Mika Nonoyama

Exercise training for people following lung resection for non-small cell lung cancer - a Cochrane systematic review.

OBJECTIVES To determine the effects of exercise training on exercise capacity, health-related quality of life (HRQoL), lung function (forced expiratory volume in one second (FEV1)) and quadriceps force in people who have had a recent lung resection for non-small cell lung cancer (NSCLC). DATA SOURCES We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SciELO and PEDro up to February 2013. REVIEW METHODS We included randomised controlled trials (RCTs) in which study participants with NSCLC, who had recently undergone lung resection, were allocated to receive either exercise training or no exercise training. Two review authors screened and identified the studies for inclusion. RESULTS We identified three RCTs involving 178 participants. On completion of the intervention period, exercise capacity, as measured by the six-minute walk distance, was statistically greater in the intervention group compared to the control group (mean difference (MD) 50.4m; 95% confidence interval (CI) 15.4-85.2m). No between-group differences were observed in HRQoL (standardised mean difference (SMD) 0.17; 95% CI -0.16-0.49) or FEV1 (MD -0.13L; 95% CI -0.36-0.11L). Differences in quadriceps force were not demonstrated on completion of the intervention period. CONCLUSIONS Evidence from our review suggests that exercise training may potentially increase the exercise capacity of people following lung resection for NSCLC. The findings of this review should be interpreted with caution due to disparities between the studies, methodological limitations, some significant risks of bias and small sample sizes.

Home Mechanical Ventilation in Canada: A National Survey

BACKGROUND: No comprehensive Canadian national data describe the prevalence of and service provision for ventilator-assisted individuals living at home, data critical to health-care system planning for appropriate resourcing. Our objective was to generate national data profiling service providers, users, types of services, criteria for initiation and monitoring, ventilator servicing arrangements, education, and barriers to home transition. METHODS: Eligible providers delivering services to ventilator-assisted individuals (adult and pediatric) living at home were identified by our national provider inventory and referrals from other providers. The survey was administered via a web link from August 2012 to April 2013. RESULTS: The survey response rate was 152/171 (89%). We identified 4,334 ventilator-assisted individuals: an estimated prevalence of 12.9/100,000 population, with 73% receiving noninvasive ventilation (NIV) and 18% receiving intermittent mandatory ventilation (9% not reported). Services were delivered by 39 institutional providers and 113 community providers. We identified variation in initiation criteria for NIV, with polysomnography demonstrating nocturnal hypoventilation (57%), daytime hypercapnia (38%), and nocturnal hypercapnia (32%) as the most common criteria. Various models of ventilator servicing were reported. Most providers (64%) stated that caregiver competency was a prerequisite for home discharge; however, repeated competency assessment and retraining were offered by only 45%. Important barriers to home transition were: insufficient funding for paid caregivers, equipment, and supplies; a shortage of paid caregivers; and negotiating public funding arrangements. CONCLUSIONS: Ventilatory support in the community appears well-established, with most individuals managed with NIV. Although caregiver competency is a prerequisite to discharge, ongoing assessment and retraining were infrequent. Funding and caregiver availability were important barriers to home transition.

Psychological wellbeing, health related quality of life and memories of intensive care and a specialised weaning centre reported by survivors of prolonged mechanical ventilation.

OBJECTIVE To compare memories and recall of intensive care unit and specialised weaning centre admission, characterise health-related quality of life and psychological morbidity, and examine the relationship between delusional memories and psychological outcomes. METHODS We recruited participants following hospitalisation that included ICU admission and subsequent weaning in a specialised centre. We administered validated questionnaires to assess memory and recall of both care locations, anxiety, depression, post-traumatic stress symptomatology and health-related quality of life. RESULTS Of 53 eligible patients discharged from the weaning centre over seven years, we recruited 27 participants. Participants had similar numbers of factual and feeling memories but reported more delusional memories for ICU than the weaning centre (1.6 vs. 0.7, P=0.004). Nine (39%) participants scored ≥ 11 on the hospital anxiety and depression scale (anxiety) and were more likely to experience delusional memories (P=0.008). Thirst (70%), no control (70%), noise (65%) were most frequently recalled ICU experiences. Procedures (83%), night awakening (70%), inability to sleep (70%) most frequently recalled from the weaning centre. CONCLUSION Delusional memories and anxiety disorder were prevalent and associated suggesting interventions to ameliorate delusional memories may reduce anxiety. Difficulty sleeping and thirst were common experiences.

Institutional care for long-term mechanical ventilation in Canada: A national survey

INTRODUCTION No national Canadian data define resource requirements and care delivery for ventilator-assisted individuals (VAIs) requiring long-term institutional care. Such data will assist in planning health care services to this population. OBJECTIVE To describe institutional and patient characteristics, prevalence, equipment used, care elements and admission barriers for VAIs requiring long-term institutional care. METHODS Centres were identified from a national inventory and snowball referrals. The survey weblink was provided from December 2012 to April 2013. Weekly reminders were sent for six weeks. RESULTS The response rate was 84% (54 of 64), with 44 adult and 10 pediatric centres providing data for 428 VAIs (301 invasive ventilation; 127 noninvasive ventilation [NIV]), equivalent to 1.3 VAIs per 100,000 population. An additional 106 VAIs were on wait lists in 18 centres. More VAIs with progressive neuromuscular disease received invasive ventilation than NIV (P<0.001); more VAIs with chronic obstructive pulmonary disease (P<0.001), obesity hypoventilation syndrome (P<0.001) and central hypoventilation syndrome (P=0.02) required NIV. All centres used positive pressure ventilators, 21% diaphragmatic pacing, 15% negative pressure and 13% phrenic nerve stimulation. Most centres used lung volume recruitment (55%), manually (71%) and mechanically assisted cough (55%). Lack of beds and provincial funding were common admission barriers.CONCLUSIONS: Variable models and care practices exist for institutionalized care of Canadian VAIs. Patient prevalence was 1.3 per 100,000 Canadians.

Patterns of healthcare utilisation for respiratory complications of adults with neuromuscular disease: a population study

Our objective was to quantify health service utilisation including monitoring and treatment of respiratory complications for adults with neuromuscular disease (NMD), identifying practice variation and adherence to guideline recommendations at a population level. We conducted a population-based longitudinal cohort study (2003–2015) of adults with NMD using hospital diagnostic and health insurance billing codes within administrative health databases. We identified 185 586 adults with NMD. Mean age 52 years, 59% female. 41 173 (22%) went to an emergency department for respiratory complications on average 1.6 times every 3 years; 14 947 (8%) individuals were admitted to hospital 1.4 times every 3 years. Outpatient respiratory specialist visits occurred for 64 084 (35%) with four visits every 3 years, although substantial variation in visit frequency was found. 157 285 (85%) went to the emergency department (all-cause) almost 4 times every 3 years, 100 052 (54%) were admitted to hospital. Individuals with amyotrophic lateral sclerosis/motor neurone disease (ALS/MND) had more emergency department visits compared with other types of NMD (p<0.0001). One-third of adults with NMD received respiratory specialist care at a frequency recommended by professional guidelines, although substantial variation exists. Emergent healthcare utilisation was substantial, emphasising the burden of NMD on the healthcare system and urgent need to improve community and social supports, particularly for ALS/MND patients. One-third of adults with neuromuscular disease received specialist respiratory care. Emergent healthcare use was substantial, emphasising an urgent need to improve community and social supports. http://ow.ly/FluZ30leuLk

Transitions to Home Mechanical Ventilation. The Experiences of Canadian Ventilator-assisted Adults and Their Family Caregivers

Rationale: Several studies have explored the experiences of ventilator‐assisted individuals living at home with family caregivers. However, few explore the experiences of these individuals as they transition from a hospital setting to living at home with a view to identifying modifiable processes that could optimize transition. Objectives: This descriptive, qualitative study sought to elucidate barriers to, and facilitators of, transition to home mechanical ventilation from the perspective of Canadian ventilator‐assisted individuals and their family caregivers. Methods: Participant recruitment occurred through hospital and community respiratory clinicians based in the four Canadian provinces of Alberta, British Columbia, Ontario, and Saskatchewan. Semistructured telephone or face‐to‐face interviews at home were undertaken with 33 individuals, including 19 ventilator‐assisted individuals and 14 family caregivers, after 3 to 24 months of transitioning to home mechanical ventilation. Interview data were analyzed by content analysis. Results: Formal teaching of knowledge and skills relevant to home mechanical ventilation within the hospital setting before transition was perceived as having an immediate and enduring positive impact on transition. However, family‐clinician conflict, information gaps, and persistent lack of trained personal support workers to provide care in the home contributed to maladjustment relating to transition. Participants strongly recommended improved transitional care in the form of respiratory health professional telephone support, home outreach, and training of personal support workers. Conclusions: Transition to home mechanical ventilation is a complex and demanding process. Extended home mechanical ventilation training and support may be helpful in mediating adjustment challenges, thus reducing stress and caregiver burden, and improving health‐related quality of life for ventilator‐assisted individuals and family caregivers.

Respiratory health service utilization of children with neuromuscular disease

To quantify health service utilization including assessment, monitoring, and treatment of respiratory complications of children with neuromuscular disease (NMD), identifying practice variation and adherence to guideline recommendations at a population level.