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Schultz A, Balaguruswamy S, Dentice R, Dobler CC, Geake J, Gibson P, Goulter P, Jayaram L, Laird PJ, Middleton PG, Seale H. Thoracic Society of Australia and New Zealand position statement: The safe clinical use of sputum induction for bio-sampling of the lower airways in children and adults. Respirology 2024; 29:372-378. [PMID: 38556839 DOI: 10.1111/resp.14707] [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: 08/31/2023] [Accepted: 03/11/2024] [Indexed: 04/02/2024]
Abstract
Sputum induction is widely used in clinical settings for collection of biological samples from the lower airways. However, in recent years sputum induction has been associated with serious adverse events and even death. This position statement was commissioned by the Thoracic Society of Australia and New Zealand to address major adverse events of two deaths associated with sputum induction that have occurred in Australia in 2021, and outlines best practice for the safe use of sputum induction. The statement resulted from systematic literature searches by a multi-disciplinary group including respiratory physicians, nurses and physiotherapists (paediatric and adults focused). Consumers had input to an advanced draft of the position statement. The position statement covers indications for sputum induction, informed consent, scope of practice of personnel administering the procedure, infection control considerations, details about the sputum induction procedure, safety considerations and risk assessment in clinical settings.
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Affiliation(s)
- André Schultz
- Wal-yan Respiratory Research Centre, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Paediatrics, Faculty of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Sathya Balaguruswamy
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Ruth Dentice
- Department of Physiotherapy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Claudia C Dobler
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Queensland, Australia
- Department of Respiratory Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - James Geake
- Department of Thoracic and Sleep Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Peter Gibson
- Centre of Excellence in Treatable Traits, College of Health, Medicine and Wellbeing, University of Newcastle, New Lambton Heights, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Patricia Goulter
- Physiotherapy Department, Te Whatu Ora (Health New Zealand), Wellington, New Zealand
| | - Lata Jayaram
- Department of Respiratory and Sleep Medicine, Western Health, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Victoria, Australia
| | - Pamela J Laird
- Wal-yan Respiratory Research Centre, Telethon Kids Institute, Perth, Western Australia, Australia
- Division of Paediatrics, Faculty of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Department Physiotherapy, Perth Children's Hospital, Perth, Western Australia, Australia
| | - Peter G Middleton
- Westmead Clinical School, University of Sydney, Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, New South Wales, Australia
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Westmead, New South Wales, Australia
| | - Helen Seale
- Department of Physiotherapy, The Prince Charles Hospital, Brisbane, Queensland, Australia
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Doumit M, Strachan R, Lazarus R, Middleton P, Dentice R, Marouvo J, Jeffrey L, Selvadurai H, Sivam S, Pacey V, Jaffe A, Gray K. Screening for Cystic Fibrosis Related Complications in the Context of a Pandemic and Altered Models of Care. Health Serv Insights 2023; 16:11786329231205145. [PMID: 37854074 PMCID: PMC10580724 DOI: 10.1177/11786329231205145] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 09/15/2023] [Indexed: 10/20/2023] Open
Abstract
Background Standard of care recommend that patients with cystic fibrosis (CF) require screening investigations to assess for complications. Changing models of care due to the COVID19 pandemic may have impacted completion of recommended screening. Objective To compare the frequency of screening investigations completed in people with CF before and after the onset of the COVID19 pandemic. Methods Medical records were reviewed at 4 CF-specialist centers to identify screening investigations completed in the 12-months before and after pandemic onset. Results Records of 625 patients were reviewed. Prior to pandemic onset, there was between center variability in completion of screening investigations. There was greatest baseline variation between centers in performing oral glucose tolerance test (OGTT); range 38%-69%, exercise tests; 3%-51% and sputum screening for non-tuberculous mycobacteria; 53%-81%. Following pandemic onset, blood tests, and sputum cultures were maintained at the highest rates. Exercise testing, CXR and OGTT exhibited the greatest declines, with reductions at individual centers ranging between 10%-24%, 22%-43%, and 20%-26%, respectively. Return to in-person visits following pandemic onset was variable, ranging from 16% to 74% between centers. Conclusion Completion of screening investigations varies between CF centers and changes in models of care, such as increased virtual care in response to COVID19 pandemic was associated with reduction in completion of investigations. Centers would benefit from auditing their adherence to standards of care, particularly considering recent changes in care delivery.
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Affiliation(s)
- Michael Doumit
- Department of Health Sciences, Macquarie University, Sydney, NSW, Australia
- School of Women’s and Children’s Health, University of New South Wales, Sydney, NSW, Australia
- Respiratory Medicine Department, Sydney Children’s Hospital, Sydney, NSW, Australia
| | - Roxanne Strachan
- Respiratory Medicine Department, Sydney Children’s Hospital, Sydney, NSW, Australia
| | - Raynuka Lazarus
- Respiratory Medicine Department, Westmead Hospital, Sydney, NSW, Australia
| | - Peter Middleton
- Respiratory Medicine Department, Westmead Hospital, Sydney, NSW, Australia
- Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Ruth Dentice
- The Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Jessica Marouvo
- The Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Laura Jeffrey
- Department of Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Hiran Selvadurai
- Respiratory Medicine Department, The Children’s Hospital at Westmead, Sydney, NSW, Australia
- Discipline of Adolescent and Child Health, University of Sydney, Sydney, NSW, Australia
| | - Sheila Sivam
- The Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Verity Pacey
- Department of Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Adam Jaffe
- School of Women’s and Children’s Health, University of New South Wales, Sydney, NSW, Australia
- Respiratory Medicine Department, Sydney Children’s Hospital, Sydney, NSW, Australia
| | - Kelly Gray
- Department of Health Sciences, Macquarie University, Sydney, NSW, Australia
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Dwyer TJ, Elkins MR, Dentice R, Forbes S, Cooper P, Jaffe A, Bishop J, Middleton PG, Wark P, Bye PTP. Saline at lower tonicity in cystic fibrosis (SALTI-CF) trial comparing 0.9% versus 3% versus 6% nebulised saline. Eur Respir J 2023; 62:2100960. [PMID: 37343977 DOI: 10.1183/13993003.00960-2021] [Citation(s) in RCA: 3] [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] [Received: 03/31/2021] [Accepted: 04/28/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND In people with cystic fibrosis (CF), regular nebulisation of 6% or 7% saline improves lung function; however, these concentrations are not always tolerable. Clinically, some CF patients report using lower concentrations of saline to improve tolerability, yet the effects of lower concentrations are unknown. This study therefore aimed to evaluate the relative effectiveness and tolerability of 0.9% versus 3% versus 6% saline nebulised twice daily with an eFlow rapid nebuliser. METHODS This was a randomised, blinded, placebo-controlled, parallel-group, multicentre study where subjects inhaled 4 mL of 0.9%, 3% or 6% saline twice daily for 16 weeks. The primary outcome was forced expiratory volume in 1 s. The secondary outcomes were: forced vital capacity (FVC) and forced expiratory flow at 25-75% of FVC; quality of life; exercise capacity; acquisition or loss of bacterial organisms in expectorated sputum; tolerability of nebulised saline; pulmonary exacerbations; and adverse events. RESULTS 140 participants were randomised to 0.9% (n=47), 3% (n=48) or 6% (n=45) saline. 134 participants (96%) contributed to the intention-to-treat analysis. 3% saline significantly improved lung function and increased the time to first pulmonary exacerbation compared with 0.9% saline but did not improve quality of life. 6% saline had similar benefits to 3% saline but also significantly improved quality of life compared with 3% saline. Only 6% saline delayed the time to intravenous antibiotics for pulmonary exacerbation. Tolerability and adherence were similar. CONCLUSIONS Dilution of 6% saline to 3% maintains the benefits for lung function and exacerbation prevention; however, the positive impacts of 6% saline on quality of life and time to i.v. antibiotics for pulmonary exacerbations are lost.
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Affiliation(s)
- Tiffany J Dwyer
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mark R Elkins
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, Australia
| | - Ruth Dentice
- Department of Physiotherapy, Royal Prince Alfred Hospital, Sydney, Australia
| | - Samantha Forbes
- Department of Respiratory Medicine, Children's Hospital Westmead, Westmead, Australia
| | - Peter Cooper
- Department of Respiratory Medicine, Children's Hospital Westmead, Westmead, Australia
| | - Adam Jaffe
- School of Women's and Children's Health, UNSW Medicine and Health, Randwick, Australia
- Department of Respiratory Medicine, Sydney Children's Hospital, Sydney, Australia
| | - Jennifer Bishop
- Department of Respiratory Medicine, Westmead Hospital, Westmead, Australia
| | - Peter G Middleton
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Respiratory Medicine, Westmead Hospital, Westmead, Australia
| | - Peter Wark
- Centre for Healthy Lungs, Hunter Medical Research Institute, New Lambton, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, Australia
| | - Peter T P Bye
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, Australia
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Cox NS, Eldridge B, Rawlings S, Dreger J, Corda J, Hauser J, Button BM, Bishop JR, Nichols A, Middleton A, Ward N, Dwyer T, Dentice R, Lazarus R, O'Halloran P, Lee JYT, Mellerick C, Mackintosh K, McNarry M, Williams CA, Holland AE. Web-based physical activity promotion in young people with CF: a randomised controlled trial. Thorax 2023; 78:16-23. [PMID: 36180067 DOI: 10.1136/thorax-2022-218702] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 01/11/2022] [Accepted: 09/13/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Physical activity levels are known to decline following hospitalisation for people with cystic fibrosis (pwCF). However, optimal physical activity promotion strategies are unclear. This study investigated the effect of a web-based application (ActivOnline) in promoting physical activity in young pwCF. METHODS Multicentre randomised controlled trial with assessor blinding and qualitative evaluation. People with CF (12-35 years) admitted to hospital for a respiratory cause were eligible and randomised to the 12-week ActivOnline intervention (AO) or usual care (UC). The primary outcome was change in device-based time spent in moderate-to-vigorous physical activity (MVPA) from baseline to post-intervention. Follow-up was at 6 months from hospital discharge when qualitative evaluation was undertaken. RESULTS 107 participants were randomised to AO (n=52) or UC (n=55). Sixty-three participants (59%) contributed to the intention-to-treat analysis. Mean (SD) age was 21 (6) years (n=46, <18 years). At baseline, physical activity levels were high in both groups (AO 102 (52) vs UC 127 (73) min/day). There was no statistically significant difference in MVPA between groups at either timepoint (post-intervention mean difference (95% CI) -14 mins (-45 to 16)). Uptake of the intervention was low with only 40% (n=21) of participants accessing the web application. CONCLUSION A web-based application, including individualised goal setting, real-time feedback and motivation for behavioural change, was no better than usual care at promoting physical activity in young pwCF following hospital discharge. High levels of baseline physical activity levels in both groups, and limited engagement with the intervention, suggest alternative strategies may be necessary to identify and support young pwCF who would benefit from enhanced physical activity. TRIAL REGISTRATION NUMBER ACTRN12617001009303, 13 July 13 2017.
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Affiliation(s)
- Narelle S Cox
- Respiratory Research@Alfred, Department of Immunology and Pathology, Monash University, Melbourne, Victoria, Australia .,Institute for Breathing and Sleep, Melbourne, Victoria, Australia
| | - Beverley Eldridge
- College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia.,Children's Medical Research Institute, Melbourne, Victoria, Australia
| | - Sarah Rawlings
- Respiratory Research@Alfred, Department of Immunology and Pathology, Monash University, Melbourne, Victoria, Australia.,Monash Health, Melbourne, Victoria, Australia
| | - Julianna Dreger
- Respiratory Research@Alfred, Department of Immunology and Pathology, Monash University, Melbourne, Victoria, Australia
| | - Jennifer Corda
- Physiotherapy, The Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Jennifer Hauser
- Tasmanian Adult CF Service, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Brenda M Button
- Physiotherapy, Alfred Health, Melbourne, Victoria, Australia.,Allergy, Immunology and Respiratory Medicine, Alfred Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jennifer R Bishop
- Respiratory Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | | | - Anna Middleton
- Physiotherapy, Sydney Children's Hospital Network Westmead, Sydney, New South Wales, Australia
| | - Nathan Ward
- Physiotherapy, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tiffany Dwyer
- Discipline of Physiotherapy, Sydney School of Health Sciences, University of Sydney, Sydney, New South Wales, Australia.,Respiratory Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Ruth Dentice
- Physiotherapy, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Raynuka Lazarus
- Respiratory Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Paul O'Halloran
- College of Science, Health and Engineering, La Trobe University, Melbourne, Victoria, Australia
| | - Joanna Y T Lee
- Respiratory Research@Alfred, Department of Immunology and Pathology, Monash University, Melbourne, Victoria, Australia
| | - Christie Mellerick
- Respiratory Research@Alfred, Department of Immunology and Pathology, Monash University, Melbourne, Victoria, Australia
| | | | | | | | - Anne E Holland
- Respiratory Research@Alfred, Department of Immunology and Pathology, Monash University, Melbourne, Victoria, Australia.,Institute for Breathing and Sleep, Melbourne, Victoria, Australia.,Physiotherapy, Alfred Health, Melbourne, Victoria, Australia
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Abstract
BACKGROUND Inhalation of the enzyme dornase alfa reduces sputum viscosity and improves clinical outcomes of people with cystic fibrosis. This is an update of a previously published Cochrane Review. OBJECTIVES To determine whether the timing of dornase alfa inhalation (in relation to airway clearance techniques or morning versus evening inhalation) has an impact on objective and subjective measures of clinical efficacy in people with cystic fibrosis. SEARCH METHODS Relevant randomised and quasi-randomised controlled trials were identified from the Cochrane Cystic Fibrosis Trials Register, the Physiotherapy Evidence Database (PEDro), clinical trial registries and international cystic fibrosis conference proceedings. Date of the most recent search: 12 October 2020. SELECTION CRITERIA Any trial of dornase alfa in people with cystic fibrosis where timing of inhalation was the randomised element in the trial with either: inhalation before compared to after airway clearance techniques; or morning compared to evening inhalation. DATA COLLECTION AND ANALYSIS: Both authors independently selected trials, assessed risk of bias and extracted data with disagreements resolved by discussion. Relevant data were extracted and, where possible, meta-analysed. We assessed the quality of the evidence using GRADE. MAIN RESULTS We identified 115 trial reports representing 55 trials, of which five trials (providing data on 122 participants) met our inclusion criteria. All five trials used a cross-over design. Intervention periods ranged from two to eight weeks. Four trials (98 participants) compared dornase alfa inhalation before versus after airway clearance techniques. Inhalation after instead of before airway clearance did not significantly change forced expiratory volume at one second (very-low quality evidence). Similarly, forced vital capacity (low-quality evidence) and quality of life (very-low quality evidence) were not significantly affected; forced expiratory flow at 25% was significantly worse with dornase alfa inhalation after airway clearance, mean difference -0.17 litres (95% confidence interval -0.28 to -0.05), based on the pooled data from two small trials in children (7 to 19 years) with well-preserved lung function. All other secondary outcomes were statistically non-significant. In one trial (25 participants), morning versus evening inhalation had no impact on lung function or symptoms (low-quality evidence). AUTHORS' CONCLUSIONS The current evidence derived from a small number of participants does not indicate that inhalation of dornase alfa after airway clearance techniques is more or less effective than the traditional recommendation to inhale nebulised dornase alfa 30 minutes prior to airway clearance techniques, for most outcomes. For children with well-preserved lung function, inhalation before airway clearance may be more beneficial for small airway function than inhalation after. However, this result relied on a measure with high variability and trials with variable follow-up. In the absence of strong evidence to indicate that one timing regimen is better than another, the timing of dornase alfa inhalation can be largely based on pragmatic reasons or individual preference with respect to the time of airway clearance and time of day. Further research is warranted.
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Affiliation(s)
- Ruth Dentice
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Mark Elkins
- Sydney Medical School, University of Sydney, Sydney, Australia
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Bell J, Sivam S, Dentice R, Dwyer T, Jo H, Lau E, Lee W, Munoz P, Shah K, Taylor N, Visser S, Yozghatlian V, Wong K. P100 Quality of home spirometry performance amongst adults with cystic fibrosis. J Cyst Fibros 2021. [DOI: 10.1016/s1569-1993(21)01126-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Dwyer T, Dentice R, Marouvo J, Bye P, Alison J. WS16.3 Relationship between physical activity and long-term health outcomes in adults with cystic fibrosis. J Cyst Fibros 2020. [DOI: 10.1016/s1569-1993(20)30252-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Abstract
BACKGROUND Inhalation of hypertonic saline improves sputum rheology, accelerates mucociliary clearance and improves clinical outcomes of people with cystic fibrosis. This is an update of a previously published Cochrane Review. OBJECTIVES To determine whether the timing of hypertonic saline inhalation (in relation to airway clearance techniques or in relation to time of day) has an impact on its clinical efficacy in people with cystic fibrosis. SEARCH METHODS We identified relevant randomised and quasi-randomised controlled trials from the Cochrane Cystic Fibrosis Trials Register, the Physiotherapy Evidence Database (PEDro), and international cystic fibrosis conference proceedings. Date of the last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register: 28 February 2019. SELECTION CRITERIA Any trial of hypertonic saline in people with cystic fibrosis where timing of inhalation was the randomised element in the study protocol with either: inhalation up to six hours before airway clearance techniques compared to inhalation during airway clearance techniques compared to inhalation up to six hours after airway clearance techniques; or morning compared to evening inhalation with any definition provided by the author. DATA COLLECTION AND ANALYSIS Both authors independently assessed the trials identified by the search for potential inclusion in the review. The certainty of the evidence was assessed using GRADE. MAIN RESULTS The searches identified 104 trial reports which represented 51 trials, of which three cross-over trials (providing data on 77 participants) met our inclusion criteria. We present three comparisons: inhalation before versus during airway clearance techniques; inhalation before versus after airway clearance techniques; and inhalation during versus after airway clearance techniques. One trial (50 participants), given its three-arm design, was eligible for all three comparisons. No trials compared morning versus evening inhalation of hypertonic saline. The evidence from the three trials was judged to be of low quality downgraded for limitations (high risk of bias due to blinding) and indirectness (all participants are adults, and therefore not applicable to children). Intervention periods ranged from one treatment to three treatments in one day. There were no clinically important differences between the timing regimens of inhaling hypertonic saline before, during or after airway clearance techniques in the mean amount of improvement in lung function or symptom scores (77 participants), with the between-group comparisons being non-significant (low-certainty evidence). While there may be little or no difference in the rating of satisfaction when hypertonic saline was inhaled before versus during the airway clearance techniques (64 participants) (with the 95% confidence interval including the possibility of both a higher and lower rating of satisfaction), satisfaction may be lower on a 100-mm scale when inhaled after the airway clearance techniques compared to before: mean difference (MD) 20.38 mm (95% confidence interval (CI) 12.10 to 28.66) and when compared to during the techniques, MD 14.80 mm (95% CI 5.70 to 23.90). Perceived effectiveness showed similar results: little or no difference for inhalation before versus during airway clearance techniques (64 participants); may be lower when inhaled after the airway clearance techniques compared to before, MD 10.62 (95% CI 2.54 to 18.70); and also when compared to during the techniques, MD 15.60 (95% CI 7.55 to 23.65). There were no quality of life or adverse events reported in any of the trials. AUTHORS' CONCLUSIONS Timing of hypertonic saline inhalation makes little or no difference to lung function (low-certainty evidence). However, inhaling hypertonic saline before or during airway clearance techniques may maximise perceived efficacy and satisfaction. The long-term efficacy of hypertonic saline has only been established for twice-daily inhalations; however, if only one dose per day is tolerated, the time of day at which it is inhaled could be based on convenience or tolerability until evidence comparing these regimens is available. The identified trials were all of very short intervention periods, so longer-term research could be conducted to establish the effects arising from regular use, which would incorporate the influence of changes in adherence with long-term use, as well as generating data on any adverse effects that occur with long-term use.
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Affiliation(s)
- Mark Elkins
- University of SydneySydney Medical SchoolEdward Ford Building A27SydneyAustraliaNSW 2006
| | - Ruth Dentice
- Royal Prince Alfred HospitalDepartment of Respiratory MedicineLevel 11, E BlockMissenden RoadCamperdownNew South WalesAustraliaNSW 2050
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Ward N, Stiller K, Holland AE, Bishop J, Button B, Chambers R, Cobb R, Corda J, Dentice R, Green M, Hall K, Hauser J, Morrow S, Netluch R, Nichols A, Rowe H, Shaw A, Shortall D, Smith T, Wood J. Exercise is commonly used as a substitute for traditional airway clearance techniques by adults with cystic fibrosis in Australia: a survey. J Physiother 2019; 65:43-50. [PMID: 30559063 DOI: 10.1016/j.jphys.2018.11.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/08/2018] [Accepted: 11/22/2018] [Indexed: 10/27/2022] Open
Abstract
QUESTIONS What airway clearance techniques and exercise regimens are used by adults with cystic fibrosis (CF) in Australia when well or unwell? What proportion of these adults believe that exercise can be used as a substitute for traditional airway clearance techniques, and how have they come to this belief? What type of exercise is used as a substitute for traditional airway clearance techniques? DESIGN Cross-sectional survey at 13 CF centres in Australia, using a purpose-designed questionnaire. PARTICIPANTS Six hundred and ninety-two adults with CF completed the questionnaire. OUTCOME MEASURES The questionnaire included questions about: the participants' current use of traditional airway clearance techniques and exercise, when well and unwell; and beliefs regarding the use of exercise as a substitute for traditional airway clearance techniques. RESULTS Coughing, huffing and positive expiratory pressure were the most commonly used airway clearance techniques. Walking, jogging and lifting weights were the most commonly used forms of exercise. Overall, 43% of participants believed that exercise could be used as a substitute for traditional airway clearance techniques, with 44% having substituted exercise for traditional airway clearance techniques in the previous 3 months. Personal experience was the most commonly reported factor influencing participants' beliefs about the use of exercise as a substitute for traditional airway clearance techniques. CONCLUSION Exercise is commonly used as a substitute for traditional airway clearance techniques. Physiotherapists should advise patients that whilst there is some research suggesting a possible mechanism for exercise as a form of airway clearance, there are currently no medium-term to long-term data supporting exercise as a stand-alone form of airway clearance. These results suggest that future research to investigate the clinical effectiveness of exercise as a substitute for traditional airway clearance techniques should be a priority. REGISTRATION ACTRN12616000994482.
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Affiliation(s)
- Nathan Ward
- Cystic Fibrosis Service, Royal Adelaide Hospital, Adelaide, Australia; Physiotherapy Department, School of Allied Health, La Trobe University, Melbourne, Australia.
| | - Kathy Stiller
- Central Adelaide Local Health Network, Adelaide, Australia
| | - Anne E Holland
- Physiotherapy Department, School of Allied Health, La Trobe University, Melbourne, Australia; Physiotherapy, Alfred Health, Melbourne, Australia
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10
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Abstract
BACKGROUND Inhalation of the enzyme dornase alfa reduces sputum viscosity and improves clinical outcomes of people with cystic fibrosis. This is an update of a previously published Cochrane Review. OBJECTIVES To determine whether the timing of dornase alfa inhalation (in relation to airway clearance techniques or morning versus evening inhalation) has an impact on objective and subjective measures of clinical efficacy in people with cystic fibrosis. SEARCH METHODS Relevant randomised and quasi-randomised controlled trials were identified from the Cochrane Cystic Fibrosis Trials Register, Physiotherapy Evidence Database (PEDro), clinical trial registries and international cystic fibrosis conference proceedings.Date of the most recent search: 06 June 2018. SELECTION CRITERIA Any trial of dornase alfa in people with cystic fibrosis where timing of inhalation was the randomised element in the trial with either: inhalation before compared to after airway clearance techniques; or morning compared to evening inhalation. DATA COLLECTION AND ANALYSIS Both authors independently selected trials, assessed risk of bias and extracted data with disagreements resolved by discussion. Relevant data were extracted and, where possible, meta-analysed. MAIN RESULTS We identified 115 trial reports representing 55 trials, of which five trials (providing data on 122 participants) met our inclusion criteria. All five trials used a cross-over design. Intervention periods ranged from two to eight weeks. Four trials (98 participants) compared dornase alfa inhalation before versus after airway clearance techniques. Inhalation after instead of before airway clearance did not significantly change forced expiratory volume at one second (very-low quality evidence). Similarly, forced vital capacity (low-quality evidence) and quality of life (very-low quality evidence) were not significantly affected; forced expiratory flow at 25% was significantly worse with dornase alfa inhalation after airway clearance, mean difference -0.17 litres (95% confidence interval -0.28 to -0.05), based on the pooled data from two small trials in children (7 to 19 years) with well-preserved lung function. All other secondary outcomes were statistically non-significant.In one trial (25 participants), morning versus evening inhalation had no impact on lung function or symptoms (low-quality evidence). AUTHORS' CONCLUSIONS The current evidence derived from a small number of participants does not indicate that inhalation of dornase alfa after airway clearance techniques is more or less effective than the traditional recommendation to inhale nebulised dornase alfa 30 minutes prior to airway clearance techniques, for most outcomes. For children with well-preserved lung function, inhalation before airway clearance may be more beneficial for small airway function than inhalation after. However, this result relied on a measure with high variability and trials with variable follow-up. In the absence of strong evidence to indicate that one timing regimen is better than another, the timing of dornase alfa inhalation can be largely based on pragmatic reasons or individual preference with respect to the time of airway clearance and time of day. Further research is warranted.
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Affiliation(s)
- Ruth Dentice
- Royal Prince Alfred HospitalDepartment of Respiratory MedicineLevel 11, E BlockMissenden RoadCamperdownNew South WalesAustraliaNSW 2050
| | - Mark Elkins
- University of SydneySydney Medical SchoolEdward Ford Building A27SydneyAustraliaNSW 2006
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11
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Sivam S, Dentice R, Reddy N, Moriarty C, Yozghatlian V, Mellis C, Torzillo P, Glanville A, Gattas D, Bye P. Use of extracorporeal membrane oxygenation in cystic fibrosis in an Australian cystic fibrosis centre. Intern Med J 2018; 48:340-343. [PMID: 29512325 DOI: 10.1111/imj.13728] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 12/04/2017] [Accepted: 12/08/2017] [Indexed: 11/26/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) support is used in selected patients with cystic fibrosis (CF) as a bridge to transplantation. Our aim was to describe briefly treatment and outcomes of six CF patients who received ECMO. One patient received a lung transplant and another recovered from acute respiratory failure. Four died despite ECMO support. Lack of timely availability of suitable donor lungs and patient selection are contributing factors.
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Affiliation(s)
- Sheila Sivam
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Ruth Dentice
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nazmeen Reddy
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Carmel Moriarty
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Veronica Yozghatlian
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Craig Mellis
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Paul Torzillo
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Intensive Care Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Allan Glanville
- Lung Transplantation Unit, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - David Gattas
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Intensive Care Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Peter Bye
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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12
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Abstract
BACKGROUND Inhalation of hypertonic saline improves sputum rheology, accelerates mucociliary clearance and improves clinical outcomes of people with cystic fibrosis. OBJECTIVES To determine whether the timing of hypertonic saline inhalation (in relation to airway clearance techniques or in relation to time of day) has an impact on its clinical efficacy in people with cystic fibrosis. SEARCH METHODS We identified relevant randomised and quasi-randomised controlled trials from the Cochrane Cystic Fibrosis Trials Register, the Physiotherapy Evidence Database (PEDro), and international cystic fibrosis conference proceedings.Date of the last search of the Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register: 19 December 2016. SELECTION CRITERIA Any trial of hypertonic saline in people with cystic fibrosis where timing of inhalation was the randomised element in the study protocol with either: inhalation up to six hours before airway clearance techniques compared to inhalation during airway clearance techniques compared to inhalation up to six hours after airway clearance techniques; or morning compared to evening inhalation with any definition provided by the author. DATA COLLECTION AND ANALYSIS Both authors independently assessed the trials identified by the search for potential inclusion in the review. MAIN RESULTS The searches identified 97 trial reports which represented 46 studies, of which two studies (providing data on 63 participants) met our inclusion criteria. Both studies used a cross-over design. Both studies had low risk of all types of bias except the participants and the therapists who applied the treatments were not blinded. Intervention periods ranged from one treatment to three treatments in one day. The effects of the various regimens on lung function were non-significant. Satisfaction was rated significantly lower on a 100-mm scale when hypertonic saline was inhaled after the airway clearance techniques: mean differences 20.38 mm (95% confidence interval 12.10 to 28.66) compared to before airway clearance techniques and 14.80 mm (95% confidence interval 5.70 to 23.90) compared to during the techniques. Perceived effectiveness showed similar significant results. Other outcomes were unaffected by the timing regimen used. No trials compared morning versus evening inhalation of hypertonic saline. AUTHORS' CONCLUSIONS People with cystic fibrosis could be encouraged to inhale hypertonic saline before or during airway clearance techniques to maximise perceived efficacy and satisfaction, even though these timing regimens may not have any better effect on lung function than inhalation after airway clearance techniques. Given the long-term efficacy of hypertonic saline has only been established for twice-daily inhalations, clinicians should advise patients to inhale hypertonic saline twice daily. However, if only one dose per day is tolerated, the time of day at which it is inhaled could be based on convenience or tolerability until evidence comparing these regimens is available.
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Affiliation(s)
- Mark Elkins
- University of SydneySydney Medical SchoolEdward Ford Building A27SydneyAustraliaNSW 2006
| | - Ruth Dentice
- Royal Prince Alfred HospitalDepartment of Respiratory MedicineLevel 11, E BlockMissenden RoadCamperdownAustraliaNSW 2050
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13
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Abstract
BACKGROUND Inhalation of the enzyme dornase alfa reduces sputum viscosity and improves clinical outcomes of people with cystic fibrosis. This is an update of a previously published Cochrane review. OBJECTIVES To determine the effect of timing of dornase alfa inhalation on measures of clinical efficacy in people with cystic fibrosis (in relation to airway clearance techniques or time of day). SEARCH METHODS Relevant randomised and quasi-randomised controlled trials were identified from the Cochrane Cystic Fibrosis Trials Register, Physiotherapy Evidence Database (PEDro), and international cystic fibrosis conference proceedings.Date of the most recent search: 25 April 2016. SELECTION CRITERIA Any trial of dornase alfa in people with cystic fibrosis where timing of inhalation was the randomised element in the study with either: inhalation before compared to after airway clearance techniques; or morning compared to evening inhalation. DATA COLLECTION AND ANALYSIS Both authors independently selected trials, assessed risk of bias and extracted data with disagreements resolved by discussion. Relevant data were extracted and, where possible, meta-analysed. MAIN RESULTS We identified 115 trial reports representing 55 studies, of which five studies (providing data on 122 participants) met our inclusion criteria. All five studies used a cross-over design. Intervention periods ranged from two to eight weeks. Four trials compared dornase alfa inhalation before versus after airway clearance techniques. Inhalation after instead of before airway clearance did not significantly change forced expiratory volume at one second. Similarly, forced vital capacity and quality of life were not significantly affected; forced expiratory flow at 25% was significantly worse with dornase alfa inhalation after airway clearance, mean difference -0.17 litres (95% confidence interval -0.28 to -0.05), based on the pooled data from two small studies in children (seven to 19 years) with well-preserved lung function. All other secondary outcomes were statistically non-significant.In one trial, morning versus evening inhalation had no impact on lung function or symptoms. AUTHORS' CONCLUSIONS The current evidence derived from a small number of participants does not indicate that inhalation of dornase alfa after airway clearance techniques is more or less effective than the traditional recommendation to inhale nebulised dornase alfa 30 minutes prior to airway clearance techniques, for most outcomes. For children with well-preserved lung function, inhalation before airway clearance may be more beneficial for small airway function than inhalation after. However, this result relied on a measure with high variability and studies with variable follow up. In the absence of strong evidence to indicate that one timing regimen is better than another, the timing of dornase alpha inhalation can be largely based on pragmatic reasons or individual preference with respect to the time of airway clearance and time of day. Further research is warranted.
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Affiliation(s)
- Ruth Dentice
- Royal Prince Alfred HospitalDepartment of Respiratory MedicineLevel 11, E BlockMissenden RoadCamperdownAustraliaNSW 2050
| | - Mark Elkins
- University of SydneySydney Medical SchoolEdward Ford Building A27SydneyAustraliaNSW 2006
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14
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Button BM, Wilson C, Dentice R, Cox NS, Middleton A, Tannenbaum E, Bishop J, Cobb R, Burton K, Wood M, Moran F, Black R, Bowen S, Day R, Depiazzi J, Doiron K, Doumit M, Dwyer T, Elliot A, Fuller L, Hall K, Hutchins M, Kerr M, Lee AL, Mans C, O'Connor L, Steward R, Potter A, Rasekaba T, Scoones R, Tarrant B, Ward N, West S, White D, Wilson L, Wood J, Holland AE. Physiotherapy for cystic fibrosis in Australia and New Zealand: A clinical practice guideline. Respirology 2016; 21:656-67. [PMID: 27086904 PMCID: PMC4840479 DOI: 10.1111/resp.12764] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 01/13/2016] [Accepted: 02/08/2016] [Indexed: 12/21/2022]
Abstract
Physiotherapy management is a key element of care for people with cystic fibrosis (CF) throughout the lifespan. Although considerable evidence exists to support physiotherapy management of CF, there is documented variation in practice. The aim of this guideline is to optimize the physiotherapy management of people with CF in Australia and New Zealand. A systematic review of the literature in key areas of physiotherapy practice for CF was undertaken. Recommendations were formulated based on National Health and Medical Research Council (Australia) guidelines and considered the quality, quantity and level of the evidence; the consistency of the body of evidence; the likely clinical impact; and applicability to physiotherapy practice in Australia and New Zealand. A total of 30 recommendations were made for airway clearance therapy, inhalation therapy, exercise assessment and training, musculoskeletal management, management of urinary incontinence, managing the newly diagnosed patient with CF, delivery of non-invasive ventilation, and physiotherapy management before and after lung transplantation. These recommendations can be used to underpin the provision of evidence-based physiotherapy care to people with CF in Australia and New Zealand.
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Affiliation(s)
| | | | | | | | | | | | | | - Robyn Cobb
- Lady Cilento Children's HospitalBrisbane
| | | | | | | | | | | | | | | | | | | | - Tiffany Dwyer
- Royal Prince Alfred HospitalNSW
- University of SydneySydneyNSW
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- Sir Charles Gairdner Hospital and Institute for Respiratory HealthWestern Australia
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15
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Elkins M, Dentice R. Inspiratory muscle training facilitates weaning from mechanical ventilation among patients in the intensive care unit: a systematic review. J Physiother 2015; 61:125-34. [PMID: 26092389 DOI: 10.1016/j.jphys.2015.05.016] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [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: 04/24/2015] [Revised: 05/18/2015] [Accepted: 05/19/2015] [Indexed: 11/29/2022] Open
Abstract
QUESTION Does inspiratory muscle training improve inspiratory muscle strength in adults receiving mechanical ventilation? Does it improve the duration or success of weaning? Does it affect length of stay, reintubation, tracheostomy, survival, or the need for post-extubation non-invasive ventilation? Is it tolerable and does it cause adverse events? DESIGN Systematic review of randomised trials. PARTICIPANTS Adults receiving mechanical ventilation. INTERVENTION Inspiratory muscle training versus sham or no inspiratory muscle training. OUTCOME MEASURES Data were extracted regarding: inspiratory muscle strength and endurance; the rapid shallow breathing index; weaning success and duration; duration of mechanical ventilation; reintubation; tracheostomy; length of stay; use of non-invasive ventilation after extubation; survival; readmission; tolerability and adverse events. RESULTS Ten studies involving 394 participants were included. Heterogeneity within some meta-analyses was high. Random-effects meta-analyses showed that the training significantly improved maximal inspiratory pressure (MD 7 cmH2O, 95% CI 5 to 9), the rapid shallow breathing index (MD 15 breaths/min/l, 95% CI 8 to 23) and weaning success (RR 1.34, 95% CI 1.02 to 1.76). Although only assessed in individual studies, significant benefits were also reported for the time spent on non-invasive ventilation after weaning (MD 16 hours, 95% CI 13 to 18), length of stay in the intensive care unit (MD 4.5 days, 95% CI 3.6 to 5.4) and length of stay in hospital (MD 4.4 days, 95% CI 3.4 to 5.5). Weaning duration decreased in the subgroup of patients with known weaning difficulty. The other outcomes weren't significantly affected or weren't measured. CONCLUSION Inspiratory muscle training for selected patients in the intensive care unit facilitates weaning, with potential reductions in length of stay and the duration of non-invasive ventilatory support after extubation. The heterogeneity among the results suggests that the effects of inspiratory muscle training may vary; this perhaps depends on factors such as the components of usual care or the patient's characteristics.
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Affiliation(s)
| | - Ruth Dentice
- Physiotherapy Department, Royal Prince Alfred Hospital, Sydney, Australia
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16
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Sivam S, Yozghatlian V, Dentice R, McGrady M, Moriarty C, Di Michiel J, Bye PTP, Rees D. Spontaneous coronary artery dissection associated with coughing. J Cyst Fibros 2013; 13:235-7. [PMID: 24157355 DOI: 10.1016/j.jcf.2013.10.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 09/30/2013] [Accepted: 10/01/2013] [Indexed: 10/26/2022]
Affiliation(s)
- S Sivam
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia; Department of Respiratory Medicine, University of Sydney, NSW 2006, Australia.
| | - V Yozghatlian
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia; Department of Respiratory and Sleep Medicine, St. George Hospital, 30 Gray Street, Kogarah, NSW 2217, Australia
| | - R Dentice
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia; Department of Respiratory Medicine, University of Sydney, NSW 2006, Australia
| | - M McGrady
- Department of Respiratory Medicine, University of Sydney, NSW 2006, Australia; Department of Cardiology, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia
| | - C Moriarty
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia; Department of Respiratory Medicine, University of Sydney, NSW 2006, Australia
| | - J Di Michiel
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia; Department of Respiratory Medicine, University of Sydney, NSW 2006, Australia
| | - P T P Bye
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia; Department of Respiratory Medicine, University of Sydney, NSW 2006, Australia
| | - D Rees
- Department of Cardiology, St. George Hospital, 30 Gray Street, Kogarah, NSW 2217, Australia
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17
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Abstract
BACKGROUND Inhalation of the enzyme dornase alfa reduces sputum viscosity and improves clinical outcomes of people with cystic fibrosis. OBJECTIVES To determine the effect of timing of dornase alfa inhalation on measures of clinical efficacy in people with cystic fibrosis (in relation to airway clearance techniques or time of day). SEARCH METHODS Relevant randomised and quasi-randomised controlled trials were identified from the Cochrane Cystic Fibrosis Trials Register, Physiotherapy Evidence Database (PEDro), and international CF conference proceedings.Date of the most recent search: 22 February 2013. SELECTION CRITERIA Any trial of dornase alfa in people with cystic fibrosis where timing of inhalation was the randomised element in the study with either: inhalation before compared to after airway clearance techniques; or morning compared to evening inhalation. DATA COLLECTION AND ANALYSIS Both authors independently selected trials, assessed risk of bias and extracted data with disagreements resolved by discussion. Relevant data were extracted and, where possible, meta-analysed. MAIN RESULTS We identified 99 trial reports representing 48 studies, of which five studies (providing data on 122 participants) met our inclusion criteria. All five studies used a cross-over design. Intervention periods ranged from two to eight weeks. Four trials compared dornase alfa inhalation before versus after airway clearance techniques. Inhalation after instead of before airway clearance did not significantly change FEV1. Similarly, FVC and quality of life were not significantly affected; FEF25 was significantly worse with dornase alfa inhalation after airway clearance, MD -0.17 litres (95% CI -0.28 to -0.05), based on the pooled data from two small studies in children (7 to 19 years) with well-preserved lung function. All other secondary outcomes were statistically non-significant.In one trial, morning versus evening inhalation had no impact on lung function or symptoms. AUTHORS' CONCLUSIONS The current evidence derived from a small number of participants does not indicate that inhalation of dornase alfa after airway clearance techniques is more or less effective than the traditional recommendation to inhale nebulised dornase alfa 30 minutes prior to airway clearance techniques, for most outcomes. For children with well-preserved lung function, inhalation before airway clearance may be more beneficial for small airway function than inhalation after. However, this result relied on a measure with high variability and studies with variable follow up. In the absence of strong evidence to indicate that one timing regimen is better than another, the timing of dornase alpha inhalation can be largely based on pragmatic reasons or individual preference with respect to the time of airway clearance and time of day. Further research is warranted.
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Affiliation(s)
- Ruth Dentice
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, Australia.
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18
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Dentice R, Elkins M, Middleton P, Bishop J, Wark P, Dorahy D, Harmer C, Bye P. WS19.4 A randomised controlled trial of the effect of hypertonic saline (HS) inhalation on exacerbation resolution, hospital length of stay and time to relapse in adults with cystic fibrosis. J Cyst Fibros 2013. [DOI: 10.1016/s1569-1993(13)60117-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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19
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Abstract
BACKGROUND Inhalation of hypertonic saline improves sputum rheology, accelerates mucociliary clearance and improves clinical outcomes of people with cystic fibrosis. OBJECTIVES To determine whether the timing of hypertonic saline inhalation (in relation to airway clearance techniques or in relation to time of day) has an impact on its clinical efficacy in people with cystic fibrosis. SEARCH METHODS We identified relevant randomised and quasi-randomised controlled trials from the Cochrane Cystic Fibrosis Trials Register, the Physiotherapy Evidence Database (PEDro), and international cystic fibrosis conference proceedings.Date of the last search of the Group's Cystic Fibrosis Trials Register: 6 December 2011. SELECTION CRITERIA Any trial of hypertonic saline in people with cystic fibrosis where timing of inhalation was the randomised element in the study protocol with either: inhalation up to six hours before airway clearance techniques compared to inhalation during airway clearance techniques compared to inhalation up to six hours after airway clearance techniques; or morning compared to evening inhalation with any definition provided by the author. DATA COLLECTION AND ANALYSIS Both authors independently assessed the trials identified by the search for potential inclusion in the review. MAIN RESULTS The search strategy identified 50 trial reports which represented 24 unique studies. One study, published only as an abstract, is awaiting further assessment. None of the other studies compared timing regimens for the inhalation of hypertonic saline and we excluded these from the review. AUTHORS' CONCLUSIONS This review did not identify any evidence comparing the timing of hypertonic saline inhalation in relation to airway clearance physiotherapy. Until such evidence becomes available, clinicians could advise patients to inhale hypertonic saline before airway clearance, because this is the only regimen evaluated in the studies that established the efficacy of the use of hypertonic saline. This review also did not identify any evidence comparing the timing of hypertonic saline inhalation in relation to time of day. Until such evidence becomes available, clinicians could advise patients to inhale hypertonic saline morning and evening; but if only one dose per day is tolerated, the time of day at which it is inhaled could be based on convenience or tolerability.Given the competing theoretical rationales about why hypertonic saline could be more effective if inhaled at certain times, a trial comparing these various timing regimens should be conducted.
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Affiliation(s)
- Mark Elkins
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, Australia.
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20
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Abstract
BACKGROUND Inhalation of the enzyme dornase alfa reduces sputum viscosity and improves clinical outcomes of people with cystic fibrosis. OBJECTIVES To determine the effect of timing of dornase alfa inhalation on measures of clinical efficacy in people with cystic fibrosis (in relation to airway clearance techniques or time of day). SEARCH STRATEGY Relevant randomised and quasi-randomised controlled trials were identified from the Cochrane Cystic Fibrosis Trials Register, Physiotherapy Evidence Database (PEDro), and international CF conference proceedings.Search date: 6 October 2010. SELECTION CRITERIA Any trial of dornase alfa in people with cystic fibrosis where timing of inhalation was the randomised element in the study with either: inhalation before compared to after airway clearance techniques; or morning compared to evening inhalation. DATA COLLECTION AND ANALYSIS Both authors independently selected trials, assessed risk of bias and extracted data with disagreements resolved by discussion. Relevant data were extracted and, where possible, meta-analysed. MAIN RESULTS We identified 92 trial reports representing 47 studies, of which five studies (providing data on 122 participants) met our inclusion criteria. All five studies used a cross-over design. Intervention periods ranged from two to eight weeks. Four trials compared dornase alfa inhalation before versus after airway clearance techniques. Inhalation after instead of before airway clearance did not significantly change FEV(1). Similarly, FVC and quality of life were not significantly affected; FEF(25) was significantly worse with dornase alfa inhalation after airway clearance, MD -0.17 litres (95% CI -0.28 to -0.05), based on the pooled data from two small studies in children (7 to 19 years) with well-preserved lung function. All other secondary outcomes were statistically non-significant.In one trial, morning versus evening inhalation had no impact on lung function or symptoms. AUTHORS' CONCLUSIONS The current evidence derived from a small number of participants does not indicate that inhalation of dornase alfa after airway clearance techniques is more or less effective than the traditional recommendation to inhale nebulised dornase alfa 30 minutes prior to airway clearance techniques, for most outcomes. For children with well-preserved lung function, inhalation before airway clearance may be more beneficial for small airway function than inhalation after. However, this result relied on a measure with high variability and studies with variable follow-up. Apart from this, the timing of dornase alfa inhalation can be largely based on pragmatic reasons or individual preference with respect to the time of airway clearance and time of day. Further research is warranted.
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Affiliation(s)
- Ruth Dentice
- Department of Respiratory Medicine, Royal Prince Alfred Hospital, Level 11, E Block, Missenden Road, Camperdown, New South Wales, Australia, NSW 2050
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21
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22
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Lau EMT, Yozghatlian V, Kosky C, Moriarty C, Dentice R, Waugh R, Torzillo PJ, Bye PT. Recombinant activated factor VII for massive hemoptysis in patients with cystic fibrosis. Chest 2009; 136:277-281. [PMID: 19584209 DOI: 10.1378/chest.08-2948] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Massive hemoptysis is a common complication in patients with cystic fibrosis (CF) and is associated with significant morbidity and mortality. Conventional treatment with antibiotic therapy and early bronchial artery embolization (BAE) is usually successful in achieving hemostasis in the majority of patients. Recombinant activated factor VII (rFVIIa), originally developed for use in patients with hemophilia, has emerged as a general hemostatic agent that is potentially useful in the management of many life-threatening bleeding conditions. In this article, we present four patients with CF lung disease and massive hemoptysis who were treated successfully with rFVIIa. We suggest that in patients with CF who present with massive hemoptysis, the use of rFVIIa can be considered in patients with refractory hemoptysis despite conventional therapy or as a temporizing therapy when BAE is not immediately available.
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Affiliation(s)
- Edmund M T Lau
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Veronica Yozghatlian
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Chris Kosky
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Carmel Moriarty
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Ruth Dentice
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Richard Waugh
- Department of Radiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Paul J Torzillo
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Peter T Bye
- Woolcock Institute of Medical Research and University of Sydney, Sydney, NSW, Australia; Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
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23
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24
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Dentice R, Elkins M. An analysis of physiotherapy research abstracts at major regional cystic fibrosis conferences. J Cyst Fibros 2008. [DOI: 10.1016/s1569-1993(08)60301-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Armstrong E, Isman K, Dooley P, Brine D, Riley N, Dentice R, King S, Khanbhai F. An investigation into the quality of life of individuals after laryngectomy. Head Neck 2001; 23:16-24. [PMID: 11190853] [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: 02/19/2023] Open
Abstract
BACKGROUND Little longitudinal data are available on the general physical, psychological, and social problems experienced as a result of laryngectomy or on the preoperative status of patients in regard to these aspects. In particular, prospective longitudinal data gathered from the same group of subjects over time and examining a variety of such outcomes is rare. This descriptive study addresses these issues. METHODS The study investigates the progress of a group of 34 laryngectomees from the preoperative stage up to 6 months after surgery. Medical complications, communication, swallowing, diet, physical, and psychosocial adjustment were measured using both the Short-Form Health Survey (SF-36) and original outcome tools. RESULTS A large percentage of subjects demonstrated significant and persistent communication and swallowing problems throughout the period studied. Low preoperative and postoperative scores on the SF-36 demonstrate that this group had a poorer state of general health in many respects than those with serious medical conditions previously documented. CONCLUSIONS The results suggest that communication and swallowing difficulties persist for many laryngectomees up to 6 months after surgery and still require further investigation. Poor preoperative and postoperative general health scores indicate that this group may require more long-term social support than is currently being offered to adjust to the laryngectomy.
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Affiliation(s)
- E Armstrong
- Speech Pathology Department, Royal Prince Alfred Hospital, CSAHS, Sydney, NSW, Australia.
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