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Winter, 2018

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

Please email us at freshaire@vitalaire.ca if you have suggestions on topics you would like highlighted in the next FreshAireTM publication.

Pulmonary Rehabilitation in Canada: a report from the Canadian Thoracic Society COPD clinical assembly 1

Pulmonary Rehabilitation (PR) is recommended in the management of chronic respiratory diseases as it reduces dyspnea, optimizes functional status and reduces health care costs through improving patient self-management and stabilizing or reversing systemic manifestations of the disease. A comprehensive PR program will include patient assessment, exercise training, education and psychosocial support. It is recommended for patients with chronic obstructive pulmonary disease (COPD) and is beneficial for individuals with other chronic lung diseases, notably interstitial lung disease (ILD), lung cancer, pulmonary arterial hypertension and those who are pre- or post-lung transplantation. The Canadian Thoracic Society has conducted three reviews of the PR programs proposed in various healthcare settings across Canada over the past 3 decades and the number of PR programs is in constant progression.

The last review of the PR programs by the CTS occured in 2015, ten years after from the previous review. All hospitals in Canada were contacted to identify PR programs. A representative from each program completed an online survey encompassing 16 domains. A total of 155 facilities in Canada have offered PR, of which 129 returned surveys (83% response rate). PR programs are located in all provinces, but none in the three territories. Most (60%) programs are located in hospital settings, 24% are in public health units and 8% in recreation centres.

The survey was created based on other surveys of PR and included questions on program delivery, patient access and completion, resources, healthcare professionals involved, aerobic and resistance testing, prescription and outcomes and finally education. The survey contained more than 175 questions and the time to complete it was 45 min.

The average number of patients enrolled in PR was ~85 per program per year. Fifty percent of programs enrolled less than 50 individuals per year. Based on these figures, the national capacity of Canadian PR programs was estimated to be 10,280 individuals per year. Respondents reported that the top three barriers to increasing access to PR were the lack of staff time to deliver PR, limited effectiveness of current referral systems, and the travel distance and/or time for patients. The program completion rate is usually high with 110 programs reporting that more than 60% of patients completed PR. Disease exacerbation is the number one reason for non-completion, reported by 50% of programs. In terms of diagnosis, patients with COPD are admitted by 100%, followed by individuals with asthma (75%) and ILD (71%). Patients with other respiratory-related conditions, such as cystic fibrosis, chest wall abnormalities, neuromuscular disorders or post-acute respiratory distress syndrome are infrequently admitted to PR. Referrals come from various sources such as respirologists, family physicians, but also from respiratory therapists and physiotherapists.

Once referred, the wait time to start PR varies between 7 to 12 weeks. Funding of PR comes usually from a single source. Important to note: 10% of programs do not have access to supplemental oxygen. Most of programs provide two to three exercise sessions per week, with a median time of 1.5h per exercise session. The duration of the programs ranges from one week to programs that do not discharge their patients, but most of the programs have a duration from 6 to 12 weeks. Education topics are consistent from one program to another and usually emphasize the understanding of chronic lung disease, medications, breathing control and oxygen therapy. Unfortunately topics such as heart health, falls prevention, understanding diagnostic tests and advance care planning are less discussed. 75% of programs have a certified respiratory educator.

Since the preview review, 60 additional PR programs have been created. Despite this progression, the low capacity of PR in Canada is in sharp contrast to cardiac rehabilitation, where a recent position paper by the Canadian Association of Cardiac Rehabilitation and the Canadian Cardiovascular Society noted that 34% of high-risk cardiac patients were referred to Ontario cardiac rehabilitation programs. Only 0.4% of Canadians with COPD have access to pulmonary rehabilitation. Encouragingly, the survey demonstrates that PR is moving into non-hospital-based settings, which may improve access to programs in the future. In addition, several provinces are exploring the use of novel methods of delivering PR, including home-based programs or telehealth.
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OSA and Diabetes

Every November, Diabetes Canada sets out to educate the public and the 11 million Canadians living with diabetes or pre-diabetes on the prevention and management of the condition during National Diabetes Month.

Given the compelling evidence linking Type 2 diabetes with obstructive sleep apnea (OSA), it is important that you are aware of the facts. Over 70% of people with Type 2 Diabetes may also have obstructive sleep apnea2. Research suggests that the interruption of sleep caused by OSA may exacerbate the effects of Type 2 diabetes, highlighting the need to both detect and treat OSA in people with Type 2 diabetes3.

Sleep apnea and diabetes
A recent study examined how full-night CPAP adherence affects glucose levels over a one week period.Participants were split into two groups - one receiving ongoing CPAP treatment and the other receiving placebo CPAP (or sham) treatment for the full duration of the night, each night, under lab supervision.

After one week, the participants’ insulin and glucose levels were tested. Participants with CPAP treatment demonstrated better overall glucose response and improved insulin sensitivity, which have been associated with a reduced risk of developing diabetes, obesity and heart disease over time. Additionally, using CPAP for the full sleep duration showed a reduction 24-hour blood pressure as compared with placebo.

Can sleep apnea cause Diabetes?
Being unable to breathe for seconds or even minutes throughout the night not only leaves you tired the next day, it also aggravates your Type 2 diabetes. Blood sugar levels increase due to the stress that interrupted sleep puts on your heart and body which, over time, can contribute to insulin resistance. Left undetected and untreated, sleep apnea can worsen your health.

How does sleep affect appetite?
There is substantial research to show that short or interrupted sleep increases your appetite for high-calorie dense foods. Interrupted sleep may increase your cravings for fatty or high carbohydrate foods.

Hormones in your body play an important role in regulating your appetite and satiety. For example, Ghrelin has been associated with stimulating appetite, which may result in overeating. Leptin has been associated with appetite suppression and an increase of energy, which may cause you to eat less.

In many people, sleeping well enables the body to regulate the release of hormones, on and off through the day, and regulate feelings of hunger. Sleep deprivation can alter ghrelin and leptin levels. For example, sleep restriction to four hours a night is associated with a rise in ghrelin levels and a decline in leptin levels, which has been linked to an increase in appetite and a greater amount of (food) intake.

Further supporting the need for a good night’s sleep, a reduction of sleep duration to 4 h for two consecutive nights has recently been shown to decrease circulating leptin levels and to increase ghrelin levels, as well as self-reported hunger4.It is crucial to keep treating OSA to ensure normal sleep and normal release of hormones.
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3D-Printed artificial lung for patients with COPD and other pulmonary disease: reality or sci-fi?5

It might be reality soon! A Veterans Affairs (VA) research team, in collaboration with Old World Labs, an American company specialized in high-resolution 3D printing, is working to develop a prototype of a wearable artificial lung that could be compatible with living tissue and able to provide respiratory support for people suffering from respiratory diseases such as COPD.

This artificial lung will fit into a backpack or waist pack and will be used for a week or more. The functional prototype is expected to ready in the upcoming months, the next step being to test it on animals.

According to Joseph Potkay, PhD, lead researcher of the project and a biomedical engineer at the VA Ann Arbor Health Care System in Michigan, this will be the first attempt to use high-resolution 3D polymer printing to create functional microfluidic lungs with three-dimensional blood flow networks. This microfluidic artificial lung is a new class of artificial organ that mimics the overall structure and blood flow of the natural organ better than other standard artificial strategies. The microfluidic 3D structure will be combined with a biocompatible coating that can prevent the immune system’s reactivity and organ rejection, as well as allow improved interactivity of the artificial lung and one’s natural tissues, increasing the lifetime of the device. “The flexibility in design afforded by 3D printing gives us more freedom and thus the ease to build artificial lungs with a small size and pressure drops that are compatible for operation with the body’s natural pressures,” Potkay said in a VA news release. This is the first time that high-resolution polymer 3D printing has been used to fabricate microfluidic lungs with 3D blood flow networks.

With a focus on treating COPD, in 2011 the team worked on a 2D-printed artificial lung that aimed at reducing CO2 levels. Using silicon tubing and an ultra-thin membrane that allowed efficient gas diffusion, the device could use air as the ventilating gas, instead of pure oxygen, as standard systems do.

COPD is one of the most prevalent and costly diseases among veterans, affecting 16% of the veteran population and about 5% of American adults.

The 2D project is ongoing, with the device currently being tested in rabbits. The team is pursuing the next stage of funding to advance the 2D lung up to sizes that could be used in people. “Although the 3D artificial lung is more promising, it is earlier in development and still not guaranteed to work,” Potkay said. “We’re further along in developing the 2D device, and we have plans to work around the challenges with that device.”

Besides helping COPD patients, the researchers expect the artificial organ to be a temporary strategy to help patients waiting for a lung transplant, or those whose lungs are healing. The goal behind the VA research is to create the first wearable artificial lung that’s compatible with living tissue and that can provide both short and long term respiratory support.

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Product review: 2 new ResMed CPAP masks hit the Canadian sleep apnea market

Resmed has recently launched 2 new masks : the nasal AirFit N30i in October 2018 and the full face AirFit F30 in November 2018. Both are innovative in their respective category. The AirFit N30i has a top-of-head design to give patients freedom to sleep in any position and closer to their bed partner. It has a curved cradle cushion for a comfortable seal under the nose. Its frame automatically adjusts to different facial profiles.

The AirFit N30i is designed to provide freedom of movement so patients can sleep in the position they find most comfortable, including their side and stomach. Even when the patient lies on their side, when air flow could potentially be reduced through one side of the frame, the prescribed therapy will continue to be delivered with compensated air flow through the other side of the frame. The curvature of the cushion and the grip from the SpringFit frame will assist in keeping the mask in place under their nose as they move.

The AirFit F30 has been designed to complement the ResMed full face mask portfolio. AirFit F30 is perfect for those patients who prefer a smaller footprint, may feel claustrophobic or want to wear their glasses thanks to its ultra compact cushion that sits lower on the face. The AirFit F30 shares some components with the 20 series such as the elbows (QuietAir and Multi-hole) and the magnetic headgear clips. The AirFit F30 has a one-size-fits-all headgear, same headgear for all patients, and only two cushion sizes for simplified ordering and fitting.

If you think these masks could meet your Sleep Apnea patients’ needs, contact VitalAire.
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TO GO FURTHER

Pulmonary Rehabilitation in Ontario: A Cross-Sectional Survey.

Bowen, Campbell, Sutherland, Bartlett, Brooks, Qureshi, Goldstein, Gershon, Prevost, Samis Kaplan 8, Hopkins, MacDougald, Nunes, O'Reilly, Goeree.https://www.ncbi.nlm.nih.gov/pubmed/26366242

An international comparison of pulmonary rehabilitation: a systematic review.

Desveaux L, Janaudis-Ferreira T, Goldstein R, Brooks D.https://www.ncbi.nlm.nih.gov/pubmed/24984085

HFNC :

Telehealth pulmonary rehabilitation: A review of the literature and an example of a nationwide initiative to improve the accessibility of pulmonary rehabilitation

A-M Selzler, J Wald, M Sedeno, T Jourdain, T Janaudis-Ferreira, R Goldstein, J Bourbeau, and MK Sticklandhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC5802662/

Inside the effort to print lungs and breathe life into them with stem cells

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