“The Ontario respiratory community joins
the Ontario Lung Association in fostering
collaboration between physicians and non
physician healthcare providers, in a joint
effort to provide excellence in clinical
care, teaching and research, that will
reduce the burden of respiratory
conditions among Ontarians, as well as
improve the quality of life of our patients.”
Dr. Roger Goldstein
Director, Respiratory Divisional Program
in Respiratory Rehabilitation, University of
Toronto; West Park Healthcare Centre
FA L L
2 0 0 5
Features
In this Issue
Editorial
Asthma Guidelines:
Making Them Happen . .2
Better Breathing 2006
February 3-4, 2006
Update from the OTS
Program Chair . . . . . . . .3
Respirology Job Fair . .3
OTS Research Awards .7
Dr. Cameron C. Gray
Fellowship Award . . . . .7
Coming Up
Idiopathic Pulmonary
Fibrosis – Is there light
at the end of the tunnel?
Winter 2005/2006
Mission Statement
To Promote Respiratory
Health through Medical
Research and Education.
The OTR can also be viewed
on-line at on.lung.ca/ots/otr.html.
www.on.lung.ca
V O L U M E
1 7 ,
N U M B E R
3
Canadian Asthma Consensus Guidelines –
From Paper to Pavement
Chris Licksai, MD, FRCPC, Respiratory and Critical Care Associate, St. Joseph’s Health Care,
London; Assistant Professor of Medicine, University of Western Ontario
INTRODUCTION
Evidence based clinical practice guidelines are
a cornerstone of modern chronic disease
management. Asthma guidelines were first
published in Canada in 1990 and since that time
have been regularly reviewed and updated.1,2,3,4
The Global Initiative for Asthma Guidelines
(GINA) have been adopted in more than
62 countries worldwide5,6 These documents
establish best practices for asthma care
supported by the highest available level of
scientific evidence. It is generally held that
guideline based care will lead to improved
patient health outcomes.
The guideline process can be viewed as a
continuum consisting of three components:
development, dissemination, and implementation.
Excellent evidence based guidelines have
been developed and published. Dissemination
strategies have been utilized extensively. While
dissemination strategies have increased physician
awareness that guidelines exist they have failed as
a method of knowledge acquisition and by
extension cannot lead to physician behaviour
change at the clinical practice level.7,8,9,10
Effective implementation of asthma
guidelines require that physicians translate the
published recommendations into clinical behaviors
and that patients have the skills, knowledge and
confidence to become active participants in their
management. The Canadian Consensus Guidelines
(CCG) recommend that the implementation of
these recommendations occur at the community
level however a validated community program
CHRIS LICKSAI
model for asthma guideline implementation does
not exist.2 An implementation strategy that
effectively translates evidence-based recommendations
into clinical practice promises to elevate the
current guideline process from an interesting
academic exercise to a powerful healthcare tool.
The development and evaluation of a
community program model for asthma guideline
implementation is required to complete the
process and deliver the expected patient health
outcomes. This academic niche opportunity was
identified by a group of health professionals in
Windsor and Essex County in 2001. It appeared
that there may be an opportunity to contribute
academically to the guideline process by creating
a comprehensive community model for asthma
guideline implementation. This work has lead to
the development of the Essex County
Community Asthma Care Strategy (ECCACS).
Continued on page 4
ONTARIO THORACIC EDITORIAL
REVIEWS
Asthma Guidelines: Making them happen
An official publication of the Ontario
Thoracic Society, Medical Section of
the Ontario Lung Association,
573 King Street East,
Toronto, Ontario M5A 4L3
(416) 864-9911 • Fax (416) 864-9916
E-mail: ots@on.lung.ca
Web Site: www.on.lung.ca
M. Diane Lougheed
ONTARIO THORACIC SOCIETY
EXECUTIVE COMMITTEE
2005-2006
Dr. Diane Lougheed (Chair)
Dr. John Bertley (Chair-Elect)
Dr. Kathleen Ferguson
Dr. John Fisher
Dr. Mark Inman
Mr. Robert Kelly (Chair, OLA)
Dr. Robin McFadden (OLA Board Rep.)
Dr. Susan Moffatt
Dr. Elizabeth Powell (OMA Rep.)
Dr. Joe Reisman
Dr. Matthew Stanbrook
Dr. Susan Tarlo
Dr. Kenneth Willis (Past Chair)
ONTARIO THORACIC REVIEWS
EDITORIAL BOARD
Dr. Robert Hyland (Editor)
Dr. Diane Lougheed (Chair, OTS)
Dr. James Edney (Ontario Chapter,
College of Family Physicians of Canada)
Mr. Manu Malkani (President & CEO, OLA)
Robert Kelly (Chair, OLA)
Dr. Hedy Ginzberg (Medical Director, OTS)
Ms. Bernie Voulgaris (OTS Administrator)
Ms. Corinne Holubiwich (Medical Librarian)
We gratefully acknowledge the
support of our sponsors:
A
health units, municipalities, school
sthma remains a common chronic
respiratory condition with
boards, primary care sites,
important adverse health and economic
community organizations, employers
consequences worldwide. One in 10 to
and university researchers.
20 Canadians have asthma.1 On an
The accompanying article in this
issue of the Ontario Thoracic Reviews
annual basis, approximately 50% of
by Dr. Chris Licskai outlines an
Canadians with asthma make an
innovative community program model
unscheduled office visit for urgent
for asthma guidelines implementation
care, 25% visit an emergency
DIANE LOUGHEED
in Windsor and Essex County. This
department and 5% are hospitalized at
least once. Asthma also adversely affects the program is founded in the principles of effective
quality of life of individuals and their families, knowledge translation: identification of needs of
results in lost productivity through absenteeism both the patient and community, use of practicefrom work and school and imposes substantial based learning and the development of tools
designed to support adherence with best practice
costs on the Canadian health care system.
Although asthma management guidelines and to enable behavior change. This novel multihave been developed addressing both ambulatory faceted community based approach to chronic
and hospital-based care, their uptake has been disease management has almost certainly
suboptimal. A national survey found only 38% of improved regional access to care, and promises to
family and general practitioners were know- lead to improved patient outcomes.
Guideline development is a lengthy, labour
ledgeable about Canadian asthma guidelines.2
More recent provincial studies have documented intensive process. Implementation is perhaps
sub-optimal adherence to asthma guidelines in even more challenging and often neglected. To
primary3 and acute care settings.4
make guidelines happen, knowledge translation
How can we make guidelines happen? theory tells us we need to assess care gaps,
Traditional methods of guidelines dissemination, respond to communities’ needs, provide consistent
such as peer-reviewed publications and continuing and simple key messages repeatedly in multiple
medical education (CME) programs, are often settings while using strategies and tools known to
of limited success.5 Many factors, including change behavior. Most importantly – we need to
characteristics of the health care professional, evaluate the effectiveness of these interventions,
patient, and practice setting may affect the as intensive community based asthma programs
guideline adoption. However, the main challenge have not been universally effective. The Windsor
appears to lie in the translation of new knowledge and Essex County program, and the APA to
into changes in attitudes and practice. Mailed which it is linked, will hopefully reduce the
print materials and didactic lecture-based CME burden of asthma in Ontario.
formats are the least effective strategies; while
interventions that enable and reinforce behavior REFERENCE LIST
Canadian Institute for Health Information, Canadian Lung
change such as academic detailing, audit and (1)
Association, Health Canada, Statistics Canada. Respiratory Disease in
feedback, and reminder systems that reinforce Canada. Ottawa: Health Canada, 2001.
(2) Jin R, Choi BC, Chan BT, McRae L, Li F, Cicutto L et al. Physician
behavior change are more effective.
asthma management practices in Canada. Can Respir J 2000; NovMany exciting initiatives are underway in Dec, 7 (6):456-465.
Ontario to support the implementation of asthma (3) Lougheed MD, Garvey N, Chapman KR, Cicutto L, Dales R, Day
guidelines. In 2002, the Ontario Ministry of A et al. Ambulatory practice patterns in emergency department asthma
patients in Ontario: a regional varation study. Am J Respir Crit Care
Health and Long-Term Care invested $4 million Med. (suppl) 2004, April, 169 (7), A360.
in annual funding for a provincial Asthma Plan of (4) Lougheed MD, Garvey N, Chapman KR, Cicutto L, Dales R, Day
et al. Emergency department management of asthma in Ontario: a
Action (APA). The APA has funded 14 innovative A
regional variation study. Am J Respir Crit Care Med. (suppl) 2004,
multidisciplinary asthma projects that focus on April,169 (7), A362.
health promotion and prevention, management (5) Davis D.A., Taylor-Vaisey A. Translating guidelines into practice.
A systematic review of theoretic concepts, practical experience and
and surveillance. In doing so, partnerships research evidence in the adoption of clinical practice guidelines. Can
have been fostered between ministries, public Med Assoc J 1997; Aug 15, 157(4):408-416.
www.on.lung.ca
2
O NTARIO T HORACIC R EVIEWS FALL 2005
Better Breathing 2006
Lung Health: A Lifetime of Lung Health
February 3rd and 4th, 2005 – Doubletree International Plaza Hotel, Toronto
Update from the Chair of the OTS Better Breathing Committee
I
am pleased to give you a preview of Better Breathing 2006, the
annual conference of the Ontario Lung Association and the
Annual General Meeting of the Ontario Thoracic Society. Plan now
to attend the OTS Program, which offers an exciting series of
lectures, lunch sessions and debates.
The focus of the Friday morning Plenary Session is
“Respiratory Disease from Cradle to Grave.” We are very
fortunate to have two expert plenary speakers from McMaster
University, Hamilton. Dr. Malcolm Sears will discuss Childhood
and the Development of Respiratory Disease. Dr. Deb Cook will
discuss Palliative Approach to Patients Suffering from Respiratory
Disease.
The OTS/ORCS Joint Session, “What’s New in Lung Health”
will feature Dr. Anna Day (Toronto) who will review Gender and
Respiratory Disease and Dr. Frederick Hargreave (Hamilton) who
will update us on the Clinical Utility of Sputum Eosinophilia
Testing. Mr. Mike Keim, RRT, will complete the mid-day session
with The Old is New Again: High Flow Nasal Cannula Oxygen
Therapy…..does it really work?
During lunch-time on
Friday, attend the General
Lunch with the exhibitors or
select one of three “Lunch
with a Professor Series”.
This year's topics are
Managing Difficult Sarcoid
Patients (Dr. Meyer Balter,
Toronto) and Staying Out of
Trouble in Respirology (Dr.
Meri Bukowskyj and Dr.
Robert Rivington, CMPA,
Ottawa). The third session
is the André Péloquin
Case Presentations from
Community Respirologists
which is dedicated to the
memory of Dr. André
Péloquin. The case presentations are facilitated by Dr. Steven
Bencze (Ottawa) and this year’s case presenters are Dr. Harry
Birman (Toronto), Dr. Marcus Newton (Owen Sound) and Dr.
Jackie Nemni (Cambridge). Please book early for the lunch-time
clinical sessions as seating is limited.
The Friday afternoon program, “Pulmonary Potpourri”, will
feature presentations on Interventional Pulmonology (Dr. Kayvan
Amjadi, Kingston) and Pulmonary Vasculitis (Dr. Chris Allen,
Hamilton). The popular and entertaining Resident Case
Presentations facilitated by Dr. Liz Tullis (Toronto) will follow the
Friday afternoon talks. The afternoon session concludes with the
OTS Annual General Meeting.
On Friday evening, enjoy meeting your friends at the annual
O NTARIO T HORACIC R EVIEWS FALL 2005
Lung Association Banquet with live entertainment provided by
Canadian singer/songwriter, James Gordon.
On Saturday morning, join the OTS Sessions for the everpopular and provocative debates: “Controversies in Pulmonary
Medicine”, chaired by Dr. Charles George (London). This year's
speakers will debate controversial statements including: All
patients with sleep apnea should be reported to the Ministry of
Transportation (Dr. Charles George, London and Dr. Michael
Fitzpatrick, Kingson); A formal incremental cardiopulmonary
exercise test should be standard practice in the evaluation of
patients with COPD (Dr. Kieren Killan, Hamilton and Dr. Nha
Voduc, Ottawa); Respiratory quinolones should be first line therapy
of CAP (Dr. Charlie Chan, Toronto and Dr. Bill Cameron, Ottawa);
and Allergy testing in Asthma patients is a waste of time (Dr. Susan
Waserman and Dr. Michael Cyr, Hamilton). You will not want to
miss your chance to vote for the winners of these debates.
Exhibitors will display their products and services and draw
prizes will be awarded throughout the conference.
Better Breathing 2006 is one of my favorite scientific
respiratory meetings. It is stimulating both professionally and
socially. We have an opportunity to get to the cutting edge of many
areas of respiratory disease. At the same time, we have the
opportunity to meet old friends and to make new ones among
health care professionals and Lung Association staff and volunteers
from across Ontario.
Watch for the program brochure later this fall. Mark February
3-4, 2006 on your calendar and register early!
Peter Macleod, MD, FRCPC
CHAIR, OTS BETTER BREATHING PLANNING COMMITTEE, 2006
Respirology Job Fair
at Better Breathing 2005
P
lease plan to attend the 3rd annual Respirology Job Fair
Friday, February 3, 2006 at 5:00 p.m. at Better Breathing
2006. You will have an opportunity to present information about
positions available in your centre (academic or community)
to all residents in the Respirology and combined Respirology/
Critical Care Programs in Ontario. The Respirology Program
Directors will be present if you wish to discuss the future
needs of your centre. Informal mingling allows for plenty of
opportunity to meet the upcoming graduates of the Ontario
Respirology Programs.
Hope to see you there!
3
From Paper to Pavement...
FIRST STEPS
Identifying the Barriers to Community
Asthma Guideline Implementation
The process began with an informal needs
assessment and identification of the barriers
that existed on the road to effective
community-based guideline implementation.
The group focused on barriers for which
practical solutions were realistically
achievable. Barriers were identified at
several levels including: 1) Community
level: (a) the absence of a viable organizational
structure to facilitate community wide
integration and implementation, (b)
insufficient intellectual resources to meet
the educational needs of the patient
population, and (c) limited financial
resources to support those educational
activities; 2) Physician level: (a) physicians
had limited access to the specific
implementation tools proscribed by the
guidelines, (b) limited CME opportunities
for guideline knowledge acquisition and
translation into clinical practice behaviour,
and (c) no formal mechanism for patient
identification; and 3) Patient level: (a)
decentralized resources made access to
guideline
proscribed
interventions
challenging; (b) limited availability of
educational resources; and (c) a large
number of patients in the community lacked
access to primary care physicians and
therefore did not have the benefit of
ongoing asthma management.
The Program Concept and Overview
We approached the challenge of asthma
guideline implementation at two levels.
First we created the tools and the care
model needed to deliver guideline based
asthma care. Second we created an
organizational structure in the community
specifically
for
asthma
guideline
implementation. Our objective was to
create “a model of direct patient care”
within an “integrated community of care”.
The care model is interdisciplinary,
electronically supported, portable, and with
the focus on primary care patient education
and self-management. The program combines
components of care central to best practices
as outlined in the asthma guidelines. It
creates an efficient practical solution for
primary care guideline implementation. To
the greatest extent possible the program is
delivered where patients normally receive
care – the primary care office.
4
Continued from page 1
Help Wanted – Asthma Educators
for Windsor and Essex County
Prior to the project there were an
insufficient number of asthma educators in
the county to meet the perceived need.
Supported by the ECCACS fourteen
Pharmacists from The Essex County
Pharmacists’Association and three Registered
Respiratory Care Practitioners from HotelDieu Grace Hospital enrolled and completed
the Michener Institute of Applied Health
Technology - Asthma Educator Program.
THE CARE MODEL
Patient Identification
We have utilized traditional strategies to
identify patients who are not achieving
published asthma control benchmarks
including referral by: the treating physician
following a scheduled clinical encounter, a
physician who assesses the patient in a
walk-in clinic, the casualty officer after an
exacerbation requiring an emergency room
visit, or by the hospital physician after a
hospitalization for asthma. In addition the
ECCACS has implemented two innovative
patient identification initiatives the primary
care “Look-back” program and a link to the
“Working
Toward
Wellness
at
DaimlerChrysler Canada Inc.” program.
The Look-Back Program: The National
Institutes of Health recommends that
physicians use audits of patient records to
identify asthma patients whose asthma
management can be improved.6 By utilizing
chart audit the Look-back program means
to identify with statistical certainty and
bring to care, the approximately 60% of
patients with asthma in the community that
are in poor control. 7
Primary care physicians and their staff
are given a Look-back tool-kit that contains
the instructions, letters, and forms needed
to complete the process. The participating
physician audits their electronic patient
record or OHIP billing records to generate
an asthma patient list. The physicians’
office staff then audits the chart using the
Look-back tool-kit. The chart is evaluated
to determine if the patients’ asthma care
includes the components of care
recommended by the CCG. Patients
identified by the screening tool receive a
letter from their physician outlining the
program and inviting participation.
Working Toward Wellness at Daimler
Chrysler Canada Inc.: This National
Quality Institute award winning program
provides health information / education to
DiamlerChrysler Canada employees,
retirees, and their families across the
country. In collaboration with the ECCACS
and the Ontario Asthma Plan of Action
Projects the Working Toward Wellness at
DaimlerChrysler Canada program has
added an asthma education module to its
wellness curriculum. The program includes:
a direct mailing to all employees, a
comprehensive confidential targeted mailing
to members with respiratory disease, inplant / work-site information and education,
group information sessions / lectures, a link
to the Asthma Action Helpline and a link to
the ECCACS for comprehensive asthma
education.
The Asthma Care Day
The Asthma Care Day is a portable,
multidisciplinary, chronic disease evaluation,
education, and treatment encounter. To the
greatest extent possible the intervention is
delivered where the patient is currently
receiving care. The Asthma Care Day is a
key component of the strategy and the
paradigm within which most of the goals
and objectives of the strategy will be
achieved.
Patients are scheduled to see the asthma
educator first and then the physician.
Following an informed consent process the
educator completes his / her evaluation
using the electronic tool created for this
project (see “Tools” below). The educator
performs spirometry as an objective
assessment of the patient’s asthma control.
Upon completing his / her assessment the
asthma educator consults the patient’s
physician and a final management plan is
arrived at collaboratively. A chart insert
tool is left in the patient chart to facilitate a
guideline-based evaluation each time that
the patient returns for assessment. At the
end of each day, the Asthma Care Day the
educator downloads encrypted data from all
patient encounters via a secure link to a
central resource database.
The patient leaves from the first
encounter having received all of the
components of guideline based care. The
educator and the physician collaboratively
Continued on page 5
O NTARIO T HORACIC R EVIEWS FALL 2005
From Paper to Pavement...
will have completed the following
education and treatment objectives: general
asthma education, advice regarding asthma
triggers and avoidance, education about the
role and importance of asthma controller
and reliever medications, inhaler device
instruction, recognizing asthma symptoms
and what is acceptable control, a written
self-management action plan, a physician
review, and all medications that are required
to achieve asthma control. The encounter
time with the educator is approximately 90
minutes including a 10 minute physician
encounter. A 30 minute education
consolidation visit is then scheduled for one
month. Further follow-up and education
appointments are at the discretion of the
educator and the physician.
The Asthma Care Day is a practice based
learning model. The portability of the
proposed program creates an opportunity
for focused practice based asthma guideline
education. The asthma educator and the
physician are learning about guideline
based care in a collaborative interdisciplinary setting. Practice based learning
– “learning by doing” has a high probability
of changing practice behaviour toward
guideline compliance and is a strategy
recommended by GINA guidelines.6, 11
Tools
Several barriers to community guideline
implementation relate to a lack of access to
the requisite tools. To eliminate these
barriers and accomplish our objectives of
portability and standardized educational
messaging we created the following: an
ECCACS patient asthma self-management
plan; an asthma educator teaching tool-kit;
a primary care assessment sheet and chart
insert tool; a Look-back program patient
identification
tool-kit;
an
on-line
communication, scheduling and education
forum with daily notification of activity;
and a standardized electronic asthma
educator patient assessment, teaching and
database tool.
Electronic Asthma Educator Assessment
and Teaching Tool: ECCACS asthma
educators complete detailed patient
assessments and data entry during the
patient encounter utilizing a user-friendly,
open database connectivity (ODBC)
compliant program developed collaboratively
with the University of Windsor O NTARIO T HORACIC R EVIEWS FALL 2005
Continued from page 4
WEDnet™. Program functionality includes
1) Data collection: patient specific
demographic data, referral information,
patient's medical history relevant to a
diagnosis of asthma, recent health care
resource utilization related to asthma,
current asthma medication, current nonpharmacologic treatment strategies, current
asthma symptoms in relation to the CCG
benchmarks, 2) Standardized Prompts for
the Educator: to participate in an informed
consent process, to assess and teach around
six key patient learning objectives, to
consider
additional
treatment
or
investigations to improve asthma control, 3)
Creation of: options for a personalized
asthma self-management plan, a physician
report that summarizes the encounter for the
patient's permanent health record, 4)
Generation of Statistics: calculates and
returns a continuous statistical analysis of
the dataset facilitating real-time daily
progress updates of the entire resident data
set; and 5) Remote program updates:
communicated via a secure link using a
standards based template replacement
process.
THE COMMUNITY OF CARE
Asthma care resources are dispersed across
communities. Primary care and specialist
offices, hospitals, emergency rooms, walkin clinics, community pharmacies, and
pulmonary function laboratories all
contribute to the care of patients with
asthma. The ECCACS is a collaborative
initiative, which seeks to create a partly
formal and partly informal network for
asthma care. Establishing linkages between
asthma care providers within an asthma care
network facilitates the integration of
multidisciplinary skill sets and resources.
Furthermore, a community network is an
effective structure for connecting to regional
and provincial asthma care resources.
The asthma strategy network in Windsor
and Essex County is being developed
continuously. At the time of publication the
community network includes the following
components either in place or in
development: 33 physicians in 19 clinic
sites, The Essex County Pharmacists’
Association, WEDnet™ - University of
Windsor, Hotel-Dieu Grace Hospital,
Asthma Research Group Windsor-Essex
County Inc., the Working Toward Wellness
at DaimlerChrysler Canada Inc. employee
wellness initiative, Leamington District
Memorial Hospital - Primary Care Clinic,
and the West Windsor Urgent Care Center.
The West Windsor Urgent Care Centre is
collaborating to provide comprehensive
asthma care to patients in the community
that do not have a primary care physician.
The community network continues to build
at multiple levels.
Beyond the community the ECCACS
has established functional linkages to the
Ministry of Health and Long-Term Care Asthma Plan of Action Projects including:
1) the “Provider Education Project” which
contributes continuing medical education
opportunities for providers utilizing a
lecture and case based learning format; 2)
the “Asthma Action Helpline” which
provides personalized patient education
over the telephone, printed resource
materials and a link to comprehensive
interdisciplinary asthma care within the
ECCACS; and 3) the “Patient and Family
Education Project” which provides patient
group education and printed resource
material.
Administration and Funding
Asthma Research Group Windsor-Essex
County Inc. is a not-for-profit corporation
created to lead the implementation and
evaluation of the Essex County Community
Asthma Care Strategy. Asthma Research
Group Inc. receives advice from a
community steering committee comprised
of: asthma educators, hospital administrators,
the project coordinator, primary care
physician, employer group representatives,
University of Windsor - WEDnet™, Essex
County Pharmacists’ Association, and other
groups to be added as needed. The day-today operation of the project is managed by
a full-time project coordinator who is a
Canadian Certified Asthma Educator.
The pilot phase of the project was funded
by grants from AstraZeneca Canada,
GlaxoSmithKline, and Schering Canada.
Full implementation of the project has been
funded to March 31, 2006 by The Ministry
of Health and Long-Term Care - Primary
Health Care Transition Fund. Final project
outcomes will be analyzed using a preintervention / post-intervention design and
submitted to a peer reviewed journal for
publication.
Continued on page 6
5
From Paper to Pavement...Continued from page 5
REFERENCES
presents the 25th annual
B ETTER B REATHING C ONFERENCE
2006
LUNG
Health
A Lifetime of
Lung Health
February 3 - 4, 2006
Doubletree® International Plaza Hotel, Toronto, Ontario
Sessions will include:
• Respiratory Disease from Cradle to Grave
• What's New in Lung Health
• Lunch with a Professor
• Pulmonary Potpourri
• Resident Case Presentations
• Controversies in Pulmonary Medicine
For further information, visit www.on.lung.ca
or call the OTS office: 416-864-9911 x 254
6
1. Hargreave FE, Dolovich J, Newhouse MT. The assessment
and treatment of asthma: a conference report. J Allergy Clin
Immunol 1990; 85 (6): 1098 – 1111.
2. Boulet, LP, Becker A, Berube D, Beveridge, R and Ernst, P.
Canadian Asthma Consensus Report 1999. CMAJ 1999; Nov
30; 161:(11 Suppl): S1-61.
3. Boulet, LP, Bai TR, Becker A et al. What is new since the
last (1999) Canadian Asthma Consensus Guidelines? Can
Respir J. 2001; Mar-Apr; 8(Suppl A): 5A-27A.
4. Lemiere C, Bai T, Balter M, Bayliff C, Becker A, Boulet, LP,
Bowie D, et al. Adult Asthma Consensus Guidelines Update
2003. Can Resp J. 2004 May; 11 (Suppl A): 9A-18A
5. Global Initiative for Asthma. Global strategy for asthma
management and prevention (1995). NHLBI/WHO Workshop
Report, US Department of Health and Human Services.
National institutes of Health, Bethesda. Pub#96-3659A.
6. World Health Organization/National Heart, Lung, and Blood
Institute (1995): Global initiative for asthma. National Heart,
Lung and Blood Institute. (revised 1998).
7. Chapman, KR, Ernst P, Grenville A, Dewland P,
Zimmerman S. Control of asthma in Canada: Failure to
achieve guideline targets. Can Resp J. 2001; Mar-Apr;
8(Suppl A):35A-40A.
8. Partridge, MR, Harrison BD, et al. The British Asthma
Guidelines – their production, dissemination and
implementation. British Asthma Guidelines Co-Coordinating
Committee. Respir Med. 1998; Aug 92(8):1046-52.
9. Rabe KF, Adachi M, Lai CK, Soriano JB, Vermeire PA,
Weiss KB, Weiss ST. Worldwide severity and control of asthma
in children and adults: the global asthma insights and reality
surveys. J Allergy Clin Immunol. 2004; Jul; 114 (1): 40-47.
10. Jin R, Choi BC, Chan BT, et al. Physician asthma
management practices in Canada. Can Respir J 2000; NovDec; 7 (6): 456-465
11. Grimshaw, JM, Russell IT. Achieving health gain through
clinical guidelines II: Ensuring guidelines change medical
practice. Qual Health Care. 1994; Mar; 3(1):45-52.
ACKNOWLEDGMENTS
I would like to acknowledge my coinvestigators Dr. Todd Sands B.Sc. Ph.D.
B.Ed. and Ms. Lisa Paolatto B.Com. B.Sc.
M.H.A. along with the many community
organizations and individuals that have
contributed freely to this project.
Join the OTS or
Renew Your
Membership
OTS Active Membership is open to individuals
with a medical degree and scientists holding a
PhD or equivalent degree of training. The 20052006 fee is $60.00. OTS Associate Membership is
available to interns, residents or graduate students
in medical or allied health science, and to fellows
during their period of training. Associate members
do not pay fees and may not vote or hold office in
the Society but enjoy all the benefits of membership.
To join the OTS or to renew your membership
for 2005-2006, call (416) 864-9911 ext. 254. For
information on OTS programs and services, visit
222.on.lung.ca/ots
O NTARIO T HORACIC R EVIEWS FALL 2005
OTS RESEARCH AWARDS
The Ontario Thoracic Society is pleased to announce funding from
The Lung Association for the following awards for the year 2005-2006:
ACUTE LUNG INJURY
Lung-liver Interactions in ARDS and Multiorgan Failure
Dr. James Lewis, University of Western Ontario, London
Pentraxin 3: A New Inflammatory Mediator in Acute Lung Injury
Dr. Mingyao Liu, University of Toronto, Toronto
Physiology of Cough in Asthma: Sensory-mechanical Responses
to High-dose Methacholine in Asthma, Cough Variant Asthma and
Eosinophilic Bronchitis
Dr. Diane Lougheed, Queen’s University, Kingston
Effects of Neutrophil vs. Macrophage iNOS in Septic Human
Endothelial Cell Injury
Dr. Sanjay Mehta, University of Western Ontario, London
Regulatory Role of TNFa in Immunity and Immunopathology
during Influenza Viral Infection in Lung
Dr. Zhou Xing, McMaster University, Hamilton
ASTHMA
Immune-inflammatory and Reparative Responses to Chronic
House Dust Mite Exposure in Mice
Dr. Manel Jordana, McMaster University, Hamilton
COPD
Optimal Therapy of COPD to Prevent Exacerbation and
Improve Quality of Life: A Randomized, Double-Blind,
Placebo-controlled Trial
Dr. Shawn Aaron, University of Ottawa, Ottawa
Molecular Mechanisms of Skeletal Muscle Atrophy in Lung Disease
Dr. Jane Batt, St. Michael’s Hospital, Toronto
LUNG DISEASE
Expression and Function of Syk Tyrosine Kinase in Pulmonary
Epithelial Cells
Dr. Chung-Wai Chow, University of Toronto, Toronto
Effects of Thoracic Restriction and Obesity on the Ventilatory
Response to Carbon Dioxide
Dr. Denis O’Donnell, Queen’s University, Kingston
Impact of Cigarette Smoke on Airway Inflammation and Tissue
Remodeling Elicited by Common Environmental Allergens in Mice
Dr. Martin Robert Stampfli, McMaster University, Hamilton
LUNG INFECTION
Viral Etiologies of Bronchiolitis in a Large Outpatient Cohort
Dr. T. Karnauchow, Children’s Hospital of Eastern Ontario, Ottawa
A Study to Derive a Clinical Decision Rule for Predicting Severe
Bronchiolitis
Dr. Amy Plint, Children’s Hospital of Eastern Ontario, Ottawa
SLEEP DISORDERS
The Effects of Repeated Hypoxic Episodes and Arousals on the
Chemoreflex Control of Breathing in Sleeping Humans
Dr. James Duffin, University of Toronto, Toronto
Mandibular Position and Upper Airway Resistance during Sleep
in Normal Subjects
Dr. Michael Fitzpatrick, Queen’s University, Kingston
2006-2007 FUNDING YEAR
Please note new application deadline: The deadline for
applications for the 2006-2007 funding year is December
2005. The grant guidelines and application forms can be
viewed at www.on.lung.ca/ots
8,
Cameron C. Gray Fellowship Recipient 2005-2006
C
VIRJANAND NARAINE
ongratulations to this year’s recipient of the Cameron C. Gary Fellowship Award, Dr. Virjanand Naraine from
the University of Toronto. Dr. Naraine is currently in his second year (PGY-5) of Respirology at the University
of Toronto. He will use this award to help further his training in Respiratory Sleep Medicine and will be attending
various outpatient sleep clinics run by internationally recognized clinicians and researchers. Attending sessions in the
sleep laboratories will assist him in achieving competence in the technical aspects of sleep medicine. Dr. Naraine
possesses a strong clinical knowledge base and good clinical judgement. He is highly regarded by his patients for
his compassion and clinical skills. He will be an excellent ambassador for this fellowship, having the ability to make
a special contribution to the field of Respiratory Medicine as did Dr. Gray, in whose honour this prestigious award
was established.
This annual award is available due to the ongoing support of the Ontario Lung Association, private donations,
Ontario Thoracic Society members, friends and patients of Dr. Cameron C. Gray.
This award was established in 1981 and has funded 20 respiratory residents. For further information on this award,
please contact the Ontario Thoracic Society.
O NTARIO T HORACIC R EVIEWS FALL 2005
7
▲
SPIRIVA significantly
reduced dyspnea1,2*§
▲
SPIRIVA maintained full
24-hour bronchodilation with
once daily inhaled dosing1,2*
▲
SPIRIVA significantly
reduced exacerbations
and exacerbationrelated hospitalizations1*¥‡
SPIRIVA is a bronchodilator, indicated for the long term, once daily maintenance treatment of bronchospasm associated with COPD,
including chronic bronchitis and emphysema.2
SPIRIVA is contraindicated in patients with a history of hypersensitivity to atropine or its derivatives, or to the excipient lactose monohydrate.2
SPIRIVA should not be used for the initial treatment of acute episodes of bronchospasm, i.e. rescue therapy.2
The most common adverse reaction was dry mouth. Other adverse reactions reported and consistent with possible anticholinergic effects
included: constipation, increased heart rate, supraventricular tachycardia, atrial fibrillation, blurred vision, glaucoma, urinary difficulty and urinary retention.2
As with other anticholinergic drugs, SPIRIVA should be used with caution in patients with narrow-angle glaucoma, prostatic hyperplasia, or
bladder-neck obstruction. Patients should be cautioned to avoid getting the drug powder into their eyes. If this occurs, they should consult
a doctor immediately.2
* Results from two 1-year, double-blind, randomized studies of SPIRIVA (n=550, 18 µg once daily) vs placebo (n=371).
Salbutamol prn was allowed throughout the study period. Concomitant use of theophyllines, inhaled steroids, and minimal
doses of oral corticosteroids (equivalent of ≤10 mg prednisone/day) was allowed if doses were stabilized for at least
6 weeks prior to screening.
§ SPIRIVA group (42-47% achieved a TDI focal score of ≥1 unit) vs placebo (29-34%)(p<0.01).
¥ SPIRIVA group (0.76 exacerbations per patient year) vs placebo (0.95)(p=0.045).
‡ SPIRIVA group with 47% reduction (0.086 events per patient per year) vs placebo (0.161)(p=0.019).
SPIRIVA is a registered trademark of Boehringer Ingelheim Ltd.