1. health and fitness
2. disease
3. asthma

“The breadth and depth
of clinical knowledge and
credibility the ORCS and
OTS contribute distinguish
our organization and
help to make us leaders
in lung health."
George Habib
President & CEO, Ontario
Lung Association
W I N T E R
2 0 0 8
Features
In this Issue
V O L U M E
2 4 ,
N U M B E R
1
Acute Exacerbations of COPD:
Acute Exacerbations
of COPD . . . . . . . . . . . . . . . 1
A Review of Medical Management and
the Role of Pulmonary Rehabilitation
Better Breathing 2008
Jocelyn Carr, PT, MSc, BScPT, Care Coordinator, West Park Healthcare Centre, Toronto
Register today! . . . . . . . . . . . 3
The OLA: Where Lung
Health is Going
A message from George Habib,
President & CEO . . . . . . . . . . 5
In the Spotlight
Congratulations to
Dr. Dina Brooks . . . . . . . . . . 5
Living with COPD:
A Patient’s Perspective
Brenda Cunningham shares
her story . . . . . . . . . . . . . . . . . 6
Smoke-Free Ontario
Important work continues . . . . 8
Posters for Better
Breathing . . . . . . . . . . . . . . 9
Around the Regions . . . 10
Regular Columns
Chair’s Message . . . . . . . . . . . 2
Editor’s Comment . . . . . . . . . . 2
Coming Events . . . . . . . . . . . . 3
Respiratory Articles of Interest. . 7
www.on.lung.ca
Background
potential causes for illness.18 General
Chronic obstructive pulmonary
laboratory work is not recommended
disease (COPD) is characterized by
except for arterial blood gases19 which
the presence of airflow obstruction due
help determine the need for assisted
to chronic bronchitis or emphysema.1,2
ventilation in patients presenting with
In Canada, its estimated prevalence is
low oxygen saturation.18,20 Sputum
5.7%.3 Among the five most common
studies should be obtained in patients
diseases, its morbidity and mortality
with “very poor lung function,
are the only ones that continue to rise4,
frequent AEs or who have been on
JOCELYN CARR
and are expected to rise further. For
antibiotics in the previous three
these reasons, the importance of managing months” to optimize antibiotic treatment and
COPD will increase.
minimize drug resistance.18 Additionally, chest xThe natural course of COPD is that of rays are recommended for patients presenting
repeated acute exacerbations (AEs) which are with severe AEs, to rule out other pathology, as
defined as changes in purulence, viscosity or an estimated 16 to 21% of those arriving at acute
volume of sputum production and/or an increase care settings have x-ray findings requiring
in dyspnea5, and may be associated with other adjustments to treatment.20,21 As spirometry is
symptoms such as increased cough or wheeze, difficult to obtain during AE, it is not
for at least two consecutive days.6 The mean recommended for patients with known
frequency of AEs in patients with severe COPD respiratory disease. Otherwise, spirometry may
is one to four per year.6-8 Three to 16% require be indicated with full PFTs recommended once
hospitalization6,9 and in severe AEs, mortality is the patient is stable.18,23
up to 10%.10,11 Although increased inflammatory
activity and worsened airway obstruction are Medical Management of Acute
found during AEs12, infections (viral, bacterial or a Exacerbations of COPD
combination of the two) account for up to 80%.13-17 Medical approaches include pharmacological
The recommended treatments are based on anti- treatment, oxygen therapy, non-invasive positive
pressure ventilation (NIPPV) and mechanical
inflammatory and anti-microbial mechanisms.
ventilation depending on the degree of symptom
severity.18,23 Acute dyspnea requires inhaled
Diagnosis of Acute Exacerbations of COPD
Diagnosis of an AE is made using the history and bronchodilator treatment.18 Initially short-acting
Continued on page 4
physical examination and must rule out other
UPDATE
An official publication of the Ontario
Respiratory Care Society, a section of
The Lung Association
573 King Street East
Toronto, Ontario M5A 4L3
(416) 864-9911 Fax (416) 864-9916
E-mail: orcs@on.lung.ca
Internet: http://www.on.lung.ca
CO-EDITORS
Dina Brooks, Ph.D., M.Sc., B.Sc.P.T.
Libby Groff, RRT, B.H.A.
CHAIR, ONTARIO RESPIRATORY
CARE SOCIETY
Julie Duff Cloutier, RN, BScN, MSc, CAE
CHAIR, ONTARIO LUNG
ASSOCIATION
Jane Wallingford
PRESIDENT & CEO,
ONTARIO LUNG ASSOCIATION
George Habib, BA, BEd, CAE
DIRECTOR, ONTARIO
RESPIRATORY CARE SOCIETY
Sheila Gordon-Dillane, BA, MPA
EDITORIAL BOARD
Yvonne Drasovean, RRT
Therese Hawn, B.Sc.P.T.
Lawrence Jackson, B.Sc.Phm.
Elizabeth McLaney, BA, B.H.Sc.(O.T.)
Mika Nonoyama, RRT, Ph.D.(c)
Dale Stedman, RN
Rosalynn St. Germain, RRT
Reny Vaughan, RRT
Opinions expressed in Update do not
necessarily represent the views of The
Lung Association nor does publication
of advertisements constitute official
endorsement of products and services.
The printing of this publication is
sponsored by a generous unrestricted
educational grant from Pfizer Canada.
ONTARIO RESPIRATORY
CARE SOCIETY
Vision
Improved lung health through
excellence in interdisciplinary
respiratory care.
Mission
Furthering excellence in the
provision of interdisciplinary
respiratory care through education,
research, collaboration, provision
of professional expertise and
support for Lung Association
efforts to improve lung health.
2
CHAIR’S MESSAGE
etter Breathing 2008 will be soon
upon us. The planning committee
has worked very hard to ensure an
energizing few days. This year’s
conference will be once again held at
Toronto Marriott Downtown Eaton
Centre from January 31 to February 2,
2008. I hope you will take advantage of
this spectacular conference. Be sure to
register early! Take this opportunity to learn
something new, meet new colleagues, and enjoy
all the benefits of your ORCS membership!
I would like to welcome George Habib as the
new President and CEO of the Ontario Lung
Association. The ORCS looks forward to
working with Mr. Habib to advance the
objectives of the ORCS and to continue to
support the work of The Lung Association in
such areas as patient and public education,
advocacy and development. I would also like to
express sincere appreciation on behalf of the
ORCS to Cindy Shcherban, who served as
B
Interim President and CEO for much
of 2007.
The Provincial Committee welcomes
Dilshad Moosa, the new GTR
Representative, replacing Paula
Cripps-McMartin, who has taken
on the role of Greater Toronto
Representative on the Membership
and Program Promotion Committee.
Thank you to Paula for her many contributions to
the work of the Provincial Committee during the
past several years.
I urge you to get involved with the ORCS by
joining one of our various committees or through
attending educational events. Don’t forget to
bring your colleagues and students along to
introduce them to all the benefits of ORCS
membership. For additional information, feel
free to contact Sheila Gordon-Dillane (orcs@
on.lung.ca) or myself (jduffcloutier@laurentian.ca).
See you at Better Breathing 2008!
JULIE DUFF CLOUTIER, CHAIR, ORCS
EDITOR’S COMMENT
appy New Year! I am not sure
where the fall went but it seemed
to have been a flurry of new students,
research grant applications and of
course kids’ hockey games. The
Editorial Board has worked on a new
issue of Update. Jocelyn Carr has
written a nice narrative summary on
acute exacerbations in COPD, a topic
of her M.Sc. thesis that was supported by an
ORCS Fellowship Award. We also have the
perspective of a patient with COPD by Brenda
Cunningham of Sudbury, originally presented as
a talk last April at the ORCS Northeastern
H
Ontario Region’s Sudbury seminar.
Joanne Di Nardo, a staff member of the
Ontario Lung Association, has written
an update on Smoke-Free Ontario. We
are also pleased to include some
comments to ORCS members from
Mr. George Habib, the new CEO of the
Ontario Lung Association. We hope
that you enjoy this issue and look
forward to seeing you at the Better Breathing
conference in Toronto.
Thank you very much to Pfizer Canada for
sponsoring the printing of this issue of Update.
DINA BROOKS, CO-EDITOR
Become an ORCS member or renew
your membership for 2008-2009
Individual $40; Student $25; RHEIG add $15
Call (416) 864-9911 for information or visit www.on.lung.ca/orcs
U PDATE W INTER 2008
BETTER BREATHING 2008:
COMING
LIFESTYLE AND THE LUNGS EVENTS
Exhibits, networking, social events and more!
egister today for The Lung Association’s
annual conference, Better Breathing 2008,
scheduled for January 31 - February 2, 2008 at
the Toronto Marriott Downtown Eaton Centre
hotel at 525 Bay St., Toronto. The ORCS
program offers a wide range of topics of interest
to people working in many respiratory care
settings including acute, chronic and critical care
in hospitals, rehabilitation, community care,
public health and education.
R
Conference Highlights
Thursday, January 31 (2 concurrent sessions)
• ORCS Respiratory Health Educators Interest
Group (RHEIG) annual session with a
presentation on Ontario’s Chronic Disease
Prevention and Management Framework and
four workshops on Patient Education Resources
for Asthma Education, Obesity and Lung
Health, Using Evidence-Based Methods for
Behavioural Modification in Practice and
Rehabilitation Pre and Post Lung Transplantation
• ORCS Critical Care Program – lectures on ICU
Pharmacology: What’s New?, Update on
Suctioning Guidelines for Adults and Treatment
of Traumatic Lung Injury due to Burns, Smoke
Inhalation and CO Poisoning
• Reception and Workshop presented by
AstraZeneca – Celebrating Asthma Educator
Leadership: Taking the Asthma Circle of Care
to the Community.
Friday, February 1
• Plenary Session: Lifestyle and the Lungs - Dr.
Andrew Pipe will discuss Smoking Cessation:
What Every Health Professional Must Know
and Dr. Robert Butcher will address Duty to
Care: Limits and Responsibilities
• ORCS and OTS joint scientific session, entitled
What’s New in Lung Health featuring talks on
Smoking and Screening: Are We Still in the 20th
Century?, Asthma Management in the
Emergency Department: The Ontario
Experience and Long-term Sequelae of
Bronchopulmonary Dysplasia
• Friday afternoon ORCS sessions addressing
Bronchial Thermoplasty: A Novel Treatment for
Asthma, Guidelines for Home Oxygen Therapy
and Effects of Air Pollution on Lung Health
• A Meet and Mingle Reception for all delegates
and exhibitor representatives featuring poster
presentations, awards, recognition of long-term
members, food stations, cash bar and
entertainment.
Saturday, February 2
• Concurrent
workshops
on
research,
rehabilitation, acute care and critical care topics
• ORCS/OTS Luncheon with Dr. Shawn Aaron
on Chronic Management of COPD, presented
by Boehringer Ingelheim and Pfizer Canada.
Thank you to our sponsors: Presenting Sponsor:
GlaxoSmithKline,
Platinum
Sponsors:
AstraZeneca, Novartis and Boehringer Ingelheim
and Pfizer Canada, Bronze Sponsors: Nycomed
and Professional Respiratory Home Care
Services, and to our exhibitors.
Please visit www.on.lung.ca/bb08 for the full
program and on-line registration or call (416)
864-9911, ext. 256 for information. Register
before January 21 to avoid the late fee.
ORCS ANNUAL GENERAL MEETING
February 1, 2008, 2:15 p.m., Grand Ballroom CD
Toronto Marriott Downtown Eaton Centre Hotel
Support The Lung
Association’s Christmas
Seal Campaign.
www.on.lung.ca
W INTER 2008 U PDATE
January 31 – February 2, 2008*
Better Breathing 2008, Lifestyle and
the Lungs – Toronto Marriott
Downtown Eaton Centre Hotel. See
article for details.
March 1, 2008
The IUATLD North American
Region’s
annual
conference,
Tuberculosis: A Disease Without
Borders, will be held in San Diego,
California. Visit www.bc.lung.ca.
April 10, 2008*
The ORCS, Eastern Ontario Region
will hold a full day seminar at The
Holiday Inn Kingston. Details to
follow.
May 16 – 21, 2008
The American Thoracic Society
annual conference will be held in
Toronto. Contact ats2008@thoracic.org.
May 22 – 25, 2008
The Canadian Society of Respiratory
Therapy National Conference and
Trade Show will be held in
Saskatoon. Visit www.csrt.ca.
May 29 – June 1, 2008
The
Canadian
Physiotherapy
Association’s National Congress
2008 will be held at the Westin
Hotel Ottawa. Visit www.physiotherapy.ca.
June 4, 2008
The ORCS, Southwestern Ontario
Region will hold a full day seminar
at the Best Western Lamplighter
Inn, London. Details to follow.
June 19 – 21, 2008
The 1st Canadian Respiratory
Conference, A Breath of Fresh Air,
will be held at the Hilton
Bonaventure Hotel in Montréal,
Québec. Visit www.lung.ca/crc.
*For further information on
upcoming ORCS programs, call
(416) 864-9911, e-mail orcs@
on.lung.ca or visit the Events page
on the web site at www.on.lung.ca/orcs.
3
Acute Exacerbations of COPD... Continued from page 1
beta-2 agonists and anti-cholinergics are
recommended. Although no difference has
been shown between using metered dose
inhalers (MDIs) with a spacing device for
inhaled medication and the nebulized
form18, it is important to note that this
evidence was collected on patients able to
use MDIs effectively. Acutely dyspneic
patients who cannot take, or hold, a deep
breath may require nebulized treatments24
until breathing control is re-established.
Oral methylxanthines should not be
initiated but may be continued if a patient is
already on this medication.18
Oral corticosteroids, targeting the
inflammatory component, improve shortterm outcomes such as FEV1 and length of
stay25-27, and reduce the risk of treatment
failure by 10%.24 Due to potential sideeffects the course should be kept to between
seven and 14 days18, as no further
significant improvement occurs.25,26
Antibiotics are also indicated.18 Patients
with more severe AEs derive more
benefit5,19,28 and significantly lower
treatment failure rates have been found with
their use.29,30 Antibiotic treatment reduces
the bacterial load and inflammatory
response31, shortens AE duration32 and
increases the time to the next AE.33
While the evidence supports antibiotic
use, it is true that pathogens are becoming
resistant, so despite the higher cost, it is
recommended that newer antibiotics, such
as fluoroquinolones, which have lower
treatment failure rates34,35, be given to
patients with more severe or more frequent
AEs. A different class of antibiotic is
recommended if a patient has received
antibiotics in the previous three months.18
Purulent sputum appears to be highly
predictive of positive bacterial culture with
84% of those with purulent sputum having
positive cultures (compared to 38% of those
with mucoid sputum).36 It has therefore
been proposed that guidelines be altered to
recommend antibiotics only be used in
patients with purulent sputum.18
Hypoxemia during AEs can become lifethreatening. Treatment with oxygen therapy
offsets pulmonary vasoconstriction, improves
cardiac output and oxygenation to vital organs37
but can worsen hypercapnia.38-40 Because
patients with hypercapnia are at the greatest
risk for respiratory failure39, keeping the
oxygen provided as low as possible, while
maintaining a PaO2 of 60mmHg, is recommended.40
4
Studies have found NIPPV to be
effective during AEs.41,42 It is less invasive
than full mechanical ventilation and costeffective.43 Clinical improvement occurring
within the first hour, reduced relative risks
of treatment failure, mortality, intubation
and complications, as well as a 3-day mean
reduction in length of stay have been
found.44 Thus, NIPPV should be considered
for patients with respiratory failure. Those
who do not improve within the first four
hours may require full mechanical
ventilation.45,46 If this occurs, the risks of
morbidity and mortality increase.47
Prevention of future AEs, also part of
medical management, involves smoking
cessation, influenza vaccination, and
effective action plans with education about
the self-management of symptoms. Action
plans are individually tailored plans for
managing symptoms and comprise both
pharmacological and non-pharmacological
approaches.48 The physician must educate
the patient and write specific medication
plans. Other members of the healthcare
team can provide education about
identifying signs and symptoms of AEs and
reinforcement
of
the
physician’s
instructions.
Self-efficacy is an important factor that
impacts on the self-management of AEs.49
To be effective patients must have
confidence in their ability to cope.49 Disease
specific self-management can lower
hospital utilization and improve health
status.50 The educational components of
most PR programs are targeted at improving
patients’ abilities to manage their disease,
so PR should be considered important
preventive care.
Role of Pulmonary Rehabilitation
after Acute Exacerbation
Despite most AEs being managed in the
community17, research has focused
predominantly on hospital admissions,
discharge planning, lengths of stay,
survival, pharmaco-therapy, and the
recovery of pulmonary function.25,26,51 Little
attention has been paid to follow-up after
acute illness or to non-pharmacological
approaches that help regain exercise
capacity and HRQL. The main objectives of
PR after AE are to enhance HRQL, to treat
muscle weakness and to improve functional
exercise capacity, which are predictors of
repeated AEs and mortality.52
A systematic review comparing the
effects of PR with usual care after AE found
a reduced risk for unplanned hospital
admissions following PR with a
consistently favourable effect on HRQL,
significant benefits in exercise capacity and
significantly decreased relative risks of
death.52 While the number of patients was
small, the effect of PR after AE appears to
be larger than the effect of PR in stable
COPD patients.52
In an RCT on subjects who had
completed a PR program53, the yearly
hospitalization and AE rates were
significantly reduced in both groups in the
2-year period following an initial PR
program. The group that received repeat-PR
at 1-year had a further reduction in AEs.53
While a paucity of literature about AEs
in those who have completed PR and about
the effect of AEs on functional exercise
capacity in individuals with COPD
exists54,55, a recent study characterizes
moderate and severe AEs in individuals
with moderate or severe COPD who
previously attended PR. Significantly lower
functional exercise capacity and HRQL
were found four weeks post-AE despite the
majority of the group experiencing
moderate (non-hospitalized) AEs and
concluding that AEs have a larger impact
than previously thought.55
The importance of PR is becoming more
apparent and early referral must be
considered for all those diagnosed with
COPD. Its large educational component,
targeting improved self-management, may
reduce delays in seeking treatment for AEs,
while the exercise training component,
targeting improved functional exercise
capacity, may decrease repeated hospital
admissions, essentially reducing the overall
impact of AEs.
References
1. Celli B, MacNee W, Agusti A, Anzueto A, Berg B, Buist A
et al. Standards for the diagnosis and treatment of patients with
COPD: A summary of the ATS/ERS position paper. Eur Respir
J 2004;23(6):932-946.
2. Morgan M, Calverley P, Clark C, Davidson A, Garrod R &
Goldman J. BTS statement. Pulmonary rehabilitation. Thorax
2001;56:827-834.
3. Lacasse Y, Brooks D & Goldstein RS. Trends in the
epidemiology of chronic obstructive pulmonary disease in
Canada, 1980-1995. Chest 1999;116:306-313.
4. Bernier M & Leonard B. Pulmonary rehabilitation after
acute COPD exacerbation. Critical Care Nursing Clinics of
North America 2001;13(3):375-387.
5. Anthonisen NR, Manfreda J, Warren CP, Hershfield ES,
Harding GKM, Nelson NA. Antibiotic therapy in exacerbation
of chronic obstructive pulmonary disease. Ann Intern Med
Continued on page 11
U PDATE W INTER 2008
THE ONTARIO LUNG ASSOCIATION:
Where Lung Health is Going
George Habib, President & CEO
The Lung Health Framework that demands more attention and resources.
n the heels of our successful
is another important initiative for
We would like to see a COPD Strategy
Holiday Ice campaign, I
the Ontario Lung Association. In modeled after our successful Asthma
thought I would quote Canadian
February, I will join several Action program that incorporates a full
hockey great Wayne Gretzky who
ORCS members and other spectrum of care. We were pleased to be
is known for saying, “I don’t
representatives of the respiratory recently named the lead organization in a
skate to where the puck is; I skate
community at a forum to discuss new Emergency Department project
to where it’s going.” As we see it,
provincial lung health issues, charged to implement asthma treatment
chronic and acute lung disease is
building on the work of a national guidelines in hospitals across the province.
becoming a bigger issue for
GEORGE HABIB
forum that was held last April. As well, we are committed to our tobacco
individuals, our over-burdened
healthcare industry and government. It is We look forward to sharing our provincial control programs and strive to keep air
with this philosophy the Ontario Lung perspective with colleagues at the national quality top of mind as environmental issues
continue to grab headlines and shape public
Association welcomes 2008 and the level.
Closer to home, we will continue to opinion.
opportunities a new year and new
advance our proposed COPD Strategy for
I look forward to working with the
perspective bring.
At the time of printing I will have been Ontario which we submitted to the Ministry ORCS in the months ahead and will make
in my position as President and CEO for a of Health and Long-Term Care in 2007. A every effort to meet members at the
mere 15 weeks. However in this short time recent report on Smoking and COPD in upcoming Better Breathing Conference.
I have had the pleasure of meeting many Canada released by the Canadian Lung
Yours in health,
ORCS members and am struck by Association confirms the increased risk and
George Habib
everyone’s willingness to get involved with prevalence of COPD, a leading health issue
our mission and the shared passion we all
have for improving lung health and
respiratory care in Ontario.
As a lung health organization, the
Ontario Lung Association values our
partnership with our two medical
he Lung Association’s prestigious Meritorious Service
societies, the Ontario Respiratory Care
Award will be presented to Dr. Dina Brooks at Better
Breathing 2008. Dina has served as a member or co-chair of
Society and the Ontario Thoracic Society.
the ORCS Editorial Board and a member of the Provincial
The breadth and depth of clinical
Committee since 1995 and has contributed greatly to ORCS
knowledge and credibility you contribute
programs, especially the Society’s publications. She has
distinguish our organization and are one of
arranged for numerous Update articles to be written and is a
the reasons we are highly respected and
skilful editor. Under her leadership, the Board initiated the
sought after leaders in lung health. This
Respiratory Articles of Interest and In the Spotlight columns.
was recently evidenced in our ability to
Dina
was
instrumental
in the creation of the ORCS Research Update
mobilize efficiently and take full advantage
publication and its successor, the joint OTS/ORCS Research Review. She has
of the public platform M.P.P. David
been the Principal or Co-Investigator on many research grants funded by the
Orazietti presented when he proposed Bill
ORCS. Dina is an Associate Professor in the Department of Physical Therapy
11, the amendment to the Smoke-Free
at the University of Toronto, a Research Associate at West Park Healthcare
Ontario Act that would see legislation
Centre and Co-Chair of the Canadian COPD Alliance. She is recognized
extend to private vehicles to protect nationally and internationally as a leading researcher in the f ields of cardiochildren under the age of 16 from second- respiratory physiotherapy and COPD and was recently awarded a Canada
hand smoke. We fully support this Research Chair in Rehabilitation in COPD. Dina has encouraged her students
legislation and will further our efforts in the to study those areas and to join and volunteer for the ORCS and has also been
next year to ensure that the Bill is accepted. involved in the development and evaluation of Lung Association patient
Expect to hear from us on this issue as your education programs for individuals with COPD. We are pleased to put Dina
continued support and participation are Brooks in the Spotlight to recognize her many contributions to respiratory care
critical.
and to the ORCS.
O
In the Spotlight: Dina Brooks
T
W INTER 2008 U PDATE
5
LIVING WITH COPD: A Patient’s Perspective
Brenda Cunningham, TEAM COPD Ambassador, Sudbury and District
From a talk presented at the ORCS, Northeastern Ontario Region Seminar, April 2007
s you know, COPD is devastating. You become
visits, “Come on in Brenda, pull up a chair, let’s have a
increasingly short of breath, suffer panic and
smoke and discuss why you are so short of breath”, and
anxiety, and stay at home because it is too much bother
when it was time to leave he would say, “ You know if you
to get dressed and go out. As a result, you become very,
lost a few pounds it might help your shortness of breath”.
very lonely and there are days when you want to just curl
You will not see that happen in today’s society. I
up in a ball and die. I have had many of those days since
continued to smoke for almost 20 years. That and the fact
I started down the road with COPD.
that I was already predisposed to COPD is probably why
COPD has been a big part of my life for over 34 years.
the onset came at such an early age.
My father was diagnosed with Emphysema in his early
At 33, I was experiencing increased shortness of
forties. In 1973 he was tested for the genetic disorder BRENDA CUNNINGHAM breath, some wheezing and a nagging little cough. I had
Alpha-1 Antitrypsin Deficiency (A1AD). The result was positive: new family, of which one was a premature infant, who had been
he was a FZ (a dysfunctional allele and a deficiency allele). So the born at only 25 weeks gestation and was now a very active 1 year
process began and the family members who agreed to be tested got old, and a teenager about to start high school. We had only recently
back their results. Can you believe it? I was the only one diagnosed moved to Sudbury. This increased my stress levels and difficulty in
a ZZ (two deficiency alleles, associated with high risk for lung breathing. I was not fully at ease with my new physician, my
damage). This meant that my mother also had to be a carrier of the condition was becoming more severe, as were my panic attacks, but
Z gene. I received a letter telling me I had an extremely rare genetic I still had a young family to care for so I had to remain strong and
disorder and should not smoke. What did that mean to me? could not put myself first. So for the most part I split my time
Absolutely nothing, back then. I was young, invincible and very between home, the Memorial Hospital ER and a Family Doctor
confident nothing would happen to me.
with whom I had very little rapport.
From 1973 to 1980 I watched a man I adored deteriorate before
Fortunately for me a new young doctor was opening up a
my eyes and finally succumb to the disease. He had smoked from practice and he accepted me as his patient. I trusted him
the time he was 10 until just shortly before he passed away; he just immediately and luckily, he was familiar with COPD and AlAD. He
couldn’t seem to stop. My father did not have access to the spent time with me during my panic attacks, my severe migraines,
medications, information, professional expertise nor had he the but most importantly, he truly understood the effects this disease
support system to allow him a good quality of life that today’s was having on me. He believed because of my family history of
patients suffering from COPD have available.
heart and lung disease that I needed a structured supervised
For my Dad, life ended years before he died. He was devastated exercise program so he sent me to Cardiac Rehab. It was working
when he was diagnosed. He lost his job or should I say jobs and I was more upbeat and had more energy. Because of financial
because he maintained two for most of his life. He could no longer commitments however, I stopped to go to work outside the home.
drink and most of his friends were either working buddies or Of course this only lasted a few years and with the breathlessness
drinking buddies and when the going got tough they stopped increasing, I soon was forced to leave my job and was readmitted to
showing up. He became despondent, angry, depressed, and as a the Cardiac program. I started developing a lot of headaches after the
result the entire family was in turmoil. I watched my Dad as he exercise on a constant basis. So my doctor referred me to a
passed through the stages all patients with a chronic illness do and Respirologist and Spirometry tests were ordered. I was diagnosed
vowed it would never be that way with me. So easy to say when you with advanced COPD and put on medication. I finally quit smoking.
are in your twenties and can still take a deep breath.
Now I had to face it. I had COPD but I felt that if I didn’t say it
As I look back at my childhood, little things pop to mind that out loud I could pretend that everything was okay. I bargained with
should have put up a red flag for the medical profession, things that God to let me live until my boys were old enough to take care of
should have indicated that something was wrong. When I had a themselves. For almost 10 years I kept up this pretence although
chest cold, it lasted twice as long as my friends. I was bubbly and occasionally it would overwhelm me. Even though I had been
bursting with energy but it fizzled out quicker than for my friends. previously diagnosed with A1AD and watched my father succumb
I loved sports and participated in track events and often won, but to the disease as well as other family members suffer with chronic
could not compete in the endurance events. This was blamed on my bronchitis, I still did not accept it. I was still in denial. I would never
being slightly overweight.
ask for help from anyone; in fact I often over exerted myself to
I was raised on a farm so naturally I was surrounded by dust and prove I was still strong and healthy. I couldn’t ask for help from my
allergens. Both my parents were heavy smokers so I was exposed to family because back when my father was alive, I had heard so many
second-hand smoke from the day I was born. I myself picked up the times, “There is nothing wrong with Walter, he just needs to get off his
habit at 15. By the time I was 25 and diagnosed A1AD, I was up to butt”. So I believed that this was how everyone was feeling about me.
1 l/2 to 2 packs a day. Those were not the cigarettes in the package
At 45, I was put on Oxygen to be used upon exertion. This was
but the good old kind you rolled yourself, and you smoked them till a wake up call; I cried for the better part of two days. My father
they burned your lip. My family doctor would often say upon my
Continued on page 7
A
6
U PDATE W INTER 2008
Living With COPD... Continued from page 6
only received oxygen a few months before he died and I knew I
could no longer deny that I had COPD and thought that like my
father I would be gone soon too. That was 13 years ago.
I was then sent to Pulmonary Rehabilitation, which in the
beginning I fought all the way. I now realize that this program can
be the turning point for people with COPD. It certainly was for me.
Did I get new lungs? …no I didn’t, but for the first time I really felt
that I had a chance for a better quality of life. I was taught proper
breathing techniques, correct ways to exercise, proper eating habits
and symptom control. The social aspect is a very important benefit
of Pulmonary Rehab. You get to mix with others who are like
yourself, experience the same fears, rejection and feel as displaced
as you do.
I have been referred back to Pulmonary Rehab a few times in the
last 12 years because I let my exercise schedule slip or I became ill
and had to start building my endurance back up. I finally
understand that I am the one that has to be in control of my
condition. That is what can be achieved at Pulmonary
Rehabilitation. We need to help this program expand because those
with COPD for the most part do not get better and after we leave
the initial program, there is no place to go. Karan Zalan, the head
of our Pulmonary Rehab Centre, is the reason I am where I am
today. I will never be able to thank her enough. It is not just me
though - all the Rehab Grads feel that way.
I have tried very hard to never allow myself the luxury of
excessive self-pity but on occasion it rears its ugly head and people
scatter. Like my dad, I too have spent many years full of anger,
resentment, fear and even hate on an occasion or two for those able
to do the things I cannot.
After almost 13 years of this nose hose, I still hate it. It makes
me stand out and be different but I realize that it will allow me to
have a longer life to enjoy and that certainly is a fair trade for a little
vanity. I try to maintain a positive attitude; I keep informed about
the new medications and equipment to ease the condition. Yes,
COPD does make you different. It is a disease that requires a
“forced lifestyle change” you must maintain forever, but you can do
it and live a full and happy life. It has been a very long and winding
road but at 58 I can finally say I am in control of my condition.
New patients will always be devastated when they are first
diagnosed, angry that it has happened to them, depressed as they
have to leave jobs they love or are left behind by family and friends
and they will be lonely…It is a very, very cold, dark place
sometimes.
I have a positive attitude, and I have a mission: Raising
Awareness of COPD and helping others over the bumpy journey
they will experience with COPD. To help accomplish this I have
joined an organization called TEAM COPD whose goal is to raise
awareness of COPD at the grassroots level. I finally have started
putting Brenda first. I have taken the time to have coffee with the
Rehab Grads and we have formed a new Lung Disease Support
Group. This Support Group is very badly needed and we are
receiving more response than we could ever have hoped for.
In conclusion I would like to sum it up this way. My boys have
grown up, I am happy and content with my new purpose in life and
I no longer live in the past. I do not concentrate on what I don’t
have but on what I do have. You might say - My life is just
beginning.
W INTER 2008 U PDATE
RESPIRATORY
ARTICLES
OF INTEREST
Nonoyama ML, Brooks D, Guyatt GH, Goldstein RS. Effect of
Oxygen on Health Quality of Life in COPD Patients with
Transient Exertional Hypoxemia. Am J Respir Crit Care Med
2007; 176: 343-349.
Ambulatory oxygen improves acute exercise performance in
people with Chronic Obstructive Pulmonary Disease (COPD) but
may not reflect how they respond symptomatically in their daily
lives. Justifying long-term ambulatory oxygen requires study of the
individual patient experience. In this study, Mika Nonoyama
undertook a series of individual randomized controlled trials (N-of1 RCTs) to measure the effect of oxygen on patients with COPD
who do not meet criteria for mortality reduction with long-term
oxygen therapy. Twenty-seven patients completed double-blind Nof-1 RCTs, each comprising 3 pairs of 2-week home treatment
periods, with oxygen provided during one period of each pair and
a placebo mixture during the other. Outcome measures included
Chronic Respiratory Questionnaire (CRQ), St. George’s
Respiratory Questionnaire (SGRQ) and 5 minute walk test
(5MWT). Among the whole group, there were no statistical or
clinical differences between oxygen and placebo for the CRQ or
for the SGRQ. The findings do not support the general application
of long-term ambulatory oxygen therapy for patients with COPD
who do not meet criteria for mortality reduction with long-term
oxygen therapy.
O’Donnell DE, Aaron S, Bourbeau J, Hernandez P, et al.
Canadian Thoracic Society Recommendations for management
of chronic obstructive pulmonary disease - 2007 update. Can
Respir J 2007; 14 (Suppl B): 5B-32B
If you work in the area of COPD, these new practice guidelines,
which reflect a rigorous analysis of the recent literature, are a
“must-read”. As you may know, the Canadian Thoracic Society
published management recommendations in 2003. Since then,
extensive scientific information has emerged. The “COPD
Recommendations – 2007 Update” presents this new evidence and
the implications to optimal management of individuals with
COPD. Some of the updated information includes: 1) new
epidemiological information on mortality and prevalence of
COPD; 2) co-morbidities in COPD; 3) discussion of acute
exacerbation; and 4) a detailed discussion of clinical assessment.
The section on management of COPD focuses on education,
smoking cessation (including a detailed table of pharmacological
aids in smoking cessation), pharmacotherapy, oxygen therapy,
pulmonary rehabilitation, surgery and non-invasive ventilation.
There are also recommendations for end-of-life issues in COPD.
Case scenarios are used to demonstrate important aspects of
assessment and therapy. For information on the CTS COPD
Guidelines Dissemination and Implementation Committee, you
can visit their website at www.COPDguidelines.ca.
Compiled by Dina Brooks.
7
With Smoke-Free Ontario Done,
More is to Come
Joanne Di Nardo, MA, Manager, Community Tobacco Control Initiatives, The Lung Association
“I live in an apartment with a child with asthma and my
The Story
neighbours smoke. The smoke smell in my unit is very
Once upon a time an ambitious newcomer entered the
bad and makes it difficult for my child to breathe. What
gates of The Lung Association’s provincial office. This
can I do?”
newcomer had always been very health conscious, eating
This type of call/e-mail is one of the most common I
well, exercising, drinking very little alcohol and never
receive. In 2006, the Ontario Tobacco-free Network
smoking a day in her life. Unbeknownst to her, this
(OTN) commissioned two polls from Ipsos Reid
newcomer was going to be charged with helping to rid
regarding the issue of second-hand smoke in multi-unit
the Ontario of a great evil – commercial tobacco. This
dwellings. The results showed that a majority, 64% of
evil was allowed to propagate unchecked, leaving illness
JOANNE DI NARDO
Ontarians living in multi-unit dwellings, if given a
and death behind. This is where the story begins, the
story about ‘the legislation that could’, the Smoke-Free Ontario Act choice, would choose to live in a smoke-free building. Based on
these results, the OTN launched a campaign in March 2007 to help
(SFOA).
In Ontario, the SFOA came into effect on May 31, 2006 to fight educate property managers, tenants and condominium owners that
the evils of tobacco. Many helped celebrate its inception, looking deeming a property smoke-free is not illegal, although it may be
forward to a decline in the 16 000 Ontarians that die from tobacco difficult to enforce, but is worth adopting as a voluntary measure
use each year. This legislation protects workers and the general for the sake of health, safety and just plain economics.
public by requiring all workplaces and public places to be 100%
“I see children across the street from my house selling illegal
smoke-free.
cigarettes, we should really check what’s in them.”
By far, one of the hottest tobacco control topics around the federal
Tobacco is done
The Smoke-Free Ontario Act brought with it a new consciousness – and provincial legislatures is contraband. The tobacco industry, the
health and the protection of children from this very well researched, convenience store associations and the Ontario Tobacco Research
dangerous but legal product. Many believed that the Smoke-Free Unit (OTRU) all agree that there is a lot of contraband product
Ontario Act had solved the problem; the tobacco issue was done. I available and it is a problem that needs to be controlled. Several
can even say that I began to think about what my new mission Federal health agencies have recently endorsed a letter produced by
would be, but then the phone started ringing, ringing and ringing: the Canadian Coalition Against Tobacco (CCAT), urging the
“Can you help me quit smoking?” “I live in an apartment with government to develop a plan to control the problem at its many
a child with asthma and my neighbours smoke. The smoke smell in sources, including First Nations. It is important to control this
my unit is very bad and makes it difficult for my child to breathe. problem in order to protect our children from becoming the next
What can I do?” “I see children across the street from my house generation of smokers simply because they can easily access this
selling illegal cigarettes, we should really check what’s in them.” very affordable black market product.
“I am a smoker, but I would never smoke in my car with my child, heck,
“I’m a smoker, but I would never smoke in my car with my child,
I don’t even smoke in my car because I know the smell lingers.”
I realized that my job was far from slowing down; instead, it was heck, I don’t even smoke in my car, period, because I know the
the beginning of a new era in tobacco control - implementing the smell lingers.”
SFOA. One by one, I responded to the questions and comments I The Governor of California, Arnold Schwarzenegger recently said,
“Hasta La Vista, baby” to the silent suffocation of children
received.
travelling in private vehicles. In November 2007, the Town of
Wolfville, Nova Scotia became the first municipality in Canada to
“Can you help me quit smoking?”
It turns out this person was not looking to quit cold turkey. He had implement a ban on smoking in vehicles carrying children. More
heard about free nicotine replacement announced by the recently, the government of Nova Scotia adopted as its own, an
government of Ontario, administered by the Centre for Addiction opposition Private Member’s Bill that would ban smoking in
and Mental Health (CAMH) through a program called the “Stop vehicles carrying children under the age of 19. Once the Bill has
Study”. The products offered by the Stop Study were nicotine gum, received Royal Assent on Friday, December 14, 2007, it will make
patch and inhaler. For some, more was needed than the free Nova Scotia the first Canadian province to ban smoking in vehicles
products being offered. A pill, bupropion, had been available for carrying children.
Here in Ontario, the OTN commissioned an Ipsos Reid poll to
several years and in 2007, a new product, varenicline, also a pillformat smoking cessation aid, was introduced with many successes gauge public support if legislation were introduced banning
reported (e.g., the Cochrane Review, Jan 2007). These drugs smoking in cars carrying children under the age of 16. The results
provide additional smoking cessation options.
Continued on page 9
8
U PDATE W INTER 2008
Poster Abstract Submissions for Better Breathing 2008
1. In COPD patients, changing the track layout used for a 6-min walk
test (6MWT) from straight to circular has only a modest effect on 6min walk distance (6MWD)
K Hill1,2, V Bansal1, T Dolmage1, L Woon1,3, R Goldstein1,2,4, D Brooks1,2.
1
Respiratory Medicine, West Park Healthcare Centre, Toronto, 2Dept of
Physical Therapy, University of Toronto, Toronto, 3Physiotherapy Dept,
West Park Healthcare Centre, Toronto
10. Ambulatory Gas Usage in Patients with COPD and Exertional
Hypoxemia
Mika Laura Nonoyama, D Brooks, GH Guyatt, RS Goldstein, West Park
Healthcare Centre, Toronto
2. Individualized Pulmonary Rehabilitation after Moderate or Severe
Exacerbation in Individuals with Chronic Obstructive Pulmonary
Disease; A Pilot Study
Jocelyn Carr, Roger Goldstein and Dina Brooks, West Park Healthcare
Centre, Toronto
12. Communication and Practice Regarding Ventilation for Individuals
with Duchenne Muscular Dystrophy (DMD)
Renata Vaughan, Hamilton Health Sciences Centre, Hamilton
3. Current Mobilization Practices with Patients with Indwelling
Femoral Lines (IFL) within University Health Network (UHN)
Nathalie Cote, Audrey Chen, Claire Hoy, Krista McIntyre, Michael
O’Brien, Carol Heck, University Health Network, Toronto
4. Practice Patterns of Physical Therapists in the Management of
Patients Hospitalized with an Acute Exacerbation of Chronic
Obstructive Pulmonary Disease
Leslie Harth, Jennifer Stuart, Catherine Montgomery, Karol Pintier, Susan
Czyzo, Dept of Physical Therapy, University of Toronto, Toronto
5. Current Mobilization Practices of Ontario Physiotherapists in
Patients with Indwelling Femoral Lines (IFL)
Therese Hawn, Nathalie Cote, Amanda Fenton, Vicky Quan, Carol Heck,
Toronto General Hospital, University Health Network, Toronto
6. Estimating maximum work rate during incremental cycle ergometry
testing from six-minute walk distance in Chronic Obstructive
Pulmonary Disease
Kylie Hill1,2,3, Sue Jenkins2,3,4, Danielle Philippe1, Nola Cecins2,3,4, David
Hillman1, Peter Eastwood1,3,5
Departments of 1Pulmonary Physiology and 2Physiotherapy, Sir Charles
Gairdner Hospital, 3School of Physiotherapy, Curtin University of
Australia, 4Lung Institute of Western Australia, and 5School of Anatomy
and Human Biology, University of Western Australia, Australia
7. Systematic Review of Arm Training in Patients with Chronic
Obstructive Pulmonary Disease (COPD)
Tania Janaudis-Ferreira1,2, Kylie Hill1,3, Roger Goldstein1, Karin Waddell2,
Dina Brooks1,3, 1Respiratory Medicine, West Park Healthcare Centre and
2
Department of Community Medicine and Rehabilitation, Umea
University, Sweden, 3Department of Physical Therapy, University of
Toronto
8. A Retrospective Review of Discharge Medications on Chronic
Obstructive Pulmonary Disease within A Group of Four Community
Hospitals with a Proposed Strategy
Lucinda Kwan, DJ Thompson, Jennifer Chien, Huron Perth Healthcare
Alliance, Stratford
9.Asthma Electronic Record for Primary Care: Development and Pilot Testing
J.P. Minard, Queen’s University, Kingston, N. Garvey, Ministry of Health
and Long-Term Care, Toronto, T.W. Sands, University of Windsor, J.
Belanger, Group Health Centre, Sault Ste. Marie and M.D. Lougheed,
Queen’s University, Kingston
W INTER 2008 U PDATE
11.Activation:A Unique Program for Chronic Obstructive Pulmonary Disease
Angela Shaw, Terry Boshart, Suzy Young, St Mary’s General Hospital, Kitchener
13. The Sensewear Armband underestimates measurements of energy
expenditure during activities of daily living in patients with COPD
Kylie Hill1,2, Lynda Woon1,3, Tom Dolmage1, Roger Goldstein1,2,4, Dina Brooks1,2
1
Resp Med, West Park Healthcare Centre, 2Dept of Physical Therapy,
University of Toronto, 3Physiotherapy Dept, West Park Healthcare Centre,
4
Dept of Medicine, University of Toronto
14. COPD Exacerbation Presentation and Treatment in a Community
Hospital in Ontario: 6 Months of Data
Suzy Young, St Mary’s General Hospital, Kitchener
Smoke-Free Ontario... Continued from page 8
of the poll were released on Thursday, December 6, 2007, reporting
that 86% of non-smokers and 66% of smokers support smoke-free
car legislation that would protect children under the age of 16. That
same day, Thursday, December 6th, Sault Ste. Marie MPP, David
Orazietti, introduced Bill 11, the Protecting Children and Youth
from Second Hand Smoke in Automobiles Act. This Bill, if passed,
would give law enforcement officers the authority to pull over and
fine anyone smoking in a private vehicle when passengers under
the age of 16 are present. The Lung Association and the OTN plan
to educate MPPs about the importance of passing Bill 11 during
National Non-Smoking Week, January 20-26, 2008.
Conclusion
There you have it. This ambitious newcomer has become
somewhat more comfortable in the ever-changing world of
tobacco-control by contributing to the implementation of the SFOA
and addressing the many questions surrounding its
implementation. What I have learned so far is that it is important
to stay one step ahead of the tobacco companies, because when we
think that tobacco is done, the tobacco companies find new ways to
market tobacco and keep their business profitable.
At the OTN, we count on our local tobacco-free coalitions/
councils to help us understand the pulse of each community so that
we can better plan our next campaign, research policy initiatives
and provide financial support to councils. I commend all those
who have participated in making Ontario smoke-free. My work
this year is not only in leading the campaigns to eradicate secondhand smoke in multi-unit dwellings and in cars, it is to find ways
to keep our local tobacco-free coalitions active, engaged and
empowered. If you know of someone interested in pursuing
tobacco control advocacy initiatives, please encourage them to
contact me about joining a local tobacco-free coalition at
jdinardo@on.lung.ca. For now, Hasta La Vista, baby!
9
Around the Regions:
ORCS Educational Opportunities for You and Your Colleagues
ll members of the ORCS who live in Ontario belong to one of
seven regional groups.
Each group has a regional
representative who sits on the ORCS Provincial Committee.
Through volunteer planning committees, usually chaired by the
regional representative and supported by the ORCS staff, regional
groups present one or more education programs in their region each
year. Members and non-members are welcome to attend. ORCS
members pay a reduced fee for all programs. Those paying the nonmember fee receive a trial membership for the balance of the
membership year (April 1 – March 31). In 2008, take advantage of
a program in your own region or another part of the province.
A
Northwestern Ontario Region
– Regional Representative: Shelley Prevost, RRT
The Northwestern Ontario Region was established in 2006 and is
based in Thunder Bay. The group held an evening program in late
September of 2007 and is planning a seminar in the early fall of
2008, either as an educational evening session or a full day
program.
Northeastern Ontario Region
– Regional Representative: Christina McMillan Boyles, RN, MScN
The Northeastern Ontario Region is based in Sudbury, where the
group offers a full day seminar every two years and educational
evenings in alternate years. A full day seminar, The Air We Breathe
and Lung Health, was held on April 24, 2007 and is planning an
educational evening seminar in the early fall of 2008.
Essex/Kent Region
– Regional Representative: Gillian Hueniken, Reg. PT
The Essex/Kent Region includes Chatham-Kent, the City of
Windsor and Essex County. Programs are held in Chatham and
Windsor. In 2007, the group held a full day seminar, Respiratory
Health for All Ages: What inspiring minds want to know in
Windsor. An educational evening will be held in Chatham in the
fall of 2008.
Thank you to our 2007 ORCS
member volunteers!
hank you to the many ORCS members who volunteered
for the ORCS during 2007. Members served on our
committees, organized education programs, wrote articles
for our publications, reviewed research grants, engaged in
advocacy activities, spoke at ORCS seminars and Lung
Association patient education forums, participated in
fundraising events and helped us achieve our goals in
these and many other ways. We appreciate your efforts!
Make volunteering for the ORCS part of your lifestyle in
2008! Contact orcs@on.lung.ca.
T
10
Southwestern Ontario Region
– Regional Representative: Justyna Couto, BScPT
The Southwestern Ontario Region is based in London. In addition
to offering full day seminars there, the group has also presented
educational evenings in London, Sarnia and St. Thomas. A full day
program, Spring Inspirations, was held in London in June of 2007.
In 2008, a full day program will be held on June 4 in London and
an educational evening will be offered in Sarnia in the fall.
South Central Ontario Region
– Regional Representative: Sheila Dedman, BSc, BHScPT
The South Central Ontario Region has several large centres
including Hamilton, St. Catharines, Niagara Falls, KitchenerWaterloo, Guelph, Burlington and Brantford so programs rotate
among various locations from year to year. A full day seminar is
held in October each year and occasional educational evenings are
offered. In 2007, the group held a full day program, A Fall Harvest
of Respiratory Care in Cambridge. In 2008, a full day program will
be planned for the Niagara area and an educational evening may be
held in the Hamilton area in the spring.
Greater Toronto Region
– Chair: Dianne Naiman, RRT, Provincial Representative:
Dilshad Moosa, RRT, CRE, Education Chair: Ana MacPherson,
RRT, MSc, CRE
The Greater Toronto Region has a more formal structure than the
other groups with an Executive Committee elected annually. One
member of the Executive Committee is appointed to the Provincial
Committee. Another member chairs the group’s Education Committee.
The group offers educational evenings in April and June (the latter
session includes the group’s annual meeting) and a full day seminar
in November. In 2007, evening sessions were held in Newmarket
and Toronto. The Region’s annual full day seminar, How Does Your
Breathing Measure Up? was held on November 1, 2007 in Markham.
Plans will be made in January for spring evening programs and the
2008 fall seminar.
Eastern Ontario Region
– Regional Representative: Jennifer Olajos-Clow, RN, MSc, APN, CAE
The Eastern Ontario Region presents full day programs in Ottawa
and Kingston and has also held educational evenings in Cornwall,
Brockville and Perth. In 2007, educational evenings were held in
Ottawa in March and Kingston in late November. Plans for 2008
are for a full day seminar in Kingston on April 10.
With Appreciation!
ORCS education programs would not be possible without the strong
support of the many ORCS members who volunteer to serve on our
planning committees, speakers (including many ORCS and Ontario
Thoracic Society members) who volunteer their time and expertise
to present at our programs and many pharmaceutical, home oxygen and
medical equipment companies that provide financial support through
exhibit fees and sponsorship contributions for the seminars.
U PDATE W INTER 2008
Acute Exacerbations of COPD... Continued from page 4
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9. Miravitles M, Espinosa C, Fernandez-Laso E, Martos J,
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14. Sethi S & Murphy T. Bacterial infection in chronic
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