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FreshAire™ VitalAire's publication for Healthcare Professionals to help you stay up-to-date on a variety of respiratory related topics

Edition - Fall 2019

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Vaping or JUULing?

Vaping is a modern and controversial trend but it’s definitely not new… As far as in Ancient Egypt, vaping techniques such as using hot stones to vape herbs were already popular...

Vaping is a modern and controversial trend but it’s definitely not new… As far as in Ancient Egypt, vaping techniques such as using hot stones to vape herbs were already popular. The first waterpipe  or shisha was introduced in Medieval India, several centuries ago. The first e-cigarette was invented by an American named Herbert A. Gilbert in 1963. He patented "a smokeless non-tobacco cigarette" that involved "replacing burning tobacco and paper with heated, moist, flavored air". This device produced flavored steam without nicotine. Gilbert's invention was ahead of its time but did not raise interest and was never commercialized because smoking was still fashionable at that time. The Chinese firm Hon Lik made the first modern e-cigarette in the mid-2000s. E-cigarettes work by heating a liquid to produce an aerosol that users inhale into their lungs. The liquid may contain nicotine, tetrahydrocannabinol (THC) and cannabinoid (CBD) oils, along with other substances and additives such as propylene glycol, glycerin, flavors, tiny amounts of toxicants, carcinogens, heavy metals, and metal nanoparticles. Its exact composition varies across and within manufacturers, and depends on the contents of the liquid, the physical and electrical design of the device and the user behavior. 

Since their entrance to the market in 2003, global use has risen exponentially. As any other electronic device, e-cigarettes become even smaller, lighter and smarter. Nowadays, the brand Juul has become particularly popular since it's e-cigarette is the smallest on the market. It's large range of flavours and “vape juices” have made it popular amongst teens and young adults. Vaping, juuling, same matter…The terms vaping and juuling are now used interchangeably. At present, scientists do not have enough data and information on the long-term effects of the liquids used in e-cigarettes. Analysis of these liquids and the vapor produced when they’re heated show that e-liquids can react to form irritating chemicals called acetals. Acetals are formed from the combination of alcohol and aldehydes; chemicals used to flavor and perfume foods and other commercial products. While some aldehydes are considered harmful, many are generally recognized as safe to eat and touch. Still, little is known about the effects of aldehydes and acetals when inhaled through an e-cigarette, although some research has demonstrated that the acetals can irritate airways more strongly than the aldehydes from which they were formed. This resulting irritation can prompt an inflammatory response in the respiratory system, particularly in the bronchioles, leading eventually to a disease called bronchiolitis obliterans, which is otherwise known as popcorn lung. Popcorn lung gets its name from a chemical called diacetyl, which was once commonly used to give food products, such as popcorn, a rich, buttery flavor. In fact, the condition was first identified among popcorn factory workers who inhaled the chemical in the workplace. The US FDA considers diacetyl generally safe to eat, but it’s dangerous when inhaled. However, diacetyl is still found in the majority of e-cigarette flavors… Symptoms of popcorn lung are similar to those of COPD. Common symptoms include difficulty breathing and a persistent, progressive and dry cough. Popcorn lung is also known as obliterative bronchiolitis, bronchiolitis obliterans, or constrictive bronchiolitis. 

Large tobacco companies have played an active role in sponsored scientific research to positively portray the tobacco industry and lobby against regulation. Leaders in vaping, like JUUL Labs, established in early 2019 the research company JLI Science with the stated goal to “better understand the effects and impact vaping products have in the long term, while also discouraging new users, and to share those results with the scientific community”. Rigorous and independent research is needed to establish acute and long-term risks and benefits of vaping for different populations and provide the evidence base for prevention, control and regulation of vaping devices. 

The ultimate goal for research, intervention and policies is to maximise potential public health benefits of vaping, if any, while minimising risks. At the present time it's still very unclear for worldwide Health authorities to take a position on this topic. The Canadian Health authorities are closely monitoring increasing reports in the United States of respiratory illnesses and deaths, potentially linked to vaping. While advertising flavours appealing to youth is prohibited in Canada, some states in the US and some countries such as Brazil, Singapore or India have decided to ban completely the e-cigarette while others focused only on the ban of flavours. The complete ban of e-cigarettes could be counterproductive from a public health standpoint as bans are typically a top-down attempt to force sudden behaviour change and often have the reverse response of triggering avoidance behaviours. It would push people towards the black market with all the associated risks. The other danger in issuing a blanket warning about all e-cigarette use is that it might discourage more smokers from making the switch in an attempt to cease tobacco smoking, which could also have negative public health consequences. There is indeed a balance to be struck when it comes to vaping: it’s not harmless and non-smokers — minors especially — should not take up the habit. However, vaping as a “safer” alternative source of nicotine for smokers who want to quit smoking should also be weighed in the decision making...



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COMET: a multicomponent home-based disease-management program

The COPD Patient Management European Trial (COMET) investigated the efficacy and safety of a home-based COPD disease management program for severe COPD patients. The study was conducted simultaneously in several European countries...

The COPD Patient Management European Trial (COMET) investigated the efficacy and safety of a home-based COPD disease management program for severe COPD patients. The study was conducted simultaneously in several European countries (France, Spain, Italy, Germany). This COPD management initiative included a self-management program, home telemonitoring, care coordination and medical management. The primary end-point was the number of unplanned all-cause hospitalization days in the intention-to-treat (ITT) population. Secondary end-points included acute care hospitalization days, BODE (body mass index, airflow obstruction, dyspnoea and exercise) index and exacerbations. Safety end-points included adverse events and deaths.

Chronic obstructive pulmonary disease (COPD) is a chronic condition that affects over 10% of adults aged over 40 years. Patients with severe to very severe COPD have worse health status, higher risk of hospitalized exacerbations, higher acute care burdens and higher mortality rates than patients with mild to moderate disease. A better control of exacerbations could slow down the disease progression and reduce hospitalization. COPD impose a heavy daily care burden on patients and their families. Moreover, patients must learn how to cope with their disease, recognise when they need professional care, adopt a healthy lifestyle, and avoid risk factors for exacerbations and hospitalizations. Effective self-management programs have focused on patient education, behaviour modification, patient motivation through coaching by a health professional, and quick access to healthcare when needed.

The aim of the COMET study was to investigate the effectiveness, safety and efficiency of a multicomponent home-based COPD disease management program specifically adapted for patients with severe COPD and which included a standardised self-management program and coaching with a case manager; a home monitoring and care coordination through an e-health platform for early detection of exacerbations; and feedback and quality control to optimize delivery of the interventions. One expected result of COMET was that the use of this multicomponent COPD disease management program would help patients adopt the right behaviours to recognize the signs of an exacerbation, avoid or reduce hospitalizations.

Patients who were eligible to participate were randomly allocated to the disease management group or to the control group however the study was open, patients were not blind regarding the group they belonged to. 

The COMET home-based disease management intervention included a self-management program, a home monitoring and an e-health telephone/web platform. The self-management program was based on the “Living Well with COPD” program developed at the Montreal Chest Institute of the McGill University Health Centre, in Montreal. The study was conducted between September 2010 and March 2015. A total of 345 patients participated to the study, 172 in the disease management group and 173 in the control group. A total of 27 patients died during the study, one of which died prior to randomisation. The mortality rate was significantly lower in the disease management group (3 patients) than in the control group (23 patients). This COMET intervention across four European countries did not achieve a statistically significant difference in the number of exacerbations although patients in the disease management group had 23% fewer all-cause hospitalization days than patients in the control group. The results of similar COPD self-management interventions in clinical trials have been inconsistent, which has created ambiguity regarding self-management interventions and has discouraged their implementation in clinical practice.

However, this study showed that the use and adaptation of a self-management program previously demonstrated to be clinically beneficial rather than creating a new program is possible and even encouraged. The COMET disease management program may thus provide a basis for future self-management interventions or for designing studies to evaluate such interventions. Particular attention was given to patient coaching by healthcare professionals (case managers). A strength of the COMET study was the use of an e-health platform for reporting frequent health status updates, rapid intervention when necessary, and oxygen therapy monitoring. Another compelling feature of the COMET initiative is that it was the first study to specifically address a disease management intervention for severe COPD, delivered by case managers, across four countries with different medical practices and healthcare systems. 

This international study supports the feasibility of a multicomponent home-based disease management intervention in severe COPD patients (many being on LTOT), and demonstrated that most patients adhered to the intervention. For future studies, it will be crucial to assess right at the beginning the patient needs and self-management skills for subsequent program tailoring. In addition, some very severe patients presenting with severe comorbidities should be clearly identified as they may not be able to fully implement the program and thus benefit from it. 


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Ask an expert - Sue Timmerman

Sue Timmerman is the Regional Director at Prairie Oxygen and VitalAire for Saskatchewan and Manitoba. She has been a registered Respiratory Therapist for 26 years practicing in Canada and abroad...

Can you describe your background and role?

I have been a registered Respiratory Therapist for 26 years, practicing in Canada and abroad as I spent three years in Saudi Arabia. I have worked in both hospital and homecare settings in various departments such as ICU, acute care, chronic disease management, ER, high risk labour and delivery, ALS clinic, and transport teams for both adults and children. Throughout my career I’ve taken on many roles including instructor and coordinator for teaching life support courses, Asthma and COPD educator, and precepting respiratory students to enhance their skills and abilities. Later on I involved myself in various committees such as Quality Improvement and Ethics. These varying roles both in Canada and abroad led me to develop an expertise in respiratory care and interest in the transition from hospital to home. 

I am currently the Regional Director at Prairie Oxygen and VitalAire for Saskatchewan and Manitoba, but I see myself more as a trouble-shooter communicator! I work every day to serve my patients and protect their voice. My role to my coworkers at Prairie Oxygen and VitalAire is to maximize their capabilities on a daily basis: I want them to grow within our company. I love my job and making people breathe and live better!

What should be the focus of a home respiratory healthcare company?

It’s obviously the customer and the relationship we develop with them. At Prairie Oxygen and VitalAire, we keep in mind that our customers are human beings, and not transactions. We work to establish trust with our patients as well as with our community partners. Homecare involves different professionals taking care of the patients and their needs at home so it is crucial to create best practices with other community healthcare professionals. 

What do you do at Prairie Oxygen that sets you apart?

Our customer service - our staff - is our most precious asset at Prairie Oxygen. We value our relationships with our customers. They know that we do not consider them just a number or a transaction. At Prairie Oxygen “you're a person not a patient”. We care to build this trust relationship with them. Because of our human approach, we are a trusted advisor and partner in the community, with respirologists, palliative care and other healthcare professionals involved in homecare services.

As a company, Prairie Oxygen is resilient and can adapt to the ever-changing homecare market. Again, we work to serve our customers as well as the health care professionals. For example, we developed for our OSA patients a program that decreases the amount of time spent travelling back and forth to the physicians before being properly set up with therapy. This program makes the life of our patients as well as healthcare professionals easier. It provides “seamless” access to safe and effective testing and treatment for Sleep Apnea in a timely manner while maintaining best practices.

What do you think of e-monitoring and home-based disease management programs for COPD patients? 

I think e-monitoring is fabulous! Saskatchewan has such rural and remote regions where having access to primary healthcare can be a challenge and e-monitoring can solve many issues remotely. With e-monitoring, an integrated and multidisciplinary team can work together for the best results. Specialists in one part of the province, or country, can collaborate with peers to solve complex cases. E-health brings patients closer as well. Support groups with peer to peer coaching are made possible thanks to e-monitoring, particularly here in Saskatoon and Regina. Surprisingly enough, e-health can help create a stronger sense of community among patients. It also helps to fill the gap between hospital care and home as it improves the transition and coordination between these two worlds. 

Which trends do you see for OSA treatment? and home oxygen? 

Despite the fact that we see more and more patients diagnosed with Obstructive Sleep Apnea, the number of patients diagnosed with mild OSA who receive treatment has dramatically decreased in Saskatchewan due to the change in funding. There is an increasing gap to address the patients needs and awareness regarding OSA. Patient’s comfort is a key trend in treating OSA: manufacturers keep developing smaller and lighter CPAP machines, as well as more comfortable masks. Giving patient’s comfort and overcoming this first resistance towards CPAP treatment leads to the development of new accessories such as oral appliances. However, these oral appliances are not adapted to every patient and it will be crucial for the coming years to develop best practices in the prescription and use of these new devices. Indeed, a respirologist will have to be kept involved in the diagnostic and the use of such devices. Trends with “home testing” to diagnosis sleep apnea is a hot topic as well. The consumer needs to be aware and educate themselves on the companies they are dealing with as well as the devices that they are being tested on to ensure proper diagnosis and treatment. Not all testing out there is the same or meets best practice standards. You need to ensure that a qualified specialist is involved as well as a sleep medicine respirologist. Some provinces that have funding for CPAP equipment many not accept testing and results if not performed as per proper Canadian Thoracic Society Guidelines or provincial funding guidelines. When someone chooses Prairie Oxygen or VitalAire to conduct testing for their sleep apnea or purchase any equipment they do not have to worry as we comply with all regulations including GMP and FDA guidelines and best practices. In addition, our business model also incorporates a National Medical Director; Raymond Gottschalk.

As for Home Oxygen, offering the best comfort for our patients is critical, and at Prairie Oxygen, we work with our patients to provide them the most adapted solution to their needs. However, it should not overcome the real medical needs of patients. We do see more and more people buying portable oxygen concentrators (POC) for their relatives who might benefit from home oxygen. Oxygen is a drug and should be used by prescription only. It is our responsibility, as a homecare provider, to raise awareness about home oxygen, its proper use, benefits and dangers. POCs are not for every person using oxygen. Prairie Oxygen can help with the testing on these units to ensure you are safe and a good candidate to use this portable device. Keep you safe, breathing, and mobile is job number one to better lung health!

The new full face mask Vitera by Fisher and Paykel

Fisher and Paykel has launched their new version of full face mask, Vitera, in June 2019 in Canada. The F&P Vitera features unique technologies designed to provide patients with comfort throughout the night; including a gentle seal designed to adapt...

Fisher and Paykel has launched their new version of full face mask, Vitera, in June 2019 in Canada. The F&P Vitera features unique technologies designed to provide patients with comfort throughout the night; including a gentle seal designed to adapt when moving. The F&P Vitera features the RollFit™ XT seal, new VentiCool™ headgear, and a low-profile stability bar.  These features will enhance patient comfort during sleep.  

Enhancing their confidence in CPAP therapy which should lead to less mask troubleshooting and increase compliance. The adaptable seal RollFit XT seal has specifically been designed for comfort. It rolls back and forth on the bridge of the nose, allowing patients to move freely as the mask adapts to different sleeping positions.  This will significantly help to maintain a comfortable seal and minimize leak. It reduces pressure and soreness on the bridge of the nose. The RollFit XT seal, which covers the nose and mouth, is designed to operate at a range of pressures from low to high. The headgear has been designed to keep patients cool and comfortable. The Vitera headgear features VentiCool technology, a custom-made breathable fabric. VentiCool is designed to allow heat and moisture to escape through the fabric to help keep cool and comfortable during sleep. Vitera features a low-profile stability bar designed to keep the seal in place, minimizing mask leaks and enhancing comfort. Some unique ease-of-use features are:

  • The unique forehead clip that keeps forehead straps together for easy disassembly and reassembly while also reducing the chance of headgear tangling.
  • The adjustable headgear that features forehead and crown straps to provide with easy and personalized sizing.
  • New headgear clips with tactile grips that help patients to easily find and position them on the mask frame
  • VisiBlue™ color cues incorporated into key components of the mask help significantly with fitting, disassembly, and reassembly.
  • If you know of a patient who may benefit from this new technology, contact VitalAire.