Fall 2018 – Issue 06

Prior to 2020, the Lung Health Foundation operated as the Ontario Lung Association. Enjoy this content from our archives.

An official publication of the Ontario Respiratory Care Society, a section of the Lung Health Foundation

Update Ontario Respiratory Care Society

Update on Respiratory Health, Research and Education is a publication of the Ontario Respiratory Care Society, a section of the Lung Health Foundation. Update is published three times per year and includes peer-reviewed original articles, clinical practice tools, health news, and communications between the ORCS and its membership.



I hope everyone was able to take a break to recharge over the summer months. Autumn is a great time to refresh and re-focus our energy towards all the activities ahead. In fact, with everyone heading back to school, and summer vacations behind us, September can feel as much like starting a new year as January does.

September is a great time to kick off some important lung health research! The ORCS Research Grants and Fellowship Awards support research and graduate study by health-care providers in the field of respiratory care. Approved by the Lung Health Foundation Board of Directors in June, $83,500 has been invested in three research grants lead by principal investigators: Darlene Reid, Sylvia Rinaldi and Marla Beauchamp, and four Fellowship Awards going to Sachi O’Hoski, Christina McMillan Boyles, Kenneth Wu and Sylvia Rinaldi. Congratulations to all and good luck with your ongoing efforts to improve lung health for Ontarians!

The Regional Planning Committees of the ORCS have planned six educational events across the province for September to November. Topics include COPD Management, pre-school asthma, non-fatal drowning, marijuana and lung health and many more. Click here to find out more about the regional education events.

The Lung Health Foundation is once again hosting its biennial Tuberculosis Conference at the Chelsea Hotel November 20 – 21 with optional preconference sessions November 19 at Toronto Public Health. This conference is particularly relevant for health and social service professionals and others working with populations at high risk of TB in such fields as medicine, nursing, public health, community health, infection control, institutional health, communicable disease and correctional services. For more information or to register, visit: http://lungontario.ca/for-health-professionals/educational-opportunities/tb-conference/

And you’ve probably by now heard about Member 365, the new ORCS and OTS membership portal that launched last year. The new portal is a system that puts membership management, communications and events all in one place. If you haven’t already set up your profile, please visit http://lungontario.ca/for-health-professionals/ontario-respiratory-care-society/ today! And, if you haven’t renewed your ORCS membership yet, renew today: http://lungontario.ca/for-health-professionals/ontario-respiratory-care-society/. Members receive a significant discount on the Better Breathing Conference registration.

I am always available to discuss any comments or suggestions that you may have. Feel free to contact me by email dina.brooks@utoronto.ca or by phone 416-978-1739.

Don’t forget to save the date for Better Breathing 2019! January 24 – 26, 2019.

Respectfully submitted,
Dina Brooks, BScPT, MSc, PhD
Chair, Ontario Respiratory Care Society.


Welcome to our Fall 2018 edition of Update on Respiratory Health, Research and Education brought to you by The Editorial Board. These members of the ORCS continue to work hard to bring you interesting and informative articles in this publication and we hope you will find the articles both interesting and relevant to your practice.

Our first feature article Doing Two Things at Once – Is it More Difficult for People Living with COPD? has been written for us by Darlene Reid, BMR, PhD, and is followed by our second feature, Patient and Family-Centered Performance Measures Focused on Actionable Processes of Care for Persistent or Chronic Critical Illness by Louise Rose, RN, BN, ICU Cert, MN, PhD, FAAN. In addition, we bring you Dyspnea from the Larynx by Jennifer Anderson, MD MSc FRCS, and Early Detection of Small Airway Disease in Poultry Farmers by Rose-Marie Dolinar, RN (EC), PhD (C).

The regular In the Toolbox section, provided for us by Jane Lindsay, BSCPT, CRE enlightens us about the Using The Lung Association’s “Find a Respiratory Program” Service, while our Eye On section presents Innovative Care for the COPD Patient in a Rural Community Hospital by Annette Stewart, RRT, CRE. In our Respiratory Articles of Interest section we provide summaries of three articles: the first is the article Idiopathic Pulmonary Fibrosis, the next is Mindfulness-based Symptom and Stress Management Apps for Adults with Chronic Lung Disease: Systematic Search in App Stores, and the third one is Preoperative Physiotherapy for the Prevention of Respiratory Complications After Upper Abdominal Surgery: Pragmatic, Double Blinded, Multicentre Randomised Controlled Trial. These have been summarized for us by Priscila Robles, BScPT, MSc, PhD, Julie Duff Cloutier, RN, MSc and Shirley Quach, HBsc, RRT respectively. Lastly, but in no way least, In the Spotlight, written for us by Sheila Gordon-Dillane, BA, MPA, shines the light on one of our ongoing stars, physiotherapist Jane Lindsay.

We encourage you to check out and attend some of the educational events this fall and to keep an eye out for information on The Lung Association conference, Better Breathing 2019.

As we provide you with this electronic publication, we look forward to hearing from you with both ideas and feedback, so, please, do let us know what you think!

Respectfully submitted,
Jocelyn Carr
Co-chair Editorial Board

The Air We Breathe…Early Detection of Small Airway Disease in Poultry Production Farmers

Submitted by: Rose-Marie Dolinar RN (EC) PhD, Health & Rehabilitation Sciences, The Universtiy of Western Ontario

Chronic Obstructive Pulmonary Disease (COPD) is preventable and treatable.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) (1) states that COPD is “characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases.” The Global Initiative for Chronic Obstructive Lung Disease further explains the variable nature of COPD as a mixture of small airway disease (e.g., obstructive bronchiolitis) and parenchymal destruction (emphysema), and that both conditions vary from person to person (2).

Volgemeir et al. (2017) summarized the changes in the 2017 GOLD diagnostic and treatment recommendations, which now include both spirometry and symptom evaluations (3). Since COPD encompasses both small airway and terminal airway diseases of chronic bronchitis and emphysema, using both spirometry and a standardized lung health questionnaire provides a more comprehensive picture of each person’s lung health, especially for those at high risk of developing chronic obstructive lung diseases.

Patients with ongoing symptoms of cough and phlegm are not being diagnosed according to a Canadian study. The range of undetected COPD is between 25 and 50% of patients with COPD symptoms and risk factors (4) (5). According to Hill, Goldstein, Guyatt et al. (2010), as many as one in five adults with known risk factors for COPD who meet spirometric criteria are not diagnosed for COPD (5). Under-diagnosis of COPD suggests a need for greater screening of at-risk individuals.

Persons at Risk for COPD
Persons at highest risk for developing COPD are those who smoke cigarettes, with a 25% prevalence of moderate to severe COPD for both men and women equally (6). Although cigarette smoking is a major risk factor, occupational health studies indicate that more than 15% of all cases of COPD are work-related (7).

Poultry Farmers Lung Health Study
This study is the result of a meeting held in January 2015 between poultry farmers and a lung health researcher to discuss concerns of the poultry farmers regarding lung health in the workplace. Following approval, obtained from the Health Sciences Research Ethics Board at the University of Western Ontario (protocol #107685), the Poultry Producers Lung Health Study was launched.

The study’s aim was to promote and protect the lung health of poultry farmers. Results of the N95 Respirator Fit-testing outreach article have been published in the 2018 Winter edition of Update. This article will report the measurement of lung health of poultry farmers, which included the spirometry and lung health symptoms and MD-confirmed diagnostic findings.

The study design was a cohort observational study with a convenience sample, based on the available two-day lung health clinic appointments. Two clinic days were available for the pilot study due to health centre booking and resource availability, as well as timing of harvest for the farmers. Participants were required to meet the following inclusion criteria: a poultry farmer 40 years of age or older who is fluent in English and has a family physician or health-care provider for ongoing medical care. Those who did not have a doctor were excluded from the study since reports of the spirometry were sent to each of the participant’s health-care provider for follow-up care.


Measuring Lung Symptoms
The standardized American Thoracic Society (ATS) Lung Health Questionnaire (LHQ) from the Division of Lung Diseases (DLD) of the National Heart, Lung, and Blood Institute, ATS-DLD78 (9), was administered to all participants. The Medical Research Council (MRC) Breathlessness Scale, which grades breathlessness related to exercise and activity, was included in the ATS-DLD78 with the following grading scale: Grade 1 Not troubled by breathlessness except on strenuous exercise; Grade 2 Short of breath when hurrying on the level or walking up a slight hill; Grade 3 Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at own pace; Grade 4 Stops for breath after walking about 100 yards or after a few minutes on level ground; and Grade 5 Too breathless to leave the house, or breathless when undressing (8).

Measuring Lung Function
Pre/post bronchodilator spirometry was performed using the National Health and Nutrition Examination Survey (NHANES III) Hankinson et al. (1999) standard reference prediction equations (9). A certified Registered Respiratory Therapist (RRT) performed all the pre/post spirometry according to Canadian Thoracic Society guidelines (10). Interpretation of the pre/post spirometry were based on GOLD 2017 (1) and D’Urzo (2011) (11) spirometry interpretation logarithms for the identification of COPD and asthma. Chronic obstructive pulmonary disease diagnostic criteria included the post-bronchodilator forced expiratory volume in one second (FEV1) and the forced vital capacity (FVC) ratio (FEV1/FVC) of less than 0.70 (<0.70), and asthma was defined as an improvement in FEV1 of 12% or over, and 200 mL after the bronchodilator challenge.

The Forced Expiratory Flow between 25 and 75% of the FVC (FEF25–75) is one of the most commonly cited measures of small airways pathology (13). The reasons that tests of small airways such as FEF 25-75% have not been utilized as part of lung function measurement include variability in test results and a lack of validated reference ranges (13). However, the FEF 25-75% was included to ensure the pre/post spirometry was able to capture any changes in both large airways and small airways of the lungs.

Independent Data Collection
Each participant’s spirometry lung function was performed independently from the Lung Health Questionnaire (LHQ) administration. Results were compared as blinded since LHQ and spirometry data were collected separately.

Two rural lung health clinics were held in Seaforth, Ontario and Clinton, Ontario on August 3rd and August 4th, 2016, respectively, to fit within harvest times for the participants.

A total of 16 poultry farmers (N=16) participated in the study. The average age of participants was 56.8 years (SD 9.74), with 82% males and 18% females.

Farm dust exposure, in numbers of years, was reported by all 16 participants with an average of 38 years (SD 14.95). Smoking status was reported as current smoker, within the last month, never smoked, or an ex-smoker for the past month. Duration of smoking was calculated by the standard measure of pack years (one pack year equivalent to 20 cigarettes per day) for one year.

Table 1: Cigarette Smoking (n=16)

Cigarette smokingResult
Current smokers1/16 (6.25%)
Never smoked8/16 (50%)
Pack years5.07 (SD 6.93)

The lung health questionnaire asked if the participant had a doctor who confirmed the presence of bronchitis, emphysema and asthma. The answers to the presence of MD-confirmed lung diseases provided an independent evaluation. There were no reports of MD-confirmed emphysema. However, three participants reported that their physicians confirmed chronic bronchitis, and two participants reported confirmation of asthma.

Table 2: Reporting of lung symptoms of cough and phlegm, wheeze, and breathlessness

SymptomResult (n=16)
Cough and phlegm3/16
Exercise limitations
(MRC grade 3,4,5)


Table 3: Results of MD-confirmed lung disease

MD-confirmed lung conditionResult (n=16)
Chronic bronchitis3/16

Spirometry Results

Sixteen (16) pre/post spirometry tests were performed and interpreted. Upon reviewing the results of the de-identified pre/post spirometry data, two spirometry results were excluded, one as it identified a pre-existing lung health condition, and the other showed non-reproducible manoeuvres. Fourteen (14) spirometry results were included in the grouped data.

All fourteen (14) post bronchodiolator FEV1/FVC ratios were above 70%. There were no results meeting FEV1 criteria for a spirometric diagnosis of asthma, as none of the 14 spirometry results showed an improvement in FEV1 of 12% or over, and 200 mL after bronchodilator.
Four of the results of post FEV1/FVC ratios were between 70 and 75%, with three approaching COPD criteria. These same four spirometry results demonstrated post FEF 25-75% reductions from predicted (between -12% and -22%), whereas all other spirometry results had no reductions in the mid-range FEF 25-75% small airway region.

Comparison of Symptoms, MD-confirmed Diagnoses and Spirometry Results
When comparing the lung health questionnaire data to the spirometry results, the participants with symptoms of cough and phlegm, and MD-confirmed diagnosis of chronic bronchitis, matched the reduced FEV1/FVC results between 70 and 75%. The post FEV1/FVC results also matched the reductions of the FEF 25-75% results.

The poultry producers’ lung health study included both pre/post spirometry and a standardized questionnaire to gather symptoms and screen for early detection of lung disease.

Results indicated that symptoms of cough and phlegm and MD-confirmed bronchitis matched FEV1/FVC ratios between 70% and 75%. According to McDonough et al. (2011), as bronchitis becomes more widespread over time, more of the small airways (<2 mm in diameter) become affected (12).

The study found that participants smoked an average of five pack years, equivalent to 20 cigarettes per day for 5 years. The average age of the poultry farmers was 56 years of age). Although individual susceptibility for the development of COPD varies, there is no minimum number of pack years which would put one person at greater risk for COPD (15).

Results of the pre/post spirometry confirmed a relationship between symptoms of chronic bronchitis and the spirometry results between 70 and 75%. The results of the post FEF 25-75% may be an important indicator to report for agricultural workers. With early detection of small airway disease, there is a potential for reversal of early stages of COPD (16).

These results point to the need for lung health screening through ongoing lung health clinics for those at high risk for developing COPD.

Lung health monitoring through standardized questionnaires and pre/post spirometry is recommended for poultry farmers. Physician-confirmed presence of bronchitis matched the presence of reduced post-FEV1/FVC spirometry and FEF 25-75% (n=14), indicating early detection of small airway disease. Future studies are required to support the use of both standardized measures.

Respiratory care health professionals, including RRTs, physicians and nurses, providing care to farmers are needed to provide screening for early signs of lung disease through pre/post bronchodilator spirometry, to be able to prevent the development of COPD.

Occupational exposure to dusts, chemicals, and gases found in poultry farming are risk factors for developing COPD (7) (14). The implications of occupational lung exposures in contributing to a diagnosis of COPD must be considered in research planning, in public policy decision-making, and in clinical practice.


  1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD 2017 Global Strategy for the Diagnosis, Management and Prevention of COPD. Global Strategy for the Diagnosis, Management and Prevention of COPD. 2017.
  2. GOLD. Global Initiative for Chronic Obstructive Lung A Guide for Health Care Professionals Global Initiative for Chronic Obstructive Disease. Glob Initiat chronic Obstr lung Dis. 2017.
  3. Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Barnes PJ, Bourbeau J, et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary. Am J Respir Crit Care Med [Internet]. 2017;195(5):557–82.
  4. Lyngso AM, Gottlieb V, Backer V, Nybo B, Ostergaard MS, Jorgensen HL, et al. Early detection of COPD in primary care: The Copenhagen COPD screening project. COPD J Chronic Obstr Pulm Dis. 2013; 10(2):208-15. doi: 10.3109/15412555.2012.714426.
  5. Hill K, Goldstein RS, Guyatt GH, Blouin M, Tan WC, Davis LL, et al. Prevalence and underdiagnosis of chronic obstructive pulmonary disease among patients at risk in primary care. CMAJ. 2010;182(7):673–8.
  6. Løkke A, Lange P, Scharling H, Fabricius P, Vestbo J. Developing COPD: a 25 year follow up study of the general population. Thorax. 2006;61(11). doi: 10.1136/thx.2006.062802.
  7. Boschetto P, Quintavalle S, Miotto D, Lo Cascio N, Zeni E, Mapp CE. Chronic obstructive pulmonary disease (COPD) and occupational exposures. J Occup Med Toxicol. 2006; 1:11.
  8. Stenton C, Shah SA, Gibson O, Clifford G, Heneghan C, Rutter H, et al. The MRC breathlessness scale. Occup Med (Chic Ill) [Internet]. 2008;58(3):226–7.
  9. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the general U.S. Population. Am J Respir Crit Care Med. 1999;159(1):179–87.
  10. Coates AL, Graham BL, McFadden RG, McParland C, Moosa D, Provencher S, et al. Spirometry in primary care. Can Respir J. 2013;20(1):13–22.
  11. D’Urzo AD. Spirometry interpretation in primary care. Canadian Family Physician. 2011; 57 (10) 1122.
  12. McDonough JE, Yuan R, Suzuki M, Seyednejad N, Elliott WM, Sanchez PG, et al. Small-Airway Obstruction and Emphysema in Chronic Obstructive Pulmonary Disease. N Engl J Med. 2011; 365:1567-1575. doi: 10.1056/NEJMoa1106955.
  13. Stockley J, Cooper B, Stockley R, Sapey E. Small airways disease: time for a revisit? Int J Chron Obstruct Pulmon Dis. 2017;12:2343–53.
  14. Viegas S, Faísca VM, Dias H, Clérigo a, Carolino E, Viegas C. Occupational exposure to poultry dust and effects on the respiratory system in workers. J Toxicol Environ Health A [Internet]. 2013;76(4–5):230–9.
  15. Aaron SD, Tan WC, Bourbeau J, Sin DD, Loves RH, MacNeil J, et al. Diagnostic instability and reversals of chronic obstructive pulmonary disease diagnosis in individuals with mild to moderate airflow obstruction. Am J Respir Crit Care Med. 2017; 196(3):306-314. doi: 10.1164/rccm.201612-2531OC.

Disclaimer: No endorsement by The Lung Association – Ontario is intended or should be inferred. The analyses, conclusions, opinions and statements expressed herein are those of the author and not necessarily those of The Lung Association.

Funding: This study was funded by The Lung Association, Ontario Respiratory Care Society (ORCS) Fellowship Grant.

Acknowledgments: The author wishes to thank Sandra Mohr, RRT for performing the standardized pre/post spirometry; Dr. Tony D’Urzo for spirometry interpretation consultation; Dr. Bruce Roberts, Ph.D., Executive Director, Canadian Poultry Research Council; Gwen Devereaux, Gateway Centre of Excellence in Rural Health. Special thank you to the poultry farmers of Huron County.

Competing interests: None declared

Poster photo credit: RM Doyon Dolinar 2017.
Poster graphic design: Jamie McLennan, Character Creative 2018.

Get Involved

Ontario Respiratory Care Society (ORCS) Committees

Provincial Committee
The Provincial Committee provides leadership to the ORCS and is comprised of the ORCS Chair, a Chair-Elect or Past Chair in alternate years, the Chairs of the five standing committees, the Chairs of the regional planning committees and a member of the Lung Health Foundation Board of Directors.

Editorial Board
Produce an electronic publication for the Ontario Respiratory Care Society (ORCS) members; provide academic content for the publication.

Respiratory Health Educators Interest Group (RHEIG)
Provide respiratory education and a half-day session at the Better Breathing Conference; provide patient education content for the ORCS publication.

Membership Engagement Committee
Recruit and build membership for the Society.

Education Committee
Session planning for the Better Breathing Conference.

Research and Fellowship Committee
Manage the funding process including Grant and Fellowship application review and funding allocation.

Regional Planning Committees
Regional Planning Committees plan educational events in their respective regions. The Regions include:
Northeastern Region
Northwestern Region
Eastern Region
Central Region
Western Region

To find out more, or to join one of these Committees, contact the OTS/ORCS Coordinator,
Natalie Bennett, nbennett@lungontario.ca

Call for Abstracts, Poster Presentation, Better Breathing 2019

The Ontario Respiratory Society of Ontario (ORCS) invites you to submit an abstract for a poster presentation at Better Breathing 2019. The poster must pertain to an aspect of respiratory health and may describe: (a) a recently completed (or will be completed by the presentation date) research investigation or (b) a recently developed program evaluation. Previously presented posters are acceptable.

For more information, visit: https://lungontario.ca/better-breathing-conference/

In the Spotlight

Submitted by Sheila Gordon-Dillane, BA, MPA

Jane Lindsay is a physiotherapist who specializes in cardio-respiratory physiotherapy. In addition to being anextraordinary lung health clinician and educator, Jane has been a highly productive volunteer for the Ontario Respiratory Care Society (ORCS) and the Lung Health Foundation for almost 30 years. Jane is widely recognized for her expertise in pulmonary rehabilitation for people with chronic obstructive pulmonary disease (COPD). Before moving to Ontario, Jane started a pulmonary rehabilitation program in Calgary, Alberta.

Beginning in the early 1990s, she coordinated the pulmonary rehabilitation program at Grand River Hospital, Freeport Health Centre in Kitchener and during her tenure provided support and encouragement to colleagues in other locations who were developing pulmonary rehabilitation programs for their patients. For many years Jane’s part time private practice offered in-home care to respiratory patients. In 2003 Jane joined the Occupational Therapist Assistant and Physiotherapist Assistant Program at Conestoga College as a Coordinator and Professor.

Throughout her career, Jane has been an outstanding volunteer leader of the ORCS and a strong advocate for lung health at the local, provincial and national levels. She joined the ORCS Provincial Committee in 1992 as the regional representative for the South Central Ontario Region after serving on the region’s education planning committee for several years. During her term as regional representative, she chaired Planning Committees for successful seminars in Brantford, St. Catharines and Kitchener and organized several educational evenings, making an effort to move educational programming around the region. In 1994, Jane was nominated as ORCS Chair-Elect. After becoming Provincial Chair in 1995, she presided over the development of the ORCS Three Year Plan for the years 1996-99 and represented the ORCS on The Lung Association – Ontario Board of Directors during a period of transition, ensuring that the value of the professional societies was recognized by the whole organization. She also volunteered for the Waterloo office of The Lung Association.

For many years, Jane served on the ORCS Education Committee, helping to organize the ORCS program for annual Better Breathing conferences. Jane has contributed as a speaker at several Better Breathing conferences and has spoken at many regional seminars. When COPD Educator certification was introduced, Jane became a member of the Respiratory Health Educators Interest Group (RHEIG) and became a Certified Respiratory Educator in 2010. She returned to the ORCS Provincial Committee in 2013 as RHEIG Co-Chair, contributing many articles to the Connections publication and helping to plan the RHEIG workshops at Better Breathing conferences.

Jane Lindsay has contributed countless hours and provided exceptional leadership to the field of respiratory care as a role model and mentor. Her lively spirit and warm collegiality has been an inspiration to her many friends and colleagues in the ORCS and The Lung Association. Jane’s many contributions are greatly appreciated. She is most deserving of being In the Spotlight!

Innovative Care for the COPD Patient in a Rural Community Hospital

Submitted by: E. Annette Stuart, RRT, CRE, CTE, Lennox & Addington County General Hospital

BREATHE….it sounds so simple. In the respiratory profession, we know that the mechanics and the execution of breathing is a big challenge for our patients with Chronic Obstructive Pulmonary Disease (COPD). With increasing focus on COPD and the associated costs of managing this disease in health care, the South East Local Health Integration Network (SELHIN) organized a regional respiratory focus group comprised of community agencies, patient advocate representatives, hospital staff and physicians to address the gaps associated with the care of a COPD patient. This “think tank” aimed to identify ways to reduce hospital readmission rates, frequent emergency room (ER) visits and the incidence of respiratory exacerbations associated with COPD. Using the lessons learned at the regional level, the Lennox & Addington County General Hospital (LACGH) in Napanee implemented its own innovative program for COPD patients in the local community. As a result, our program goals have been met while helping patients dealing with COPD achieve improved quality of life, greater independence and an increase in self-confidence. I would like to introduce our BREATHE program.

In an effort to model the excellent work already done in Canada, such as that of Dr. Graeme Rocker in Halifax with the INSPIRED project, we examined our hospital’s discharge strategy for COPD patients exhibiting a level of 4 or 5 on the Medical Research Council (MRC) dyspnea scale and identified an opportunity to improve the inpatient education and discharge process. We developed a Pre-Discharge COPD Order Set to address care delivery process issues in areas such as spirometry, medication optimization and inhaler technique, COPD action plans, weight management and exercise, smoking cessation, support for difficult emotions related to chronic disease, advanced care planning and ongoing support after discharge from hospital. Each patient receives a checklist to ensure all aspects related to COPD management are addressed prior to discharge. A drop in Breathe Clinic was established for those instances where patients were unable to receive all the necessary information prior to discharge due to short admission times or even the patient’s ability to cope with influx of information. The Breathe Clinic is staffed by a Registered Respiratory Therapist (RRT) and a Nurse Practitioner (NP) on a regular basis and an Internal Medicine Specialist on an as needed basis.

Pulmonary rehabilitation was another challenge that needed to be addressed for all COPD patients as the two available programs in the area had extensive wait lists. The Quality Based Procedures for COPD, as set out by Health Quality Ontario, indicates that access to an exercise program within 4-6 weeks of discharge from hospital due to an acute exacerbation of COPD is one of the key components to ensure respiratory health success. To pool our resources, we aligned with our Cardiac Rehabilitation program since many cardiac patients have co-morbid respiratory disease and assimilated COPD patients into the existing exercise program to enable our hospital to offer Respiratory Rehabilitation. With that need addressed, the last piece of the puzzle required for a successful comprehensive program was access to care after discharge through community outreach. Although a BREATHE Help Line existed, the benefit of a physical visit to assess the patient could not be fully achieved within the confines of a phone call.

In our geographical area many patients live in remote communities and are isolated due to limited access to transportation, financial constraints or minimal family support. For various reasons, many of our patients are unable to accommodate frequent travel to hospital or clinic follow-up visits. Even those patients that are not geographically isolated may have limited access to services simply based on the extreme challenges associated with shortness of breath.

Our Chief of Staff at LACGH found a possible solution for this problem when she attended the e-Health conference in 2017, where she connected with a virtual health program provider. The possibility of doing follow-up clinic visits and monitoring through technology that could break down the barrier of access for many of our patients was realized. LACGH invested in the virtual health technology and began using it with discharged COPD patients in the BREATHE program in January 2018. The virtual health program allows us to monitor oxygen saturations, heart rate, blood pressure and weight remotely and visualize trends over time. It also allows us to “push” information to patients through reminders regarding medication adherence, signs of a lung flare-up, shortness of breath levels, and breathing techniques to name a few. The patient is able to call the RRT or NP during regular work hours to address any questions they might have regarding management of their COPD. No longer will the patient be required to travel to the BREATHE clinic appointments at the hospital. Clinic visits are scheduled via the virtual health program. This provides the health-care professional a visual of how the patient is doing, their respiratory pattern, use of accessory muscles, skin colour and also opportunity of ongoing education as it provides ability to assess patient management. We can also determine if the patient is experiencing the symptoms of an exacerbation and educate them to refer to their COPD action plan and provide guidance to access their primary care provider(PCP) for management. If the PCP is not available, the NP or Internal Medicine Specialist will provide the prescriptions necessary to manage and control the exacerbation. The other significant benefit from this virtual program is the involvement of family and caregivers. They can participate in the virtual monitoring with their loved one and also connect with the BREATHE program team should they have concerns. It provides a continuum in the circle of care for the patient.

Twenty-three patients have been enrolled since the inception of the BREATHE program. We have prevented 13 re-admissions to hospital by helping the patient manage their symptoms at home. Although not all re-admissions can be prevented, we have seen a decrease in frequency from those enrolled in the program. Patients enrolled in the virtual program have saved the time and cost associated with more than 4,000 km’s in travel to attend the hospital, clinic or ER. Typically, patients stay connected through the virtual program for about three months and once they are well established in the management of their COPD, they rely less on the program and more on their own newly developed self-management skills. They have ongoing access to the BREATHE clinic and the BREATHE Help Line. Patients are also regularly participating in respiratory rehabilitation or an exercise program in their community. Patient and family feedback has been positive and has encouraged LACGH to continue with all aspects of the BREATHE program.

To improve the lives of patients living with COPD in our area we implemented 3 innovative strategies, a Pre-Discharge COPD Order Set, a combined Cardiac-Pulmonary Rehabilitation Program and a virtual health technology service to link the Breathe Clinic to the patient’s home. Ultimately, our goal was to ensure patients received the knowledge and COPD management skills to permit a reduction in our hospital readmission rate. In the end we also gained an appreciation for the benefits of creating a system where the patient feels they can control their COPD rather than being at the mercy of their symptoms, be more confident in their ability to manage their condition and enjoy an improved quality of life.

The Respiratory Health Education Interest Group (RHEIG) is a multi-disciplinary group of ORCS members who promote and advance the field of respiratory education, with a specific interest in applying theory in a practical way.

Patient-and-Family centered performance measures focused on actionable processes of care for persistent or chronic critical illness.

Submitted by Louise Rose, RN, BN, ICU Cert, MN, PhD, FAAN

Advances in technology and adoption of efficacious interventions into clinical practice have improved intensive care unit (ICU) survival rates. However, approximately 10% of critically ill adults experience persistent or chronic critical illness. This results in protracted ICU length of stay, ongoing dependency on resource-intensive therapies, and long-term physical and cognitive deficits, complicating and prolonging recovery. 

Family members of these patients also experience enormous emotional distress. Patients with persistent or chronic critical illness have unique and complex needs requiring a change in the clinical management plan and overall goals of care to a focus on rehabilitation, symptom relief, and in some cases, end-of-life care. Existing ICU care quality and tools, such as daily rounding checklists, are not sufficiently inclusive of actionable processes of care (i.e., care we can change) appropriate to patients with persistent or chronic critical illness. Further, these measures or tools have not been developed with the patient and family perspectives at the forefront. Our project, partly funded by the Ontario Respiratory Care Society/The Lung Association, will address this gap by identifying care priorities and developing a tool to help us deliver care to improve the ICU experience for these patients and their family members.

In this project we will answer the following research questions:

  1. What does the evidence base tell us about actionable processes of care for patients with persistent or chronic critical illness?
  2. What do survivors of persistent or chronic critical illness and their family recall about their ICU experience that can identify actionable processes of care of importance to them?
  3. What do ICU clinicians perceive to be important for the delivery of high-quality care to these patients and their family members?
  4. Which processes of care and outcomes are prioritized by key stakeholders including survivors of persistent or chronic critical illness, their family members, and the clinicians that treat them?

To answer these research questions, we have completed a systematic review of published evidence relating to our population of interest. This review has produced 36 actionable processes of care of potential relevance. We are now conducting narrative-based, loosely structured video interviews of ICU survivors and family members to help us identify ICU processes of care of importance to them. These interviews will be combined to generate a touch-point video – a research tool that helps identify aspects of care relevant to care recipients. This video will be shown to clinicians. Following, interviews will be conducted with them to identify aspects of care important to clinicians. We then intend to conduct a consensus ranking exercise to identify 8 to 10 actionable processes of care to be embedded into a daily rounding checklist for ICU patients with a length of stay over 7 days. Next steps of our research program will be to determine the feasibility and pilot test implementation of this daily rounding tool. If you know of an ICU survivor or family member that might be interested in participating in an interview or consensus exercise, or if you as a clinician would like to participate, for further information please contact Dr. Louise Rose – louise.rose@utoronto.ca.

Doing two things at once – Is it more difficult for people living with COPD?

Submitted by Darlene Reid, BMR, PhD
Background – Does multitasking take more brain-power and lead to more mistakes?

Multitasking, such as walking across the street while looking at a cell phone, often results in doing one or both things poorly. People with cognitive impairment have more limitations when multitasking because they do not have the “brain-power” to do more than one activity with complete accuracy. For decades, people with chronic obstructive pulmonary disease (COPD) have been known to have mental challenges with memory and attention. The reported prevalence of cognitive impairment in people with COPD ranges between 36 to 57%.1-3 Research has focused on how cognitive impairment affects mental functions such as memory or attention but has not addressed how limited brain-power affects physical activity like balance and walking in people with COPD.

Walking is usually considered to be fairly automatic but it often requires multitasking because we might be thinking about things while we walk (e.g., talking to a friend or what to buy at the hardware store) or manoeuvring around objects, like frost heaves in the sidewalk or furniture in our home. Recently, impaired balance and greater falls have been reported in people with COPD.4-6 Much work has focused on peripheral issues such as muscle strength, physical performance tasks and cellular attributes of muscle fibres to explain their slow walking and poor balance. However, limited functional mobility may in part be attributed to impairment of brain areas that provide input to movement and balance.

What is our research question?

As a first step to explore the brain’s contribution to multi-tasking, we monitored brain activity during single tasks and combined tasks in people with COPD. We also studied comparison groups of younger adults and an older age-matched healthy cohort. The purpose of our study was to compare dual tasks’ error to single tasks’ error while measuring prefrontal cortex oxygenated haemoglobin as a marker of neural activity in these three groups of participants.

How are we studying the problem?

Brain activity of the prefrontal cortex was evaluated by measuring oxygenated hemoglobin via functional near infrared spectroscopy (fNIRS)7,8 (see picture to the right). Increased neural activity in the prefrontal cortex (front of the brain) increases the metabolic demand of the neurons, which in turn increases blood flow to the brain region and increases the amount of oxygenated haemoglobin. We evaluated neural activity of the prefrontal cortex during walking at the participant’s usual pace and when the person walked as quickly and safely as possible. We also asked the person to spell five-letter words backwards. We then asked the participant to do two things at once – to walk at their usual pace while spelling words backwards and to walk at a very quick pace while spelling words backwards. In addition to monitoring neural activity using fNIRS, we also measured the accuracy of spelling backwards and the variability in walking. We used a Zeno pressure sensitive mat (see picture below) that has ~14,000 sensors. Using the associated software, various measures of gait such as velocity, stride length and variability of these parameters were derived. My Masters student, Ahmed Hassan, has done the majority of the work on this project. He was also assisted by my postdoctoral fellow, Dr. Karina Kasawara, and two visiting scientists, Dr. Leandro Bonetti from Brazil and Dr. Masatoshi Hanada from Japan. Dr. Kara Patterson, a colleague in the Department of Physical Therapy at the University of Toronto, has also provided substantial expert consultation.

What have we discovered?

Our sample sizes are small right now and the study is ongoing so these results are preliminary. We have found that people with COPD make more errors when spelling backwards during walking compared to simply spelling backwards. The number of spelling errors made during dual tasking in COPD participants was greater than those errors made by younger and older adults. They also walk more slowly while spelling backwards compared to walking alone. Lastly, neural activity of the prefrontal cortex increased more during dual versus single tasks in the older group and tended to increase in the COPD participants.

What next? How do we help our patients?

One of the most effective ways to improve the quality of life in people with chronic obstructive lung disease is to improve their fitness. Although people with COPD have a tendency to fall more often than other older adults, the best ways to improve balance and walking ability are not known. Although not all tested in COPD patients, several interventions have the potential to improve mobility while multi-tasking in COPD patients such as virtual reality and complex obstacle training simulations. Even aerobic training can increase cognitive function in the elderly9 so this intervention alone, in our COPD clients, has the potential of improving their function in more complex situations.


  1. Grant I, Heaton RK, McSweeny AJ, et al. Neuropsychologic findings in hypoxemic chronic obstructive pulmonary disease. Arch Intern Med 1982; 142: 1470–1476.
  2. Grant I, Prigatano GP, Heaton RK, et al. Progressive neuropsychologic impairment and hypoxemia. Relationship in chronic obstructive pulmonary disease. Arch Gen Psychiatry 1987; 44: 999–1006.
  3. Villeneuve S, Pepin V, Rahayel S, et al. Mild cognitive impairment in moderate to severe COPD: a preliminary study. Chest. 2012;142(6):1516-1523.
  4. Butcher SJ, Reductions in functional balance, coordination, and mobility measures among patients with stable chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 2004;24:274–80.
  5. Roig M, Eng JJ, MacIntyre DL, et al. Falls in people with chronic obstructive pulmonary disease: an observational cohort study. Respir Med. 2011;105(3):461-469.
  6. Roig M, Eng JJ, Road JD, et al. Falls in patients with chronic obstructive pulmonary disease: a call for further research. Respir Med. 2009;103(9):1257-1269.
  7. Ayaz H. Continuous monitoring of brain dynamics with fNIRS as a tool for neuroergonomic research; Frontiers Human Neurosci. Dec 2013; 7(87) 1-5. Doi 10.2289/fnhum.2013.00871
  8. Access at https://www.biopac.com/application/fnir-functional-near-infrared-optical-brain-imaging/
  9. Kelley et al. The impact of exercise on cognitive functioning of healthy older adults: a systematic review and meta-analysis. Aging Research Reviews 2014; 16:12-31.



We are grateful to the ORCS of The Lung Association – Ontario who provided us with funding in 2017-18 to perform this study. We also very much appreciate the contributions of the participants who devoted their time in performing this study.

Darlene Reid, a member of ORCS, is a physiotherapist and professor in the Department of Physical Therapy at the University of Toronto.


Jocelyn Carr, BScPT, MSc
Lorelei Samis, BScPT

Julie Duff Cloutier, RN, MSc, CAE
Yvonne Drasovean, RRT
Elizabeth Gartner, BScOT
Lawrence Jackson, BScPhm
Rachel McLay, HBSc (Kinesiology)
Shirley Quach, HBsc, RRT
Priscila Robles, BScPT, MSc, PhD
Lily Spanjevic, RN, BScN, MN, GNC(C), CRN(C), CMSN(C)

Dina Brooks, BScPT, MSc, PhD

PRESIDENT & CEO, THE Lung Health Foundation
George Habib, BA, BEd, CAE

Sherry Zarins

OTS/ORCS Coordinator
Natalie Bennett

RHEIG Executive Team

Jane Lindsay, BScPT, CRE
Lorelei Samis, BScPT

Michael Callihoo, RRT, CRE
Rose-Marie Dolinar, RN(EC), MScN, PhD
Diane Feldman, RRT, CRE
Olivia Ng, BScPhm, RPh, PharmD (Candidate)
Kitty Seager, CRE, CTE,RPN
Maria Willms, RN, CRE

An official publication of the Ontario Respiratory Care Society, a section of the Lung Health Foundation.