Measuring Peak Inspiratory Flow in Patients with Chronic Obstructive Pulmonary Disease.

Dry powder inhalers (DPIs) are breath actuated, and patients using DPIs need to generate an optimal inspiratory flow during the inhalation maneuver for effective drug delivery to the lungs. However, practical and standardized recommendations for measuring peak inspiratory flow (PIF)-a potential indicator for effective DPI use in chronic obstructive pulmonary disease (COPD)-are lacking. To evaluate recommended PIF assessment approaches, we reviewed the Instructions for Use of the In-Check™ DIAL and the prescribing information for eight DPIs approved for use in the treatment of COPD in the United States. To evaluate applied PIF assessment approaches, we conducted a PubMed search from inception to August 31, 2021, for reports of clinical and real-life studies where PIF was measured using the In-Check™ DIAL or through a DPI in patients with COPD. Evaluation of collective sources, including 47 applicable studies, showed that instructions related to the positioning of the patient with their DPI, instructions for exhalation before the inhalation maneuver, the inhalation maneuver itself, and post-inhalation breath-hold times varied, and in many instances, appeared vague and/or incomplete. We observed considerable variation in how PIF was measured in clinical and real-life studies, underscoring the need for a standardized method of PIF measurement. Standardization of technique will facilitate comparisons among studies. Based on these findings and our clinical and research experience, we propose specific recommendations for PIF measurement to standardize the process and better ensure accurate and reliable PIF values in clinical trials and in daily clinical practice.

Implementation of a Screening Program for Patients at Risk for Posttraumatic Stress Disorder.

INTRODUCTION: Implantable cardioverter defibrillator (ICD) recipients who suffer from posttraumatic stress disorder (PTSD) are known to be associated with significant cardiac-specific mortality. Clinical observations suggest that PTSD is frequently undetected in ICD recipients followed up at electrophysiology (EP) outpatient clinics. Early recognition of PTSD is important to reduce the risk of serious manifestations on patient outcomes. METHODS: All ICD recipients aged 19 years or older at the Washington University School of Medicine (WASHU) EP clinic, a large urban EP clinic, were invited to participate in the project. An informed consent letter with an attached primary care: posttraumatic stress disorder (PC: PTSD) survey was offered to the participants who met the inclusion criteria. Those who completed the survey were included in the project. Individuals with positive survey result were offered a referral to mental health services. Comparisons between PTSD and non-PTSD patients were done using a two-sample t-test for continuous variables. Using Fisher's exact test, PTSD prevalence was compared to the study by Ladwig et al in which prevalence was determined as the proportion of patients with positive findings of PTSD (n = 38/147). All analyses were conducted using SAS v9.4. The proportion of patients having PTSD was determined and an exact 95% confidence interval was evaluated based on the binomial distribution. RESULTS: Using a convenience sample, 50 ICD recipients (33 males and 17 females) were enrolled. The project had a 30-day outcome period. Nine (18%) of the 50 participants had positive PC: PTSD findings and all these nine participants were referred to a mental health specialist. The current project demonstrated an 18% (9/50) PTSD prevalence rate when compared to a 26% (38/147) prevalence rate in the study by Ladwig et al (P = 0.34). Although this project did not demonstrate 20% PTSD prevalence rate, as hypothesized, the 18% PTSD prevalence rate is consistent with previous research. CONCLUSION: The prevalence of PTSD noted in the current project is consistent with previous research and validates underrecognition of PTSD in ICD patients. Offering a referral to all ICD recipients at EP clinic visits with a positive PC: PTSD screening to a mental health specialist is an important step in reducing the risk of serious manifestations on patient outcomes.

Practical guidance on the recognition of uncontrolled asthma and its management.

PURPOSE: To highlight the significance of asthma in primary care and offer a practitioner-friendly interpretation of the asthma guidelines for the busy provider, while introducing new treatment options currently in clinical trials, such as the once-daily long-acting anticholinergic bronchodilator tiotropium Respimat. DATA SOURCES: Articles with relevant adult data published between 2004 and 2015 were identified via PubMed. Additional references were obtained by reviewing bibliographies from selected articles. CONCLUSIONS: In the United States, uncontrolled or symptomatic asthma is common, with rates of 46%-78% in primary care. Uncontrolled asthma has a substantial impact on patients' quality of life and represents a significant healthcare burden. Nurse practitioners can improve patients' asthma control through education, monitoring, assessment, and treatment. Although asthma management guidelines are readily available, the authors recognize that nurse practitioners see patients with multiple comorbidities, all of which have treatment guidelines of their own. IMPLICATIONS FOR PRACTICE: Nurse practitioners have a compelling opportunity as frontline caregivers and patient educators to recognize and assess uncontrolled asthma, along with determining the steps necessary to help patients gain and maintain symptom control.

Negative effects of pretransplant body mass index on physical health-related quality of life after lung transplant.

BACKGROUND: Although current national data show improved graft and patient survival following lung transplant, the effects of several modifiable preexisting comorbid conditions on health-related quality of life after transplant have not been evaluated. This study examines the effects of 3 comorbid conditions present before lung transplant (reduced bone density, diabetes mellitus, and elevated body mass index) on health-related quality of life after lung transplant. METHODS: The Short Form 36 Health Survey was completed by 92 adult recipients at various times after lung transplant (mean, 41 months; range, 1-127 months). Multiple linear regression models that controlled for underlying disease, chronic rejection, and time after transplant tested the independent effects of the 3 pretransplant conditions on posttransplant health-related quality of life. RESULTS: The effects of pretransplant reduced bone density and diabetes mellitus were not statistically significant in these models. However, pretransplant body mass index had a significant negative effect (ß = -.29, P = .007) on posttransplant physical health-related quality of life. Additionally, overweight status and obesity exerted comparable independent negative effects (P = .01 and P = .03, respectively) on the physical function scale of the Short-Form 36 Health Survey compared with persons who were underweight or normal weight before transplant. CONCLUSIONS: Reevaluation of elevated body mass index before transplant as a risk for reduced physical quality of life after lung transplant should be considered.