respiratory training, which was continued at home for another 12 weeks. Medication remained constant during the study period. Blinded observers assessed efficacy parameters at baseline (I) and after 3 (II) and 15 weeks (III). Respiratory muscle function was assessed by twitch mouth pressure (TwPmo) during nonvolitional supramaximal magnetic phrenic nerve stimulation.

Results

Seven PAH patients (4 women; mean pulmonary artery pressure 45 ± 11 mmHg, median WHO functional class 3.1 ± 0.4, idiopathic/associated PAH n = 5/2) were included. The training program was feasible and well tolerated by all patients with excellent compliance. TwPmo was I: 0.86 ± 0.37 kPa, II: 1.04 ± 0.29 kPa, and III: 1.27 ± 0.44 kPa, respectively. 6MWD was I: 417 ± 51 m, II: 509 ± 39 m, and III: 498 ± 39 m, respectively. Both TwPmo (+0.41 ± 0.34 kPa, +56 ± 39 %) and 6MWD (+81 ± 30 m, +20 ± 9 %) increased significantly in the period between baseline and the final assessment (pairwise comparison: p = 0.012/<0.001; RM-ANOVA considering I, II, III: p = 0.037/<0.001).

Conclusions

Exercise and respiratory training as an adjunct to medical therapy may be effective in patients with PAH to improve respiratory muscle strength and exercise capacity. Future, randomized, controlled trials should be carried out to further investigate these findings.     

Medical Simulation in Respiratory and Critical Care Medicine

Simulation-based medical education has gained tremendous popularity over the past two decades. Driven by the patient safety movement, changes in the educational opportunities available to trainees and the rapidly evolving capabilities of computer technology, simulation-based medical education is now being used across the continuum of medical education. This review provides the reader with a perspective on simulation specific to respiratory and critical care medicine, including an overview of historical and modern simulation modalities and the current evidence supporting their use.     

Lung Function and Respiratory Symptoms in Association with Mortality: The HUNT Study

Whether respiratory symptoms are associated with mortality independent of lung function is unclear. The authors explored the association of the exposures i) lung function, ii) respiratory symptoms, and iii) lung function and respiratory symptoms combined, with the outcomes all-cause and cardiovascular mortality. The study included 10,491 adults who participated in the Nord-Trøndelag Health Study (HUNT) Lung Study in 1995–1997 and were followed through 2009. Cox regression was used to calculate adjusted hazard ratios (HRs) with 95% confidence intervals for all-cause and cardiovascular mortality associated with pre-bronchodilator% predicted forced expiratory volume in 1 second (ppFEV₁), chronic obstructive pulmonary disease (COPD) grades, and respiratory symptoms (chronic bronchitis, wheeze, and levels of dyspnoea). Lung function was inversely associated with all-cause mortality. Compared to ppFEV₁ ≥100, ppFEV₁ <50 increased the HR to 6.85 (4.46–10.52) in women and 3.88 (2.60–5.79) in men. Correspondingly, compared to normal airflow, COPD grade 3 or 4 increased the HR to 6.50 (4.33–9.75) in women and 3.57 (2.60–4.91) in men. Of the respiratory symptoms, only dyspnoea when walking remained associated with all-cause mortality after controlling for lung function (HR 1.73 [1.04–2.89] in women and 1.57 [1.04–2.36] in men). Analyses of lung function and dyspnoea when walking as a combined exposure further supported this finding. Overall, associations between lung function and cardiovascular mortality were weaker, and respiratory symptoms were not associated with cardiovascular mortality. In conclusion, lung function was inversely associated with all-cause and cardiovascular mortality, and dyspnoea when walking was associated with all-cause mortality independent of lung function.     

Effect of Vitamin D and Inhaled Corticosteroid Treatment on Lung Function in Children

Rationale: Low vitamin D levels are associated with asthma and decreased airway responsiveness. Treatment with inhaled corticosteroids improves airway responsiveness and asthma control. Objectives: To assess the effect of vitamin D levels on prebronchodilator FEV(1), bronchodilator response, and responsiveness to methacholine (PC(20), provocative concentration of methacholine producing a 20% decline in FEV(1)) in patients with asthma treated with inhaled corticosteroids. Methods: We measured 25-hydroxyvitamin D levels in the serum of children with persistent asthma at the time of enrollment in the Childhood Asthma Management Program. We divided subjects into the vitamin D sufficiency (>30 ng/ml), insufficiency (20-30 ng/ml), and deficiency (<20 ng/ml) groups. Covariates included age, treatment, sex, body mass index, race, history of emergency department visits, hospitalizations, and season that vitamin D specimen was drawn. Our main outcome measures were change in prebronchodilator FEV(1), bronchodilator response, and PC(20) from enrollment to 8-12 months. Measurements and Main Results: Of the 1,024 subjects, 663 (65%) were vitamin D sufficient, 260 (25%) were insufficient, and 101 (10%) were deficient. Vitamin D-deficient subjects were more likely to be older, African American, and have a higher body mass index compared with the vitamin D-sufficient and insufficient subjects. In the inhaled corticosteroid treatment group, prebronchodilator FEV(1) increased from randomization to 12 months by 140 ml in the vitamin D-deficient group and prebronchodilator FEV(1) increased by 330 ml in the vitamin D insufficiency group and by 290 ml in the vitamin D sufficiency group (P = 0.0072), in adjusted models. Conclusions: In children with asthma treated with inhaled corticosteroids, vitamin D deficiency is associated with poorer lung function than in children with vitamin D insufficiency or sufficiency.     

Patient, Primary Care Physician and Specialist Expectations of Primary Care Physician Involvement in Cancer Care

Background  

In Canada, many health authorities recommend that primary care physicians (PCP) stay involved throughout their patients’ cancer journey to increase continuity of care. Few studies have focused on patient and physician expectations regarding PCP involvement in cancer care.     

Bronchial Hyperresponsiveness in Farmers: Relation to Respiratory Symptoms, Lung Function, and Atopy

There is only limited information on the factors associated with nonspecific bronchial hyperresponsiveness (BHR) in farmers. Our purpose was to examine the relationship between BHR and respiratory symptoms, atopy, and abnormalities of lung function in a sample of French farmers. Farmers scheduled for a preventive medicine check-up in northeastern France were examined. Occupational exposure, respiratory symptoms, and work-related symptoms were assessed by questionnaire, sensitization to 34 common and agricultural allergens by skin prick tests, and BHR by the single-dose (1,200 μg) acetylcholine (ACh) challenge test. Data were obtained from 741 farmers (95% of those invited). Seventy-seven subjects (10.3%) had BHR defined as a fall in forced expiratory volume in 1 s (FEV₁) ≥ 10% after the inhalation of ACh or, for those with a poor lung function, an increase in FEV₁ > 10% and > 200 ml after the inhalation of 200 μg of salbutamol. The proportion of asthmalike symptoms, especially wheeze during work, positive skin tests to acarian (storage mites) and cereal dust allergens, and low levels of lung function was significantly greater among reactors than among nonreactors. Stepwise logistic regression analysis showed a significant and independent association between BHR and wheezing during work (OR = 4.99; 95% CI = 2.29–10.89; p= 0.0001) and baseline FEV₁ (OR = 1.49; 95% CI = 1.05–2.20; p= 0.026). In conclusion, hyperreactive farmers had significantly more asthmalike symptoms, positive skin tests, and abnormal lung function than normoreactive farmers. Work-related wheeze and low baseline FEV₁ were significantly and independently associated with BHR. Accepted for publication: 26 January 1999     

Health Outcomes Associated with Lung Function Decline and Respiratory Symptoms and Disease in a Community Cohort

Background: In workplace respiratory disease prevention, a thorough understanding is needed of the relative contributions of lung function loss and respiratory symptoms in predicting adverse health outcomes. Methods: Copenhagen City Heart Study respiratory data collected at 4 examinations (1976–2003) and morbidity and mortality data were used to investigate these relationships. With 15 or more years of follow-up for a hospital diagnosis of chronic obstructive pulmonary disease (COPD) morbidity, COPD or coronary heart disease (CHD) mortality, and all-cause mortality, risks for these outcomes were estimated in relation to asthma, chronic bronchitis, shortness of breath, and lung function level at examination 2 (1981–1983) or lung function decline established from examinations 1 (1976–1978) to 2 using 4 measures (FEV₁ slope, FEV₁ relative slope, American College of Occupational and Environmental Medicine's Longitudinal Normal Limit [LNL], or a limit of 90 milliliters per year [ml/yr]). These risks were estimated by hazard ratios (HR) and 95% confidence intervals (CI) adjusted for age, height-adjusted baseline forced expiratory volume in 1 second (FEV₁/height²), and height. Results: For COPD morbidity, the increasing trend in the HR (95% CI) by quartiles of the FEV₁ slope reached a maximum of 3.77 (2.76–5.15) for males, 6.12 (4.63–8.10) for females, and 4.14 (1.57–10.90) for never-smokers. Significant increasing trends were also observed for mortality, with females at higher risk. Conclusion: Lung function decline was associated with increased risk of COPD morbidity and mortality emphasizing the need to monitor lung function change over time in at-risk occupational populations.     

Relationship between Exhaled Nitric Oxide and Small Airway Lung Function in Normal and Asthmatic Children

BackgroundIn children, exhaled nitric oxide (eNO) is usually confounded by factors such as age and height. We evaluated the relationship between eNO and lung function by minimizing the effects of aging and height.MethodsIn Study 1, the subjects comprised 738 elementary school children and junior high school children (aged 6 to 15 years, 366 males and 372 females). They were divided into two groups according to age (6–10 years and 11–15 years). A height range was determined by a histogram of height in each group. In Study 2, lung function, respiratory resistance and eNO level were measured in age- and height-limited groups.ResultsIn Study 1, total of 148 younger children ranging in height from 120 to 130 cm and 180 older children ranging in height from 148 to 158 cm participated in Study 2. The level of eNO among asthmatic children was higher than that of normal children in both the younger and the older groups. The decrease in forced expiratory volume in 1 second (FEV1) and other parameters of central airway resistance did not correlate with the eNO level. However, the small airway parameters of MMEF and V25/HT in older asthmatic children, and V25/HT and R5-R20 in younger asthmatic children inversely correlated with eNO.ConclusionsOur data suggest that eNO level inversely correlates with small airway narrowing, and airway inflammation has a significant effect on small airway lung function in asthmatic school children.     

Academic Detailing in Diabetes: Using Outreach Education to Improve the Quality of Care

Most diabetes care is provided in primary care settings, but typical primary care clinicians struggle to keep up with the latest evidence on diabetes screening, pharmacotherapy, and monitoring. Accordingly, many patients with diabetes are not receiving optimal guideline-based therapy. Relying on front-line clinicians on their own to assess the huge volume of new literature and incorporate it into their practice is unrealistic, and conventional continuing medical education has not proven adequate to address gaps in care. Academic detailing, direct educational outreach to clinicians that uses social marketing techniques to provide specific evidence-based recommendations, has been proven in clinical trials to improve the quality of care for a range of conditions. By directly engaging with clinicians to assess their needs, identify areas for change in practice, and provide them with specific tools to implement these changes, academic detailing can serve as a tool to improve care processes and outcomes for patients with diabetes.     

Comparison of Asthma-Related Functional Consequences and Health Care Utilization among Children with and without Upper Respiratory Infection-Triggered Wheezing

Objective. We compared differences in functional consequences and health care utilization in middle school-age children, based on whether they reported wheezing triggered by upper respiratory infections (URI-TW). Methods. Information on asthma symptoms, URI-TW, and functional consequence and health care use outcomes was collected from approximately 128,000 children; symptomatic participants were included in the analysis. Adjusted prevalence odds ratios were used to make comparisons. Results. URI-TW was significantly associated with most outcomes examined, with stronger associations at increasing levels of outcomes for sleep disturbances, school absences, activity limitations, physician visits, emergency room visits, hospitalizations, inhaler use, and tablets/pills to help breathing. Conclusion. Children who report URI-TW during their middle school years experience substantial morbidity and high health care utilization compared with symptomatic children without URI-TW.     

Lower Respiratory Tract Infection and Genus Enterovirus in Children Requiring Intensive Care: Clinical Manifestations and Impact of Viral Co-Infections

Infection by rhinovirus (RV) and enterovirus (EV) in children ranges from asymptomatic infection to severe lower respiratory tract infection (LRTI). This cohort study evaluates the clinical impact of RV/EV species, alone or in codetection with other viruses, in young children with severe LRTI. Seventy-one patients aged less than 5 years and admitted to the Paediatric Intensive Care Unit (PICU) of a reference children’s hospital with RV or EV (RV/EV) LRTI were prospectively included from 1/2018 to 3/2020. A commercial PCR assay for multiple respiratory pathogens was performed in respiratory specimens. In 22/71, RV/EV + respiratory syncytial virus (RSV) was found, and 18/71 had RV/EV + multiple viral detections. Patients with single RV/EV detection required invasive mechanical ventilation (IMV) as frequently as those with RSV codetection, whereas none of those with multiple viral codetections required IMV. Species were determined in 60 samples, 58 being RV. No EV-A, EV-C, or EV-D68 were detected. RV-B and EV-B were only found in patients with other respiratory virus codetections. There were not any associations between RV/EV species and severity outcomes. To conclude, RV/EV detection alone was observed in young children with severe disease, while multiple viral codetections may result in reduced clinical severity. Differences in pathogenicity between RV and EV species could not be drawn.     

Association Between Primary Care Visits and Colorectal Cancer Screening Outcomes in the Era of Population Health Outreach

Background

Population outreach strategies are increasingly used to improve colorectal cancer (CRC) screening. The influence of primary care on cancer screening in this context is unknown.

Objective

To assess associations between primary care provider (PCP) visits and receipt of CRC screening and colonoscopy after a positive fecal immunochemical (FIT) or fecal occult blood test (FOBT).

Design

Population-based cohort study.

Participants

A total of 968,072 patients ages 50–74 years who were not up to date with CRC screening in 2011 in four integrated healthcare systems (three with screening outreach programs using FIT kits) in the Population-Based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium.

Measures

Demographic, clinical, PCP visit, and CRC screening data were obtained from electronic health records and administrative databases. We examined associations between PCP visits in 2011 and receipt of FIT/FOBT, screening colonoscopy, or flexible sigmoidoscopy (CRC screening) in 2012 and follow-up colonoscopy within 3 months of a positive FIT/FOBT in 2012. We used multivariable logistic regression and propensity score models to adjust for confounding.

Results

Fifty-eight percent of eligible patients completed a CRC screening test in 2012, most by FIT. Those with a greater number of PCP visits had higher rates of CRC screening at all sites. Patients with ≥1 PCP visit had nearly twice the adjusted-odds of CRC screening (OR?=?1.88, 95 % CI: 1.86–1.89). Overall, 79.6 % of patients with a positive FIT/FOBT completed colonoscopy within 3 months. Patients with ≥1 PCP visit had 30 % higher adjusted odds of completing colonoscopy after positive FIT/FOBT (OR?=?1.30; 95 % CI: 1.22–1.40).

Conclusions

Patients with a greater number of PCP visits had higher rates of both incident CRC screening and colonoscopy after positive FIT/FOBT, even in health systems with active population health outreach programs. In this era of virtual care and population outreach, primary care visits remain an important mechanism for engaging patients in cancer screening.

     

Exercise Capacity Improves after Transcatheter Closure of the Fontan Fenestration in Children

Objectives. This study evaluated the aerobic capacity, exercise capacity, and arterial oxygen saturation (O₂Sat) in children before and after transcatheter Fontan fenestration closure. Design. Observational study comparing exercise parameters and hemodynamics before and after transcatheter fenestration closure in Fontan patients. Outcome Measures. Working capacity, exercise duration, oxygen consumption (VO₂), and arterial O₂Sat were evaluated during aerobic exercise. Results. Twenty patients (mean age 11.4 years) underwent standardized exercise testing before and after fenestration closure. Twelve patients underwent cycle ergometry testing (mean age 14.8 years) (group1), and eight younger patients (mean age 6.4 years) underwent Bruce treadmill testing (group 2). The same exercise protocol was used in each patient before and after fenestration closure (interval between tests: 118 ± 142 days). Immediately following fenestration closure at cardiac catheterization, cardiac index decreased (3.0 to 2.1 L/minute/m²) and Fontan pressure increased (11 ± 2 to 12 ± 2 mm Hg) with an increased arterial saturation (92 to 96%) (P < .001). The total group demonstrated no significant change in pre‐ and postclosure maximal heart rates (164 ± 21 and 169 ± 19 bpm). Rest and exercise O₂Sat increased (89 and 82 to 95 and 92%) (P < .0001). Exercise duration increased (7.7 ± 1.9 to 9.2 ± 2.4 minutes) (P < .0005). Maximal VO₂, indexed maximal VO₂, and total working capacity in kilopond‐meters (kpm) increased (1.2 ± 0.5, 27 ± 7 and 2466 ± 1012 to 1.3 ± 0.4 L/minute, 31 ± 9 mL/kg/minute and 2869 ± 1051 kpm, respectively) (P < .005). Conclusion. In children with a univentricular heart after Fontan palliation, transcatheter fenestration closure improves exercise arterial O₂Sat and aerobic capacity despite a restricted resting cardiac output documented by catheterization immediately after the closure procedure.     

Lung Ultrasound for the Diagnosis and Management of Acute Respiratory Failure

For critically ill patients with acute respiratory failure (ARF), lung ultrasound (LUS) has emerged as an indispensable tool to facilitate diagnosis and rapid therapeutic management. In ARF, there is now evidence to support the use of LUS to diagnose pneumothorax, acute respiratory distress syndrome, cardiogenic pulmonary edema, pneumonia, and acute pulmonary embolism. In addition, the utility of LUS has expanded in recent years to aid in the ongoing management of critically ill patients with ARF, providing guidance in volume status and fluid administration, titration of positive end-expiratory pressure, and ventilator liberation. The aims of this review are to examine the basic foundational concepts regarding the performance and interpretation of LUS, and to appraise the current literature supporting the use of this technique in the diagnosis and continued management of patients with ARF.

     

Evaluation and Peer Review of the Role of Specialist and General Medical Units in a Teaching Hospital

Summary: Evaluation and peer review of the role of specialist and general medical units in a Caching hospital.
The trend toward increasing specialization in the medical wards of teaching hospitals has important implications for future health care delivery and student teaching. A study of the likely implications of a change to a specialty oriented medical admission system at the Royal Adelaide Hospital has shown that already the general physicians are seeing little renal and endocrine disease and, that work satisfaction is greater on the specialty units than on the general medical units. Patient satisfaction marginally favoured the specialty units.
A peer review audit method was introduced to try and discern whether the quality of care was significantly different on the two types of units. Most physicians cooperated in at least one or two audits which involved them in judgements about adequacy of casenotes, management decisions, follow-up arrangements, length of stay and investigations in randomly assigned specialty pairs of patients (cared for by specialist or general units). No clear-cut trend was discerned favouring specialist or genera list care amongst 17 randomly selected pairs, but this part of the study was never completed, perhaps partly because of lack of enthusiasm for it by busy clinicians. The importance of maintaining a model of generalism for medical students on the teaching hospital campus is discussed in the light of the decline of the role of general physicians.     

Role of Adenoidectomy in Otitis Media and Respiratory Function

Adenoidectomy is among the most frequent surgical procedures performed on children. The rationale for adenoidectomy is to remove a chronically infected or enlarged and obstructing adenoid. Adenoidectomies are performed on children who have recurrent or chronic otitis media with effusion, on children with chronic rhinosinusitis, and on children with nasopharyngeal obstruction causing sleep disturbances and continuous mouth breathing. Various underlying factors that lead to adenoidectomy are also associated with asthma. Asthma is associated with recurrent respiratory tract infections predisposing individuals to recurrent or chronic otitis media and chronic rhinosinusitis. Children with asthma also have an increased risk of sleep-disordered breathing that is treated with adenoidectomy in the presence of nasopharyngeal obstruction. In nonasthmatic children, adenoidectomy does not influence the development of IgE-mediated allergy, bronchial hyperreactivity, or exhaled nitric oxide concentrations, all of which are surrogate asthma markers. Adenoidectomy in selected asthmatic children may relieve comorbidities associated with asthma.