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Toussaint M, Wijkstra PJ, McKim D, Benditt J, Winck JC, Nasiłowski J, Borel JC. Building a home ventilation programme: population, equipment, delivery and cost. Thorax 2022; 77:thoraxjnl-2021-218410. [PMID: 35868847 PMCID: PMC9606503 DOI: 10.1136/thoraxjnl-2021-218410] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 03/31/2022] [Indexed: 11/03/2022]
Abstract
Home mechanical ventilation (HMV) improves quality of life and survival in patients with neuromuscular disorders (NMD). Developing countries may benefit from published evidence regarding the prevalence, cost of equipment, technical issues and organisation of HMV in NMD, facilitating the development of local turn-key HMV programmes. Unfortunately, such evidence is scattered in the existing literature. We searched Medline for publications in English and French from 2005 to 2020. This narrative review analyses 24 international programmes of HMV. The estimated prevalence (min-max) of HMV is ±7.3/100 000 population (1.2-47), all disorders combined. The prevalence of HMV is associated with the gross domestic product per capita in these 24 countries. The prevalence of NMD is about 30/100 000 population, of which ±10% would use HMV. Nocturnal (8/24 hour), discontinuous (8-16/24 hours) and continuous (>16/24 hours) ventilation is likely to concern about 60%, 20% and 20% of NMD patients using HMV. A minimal budget of about 168€/patient/year (504€/100 000 population), including the cost of equipment solely, should address the cost of HMV equipment in low-income countries. When services and maintenance are included, the budget can drastically increase up to between 3232 and 5760€/patient/year. Emerging programmes of HMV in developing countries reveal the positive impact of international cooperation. Today, at least 12 new middle, and low-income countries are developing HMV programmes. This review with updated data on prevalence, technical issues, cost of equipment and services for HMV should trigger objective dialogues between the stakeholders (patient associations, healthcare professionals and politicians); potentially leading to the production of workable strategies for the development of HMV in patients with NMD living in developing countries.
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Affiliation(s)
- Michel Toussaint
- Centre de Référence Neuromusculaire, Cliniques Universitaires de Bruxelles (ULB), Hôpital Erasme, Université libre de Bruxelles (ULB), Brussels, Belgium
- Department of Neurology, Hospital Erasme, Brussels, Belgium
| | - Peter J Wijkstra
- Pulmonary Diseases, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Doug McKim
- CANVent Respiratory Services, Ottawa Hospital Respiratory Rehabilitation and The Ottawa Hospital Sleep Centre and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Benditt
- Respiratory Care Services, University of Washington Medical Center, Seattle, Washington, USA
| | | | - Jacek Nasiłowski
- Department of Internal Medicine, Pulmonary Diseases and Allergy, Medical University of Warsaw, Poland, Warsaw, Poland
- Department of Pharmacology and Clinical Pharmacology, Faculty of Medicine, Collegium Medicum. Cardinal Stefan Wyszyński University, Warsaw, Poland
| | - Jean-Christian Borel
- Sleep Laboratory and EFCR, Grenoble University Hospital, Grenoble Cedex 09, France
- R&D, AGIR a dom, Meylan, France
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2
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Katz SL, Mah JK, McMillan HJ, Campbell C, Bijelić V, Barrowman N, Momoli F, Blinder H, Aaron SD, McAdam LC, Nguyen TTD, Tarnopolsky M, Wensley DF, Zielinski D, Rose L, Sheers N, Berlowitz DJ, Wolfe L, McKim D. Routine lung volume recruitment in boys with Duchenne muscular dystrophy: a randomised clinical trial. Thorax 2022; 77:805-811. [PMID: 35236763 PMCID: PMC9340020 DOI: 10.1136/thoraxjnl-2021-218196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 01/25/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Impaired cough results in airway secretion retention, atelectasis and pneumonia in individuals with Duchenne muscular dystrophy (DMD). Lung volume recruitment (LVR) stacks breaths to inflate the lungs to greater volumes than spontaneous effort. LVR is recommended in DMD clinical care guidelines but is not well studied. We aimed to determine whether twice-daily LVR, compared with standard of care alone, attenuates the decline in FVC at 2 years in boys with DMD. METHODS In this multicentre, assessor-blinded, randomised controlled trial, boys with DMD, aged 6-16 years with FVC >30% predicted, were randomised to receive conventional treatment or conventional treatment plus manual LVR twice daily for 2 years. The primary outcome was FVC % predicted at 2 years, adjusted for baseline FVC % predicted, age and ambulatory status. Secondary outcomes included change in chest wall distensibility (maximal insufflation capacity minus FVC) and peak cough flow. RESULTS Sixty-six boys (36 in LVR group, 30 in control) were evaluated (median age (IQR): 11.5 years (9.5-13.5), median baseline FVC (IQR): 85% predicted (73-96)). Adjusted mean difference in FVC between groups at 2 years was 1.9% predicted (95% CI -6.9% to 10.7%; p=0.68) in the direction of treatment benefit. We found no differences in secondary outcomes. CONCLUSION There was no difference in decline in FVC % predicted with use of twice-daily LVR for boys with DMD and relatively normal lung function. The burden associated with routine LVR may outweigh the benefit. Benefits of LVR to maintain lung health in boys with worse baseline lung function still need to be clarified. TRIAL REGISTRATION NUMBER NCT01999075.
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Affiliation(s)
- Sherri L Katz
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada .,CHEO Research Institute, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jean K Mah
- Division of Pediatric Neurology, Alberta Children's Hospital, Calgary, Alberta, Canada.,Department of Pediatric and Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Hugh J McMillan
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada.,CHEO Research Institute, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Craig Campbell
- Department of Pediatrics, Epidemiology and Clinical Neurological Sciences, University of Western Ontario, London, Ontario, Canada.,Department of Pediatrics, London Health Sciences Centre Children's Hospital, London, Ontario, Canada
| | - Vid Bijelić
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Nick Barrowman
- CHEO Research Institute, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Shawn D Aaron
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Respirology, Department of Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Laura C McAdam
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - The Thanh Diem Nguyen
- Department of Respiratory Medicine, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Mark Tarnopolsky
- Division of Neuromuscular and Neurometabolic Disease, McMaster University, Hamilton, Ontario, Canada
| | - David F Wensley
- Division of Pediatric Respirology, Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia, Canada.,Department of Pediatrics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - David Zielinski
- Division of Pediatric Respirology, Department of Pediatrics, Montreal Children's Hospital, Montreal, Quebec, Canada.,Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Louise Rose
- Department of Midwifery and Palliative Care, King's College London Florence Nightingale School of Nursing and Midwifery, London, London, UK.,Critical Care Directorate and Lane Fox Respiratory Unit, Guy's and St Thomas' NHS Foundation Trust, London, London, UK
| | - Nicole Sheers
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia.,Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Faculty of Medicine Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - David J Berlowitz
- Department of Respiratory and Sleep Medicine, Institute for Breathing and Sleep, Heidelberg, Victoria, Australia.,Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lisa Wolfe
- Department of Medicine and Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Department of Respiratory Care, Shirley Ryan AbilityLab, Chicago, Illinois, USA
| | - Doug McKim
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,CANVent Respiratory Rehabilitation Services, Ottawa Hospital Rehabilitation Centre, Ottawa, Ontario, Canada
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3
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Rose L, Fisher T, Pizzuti R, Amin R, Croxford R, Dale CM, Goldstein R, Katz S, Leasa D, McKim D, Nonoyama M, Tandon A, Gershon A. Health Care Use, Costs, and Survival Trajectory of Home Mechanical Insufflation-Exsufflation. Respir Care 2022; 67:191-200. [PMID: 34670856 PMCID: PMC9993949 DOI: 10.4187/respcare.09263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Despite expert recommendations for use, limited evidence identifies effectiveness of mechanical insufflation-exsufflation (MI-E) in addressing respiratory morbidity and resultant health care utilization and costs for individuals with neuromuscular disorders. We examined the impact of provision of publicly funded MI-E devices on health care utilization, health care costs, and survival trajectory. METHODS This is a retrospective pre/post cohort study linking data on prospectively recruited participants using MI-E to health administrative databases to quantify outcomes. RESULTS We linked data from 106 participants (8 age < 15 y) and determined annualized health care use pre/post device. We found no difference in emergency department (ED) visit or hospital admission rates. Following MI-E approval, participants required fewer hospital days (median [interquartile range] [IQR]) 0 [0-9] vs 0 [0-4], P = .03). Rates of physician specialist visits also decreased (median IQR 7 [4-11] vs 4 [2-7], P < .001). Conversely, rates of home care nursing and homemaking/personal support visits increased. Following MI-E, total costs were lower for 59.4%, not different for 13.2%, and higher for 27.4%. Physician billing costs decreased whereas home care costs increased. Regression modeling identified pre-MI-E costs were the most important predictor of costs after approval. At 12 months, 23 (21.7%) participants had died. Risk of death was higher for those using more medical devices (hazard ratio 1.12, [95% CI 1.02-1.22]) in the home. CONCLUSIONS Provision of publicly funded MI-E devices did not influence rates of ED visits or hospital admission but did shift health care utilization and costs from the acute care to community sector. Although increased community costs negated cost savings from physician billings, evidence suggests costs savings from reduced hospital days and fewer specialist visits. Risk of death was highest in individuals requiring multiple medical technologies.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, United Kingdom.
| | - Tom Fisher
- Ventilator Equipment Pool, Kingston, Canada
| | | | - Reshma Amin
- Division of Respiratory Medicine, Hospital for Sick Children (SickKids) and SickKids Research Institute, University of Toronto, Toronto, Canada
| | | | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada; and Department of Critical Care, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, Canada
| | - Roger Goldstein
- West Park Healthcare Centre, Toronto, Canada and also affiliated with the Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sherri Katz
- Children's Hospital of Eastern Ontario and Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - David Leasa
- Department of Medicine, Divisions of Critical Care and Respirology, London Health Sciences Centre, London, Canada; and Faculty of Medicine, Western University, London, Canada
| | - Doug McKim
- The Ottawa Hospital Respiratory Rehabilitation and The Ottawa Hospital Sleep Centre and Ottawa Hospital Research Institute, Ottawa, Canada and also affiliated with the Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Mika Nonoyama
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada and also affiliated with the Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
| | - Anu Tandon
- Division of Respirology, Sunnybrook Health Sciences Centre and also affiliated with the Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Andrea Gershon
- Division of Respirology, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Toronto, Canada; ICES, Toronto, Canada and also affiliated with the Faculty of Medicine, University of Toronto, Toronto, Canada
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4
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Thebault S, Gibbs E, Bourque P, McKim D, Rakhra K, Breiner A, Frykman H, Warman-Chardon J. MuSK not MNGIE: Atypical MuSK-antibody myasthenia presenting as a genetic disorder. Neuromuscul Disord 2021; 31:1279-1281. [PMID: 34690051 DOI: 10.1016/j.nmd.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/25/2021] [Accepted: 08/31/2021] [Indexed: 11/19/2022]
Abstract
Myasthenia gravis is a treatable autoimmune disease caused by autoantibodies directed against membrane proteins at the neuromuscular junction. While acetylcholine receptor antibodies are most common, a minority of patients have antibodies directed against muscle-specific kinase (MuSK-antibody). Differentiating features often include subacute onset and rapid progression of bulbar, respiratory and neck extensor muscles, with sparing of distal appendicular muscles, most commonly in middle-aged females. Here we present an atypical presentation of MuSK-antibody myasthenic syndrome in a young male consisting of a gradual-onset, insidiously-progressive, non-fatigable and non-fluctuating ocular, bulbar and oesophageal weakness, with a normal frontalis single fibre EMG. This case clinically resembled a mitochondrial myopathy (Mitochondrial Neurogastrointestinal Encephalopathy-MNGIE) with a poor prognosis. Because of the atypical presentation, MuSK antibodies were identified very late in the disease course, at which point the patient responded very well to immunotherapy. We report an unusual presentation of an uncommon but treatable condition, illustrating significant phenotypic heterogeneity possible in MuSK-antibody myasthenic syndrome.
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Affiliation(s)
- Simon Thebault
- Department of Medicine, The Ottawa Hospital, Centre for Neuromuscular Disease and University of Ottawa, Canada.
| | - Ebrima Gibbs
- The University of British Columbia Neuroimmunology lab, Canada
| | - Pierre Bourque
- Department of Medicine, The Ottawa Hospital, Centre for Neuromuscular Disease and University of Ottawa, Canada
| | - Doug McKim
- Department of Medicine, The Ottawa Hospital, Centre for Neuromuscular Disease and University of Ottawa, Canada
| | - Kawan Rakhra
- Department of Diagnostic Imaging, The Ottawa Hospital and University of Ottawa, Canada
| | - Ari Breiner
- Department of Medicine, The Ottawa Hospital, Centre for Neuromuscular Disease and University of Ottawa, Canada
| | - Hans Frykman
- The University of British Columbia Neuroimmunology lab, Canada
| | - Jodi Warman-Chardon
- Department of Medicine, The Ottawa Hospital, Centre for Neuromuscular Disease and University of Ottawa, Canada; Department of Genetics, Children's Hospital of Eastern Ontario Research Institute.
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5
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Toussaint M, Chatwin M, Gonçalves MR, Gonzalez-Bermejo J, Benditt JO, McKim D, Sancho J, Hov B, Sansone V, Prigent H, Carlucci A, Wijkstra P, Garabelli B, Escarrabill J, Pinto T, Audag N, Verweij-van den Oudenrijn L, Ogna A, Hughes W, Devaux C, Chaulet J, Andersen T. Mouthpiece ventilation in neuromuscular disorders: Narrative review of technical issues important for clinical success. Respir Med 2021; 180:106373. [PMID: 33798870 DOI: 10.1016/j.rmed.2021.106373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/26/2022]
Abstract
In neuromuscular disorders (NMDs), nocturnal non-invasive ventilation (NIV) via a nasal mask is offered when hypercapnic respiratory failure occurs. With disease progression, nocturnal NIV needs to be extended into the daytime. Mouthpiece ventilation (MPV) is an option for daytime NIV. MPV represents a difficult task for home ventilators due to rapidly changing load conditions resulting from intermittent connections and disconnections from MPV circuit. The 252nd ENMC International Expert Workshop, held March 6th to 8th 2020 in Amsterdam, reported general guidelines for management of daytime MPV in NMDs. This report could not present all the detail regarding the technical issues important for clinical success of MPV. Based on the expert workshop discussions and the evidence from existing studies, the current narrative review aims to identify the technical issues of MPV and offers guidance via a decisional algorithm and educational figures providing relevant information that is important for successful implementation of MPV.
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Affiliation(s)
- Michel Toussaint
- Neuromuscular Excellency Centre VUB- Inkendaal, Center for Home Mechanical Ventilation ZH Inkendaal Rehabilitation Hospital, Brussels, Belgium.
| | - Michelle Chatwin
- Clinical and Academic Department of Sleep and Breathing, Royal Brompton, London, UK.
| | - Miguel R Gonçalves
- Noninvasive Ventilatory Support Unit, Emergency and Intensive Care Medicine Department, Pulmonology Department, São João University Hospital. Faculty of Medicine, University of Porto, Portugal.
| | - Jésus Gonzalez-Bermejo
- Sorbonne-Université, Service de pneumologie et réanimation respiratoire, Groupe hospitalier de la Pitié-Salpêtrière-Charles Foix, Paris, France.
| | | | - Doug McKim
- University of Ottawa, CANVent Respiratory Services, The Ottawa Hospital Sleep Centre, Canada.
| | - Jesus Sancho
- Respiratory Care Unit, Respiratory Medicine Department, Hospital Clínico Universitario, Health Research Institute INCLIVA, Valencia, Spain.
| | - Brit Hov
- Paediatric Department, Oslo University Hospital, Oslo, Norway.
| | - Valeria Sansone
- The NEMO Clinical Center, Neurorehabilitation Unit, University of Milan, Italy.
| | - Hélène Prigent
- Service de Physiologie et Explorations Fonctionnelles, Hôpital Raymond Poincaré, GHU PIFO, APHP, Garches, France; UFR Simone Veil, Université de Versailles, Saint Quentin en Yvelines, Montigny le Bretonneux, France.
| | - Annalisa Carlucci
- Pulmonary Rehabilitation and Weaning Center, Istituti Clinici Scientifici-Maugeri, Pavia, Italy.
| | - Peter Wijkstra
- Department of Home Mechanical Ventilation and Pulmonary Diseases, University Medical Center Groningen, Groningen, the Netherlands.
| | - Barbara Garabelli
- Respiratory Unit, Neuromuscular OmniCentre (NeMO), Niguarda Hospital, Milan, Italy.
| | - Joan Escarrabill
- Hospital Clínic-Barcelona & Master Plan For Respiratory Diseases, Ministry of Health (Government of Catalonia), Barcelona, Spain.
| | - Tiago Pinto
- Lung Function and Ventilation Unit - Pulmonology Department, São João University Hospital, Porto, Portugal.
| | - Nicolas Audag
- Unité de Pneumologie pédiatrique, Cliniques universitaires Saint-Luc, Brussels, Belgium.
| | | | - Adam Ogna
- Servizio di pneumologia, Ospedale Regionale di Locarno, Switzerland.
| | | | | | | | - Tiina Andersen
- Norwegian Advisory Unit on Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway.
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6
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Dale CM, McKim D, Amin R, Carbone S, Fisher T, Goldstein R, Katz S, Gershon A, Leasa D, Nonoyama M, Pizutti R, Tandon A, Rose L. Education Experiences of Adult Subjects and Caregivers for Mechanical Insufflation-Exsufflation at Home. Respir Care 2020; 65:1889-1896. [PMID: 32606074 DOI: 10.4187/respcare.07534] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In 2014, the Ministry of Health of Ontario, Canada, approved a program of public funding for specialist-prescribed mechanical insufflation-exsufflation (MI-E) devices for home use by individuals with neuromuscular respiratory insufficiency. Since 2014, 1,926 MI-E devices have been provided, exceeding device-use projections. Few studies describe the initial and ongoing education and support needs of home MI-E users and their family caregivers. This study aimed to explore the requirements of initial and ongoing education and support for MI-E device use, user confidence, and barriers and facilitators to home MI-E. METHODS We conducted semi-structured interviews with new (< 6 months) and established (6-48 months) MI-E users and family caregivers. Device users rated their confidence on a numeric rating scale of 1 (not confident) to 10 (very confident). RESULTS We recruited 14 new and 14 established MI-E users and caregivers (including 9 dyads), and we conducted 28 interviews. Both new and established users were highly confident in use of MI-E (mean ± SD scores were 8.8 ± 1.2 and 8.3 ± 2.1, respectively). Overall, the subjects were satisfied with their initial education, which consisted of a 1-2 h one-on-one session at home or in the clinic with a device demonstration and hands-on practice. Subjects viewed hands-on practice and teaching of caregivers as more beneficial than written materials. Ongoing support for device use was variable. Most subjects indicated a lack of specific follow-up, which resulted in uncertainty about whether they were using the MI-E device correctly or whether MI-E was effective. Facilitators to device utilization were ease of use, initial training, support from formal or informal caregivers, and symptom relief. Barriers were inadequate education on MI-E purpose, technique, and benefit; lack of follow-up; and inadequate knowledge of MI-E by nonspecialist health providers. CONCLUSIONS The current model of home MI-E education at initiation meets user and caregiver needs. Better ongoing education and follow-up are needed to sustain the benefits through assessment of MI-E technique and its effectiveness.
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Affiliation(s)
- Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada. .,TECC Program, Sunnybrook Health Sciences Centre and Research Institute, Toronto, Canada
| | - Doug McKim
- The Ottawa Hospital Respiratory Rehabilitation, The Ottawa Hospital Sleep Centre and Research Institute, Ottawa, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Reshma Amin
- Division of Respiratory Medicine, SickKids Research Institute, University of Toronto, Toronto, Canada
| | - Sarah Carbone
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Tom Fisher
- Ventilator Equipment Pool, Kingston, Canada
| | - Roger Goldstein
- West Park Healthcare Centre, Toronto, Canada.,Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sherri Katz
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Andrea Gershon
- Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Respirology and Clinical Immunology, Sunnybrook Health Sciences Centre and Research Institute, Toronto, Canada.,Institute of Clinical Evaluative Sciences, Toronto, Canada
| | - David Leasa
- Department of Medicine, Divisions of Critical Care and Respirology, London Health Sciences Centre, London, Canada.,Faculty of Medicine, Western University, London, Canada
| | - Mika Nonoyama
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
| | | | - Anu Tandon
- Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Respirology and Clinical Immunology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom.,Sunnybrook Research Institute, Toronto, Canada.,Institute of Clinical Evaluative Sciences, Toronto, Canada
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7
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McKim D, Rose L. Efficacy of Mechanical Insufflation-Exsufflation in Extubating Unweanable Subjects With Restrictive Pulmonary Disorders. Respir Care 2015; 60:621-2. [DOI: 10.4187/respcare.04051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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8
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Bach JR, Bianchi C, Finder J, Fragasso T, Goncalves MR, Ishikawa Y, Ramlall AK, McKim D, Servera E, Vianello A, Villanova M, Winck JC. Tracheostomy tubes are not needed for Duchenne muscular dystrophy. Eur Respir J 2007; 30:179-80; author reply 180-1. [PMID: 17601977 DOI: 10.1183/09031936.00156806] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Schünemann HJ, Goldstein R, Mador MJ, McKim D, Stahl E, Puhan M, Griffith LE, Grant B, Austin P, Collins R, Guyatt GH. A randomised trial to evaluate the self-administered standardised chronic respiratory questionnaire. Eur Respir J 2005; 25:31-40. [PMID: 15640320 DOI: 10.1183/09031936.04.00029704] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The original chronic respiratory questionnaire (CRQ), one of the most widely used measures of health-related quality of life (HRQL) in chronic respiratory disease (CRD), is traditionally interviewer administered (IA) and includes an individualised dyspnoea domain. The present authors studied the impact of self-administered (SA) and standardised dyspnoea questions on CRQ measurement properties. In a factorial design multicentre trial, 177 patients with CRD (mean age 67.7 yrs; mean forced expiratory volume in one second per cent predicted 44.6%) were randomised to CRQ-IA (n = 86) or CRQ-SA (n = 91), and to initially complete the standardised or individualised items before and after respiratory rehabilitation. While maintaining validity, the CRQ-SA proved more responsive to changes in HRQL than the CRQ-IA in all domains. Compared with the standardised dyspnoea domain, the individualised dyspnoea domain indicated greater responsiveness. The correlations of baseline scores and change scores with other HRQL instruments indicated good validity of the CRQ-SA. In conclusion, self-administration and standardisation of the chronic respiratory questionnaire maintains validity and responsiveness relative to the interviewer-administered chronic respiratory questionnaire. These results challenge the assumption that interviewer-administered questionnaires are superior to self-administered questionnaires in older patients with chronic respiratory disease.
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Affiliation(s)
- H J Schünemann
- Department of Medicine, University Health Sciences Centre, Room 2C12, Hamilton, Ontario L8N 3Z5, Canada.
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10
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Dales RE, O'Connor A, Hebert P, Sullivan K, McKim D, Llewellyn-Thomas H. Intubation and mechanical ventilation for COPD: development of an instrument to elicit patient preferences. Chest 1999; 116:792-800. [PMID: 10492288 DOI: 10.1378/chest.116.3.792] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Whether to simply provide palliative care or to intubate and use mechanical ventilation (MV) in a patient with severe COPD in acute respiratory failure is a difficult decision. The outcome of MV cannot be accurately predicted. Some patients cannot be weaned from the ventilator; those who are weaned often return to chronic severe respiratory disability. It is important that patients participate in this decision, but assistance is required. To address these issues, we developed and pilot-tested an aid to assist patients with MV decisions. METHODS A scenario-based decision aid was developed consisting of an audiocassette and a booklet describing intubation and MV and its possible outcomes. We used a probability tradeoff technique to elicit the patients' preferences and a decisional conflict scale to evaluate satisfaction. RESULTS With the assistance of the decision aid, all patients (10 men and 10 women) reached a decision. Two men and all 10 women declined MV. Mean decisional conflict was low (2.2 of a possible 5; SD, 0.9). At 1 year, only two patients (11%) had changed their decision. The agreement between physicians and patients was 65%; between next-of-kin and patients, there was uniform disagreement. CONCLUSION With the decision aid, stable decisions were made with satisfaction and confidence. Proxy decisions were incongruent, especially when made by family members. The strong gender effect should be further investigated. We suggest that the COPD decision aid be further tested in a community clinical setting.
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Affiliation(s)
- R E Dales
- Department of Medicine, University of Ottawa, Ontario, Canada
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McNeely PD, Hébert PC, Dales RE, O'Connor AM, Wells G, McKim D, Sullivan KE. Deciding about mechanical ventilation in end-stage chronic obstructive pulmonary disease: how respirologists perceive their role. CMAJ 1997; 156:177-83. [PMID: 9012718 PMCID: PMC1226905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE To determine when respirologists approach patients with end-stage chronic obstructive pulmonary disease (COPD) to decide about the use of mechanical ventilation, what information they provide to patients and how they provide it. DESIGN Self-administered national survey. PARTICIPANTS All Canadian specialists in respiratory medicine; of 401 eligible respirologists, 279 (69.6%) returned a completed questionnaire. OUTCOME MEASURES Timing and content of doctor-patient discussions regarding mechanical ventilation; physicians' perception of their level of involvement in the decision-making process; and patient and physician characteristics that may influence decisions. RESULTS Discussions were reported to occur most often at advanced stages of COPD: when the patient's dyspnea was severe (reported by 235 [84.2%] of the respondents) or when the patient's forced expiratory volume in the first second was 30% or less than predicted value (reported by 210 [75.3%]). A total of 120 respondents (43.0%) stated that they discuss mechanical ventilation with 40% or less of their COPD patients before an exacerbation necessitates ventilatory support. Most (154 [55.2%]) described the decision-making process as a collaboration between patient and physician; 83 (29.7%) reported that the patient decides after he or she has considered the physician's opinion. Over half (148 [53.0%]) of the respondents indicated that they occasionally, often or always modify the information provided to patients in order to influence their decision about mechanical ventilation. CONCLUSIONS Discussions with COPD patients concerning end-of-life decisions about mechanical ventilation are reported to occur in advanced stages of the disease or not at all, with patients' input where possible. Information presented to patients is often modified in order to influence the decision. Future studies should explore ways to involve patients further in the decision-making process and to improve the process for both patients and physicians.
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Affiliation(s)
- P D McNeely
- Department of Medicine, School of Nursing, University of Ottawa, Ont
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Abstract
The role of central respiratory muscle fatigue in determining endurance time (ET) of steady-state ergometry, ventilation (VE), and breathing pattern during exhaustive submaximal exercise is not known. Six normal subjects exercised on a cycle ergometer to exhaustion at 72-82% of maximal power output on three occasions. During the second test, inspiratory muscle load was reduced (approximately 50% of baseline load) for all but the last 3 min of exercise. ET was determined, and VE, tidal volume (VT), respiratory rate (f), and sense of breathing effort (Borg scale) were assessed at different points during the assisted exercise and compared with the values obtained at the same time in identical tests without assist, carried out before and after the assisted test (different days). Borg scale rating was less and there was a nonsignificant trend for VT and VE to be higher and for f to be lower when the assist was in place than at the same time during the unassisted runs. In the last 3 min of exercise, when the respiratory load was comparable (assist removed) but ventilatory work history was different, there were no significant differences in sense of respiratory effort, VE, VT, or f between the experimental and control tests, and ET was also similar. We conclude that central respiratory muscle fatigue plays no role in determining ET, sense of respiratory effort, or breathing pattern in normal subjects during exhaustive submaximal exercise.
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Affiliation(s)
- D Marciniuk
- Department of Medicine, University of Manitoba, Winnipeg, Canada
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Abstract
Inflammation of the fat in lupus erythematosus also known as lupus erythematosus profundus (panniculitis) is a rare clinical entity. As the presenting feature of lupus, it is even more unusual. In this report, we describe an elderly woman who presented with an orbital mass infiltrate as the initial manifestation of lupus that had the classical histological features of lupus panniculitis.
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Affiliation(s)
- D R Jordan
- Department of Ophthalmology, University of Ottawa, Ontario, Canada
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Abstract
Growth data from a number of species of Old and New World primates have been analyzed by calculating instantaneous relative growth rates. Species discussed are the New World species Saimiri sciureus and Saguinus nigricollis, and the Old World species Pan troglodytes and Macaca mulatta. The analysis of the perinatal growth data indicated that differences in relative growth rates are present during early periods of growth. More specifically, it was found that the closer taxonomically a species is to man the greater the deceleration of growth during the first postnatal year. It is suggested that this may be a general primate trend.
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McKim D, Hutchinson TC, Gavan JA. Prenatal growth of long bones in rhesus and squirrel monkeys (Macaca mulatta and Saimiri sciureus). Am J Phys Anthropol 1972; 36:353-7. [PMID: 4624654 DOI: 10.1002/ajpa.1330360305] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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