Improving Referral Patterns for Bronchoscopic Lung Volume Reduction: A Quality Improvement Initiative.

Bronchoscopic lung volume reduction (BLVR) is a minimally invasive treatment option for patients with severe emphysema and hyperinflation refractory to optimal medical care. This therapy is effective in improving functional status and quality of life, underscoring the importance of identifying potential procedure candidates. To our knowledge, scalable strategies to improve the referral of advanced lung disease patients are lacking. This quality improvement project aimed to increase identification and referral for BLVR in a large Veterans Affairs academic medical center. We show implementing case identification within a pulmonary function testing report, in conjunction with provider education, increased referral rates for BLVR. Because of the ubiquity of lung function testing, other advanced lung disease programs may consider adopting this strategy to improve patients' access to timely clinical evaluation and therapy.

Adherence to adding inhaled corticosteroids to rescue therapy in a pragmatic trial with adults with asthma: A pilot study.

BACKGROUND: Underuse of guideline-recommended inhaled corticosteroids (ICS) controller therapy is a risk factor for greater asthma burden. ICS concomitantly used with rescue inhalers (Patient-Activated Reliever-Triggered ICS ['PARTICS']) reduced asthma exacerbations in efficacy trials, but whether PARTICS is effective in pragmatic trials is unknown. OBJECTIVE: We conducted this pilot to determine the feasibility of executing a large-scale pragmatic PARTICS trial and to improve study protocols. METHODS: Four sites recruited 33 Hispanic or black adults with persistent asthma, randomized them approximately 3:1 to intervention or usual care, and followed them for 12 weeks. All participants received asthma guideline-based educational videos; intervention participants received video-based instructions on implementing PARTICS plus usual medications. The study involved 1 randomization visit and monthly questionnaires. Timely questionnaire responses (±2 weeks) were monitored. Participants underwent qualitative phone interviews to assess self-reported adherence to PARTICS and understand barriers to completing study procedures. RESULTS: Timely questionnaire response rates were 61%, 64%, and 70% at 4, 8, and 12 weeks, respectively. Self-reported adherence to PARTICS was 76% (95% confidence interval [CI], 58%-94% [n = 21]), 88% (95%CI, 72%-100% [n = 16]), and 62% (95%CI, 36%-88% [n = 13]) at weeks 1, 6, and 12, respectively. Barriers to completing study procedures included difficulties with questionnaire access, remembering to use ICS and rescue inhalers together, and obtaining refills. Only 22% of participants recognized their short-acting bronchodilator as "reliever" or "rescue." CONCLUSION: Recruitment was feasible within the allocated period. Adherence to PARTICS was incomplete, questionnaire completion was suboptimal, and common rescue inhaler nomenclature usage was limited. We have modified the full study protocol to attempt to improve adherence to PARTICS and minimize barriers to study procedures. CLINICAL TRIALS REGISTRATION: pilot study for 'PeRson EmPowered Asthma Relief' (PREPARE, NCT02995733).

Hepatic Sarcoidosis: An Uncommon Cause of Cirrhosis.

Sarcoidosis is a multi-organ inflammatory disease of unclear etiology. The hallmark of the disease is the formation of non-caseating granulomas. The prevalence of sarcoidosis is 5-30% in the general population and up to 80% in autopsy series. Hepatic involvement is seen in almost 50% of cases of sarcoidosis, though the clinical consequences are variable. In this study, we describe the case of three patients from our institution with hepatic sarcoidosis. Two of them eventually went on to develop liver cirrhosis.

Where there is smoke there is sleep apnea: exploring the relationship between smoking and sleep apnea.

Smoking and OSA are widely prevalent and are associated with significant morbidity and mortality. It has been hypothesized that each of these conditions adversely affects the other, leading to increased comorbidity while altering the efficacy of existing therapies. However, while the association between smoking and OSA is plausible, the evidence is less than conclusive. Cigarette smoking may increase the severity of OSA through alterations in sleep architecture, upper airway neuromuscular function, arousal mechanisms, and upper airway inflammation. Conversely, some evidence links untreated OSA with smoking addiction. Smoking cessation should improve OSA, but the evidence to support this is also limited. This article reviews the current evidence linking both conditions and the efficacy of various treatments. Limitations of the current evidence and areas in need of future investigation are also addressed.

Which chronic obstructive pulmonary disease patients will be likely to attend consistently a pulmonary rehabilitation program?

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States, and millions of COPD patients are disabled and unable to work. Pulmonary rehabilitation (PR) programs are available to assist with disability, but it is not clear who is likely to consistently participate in them. The purpose of this study was to determine which participants were likely to consistently attend a PR program. METHODS: A retrospective medical record review was used to assess 104 community-dwelling adults with COPD who completed the PR program at a Midwest medical center between 2000 and 2005. SAMPLE: The sample consisted of 32 men and 72 women with a mean age of 59.9 years (±19.10 years), mean predicted one-second forced expiratory volume (FEV(1)) of 46.45% (SD = 20.1), mean percent forced vital capacity (FVC%) of 67.61 (SD = 16.61), mean FEV(1)/FVC% ratio of 51.15% (SD = 18.17), and mean residual volume (RV) of 150.66% (SD = 67.01). RESULTS: Contextual variables of current smoking (beta = -.36), male sex (beta = .19), not having emphysema (beta = -.27), and FVC% (beta = .32) were significant predictors of attendance at (a dose of) PR. The number of selected comorbidities significantly predicted the dose of PR (beta = -.20). CONCLUSION: These findings support the ability to identify factors that predict attendance at a PR program. Nurses can assess patients at risk for lack of consistent PR attendance and implement interventions to improve attendance. Specifically, smoking cessation prior to or as an integral part of PR programs may improve attendance.