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Secondhand Tobacco Smoke and COPD Risk in Smokers: A COPDGene Study Cohort Subgroup Analysis.

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2HTSBackground: Exposure to secondhand tobacco smoke (SHS) can be a risk factor for chronic obstructive pulmonary disease (COPD), but its role among relatively heavy smokers with potential co-exposure to workplace vapors, gas, dust, and fumes (VGDF) has not been studied.

Methods: To estimate the contribution of SHS exposure to COPD risk, taking into account smoking effects and work-related exposures to VGDF, we quantified SHS based on survey responses for 1400 ever-employed subjects enrolled in the COPDGene study, all current or former smokers with or without COPD. Occupational exposures to VGDF were quantified based on a job exposure matrix. The associations between SHS and COPD were tested in multivariate logistic regression analyses adjusted for age, sex, VGDF exposure, and cumulative smoking.

Results and Discussion: Exposures to SHS at work and at home during adulthood were associated with increased COPD risk: odds ratio (OR) = 1.12 (95% confidence interval [CI]: 1.02-1.23; p = 0.01) and OR = 1.09 (95%CI: 1.00-1.18; p = 0.04) per 10 years of exposure adjusted for smoking and other covariates, respectively. In addition, subjects with employment histories likely to entail exposure to VGDF were more likely to have COPD: OR = 1.52 (95%CI: 1.16-1.98; p < 0.01) (adjusted for other covariates). While adult home SHS COPD risk was attenuated among the heaviest smokers within the cohort, workplace SHS and job VGDF risks persisted in that stratum.

Conclusion: Among smokers all with at least 10 pack-years, adult home and work SHS exposures and occupational VGDF exposure are all associated with COPD.

COPD-related Bronchiectasis; Independent Impact on Disease Course and Outcomes.

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Background: COPD and radiographic bronchiectasis frequently coexist but the effect of this on the clinical course of COPD is not fully understood. We determined the impact of bronchiectasis on clinical outcomes in COPD patients, independent of coexisting emphysema and bronchial wall thickening (BWT).

Methods: COPD patients admitted with first exacerbation 1998-2008 were identified retrospectively using ICD10 codes J44.0,1,8,9. Patients with suitable CT scans were graded for severity of bronchiectasis, emphysema and BWT on a 5 point scale (0-absent, 1-minor, 2-mild, 3-moderate, 4-severe).

Results: 406 patients (71 ± 11 years, 56% male, FEV1 52 ± 23% predicted) were included; 278 (69%) patients had bronchiectasis: minor, 112 (40%); mild, 81 (29%); moderate, 62 (22%); severe 23 (8%). Bronchiectasis severity correlated with severity of BWT (p < 0.001) but not emphysema (p = 0.090). Bronchiectasis independently determined sputum isolation of Pseudomonas aeruginosa (Odds ratio (OR) 1.39 (95% CI 1.07 to 1.80), p = 0.013) and atypical mycobacteria (OR 2.44 (95% CI 1.04 to 5.69), p = 0.040), annual respiratory admissions (p = 0.044) and inpatient days (p < 0.001), but did not predict survival (p = 0.256).

Conclusions: Radiographic bronchiectasis in COPD patients is associated with increased respiratory infection and hospitalisation, independent of coexisting emphysema and BWT. COPD-related bronchiectasis is therefore an important diagnosis with potential implications for treatment.

Implementation of a Titrated Oxygen Protocol in the Out-of-Hospital Setting.

Oxygen is one of the most frequently-used therapeutic agents in medicine and the most commonly administered drug by prehospital personnel. There is increasing evidence of harm with too much supplemental oxygen in certain conditions, including stroke, chronic obstructive pulmonary disease (COPD), neonatal resuscitations, and in postresuscitation care.

Recent guidelines published by the British Thoracic Society (BTS) advocate titrated oxygen therapy, but these guidelines have not been widely adapted in the out-of-hospital setting where high-flow oxygen is the standard.

This report is a description of the implementation of a titrated oxygen protocol in a large urban-suburban Emergency Medical Services (EMS) system and a discussion of the practical application of this out-of-hospital protocol.

Prescription of Walking Exercise Intensity From the 6-Minute Walk Test in People With Chronic Obstructive Pulmonary Disease.

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6-Minute_Walk_TestThe 6-minute walk test (6MWT) is widely used in clinical practice, particularly to assess functional exercise capacity and to prescribe walking training intensity in people with chronic obstructive pulmonary disease (COPD). However, the actual walking intensity prescribed from the 6MWT, in terms of percent peak oxygen uptake (%VO2peak) and percent VO2 reserve (%VO2R), has not been previously reported. This study aims to examine the exercise intensity when walking training is prescribed at 80% average 6MWT speed.

METHODS:: Patients with COPD (N = 45) were recruited. Peak VO2 from an incremental cycle test and 6MWT and VO2 from a 10-minute walking exercise (Walk-10) were measured by a portable metabolic system (Cosmed K4b; Cosmed, Rome, Italy). Walk-10 was done on the same oval course as the 6MWT. Participants were asked to walk at 80% average 6MWT speed for 10 minutes continuously.

RESULTS:: Four participants could not complete Walk-10 and 2 did not perform Walk-10 due to low 6MWT distance. The remaining 39 participants with mean (SD) forced expiratory volume in 1 minute of 58 (19)% predicted completed Walk-10. The mean intensity of Walk-10 was 69 (17)% VO2R or 77 (13)% VO2peak. Steady-state VO2 was achieved within the first 4 minutes of Walk-10.

CONCLUSION:: Walking exercise prescribed at 80% average 6MWT speed resulted in a high but tolerable exercise intensity that is likely to result in training benefits in most people with COPD.

Mechanical ventilation and the role of saline instillation in suctioning adult intensive care unit patients: an evidence-based practice review.

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Saline instillation in suctioning mechanically ventilated patients remains a common practice in the intensive care unit (ICU). Many respiratory therapists and nurses are using saline with suctioning without an adequate knowledge of the current evidence-based research to guide this practice.

OBJECTIVES: The purpose of this study was to determine if this routine method is beneficial or harmful to the patients and provide evidence-based practice recommendations that will serve as a guide for practice.

METHODS: This is a comprehensive review on the use of saline instillation in suctioning mechanically ventilated adult ICU patients. Database such as CINAHL, MEDLINE, Cochrane, PsycINFO, and national guidelines are extracted for the review of literature. The study population consists of patients 18 years or older, who are intubated or have a tracheostomy in place, requiring mechanical ventilation, and who are admitted in the ICU.

RESULTS: Although most of the evidence suggests not to use saline when suctioning, there are various limitations to the studies such as small sample size, settings, inconsistencies in data collection, or not enough or outdated research clinical trials, which calls for further studies.

CONCLUSION: This study does not support the use of saline instillation when suctioning an artificial airway. Further clinical trials are crucial to effectively determine if saline instillation use with suctioning an artificial airway is deemed harmful, which can be strictly enforced as a mandatory clinical guideline for all hospitals to include in their standardized protocol to not use saline instillation with suctioning.

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