CJRT Winter 2004, volume 40 (5)

Winter 2004, Volume 40 (5)

Features■■ COPD Management 14

■■ Weedless Wednesday 17

■■ Mechanical Ventilation 22

■■ Forum 2005 Information 6

On Air■■ Beirut Project 5

■■ RT Week 6

RT Week October 2004Mutual RecognitionAgreement 17

The journa l fo r re sp i ra to r yhea l th p ro fes s iona l s in Canada

La revue des professionnels de lasanté respiratoire au Canada

PUBLICATIONS MAIL AGREEMENT NO. 40012961REGISTRATION NO. 09846 RETURN UNDELIVERABLE CANADIAN ADDRESSES TO CSRT102 – 1785 Alta Vista DriveOttawa ON K1G [email protected]

Table of ContentsOn Air . . . . . . . . . . . . . . . . .5Beirut Project RT WeekNuggets

President’s Message . . . . . .9

CSRT News . . . . . . . . . . . . . .11Forum InformationMRA AnnouncementHouse of DelegatesCOPD and WomenCoARTE

Special Interest Groups . . .17Weedless Wednesday

Scientific News 21AbstractsCOPD ManagementNon-Invasive Mechanical Ventilation forExacerbation of COPD

Industry News . . . . . . . . . . .31Blood Gas Testing Solutions

The CJRT acknowledges the financial support of the Government ofCanada, through the Publications Assistance Program (PAP), toward ourmailing costs.

Cover Photo RT Week at the College of the North Atlantic

Third Year Respiratory Therapy students, of the College of the NorthAtlantic (CNA), answered many questions for the hospital visitors attheir display booth during RT week. (From left to right DanielleFitzgerald, Steve Chard and Rhonda Hurdle). They were on hand toanswer questions and to present their poster displays on SARS andDifficult Intubations!

From Wade Wheeler

Winter 2004 Canadian Journal of Respiratory Therapy — www.csrt.com 3

Contents ■ Table des matières

CSRT membership inquiries /Questions concernant l’adhésion à la SCTR :

102 – 1785 Alta Vista Dr.,Ottawa, Ontario, K1G [email protected]

Canadian Journal ofRespiratory Therapy

Revue canadienne dela thérapie respiratoire

Official Journal of the CSRTRevue officielle de la SCTR

CSRT Board Representative / Représentante duConseil d’administration de la SCTR Colya Kaminiarz, RRT

Managing Editor / Directrice de la rédactionRita Hansen

Consulting Editors / Rédacteurs-conseilMembers of the Scientific Review Committee

President. CSRT / Président, SCTRBrent Kitchen, RRT

The Canadian Journal of Respiratory Therapy (CJRT)(ISSN 1205-9838) is produced for RRT: The CanadianJournal of Respiratory Therapy, Inc., by the GraphicCommunications Department, Canadian PharmacistsAssociation and printed in Canada by Gilmore Printing.Publications mail registration no. 40012961. CJRT is pub-lished 5 times a year (in February, May, July, October andDecember); one of these issues is a supplement pub-lished for the Annual Educational Forum of the CanadianSociety of Respiratory Therapists (CSRT).

La Revue canadienne de la thérapie respiratoire (RCTR)(ISSN 1205-9838) est produite pour le compte de RRT :The Canadian Journal of Respiratory Therapy, Inc., parCommunications graphiques de l’Association des phar-maciens du Canada et imprimée au Canada par HarmonyPrinting. Courrier de publications no 09846. La RCTRparaît cinq fois l’an (en février, mai, juillet, octobre etdécembre); un de ces numéros constitue un supplémentpublié pour le compte du Forum éducatif annuel de laSociété canadienne des thérapeutes respiratoires (SCTR).

Advertiser’s IndexSpiriva . . . . . . . . . . . . . . . . . . . . . . . . . IFC, PI 32, 33

AstraZeneca . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IBC

Datex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OBC

On Air

4 D’hiver 2004 Revue canadienne de la thérapie respiratoire — www.csrt.com

By the time this issue of thejournal hits your mailboxes theCSRT will have held a specialgeneral meeting and completeda vote about complying with theMutual Recognition Agreement(MRA) for our members, allow-ing them free movement towork throughout Canada. Readmore about this important mile-stone for the CSRT and the implication of the results of the vote.

In this issue we are featuring articles from your peers onCOPD Management and Mechanical Ventilation. You’ll alsofind reports about successful RT week events across thecountry, as well as updates on CoARTE, the new NationalCompetency Profile (NCP) and the CSRT House of Delegates.

Planning is well on the way for the 2005 Educational Forumin Edmonton. It looks like its going to be a great educationalopportunity for RTs in all areas of practice, from anesthesia to critical care, and with new streams to deal with topics of special interest to educational and management issues. I encourage you to start planning on attending thiseducational and networking opportunity!

Over the next few months we will be creating a newcommittee to oversee the CJRT and are looking for volunteers!Are you interested in learning more about the CSRT, the journal and your profession? This is a great way to becomeinvolved. Drop me a note and I'll give you more information!

Enjoy the journal — and please give us feedback on whatyou would like to see in future issues of the journal!

Colya KaminiarzDirector of Membership Services, [email protected]

Welcome from Colya

Design and production / Conception et productionCanadian Pharmacists Association / Association des pharmaciens du Canada

Marketing and Advertising Sales / Marketing et publicitéKeith Health Care Inc.Mississauga 905 278-6700, fax 905 278-4850Montréal 877 761-0447, fax 514 624-6707

Classified Advertising / Annonces classéesCSRT102 – 1785 prom. Alta Vista Dr.Ottawa ON K1G 3Y6800 267-3422 or fax 613-521-4314

Subscriptions / AbonnementsAnnual subscriptions are included in annual membership to theCSRT. Subscription rate for 2004 for other individuals and institutionswithin Canada is $44 and $44(US) for others outside Canada. AllCanadian orders are subject to 7% GST / 15% HST as applicable.Requests for subscriptions and changes of address: Member ServiceCentre, CSRT, 102 - 1785 Alta Vista Dr., Ottawa ON K1G 3Y6.

L’abonnement annuel est compris dans la cotisation des membres dela SCTR. Le tarif annuel d’abonnement pour les non-membres et lesétablissements au Canada est de 44$ et de 44$ US à l’étranger. LaTPS de 7% ou la TVH de 15% est ajoutée aux commandes canadi-ennes. Veuillez faire parvenir les demandes d’abonnement et leschangements d’adresse à l’adresse suivante: Centre des services auxmembres, SCTR, 102 - 1785 prom. Alta Vista, Ottawa ON K1G 3Y6.

Once published, an article becomes the permanent property of RRT:The Canadian Journal of Respiratory Therapy, Inc., and may not bepublished elsewhere, in whole or in part, without written permissionfrom the Canadian Society of Respiratory Therapists, 102 - 1785 AltaVista Dr., Ottawa ON K1G 3Y6. / Dès qu’un article est publié, ildevient propriété permanente de RRT: The Canadian Journal ofRespiratory Therapy, Inc., et ne peut être publié ailleurs, en totalitéou en partie, sans la permission de la Société canadienne desthérapeutes respiratoires, 102 - 1785 prom. Alta Vista, Ottawa ONK1G 3Y6.

All editorial matter in CJRT represents the opinions of the authorsand not necessarily those of RRT: The Canadian Journal ofRespiratory Therapy, Inc., the editors or the publisher of the journal,or the CSRT. / Tous les articles à caractère éditorial dans le RCTRreprésentent les opinions de leurs auteurs et n’engagent ni le RRT:The Canadian Journal of Respiratory Therapy, Inc., ni les rédacteursou l’éditeur de la revue, ni la SCTR.

RRT : The Canadian Journal of Respiratory Therapy Inc. assumes noresponsibility or liability for damages arising from any error or omis-sion of from the use of any information or advice contained in theCJRT including editorials, articles, reports, book and video reviewsletters and advertisements. / RRT : The Canadian Journal ofRespiratory Therapy, Inc. décline toute responsabilité civile ou autrequant à toute erreur ou omission, ou à l’usage de tout conseil ouinformation figurant dans le RCTR et les éditoriaux, articles, rapports,recensions de livres et de vidéos, lettres et publicités y paraissant.

All prescription drug advertisements have been cleared by thePharmaceutical Advertising Advisory Board. / Toutes les annonces demédicaments prescrits ont été approuvées par le Conseil consultatifde publicité pharmaceutique.

Colya Kaminiarz

Welcome!

OnAir


Respiratory Therapy in the Middle East —Live From BeirutDennis Hunter RRT

Beirut Lebanon is not a city mostCanadian Respiratory Therapists (RTs)would associate with RespiratoryTherapy (RT), but in June 2002, thereI was in Beirut, standing in the ICU atMakassed General Hospital. I wasobserving patients being ventilatedon such familiar modes as PressureControl Ventilation (PCV) and CPAPwith Pressure Support (PSV). Afteralmost 30 years as a RespiratoryTherapist, I remember thinking atthat moment just how far ourprofession has come.

My visit to Beirut came aboutthrough the InternationalPartnership Office at FanshaweCollege, London, Ontario. Over thepast few years, Fanshawe hasdeveloped a unique partnership with Makassed General Hospital. As Beirut had no funded emergencyambulance service, Fanshawe wasasked to assist in the developmentof this system. Administered by theAssociation of Canadian CommunityColleges (ACCC) and funded by theCanadian International DevelopmentAgency (CIDA), Fanshawe Collegeand La Cité Collégiale from Ottawa,have been assisting the develop-ment of a training program forEmergency Medical Technicians(EMT) at Makassed. The ParamedicProgram Coordinators from bothcolleges have visited Lebanon anumber of times to assist Makassedin the development of curriculumand a train-the-trainer program.

It was from this successful partner-ship, Dr. Hani Lababidi, Chief ofMedical Staff at Makassed Generalthen inquired about the RespiratoryTherapy program at FanshaweCollege. Dr. Lababidi, AmericanBoard Certified in Internal Medicine,

Pulmonary and Critical Care, hadworked closely with RespiratoryTherapists while training in theUnited States. His return to Beirut in1999 was instrumental in furtheringthe role of the RTs at MakassedGeneral. Dr. Lababidi had the oppor-tunity to visit one of Fanshawe’sclinical affiliates in the spring of2002 while attending a nearby con-ference. He was able to observe firsthand Fanshawe students at work inthe clinical environment. After hisvisit, discussions were held andplans were finalized for my first visitto Beirut. My role on this June 2002visit to Beirut was to observe andadvise on the possibility of having aformal Respiratory Therapy Programat Makassed General. At this timethe current staff of 5 RespiratoryTherapists at Makassed Generalwere graduates of the hospital'sBachelor of Nursing program andformal training for RT was done onthe job.

Makassed General Hospital wasestablished in 1930 to provide quali-ty health care in Beirut. The 80 yearold hospital is a bustling, full service200 bed teaching hospital located ina heavily populated area of the city.Surrounding the hospital are narrowbusy streets crowded with open airvendors selling everything from freshfruits and vegetables to housewares. Inside Makassed, one findsall the services we see in Canadianhospitals such as MRI and a CTscanner. In the 6 bed adult ICU (plus 2 post cardiac beds), patientsare ventilated on the Viayss Vela(the European equivalent of theAvea) and the PB760. In the 15 bedpaediatric/neonatal ICU patients areventilated on the Babylog, InfantStar and a new European infantventilator, the SLE 2000. RTs are alsoinvolved with nitric oxide therapy inthe unit. For pulmonary functiontesting, patients encounter thespirometer system.

Continued on page 30

Old Beirut, Lebanon looking south.


On Air

National Respiratory Therapy Week was celebrated atSeven Oaks General Hospital in Winnipeg, MB with adisplay at the Garden City Shopping Centre. SandraBiesheuvel BSc RRT CAE and Raquel Fernandes RRT CAEwere on hand to provide information to the publicabout the work of a Respiratory Therapist. The focuswas on the role of the RT as an educator, so the displayfeatured information on the Community Asthma Care Centre, and the new Pulmonary RehabilitationProgram at Seven Oaks General Hospital and theWellness Institute.

Raquel and Sandra were busy throughout the dayanswering questions about asthma and COPD, as wellas smoking cessation. The video “What You ShouldKnow about COPD” featuring the late Peter Gzowski ofCBC radio and television played throughout the day, anddrew a lot of people to the display. The large number ofpeople who stated that they either have a chronic lungdisease or know someone else who does, was an indica-tion of the importance of the role of the RespiratoryTherapist in providing patient education. Many hadnever heard of a Respiratory Therapist or knew aboutthe many responsibilities and areas of work of RTs. In addition to receiving pamphlets on asthma, COPDand smoking, visitors could also enter a draw for t-shirts,books, and gift certificates. The day at the mall was a success!

RT Week WinnipegSandra Biesheuvel BSc RRT CAE

CARTA Conference Breaks Attendance RecordBryan Buell, RRT, BGS, CARTA Registrar-Executive Director

The CARTA Educational Forum and Trade show, held October 28 to 30, 2004 enjoyed a record turnout. Judy Duffett-Martin RRT, Jeff Ung RRT, Owen Giesbrecht RRT and Denise Reid RRT were the conference organizers of the mostsuccessful conference to date. There were 245 registered RT delegates and 44 exhibitor/sponsor delegates for a total of 289 conference delegates shattering the previous mark of 242.

The first “Nelson Kennedy Lecture” was launched in recognition of life-time achievements by retired member NelsonKennedy. Nelson was the former Dean of Health Sciences and Business at the Northern Alberta Institute of Technologyin Edmonton. His distinguished career will be recognized with on going keynote addresses by hallmark speakers duringCSRT or CARTA Education Conferences. The inaugural lecture consisted of a panel discussion on Airway PressureRelease Ventilation.

The next Nelson Kennedy lecture will be convened in the Edmonton Shaw Conference Center on June 4 at the CSRT“Compassion in Action” Education Forum by Stephen Lewis former Canadian ambassador to the United Nations andspecial envoy to Africa.

RRTs Sandra Biesheuvel (left) and Raquel Fernandes providedWinnipeg mall visitors with information and insights to manyaspects of the RT profession.


On Air

RT Week Credit ValleyAna MacPherson, RRT

Respiratory Therapy Week was a great opportunity toshowcase some of the specialty respiratory therapistsroles at Credit Valley Hospital in Ontario. The OperatingRoom RT, Special Care Nursery RT, Pulmonary FunctionRT and Asthma Educator RT were the four specialtyroles highlighted for the staff. An open house wasorganized during RT Week 2004. A continuous powerpoint presentation played along with display boardsfocusing on the RT profession. Through the presenta-tions, the attendees were able to follow each of theRespiratory Therapists through their day.

Here is a look inside a typical day in the life of each ofthe specialized RT positions.

As the Operating Respiratory Therapist, the day beginsby completing the daily maintenance check on all theanaesthetic gas machines. Throughout the day, the RTassists the anaesthesiologists with airway managementand difficult intubation as well as the set up and inser-tion of arterial, central venous, and pulmonary arterylines. An RT at Credit Valley Hospital, is certified in intu-bation and insertion of arterial lines. Other responsibili-ties include airway management and initiation of venti-lation for the post operative patient, in servicing staff,the evaluation and demonstration of new equipment,coordinating visiting Paramedics in the operating room,and assisting the Chief of Anaesthesia in the opera-tional budget.

Working in a Level II Advance Nursery, the Special CareNursery RT has many duties. As a member of the HighRisk Team, this includes attending all caesarians sectionsas well as other deliveries with potential complicationsto either the newborn or mother. The RTassists the pae-diatrician/neonatologist in airway management, whichmay include intubation and initiation of ventilation ornasal CPAP. Other skills include endotracheal intubation,arterial blood gas punctures, capillary blood gas collec-tion, drawing blood from umbilical arterial lines, andsurfactant administration. The RT also provides bothclinical and technical in services to the multidisciplinarystaff, evaluates all new equipment, and develops policyand procedures.

Work in the Pulmonary Diagnostic area includes per-forming a variety of tests, including Pulmonary FunctionTesting, Provocholine Challenges, Exercise Stress testand Metabolic studies both static and dynamic. Thisrole also involves our Hospital Home Care Services, suchas Nasal CPAP and Home O2 education and set ups.

The Certified Asthma Educator RT is responsible for co-coordinating and providing the education/research in relation to asthma in the hospital and community.

Angeline Robitaille-Filion, OR RT, at Credit Valley Hospital,performs her daily preparation and calibration of theanaesthetic machine.

In Newfoundland, Staff Respiratory Therapists, (from St. Clare’sMercy Hospital Site of the Health Care Corporation of St. John’s, NL) and the CNA Clinical Instructor (Wade Wheeler)also took time out to get a group photo with the RT students!(left to right Peter Fikis, Tina Hurley, Jesse Cox, DanielleFitzgerald, Rhonda Hurdle, Steve Chard, Wade Wheeler)

RT Week Newfoundland


On Air ON AIR NUGGETS

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International AbstractsBecause of the volume of Abstracts producedeach month, the CSRT website has added anew section to accommodate internationalabstracts. Check under About — CJRT and goto the bottom of the page. Abstracts areadded as they become available.

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CSRT Membership Renewals — DueMarch 31, 2005A reminder that CSRT Members are due in just afew short months. Members have the option ofusing the CSRT Debit Plan to pay their CSRT fees,as well as their professional association member-ship and related fees. You can arrange to havemonthly installments for your membershipdeducted directly from you bank account.

For CRTO and CARTA members who wish to takeadvantage of CSRT Membership, renewals mustbe received no later than February 15, 2005.

For more information please contact the CSRToffice (1-800-267-3422) or visit the Membershippage on our website to download theMembership Renewal Form.▲

CIHI New StatsBetween 1993 and 2002 there has been an34.8 per cent increase in the number of RRTs in Canada. This is just one of the statsavailable in the new report issued by theCanadian Institute for Health Information. The report “Health Personnel Trends inCanada 1993–2002” is downloadable fromtheir web site www.cihi.ca. This report covers statistics for a wide rage of health careworkers from chiropractors to social workers.

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Awards DeadlinesThe Robert Merry Memorial Award applicationdeadline is January 31, 2005.

Application for the CSRT Education Award for Advanced Respiratory Practice is February 1, 2005.

The AstraZeneca Award for Excellence inAsthma Education application deadline isMarch 31, 2005.

Details can be found on the website underCanadian Respiratory Foundation.

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We’d like your opinion!Please check our Opinion box at the bottomof the CSRT home page on our website. We are soliciting comments, ideas andopinions regarding topical issues. Insightfulcomments will be published in the Journal.Please join the discussion on issues that arerelevant to RTs and the CSRT.

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Congratulations Dallas

On October 29 the College and Associationof Respiratory Therapists of Albertarecognized the outstanding service awardpresented to Dallas Schroeder, RRT fromthe University of Alberta Hospitals inEdmonton. Dallas was nominated by 5 registered members of the College andAssociation and the Council unanimouslyapproved her receiving the award onAugust 27. CARTA President Jerry SpenceRRT did the honour presenting Dallas withher award at the Education Conferenceand Tradeshow following the inauguralNelson Kennedy lecture.

The CARTA outstanding service award ispresented to deserving registered memberswho make a significant contribution topatient care and professional advocacy.Recipients receive a framed certificate ofhonour and a teal coloured cashmere/silkpashmina shawl or a limited edition blackCARTA team jacket. This year’s award wasvery unique in that more than one group ofcolleagues desired to have Dallas nominat-ed for the award. This is a significant trib-ute to her ongoing patient commitment toexcellence. Congratulations to DallasSchroeder, RRT, 2004 CARTA OutstandingService Award winner!


I believe the CSRT must change from what it was towhat it needs to become. Currently, it is both a regula-tor (in the non-regulated provinces), and our nationalprofessional association. That has been the role of theCSRT for more than forty years. With time the profes-sion has become self-regulated in some provinces, and that number continues to grow. Respiratory therapywill eventually be self-regulated in all provinces.Provincial regulatory bodies have the exclusive, legislat-ed authority to license RTs working in their province.The CSRT does not have the legislated authority tolicense RTs anywhere in Canada. We provide a regula-tory role in the non-regulated provinces because thoseemployers accept our credential as certification to prac-tice in their jurisdictions. Provincial regulatory bodiesare and will continue to take over the regulatory rolethat the CSRT once provided to all RTs. This is a natu-ral progression and a positive step for our profession aslong as respiratory therapists participate in the processand the needs of RTs are met. But regulatory bodieswill never work solely to advance the profession, toprovide services and benefits to RTs, to raise publicawareness and will not consider the interests of RTs as their first priority. The CSRT can do exactly that. This must become the primary focus of the CSRT.

The need for the CSRT as a regulator may be disap-pearing, but the need for the CSRT as a powerful pro-fessional association is now more important than ever.If we accept this, and start making the necessarychanges to become a more powerful professional asso-ciation, there is an opportunity to position the CSRTand our profession for a much more successful future.

Acting as both the regulator in the non-regulatedprovinces and the national professional association forall of Canada is difficult. Regulation deals with veryserious issues. The processes involved are expensive. In business terms the risk versus return in doing this isextremely high for the CSRT. The return on investmenthas been low. The services and benefits you receive

from the CSRT depends on which province you workin. Right now, the CSRT spends half of its resources onregulation/credentialling issues. Approximately one half of our members live in the non-regulated provincesand require the CSRT credential to work. The other halflive in the regulated provinces and are already regulat-ed/licensed by their provincial regulatory body. If weaccept that all provinces will become self-regulated, theCSRT faces a challenge. Historically, when provincesbecome self-regulated and CSRT membership becomesvoluntary instead of mandatory, membership drops.This is one reason why less than 30% of the RTs inCanada are CSRT members. Secondly, in the past wehave restricted membership to only those who comethrough our CSRT specific training and testing process.At the November special meeting of the CSRT themembership approved a bylaw change to allow RTswho qualify under the Mutual Recognition Agreementto become full CSRT members. I believe this is a verypositive step for the CSRT. There is now an opportunityfor the CSRT to represent all RTs and to truly representthe entire profession in Canada. We now have a new opportunity to recruit and include more RTs in our society. To capitalize on this opportunity wemust demonstrate and market the tangible benefits of membership.

Some of the essential activities the CSRT performs andmust continue to perform are difficult for the averagemember to see as a direct benefit. For example, advo-cating for common national processes and standardswith regulators, advocating with governments, collabo-rating with our international partners and participatingwith other health disciplines in areas of mutual interestare rather intangible. I would argue that supportingthese types of endeavors by your national professionalassociation is exactly what makes you a professional.The CSRT must change its focus and its practices toplace more focus on being a stronger association ratherthan a regulator. Otherwise membership will declineand so will the organization. If there is no CSRT to

Message from the President


Brent Kitchen

A Vision for the Future of the CSRT

“Resolve to be a master of change rather than a victim of change.” —Brian Tracy

provide benefits to RTs, to advocate for commonnational processes among regulators, to push toadvance the profession and the other activities that a strong association does, who will do it? These issues are not, and will never be, the top priorities of the regulators.

Let us realize that there is a limited future in theregulatory role of the CSRT. It does not matter whetherit is 5, 10 or 20 years before all provinces are regulated.The future of the CSRT is as strong professional associ-ation and in showing the value of membership throughservices and benefits. Focussing on this now willensure a prosperous future. It will not only guaranteethe viability of the organization, but will also allow theprofession to advance and grow. This is my vision for

the future of the CSRT. The CSRT, its employees and itsvolunteers are working diligently to be the organizationwe all need to ensure a successful future, but it cannotand will not happen without your ongoing support.

Brent Kitchen, RRTCSRT President



Message from the President continued from page 9

Message du président

Une vision pour l’avenir de la SCTR

« Ayez à cœur de maîtriser le changement et non de le subir. » — Brian Tracy

J’ai la conviction que la SCTR doit passer de ce qu’elle a étéà ce qu’elle doit devenir. Présentement, elle est d’une part unorganisme de réglementation (dans les provinces non régle-mentées) et, d’autre part, notre association professionnellenationale. La SCTR combine ces deux fonctions depuis plusde quarante ans. Au fil du temps, certaines provinces ontadopté une politique d’autoréglementation. Le nombre deprovinces où la profession est autoréglementée continued’augmenter, et la thérapie respiratoire sera tôt ou tardautoréglementée partout au pays. Les organismes de régle-mentation provinciaux ont la compétence légale exclusivepour accréditer les TR exerçant dans leur territoire, tandisque la SCTR n’a pas la compétence nécessaire pour permettreà des TR d’exercer n’importe où au Canada. Nous jouons unrôle de réglementation dans les provinces non réglementéesparce que ces employeurs acceptent notre agrément pouroctroyer un permis d’exercer sur leurs territoires. Mais le rôlede réglementation que jouait autrefois la SCTR pour tous lesTR est graduellement pris en charge par des organismes deréglementation provinciaux. C’est une progression naturelle etune avancée positive pour notre profession, en autant queles thérapeutes respiratoires participent au processus et queles besoins des TR sont comblés. Toutefois, les organismesde réglementation ne travailleront jamais uniquement à faireprogresser la profession, à fournir des services et des avan-tages aux TR et à mieux sensibiliser la population à notretravail; ils ne considéreront jamais les intérêts des TR commeleur principale priorité. Par contre, c’est exactement ce que laSCTR peut faire et cela doit devenir notre principal objectif.

Le rôle d’organisme de réglementation de la SCTR déclinepeut-être, mais le besoin d’une solide association profession-nelle est aujourd’hui plus important que jamais. Si nous enconvenons et que nous entreprenons les changements néces-saires pour devenir un organisme professionnel plusdynamique, nous avons l’option de créer un avenir beaucoupplus fructueux pour la SCTR et pour notre profession.

Agir à la fois comme organisme de réglementation dans lesprovinces non réglementées et comme association profession-nelle à l’échelle nationale s’avère difficile. La réglementationporte sur des enjeux très sérieux. Les processus impliquéssont coûteux. En termes d’affaires, le rapport risque-avantageest extrêmement élevé pour la SCTR, avec un faible rende-ment sur les sommes investies. Les services et les avantagesque vous recevez de la SCTR varient selon la province oùvous travaillez. Présentement, la SCTR consacre la moitié deses ressources aux questions de réglementation/accréditation.Environ la moitié de nos membres vivent dans les provincesnon réglementées et ont besoin de l’accréditation de la SCTRpour travailler. L’autre moitié de nos membres vivent dans lesprovinces réglementées et sont déjà réglementés/agréés parleur organisme provincial. Si nous prenons pour acquis quetoutes les provinces seront un jour autoréglementées, la SCTRse retrouve devant un défi. On a constaté que, lorsque lesprovinces deviennent autoréglementées et que l’adhésion à laSCTR devient volontaire plutôt qu’obligatoire, le nombre demembres décroît. C’est une des raisons qui font que moinsde 30 % des TR au Canada sont membres de la SCTR. Deplus, nous avons par le passé réservé le statut de membreaux personnes qui complétaient la formation spécifique de laSCTR et qui réussissaient notre examen. À l’assembléegénérale spéciale de la société tenue en novembre, les mem-bres ont approuvé un changement de règlement pour perme-ttre aux TR qui se qualifient aux termes de l’Entente de

Suite à la page 20


CSRT NEWS

Educators from the schools of respiratory therapyacross Canada met in Banff, Alberta, in earlyOctober 2004, to review the new RespiratoryTherapy National Competency Profile and tolearn more about competency based education.Approximately 30 RT educators and representa-tives from each of the regulatory bodies inCanada, the CSRT and CoARTE attended. Withonly one exception, all schools were representedat this historic event.

Educators reviewed the National CompetencyProfile which will serve as a template for whatschools are required to teach respiratory therapystudents and how students are to be evaluated.After receiving feedback from the educatorsgroup, the National Alliance of RespiratoryTherapy Regulators met, revised the NCP docu-ment and approved it.

Paula Burns and Louis Phillip Belle-Isle, botheducators with experience in competency-basededucation, facilitated the meeting and providedinstruction on applying competency-based edu-cation principles in the education of respiratorytherapists. Sessions were held in both Frenchand English. The next steps required to createexams based on the NCP were also discussed.Attendees took this opportunity to learn moreabout the different processes in place for teach-ing and evaluation in Canada — such as thedifferences between the process used in Quebecand other provinces. Educators from outside ofQuebec learned more about Quebec’s process of using a common school exit exam. Quebeceducators heard an overview of the licensing/credentialling exam system used elsewhere fromPaul Williams, Chair of the CBRC ExamCommittee.

Becoming better informed of the processes usedby others and having the chance to network witheducators dispelled a lot of myths among thedelegates. It was a tremendous opportunity forall those involved to broaden their understandingof the various educational processes used inCanada.

The CSRT will be holding an Educators Congressin conjunction with the CSRT Education Forumin Edmonton, June 2, 2005. Once again educa-tors will get together to learn, share their best-practices and to maintain a high level of com-monality in respiratory therapist education insti-tutions across Canada.

Successful Meeting on NationalCompetency Profile


CSRT News

CARTA Launches Nelson Kennedy Lecture CARTA has launched the inaugural NelsonKennedy Lecture in recognition of NelsonKennedy's distinguished lifetime achievement asa Registered Respiratory Therapist from Alberta.Nelson recently retired to Salt-Spring Island BCfrom Edmonton. While at NAIT he was theDean of the Health Sciences and BusinessDepartment.

The first lecture consisted of a four memberpanel discussion on Airway Pressure ReleaseVentilation by Dr. John Downs from theUniversity of Southern Florida in GainesvilleFlorida who created the mode of ventilation.

Also on the panel were Mrs. Roberta Hales RRT,RN from the Children’s Hospital of Philadelphia,Robert Kacmarek RRT, PhD from HarvardUniversity in Boston and Dr. Neil McIntyre fromDuke University in Durham North Carolina.The first lecture was sold out. The second lectureis scheduled for June 5 2005, in Edmonton at the Shaw Conference Center at the EducationForum of the Canadian Society of RespiratoryTherapists. The speaker will be Stephen Lewis,Veteran Diplomat and UN Special Envoy forHIV/AIDS in Africa.

Special MRA AnnouncementOn November 20, 2004 the CSRT held a specialmeeting of its members for the purpose of votingon a proposed bylaw change. The meeting washeld in the Ottawa area at the Four PointsSheraton Hotel in Gatineau, Quebec, inconjunction with the CSRT annual Board ofDirectors meeting.

The requirements of quorum for this meetingwere met, with greater than two memberspresent in person and more than 10% of themembership represented in person or by proxy. The results of the vote were 329 members votingfor making the proposed bylaw change and 14 members voting against. The proposed bylawchange will be forwarded to Industry Canada forfinal approval.

The proposed bylaw change was required inorder to allow the CSRT to give the CSRT registrycertificate and registered membership to individ-uals that meet the requirements of the MutualRecognition Agreement. The CSRT, along withthe regulatory bodies of respiratory therapysigned this agreement in November of 2001. The successful passing of the proposed bylawchange will allow the CSRT to apply the terms

of the MRA along side its partners in the regula-tion of respiratory therapy in Canada.

The effect of this bylaw change will be unimped-ed interprovincial mobility throughout Canadafor RRT’s that meet the conditions of the MRA.

More importantly this means that the CSRT isanother step forward in its mandate of providingleadership through services and advocacy to allRRT’s in Canada regardless of which jurisdictionthey entered the profession through.

Thank you to all of the members that called the head office with questions, sent emails,participated in the online discussion, sent in theirproxies and attended the meeting in person.Without the support and participation of themembership the CSRT Board of Directors cannotmake effective decisions that support the wishesof the members.

Douglas Maynard RRT, MBAExecutive Director


The CSRT House of Delegates was created inJune 2004 as a result of the restructuring of theCSRT Board of Directors.

The House of Delegates is designed to be acommunication link between the Provincial orTerritorial Associations and the CSRT. It isthrough this link that the Provincial Associationsand their members may communicate uniqueand/or common concerns and issues that theyfeel the CSRT should be aware of.

The CSRT also uses this link to correspond with the general membership. We have alreadyutilized this important communication link,informing/reminding members of the CSRTSpecial Meeting regarding the MRA. We expectthat there will be regular information sharing toand from the CSRT members utilizing the newHouse of Delegates.

The House is also responsible to participate inthe governance of the Society as well as makingrecommendations regarding

■ Goals and Objectives of the CSRT

■ Services offered by the CSRT

Membership in the House ofDelegatesEach Provincial or Territorial Association is ableto designate one representative to the House ofDelegates. We encourage all of the Associationsto become involved in this important communi-cation and networking link.

At this time the following Associations haveidentified their representative to the CSRT Houseof Delegates:

■ British Columbia Society of RespiratoryTherapists (BCSRT),

■ Saskatchewan Association of RespiratoryTherapists (SART),

■ Manitoba Association of Registered RespiratoryTherapists, Inc. (MARRT)

■ Respiratory Therapy Society of Ontario (RTSO)

■ Respiratory Therapy Society of Nova Scotia(RTSNS)

■ New Brunswick Association of RespiratoryTherapists, Inc. (NBART),

■ Newfoundland and Labrador Association ofRespiratory Therapists (NLART)

The House of Delegates links to the CSRT Boardof Directors, through the Director of NationalProvincial Relations, who is an ex-officiomember of the House.

The House of Delegates has recommended anominal membership fee be paid to the CSRT to assist in covering the costs of operating theregular business of the House.

Current Work Plan for the CSRTHouse of DelegatesThe first year in the House will be a busy one.In addition to our liaison work with the CSRT aspreviously mentioned, representatives within theHouse have identified a number of Policies thatneed to be developed, as well as the recruitmentof Delegates from the Provincial and TerritorialAssociations yet to participate in the House. To facilitate this work, we are planning toteleconference on a regular basis, in addition to utilizing the wonderful world of electroniccommunication!

On a Personal NoteThe House of Delegates is comprised of a greatgroup of fun, focused professionals. We maycome together with slightly different issues andperspectives, but we are creating a productivegroup that is motivated to make a positive contri-bution to the CSRT.

CSRT House of DelegatesRick Culver,RRTChair, House of Delegates

CSRT News


CSRT News

Chronic obstructive pulmonary disease (COPD)is taking over the lives of Canadian women at analarming rate. In 1999 COPD accounted foralmost four per cent of deaths among women inCanada, making it the fifth leading cause ofdeath for women.1

Overall, mortality rates for COPD have increased.From 1988 to 1999 the mortality rate for womenwith COPD increased by 53 per cent, and hascontinued to increase.2 What is significant is thatduring this time, the COPD rate among mendecreased by seven per cent, and has continuedto fall.3 What was formerly an “old man’sdisease” now belongs to middle-aged moms. What many Canadians don’t realize is that smok-ing accounts for 80 to 90 per cent of all COPD.4

Current statistics show that hospitalizations forCOPD care among women are expected toincrease so that by the year 2015, approximatelytwice as many women will be hospitalized forCOPD case as men, and death rates are expect-ed to follow the same pattern.5

“Smoking cessation is the single most effectiveintervention to reduce the risk of developingCOPD and to slow disease progression,” said Dr. Paul Hernandez, Associate Professor ofMedicine, Dalhousie University; Chair, CTSCOPD Guidelines Dissemination andImplementation Committee; and medicaladvisory board member at The Lung Association. “As physicians, we need to continue to stress thelong term effects smoking has, and educate ourpatients about COPD and the impact it has onquality of life.”

COPD is Under Diagnosed,Particularly in WomenThe primary concern is that COPD is underdiagnosed. In a recent study, 20 per cent ofphysicians considered other diagnoses more likely than COPD when presented with a breath-less, former smoker, whose documented airflow

limitation was unresponsive to bronchodilatorsand oral corticosteroids.6

Furthermore, gender bias plays a role in underdiagnoses as physician response revealed thattwo thirds of physicians considered COPD to bethe likeliest diagnoses when reviewing a malepatient presenting with COPD symptoms. Whenphysicians were evaluating a female patient withidentical symptoms, however, fewer than half ofthe physicians considered COPD to be the likeli-est of diagnoses.7 All patients with suspectedCOPD must have a spirometry test to confirmdiagnosis and this gender gap is not likely to beremedied until physicians begin to use spiromet-ric testing to screen for this disease.8

The Role of the Physician Who TreatsCOPD To optimize early diagnosis, prevention andmanagement of COPD in Canada, the CanadianThoracic Society (CTS) introduced new treatmentguidelines in June 2003. According to the guide-lines, the goals of managing COPD are to pre-vent disease progression, reduce and alleviatebreathlessness and other respiratory symptoms,improve exercise tolerance, prevent and treatflare-ups, and reduce mortality.

The guidelines recommend a stepwise approachto management, based on severity of symptomsand disability. Furthermore, family physicianshave a primary role in the management of COPDas it relates to identifying and diagnosing the dis-ease at an early stage, and educating diseaseprevention.

“The guidelines have been created in responseto this devastating disease — so that familyphysicians are equipped to optimize earlydiagnoses, prevention and management ofCOPD as tobacco-induced lung damage is prima-rily irreversible,” said Dr. Denis O’Donnell, Chair, Canadian Thoracic Society COPD

COPD Dramatic Increase Among Women From the Lung Association


CSRT News

Guideline Development Committee. “It is impera-tive that physicians review and implement theguidelines into their clinical practice so that theyare able to better diagnose patients with COPD,better help manage and treat those who alreadysuffer from the disease, and help prevent othersfrom ever getting it.”

Additional Resources Other resources are available, such as The LungAssociation’s BreathWorks™ Program, an initia-tive designed to help patients, and their familiesand caregivers, cope with the emotional hurdlesand physical challenges of living with COPD. Formore information, visit www.copdguidelines.ca.

References1. O’Donnell DE, Aaron S., Bourbeau J. et al. Canadian

Thoracic Society recommendations for managementof chronic obstructive pulmonary disease — 2003.Can Resp J 2003;10 (Suppl A):11B

2. O’Donnell DE, Aaron S., Bourbeau J. et al. CanadianThoracic Society recommendations for managementof chronic obstructive pulmonary disease — 2003.Can Resp J 2003;10 (Suppl A):11B

3. O’Donnell DE, Aaron S., Bourbeau J. et al. CanadianThoracic Society recommendations for managementof chronic obstructive pulmonary disease — 2003.Can Resp J 2003;10 (Suppl A):11B

4. Retrieved November 5, 2004 fromhttp://www.smoke-free.ca/Health/pscissues_health.htm

5. Chapman KR et al. Chronic obstructive pulmonarydisease: are women more susceptible than men?Clinics in Chest Medicine — 2004 6 (Vol. 25, Issue02725231):332




Dr. Paul Hernandez, Associate Professor of Medicine,Dalhousie University; Chair, CTS COPD GuidelinesDissemination and Implementation Committee; andmedical advisory board member at The LungAssociation.

Dr. Denis O’Donnell, Professor and Head of theRespiratory division at Queens University; Chair,Canadian Thoracic Society COPD GuidelineDevelopment Committee.

Looking for Old PhotosThe CSRT is pleased to announce that we are inthe process of publishing a book on the historyof the CSRT. The painstaking task of researchingand writing a Reflective History of the CanadianSociety of Respiratory Therapists has beenundertaken by Mike Andrews. We are nowlooking for photographs to complement thiswork — old equipment, RTs at work in theiryounger days etc. Please have a look throughyour albums and shoeboxes. If you have some-thing you think we might be able to use, pleasecontact us. We will return all images that wereceive. Here are the Chapter titles — that might give some idea of how your photosmight fit in.

The Evolving role of the Respiratory TherapistThe Early YearsPhysician SupportThe Foundation Years 1964–1967Gaining Momentum 1967–1970The Examination Process

Our deadline is February 28, 2005. Pleaseremember to identify who and what the photo represents. Please include a return address.Send to:Rita HansenCSRT102-1785 Alta Vista Drive,Ottawa ON K1G 3Y6


Volunteer RecognitionVolunteers are crucial to the CSRT’s Accreditationprogram. The time and expertise donated byrespiratory therapists, physicians, school administra-tors and the public has greatly contributed toCoARTE’s ongoing success. Without them, the pro-gram could not exist. CoARTE members spendmany hours reviewing reports, developing policies,participating in teleconferences and meetings in theinterest of promoting national standards. Documentreviewers and program review team members takeon the responsibility for assessing the extent towhich schools meet the national standards. Thework is intense but deeply gratifying.

CoARTE would like to acknowledge the contribu-tions of its members, document reviewers and teammembers who served on program review teamsduring the calendar year 2004. It is their commit-ment to excellence that assures the quality of theAccreditation programs and activities.Sincere appreciation is extended to the followingindividuals for their generous contribution of timeand expertise.

CoARTE membersDebbie Cain, Clinical EducationHelen Clark, Employer Myrna Gunter, Public MemberTom Dorval, Didactic EducationDr. Don Reid, PhysicianFred MacDonald, Senior Educational

Administration Josée Prud’Homme, National AllianceRepresentativeDoug Maynard, Executive Director for the CSRT

Document Reviewers and Program ReviewersRespiratory TherapistsMichael BachynskyDebbie CainRay HubbleSusan DuningtonThelma CashenTom DorvalMark Murray

France GermainMaryse AudetAdrienne LeachJoel MacPherson

PhysiciansDr. Don ReidDr. Nigel Duguid Dr. Paul Hernandez Dr. Sharon Peters

Educational AdministratorsFred MacDonaldPamela SkinnerMarie-France BélangerJo-Ann AubutJune MacDonaldMarlene Raasok

Regulator RepresentativeDennis Hunter, CRTOMartine Gosselin, OPIQDale Mackey, CRTODawn Brunelle, CRTO

Program RecognitionCoARTE members would also like to extend appre-ciation to the programs who have worked hard thisyear to prepare for their accreditation site visit.Programs such as UCC and Vanier College wel-comed Program Reviewers during the site visits anddemonstrated deep gratitude for the team member'shard work throughout the process.

Accreditation SecretariatMichelle Kowlessar will be taking her maternityleave on January 28, 2004. The CSRT is currentlysearching for a replacement for a one-year term tofill the position of Accreditation and EducationManager.

Holiday WishesCoARTE would like to wish everyone a joyful,healthy and safe holiday season.

CoARTE News

CoARTE NewsMichelle Kowlessar, CoARTE Accreditation and Education Manager


National Non-Smoking Week

January 19, 2005 is Weedless Wednesday. It is part ofthe National Non-Smoking Week (January 16–22,2005). This Canada-wide endeavour involves agenciesand individuals working at the federal, provincial/territorial, regional and local levels. Thousands ofpeople — both volunteers and staff — participate inthe campaign, including local health units, local andprovincial/territorial councils on smoking and health,health charities such as the Canadian Cancer Society,the Heart and Stroke Foundation of Canada, theCanadian Lung Association, and also provincial, territo-rial and federal Ministries of Health.

National Non-Smoking Week has been observed formore than twenty years. From its inception in 1977 thegoals have been to:

■ educate Canadians about the dangers of smoking;

■ prevent non-smokers from beginning to smoke andbecoming addicted to tobacco;

■ help smokers quit;

■ promote the right of individuals to breathe airunpolluted by tobacco smoke;

■ denormalize the tobacco industry, tobacco industrymarketing practices, tobacco products, and tobaccouse; and

■ assist in the attainment of a smoke-free society in Canada.

The National Clearinghouse on Tobacco and Healthwebsite has information that includes smokers healthlines, legislation, taxation, prevention and links to edu-cational tools, conferences, trends and on-line journalswww.ncth.ca/NCTH_new.nsf.

Did you Know?■ In 1977, when Canada had its first National Non-

Smoking Week, over 40 per cent of Canadianssmoked. Today, 25 years later, only 24 per cent ofCanadians smoke, with BC leading the pack withonly 20 per cent of the population lighting up.

■ Many smokers believe that smoking relaxes them. In fact, smoking makes your heart beat faster, makesyou breath quicker, and raises your blood pressure.

■ You are never too old to quit — benefits begin rightaway. After one year of not smoking, your risk ofhaving a heart attack is cut in half.

■ Quitting smoking is one of the best things you cando for your children. Children of non-smokers havelower rates of asthma and chest infection.

■ If current trends persist — 500 million people alivetoday, many of them still children, will eventuallydie of tobacco-related diseases.

■ The effect of one cigarette stays in your home sevendays and two thirds of the smoke from a burningcigarette goes into the air

■ Exposure to second hand smoke is estimated tocause about 300 lung cancer deaths a year inCanada.

Looking for facts and figures on tobacco?Try the World Bank Public Health Site: www1.worldbank.org/tobacco/

Smoking Cessation Programs?Try the Canadian Lung Association sitewww.lung.ca/smoking/

Weedless Wednesday


Forum 2005

Shaw Conference Centre, Edmonton, Alberta, June 2–5, 2005

The CSRT invites administrators, practitioners,researchers, educators, students, health policyand health services planners to submit abstractsfor poster or paper presentation at “Forum2005 Compassion in Action” in Edmonton.

Proposals may pertain to clinical practice areas,program development, research investigation,

evaluation of a process/program and respiratoryhealthcare delivery.

Deadline for submissions is February 18,2005.

For complete instructions, guidelines andapplication details visit the CSRT website.

Education modules will include Critical

Care, Anesthesia & Perfusion,

Leadership, Neonatology & Pediatrics,

Diagnostics and “Taking Care of Me”.

CSRT Annual Educational Forum

CSRT Annual Educational Forum

Edmonton 22005

CCommpaassssiioon in AAccttiion

“Compassion in Action”

Call for Poster and Papers — Forum 2005

College and Association of Respiratory Therapists of AlbertaCARTA

Thank You to Our Platinum Sponsors

Registration includes Exhibitors Breakfast, Sunday ContinentalBreakfast, two lunches and breaks, Fun Night, Wine and CheeseReception, all lectures and workshops, entry to Exhibit Hall.GST is included in the total #119220010 RT

Refunds: Refunds are subject to a $50.00 administration fee.

❒ y ❒ a

METHOD OF PAYMENT

CARD NUMBER EXPIRY DATE

SIGNATURE

EMPLOYER

NAME

YOUR ADDRESS

CITY PROVINCE POSTAL CODE

POSITION (TITLE)

CSRT FILE #

HOME TEL. WORK TEL.

TOTAL PAYMENT $

* Pre-registration deadline April 22, 2005**Must be currently enrolled in a CSRT approved program

to qualify for the student rate

Send to: CSRT 102 - 1785 Alta Vista Drive. Ottawa, Ontario K1G 3Y6

For more information please contact the CSRT at 1-800-267-3422 or (613) 731-3164 Fax: (613) 521-4314 E-mail: [email protected]

E-MAIL

PRINT NAME

■■ Full Registration — Members 2005–2006*Pre-registration 325.00 ❒After April 22, 2005 395.00 ❒■■ Full Registration — Non-members*Pre-registration 470.00 ❒After April 22, 2005 540.00 ❒■■ Full Registration — CSRT Student MembersStudent Members* 50.00 ❒■■ Full Registration — Non-CSRT Student Members*Pre-registration 75.00 ❒After April 22, 2005 100.00 ❒■■ Daily Registration ❒ Fri. ❒ Sat. ❒ Sun.Members 150.00 ❒Non-members 185.00 ❒Student Members** 50.00 ❒■■ OptionsPresident’s Banquet 50.00 ❒Additional Exhibitor Representative 150.00 ❒

Forum HighlightsThursday, June 2, 2005 Educator’s Congress ■ Clinical Simulations: What They Are and How We Use Them ■ Competency Based Evaluation Strategies■ Assessing Competency: Knowledge vs. Skills vs. Competency ■ The Future of the Educators Congress — group discussion on

the formation of a special interest group within the CSRT

Wine and Cheese Reception

Friday, June 3, 2005■ Exhibitors’ Breakfast■ FREE Fun Night and Olympics at Red’s, West Edmonton Mall

Saturday, June 4, 2005 ■ CSRT Annual General Meeting■ President’s Banquet and Awards with Keynote Speaker —

Stephen Lewis

Confirmed speakers include:■ Richard Branson: Nutritional Support and the Pulmonary

Patient/Mechanical Ventilation: Past Present and Future■ Dr. Peter Brindley: Critical Care■ Helen Clark: Regional Management of Respiratory Services■ Dr. Leslie Dort: The Role of Oral Appliances in the Treatment of

Sleep Disordered Breathing■ Dan Granoski: Role of the RT in ECMO■ Dr. Dean Hess: Selection of an Aerosol Delivery

Device/Approaches to Discontinuation of MechanicalVentilation

■ Cheryl Misak: Intubation and the ICU Patient■ Pat Mussieux: Driving Behavior Change■ Dr. Michael Narvey: Neonatal Ventilator Strategies■ Dr. Peter Norton: The Second Victim ■ Dr. Peter Papadakos: ARDS Treatment in Evolution/Update on

Sedation/Management of Massive Lung Trauma■ Dr. Kumar Ramlall: Community Based Pediatric Asthma

Programs■ Dr. John Remmors: Sleep Apnea and Cardiovascular Disease■ Dr. Stuart Robertshaw: The Healing Power of Humour■ Dr. Craig Scanlan: Fostering Leadership Development ■ Dr. Rob Seal: Anesthesia/Perfusion■ Dr. Dan Stollery: Pulmonary Hypertension■ Dr. Bernard Thebaud: Bronchopulmonary Dysplasia■ Dr. Juzer Tyebkhan: NIDCAP

Panel: Respiratory Research Opportunities and Barriers; Dean Hess, Richard Branson; Craig Scanlan

Forum 2005


CALENDAR OF EVENTSJanuary 15–19, 200534th Society of Critical CareMedicine CongressPhoenix, Arizonahttp://www.sccm.org/education/annual_congress/index.asp

January 16–23, 200523rd Annual Symposium ClinicalUpdate in Anesthesiology andAdvances in Techniques ofCardiopulmonary BypassFajardo, Puerto Rico Puerto [email protected]

January 21–25, 200535th Critical Care CongressNew Orleans, Louisianahttp://www.sccm.org/education/index.asp

January 28–30, 200543rd Clinical Conference inPediatric AnesthesiologyHollywood, [email protected]

January 30–February 2, 2005Canadian CardiovascularSociety Winter SymposiumWhistler, British Columbiahttp://www.ccs.ca

February 5–8, 2005III World Congress onImmunopathology &Respiratory AllergyPattaya, Thailandhttp://www.isir.ru

February 5–12, 200530th Annual Vail Symposium in Intensive CareVail Colorado, USAwww.cmeprofessionalseminars.org

February 24–27, 2005Pediatric Anesthesiology 2005Miami Beach, Floridawww.pedsanesthesia.org

March 11–15, 200579th Clinical and ScientificCongress of the InternationalAnesthesia Research SocietyHonolulu, Hawaiiwww.iars.org

March 17–19, 2005 NAMDRC 28th Annual Meetingand Educational ConferenceSan Diego, Californiahttp://www.namdrc.org//annual/annmeet.html

March 18–20, 2005European Respiratory SocietyLung Science Conference Taormina, Italyhttp://www.ersnet.org/ers/

March 18–22, 2005American Academy of Allergy,Asthma and Immunology60st Annual MeetingSan Antonio, Texashttp://www.aaaai.org/

March 20–23, 20057th Annual EuropeanConference Society for Researchon Nicotine and TobaccoPrague, Czech Republichttp://www.srnt.org/

April 9–10, 2005Toronto Anesthesia SymposiumToronto, [email protected]

April 27–29, 20055th International Symposiumon Antimicrobial Agents andResistanceSeoul, Koreahttp://www.isaar.org/

May 4–7, 200537th Annual Meeting of theSociety for Obstetric Anesthesiaand PerinatologyPalm Desert Californiawww.soap.org

May 14–18, 2005Society of CardiovascularAnesthesiologists AnnualMeetingBaltimore, [email protected]

Calendar of Events

Message du présidentsuite de la page 10

reconnaissance mutuelle de devenir membres à partentière de la SCTR. Je crois qu’il s’agit là d’un grandpas en avant pour la société. Cet ajout offre à laSCTR l’occasion de représenter tous les TR et dedevenir un véritable porte-parole de toute la profes-sion au Canada. C’est une nouvelle occasion derecruter et d’intégrer encore plus de TR dans notreorganisme. Pour profiter de cette occasion, nousdevons démontrer et vendre les avantages concretsde l’adhésion à la SCTR.

Il est vrai que certaines des activités essentiellesdont la SCTR s’acquitte et doit continuer de s’acquit-ter sont difficiles à percevoir comme des avantagesdirects par les membres en général. Par exemple, lefait d’intervenir auprès des organismes de réglemen-tation en vue d’une uniformisation nationale desprocessus et des normes, celui de défendre nosintérêts devant les gouvernements, de collaboreravec nos partenaires internationaux et de faire causecommune avec d’autres professionnels de la santédans des domaines d’intérêts mutuels sont des activ-ités plutôt intangibles. J’alléguerais pourtant quec’est précisément en appuyant ce type d’activités devotre association professionnelle nationale que vousagissez en véritables professionnels. La SCTR doitdéplacer ses centres d’intérêts et ses pratiques pourse positionner comme association proactive plutôtque comme simple organisme de réglementation.Sinon, nous perdrons des membres et l’organisationdéclinera. Si la SCTR n’est pas là pour offrir desavantages aux TR, plaider en faveur de processuscommuns nationaux auprès des organismes deréglementation, exercer des pressions pour faireavancer la profession et accomplir toutes les autresactivités qu’une association forte se doit d’accomplir,qui le fera? Ces enjeux ne sont pas et ne serontjamais prioritaires pour les organismes deréglementation.

Nous devons réaliser que le rôle d’organisme deréglementation de la SCTR a atteint ses limites. Il importe peu que cela prenne 5, 10 ou 20 ansavant que toutes les provinces soient autoréglemen-tées. L’avenir de la SCTR réside plutôt dans uneassociation professionnelle forte et dans unedémonstration des services et des avantages réelsofferts à ses membres. Il faut mettre l’accent là-dessus dès maintenant pour nous assurer un avenirprospère. En plus de garantir la viabilité de l’organi-sation, cette orientation contribuera aux progrès denotre profession. Voilà ma vision pour l’avenir de laSCTR. Notre société, ses employés et ses bénévolestravaillent avec diligence à structurer l’organisationdont nous avons tous et toutes besoin pour nousassurer un avenir fructueux, mais cet avenir exigeen outre votre appui soutenu.

Brent Kitchen, RRTPrésident de la SCTR


The Influence of Active and Passive Smoking onHabitual Snoring

Karl A. Franklin, Thórarinn Gíslason, Ernst Omenaas,Rain Jõgi, Erik Juel Jensen, Eva Lindberg, MariaGunnbjörnsdóttir, Lennarth Nyström, Birger N. Laerum,Eythor Björnsson, Kjell Torén and Christer Janson

Department of Respiratory Medicine, University Hospital,Ume; Department of Respiratory Medicine andAllergology, Uppsala University, Uppsala; andDepartment of Occupational and EnvironmentalMedicine and Allergology, Sahlgrenska UniversityHospital, Göteborg, Sweden; Department of PulmonaryMedicine, Landspitali University Hospital, Reykjavik,Iceland; Department of Thoracic Medicine and Centerfor Clinical Research, Haukeland University Hospital,Bergen, Norway; Lung Clinic, Foundation TartuUniversity Clinics, Tartu, Estonia; Department ofRespiratory Diseases, University Hospital, Aarhus,Denmark Correspondence and requests for reprints should be addressedto Karl A. Franklin, M.D., Ph.D., Department of RespiratoryMedicine, University Hospital, SE-901 85 Umeå, Sweden. E-mail: [email protected]

The impact of active smoking, passive smoking, andobesity on habitual snoring in the population is mainlyunknown. We aimed to study the relationship of habitu-al snoring with active and passive tobacco smoking in apopulation-based sample. A total of 15,555 of 21,802(71%) randomly selected men and women aged 25–54years from Iceland, Estonia, Denmark, Norway, andSweden answered a postal questionnaire. Habitualsnoring, defined as loud and disturbing snoring at least3 nights a week, was more prevalent among currentsmokers (24.0%, p < 0.0001) and ex-smokers (20.3%, p < 0.0001) than in never-smokers (13.7%). Snoringwas also more prevalent in never-smokers exposed topassive smoking at home on a daily basis than in never-smokers without this exposure (19.8% vs. 13.3%,p < 0.0001). The frequency of habitual snoringincreased with the amount of tobacco smoked. Active smoking and passive smoking were related tosnoring, independent of obesity, sex, center, and age.Ever smoking accounted for 17.1% of the attributablerisk of habitual snoring, obesity (body mass index 30 kg/m2) for 4.3%, and passive smoking for 2.2%.Smoking, both current and ex-smoking, is a major con-tributor to habitual snoring in the general population.Passive smoking is a previously unrecognized risk factorfor snoring among adults.

Key Words: epidemiology • obesity • smoking • snoring • tobacco

American Journal of Respiratory and Critical CareMedicine Vol 170. pp. 799-803, (2004)

© 2004 American Thoracic Societydoi: 10.1164/rccm.200404-474OC

Respiratory Capacity Course in Patients WithInfantile Spinal Muscular Atrophy*

Christine Ioos, MD; Danièle Leclair-Richard, MD; SlahMrad, MD; Annie Barois, MD and Brigitte Estournet-Mathiaud, MD

* From the Department of Pediatric Neurology, HôpitalRaymond Poincaré, Garches, France. Correspondence to: Christine Ioos, MD, Department ofPediatric Neurology, Hôpital Raymond Poincaré, 104,Boulevard Raymond Poincaré, 92380 Garches, France78-83; e-mail: [email protected]

Study objectives: To describe the clinical and respirato-ry course in infantile spinal muscular atrophy (SMA) type I, type II, and type III, and to evaluate therespiratory needs for these patients, using noninvasiveor tracheostomy ventilation.

Design: Retrospective cohort study.

Methods: We report 33 patients with SMA true type I(onset before age 3 months), 35 patients with SMAintermediate type I (onset between 3 months and 6 months),100 patients with SMA type II (onsetbetween 6 months and 18 months),12 patients withSMA type III (onset after age 18 months). We report the clinical symptoms, respiratory course, and respiratorymanagement: respiratory physiotherapy, periodichyperinsufflation, nasal nocturnal ventilation (NNV), and tracheostomy. Also, we measured the FVC overseveral years during childhood and adolescence.

Results: In patients with SMA true type I, 82% ofpatients died, one third of whom underwent tracheosto-my. In patients with SMA intermediate type I, 43%needed NNV, 57% underwent tracheostomy, and 26%died. In patients with SMA type II, 38% needed NNV,15% underwent tracheostomy, and 4% died. In patientswith SMA type III, respiratory impairment was moderateand began during the second decade of life. Conclusion: This data shows the progressively worseningcourse of restrictive respiratory insufficiency in patientswith SMA, and the importance of early respiratory man-agement to limit pulmonary complications and improvethe quality of life for these patients.

Key Words: children • FVC • nasal nocturnal ventilation• periodic hyperinsufflation • respiratory insufficiency • spinal muscular atrophy • tracheostomy

(Chest. 2004;126:831-837.)© 2004 American College of Chest Physicians

Abstracts

SCIENTIFIC NEWS


Non-invasive Mechanical Ventilation (NIMV) forExacerbation of COPDJennifer Drummond, RRT

The ResearchOver the last 15 years non-invasive mechanicalventilation has evolved from a research curiosityto an established clinical practice. Plant, et al 1

recruited and randomized 236 patients sufferingfrom an exacerbation of COPD into two groupsof 118. Each group shared similar characteristicsat enrollment. One group received standardtherapy alone and the other group received non-invasive ventilation in addition to standardtherapy. The results of the study demonstrateddecreases in both intubation and mortality in thenon-invasive group. Twenty seven percent of thestandard group required intubation comparedwith fifteen percent of the non-invasive ventila-tion group. There was twenty percent mortalityin the standard group compared to ten percentin the non-invasive group. Another similar studyby Brochard, et. al 2 with 85 patients in totaldemonstrated the same impressive results.

Creating a ProgramDr. Irvin Mayers, M.D., FRCPC, Director of theDivision of Pulmonary Medicine at the Universityof Alberta Hospital in Edmonton, Alberta, wasmotivated by the potential to decrease themortality of COPD exacerbation by up to 50%.He was granted funding from governmentdepartment of Alberta Health and Wellness’Health Innovation Fund to establish a program to deliver consistent state-of-the-art ventilatorysupport for COPD patients experiencing acuteexacerbation. It was anticipated that by creatingthis comprehensive service there would be adecrease in mortality, reduction in ICU bedutilization and decrease in total hospital length of stay.

A Respiratory Therapist was the logical choice ofCoordinator for the project. Although my back-ground was primarily adult intensive care, I had

supervisory experience and had acted as siteCoordinator on a previous research project. I welcomed the challenge of creating anddeveloping the NIMV Project, and felt fortunateto be the successful applicant for the NIMVCoordinator position.

Getting started with the Non-invasiveMechanical Ventilation (NIMV) ProjectWe established a steering committee for theproject, with an independent evaluator, R.T.’s,R.N.’s, physicians, and managers from Pulmonaryand Emergency. We developed inclusion andexclusion criteria based on those used in thePlant and Brochard studies. Patients presenting

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Heather Gillard, a senior Respiratory Therapist on thepulmonary ward.


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with exacerbation of COPD had to be conscious,cooperative and dyspneic. Decompensation fromother co-morbidity’s requiring specific treatmentserved as exclusion criteria (e.g. peritonitis,septic shock, acute MI, pulmonary embolism,hemoptysis). Unlike the studies conducted byPlant and Brochard, we chose not to deny NIMVtherapy to patients with DNR directives.

The first ten patients were run as a pilot projectto help us further refine and develop our criteriaand protocols. During that time, the projectobtained 6 Respironics Vision® Ventilators and awide variety of both nasal and full-face masks.Physicians, respiratory therapists and nursingstaff in ER and Pulmonary were intensivelyinserviced on the practice and the theory of non-invasive ventilation, as well as on the equipment.Patients were awake, cooperative and werecoached about removing the mask if they shouldfeel nauseated. Once stable, the patients weregiven priority access to the NIMV sub-unit creat-ed for this project on the Pulmonary Medicineward. Our hospital policy governing non-invasiveventilation was amended to allow full-face masknon-invasive ventilation on the ward for theexacerbation of COPD patient population only.All other patients requiring full-face mask ventila-tion for acute respiratory exacerbation or otherreason continue to require transfer to the ICUwhere there is an increased nurse/patient ratio.

NIMV Project in ActionWell into our third year, the NIMV Project isrunning smoothly. Protocols have been devel-oped and implemented to cover initiation oftreatment, ongoing management and weaning.Staff education remains an ongoing priority.

When a patient presents to the ER, the respiratorytherapists and the ER and Pulmonary physicianswork together to identify and enroll potential can-didates as quickly as possible. Once the patient isidentified, the option of non-invasive ventilation isdiscussed with the patient. Many suffer from anxi-ety associated with their shortness of breath andcan become claustrophobic with a mask on theirface. This can be partially alleviated by fully dis-cussing the treatment with the patient, showing the

patient the mask and then gently holding theunattached mask on the patient's face and coach-ing them to breath slowly through the mask. If thepatient is able to tolerate the mask over their face,we try connecting the mask to the VisionVentilator while still holding the mask over thepatient’s face. Only after the patient has demon-strated treatment tolerance is headgear used tosecure the mask.

Our protocol calls for initiation of ventilation atlow pressures — IPAP 8 cm H2O and EPAP 4 cmH2O. IPAP is quickly increased as tolerated bythe patient. The aim is to decrease respiratoryrate, increase tidal volume and decrease dyspnea(as measured subjectively on the modified Borg scale). EPAP will be increased if the patientsuffers from refractory hypoxemia, or demon-strates difficulty in triggering inspiration in thepresence of autoPEEP. The Vision Ventilator isvery sensitive thus we have infrequently found itnecessary to match intrinsic PEEP to permit suc-cessful inspiratory triggering.

Initially the majority of our patients require afull-face mask as their dyspnea makes thecoordination necessary for successful use of anasal mask difficult. One clinical indicator ofsuccessful treatment is when the patient fallsasleep quickly. This occurs often, as successfulapplication of non-invasive ventilation providesthem with relief of dyspnea and anxiety.Changes in ventilator settings are made inresponse to ABG results, clinical observation and patient comfort/feedback. We frequently see dramatic improvement in ABG’s anddecreased dyspnea.

The patient is encouraged to remain on NIMV asmuch as possible during the first twenty-fourhours in order to provide much neededunloading of the respiratory muscles. NIMV istemporarily discontinued for eating, drinking,inhaled bronchodilator therapy and mobilityneeds (e.g. trips to the bathroom). Periods oftime off of the NIMV are extended as tolerateduntil the patient has been stable for twenty-fourhours, at which time they are considered to besuccessfully weaned.


Arterial blood gases are done prior to initiatingthe NIMV treatment and at one hour, six hoursand then twenty-four hours after finalizing venti-lator parameters. All starts and stops in NIMV areperformed and documented by a RespiratoryTherapist. The total number of hours of treat-ment depends on the patient’s response and theacuity of the exacerbation. Most patients receivebetween 10–40 hours of treatment over 2 to 7days. Some patients have demonstrated a muchhigher energy level with treatment and havebeen discharged home on BiPAP with goodresults. Data collection occurs throughout thecourse of the therapy and is ongoing, includingQuality of Life follow-up surveys.

Developing a PAV (Proportional AssistVentilation) ProtocolIn May 2002, we started using PAV as the primarymode of ventilation for the NIMV Project patients.The PAV protocol followed the Respironics recom-mendations for custom titration of PAV. In ourexperience, PAV has been well tolerated by mostpatients. We initiate treatment at low flows andpressures, starting with Custom % Set of 30%,Volume Assist (VA) of 5 cm H2O/L and Flow Assist(FA) of 2 cm H2O/L/sec. We rapidly increase theCustom % Set to 60–80%, then increase the VA andFA as tolerated by the patient to meet the objec-tives of decreasing RR, increasing Vt, and decreas-ing WOB.

Data AnalysisTo date, we have screened 237 patients andenrolled 150 patients into the NIMV Project(exclusive of the pilot project). Approximately20% of our patients were judged as being savedfrom intubation and ICU admission. We haveexperienced a project mortality rate of approxi-mately 10%; comparable to the results achievedin the Plante and Brochard studies. However, itis interesting to note that only one third of ourmortality occurred in patients with a Do NotResuscitate order. Our experience demonstratesthat even those patients deemed end stageCOPD with a Do Not Resuscitate Directive canbe successfully managed through an exacerba-tion using non-invasive ventilation.

Canadian PracticeFourteen studies of patients with moderate to severe COPD comparing standard care (O2, bronchodilators, antibiotics and steroids)with standard care plus NIMV. were included inthe Cochrane review3 updated in September2003. NIMV resulted in decreased mortality(Relative Risk 0.52; 95%CI 0.35, 0.76), decreasedneed for intubation (RR 0.41; 95%CI 0.33, 0.53),reduction in treatment failure (RR 0.48; 95%CI0.37, 0.63), rapid improvement within the firsthour in pH (Weight Mean Difference 0.03; 95%CI0.02, 0.04), PaCO2 (WMD -0.40 kPa; 95%CI -0.78,-0.03) and respiratory rate (WMD -3.08 bpm;95%CI -4.26, -1.89). In addition, complicationsassociated with treatment (RR 0.38; 95%CI 0.24,0.60) and length of hospital stay (WMD -3.24days; 95%CI -4.42, -2.06) was also reduced in theNIMV group. The review concluded that NIMVshows benefit as a first line intervention adjuncttherapy for management of acute exacerbation ofCOPD, and should be considered early in thecourse of respiratory failure.

In March 2004, we conducted a survey on theuse of non-invasive ventilation for exacerbationof COPD. We surveyed 33 teaching and commu-nity hospitals in the majority of urban centers.We found marked differences in practice acrossCanada. 82% of Canadian hospitals routinely useNIV in ER, however only 58% routinely use NIVfor treatment of COPD exacerbation. Patients are

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SeverityNo Breathlessness* At AllVery Very Slight (Just Noticeable)Very SlightSlight BreathlessnessModerateSome What SevereSevere Breathlessness

Very Severe Breathlessness

Very Very Severe (Almost Maximum)Maximum

Modified Borg Scale

Scale00.5123456789

10


admitted only to an ICU or an ICU step-downunit in 70% of Canadian hospitals. It is clear thatdespite evidence-based guidelines, application ofthis life saving treatment is inconsistent acrossthe country.

Other findingsEarly in the project we were using our own re-usable circuits with a heated inspiratory lineand Fischer Paykel® humidifiers for all patients.We noted incidents where the ventilator becameinsensitive to patient efforts, or alarmed ‘ventila-tor inoperative.’ Our technical support serviceRespiratory therapists worked in conjunctionwith engineers from Respironics to investigatethe problems. After extensive bench testing wedetermined that the high flows generated by theVision's leak compensation mechanism causedhuge increases in resistance to gas flow, due tocircuit components. The main line filter, the O2

analyzer and the heating wire were the primaryculprits. We now use the lowest resistancemainline filter, ensure that the O2 T is positionedfor laminar flow, and use a low resistanceinspiratory limb with no heated wire. Thesechanges seem to have solved the problems.

The FutureNon-invasive mechanical ventilation technologyhas improved immensely in the last ten years.The use of non-invasive ventilation therapy in acarefully selected patient population will contin-ue to increase in popularity as significant andoften impressive clinical results are demonstrat-ed. NIMV is recognized in the CanadianGuidelines for the Management of AcuteExacerbations of Chronic Bronchitis4 as beingGOLD standard for treatment of moderate tosevere exacerbation of COPD.

ConclusionsNon-invasive ventilation is a safe, effectiveadjunct therapy for COPD.

■ We have experienced a project mortality rateof approximately 10%; comparable to theresults achieved in the Plante and Brochardstudies.

■ Approximately 20% of our patients werejudged as being saved from intubation and ICUadmission.

■ DNR patients can be successfully managedthrough an exacerbation.

■ Best technical results are achieved by minimiz-ing ventilator circuit resistance.

I would be very happy to share experiences andinformation with other respiratory therapy pro-fessionals. Please feel free to contact me byemail at [email protected].

References1. Plant P.K. Owen J.L. Elliot M.W. (2000). Early use of

non-invasive ventilation for acute exacerbation ofchronic obstructive pulmonary disease on generalrespiratory wards: a multicentre randomised con-trolled trial. Lancet 355: 193-1935

2. Brochard L. Mancebo J. Wysocki M. Lofaso F. ContiG. Rauss A. Simmoneau G. Benito S. Gasparetto A.Lemaire F. Isabey D. Harf A. (1995) Noninvasive ven-tilation for acute exacerbations off chronic obstruc-tive pulmonary disease. New England Journal ofMedicine 333:817-822

3. Ram FSF, Lightowler JV, Wedzicha JA. Non-invasivepositive pressure ventilation for treatment of chronicobstructive pulmonary disease (Cochrane Review).In: The Cochrane Library, Issue 4. Oxford, UpdateSoftware, 2003.

4. Balter M. La Forge J. Low D. Mandell L. Grossman R.(2003) Canadian guidelines for the management ofacute exacerbations of chronic bronchitis. CanadianRespiratory Journal Volume 10 Supplement BJuly/August

Jennifer Drummond, RRT, is currently engaged indata collection and analysis. She hopes to provideconcrete evidence of the effectiveness of thera-peutic NIV for exacerbation of COPD, as well as asummary of the financial implications. Whileheavily involved in education at the University ofAlberta Hospital, Jennifer also speaks at variousconferences including the CSRT EducationalForum, the BCSRT and the SCRT.

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IntroductionChronic obstructive pulmonary disease (COPD)is a chronic respiratory condition characterizedby progressive airflow limitation and symptomsof dyspnea, cough, sputum production, wheeze,and exercise intolerance.1,2 With disease progres-sion, systemic manifestations and recurrent acuteexacerbations of COPD (AECOPD) further con-tribute to a decline in quality of life. As one ofthe leading causes of morbidity and mortality inour aging population, the impact and cost ofCOPD on the health care system is enormousand growing. Optimal management is directedtowards primary and secondary prevention (e.g. slowing disease progression) primarilythrough smoking cessation, minimizing patientsymptoms, reducing frequency and severity ofAECOPD in an effort to slow the decline inquality of life.1,2 A comprehensive, managementstrategy consisting of pharmacotherapy and non-pharmacologic interventions has been advo-cated in recent clinical practice guidelines, wheretherapy is escalated based upon disease severityprogression.1,2 At the foundation of optimalCOPD management is education of patients, their families, health care professionals and thegeneral public.1,2

Management of acute and sub-acute episodes ofillness relies largely on physicians choosing thecorrect intervention, with cure as the expectedoutcome. However, effective chronic diseasemanagement ultimately depends on patients’actions on a day-to-day basis. Additionally, the

treatment of chronic conditions, such as COPD, is often complicated by coexistence of multiple medical conditions and psychosocial(e.g. poverty, social isolation) barriers to care.Current health care systems, which are focusedon treatment of episodic acute illness, ignore thepatient's role in management, rely on sporadicfollow-up and tend to ignore available communi-ty resources, are maladapted to meet the needsof patients with COPD who suffer a continuumof recurring, chronic problems.3 A number ofinnovative health care models have been pro-posed to better manage chronic conditions thatare not amenable to cure. This paper will brieflyexamine two such models in COPD, case man-agement and disease management, which bothemphasize the essential role of patient educationand collaboration between patient and healthcare system through the guidance of a COPDcase manager. The emerging opportunity forRespiratory Therapists (RT) to use their uniqueknowledge and skill sets as COPD case man-agers within these systems is explored.

COPD Patient EducationPatient-focused care recognizes the value ofpatient expertise that reflects the perspective ofone living with a chronic illness. Patient educa-tion aims to further improve disease-specificknowledge, lifestyle behaviours and technicalskills essential to better cope with living with achronic illness.4 Collaborative self-managementpatient education goes beyond traditional patienteducation by empowering patients to identify

Observer # 1

The COPD Case ManagerAn Emerging Opportunity for Respiratory TherapistsScott MacKeigan, BHSc, RRT1 and Paul Hernandez, MDCM, FRCPC2

AbbreviationsAECOPD — Acute exacerbation of chronic obstructive pulmonary diseaseCLA — Canadian Lung AssociationCOPD — Chronic obstructive pulmonary diseaseRT — Respiratory therapists


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and solve problems that gives them the confi-dence to incorporate those skills into their dailylife and assume responsibility for their chronicdisease management.5-7 Ongoing collaborationwith and feedback from a case managerenhances patient self-efficacy by reinforcingpositive choices and helping to correct problembehaviours. A number of key functions areexpected of patients with chronic disease wheninvolved in a collaborative self-managementprogram (Table 1).8

Two examples of patient education resourcescommonly employed in Canada include LivingWell with COPD (Boehringer Ingelheim Canada,Burlington, Ontario) and Breathworks,TM theCanadian Lung Association’s national patienteducation program. Essential elements of adisease-specific, COPD collaborative self-management patient education program areidentified in Table 2.1 Unfortunately, nation-wideimplementation of COPD collaborative self-management patient education programs iscurrently lacking in Canada and hindered by theabsence of a nationally-certified COPD educatorprogram. This gap in COPD care may in parthelp explain the results of a recent survey of 401 Canadians with COPD, entitled ConfrontingCOPD International Survey, in which only 42%reported being very well informed about theirrespiratory condition.9

The results of trials evaluating the impact ofCOPD patient education have been inconclusivefor a variety of reasons (e.g. poor study design,small sample size, non-standardized educationintervention). However, a few recent studiescomparing the addition of patient education tousual COPD care have been able to demonstratean improvement in patient satisfaction with thehealth care system, an improvement in healthstatus, and a decrease in AECOPD frequency,unscheduled physician visits, work absen-teeism.6,10,11 Education alone (e.g. withoutexercise training) does not change lung functionor exercise performance.12

Table 1. Expectations of COPDpatients in a collaborativeself-management program

Learning about their illness

Adhering to healthy lifestyle choices

Adhering to an individualized treatment regimen

Taking responsibility for ongoing chronic diseasemanagement

Assessing symptoms in order to initiate action plansand contact their case manager when there is an acutedeterioration in their health

Table 2. Elements of COPD collabora-tive self-managementpatient education program

Patient-focused information about COPDpathophysiology and symptoms

Identification of COPD risk factors

Modification of COPD risk factors (e.g. smokingcessation program)

Knowledge of drug therapy options

Acquisition of good inhaler technique

Proper use of respiratory equipment (e.g. oxygendelivery systems)

Regular involvement in a safe and effective exerciseregime

Good nutritional practices

Recognition of warning signs of acute exacerbation

Appropriate use of an action plan during an acuteexacerbation

Relaxation techniques and coping skills

Awareness of local community COPD resources

Discussing end of life decisions with care givers (e.g. communicating advance directives)


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COPD Case ManagementCase management has been proposed as a sys-tem of managing complex patients with a focuson meeting the needs of individuals, not popula-tions. Case management can be defined as a col-laborative process between patient and casemanager, who assesses, plans, coordinates, moni-tors, and evaluates services to meet an individ-ual's health needs through optimal use of avail-able resources.13 It promotes continuity of careand improved communication and collaborationbetween patient and health care system. Casemanagers play a key role in this model of healthcare delivery. Case management systems havebeen shown to be effective in addressing chronicconditions (e.g. diabetes mellitus, congestiveheart failure) and unhealthy lifestyle behaviors(e.g. smoking, physical inactivity).14

Case management succeeds by employingunique means that are more cost effective andconvenient to patients. As an alternative to tradi-tional systems that rely on physicians and spo-radic emergency department or clinic visits, casemanagement depends chiefly on collaborationbetween patient and case manager, and replacesmany physician visits with telephone contact,mail and home visits. Success using this modelrequires informed patient actions (Table 1).Accordingly, self-management education affordspatients the knowledge, skills and self-efficacynecessary to collaborate more effectively withtheir COPD case manager in the care of theirchronic illness.

AECOPD contributes to a decline in lung func-tion and health status in COPD patients and isthe main cause of unscheduled clinic and emer-gency department visits, hospitalization, death,and direct and indirect COPD care costs to theCanadian health care system.1,2 Treatment ofCOPD with a case management model increasesthe likelihood that patients will receive optimalcare aimed to reduce AECOPD frequency, betaught to recognize respiratory symptoms thatindicate an AECOPD and collaboratively self-manage AECOPD in a more effective manner. As a result, case management has the potentialto improve outcomes in patient health status,health resource utilization and health care costs.

Bourbeau and his colleagues in the province ofQuebec conducted a multicentre, randomized,controlled trial in 191 patients with COPD com-paring usual care to a disease-specific self-man-agement program and ongoing attention andcommunication with a COPD case manager.15

Hospital admissions for AECOPD were dramati-cally reduced (-40%), as were emergencydepartment (-41%) and unscheduled physicianvisits (-59%) in the intervention group. There wasalso a significant improvement in health status.Other investigators have also demonstrated thatCOPD case management may result in a reduc-tion in health resource utilization and improve-ment in health status.11,16

COPD Disease ManagementDisease management programs provide newopportunities and roles for case mangers toprovide population-based healthcare to thechronically ill. Chronic illnesses are most oftentargeted for disease management programs (e.g. cancer, diabetes, mental health disorders,stroke, congestive heart failure) because they arecostly to the healthcare system, result in signifi-cant impact on patient lives, have a diseasecourse that is amenable to therapy, and a poten-tial for high rate of non-adherence, which isresponsive to patient education.13

The focus assumed by a case manager in a dis-ease management program is population basedand proactive, rather than patient-focused andreactive. As a result, some of the functions of thecase manager differ, particularly when the dis-ease management program is new. These newroles include performing a baseline assessmentof the care patients with COPD receive, econom-ic analyses, assessing health resource utilizationby COPD patients, developing and/or imple-menting evidence-based treatment guidelines andclinical pathways, and data management for out-comes assessment.13 Education of patientsremains a central role, as it is to all case man-agers, but disease management case managersmay also be called upon to educate other healthcare professionals and the general public. Thecase manager may also be involved in identifying


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individuals at-risk for, but not yet diagnosedwith, COPD through targeted screening pro-grams. Following referral of COPD patients, casemanagers provide consultation and ongoing fol-low-up in a similar fashion to case managementsystem. Finally, case manager must evaluate the disease management program itself byassessing patient and program outcomes againstpreset goals.

At times, the case manager in a diseasemanagement program faces conflictingobligations: to manage the use scarce health care resources in a cost effective manner, whileensuring that their patients remain satisfied andreceive the highest quality COPD care available.This aspect can add another element of interestand challenge to the role.

Emerging Opportunities forRespiratory Therapists as COPD Case ManagersThere are emerging opportunities for RT to uti-lize their unique knowledge and skill sets in anexpanded role as case managers for patients withchronic respiratory conditions, such as COPD.17

As acceptance of the importance of newapproaches to chronic disease care increasesamong patients, health care professionals, admin-istrators and payers in this country, the need foradequate numbers and equal distribution ofappropriately trained COPD educators and casemanagers will grow. RT have valuable character-istics specific to COPD that other health careprofessionals would need to develop to providecare to this patient population (Table 3).

Success as a COPD case manager requires thatthe RT be able to re-conceptualize the healthcaresystem, understand the needs of the chronicallyill, and be innovative in identifying solutions totheir problems.13 COPD care employing casemanagers can be effective in improving patientsatisfaction and health status, while decreasinghealth resource utilization and costs. These posi-tive outcomes provide strong justification andmotivation to health care system administratorsto support the emerging role of COPD casemanagers within new approaches to COPDmanagement.

References1. O’Donnell DE, Aaron S, Bourbeau J, et al. Canadian

Thoracic Society recommendations for managementof chronic obstructive pulmonary disease — 2003.Can Respir J 2003; 10(Suppl A):11A-33A.

2. Pauwels RA, Buist SA, Calverley CMA, et al. Globalstrategy for the diagnosis, management and preven-tion chronic obstructive pulmonary disease.NHLBI/WHO Global Initiative for Chronic ObstructivePulmonary Disease (GOLD) Workshop Summary. AmJ Respir Crit Care Med 2001; 163:1256-76.

3. Epping-Jordan J. Innovative Care for ChronicConditions. Meeting Report, 30-31 May 2001.Noncommunicable Diseases and Mental Health,World Health Organization, 2001.

4. Van den Borne H. The patient from receiver ofinformation to informed decision-maker. PatientEduc Counsel 1998; 34:89-102.

Table 3. Valuable characteristics ofRespiratory Therapists asCOPD case managers

Knowledge of COPD pathophysiology and treatment

Knowledge of management of common respiratory co-morbidities (e.g. sleep apnea)

Knowledge and technical skills related to use ofrespiratory equipment (e.g. inhaler devices, oxygendelivery systems, mechanical ventilators)

Technical skills to perform and knowledge to interpretpulmonary function tests

Good communication skills

Training and work experience as adult educators

Training and work experience in hospital, outpatientand home environments

Training and work experience in multidisciplinarysetting

Training and work experience in respiratory researchmethods

Training and work experience as health care manager

Training and work experience managing COPD patientsat the end of life


5. Bourbeau J, Nault D, Borycki E. In, Comprehensivemanagement of chronic obstructive pulmonary dis-ease. Hamilton: BC Decker Inc. 2002.

6. Worth H. Self management in COPD: one stepbeyond? Patient Educ Counsel 1997;32(1Suppl):S105-9.

7. Von Korff M, Gruman J, Schaefer J, et al.Collaborative management of chronic illness. AnnIntern Med 1997; 127:1097-1102.

8. Stubblefield C, Mutha S. Provider-patient roles inchronic disease management. Journal of AlliedHealth 2002; 31:87-92.

9. Rennard S, Decramer M, Calverley PMA, et al.Impact of COPD in North America and Europe in2000: subjects’ perspective of Confronting COPDInternational Survey. Eur Respir J 2002; 20:799-805.

10. Gallefoss F, Sigvald Bakke P. Patient satisfaction withhealthcare in asthmatics and patients with COPDbefore and after patient education. RespiratoryMedicine 2000; 94(11):1057-64.

11. Gallefoss F, Sigvald Bakke P. Impact of patient edu-cation and self-management on morbidity in asth-matics and patients with chronic obstructive pul-monary disease. Respiratory Medicine 2000; 94:279-287.

12. Ries AL, Kaplan RM, Limberg TM, et al. Effects ofpulmonary rehabilitation on physiologic and psy-chosocial outcomes in patients with chronicobstructive pulmonary disease. Ann Intern Med1995; 122:823-32.

13. Huston CJ. The role of the case manager in a dis-ease management program. Lippincott’s CaseManagement 2002; 7:221-227.

14. Debusk RF, West JA, Houston-Miller N, Taylor CB.Chronic disease management: treating the patientwith disease(s) vs. treating disease(s) in the patient.Arch Intern Med 1999; 159:2739-2742.

15. Bourbeau J, Julien M, Maltais F, et al. Reduction ofhospital utilization in patients with chronic obstruc-tive pulmonary disease. Arch Intern Med 2003;163:585-591.

16. Poole PJ, Chase B, Frankel A, Black PN. Case man-agement may reduce length of hospital stay inpatients with recurrent admissions for chronicobstructive pulmonary disease. Respirology 2001; 6:37-42.

17. Mishoe S. Expanding professional roles for respira-tory care practitioners. Respiratory Care 1997;42(1):71-91.

Address for correspondence:

Scott MacKeigan, BHSc, RRT1 Respiratory Therapist,Thompson General Hospital, Burntwood RegionalHealth Authority, 871Thompson Drive South Thompson, MB R8N 0C8

Paul Hernandez, MDCM, FRCPC2Respirologist, QEII Health Sciences Centre, AssociateProfessor of Medicine, Dalhousie University, Halifax, NS

Scientif ic News

Live from Beirut Continued from page 5

In March 2003, Fanshawe College was proud to host a contingent from Makassed General Hospitalconsisting of Mr. Mohammed Firikh, Hospital Director, Mr. Mohammad Ali-Hamandi, Hospital Vice-Administrator, Madame Sawsan Ezzeddine, Director of Higher Institute of Nursing and Mr. Abed Aslan,Chief Respiratory Therapist.

While visiting Fanshawe, discussions were held regard-ing the existing joint EMT program and were expandedto include the possibility of a Respiratory Therapyprogram at Makassed. While the daily agenda was full,our guests were able to enjoy our Canadian winter andexperience for the first time a Junior A hockey game.Needless to say, I had a little explaining to do about thegame of hockey when the occasional donnybrookbroke out on the ice.

Mr. Abed Aslan, Chief Respiratory Therapist remainedbehind for a couple of weeks after the rest of theguests returned to Lebanon to get the feel of theprogram at Fanshawe and to observe what RespiratoryTherapy in Canada was all about. During this time Mr. Aslan attended many of our classroom lectures,participated in labs with our students and was also able to spend time with the Clinical Coordinators atdifferent affiliated sites.

In June 2004 I again returned to Beirut to assist oncurriculum development for the proposed new programwith a projected start date of October 2004. At thetime of this writing, the hospital is still awaiting government approval to start the program.

The projection for the Respiratory Therapy program atMakassed General Hospital looks very promisingindeed. They are very interested in maintaining strongties with Fanshawe and on a larger scale with theCSRT. In the future the idea of a site visit for theCoARTE accreditation team may take on a whole newmeaning.


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The CSRT wishes to acknowledge the on-going support of our CorporateMembers. Sponsorship by our Corporate Members helps the CSRT maintain the current standards of excellence in the profession. Thank you!

CSRT Corporate Members 2004 – 2005

Classif ied and Publice Service Announcements

New Books from the LungAssociationThe Lung Association’s new children’seducational asthma book “Call Me BraveBoy” is targeted to children aged 2–6. This picture book is designed for a parentor caregiver to read to a child who hasasthma. It is illustrated by MichaelMartchenko, Canada’s foremost children’sbook illustrator, and written by JennyShinder, a parent of a child with asthma.“Asthma Active”, an activity booktargeted to children 7–12 years of age, is full of educational games that teachabout asthma in a fun way.

Development and printing of these books was funded by the Government of Ontario. These materials are free inOntario. Other provinces can order themby calling the Asthma Action Helpline at 1-800-668-7682.

Canadian Society of Respiratory Therapy1785 Alta Vista Dr. Suite 102,Ottawa ON K1G 3Y6

Phone (613) 731-3164 or (800) 267-3422

Fax (613) 521-4314

Email [email protected]

Membership [email protected]

Need to Contact Us?

Executive DirectorDoug MaynardPhone (613) 731-3164 email: [email protected]

Editor CJRTRita HansenPhone (613) 731-3164 ex 23email: [email protected]

CJRT Winter 2004, volume 40 (5)

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