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“Spread the word how
wonderful it is to live
and work in our new
Smoke-Free Ontario!”
Joanne Di Nardo
Tobacco Control Specialist,
The Lung Association, Ontario
Tobacco-Free Network (OTN)
FA L L
2 0 0 6
Features
In this Issue
Heliox Delivery
Applications with
noninvasive ventilation
in COPD treatment . . . . . . 1
Better Breathing 2007
Mark your calendar and
plan to register!. . . . . . . . . . . 3
In Memoriam
A Tribute to Alan McFarlane. 3
Work-related Asthma
Preventing Asthma in Higher
Risk Industries. . . . . . . . . . . . 6
Respiratory Care
Perspectives
Cardiorespiratory Physiotherapy
in Western Australia. . . . . . . . 8
Research and
Fellowship Awards . . . . . 9
Welcome to
Smoke-Free Ontario
Historic legislation came
into effect on May 31 . . . . . 10
Regular Columns
Chair’s Message . . . . . . . . . . 2
Editor’s Comment . . . . . . . . . 2
Coming Events . . . . . . . . . . . 3
Respiratory Articles of Interest. 11
www.on.lung.ca
V O L U M E
2 2 ,
N U M B E R
3
Heliox Delivery with Noninvasive Ventilation
in the Treatment of Individuals with
Chronic Obstructive Pulmonary Disease
Wayne Nelson, BSc, RRT, RPSGT, Respiratory Therapist, Royal Victoria Hospital, Barrie
with COPD with acute respiratory
Introduction
failure, the unloading effects of NIPPV
Chronic obstructive pulmonary
may be enhanced, improving the
disease (COPD) is a term applied to
efficacy of NIPPV to a point where
patients with chronic cough,
this could become the treatment of
expectoration, exertional dyspnea, and
choice to avoid the need for intubation.
airflow limitation as measured by
forced expiratory volume in one
Background
second (FEV1). In individuals with
The underlying cause of excessive Raw
COPD, the respiratory muscles operate
WAYNE NELSON
can be attributed to the turbulence of
at a mechanical disadvantage due to
the high resistive and elastic loads as a result of flow in the airways. The majority of Raw occurs
airway obstruction and lung hyperinflation. An in the more proximal regions where turbulent
acute exacerbation of COPD (AECOPD) flow is the greatest. Transitional flow conditions
imposes an additional load on the respiratory then exist until giving way to laminar flow in the
muscles, leading to ineffective alveolar more distal airways. This progression of flow is
ventilation. An attempt to compensate with rapid determined by various key factors, including the
shallow breathing may ensue but this only further branching patterns of trachea and bronchi, the
increases airway resistance (Raw), work of diameter of the conduits, the angles of branching,
breathing (WOB), and oxygen consumption. the degree of roughness of the walls and rate of
With these come worsening hypoxia, hypercapnia, flow in health and disease.
The type of flow occurring at any given point
acidosis, and the development of a vicious circle.
Noninvasive positive pressure ventilation is determined by the Reynolds number (Re) of
(NIPPV) has become the standard initial the gas. This is a unitless quantity that is
treatment in the majority of AECOPD who are at proportional to the airway diameter and the
risk for respiratory failure. NIPPV decreases the velocity and density of the gas, divided by its
WOB in these patients and has considerably viscosity. When the Re is high (greater than
reduced intubation rates, although many still 4000), flow is predominantly turbulent, when the
require intubation mostly because of respiratory Re is low (less than 2000), flow is predominantly
muscle fatigue. Consequently, technical laminar. In between is considered a combination
improvements in NIPPV aimed at reducing the of the two (transitional).
Helium (He) is a biologically inert gas with a
intubation rate further would be welcome. By
combining the use of NIPPV and heliox (a density that is considerably lower than that of air
Continued on page 4
mixture of helium and oxygen) in individuals
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: [email protected]
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
Lisa C. Cicutto, RN, Ph.D., ACNP, C.A.E.
CHAIRMAN, ONTARIO
LUNG ASSOCIATION
Robert Kelly
PRESIDENT & CEO,
ONTARIO LUNG ASSOCIATION
Manu Malkani
DIRECTOR OF ADMINISTRATION,
ONTARIO RESPIRATORY CARE SOCIETY
Sheila Gordon-Dillane
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 generous unrestricted
educational grants from VitalAire
Healthcare, Medigas and McArthur
Medical Sales Inc.
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
hope that you enjoyed some summer
fun and relaxation! As you have
probably noticed, the days are getting
shorter and it is becoming increasingly
apparent that life is ramping back up to
a faster pace.
There were a few events that
occurred over the spring and summer
that I would like to share with you. On
May 31st, our efforts to make Ontario smokefree became one step closer; the Smoke-Free
Ontario Act was announced and implemented.
Several ORCS members attended the rally at
Queen's Park to celebrate this initiative.
Congratulations to all of you who worked so hard
to make this a reality!
In addition, several successful seminars were
held throughout the province. Educational
evenings were held in Toronto and St. Catharines
and full day programs took place in Thunder Bay
and Ottawa. Many thanks to all of our members
who organized and attended these events.
I would like to thank Paula Burns for her
commitment and dedication to the Research and
Fellowship Committee. Paula has stepped down
from her position as Chair of the Committee. I
am delighted to announce that Judy King, a
physiotherapist in Ottawa, has accepted the
I
position. Judy has extensive experience
in research and understands the
importance and role of this committee
well. Thank you Judy for assuming this
important leadership role!
Not all of the summer events were
joyful at The Lung Association. Alan
McFarlane, Manager of The Lung
Association’s COPD Program, passed
away as a result of cancer. Alan was instrumental
in the development of the BreathWorks program
and did an outstanding job with the program in
Ontario and across Canada. His ideas, energy,
and spirit will be greatly missed by all of us. As
a celebration of his contributions to lung health
and the lung community, you will be able to read
a tribute to Alan in this issue.
I know your calendar is starting to fill up but
make sure that you have blocked off days to attend
one of the fall seminars in your area and Better
Breathing 2007 (February 1-3). This year Better
Breathing will be held in downtown Toronto.
Hope to see you at a seminar!
LISA CICUTTO, CHAIR, ORCS
P.S. If you have not renewed your membership,
please do. Your membership and involvement
are important to us.
EDITOR’S COMMENT
am breaking the normal pattern as a
Co-Editor in my comments. Editor’s
Comments are not usually personal but
are used to highlight the articles in
Update and the work of the Editorial
Board. In this issue, sponsored by
VitalAire Healthcare, Medigas and
McArthur Medical, I will leave you to
read and enjoy the clinically relevant
articles on heliox, occupational asthma, smokefree Ontario and an international perspective on
respiratory care. Instead, I will make some
personal comments!
I was recently asked why I choose to volunteer
for The Lung Association and not other
important associations like the Cancer Society,
Heart and Stroke or Physiotherapy Foundation.
My honest answer was “because lung disease is
close to my heart” although I could not make the
specific personal connection. However, recent
events have reminded me why lung disease is so
close to my heart!
My family and I have observed the recent
events in the Middle East with terror, sadness and
a feeling of déjà vu. I spent most of the first 20
I
years of my life in Lebanon and have
lived through war. My memories of that
time consist of bomb shelters filled with
smoke. My parents, neighbours and family
members all smoked and my sister and
I were exposed to at least 3 packs of
second-hand smoke daily, made worse
by the small quarters of bomb shelters.
Unfortunately, the people of that
region, including many of my family and friends,
are again experiencing war. I sincerely hope that
a lasting peace arrangement can soon be found.
Over the last year, I was inspired by Heather
Crowe, an individual who used her misfortune to
make a huge difference through her work on the
Smoke-Free Ontario campaign. Maybe through
my volunteer work for The Lung Association, I
too can make a small difference to those who,
like my family members, have suffered lung
disease from smoking.
As I pack my car to go on holiday with my
children who have never been exposed to secondhand smoke or a bomb shelter, I dream of and
wish for a Smoke and Violence Free World!
DINA BROOKS, CO-EDITOR
FALL 2006 UPDATE
BETTER BREATHING 2007 – 27th ANNUAL CONFERENCE COMING EVENTS
THE EVOLUTION OF LUNG HEALTH
FEBRUARY 1-3, 2007 – TORONTO MARRIOTT DOWNTOWN EATON CENTRE, TORONTO
lan now to attend Better Breathing 2007, the
annual Lung Association conference and the
Ontario Respiratory Care Society’s province-wide
Scientific Sessions and Annual Meeting. The ORCS
program offers exciting educational opportunities
for respiratory health professionals. Watch for the
program brochure later this fall. The conference
has returned to a downtown Toronto location.
On Thursday, February 1, the Respiratory
Health Educators Interest Group (RHEIG) will
host its annual Pre-Conference Workshop. This
session is open to all health professionals and
will include a presentation on Key Concepts in
Palliative Care, the RHEIG Annual Meeting and
workshops on Practical Lessons in End-of-Life
Care, Anaphylaxis Management, Helping Chronic
Lung Disease Patients Cope with Anxiety, Panic
and Depression and Work-Related Asthma.
The Friday morning Plenary Session theme is
The Evolution of Health Care Delivery, featuring
Dr. James MacLean (Ministry of Health and
Long-Term Care) on Primary Health Care
Reform: How does it affect us?, and Dr. Maurice
McGregor (McGill) on Assessment and Integration
of Respiratory Technology. The ORCS/OTS Joint
Session will feature presentations on Occupational
Asthma by Dr. Susan Tarlo (Toronto), Chronic
Ventilation in the Community: Challenges and
Opportunities by Jane Montgomery, RRT
(London) and What Every Adult Clinician Needs
to Know about Pediatric Respirology by Dr. Tom
Kovesi (Ottawa). A special luncheon will be
offered for new members and first-time attendees
at the conference, giving you an opportunity to
be introduced to the ORCS.
The ORCS Friday afternoon sessions feature
three speakers on important issues related to both
P
hospital and community care: Supplemental
Oxygen: What’s the Evidence?, Nutritional
Therapy in the ICU Patient and Critical Care
Response Teams. The ORCS Annual Meeting will
be held during these sessions. Friday closes with a
Networking Reception - meet your friends and the
exhibitor representatives at this informal event,
featuring a variety of food stations and brief
awards presentations.
On Saturday morning, attend two of our
popular workshop sessions. Sessions include
Poster Presentations, Airway Clearance
Techniques, Managing the Difficult Airway, Lung
Association Provider Education, Research
Presentations, Assessing Learners in the Clinical
Setting, Tracheostomy Care and Herbal
Remedies in Respiratory Care.
For the second year, a Critical Care Saturday
afternoon session will be offered: Judy Ferguson,
RN (Kingston), will address Influencing Bedside
Practices to Reduce Patient Risk Factors
Associated with ICU Admission and Dr. Christine
D’Arsigny (Kingston) will discuss Assessing and
Weaning Ventilated Patients in the ICU.
Be sure to visit the exhibitors during the
breaks on Friday and Saturday. Several of our
pharmaceutical partners will offer sponsored
breakfasts with speakers on Friday and Saturday
and a sponsored lunch with a speaker on
Saturday. Better Breathing 2007 provides
excellent learning and networking opportunities.
Don’t miss it!
Note: Poster Abstract deadline - October 16,
2006. For the abstract form, call the ORCS or
visit www.on.lung.ca/orcs.
ROB BRYAN, RRT, EMCA-A
CHAIR, ORCS EDUCATION COMMITTEE
A Tribute to Alan McFarlane
lan McFarlane lived fully if not long. For a life that spanned only 37
years, Alan accomplished so much. His commitment to lung health began
in his teens when his grandfather died from asthma. Alan had always adored
his grandfather and used this personal loss as motivation to become a catalyst
for lung health. While with the Windsor-Essex and Hamilton Health Units in
the 1990s, Alan worked hard to influence local smoking by-laws, playing a
key role in convincing municipal councils to hold historic votes on the issue
of tobacco control.
Alan joined The Lung Association in the spring of 2000, finding a home
and many mentors who shared his passion for health promotion. He crusaded
to heighten awareness about two key health issues: tobacco use and COPD.
A
October 2-5, 2006
The Centre for Addiction and Mental
Health and Smoke-Free Ontario present
courses on Smoking Cessation for health
professionals at the MaRS Collaboration
Centre in Toronto. Contact yvonne_hinds@
camh.net.
October 3, 2006*
The ORCS, Northeastern Ontario Region
presents an educational evening on
Pulmonary Hypertension and Indoor
Air Quality at the Parker Building,
Laurentian University, Sudbury.
October 19, 2006*
Inspirations: A Respiratory Care Update,
presented by the ORCS, South Central
Ontario Region. Lectures and workshops
address Bronchial Thermoplasty, IPF,
Work-Related Asthma, Outcome Measurement
in COPD, Paediatric Asthma Education,
Managing Dyspnea, Nutrition and Lung
Disease, Ventilation and Airway Inflammation.
October 21-26, 2006
Chest 2006 will be held in Salt Lake City,
Utah. www.chestnet.org/CHEST.
October 25-27, 2006
The Toronto Critical Care Medicine
Symposium 2006 (including the RTSO
AGM) will be held at the Metro Toronto
Convention Centre. www.tccms.com.
October 26-28, 2006
The Toronto Rehabilitation Institute’s
2nd National Spinal Cord Injury
Conference – The Evolving Architecture
of Research, Patient Care and Education
will be held at the Toronto Marriott
Downtown Eaton Centre. 416-597-3422,
ext. 3693 or www.torontorehab.com.
November 1, 2006*
Hot Topics in Respiratory Care, presented
by the ORCS, Southwestern Ontario
Region. Topics include Skeletal Muscle
Dysfunction in COPD, Home Oxygen
Therapy, End-of-Life Care, Life after
ARDS, Asthma Management in Female
Athletes and Ethical Issues.
November 9, 2006*
Difficult to Manage Lung Disease,
presented by the ORCS, Greater Toronto
Region. Topics include Pulmonary
Fibrosis, Bronchiectasis, Pulmonary
NonTuberculous
Mycobacterial
Infections, Cystic Fibrosis, MDR-TB and
Antibiotic Resistance.
November 16-17, 2006
The Second Annual CTS Clinical Trials
Coordinated
Respiratory
Clinical
Research Consortium Meeting will be
held at The Westin Calgary Hotel,
Calgary. www.crcrc.ca.
November 17-19, 2006
Optimizing Wellness in COPD, presented
by The Canadian COPD Alliance takes
place at The Westin Calgary Hotel,
Calgary. www.lung.ca.
November 20-21, 2006
The Face of TB, presented by The Lung
Association’s Tuberculosis Committee
will be held at the Crowne Plaza Hotel,
Toronto. www.on.lung.ca/tbconf.
Continued on page 7
Continued on page 10
FALL 2006 UPDATE
3
Heliox Delivery... Continued from page 1
or any of its components. Because heliumoxygen (He-O2) is less dense than airoxygen, heliox mixtures lower the Re which
has the potential to convert turbulent flow to
laminar flow, thus substantially decreasing
Raw to flow and therefore decrease the
WOB in those situations associated with
increased Raw. Patients with COPD have
markedly increased resistance to flow due
to narrowing of the airways by edema,
mucous and loss of lung collagen. It can be
expected then that breathing a high mixture
of helium would result in lower resistance to
flow and a decrease in WOB.
Administration and Technical Implications
Before attempting heliox therapy in the
setting of NIPPV, it is recommended that
physicians, nurses and respiratory therapists
familiarize themselves with the processes
that are involved in heliox administration.
The use of heliox with NIPPV raises
various technical and safety issues that need
to be resolved before one can begin to use
this mixture of gas on patients. Although
most issues arising with the delivery of
heliox are generic to all ventilators, the
BiPAP Vision® ventilator, with which my
hospital is most familiar, has some technical
features that require more specific
illustrations.
Using the BiPAP Vision® ventilator to
deliver heliox with NIPPV is unique
because it has an oxygen module that allows
the desired fraction of inspired oxygen to be
set. Heliox can be delivered directly into
the oxygen module using an external
oxygen blender. An 80%-20% heliumoxygen mixture at 50 psig is connected to
the air inlet of an oxygen blender and
oxygen is added to the oxygen inlet of the
blender in the usual manner. The outlet of
the blender is connected to the oxygen
module of the ventilator. The FiO2 on
the Vision® is then fixed at 1.0 to deliver
only the gas mixture from the external
blender.
In theory, the goal is to provide maximal
He concentration while still maintaining
sufficient oxygenation. The higher the He
concentration of the inspired gas, the
greater the likelihood of benefit. The
Vision® can deliver He concentrations of
about 60% when the ventilator is set to
100% and the blender is at 21% - a setting
that theoretically should deliver 80%
helium. The most likely reason for this
4
discrepancy is that the Vision®, like all
noninvasive ventilators, is a blower device.
Gas from the oxygen module is diluted with
room air, and this effect may be magnified
when heliox is introduced to the oxygen
module of this ventilator. It may be possible
to achieve higher helium concentrations if
100% helium is used rather than 80% helium
as the source gas. This approach is dangerous,
however, because it permits the possibility
of delivering a hypoxic gas mixture.
Non-invasive ventilators are designed to
operate in the presence of a fixed leak.
Because of the lower density of heliox, gas
flow is greater through this fixed leak. It is
not unreasonable then to expect that this
might affect the ventilator’s ability to trigger
breaths and cycle effectively. Again, the
Vision® ventilator is unique in that it allows
the user to conduct an exhalation port leak
test at the time of ventilator start-up, which
is intended to improve triggering accuracy.
Differences in gas density between the
exhalation port test and subsequent heliox
delivery cause erratic triggering and cycling
of the ventilator. To correct this problem,
heliox is delivered after bypassing the
exhalation port leak test at start-up.
It is important to note that gas density
will not affect pressure monitor accuracy,
hence the performance of pressure transducers
is not altered by heliox. Although the IPAP
and EPAP settings are not affected by
heliox, it will affect measurements of volume
and flow. Because of the physical properties
of heliox (it has a higher specific heat than
air and a higher viscosity), the ventilator’s
volume and flow measuring devices are
affected. This in turn causes erroneous readings
and underestimates the actual tidal volume
and flow. The measurement of the fraction
of inspired oxygen in modern ventilators is
not confounded by heliox and is reliable.
It should be noted that [He] has a high
thermal conductivity (six times the thermal
conductivity of air), and may be associated
with a lowering of body temperature when
used for prolonged periods. Therefore, a
patient’s temperature should be monitored
during prolonged periods of administration
as there is a risk of increased heat loss
for patients during He-O2 delivery. Heliox
gases should also be humidified since
delivering heliox without proper humidity
could lead to increased difficulty with thick,
dried secretions that could further obstruct
the airways.
Clinicians need to appreciate the effect
of heliox titration with a non-invasive
ventilator on resource utilization. A typical
heliox cylinder contains 4,500 L of gas.
Approximately 4-6 tanks are required for 24
hours of treatment. Heliox cylinders cost
about four times as much as an equal
volume of oxygen. Taking everything into
account, the cost of heliox therapy
compares favourably with the cost
associated with intubation and mechanical
ventilation. If ventilatory failure can be
avoided, heliox may be a preferred therapy
on a cost as well as efficacy basis.
Beneficial Effects
By using a lower density gas mixture like
He-O2, the Re is reduced. This Re decrease
with He-O2 has the following effects: (1)
flow becomes laminar over a larger number
of airway generations, (2) the driving
pressures needed to generate flow to
ventilate the lung are reduced, and (3)
laminar entrance effects generated by the
interactions between airway bifurcations,
curvature and gas flow develop over a
longer distance in each airway than when
flow is turbulent. This suggests that heliox
may actually decrease the resistance of
airways in series.
To be effective in reducing Raw,
concentrations of He must be high, ideally
above 60% of the inhaled gas mixture. This
of course limits the amount of O2 that can
be administered simultaneously.
The
hypoxemia associated with airway disease
is usually modest and responsive to O2
therapy because the underlying mechanism
of gas exchange impairment is a ventilation
perfusion mismatch. Thus, a low FiO2 is
often sufficient in COPD patients during
NIPPV, allowing for an effective He
concentration to be achieved.
Another finding common to individuals
with COPD is that they suffer from air
trapping or auto-PEEP (gas that remains in
the lungs, above FRC, at the end of
exhalation). Heliox alleviates auto-PEEP by
increasing expiratory flow rates. As lung
volumes return to normal, the WOB
decreases and pulmonary compliance
increases, enlarging the tidal volume that
can be generated per cmH2O.
Another means of improving tidal
volume in NIPPV is to increase the pressure
support (PS) level. However, there are
Continued on page 5
FALL 2006 UPDATE
Heliox Delivery...
Continued from page 4
several problems associated with high PS
levels. Hyperinflation and barotrauma may
occur because of the delivery of high
pressures at the end of inspiration.
Desynchronization between the patient’s
spontaneous breathing and the ventilator
may take place. A very rapid flow acceleration
may result and could potentially cause poor
tolerance. Finally, high PS levels may also
increase leaking around the face mask.
Similar levels of unloading can be obtained
at lower PS levels by substituting heliox for
air-oxygen during NIPPV. The behaviour of
the respiratory control system differs
between unloading achieved by use of
heliox and unloading achieved by use of
higher PS levels. Two processes may occur
when heliox unloads the respiratory control:
it can either maintain a constant central
respiratory output to produce more
ventilation for the same effort or, maintain
constant ventilation to reduce respiratory
muscle work. The respiratory control
system will choose the latter if given the
choice. These findings suggest patients
who fail to respond to or cannot tolerate
high PS levels may be good candidates for
NIPPV with helium-oxygen.
Replacing air with He also proves
beneficial by providing a higher peak
inspiratory flow and a shorter inspiratory
time (Ti). Increasing the initial flow rate,
and allowing the peak pressure to be
reached more rapidly (faster ramp), results
in a decrease in the respiratory drive and
WOB compared with slower ramps. A slow
ramp may increase a patient’s inspiratory
drive because the level of pressure support
might not be reached by the time the
patient’s neural inspiratory time is over.
Concomitantly, a slow ramp can cause
mechanical inflation to continue into neural
expiration, which the patient counteracts by
expiratory muscle activation, resulting in
patient-ventilator dyssynchrony. Thus, the
fast ramp induced by heliox could reduce
the WOB during NIPPV through improved
patient-ventilator interaction. Also, with a
fast ramp and shorter Ti, if respiratory rate
remains constant, more time will be
available for expiration as the Ti/Ttot
decreases. This should allow more time for
expiration and hence, less hyperinflation
and improved gas exchange.
A lower PaCO2 value obtained with
heliox is another beneficial effect. The
mechanism of this effect may be
attributable to a decrease in CO2 production
and/or to an increase in alveolar ventilation
and hence CO2 elimination. Respiratory
muscle unloading may be associated with a
decrease in CO2 production. Improved
expiratory lung emptying and a reduction in
hyperinflation contribute to increased
alveolar ventilation and enhanced CO2
elimination. Paralleling an increase in
alveolar ventilation is the facilitated
transport of carbon dioxide by diffusion.
Because He enhances the diffusion of CO2
(CO2 diffuses four to five times faster in
heliox than in air-oxygen), a greater amount
of carbon dioxide will be eliminated in
heliox per unit of time.
Conclusions
Helium-oxygen has no curative effects. Its
real value is in buying time for the efficacy
of other therapies or allowing exacerbated
disease processes to resolve themselves.
There are two primary pitfalls to heliox
ventilation. First, the physical properties of
heliox affect ventilator functions. Second,
in this age of cost control, the expense to
administer heliox for medical purposes is
fairly high. Before its widespread use can
gain acceptance, proof that NIPPV with
heliox is superior to air-oxygen NIPPV in
avoiding intubation in COPD patients with
acute respiratory failure is needed. Two
ongoing multicentre trials in Europe are
attempting to resolve this issue. Until the
results of those studies are known, adhering
to evidence-based practice is not possible.
While the Cochrane Review concludes that
currently there is not enough evidence to
support the use of heliox mixtures to treat
AECOPD, this conclusion was based on the
fact that much of the evidence reviewed was
of low methodological quality. Accepting
the difficulties associated with studying
heliox makes rigorous scientific assessment
problematic. Blinding is difficult as
investigator and patient can easily detect the
change in voice when breathing heliox and
technical details in administration of heliox
prevent blindness of the investigator.
For now, heliox use remains variable and
institution specific. Perhaps in the individual
case of severe COPD where intubation is
required but would be undesirable, it is a
treatment worthy of consideration. If new
studies are able to show evidence-based benefits
of heliox treatment, it may well become the
standard of care performed in our ERs and ICUs.
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Austan F, Polise M. Management of respiratory failure with
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Become an ORCS member or renew
your membership for 2006-2007
Manthous CA, Morgan S, Pohlman A, et al. Heliox in the
treatment of airflow obstruction: a critical review of the
literature. Respir Care 1997; 42(11):1034-1042.
Individual $40; Student $25; RHEIG add $15
Call (416) 864-9911 for information or visit www.on.lung.ca/orcs
Reuben AD, Harris AR. Heliox for asthma in the emergency
department: a review of the literature. Emerg Med J 2004;
21:131-135.
FALL 2006 UPDATE
O’Donnell DE, Aaron S, Bourbeau J et al. Canadian Thoracic
Society recommendations for management of chronic
obstructive pulmonary disease – 2003. Can Respir J 2003; 10
(Suppl A): 11A-33A.
Rodrigo G, Pollack C, Rodrigo C, et al. Heliox for treatment
of exacerbations of chronic obstructive pulmonary disease
(Cochrane Review). In: The Cochrane Library, Issue 2, 2005.
Oxford: Update Software.
5
Work-related Asthma:
Working At Prevention in Higher Risk Industries
Nancy Bradshaw, BASc, Project Manager, Occupational Asthma Project for Workers and Employers; Industrial Accident Prevention
Association and Occupational Health Clinics for Ontario Workers, Toronto
ork-related asthma is the most
common occupational lung disease in
Canada, accounting for over half of all
reported cases. Approximately 10 –15% of
all new adult asthma cases are thought to be
work-related, however, these numbers are
likely underestimated, due to low rates of
reporting, recognition and diagnosis.1, 2, 3
In Ontario, over 10 million dollars in
compensation was awarded for work-related
asthma cases from 2000 to 2004. Bakeries,
automotive parts manufacturing, and foam
and plastic manufacturing have some of the
highest rates and costs associated with
work-related asthma in Ontario, according
to the Workplace Safety and Insurance
Board (WSIB). The financial and human
costs of untreated work-related asthma
affect employers, workers and all taxpayers
(Table 1).
temperatures, dry air or exertion
workplace exposures to sensitizing
at work, particularly if the asthma
agents over the patient’s entire
is moderate to severe or poorly
work history, not just in their
controlled. Asthmatic patients,
current job or occupation. Some
therefore, need to pay attention to
common sensitizing agents
any changes in their asthma
found in bakeries and automotive
symptoms whenever they start a
parts and plastic and foam
new job or change their duties at
manufacturing are listed in
work. Any changes should be
Table 2.
NANCY BRADSHAW
reported immediately to their
The
other
form
of
doctor, to obtain the proper medical occupational asthma, reactive airway
treatment, and to their employer, joint dysfunction syndrome (RADS), occurs
occupational health and safety committee when a person’s lungs become severely
(JOHSC) and/or Union representative, to irritated following contact with a high-level,
reduce exposures to workplace irritants, as often accidental, exposure to a workplace
required.
irritant, such as a chemical spill. There is no
latency period; symptoms usually start
Occupational Asthma
within 24 hours after the airways become
Occupational asthma is diagnosed when highly irritated. RADS is diagnosed when
asthma is caused by a specific agent in the the symptoms last 3 months or longer.
Early recognition is very important to
TABLE 1: Comparison of Results of Untreated Work-related Asthma and
help prevent progression of the illness in the
individual(s) with the disease and to prevent
of a Work-related Asthma Prevention Strategy in the Workplace
other employees from developing OA. The
Untreated Work-related Asthma
Work-related Asthma Prevention Strategy
diagnosis of even one worker with OA in a
Loss of productivity
Greater productivity
workplace should be viewed as a sentinel
Staff turnover
Improved working conditions
event, indicating the need for workplace
interventions to protect the other workers
Increased insurance costs
Reduced insurance premiums
from exposure to the agent(s).
Disability
Less sick time
The symptoms of OA are the same as
Loss of work and income
Decreased economic burden for all taxpayers
those found in asthma, however, workers’
Reduced quality of life
Improved quality of life
symptoms often become pronounced as the
workday and/or work-week progress. Below
What is Work-related Asthma?
workplace. Over 90% of occupational is a checklist that can help employees,
Work-related asthma is asthma that is asthma cases are sensitizer-induced; employers and health professionals assess
induced or aggravated by a workplace agent/ whereby an individual becomes sensitized the employee’s risk of OA.
occupational environment, generally in the to a workplace agent via an IgE mediated, or
form of dusts, fumes, gases and vapours.4, 5 other immune, response. The latency period
There are two types of work-related asthma: can be from two weeks to 30 years,
Continued on page 7
occupational asthma and work-aggravated therefore it is important to determine
asthma. It is important to distinguish
between occupational and work-aggravated Table 2: Common sensitizing agents in the bakery, automotive parts,
asthma as the management and
plastic and foam manufacturing and health care industries
compensation can differ, although both are
Agents
Industry
compensable under the WSIB.6
W
Work-aggravated Asthma
Pre-existing asthma can be aggravated by
non-specific irritants in the workplace, such
as dusts, smoke, fumes, sprays, cold
6
Flour, enzymes (particularly alpha amylase), milk powder, egg
powder, nuts, sesame seeds, yeast, moulds, mites, insects
Bakery
Isocyanates, acid anhydrides, metal dust and fumes,
colophony flux, metal working fluids
Auto parts and/or foam
and plastic manufacturing
FALL 2006 UPDATE
Work-related Asthma... Continued from page 6
1. Does the patient work with any asthmacausing agents?
❏ Yes ❏ No
2. Does the patient have symptoms of
asthma?
❏ Yes ❏ No
3. Did the symptoms of asthma first start
after he/she began to work in this job or
field of work?
❏ Yes ❏ No
4. Do the symptoms get worse as the
workday goes on?
❏ Yes ❏ No
5. Do the symptoms improve on holidays
and/or when the patient is away from work?
❏ Yes ❏ No
6. Do the patient’s co-workers have
symptoms of asthma?
❏ Yes ❏ No
With early recognition, the course of OA
can be reversed. The sooner a worker with
sensitizer-induced OA is removed from the
exposure, the more likely complete
recovery will be possible. This can involve
changing a worker’s duties to eliminate the
exposure, changing jobs to one where the
worker is not exposed to the offending
agent, or temporary leave with
compensation. If left untreated, chronic,
long-term changes to lung functioning
can occur and the worker may remain
unable to work.7
Workers diagnosed with workaggravated asthma or RADS are often able
to remain working in the same
job/workplace once their asthma is wellmanaged. Some of these patients, however,
may also require workplace modifications
to reduce exposure to aggravating irritants
and, in the case of RADS, to reduce the risk
of future accidental exposures.6
How can Occupational Asthma
be Prevented?
Occupational asthma is largely preventable
through 1) exposure control in the workplace,
2) ongoing medical surveillance and 3)
managing existing work-related asthma.
Employers, industries, workers, unions,
JOHSC’s and health care professionals need
to work together to prevent work-related
asthma and its consequences.
FALL 2006 UPDATE
ONTARIO RESPIRATORY CARE SOCIETY
To provide information about OA
prevention in higher risk sectors, the
Ministry of Health and Long-Term Care
(MOHLTC) and the Ministry of Labour
have provided funding to the Industrial
Accident Prevention Association (IAPA)
and the Occupational Health Clinics for
Ontario Workers (OHCOW) to develop
resources on prevention of work-related
asthma, as part of the MOHLTC’s Asthma
Plan of Action. Fact sheets and booklets for
patients on baker’s asthma and OA in the
automotive parts and foam and plastic
manufacturing sectors are available through
The Lung Association.
PROVINCIAL COMMITTEE 2006-2007
CHAIR
Lisa Cicutto, RN, PhD, ACNP, CAE
CHAIR-ELECT
Julie Duff Cloutier, RN, BScN, MSc, CAE
CHAIR, RESEARCH & FELLOWSHIP COMMITTEE
Judy King, BHScPT, MHSc(HCP), PhD(c)
CO-CHAIRS, EDITORIAL BOARD
Dina Brooks, BScPT, MSc, PhD
Libby Groff, RRT, BHA
CHAIR, EDUCATION COMMITTEE
Rob Bryan, RRT
CHAIR, MEMBERSHIP & PROGRAM PROMOTION COMMITTEE
Miriam Turnbull, RRT, MBA
REGIONAL REPRESENTATIVES
EASTERN ONTARIO
Harold Joubert, RRT
ESSEX/KENT
If you would like to find out more about
this project, please contact:
Nancy Bradshaw, Project Manager
Occupational Asthma Prevention Project
for Workers and Employers
Industrial Accident Prevention Association
and Occupational Health Clinics for
Ontario Workers
[email protected] or
(416) 636-8008.
Other Useful Resources:
Occupational Health Clinics
for Ontario Workers:
www.ohcow.on.ca or 1-877-817-0336
Industrial Accident Prevention
Association:
www.iapa.ca or 1-800-406-4272
Workplace Safety & Insurance Board:
www.wsib.ca or 1-800-387-0750
References
1. American Thoracic Society Statement: Occupational
contribution to the burden of airway disease. Am J Respir Crit
Care Med 2003; 167: 787-97
2. Milton DK, Solomon GM, Rosiello RA, Herrick RF. Risk
and incidence of asthma attributable to occupational exposure
among HMO members. Am J Ind Med 1998; 33(1):1-10
3. Arnaiz NO, Kaufman JD. New developments in workrelated asthma. Clin Chest Med 2002; 23(4):737-47
4. Cartier A. Diagnosing occupational asthma. Journal of the
World Allergy Organization 2003; 15(5):197-201
5. Chan-Yeung M. and Malo J. Occupational asthma. The New
England Journal of Medicine July 1995; 333(2):107-12
6. Tarlo S, Liss G. Occupational asthma: an approach to
diagnosis and management. Canadian Medical Association
Journal April 2003; 168(7)
7. Chan-Yeung M. Occupational asthma – the past 50 years.
Canadian Respiratory Journal Jan/Feb 2004; 11(01):21-6
Gillian Hueniken, BScPT
GREATER TORONTO
Paula Cripps-McMartin, RRT, CAE
NORTHEASTERN ONTARIO
Christina McMillan Boyles, RN, MScN
NORTHWESTERN ONTARIO
Shelley Prevost, RRT, MASc(Respiratory)(cand.)
SOUTH CENTRAL ONTARIO
Sheila Dedman, BSc, BHScPT
SOUTHWESTERN ONTARIO
Justyna Couto, BScPT
RESPIRATORY HEALTH EDUCATORS
INTEREST GROUP REPRESENTATIVE
Lorelei Samis, BScPT
COMMUNITY SERVICES LIAISON
Cathy Relf, BScPT
ONTARIO LUNG ASSOCIATION BOARD
OF DIRECTORS REPRESENTATIVE
Nancy Hanson
DIRECTOR OF ADMINISTRATION
Sheila Gordon-Dillane, BA, MPA
COMING
EVENTS
Continued from page 3
November 23, 2006*
The ORCS Essex/Kent Region is planning an
educational evening at the Chatham-Kent Health
Alliance. Tentative topics are Pulmonary Fibrosis and
Respiratory Medications.
November 30, 2006*
The ORCS Eastern Ontario Region and the Ontario
Thoracic Society present an educational evening on
Asthma vs. COPD at the Holiday Inn, Kingston.
December 4-6, 2006
Ontario Tobacco Control Conference 2006, Investing
in Social Change will be held at the Sheraton on the
Falls in Niagara Falls. www.otcconference.com.
February 1-3, 2007*
Better Breathing 2007 will be held at the Toronto
Marriott Downtown Eaton Centre (see article in this issue).
*For further information on ORCS programs, call (416)
864-9911, e-mail [email protected] or visit the Events page
at www.on.lung.ca/orcs. CRTO Portfolio Workshops will be
held after each the three ORCS seminars in Hamilton,
London and Toronto. Contact [email protected] for
details or to register.
7
RESPIRATORY CARE PERSPECTIVES:
Cardiorespiratory Physiotherapy in Western Australia (WA)
Kylie Hill, BSc (Physiotherapy), PhD, Research Fellow, West Park Healthcare Centre, Toronto
following surgical procedures; inspiratory muscle
Introduction
training; the role of physiotherapy in the prevention and
Having recently completed my PhD in the area of cardiotreatment of ventilator acquired pneumonia; the effects of
pulmonary physiotherapy at Curtin University of
breathing exercises and sputum clearance techniques; the
Technology, I find myself 18,000 km from home, living
assessment of exercise capacity and upper limb endurance
in London, Ontario. My home town is Perth which is
capacity in COPD patients and education programs for
located on the southwestern coast of the Australian
children with cystic fibrosis.
continent. It is the fourth largest city in Australia with a
Interest in cardiorespiratory physiotherapy research in
population of over 1.4 million people and is
WA
has been pioneered predominantly through the
acknowledged as the most isolated capital city in the
KYLIE HILL
efforts of Dr. Sue Jenkins. Sue has supervised all the past
world. In this editorial, I will provide an overview of the
Schools of Physiotherapy in Perth, cardiorespiratory research and present students that have undertaken research in the area of
interests, novel aspects of clinical practice demonstrated by cardiorespiratory physiotherapy at Curtin University.
Western Australian physiotherapists and professional issues
Unique Aspects of Clinical Practice
pertaining to cardiorespiratory physiotherapy in Australia.
Most physiotherapists with an interest in cardiorespiratory clinical
physiotherapy practice will seek work in one of the three publicly
Schools of Physiotherapy in Western Australia
Two of the five universities located in Perth have Schools of funded tertiary teaching hospitals in Perth: Royal Perth Hospital;
Physiotherapy. Curtin University of Technology is the largest Sir Charles Gairdner Hospital or Fremantle Hospital. All three
university in WA, with over 31,000 students. Curtin’s School of hospitals provide exposure to cardiorespiratory clinical practice
Physiotherapy, located on the main campus, has been graduating across the continuum of care spanning from intensive care units and
entry-level physiotherapy practitioners for over 50 years. Curtin’s in-patient wards to out-patient respiratory services including
School of Physiotherapy offers a four-year Bachelor of Science pulmonary rehabilitation and services in the community. The Australian
(BSc) in Physiotherapy and a 6 semester graduate-entry Master of health care system does not include Respiratory Therapists and
Physiotherapy degree. Canadians comprise the largest group of therefore those duties performed by Respiratory Therapists in Canada
overseas students that undertake the graduate-entry Master of are absorbed by other members of the health care team, including
Physiotherapy degree. An Honours program is offered to those physiotherapists. For example, physiotherapists play an important role
students undertaking the BSc in Physiotherapy with the highest in monitoring oxygen therapy including weaning patients from
academic performance. The School offers a number of clinical supplementary oxygen following acute illness or surgical procedures.
In 2000, the Physiotherapy Department, in conjunction with the
post-graduate programs including a Masters in Manipulative
Therapy and Masters in Sports Therapy in addition to higher Department of Respiratory Medicine at Royal Perth Hospital,
degrees via research (Masters of Science and Doctor of initiated a non-invasive ventilation (NIV) service. This service
aims primarily to provide ward-based NIV for patients admitted
Philosophy) (http://www.physiotherapy.curtin.edu.au/).
The University of Notre Dame Australia (UNDA) also has a with acute hypercapnic respiratory failure. Upon receiving a referral
Physiotherapy program offering a 4-year undergraduate Bachelor for NIV from a member of the medical staff, physiotherapists are
of Physiotherapy degree and an Honours program. The primary responsible for: (i) ensuring the patient has been referred to a
campus of UNDA is located on the coast of WA in the port city of Respiratory Physician for review and follow-up; (ii) assessing the
Fremantle, 18 km west of Perth. The undergraduate physiotherapy patient and initiating NIV and supplementary oxygen with
program offered at UNDA commenced in 2002 with its first cohort consideration for issues such as modes, parameters / settings, interfaces
and humidification; (iii) titrating ventilation parameters according
due to graduate in September of this year.
to changes in clinical status and arterial blood gases and; when
(http://www.nd.edu.au/fremantle/colleges/health/schools/physiotherapy/index.shtml).
appropriate (iv) initiating the weaning process and removal from
NIV and supplementary oxygen. One of the perceived strengths of
Cardiorespiratory Physiotherapy Research Interests
Over the past 11 years, the School of Physiotherapy at Curtin University this service is that physiotherapists are involved in the patient care
of Technology has graduated 6 Masters of Science (MSc) and 4 from the acute presentation in the emergency department, to the
Doctors of Philosophy (PhD) in the area of cardiorespiratory critical care wards if required, to the general wards and through to
physiotherapy. Three students are currently enrolled in PhD studies the domiciliary setting. The NIV service is also used in the
in cardiorespiratory physiotherapy. Specifically, the research undertaken management of tetraplegic patients outside of the critical care
for these higher degrees has been in areas related to: the wards and in the outpatient pulmonary rehabilitation program. The
physiotherapy management of patients following cardiac surgery in NIV service is provided in close collaboration with the Respiratory
both the intensive care unit and the early post-operative period; Physicians. Royal Perth Hospital is unique in providing a rostered
exercise training in patients with COPD, life long asthma, on-site physiotherapy service 24 hours a day, 7 days a week.
paediatric lung disease, primary pulmonary hypertension and
Continued on page 9
8
FALL 2006 UPDATE
Respiratory Care Perspectives... Continued from page 8
ORCS RESEARCH AND FELLOWSHIP AWARDS
Professional Practice Issues
Australian Physiotherapy Association (APA)
The APA is the national organisation representing the physiotherapy
profession. It has a number of National Special Groups (NSG), including
Cardiorespiratory Physiotherapy Australia (CRPA). The APA supports
research and professional development. Interest is increasing in
developing extended scope practitioners in cardiopulmonary
physiotherapy. However, the framework adopted for such clinical
roles in the United Kingdom is not currently permitted under Australia’s
legislation. The APA continues to monitor this issue and lobby for
national reform to the health care system (http://apa.advsol.com.au/).
The ORCS Research and Fellowship Committee is pleased to
announce Lung Association funding for the following Awards
for the year 2006-2007:
Thoracic Society of Australia and New Zealand (TSANZ)
The TSANZ is a professional society of physicians, scientists and other
health care workers involved in lung disease. Cardiorespiratory
physiotherapists actively contribute to the TSANZ. The society hosts
an Annual Scientific Meeting in March of each year which provides
an opportunity for physiotherapists from throughout Australia and
New Zealand to present the results of research related to cardiorespiratory physiotherapy practice. A prize ($500), sponsored by
MayoHealthCare is awarded to the best presentation by a physiotherapist
at the TSANZ Annual Scientific Meeting (http://www.thoracic.org.au/).
Increasing Access to Supportive Care for Lung Cancer Patients:
A Feasibility Study
Principal Investigator: Margaret Fitch, RN, PhD, Head, Oncology
Nursing and Supportive Care, Toronto Sunnybrook Regional Cancer Centre
Co-Investigator: Rose Steele, RN, PhD, Associate Professor, York
University School of Nursing
Australian Lung Foundation (ALF)
The ALF is a national non-profit organization that provides reliable
information regarding issues relating to respiratory medicine. The ALF
in conjunction with the CRPA supported a multidisciplinary working
party that included a high proportion of cardiorespiratory
physiotherapists to develop a pulmonary rehabilitation tool kit. The aim
of this toolkit is to assist health professionals to establish pulmonary
rehabilitation programs throughout Australia (www.pulmonaryrehab.com.au).
Australian and New Zealand Intensive Care Society (ANZICS)
For those with an interest in the critical care ANZICS, whilst
primarily a medical based organization, does provide an opportunity
for physiotherapists to participate and contribute to their
professional development events and annual conferences. At present
there is support to create an allied health group within the
organization to acknowledge and further support the role of
professions such as physiotherapy. (http://www.anzics.com.au).
Research Grants
Satisfaction with Rollators among Individuals Living in the Community
Principal Investigators: Dina Brooks, BScPT, MSc, PhD, Associate
Professor, Department of Physical Therapy, University of Toronto
& Cathy Relf, BScPT, Physiotherapist, West Park Healthcare Centre
Co-Investigators: Dr. Roger Goldstein, Respirologist & Elizabeth
Gartner, Occupational Therapist, West Park Healthcare Centre
Fellowship Awards
Ann Bartlett, RN, CAE, Hamilton: Master of Respiratory Care,
Open University, National Respiratory Training Centre, Warwick, UK
Nancy Garvey, RRT, CAE, Georgetown: Master of Applied
Science (Respiratory Science), Charles Sturt University, Australia
Mika Nonoyama, BSc, RRT, Toronto: Ph.D., Rehabilitation
Science, University of Toronto
Shelley Prevost, RRT, Thunder Bay: Master of Applied Science
(Respiratory Science), Charles Sturt University, Australia
Education Awards for Advanced Respiratory Practice
Yvonne Drasovean, RRT, London: Asthma Educator Post-Diploma
Program, The Michener Institute for Applied Health Sciences
Steve Mulholland, RRT, Hamilton: Asthma Patient Care Program,
Ontario Pharmacists’ Association
Lisa Wickerson, BScPT, CCE, Toronto: Clinical Research Associate
Program, The Michener Institute for Applied Health Sciences
2007-2008 Funding Year
The deadlines for funding for the 2007-2008 funding year are
November 1, 2006 for Research Grants and February 1, 2007 for
Conclusion
Since arriving in Canada I have enjoyed the opportunity to become Fellowships and Education Awards for Advanced Respiratory
familiar with new aspects of clinical and research practice. The Practice. For copies of application forms and program guidelines,
Physiotherapists Registration Board of WA has recently granted call (416) 864-9911 or visit www.on.lung.ca/orcs.
immediate recognition of physiotherapy qualifications obtained in
Canada. This means that Canadian-trained physiotherapists are able
to obtain registration to work as physiotherapist in WA without the
need to successfully complete the examinations conducted by the
Australian Examining Council for Overseas Physiotherapists. This
provides a unique opportunity for Canadian-trained physiotherapists
to work in a new health care system and become familiar with novel
aspects of clinical practice.
Acknowledgement
The assistance of Dr. Sue Jenkins and Dr. Shane Patman in the
preparation of this article is gratefully acknowledged.
FALL 2006 UPDATE
9
Welcome to Smoke-Free Ontario
Joanne Di Nardo, MA, Tobacco Control Specialist, The Lung Association, Ontario Tobacco-Free Network (OTN), [email protected]
ay marked an historic month
retail displays will be effective on
for Ontario, as finally, the
May 31, 2008.
Smoke-Free Ontario Act was
Since its inception in 1900,
implemented on May 31, 2006.
The Lung Association has been
According to the Smoke-Free
an avid supporter of smoke-free
Ontario legislation, the following
legislation in Ontario. Although
places are now to be 100%
not originally revealed by the
smoke-free:
tobacco industry, smoking and
• Restaurants, bars, banquet halls
second-hand smoke cause COPD,
JOANNE DI NARDO
and entertainment facilities
heart disease, cancers, including
• Healthcare facilities
lung cancer and other lung diseases.
• Public and private schools and school
As we rang in the year 2000, meetings
property
with government officials began to occur,
• Casinos, gambling facilities and bingo halls asking for legislation banning smoking in
• Private clubs, including legion halls
public places. Some municipal bylaws were
• Common areas in residential/multi-unit
passed with the help of Lung Association
buildings/dwellings (hotels, motels,
volunteers all over Ontario, who brought
apartment and condominium buildings)
forth deputations to city councils asking for
• All offices and government buildings
municipal bylaws that would protect citizens
• Work vehicles
from second-hand smoke in public places.
• All enclosed public places including
These advocacy efforts were successful
parking garages
in making communities aware of the
• Day nurseries
dangers of second-hand smoke. However,
• Private home day care, even when
some communities created stronger bylaws
children are not present
than others. Some bylaws banned smoking
• Reserved seating in sporting arenas or
in restaurants, but still allowed smoking in
entertainment venues
bars, or allowed for designated smoking
rooms (DSRs) instead of banning them
Smoking is prohibited on bar and outright. It was time for overarching,
restaurant patios where there is a permanent comprehensive, provincial legislation that
full or partial roof, or awning. If the patio would frame the whole province equally.
does not have a roof, smoking is allowed.
The legislation would fill in the missing
Designated smoking rooms (DSRs) are pieces where municipal bylaws were
no longer allowed, except in specified lacking, and go even further.
residential care facilities where strict
Even though there was a great ‘hoorah’
criteria are followed to create a controlled on May 31, 2006, World No Tobacco Day, it
smoking area.
was also a day of remembrance of all those
All countertop displays and promotion who worked tirelessly for a Smoke-Free
of tobacco products in retail outlets are Ontario and passed away before it
prohibited. A full ban on tobacco product happened. One of the key recognizable
M
advocates for a Smoke-Free Ontario was
Heather Crowe, an Ottawa waitress who
developed lung cancer from second-hand
smoke in the restaurant where she worked.
Heather put a face to the fight against
second-hand smoke in public places, as her
commercials could be seen often on
television. Heather Crowe had hoped to
survive her lung cancer a little longer, for
the official implementation of Smoke-Free
Ontario, but passed away on May 22, 2006.
Fortunately, no other person working in a
public establishment will be affected by
second-hand smoke, ever again.
Moving forward, there is still much work
to be done. The Lung Association will be
busy ensuring that Smoke-Free Ontario is
here to stay and our children are not only
protected in public places, but in their
homes and when passengers in vehicles as
well. Second-hand smoke exposure in any
enclosed space is dangerous and The Lung
Association will continue to advocate and
educate the people we serve and the general
public, about tobacco use and the risks.
This fall, take a look around when you are
out and about. Are restaurants and bars
complying with the legislation? Do you see
large price signs outside of stores, or gas
bars? Are tobacco promotional signs on the
counter, or hanging from the ceilings in
convenience stores? If you come across an
establishment not complying with the rules
of the legislation, please, drop me a line, or let
your local public health unit know, so the proper
enforcement can be done.
Spread the word, how
wonderful it is to live and
work in our new Smoke-Free
Ontario!
A Tribute to Alan McFarlane... Continued from page 3
“Alan had an energy and enthusiasm for what he was doing that
seemed larger than life,” says Cindy Shcherban, Vice PresidentProvincial Programs. “He was able to get everyone interested in his
COPD plans and we needed that type of involvement to build that
program.” Alan was the architect of the provincial and then
national BreathWorks program for people with COPD, for which he
received The Lung Association’s President’s Award for Employee of
the Year, recognition that he cherished. He was also instrumental in
the creation of the Youth Tobacco Team that received significant
provincial support and has now become the Youth Advocacy
Training Institute (YATI), extending youth influence province-wide
by partnering with public health units.
10
Alan faced his greatest challenge, cancer, with tenacity. When
he presented at the 2006 Better Breathing Conference, only he and
his wife Margot knew how much pain he was in. Alan went into
hospital the next day. “He taught us all a life lesson in his last year,”
says Diane Feldman, Asthma/COPD Educator, who worked closely
with Alan. “He loved what he was doing and that seemed to carry him.”
Alan lived to see the Smoke-Free Ontario legislation
implemented on May 31, 2006. For the husband, father, son, sports
nut, Star Wars fanatic, friend, professional and advocate who had
lived a busy and productive life, on June 1, 2006 it was time to rest
…or at least to finish his conversation with his grandfather.
Adapted from text written by Karen Connor Petcoff for The Lung Association.
FALL 2006 UPDATE
RESPIRATORY ARTICLES OF INTEREST
Marra F, Lynd L, Coombes M, Richardson K, Legal M, FitzGerald MJ, Marra CA.
Does Antibiotic Exposure During Infancy Lead to Development of Asthma?
A Systematic Review and Metaanalysis
Asthma is now the most common chronic disease of childhood. Increased antibiotic use for
the treatment of infections during early childhood has been linked with an increase in the
prevalence of asthma. This observation has led to the hypothesis of a possible association
between excessive antibiotic exposure during childhood and asthma. Prospective and
retrospective studies that examined the association between exposure to at least one course of
antibiotics and development of childhood asthma were analyzed. The authors considered
studies that looked at the number of antibiotic courses in the first year of life as well as
dose-response relationship. As a result of the metaanalysis of four prospective and four
retrospective studies, it has been concluded that exposure to at least one course of antibiotics
in the first year of life appears to be a risk factor for the development of childhood asthma.
Further large-scale studies are needed though, to confirm the association.
McGhan SL, Cicutto LC, Befus AD. Advances in development and evaluation
of asthma education programs. Curr Opin Pul Med 2005;11:61-68.
Effective asthma education requires more than merely providing information on asthma.
Behaviour change and learning principles must be incorporated into educational programs.
Successful asthma education programs include behaviour change strategies, shared care
practices and communication skills, a clear educational process, tailoring to the client needs
and influencing factors, multiple teaching formats, and a continuum of care.
Berry MJ, Adair NE and Rejeski WJ. Use of Peak Oxygen Consumption in Predicting
Physical Function and Quality of Life in COPD Patients. Chest 129(6): 1516-1522
Staging and classification of COPD is based on the level of lung impairment, which is
associated with physical function and quality of life. However, there is only modest evidence
showing that FEV1 alone can accurately predict these 2 components. The primary aim of this
trial was to determine if peak oxygen consumption (VO2peak) could add to the power of
FEV1 in predicting physical function and quality of life in 291 COPD patients (of various
severity levels). Outcomes included PFTs, disease-specific health-related quality-of-life, a
graded exercise test (treadmill), physical function tests and self-reported physical function.
After accounting for FEV1, VO2peak added significantly to the prediction of 6-min walk
distance; stair climb time; self-reported function; and health-related quality-of-life domain of
mastery. Only VO2 peak was found to significantly predict the health-related quality-of-life
domain of fatigue. These results provide support for the use of VO2 peak in the multidimensional assessment of COPD patients. This study’s methodology and statistical analysis
were well thought out. Its simplicity added to the study’s strengths and conclusions.
Compiled by Yvonne Drasovean, Larry Jackson and Mika Nonoyama
Preliminary Announcement: Second Annual CTS Clinical Trials
Coordinated Canadian Respiratory Clinical Research Consortium Meeting
The Second Annual CTS Clinical Trials Coordinated Canadian Respiratory Clinical Research
Consortium Meeting will be held on November 16th and 17th in Calgary at the Westin Calgary.
The deadline for submission of protocol outlines, for review and for presentation will be
September 15th. The meeting will begin with a half day focused on clinical trial methodology
and will be followed by protocol presentations and disease specific mini meetings. Full details
can be found at www.crcrc.ca or by contacting Rajashree Devarakonda, email:
[email protected].
Please note that the COPD Alliance Conference, Optimizing Wellness in COPD, will follow
immediately. Please plan to attend this meeting also. Details of this meeting can be found at
www.lungca/cca-cca_e.php.
FALL 2006 UPDATE
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11
The Lung Association’s Asthma
Action Program’s Newest Resources
The book “Asthma in Children” has been
updated with current information and is
now available for parents of children with
asthma.
We have updated our Asthma Action
Handbook with the most recent
information and enhanced graphics in
“The New Asthma Action Handbook”.
The Hospital for Sick Children and The
Lung Association have recently launched an
exciting new book “Questions and Answers
about Asthma – Information for Parents”.
If you have any questions about asthma or to order our
resources, please call our Asthma Action Helpline at
1-800-668-7682. We have Certified Asthma Educators
available to answer any queries.
12
FALL 2006 UPDATE