Development of a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbation of chronic obstructive pulmonary disease

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted. https://bmjopenrespres.bmj.com/content/bmjresp/5/1/e000265.full.pdfAlberta Innovates Health Solutions Partnership for Research and Innovation in the Health System Program (AIHS PRIHS 201400390), Alberta Health ServicesPeer ReviewedIntroduction: Hospital and emergency department discharge for patients with chronic obstructive pulmonary disease (COPD) is often poorly organised. We developed a patient-centred, evidence-based and consensus-based discharge care bundle for patients with acute exacerbations of COPD. Methods: A purposeful sample of clinicians and patients were invited to participate in a two-round Delphi study (July–November 2015). In round 1, participants rated on a seven-point Likert scale (1=not at all important; 7=extremely important) the importance of 29 unique COPD care actions. Round 2 comprised items selected from round 1 based on consensus (>80%endorsement for Likert values 5–7). A list of 18 care items from round 2 was discussed in a face-to-face nominal group meeting. Results: Seven care items were included in the COPD discharge bundle based on clinician and patient input: (1) ensure adequate inhaler technique is demonstrated; (2) send discharge summary to family physician and arrange follow-up; (3) optimise and reconcile prescription of respiratory medications; (4) provide a written discharge management plan and assess patient’s and caregiver’s comprehension of discharge instructions; (5) refer to pulmonary rehabilitation; (6) screen for frailty and comorbidities; and (7) assess smoking status, provide counselling and refer to smoking cessation programme. Conclusion: We present a seven-item, patient-centred, evidence-based and consensus-based discharge bundle for patients with acute exacerbations of COPD. Alignment with clinical practice guidelines and feasibility of local adaptations of the bundle should be explored to facilitate wide applicability and evaluation of the effectiveness of the COPD discharge bundle

Pulmonary Rehabilitation With Balance Training for Fall Reduction in Chronic Obstructive Pulmonary Disease: Protocol for a Randomized Controlled Trial

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. A growing body of evidence shows that individuals with COPD have important deficits in balance control that may be associated with an increased risk of falls. Pulmonary rehabilitation (PR) is a key therapeutic intervention for individuals with COPD; however, current international guidelines do not include balance training and fall prevention strategies. OBJECTIVE: The primary aim of this trial is to determine the effects of PR with balance training compared to PR with no balance training on the 12-month rate of falls in individuals with COPD. Secondary aims are to determine the effects of the intervention on balance, balance confidence, and functional lower body strength, and to estimate the cost-effectiveness of the program. METHODS: A total of 400 individuals from nine PR centers across Canada, Europe, and Australia will be recruited to participate in a randomized controlled trial. Individuals with COPD who have a self-reported decline in balance, a fall in the last 2 years, or recent near fall will be randomly assigned to an intervention or control group. The intervention group will undergo tailored balance training in addition to PR and will receive a personalized home-based balance program. The control group will receive usual PR and a home program that does not include balance training. All participants will receive monthly phone calls to provide support and collect health care utilization and loss of productivity data. Both groups will receive home visits at 3, 6, and 9 months to ensure proper technique and progression of home exercise programs. The primary outcome will be incidence of falls at 12-month follow-up. Falls will be measured using a standardized definition and recorded using monthly self-report fall diary calendars. Participants will be asked to record falls and time spent performing their home exercise program on the fall diary calendars. Completed calendars will be returned to the research centers in prepaid envelopes each month. Secondary measures collected by a blinded assessor at baseline (pre-PR), post-PR, and 12-month follow-up will include clinical measures of balance, balance confidence, functional lower body strength, and health status. The cost-effectiveness of the intervention group compared with the control group will be evaluated using the incremental cost per number of falls averted and the incremental cost per quality-adjusted life years gained. RESULTS: Recruitment for the study began in January 2017 and is anticipated to be complete by December 2019. Results are expected to be available in 2020. CONCLUSIONS: Findings from this study will improve our understanding of the effectiveness and resource uses of tailored balance training for reducing falls in individuals with COPD. If effective, the intervention represents an opportunity to inform international guidelines and health policy for PR in individuals with COPD who are at risk of falling

Canadian Consensus Recommendations for a Research Agenda in Pulmonary Rehabilitation Post-Acute Exacerbation of COPD: A Meeting Report

Rationale: A recent Cochrane review concluded that Pulmonary Rehabilitation (PR) post-acute exacerbations of chronic obstructive pulmonary disease (AECOPD) is safe, reduces hospital admissions and improves quality of life and exercise capacity of patients post-AECOPD. Despite these benefits, recent reports have highlighted poor referral, uptake, and completion rates of early post-AECOPD PR. These concerns provided the foundation for the “PR Post-AECOPD Meeting”, which was funded by the Canadian Institutes of Health Research and held in Montreal in November 2017. Objectives: To identify key research priorities in the complex area of care of delivering PR post-AECOPD.Methods: Meeting participants were asked to complete a pre-meeting survey in order to foster thinking prior to the beginning of the discussions. The first day of the meeting involved presentations from experts and a review of the pre-meeting survey results. Facilitated small group discussions occurred using the consensus building technique (Strengths, Weaknesses, Opportunities, and Threats (SWOT) method). The second day focused on large group discussions in order to identify the research themes.Results: The top three research themes identified were: 1) a phased approach to PR post-AECOPD, 2) patient-centered interventions and outcomes, and 3) gaining a greater understanding of the emotional and psychological impacts of AECOPD. Other identified themes were: how to improve referral, uptake and access to PR post-AECOPD, how to reach under-served patient groups and cost-effectiveness of potential individualized interventions.Conclusions: In this meeting the stakeholders identified research priorities that should guide clinicians and researchers in their efforts to produce high-quality evidence. <br/

The effect of lung volume below normal functional residual capacity on respiratory system mechanics

This thesis examines changes in the mechanical behaviour of the canine and human respiratory systems to changes in lung volume below normal functional residual capacity (FRC). In open chested dogs lung elastance (E$sb{ rm L}$) increased and lung resistance (R$sb{ rm L}$) changed little with decreases in positive end-expiratory pressure (PEEP) of the ventilatory circuit. The dominance of plastoelastic lung tissue properties at low lung volumes was used to interpret the lack of change in R$sb{ rm L}$. Computed tomography demonstrated that pleural effusion (PE) created atelectasis in dependent caudal lung regions which contributed to the overall lung volume loss. PE produced a decrease in only lung vertical height while chest wall dimensions changed both vertically and horizontally. E$sb{ rm L}$ and R$sb{ rm L}$ increased while elastance and resistance of the chest wall were little affected by these shape and density changes. In close-chested, anesthetised, paralysed, ventilated humans a decrease in PEEP below normal FRC caused an increase in R$sb{ rm L}$, E$sb{ rm L}$ and both chest wall elastance and resistance. Median sternotomy caused E$sb{ rm L}$ to increase with increasing PEEP while the negative volume dependence of R$sb{ rm L}$ remained. Most of the difference between open-chested and closed-chested E$sb{ rm L}$ was presumably due to lung collapse in the open-chested state