Hand-held fans: Physical Properties and Perceptions of Patients with COPD.

RATIONALE: Patients with chronic obstructive pulmonary disease (COPD) may remain breathless despite optimal medical treatment. Hand-held fans (HHFs) are recommended to relieve breathlessness, but little is known about physical properties of different fans and the impact HHF properties may have on patient perceptions of fans. OBJECTIVE: To describe the physical properties of HHFs and investigate the relationship of these properties to patient fan preference. METHODS: We recruited 33 participants with COPD who were attending a pulmonary rehabilitation program. Participants trialled 5 HHFs in random order. Participants rated perceived airflow, pleasantness of airflow, noisiness, and ease of use of each fan using a 1-10 numerical rating scale (NRS). After trialling all 5 fans, participants ranked each HHF from best (5 arbitrary units; a.u.) to worst (1 a.u.). Rankings for each fan were tallied to produce total HHF scores (T-HHF; maximum=165 a.u.). Objective measurements were made of sound intensity (dB; sound level meter), airflow between 5cm and 30cm from the middle of the fan (anemometer), blade rotation speed, blade size and total fan weight. We assessed the strength of association of T-HHF scores against mean NRS values using Spearman correlation coefficients and used linear regression to compare measured to perceived airflow, and noisiness to sound intensity. RESULTS: Participants were 68.5 ± 8.9 years (mean ± SD), 63% male, with a median FEV1 of 0.99L(IQR 0.76-1.31L). There was considerable variability between the 5 fans tested in terms of participant perceptions and physical properties with an almost 5-fold difference in air velocity at 30cm and a 3-fold difference in blade rotation speed. The most preferred fan had a T-HHF score of 140 and had the highest airflow (1.9 m/s) measured at 30cm. T-HHF score positively correlated with pleasantness of airflow (r = 0.46; P < 0.001), perceived airflow (r=0.58; P<0.001) and airflow velocity at 30cm from fan blades (r=1.0; P = 0.02). There were positive linear relationships between fan airflow velocity and perceived air amount, and between measured sound intensity and perceived noisiness(both P<0.001). Women reported significantly higher perceived airflow than men (P < 0.001). CONCLUSIONS: The physical properties of the five included HHFs are quite distinct. Patient preference was related to pleasantness of airflow, perceived airflow, and measured airflow at 30cm. Gender differences in perceived airflow were noted. Future research should explore the relationship between HHF characteristics and relief of breathlessness.

Protocol for a Single-Blind, Randomized, Parallel-Group Study of a Nonpharmacological Integrated Care Intervention to Reduce the Impact of Breathlessness in Patients with Chronic Obstructive Pulmonary Disease.

Background: Patients with chronic obstructive pulmonary disease (COPD) frequently experience breathlessness despite maximal medical therapy. Nonpharmacological management is effective in studies enrolling patients with a variety of respiratory diseases; however, the impact on patients with COPD is unclear. Methods: A protocol for a mixed-methods, single-center, observer-blinded, fast-track randomized-controlled, parallel-group trial comparing an immediate eight-week nonpharmacological Westmead Breathlessness Service (WBS) to a standard care control group is described. Population: At least moderate COPD (FEV1:FVC ≤0.7; FEV1%predicted ≤60%) and persistent disabling breathlessness (modified Medical Research Council ≥2). Intervention: Individualized prescription of nonpharmacological breathlessness interventions, including a handheld fan, breathing techniques, postures to relieve breathlessness, relaxation, nutritional advice, energy conservation, and exercise advice delivered by a team including doctors, nurses, a physiotherapist, an occupational therapist, a dietitian, and speech pathologist. Control: Participants who receive the WBS intervention after an eight-week period while receiving usual care (standard care group). Outcome: Primary outcome-Chronic Respiratory Questionnaire (CRQ) Mastery subscale. Secondary outcomes include numerical rating scale of breathlessness intensity, unpleasantness, and confidence managing breathlessness; quality of life as measured by other CRQ subscales; Hospital Anxiety and Depression Scale score; daily step count; health resource utilization 12 months pre- and postintervention; and cost-effectiveness. Qualitative analysis of participant interviews will provide additional context for interpreting the quantitative results. Discussion: This study aims to establish the efficacy and cost-effectiveness of an eight-week nonpharmacological breathlessness intervention in patients with COPD. Trial Registration: The Australian New Zealand Clinical Trial Registry ACTRN12617000499381 (06/04/17).

Experience of acute noninvasive ventilation-insights from 'Behind the Mask': a qualitative study.

OBJECTIVE: Non-invasive ventilation (NIV) is widely used in the management of acute and acute-on-chronic respiratory failure. Understanding the experiences of patients treated with NIV is critical to person-centred care. We describe the subjective experiences of individuals treated with NIV for acute hypercapnic respiratory failure. DESIGN: Qualitative face-to-face interviews analysed using thematic analysis. SETTING: Australian tertiary teaching hospital. PARTICIPANTS: Individuals with acute hypercapnic respiratory failure treated with NIV outside the intensive care unit. Individuals who did not speak English or were unable or unwilling to consent were excluded. RESULTS: 13 participants were interviewed. Thematic saturation was achieved. Participants described NIV providing substantial relief from symptoms and causing discomfort. They described enduring NIV to facilitate another chance at life. Although participants sometimes appeared passive, others expressed a strong conviction that they knew which behaviours and treatments relieved their distress. Most participants described gaps in their recollection of acute hospitalisation and placed a great amount of trust in healthcare providers. All participants indicated that they would accept NIV in the future, if clinically indicated, and often expressed a sense of compulsion to accept NIV. Participants' description of their experience of NIV was intertwined with their experience of chronic disease. CONCLUSIONS: Participants described balancing the benefits and burdens of NIV, with the goal of achieving another chance at life. Gaps in recall of their treatment with NIV were frequent, potentially suggesting underlying delirium. The findings of this study inform patient-centred care, have implications for the care of patients requiring NIV and for advance care planning discussions.

Respiratory Failure, Noninvasive Ventilation, and Symptom Burden: An Observational Study.

BACKGROUND: Noninvasive ventilation (NIV) is commonly used to manage acute respiratory failure due to decompensated cardiorespiratory disease. We describe symptom burden in this population. MEASURES: Fifty consecutive, consenting, English-speaking, cognitively intact patients, admitted to wards other than the intensive care unit in a tertiary teaching hospital and treated with NIV for hypercapnic respiratory failure, were recruited. The 14-item Condensed Memorial Symptom Assessment Scale was used to assess physical and psychological symptoms within 36 hours of commencing NIV. Breathlessness (using Borg score), pain location and intensity using a numerical rating scale, and four symptoms potentially prevalent in patients undergoing NIV (cough, sputum, gastric bloating, and dry eyes) were also assessed. OUTCOMES: Patients reported a median of 10 symptoms (IQR 9-13). A median of five symptoms (IQR 3-7) were rated as severe. Breathlessness was the most prevalent and most distressing symptom, with participants reporting a mean maximum Borg score of 7.55 over the 24 hours before admission. Dry mouth, lack of energy, cough, sputum, difficulty sleeping, and psychological symptoms were prevalent. Pain, when reported, was of moderate intensity and contributed to distress. CONCLUSIONS/LESSONS LEARNED: This study describes the patient-reported symptoms occurring during an episode of acute respiratory failure. Understanding the symptom profile of patients in this setting may allow clinicians to target symptom relief while simultaneously managing respiratory failure, enhancing care.

Perspectives on advance care planning among patients recently requiring non-invasive ventilation for acute respiratory failure: A qualitative study using thematic analysis.

BACKGROUND: Patients requiring non-invasive ventilation for acute-on-chronic respiratory failure due to chronic obstructive pulmonary disease or heart failure exacerbations may have a poor prognosis underscoring the importance of advance care planning. AIM: We aimed to describe attitudes to, and experiences of, discussing the future among patients recently treated with non-invasive ventilation. DESIGN: Qualitative research using thematic analysis. SETTINGS AND PARTICIPANTS: Tertiary teaching hospital. Patients with acute hypercapnic respiratory failure requiring non-invasive ventilation. RESULTS: Individuals recently treated with non-invasive ventilation describe feeling the future is beyond their control and instead controlled by their illness. Participants often recognised their poor prognosis but avoided discussing some difficult topics. The majority preferred not to undergo cardiopulmonary resuscitation but most had not discussed this with healthcare professionals. When participants voiced concerns about their future health to family members, they were met with polarised responses. Some encountered willingness for further discussion, while others met deflection, deterring further conversation. An overarching narrative of 'Looking through my illness to an uncertain but concerning future' unites these themes. CONCLUSION: This study suggests opportunities and barriers for advance care planning in individuals with chronic disease. Patients' understanding of their prognosis and their attitudes to cardiopulmonary resuscitation suggests an opportunity for advance care planning. Structuring discussions around patients' preferences for care during future exacerbations may foster a sense of control over the future despite illness. The diversity of familial responses to patients' concerns about their future health has implications for advance care planning. These findings have the potential to improve care for patients with respiratory failure and suggest an important ongoing research agenda.

Epigenetic divergence as a potential first step in darter speciation.

Recent studies show that epigenetic variation in the form of DNA methylation may serve as a substrate for selection. Theory suggests that heritable epigenetic marks that increase fitness should increase in frequency in a population, and these changes may result in novel morphology, behaviour, or physiology, and ultimately reproductive isolation. Therefore, epigenetic variation might provide the first substrate for selection during the course of evolutionary divergence. This hypothesis predicts that populations in the earliest stages of divergence will differentiate in their methylome prior to any genetic differentiation. While several studies have investigated natural epigenetic variation, empirical studies that test predictions about its role in speciation are surprisingly scarce. Here, we investigate DNA methylation variation using an isoschizomeric digest method, Methyl-Sensitive Amplified Polymorphism, across multiple stages of evolutionary divergence in natural populations of North American stream fishes. We show that epigenetic differentiation between methylomes is greater than genetic divergence among closely related populations across two river drainages. Additionally, we demonstrate that epigenetic divergence is a stronger predictor of the strength of behavioural reproductive isolation and suggest that changes in the methylome could influence the evolution of reproductive isolation between species. Our findings suggest a role for epigenetics not only in the initiation of divergence, but also in the maintenance of species boundaries over greater evolutionary timescales.

Specialist respiratory physicians' attitudes to and practice of advance care planning in COPD. A pilot study.

BACKGROUND: Advance care planning (ACP) is increasingly recognised as important in chronic obstructive pulmonary disease (COPD). Specialist respiratory physicians (RPs) are crucial in enabling ACP in patients with COPD. Accordingly, understanding their practice and attitudes regarding ACP is important. METHODS: We developed and piloted a survey to assess RPs practices, attitudes and educational needs in ACP. RESULTS: The response rate was 41% (17/41). The instrument was brief and acceptable to participants. Among respondents, 13% reported they had discussed ACP with "most" of their patients; 31% with "about half"; 50% with "a few" and 6% with "none or almost none". Although 57% of respondents preferred outpatient discussions, most discussions occurred as inpatients. Diagnosis, purpose of treatment and incurability of COPD were reported as commonly discussed but the appointment of a health care proxy, the patients' values and goals, and palliative care options were rarely addressed. Reported barriers to ACP included: difficulty prognosticating; time constraints; and perceived patient reticence. Facilitators included increasing patient frailty and patient willingness to discuss. Most respondents reported receiving some formal training in ACP and refined skills by observing colleagues. Many were interested in further educational opportunities. CONCLUSION: This pilot found the new instrument was acceptable. Findings suggest that ACP discussions are infrequent with the majority occurring in the inpatient setting, with key elements omitted. Participants generally had favourable attitudes to ACP and recognised for the need for ongoing training. These early findings require further investigation.

The use of non-invasive ventilation for the relief of dyspnoea in exacerbations of chronic obstructive pulmonary disease; a systematic review.

BACKGROUND AND OBJECTIVE: Non-invasive ventilation (NIV) improves outcomes in patients with acute exacerbations of COPD (AECOPD); however, the efficacy in relieving dyspnoea is uncertain. The objective of this systematic review was to identify, synthesize and interpret the data regarding the relief of dyspnoea afforded by NIV in patients admitted with acute respiratory failure occurring during AECOPD. METHODS: Randomized controlled trials (RCTs) comparing usual medical care (UMC) to UMC plus NIV and reporting dyspnoea as a patient-reported outcome were identified by searching relevant databases and manual searching. The full text of potentially relevant articles was retrieved. Data describing the impact of NIV on dyspnoea was extracted. RESULTS: Four RCTs met the review criteria. One found NIV did not relieve dyspnoea. The other three RCTs reported NIV relieving dyspnoea. The degree of dyspnoea relief was clinically significant in two of these three studies. However, in all but one RCT, methodological or reporting limitations constrain the confidence that can be had in this conclusion. CONCLUSIONS: Limited data exist to determine if NIV relieves subjective dyspnoea in AECOPD. Due to limitations in these studies, it is not possible to definitively conclude if NIV relieves dyspnoea. Standardized reporting and analysis of patient reported outcomes will facilitate objective comparisons of interventions with respect to symptom relief. Future studies involving NIV should routinely incorporate patient reported outcomes in order to answer the important clinical question: 'Does NIV relieve dyspnoea?'

Development of a clinical prediction rule to identify patients with neck pain likely to benefit from cervical traction and exercise.

The objective of the study was to develop a clinical prediction rule (CPR) to identify patients with neck pain likely to improve with cervical traction. The study design included prospective cohort of patients with neck pain referred to physical therapy. Development of a CPR will assist clinicians in classifying patients with neck pain likely to benefit from cervical traction. Eighty patients with neck pain received a standardized examination and then completed six sessions of intermittent cervical traction and cervical strengthening exercises twice weekly for 3 weeks. Patient outcome was classified at the end of treatment, based on perceived recovery according to the global rating of change. Patients who achieved a change > or =+6 ("A great deal better" or "A very great deal better") were classified as having a successful outcome. Univariate analyses (t tests and chi-square) were conducted on historical and physical examination items to determine potential predictors of successful outcome. Variables with a significance level of P < or = 0.15 were retained as potential prediction variables. Sensitivity, specificity and positive and negative likelihood ratios (LRs) were then calculated for all variables with a significant relationship with the reference criterion of successful outcome. Potential predictor variables were entered into a step-wise logistic regression model to determine the most accurate set of clinical examination items for prediction of treatment success. Sixty-eight patients (38 female) were included in data analysis of which 30 had a successful outcome. A CPR with five variables was identified: (1) patient reported peripheralization with lower cervical spine (C4-7) mobility testing; (2) positive shoulder abduction test; (3) age > or =55; (4) positive upper limb tension test A; and (5) positive neck distraction test. Having at least three out of five predictors present resulted in a +LR equal to 4.81 (95% CI = 2.17-11.4), increasing the likelihood of success with cervical traction from 44 to 79.2%. If at least four out of five variables were present, the +LR was equal to 23.1 (2.5-227.9), increasing the post-test probability of having improvement with cervical traction to 94.8%. This preliminary CPR provides the ability to a priori identify patients with neck pain likely to experience a dramatic response with cervical traction and exercise. Before the rule can be implemented in routine clinical practice, future studies are necessary to validate the rule. The CPR developed in this study may improve clinical decision-making by assisting clinicians in identifying patients with neck pain likely to benefit from cervical traction and exercise.

The incidence of injury in light infantry soldiers.

U.S. Army soldiers lose substantial training hours as a result of musculoskeletal injuries. Most military injury data have focused on basic trainee populations. This study examines activities associated with injuries in operational infantry soldiers. We conducted a randomized, retrospective medical record review of 339 records from a total of 3,195 light infantry soldiers over 13 months. The annualized incidence of injuries was 95 per 100 soldiers per year vs. 74 per 100 for illness. There were 372 injuries, representing 56% of sick-call diagnoses. Physical training caused 50% of all injuries, and 30% of those were linked to running. Injuries caused nearly 10 times the number of limited duty days as illness. Soldiers with lower extremity running injuries spent seven times more days on profile than those with nonrunning injuries. We conclude that physical training is related to a high number of injuries in infantry soldiers. This study provides important data on activities and injuries in operational infantry soldiers.