e31Can Respir J Vol 19 No 3 May/June 2012

Presenting Author / Auteur Présentateur Abstract Title / Titre d’abrégé Page Stream 1: Asthma Basic Science / Séance 1: Asthme – Science fondamentaleÉthier, Caroline Anti-Apoptotic Effect of 1.25-Dihydroxycholecalciferol on Eosinophils from Allergic Asthmatics e33Hyung Ryu, Min Development of a Tubular Nano-Fiber Scaffold for Functional Study of Human Airway Smooth Muscle Cells e33Leung, Clarus Investigation of the Barrier Properties of Differentiated Human Airway Epithelium from Normal and Asthmatics In Vitro e33Singh, Amrit Plasma Proteomics of Asthmatic Individuals Undergoing Allergen Inhalation Challenge e34Singhera, Gurpreet Environmental Challenge and IL-33 Release by Airway Epithelial Cells e34Xu, Janet Surfactant Protein-A and –D Expression in Airway Epithelium of Asthmatics and its Modulation by Viral Infection e34Yamamoto, Masatsugu Comparison of miRNA Expression Profiles in Peripheral Blood of Early and Dual Responders Undergoing Allergen Inhalation Challenge e35Yang, Jasemine Dysregulated Expression of IL-13 Receptors in the Asthmatic Airway Epithelium e35Stream 2: Asthma Clinical / Séance 2: Asthme – CliniqueChuang, Junior Optimal Fixed Cut-Offs for FEV1/FEV6 as Alternatives for FEV1/FVC for Detection of Airway Obstruction: Results from the

Population-Based Canadian Obstructive Lung Disease (COLD) Studye35

D’urzo, Anthony Simple Spirometry as a First Line Test for Asthma Diagnosis in Primary Care e36Garvey, Nancy The Association of Asthma Education Centres on Repeat Hospitalizations and Emergency Department Visits for Asthma in Ontario e36Harkness, Howard Valved Holding Chambers (VHCs) are Non-Interchangeable: Development of a Universal VHC that Provides Assurance of Drug

Delivery to Patients and Health Care Providerse36

Jimenez-Mendez, Ricardo Impact in Healthcare Service Use of Asthma Patient with Changing Medication Regimens - The Importance of Optimal Management e37Leigh, Richard Asthma in Older Adults: Potential Factors to Explain the Increased Mortality Rates e37Sadatsafavi, Mohsen Asthma Control in a Random Sample of Canadian Asthma Patients e37Sadatsafavi, Mohsen Use of Complementary and Alternative Therapies in Patients with Asthma: Preliminary Results from a Prospective Study e38Sinnatamby, Shamara Do Hairdressers Experience More Respiratory Symptoms than Non-Hairdressers? e38Villa-Roel, Cristina Asthma and COPD Patients’ Care Gaps at Emergency Department Discharge e38Wilkinson, Bryan Preventing Asthma Exacerbations with a Short Course of Oral Steroids at the Earliest Sign of Upper Respiratory Tract Infections:

Preliminary Results of an Ongoing Policy Triale39

Stream 3: COPD / OSA Clinical / Séance 3: MPOC / ASO – CliniqueChen, Hui KlearwayTM Oral Appliances for Pediatric Patients with Retruded Mandibles e39Joubert, Alexandre Effect of an Integrated Care Approach with Self-Management in Patients with COPD e39Kaplovich, Eric The Impact of Polypharmacy on the Outcomes of Pulmonary Rehabilitation e39Lawson, Joshua Respiratory Symptoms Associated with Chronic Conditions among Those with and without Asthma or COPD e40Nguyen, Marilyse Perceived Needs of COPD Patients from Different Illness Severities Around the Approach to Advance Care Planning e40Rocker, Graeme Evaluating Impacts of a New COPD Outreach Program (INSPIRED) e40Rocker, Graeme Using Opioids to Treat Refractory Dyspnea in Advanced COPD: Early Insights from a Clinical Trial e41Sherwood, Karen Proteomic Signature in Plasma of Chronic Obstructive Pulmonary Disease Subjects Can Differentiate Frequent Exacerbators from

Non-Exacerbatorse41

Sima, Carmen Diabetes Mellitus and Pulmonary Function in Hospitalized Patients with Acute Exacerbation of COPD e41Smith, Ashley Prevalence of Unrecognized Osteoporosis among COPD Patients e42

A Breath of Fresh Air / Une boufée d’air frais: Abstracts from the 2012 Canadian Respiratory Conference

April 26 – 28, 2012, Vancouver, British Columbia

The present online supplement highlights the poster abstracts selected for presentation at the 5th Annual Canadian Respiratory Conference (CRC) held in Vancouver, British Columbia, in April 2012. The CRC is a partnership initiative of the Canadian Thoracic Society, Canadian Respiratory Health Professionals, The Lung Association and the Canadian COPD Alliance and has become the premiere national educational and scientific meeting for the respiratory community in Canada. I would like to acknowledge the leadership and expertise of the Scientific Committee, our conference speakers and abstract pre-senters, all of whom contributed to the delivery of an excellent pro-gram. The next Canadian Respiratory Conference will be held in Québec City, Quebec, April 11 to 13, 2012 (www.lung.ca/crc). We look forward to seeing you there!

Pearce Wilcox, CTS Co-Chair, Canadian Respiratory Conference Scientific Committee

Le présent cybersupplément fait ressortir les résumés par affiche sélec-tionnés en vue d’être présentés au 5e Congrès canadien sur la santé respiratoire (CCSR) annuel, qui s’est déroulé à Vancouver (Colombie-Britannique) du 26 au 28 avril 2012. Le CCSR, un partenariat entre la Société canadienne de thoracologie, les Professionnels canadiens en santé respiratoire, L’Association pulmonaire et l’Alliance canadienne sur la MPOC, est devenu le principal congrès scientifique et de forma-tion national pour la communauté des soins respiratoires au Canada. Je tiens à souligner le leadership et les compétences du comité scienti-fique, des conférenciers et des présentateurs de résumés, qui ont tous contribué à l’excellence du programme. Le prochain Congrès canadien sur la santé respiratoire aura lieu à Québec (Quebec) du 11 au 13 avril 2012 (www.poumon.ca/crc). Nous avons hâte de vous y rencontrer.

Pearce Wilcox, SCT coprésidentComité scientifique du Congrès canadien sur la santé respiratoire

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e32 Can Respir J Vol 19 No 3 May/June 2012

Presenting Author / Auteur Présentateur Abstract Title / Titre d’abrégé Page Stream 4: COPD Exercise Therapy / Séance 4: Thérapie par l’exercice en COPDBeauchamp, Marla Feasibility and Acceptability of a Community-based Maintenance Exercise Program for People with COPD e42Boim, Clarisa Physical Exercise, Our Tool e42Sousa Sena, Riany Eccentric Cycle Exercise for Patients with Severe COPD: Training Application and Feasibility e43Dhillon, Satvir Factors Associated with Low Six Minute Walk Distance in Advanced Cystic Fibrosis e43Dolmage, Thomas Arm Elevation and Coordinated Breathing Strategies in Patients with Severe Chronic Obstructive Pulmonary Disease (COPD) e43Dolmage, Thomas Investigation of a Simple Method to Set the Walking Speed for the Assessment of Ambulatory Oxygen in Patients with Chronic

Lung Diseasee44

Down, Ray Home-Based Exercise Programming in Pulmonary Rehabilitation: A Case Report of a New Approach e44Janaudis-Ferreira, Tania How Should We Measure Arm Exercise Capacity in COPD? A Systematic Review e44Robles-Ribeiro, Priscila Skeletal Muscle Atrophy is Associated with Physical Function in People with COPD e45Wickerson, Lisa Physical Activity Profile in Lung Transplant Candidates with Interstital Lung Disease Undergoing Pulmonary Rehabilitation e45Woon, Lynda Energy Economy of Walking with a Wheeled Ambulatory Aid (Rollator) in Patients with Chronic Obstructive Pulmonary Disease

(COPD)e45

Stream 5: General Lung Diseases Basic Science / Séance 5: Maladies pulmonaires générales – Science fondamentaleAlahmadi, Turki Inflammatory Responses are Qualitatively, but not Quantitatively, Similar between Airway and Monocyte-Derived Macrophages e46Dominelli, Paolo Utilizing Near Infrared Spectroscopy and Indocyanine Green Dye to Estimate Respiratory and Leg Blood Flow During Continuous

Exercisee46

Jamal, Mobin Understanding the Role of Reactive Oxygen Species in Alveolar Formation of Neonatal Rat Lungs e46Kelly, Margaret IL-17A Positive Cells in the Lungs of Patients with Hypersensitivity Pneumonitis e46Sze, Marc A Preliminary Assessment of the Fungal Microbiome in the Lung e47Sze, Marc The Lung Tissue Microbiome in COPD e47Wadsworth, Samuel PneumaCultTM-ALI: An Improved Media for Mucociliary Differentiation of Primary Human Bronchial Epithelial Cells e47Stream 6: Knowledge Translation / Critical Care / General Clinical / Séance 6: Application du savoir / Soins critiques / Général – CliniqueEzer, Nicole Impact of Rapid Investigation Clinic on Timeliness of Lung Cancer Diagnosis and Staging e48Haskell, Susan Out of Breath: Advance Care Planning and End of Life Care Initiatives in Pulmonary Rehabilitation e48Malhotra, Rohin Acute Exacerbation of Interstitial Lung Disease Associated with Connective Tissue Disease: Report of Two Cases and Review of

the Literaturee48

Rakovich, George Clinicopathological Conferences in the Canadian Respiratory Journal: A New Format for Maximizing the Educational Value of Case Reports

e49

Reid, Constance Non-Invasive Ventilation on Acute and Chronic Care Units: Is it Safe? e49Shilo, Natalie Pediatric Sickle Cell Disease and Airway Hyperreactivity: Prevalence in Asymptomatic Patients e49Thain, Katherine The Canadian Respiratory Journal Comes of Age (18) and Goes Online! e50

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Asthma Basic ScienceAsthme – Science fondamentale

1Anti-ApoptotiC EFFECt oF 1 25-DihyDRoxyCholECAlCiFERol on EoSinophilS FRom AllERgiC ASthmAtiCSCaroline Éthier1, Fanny pallot1*, isabelle Chapados2, yingqi Wu1, Darryl James Adamko1,4, Francis Davoine1*1pulmonary Research group, *Campus Saint Jean & 2Department of pediatrics, University of Alberta, Edmonton, AB; 3Department of pediatrics, University of Saskatchewan, Saskatoon, SKRationale: The prevalence of allergic diseases and asthma has increased worldwide at least during the last 3 decades. Meanwhile the incidence of various autoimmune and allergic conditions appears to be higher further away from equator. Amongst the hypothesis suggested to connect these observations is the lack of exposure to sufficient sunlight and therefore relative vitamin D deficiency. Mucosal dendritic cells can hydroxylate vitamin D into bioactive calcitriol (1.25-dihydroxycholecal-ciferol). This hormone suppresses Th17 and Th1 cytokine production by Th lymphocytes and therefore contributes to reduction in allergic inflam-mation. Although, nothing is known about the possible direct activity of calcitriol on eosinophils, an inflammatory cell characteristic of lung mucosal infiltration in allergic asthma.HypotHesis: Calcitriol exerts mucosal regulatory effect directly on eosinophils.MetHods: Blood eosinophils from atopic asthmatic donors were iso-lated and incubated with physiological concentrations of calcitriol (0 to 100 nM). Annexin V-PI flow cytometry assay was used to measure apopto-sis and viability of eosinophils.Results: Preliminary results indicate that increasing concentrations of calcitriol are able to sustain viability of blood eosinophils in vitro without the addition of any other anti-apoptotic factors (n=6, p<0.05). Over a 7-day period, an additive effect of calcitriol on eosinophils viability is observed, when co-cultured with IL-5.ConClusion: Our preliminary data suggests that calcitriol is a potent immune regulator of eosinophil viability. Reduced eosinophils mortality may be associated with a reduction of mediator shedding in mucosa from necrotic and apoptotic eosinophils. We hope to unveil some other activi-ties of this vitamin on eosinophils and perhaps explain further the complex physiopathology of allergic asthma.

2DEVElopmEnt oF A tUBUlAR nAno-FiBER SCAFFolD FoR FUnCtionAl StUDy oF hUmAn AiRWAy Smooth mUSClE CEllSmin hyung Ryu1,6,8, Samuel Wadsworth7,8, Delbert Dorscheid7,8, malcolm xing4,5,6,8, gerald l Stelmack1,6, helmut Unruh2, and Andrew J halayko1,2,3,6,8

1Departments of physiology; 2internal medicine, pediatrics and 3Child health; 4Biochemistry and molecular genetics, and 5nano-medicine and tissue Engineering, University of manitoba; 6Biology of Breathing theme, manitoba institute of Child health, Winnipeg, mB; 7Department of medicine, University of British Columbia, and 8BRonCh partnership, University of manitoba, Winnipeg, mB and University of British Columbia, Vancouver, BC Rationale: Bio-engineered tissues are needed for reliable translation of pre-clinical data. Bioengineered nano-fiber scaffolds exhibit biocompat-ibility and mimic three dimensional tissue structure. Intrinsic stiffness of engineered scaffolds determines cell fate, survival, and phenotype, thus unique physical properties are needed for specific cell types. Airway smooth muscle (ASM) encircles the bronchi and controls airway caliber, the principal factor that determines airflow resistance. Therefore, optimiz-ing a scaffold matrix to support long-term survival and contractile function of ASM is essential to develop functional, multi-cellular bioengineered human airways for experimentation.

MetHods: Polyhydroxybutyrate (PHB) and gelatin, 1:1 by weight, were co-electrospun on a high speed rotating metal rod to create circumferen-tially aligned nano-fibrous tubular scaffolds. Ultrastructure of scaffolds was assessed using scanning electron microscopy (SEM). The passive length-tension (L-T) relationship of scaffolds was assessed by myography; change during prolonged cell-free culture was assessed. Primary human ASM cell adherence to the scaffolds in DMEM/0.5% fetal bovine serum culture medium was assessed by cell counting.Results: We electrospun tubular, 2 mm diameter scaffold in which nano-fibres were circumferentially aligned (see figure). The passive L-T relationship of scaffolds was exponential in nature (eg. 0.00023.48x, R2=0.96, 5 days culture). Scaffold elasticity was decreased after 4 weeks in cell-free culture (0.00053.69x, R2=0.98). The PHB:gelatin scaffold sup-ported significant adherence of human ASM cells, attaining a cell density of 3.1×104/cm2 48 hrs after seeding. Notably, 78.8% of these cells adhered within 2 hrs of seeding.

ConClusion: PHB:gelatin is suitable to generate tubular nano-fibrous scaffolds with structural, mechanical and chemical properties that mimic intact airways and support adherence and spreading of human ASM cells. This approach offers potential to develop functional bioengineered airways harboring human cells.Funding: National Sanitarium Association and MICH. AJH is supported by Canada Research Chairs Program

3inVEStigAtion oF thE BARRiER pRopERtiES oF DiFFEREntiAtED hUmAn AiRWAy EpithEliUm FRom noRmAl AnD ASthmAtiCS in VitRoC leung, S Wadsworth , D DorscheidJames hogg Research Centre, University of British Columbia; providence heart + lung institute; St paul’s hospital, Vancouver, BC Rationale: The airway epithelium forms a barrier against inhaled noxious substances, simultaneously transporting certain molecules into the airway lumen. In asthma the airway epithelium is held in a repair pheno-type which may prevent the development of normal barrier function. We used primary human bronchial epithelial cells (HBECs) from normals and asthmatics to investigate barrier functions in health and disease in vitro.MetHods: Primary HBECs from normals and asthmatics were differen-tiated into a mucociliated phenotype in specialised PneumaCult-ALI (StemCell) media for 21 days in air-liquid interface (ALI) culture. At weekly time-points barrier function was assessed by trans-epithelial electri-cal resistance (TEER), and permeability by diffusion of FITC-labeled dex-tran (4kDa) and horseradish peroxidase (HRP, 44kDa). At 21d ALI, cultures were fixed and stained to image culture morphology and junc-tional protein expression.Results: Pneumacult-ALI cultures are stratified and mucociliated. At 14d post-ALI, cells from asthmatic donors demonstrated significantly greater TEER (501.8Ω.cm2±59.4 SD) compared to normal cultures

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(193.8Ω.cm2 ±59.4 SD, p<0.0001). At all time points normal and asth-matic cells demonstrated approximately 10–fold greater diffusion of 4kDa dextran than 44kDa HRP. At d0 ALI, normal and asthmatic cultures dem-onstrated similar diffusion rates in apical to basal (A-B), and basal to apical (B-A) directions. At d14 ALI, normal cells developed significantly greater diffusion rates in the B-A direction than A-B for 4kDa dextran and 44kDa HRP. In contrast, cultures from asthmatic donors did not demonstrate higher diffusion rates in the B-A direction for either tracer molecule.ConClusion: We have demonstrated airway epithelial cultures from asthmatic donors are less permeable than normals as measured by TEER, but they do not develop asymmetrical barrier properties, and in this respect are similar to undifferentiated cultures of normals cells. Our data suggests the “immature” epithelium in asthmatic airways forms an intact barrier, but a lack of basal-apical trans-epithelial molecular transport may compromise innate immune functions, such as immunoglobulin transport.Funding: The National Sanitarium Association.

4plASmA pRotEomiCS oF ASthmAtiC inDiViDUAlS UnDERgoing AllERgEn inhAlAtion ChAllEngEAmrit Singh1,2, gabriela V Cohen Freue2,3,4, Jean l oosthuizen1,2, Sarah h y Kam1,2, Jian Ruan1,2, mandeep K takhar2,3, gail m gauvreau5, paul m o’Byrne5, J mark Fitzgerald2,6,7, louis-philippe Boulet8, Christoph h Borchers9, Scott J tebbutt1,2,3,6

1James hogg Research Centre, St paul’s hospital, University of British Columbia; 2institute for hEARt+lUng health; 3pRooF Centre of Excellence; 4Department of Statistics, University of British Columbia, Vancouver, BC; 5Department of medicine, mcmaster University, hamilton, on; 6Department of medicine, Division of Respiratory medicine, University of British Columbia; 7Vancouver Coastal health Research institute, Vancouver general hospital, Vancouver, BC; 8Centre de pneumologie de l’hopital, Université laval, Sainte-Foy, QC; 9genome BC proteomics Centre, University of Victoria, Victoria, BCRationale: Atopic asthmatic individuals respond differently, but reproducibly, to allergen inhalation challenge (AIC). Some individuals develop an isolated early response while others develop isolated late or dual responses. The purpose of this study was to identify proteomic bio-signa-tures of isolated early and dual responses induced through allergen inhala-tion challenge.MetHods: Eight adult subjects [4 early responders (ERs) and 4 dual responders (DRs)] participated in the AIC. Blood samples were collected prior to and 2h after the inhalation challenge. 16 plasma samples (2 per subject) as well as pooled controls were analyzed using isobaric Tags for Relative and Absolute Quantitation (iTRAQ) mass spectrometry. Data was processed using ProteinPilot™ and summarized using the Protein Group Code Algorithm. Moderated robust regression in R (statistical com-puting program) was used to determine differentially expressed Protein Groups (PGs) using an FDR cut-off of 15%. Ingenuity Pathway Analysis (IPA) was used to determine biological functions, canonical pathways and networks.Results: 28 (10 over-expressed and 18 under-expressed) PGs were found to be differentially expressed when comparing ER and DRs at pre-challenge. Complement proteins were significantly under-expressed in DRs relative to ERs at pre-challenge. Fibronectin (FN1) was differentially expressed between ERs and DRs at both pre- and post-challenge time points. IPA indicated Infectious Disease, Inflammatory Response, Antigen Presentation, Cell-To-Cell Signaling and Interaction and Hematological System Development as the top biological functions.ConClusions: Proteomic analysis has shown significant differences between ERs and DRs prior to and following AIC. Reduced expression of complement proteins in DRs implicates innate immunity in asthmatic responses. FN1 levels suggest differences in the extent of tissue remodeling between ERs and DRs. Thus, the AIC model may improve understanding of molecular mechanisms associated with asthma.Financial support: BC Proteomics Network (MSFHR); AllerGen NCE Inc. (Allergy, Genes and Environment Network); Canadian Institutes of Health Research

5EnViRonmEntAl ChAllEngE AnD il-33 RElEASE By AiRWAy EpithEliAl CEllSgurpreet K Singhera, Jeremy hirota, tillie hackett, Darryl Knight, Delbert R DorscheidJames hogg Research Centre, St paul’s hospital, University of British Columbia, Vancouver, BCRationale: Interleukin (IL)-33 is a novel member of the IL-1 family with a dual function, as a cytokine acting through activation of the ST2L receptor and as an intracellular nuclear factor with potential transcrip-tional regulatory properties. As an “alarmin molecule” it induces either pro- or anti-inflammatory cascades. In this study we have investigated the localization of IL-33 in diseased human airways and the specific challenges that affect IL-33 production and release.aiM: Characterize IL-33 expression in asthmatic and non-asthmatic airway epithelial cells (AEC) and the specific signals required for IL-33 release.MetHods: Using immunohistochemistry (IHC) techniques, IL-33 expression was characterized in airway sections of normal and diseased airways (asthma, COPD and cystic fibrosis (CF) from the JHRC Biobank using semi-quantitative scoring tool. In an in vitro model, primary human bronchial epithelial cells (HBEC) were incubated with RSV, Thrombin, Fas, or TRAIL and subsequent detection of IL-33 by either ELISA or Western Blots (WB).Results: IHC data demonstrates that in airway sections from all donors IL-33 is characterized predominantly by a nuclear pattern within the basal cells of the epithelium. With respect to normal tissue, asthmatic airways demonstrate a non-significant increase in IL-33 detection. However asth-matic airways had a significant increase in IL-33 when compared to COPD and CF airways. In vitro AEC experiments demonstrated higher IL-33 release from asthmatic AEC at baseline and after stimulation. Compartmentalization of IL-33 between total cellular and nuclear frac-tions was altered with similar stimulation.ConClusions: In summary, IL-33 release can be induced from AEC. IL-33 plays a role in allergic processes and interestingly there is less IL-33 detection in COPD/CF airways, diseases thought to be mediated by neutro-phils. Understanding the regulation of IL-33 expression as determined by environmental challenges is important to affect better control of allergic inflammation as a contributor in asthma.Funding: CIHR: Allergen, NCE

6SURFACtAnt pRotEin-A AnD -D ExpRESSion in AiRWAy EpithEliUm oF ASthmAtiCS AnD itS moDUlAtion By ViRAl inFECtionJanet xu, gurpreet K Singhera, Delbert R DorscheidJames hogg Research Center, St paul’s hospital, University of British Columbia, Vancouver, BCRationale: Surfactant proteins (SP) are part of the innate immune system as pattern recognition molecules. Respiratory syncytial virus (RSV) is a leading cause of lower respiratory tract infections and has been linked to the asthma etiology. SP-A and SP-D have been reported in the clear-ance of RSV. Characterization of surfactant protein expression may con-tribute to the understanding of asthmatic susceptibility to viral infection.aiM: Characterize SP-A and -D expression in asthmatic and non-asth-matic airway epithelial cells (AEC).MetHods: Human airway sections from asthmatic and non-asthmatics and sections of pseudostratified air-liquid interface (ALI) were used to quantify SP-A and SP-D by immunohistochemistry. Protein levels of SP-D were determined using Western blotting on protein lysates of both RSV infected and non-infected human AEC.Results: Both SP-A and SP-D molecules were expressed in intact human airway sections. SP-A expression was low and localized mainly in small airways whereas SP-D expression was highly expressed and detected in airways of different sizes. SP-A expression in small airways (<1 mm) was found to be 2.5 fold higher (p=0.018) in asthmatic airways than non-asthmatic airways. SP-D expression was found to be significantly higher (p<0.004) in asthmatic airways. In the ALI cultures, RSV infection

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induced a marked reduction in SP-D expression however, pre-treatment with conjugated linoleic acid (CLA) prior to RSV infection showed a 3.8 fold increase (p<0.05) in SP-D expression compared to RSV infection alone. Sucrose gradient fractions of protein lysates showed SP-D proteins in non-lipid fractions.ConClusions: Our data demonstrates surfactant proteins are expressed differently in the airways of asthmatics. The increased SP-A and SP-D detected in the asthmatic airway may reflect an increased susceptibility to viral infections due to dysregulated protein expressions, dysfunctional pro-tein products, or chronic injury of airway tissue and requires further study.Funding: CIHR: Allergen, NCE

7CompARiSon oF miRnA ExpRESSion pRoFilES in pERiphERAl BlooD oF EARly AnD DUAl RESponDERS UnDERgoing AllERgEn inhAlAtion ChAllEngEmasatsugu yamamoto1,2,3,4, Amrit Singh1,2, Jian Ruan1,2, gail m gauvreau5, paul m o’Byrne5, Chris Carlsten2,3,4, J mark Fitzgerald2,3,4, louis-philippe Boulet6, Scott J tebbutt1,2,3

1James hogg Research Centre, St paul’s hospital, University of British Columbia, Vancouver; 2institute for hEARt+lUng health; 3Department of medicine, Division of Respiratory medicine, University of British Columbia; 4Vancouver Coastal health Research institute, Vancouver general hospital, Vancouver, BC; 5Department of medicine, mcmaster University, hamilton; 6Centre de pneumologie de l’hopital, Université laval, Sainte-Foy, QCRationale: The early and late responses can be detected in atopic asthmatic undergoing allergen inhalation challenge (AIC). MicroRNAs (miRNAs) are small non-coding RNAs that can bind to multiple target mRNAs to regulate protein production. While some miRNAs have been reported to be dysregulated in some diseases, changes of miRNA profiles in blood cells of early responders (ERs) and dual responders (DRs) undergo-ing AIC have not been studied. We have investigated cellular miRNA profiles in whole blood in atopic asthmatics undergoing AIC.MetHods: Four ERs and four DRs participated in the ethically approved AIC. Venous blood was collected (EDTA tubes) immediately prior to chal-lenge (pre) and 2 hours post-challenge. Total RNA was extracted using a Qiagen miRNA mini kit. A total of 734 miRNAs derived from miRBase were profiled using the nCounter Expression Assay (NanoString Technologies, Seattle). After data processing and initial filtering, moder-ated robust regression in R (statistical computing program) was used to assess differential (FDR=10%) expression of miRNAs. Ingenuity Pathway Analysis (IPA) was used to determine top biological functions.Results: A total of 149 miRNAs were expressed across all samples; 242 miRNAs were below the detection threshold for all samples. A total of 48 (16 up- and 32 down-regulated) differentially expressed miRNAs were identified in the pre vs. post comparison in ERs. However, only one miRNA was differentially expressed in the pre vs. post comparison in DRs. The top biological functions identified using IPA for post- compared to pre-challenge in ERs included Inflammatory Disease, Connective Tissue Disorders, and Respiratory Disease.ConClusion: Significant changes in miRNA levels can be detected in peripheral blood following AIC. These changes are more significant in ERs than DRs. This study shows the use of the AIC in order to improve under-standing of regulatory mechanisms in asthma.Financial support: AllerGen NCE Inc. (Allergy, Genes and Environment Network); Canadian Institutes of Health Research

8DySREgUlAtED ExpRESSion oF il-13 RECEptoRS in thE ASthmAtiC AiRWAy EpithEliUmJasemine S yang, Angela Saunders, Sima Allahverdian, Samuel J Wadsworth, gurpreet K Singhera, Delbert R DorscheidJames hogg Research Centre, University of British Columbia institute for heart + lung Research, St paul’s hospital, University of British Columbia, Vancouver, BCRationale: The airway epithelium serves as a defense barrier and suffers frequent injury as a result, requiring repair coordinate with inflammation.

Interleukin-13 (IL-13) is known to be a key cytokine in mediating inflam-matory and remodelling processes in asthma. The actions of IL-13 are mediated by IL-13 receptor α1 (IL-13Rα1) and IL-13 receptor α2 (IL-13Rα2). Our lab has demonstrated that IL-13 is critical to normal air-way epithelial repair via signaling the release of HB-EGF and activation of EGF-R. Appropriate control of inflammatory and repair processes is tightly regulated by the balance of IL-13Rα1 and IL-13Rα2 expression and func-tion in response to injury.aiM: To investigate the expression of IL-13Rα1 and IL-13Rα2 in normal and asthmatic airways.MetHods: Expressions of IL-13Rα1 and IL-13Rα2 in sections from nor-mal and asthmatic lung tissue were determined via immunohistochemistry and quantified using ImagePro Plus. Primary airway epithelial cells (AEC) from normal and asthmatic donors were cultured in monolayers and sub-jected to mechanical wounding and IL-13 stimulation over a time course of 24 hours. The cultures were then lysed for protein and RNA extraction and IL-13Rα1 and IL-13Rα2 levels were detected via Western blotting and qRT-PCR respectively.Results: Immunohistochemical detection demonstrated that asthmatic airways, specifically in the epithelium expressed significantly (p<0.05) higher levels of IL-13Rα1 compared to normal donors. Asthmatic airways also do not express significant levels of IL-13Rα2 and exhibit epithelial abnormalities. Cultured monolayer AEC from asthmatic donors continue to secrete IL-13 in excess relative to normal AEC. In addition to dysregu-lated IL-13 release, these cells demonstrate abnormal IL-13Rα2 expression and function with markedly impaired repair.ConClusion: Our data indicates that expression of IL-13 receptors is dysregulated in the airways of asthmatics and this contributes to the dys-functional repair phenotype observed in the asthmatic epithelium.Funding: AllerGen-NCE, CIHR

Asthma Clinical Asthme – Clinique

9optimAl FixED CUt-oFFS FoR FEV1/FEV6 AS AltERnAtiVES FoR FEV1/FVC FoR DEtECtion oF AiRWAy oBStRUCtion – RESUltS FRom thE popUlAtion-BASED CAnADiAn oBStRUCtiVE lUng DiSEASE (ColD) StUDyJunior Chuang1, WC tan1, J Bourbeau2, p hernandez3, K Chapman4, R Cowie5, mJ Fitzgerald6 , S Aaron7, DD marcinuik8, F maltais9, DE o’Donnell10, R goldstein11, D Sin1 1James hogg Research laboratories, University of British Columbia, BC providence heart + lung institute, St paul’s hospital, University of British Columbia, Vancouver, BC; 2Respiratory Epidemiology and Clinical Research Unit, montreal Chest institute, mcgill University, montréal, QC; 3Department of medicine, QEii health Sciences Centre, Dalhousie University, halifax, nS; 4Division of Respiratory medicine, toronto Western hospital, University of toronto, toronto, on; 5Departments of medicine and Community health Sciences, University of Calgary, Calgary, AB; 6Division of Respiratory medicine, University of British Columbia, Vancouver general hospital, Vancouver, BC; 7ottawa hospital Research institute, University of ottawa, ottawa, on; 8University of Saskatchewan, Royal University hospital, Saskatoon, SK; 9Centre de pneumologie, institute Universitaire de Cardiologie et de paneumologie de Quebec, Quebec, QC; 10Division of Respiratory & Critical Care medicine, Queen’s University Kingston; 11physical therapy-Respiratory Division, University of toronto, toronto, on BaCkgRound: The ratio of forced expiratory volume in one second to that in 6 seconds FEV1/FEV6, has been suggested as a surrogate for FEV1/forced vital capacity(FVC) for screening airflow obstruction.aiM: The purpose of the study is to determine the optimal fixed cut-off points for FEV1/FEV6 as an alternative to FEV1/FVC in the detection of spirometric obstruction.

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MetHods: 3,042 people aged 40 years and older from 5 sites in Canada completed interviewer administered questionnaires and performed spirom-etry before and after administration of 200ug of inhaled salbutamol (albuterol). The data from 2911 [96%] subjects with ATS acceptable spiro-metric data on bronchodilator response, was used for analysis.The cutoff value for FEV1/FEV6 with the best sum of sensitivity and specificity was determined from receiver operating characteristics (ROC) curves.Results: FEV1/FEV6 <77% was the best cut-off that corresponded to fixed ratio FEV1/FVC <70% , while FEV1/FVC<75% matched lower limits of normal (LLN) FEV1/FVC for detection of airflow limitation, as deter-mined from the ROC curves shown below. The sensitivity, specificity for FEV1/FEV6<77% cut-off were: 94.3%, 87.0% respectively; the correspond-ing values for FEV1/FEV6 <75% cut-off were: 91.4%, 91.6%.

ConClusions: Optimal fixed cut-offs of FEV1/FEV6 can be used as valid substitutes to FEV1/FVC fixed ratio or FEV1/FVC LLN, respectively in the screening of airflow limitation in unselected general populations.Funding: Support for the COLD(CanCOLD) study was provided by unre-stricted educational grants from AstraZeneca Canada, Boehringer Ingelheim Canada, GlaxoSmithKline Canada, Pfizer Canada and CIHR Rx&D Collaborative Research Program.

10SimplE SpiRomEtRy AS A FiRSt linE tESt FoR ASthmA DiAgnoSiS in pRimARy CAREAnthony D’urzoDepartment of Family and Community medicine, University of toronto, toronto, onRationale: Spirometry is recommended as a first line test for asthma diagnosis in a number of guidelines. The present study was undertaken to determine whether there is sufficient evidence to promote spirometry as a first line test for asthma diagnosis in primary care as compared to MCT.MetHods: Medline/Embase were used (search words, spirometry, bron-chodilator responsiveness (BDR), asthma diagnosis, methacholine challenge testing, comparison, sensitivity, specificity) to identify articles comparing BDR using simple spirometry to MCT in the primary care setting. There were insufficient randomized-controlled studies with comparable design, patient populations and outcomes to carry out a systemic review or meta-analysis. A critical analysis of relevant publications was carried out.Results: The available publications reviewed suggest that MCT has far greater sensitivity for asthma diagnosis (among primary care patients) compared to BDR using simple spirometry. In fact, most asthma patients in primary care present with normal baseline spirometry on initial testing; few studies describe practical strategies for spirometric asthma diagnosis and management when initial spirometric testing is normal.ConClusions: This study suggests that asthma diagnosis can be con-firmed in only a small minority of patients using simple spirometry and BDR compared to MCT. The current evidence does not support simple spirometry as a first line test for asthma diagnosis in primary care. Further studies comparing simple spirometry to MCT for asthma diagnosis confir-mation and de-novo asthma diagnosis in primary care are required. Such studies should also address practical considerations related to how test selection may influence costs and outcomes related to asthma care. Current Canadian asthma guidelines should highlight the low sensitivity of simple spirometry for asthma diagnosis compared to MCT, including practical strategies designed to promote management of patients in the interim between suspected and confirmed asthma diagnosis.

11thE ASSoCiAtion oF ASthmA EDUCAtion CEntRES on REpEAt hoSpitAlizAtionS AnD EmERgEnCy DEpARtmEnt ViSitS FoR ASthmA in ontARionancy J garvey1,2, yan lu2, Jun guan2, phillip t Bwititi1, therese Stukel2,3,4, Astrid guttmann2,3

1Charles Stuart University, Wagga Wagga, new South Wales, Australia; 2institute for Clinical Evaluative Sciences; 3University of toronto; 4Sunnybrook health Sciences Centre, toronto, onRationale: Clinical practice guidelines for asthma recommend patient education as an essential component of optimal asthma manage-ment. Since 1990, over 30 hospital-based asthma education centres (AECs) have been established in Ontario. This study investigated whether access to AECs by patients in Ontario is associated with reduced risk of asthma readmissions and repeat emergency department (ED) visits.MetHods: This retrospective population-based cohort study using linked health administrative and survey data included all children and adults aged 2 to 55 hospitalized or admitted as high triage score ED attend-ees with a diagnosis of asthma in Ontario from April, 2004 to March, 2007. Poisson regression modeled the effect of AEC availability at the index hospitalization or ED visit (none, part-time, full-time and extended hours) controlling for age, gender, socioeconomic status, rural residence, history of prior asthma admissions, primary and/or specialist asthma care, and hospi-tal type on outcomes: readmissions or high triage ED visits or death in the 6 to 36 months following the index event.Results: Of the 163 acute care facilities in Ontario included in the study, 36 had hospital-based AECs and 17 others provided referral service to a hospital-based site. 75,054 children and adults who had been hospital-ized or admitted to the ED were included in the cohort. There was a signifi-cant decrease in repeat ED visits for patients who had access to an AEC that offered extended hours (mean estimate 0.7831, 95 percentile confi-dence intervals 0.68-0.90, p=0.0003) as compared with those with no access to AEC. There were no significant advantages to patients with access to AECs with limited or part-time hours.ConClusions: As currently implemented in Ontario, access to AECs is only associated with measurable benefit if AECs offer fulltime regular and extended hours. Implementation of AECs should consider availability of services.Funding: Grant from the Canadian Institutes for Health Research

12VAlVED holDing ChAmBERS (VhCS) ARE non-intERChAngEABlE: DEVElopmEnt oF A UniVERSAl VhC thAt pRoViDES ASSURAnCE oF DRUg DEliVERy to pAtiEntS AnD hEAlth CARE pRoViDERSh harkness, C C Doyle, R Ali , V Avvakoumova, J p mitchell, mW nagelmedical Aerosol laboratory, trudell medical international, london, ontario, onRationale: Achieving compliance with inhaled therapy is challeng-ing. Developing patient friendly VHCs that provide feedback of proper use (example, Inspiratory Flow Indicator) can help on the patient side. However, practitioners need security in knowing that the VHC prescribed will not impact the amount of inhaled drug delivered. Each pMDI+VHC combination is unique and only chambers that have been tested with a particular inhaler should be recommended. This laboratory investigation was undertaken to assist practitioners in the pMDI+AS-VHC selection.MetHods: AeroChamber® Girlz/Boyz® VHCs (Trudell Medical International, London, Canada) manufactured from non-conducting materials were evaluated with several pressurized metered-dose inhaler (pMDI) products (n=5 devices/group). VHCs were prepared in accordance with manufacturer instructions. Measurements of fine particle mass <4.7 µm aerodynamic diameter (FPM <4.7µm) were made at 28.3 L/min by Andersen multi-stage cascade impactor (ACI) equipped with USP/Ph.Eur. induction port operated with a 2 s delay interval between pMDI actuation and the onset of sampling, simulating use by an uncoordinated patient. FPM <4.7µm was also determined for the pMDI alone (no delay). Assay for

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the active pharmaceutical ingredient(s) recovered from the components of the measurement apparatus was undertaken by validated methods based on HPLC-spectrophotometry.Results: FPM <4.7µm for the pMDI alone and pMDI+AS-VHC (mean ± S.D.) respectively are summarized for the following pMDI products: Flovent®-125: 46.2±2.1, 44.7±2.8; Ventolin®: 34.8±1.4, 33.4±4.2; Advair®50/25 – fluticasone propionate component: 17.4±2.1, 19.7±1.0; Advair®50/25 – salmeterol xinafoate component: 8.9±1.3, 9.5±0.6; Atrovent®: 6.7±0.4, 7.1±0.7; Alvesco®:99.9±2.5, 97.1±6.1; Qvar™: 41.9±2.2, 42.6±5.7; Zenhale® – mometasone furoate component: 43.8±1.7, 41.9±3.5; Zenhale® – formoterol component: 2.4±0.3, 2.0±0.1.ConClusion: The AeroChamber® Girlz/Boyz® VHC can be used with the pMDI medications studied without modifying prescribing instruc-tions, as the pMDI alone and pMDI+VHC drug delivery are substantially equivalent.Financial support: The authors are employees of Trudell Medical International, who funded the study.

13impACt in hEAlthCARE SERViCE USE oF ASthmA pAtiEnt With ChAnging mEDiCAtion REgimEnS – thE impoRtAnCE oF optimAl mAnAgEmEntt zhang1,2, R Jimenez-mendez1,3,4, A Smith3,4, B Carleton1,2,3,4

1Faculty of medicine, Department of paediatrics; 2Faculty of pharmaceutical Sciences, University of British Columbia; 3pharmaceutical outcomes programme, BC Children’s hospital; 4Child and Family Research institute, Vancouver, BCintRoduCtion: Suboptimal medication regimen in Asthma is asso-ciated with a higher risk of exacerbations. Unfortunately, a substantial number of patients remain on suboptimal therapy. This study determined the association between changes of asthma drug therapy (i.e. suboptimal to optimal) and patients’ health service utilization over a nine-year period.MetHods: A cohort of 129,698 asthma patients between 5 and 55 years were identified using provincial health service utilization data between 1996 and 2004. The National Heart, Lung and Blood Institute Asthma Guidelines recommendations for optimal drug therapy were used to categorize patient-specific yearly regimens of short-acting bronchodilators with or without inhaled corticosteroids (ICSs) as optimal or suboptimal. Analyses focused on patients with nine suboptimal or optimal regimen years and patients with up to 7 suboptimal regimen years followed by 2 years of optimal regimens. Outcomes were the occurrence of asthma-related emergency department (ED) visits or hospitalizations during the suboptimal or optimal time period. Generalized estimating equation models were used for the analysis.Results: Patients who used asthma medication suboptimally over the entire study period were six times more likely to use ED (OR 5.8, 95% CI 4.8-7.3) and eight times more likely to use hospital services (OR 8.3, 95% CI 5.3-13.1) for asthma compared to patients who used their medications opti-mally over 9 years. Patients who changed their drug therapy from suboptimal to optimal were significantly less likely to be admitted to ED or hospital for asthma compare to patients who used their medications suboptimally over the entire 9 years (e.g., among patients with 4 suboptimal regimen years fol-lowed by 2 optimal regimen years, OR 0.1, 95% CI 0.02-0.46).ConClusion: Changing from suboptimal to optimal therapy results in reductions in healthcare service use by asthma patients. Findings from this study suggest the need of close monitoring of patients’ therapy and encour-aging adherence to guidelines.

14ASthmA in olDER ADUltS: potEntiAl FACtoRS to ExplAin thE inCREASED moRtAlity RAtESRichard leigh1, tony W meng1, Charity D greene1, Suzanne l traves1, margaret m Kelly1, David proud1 1Airway inflammation Research group, University of Calgary, Calgary, AB Rationale: It is estimated that 7% of people over 65 have asthma. Of concern is that asthma-related mortality rates are about 10-fold higher in asthmatics over 65, compared to any other age group. The reasons for this

difference are unknown and, in this study, we sought to test the hypothesis that airway inflammatory phenotypes in older adults with asthma differ from other age groups.MetHods: Induced sputum cell counts are performed on all patients attending our hospital-based asthma clinic to guide clinical management. Patient data, including medications, spirometry measurements and sputum cell counts are entered into an electronic database. We therefore per-formed a retrospective analysis of these data to determine the nature of the airway inflammation in patients > 65 years (older) compared to those under 65 (younger) with physician-diagnosed asthma.Results: Between 2005 and 2011, 1046 patients with physician-diag-nosed asthma had sputum analysis. Of these, 930 were under 65 and 116 were > 65 years old. The majority (75%) of older patients had sputum eosinophils >2.0%, vs. 54% of patients <65 (p<0.001). The median eosinophil count in the older group was 7% (IQR 1.5-31%) vs. 2% (0.3-9%) in the younger group (p<0.001). The older group had more severe airflow obstruction (FEV1 75% predicted) vs. the younger group (FEV185%) (p<0.001). There were no differences in treatment regimens between the 2 groups.ConClusions: Asthmatic patients over the age of 65 have a higher proportion of eosinophilic airway inflammation when compared to younger patients. This is despite the fact that both groups received similar treat-ment regimens. These results indicate that the asthma in the elderly is unlikely to be due to misclassification of COPD, and implies that elderly patients are either less adherent to current asthma therapies or that the underlying airway inflammation is relatively resistant to current anti-inflammatory therapies.Funding: Alberta Health Services

15ASthmA ContRol in A RAnDom SAmplE oF CAnADiAn ASthmA pAtiEntSmohsen Sadatsafavi1, Roxanne Rousseau2, larry D lynd1, Carlo A marra1, Wan C tan2, mark J Fitzgerald2

1Faculty of pharmaceutical Sciences; 2Faculty of medicine; University of British Columbia, Vancouver, BCintRoduCtion: Asthma control has been documented as being sub-optimal in many studies. The reported prevalence of asthma control has not always been population-based and may be severely biased by the sam-pling method.MetHods: We prospectively recruited subjects 1- to 85-years-old in British Columbia, Canada, using random digit dialing. Included subjects had a physician diagnosis of asthma with at least one asthma-related medi-cal encounter in the past five years. At baseline we collected information on the demographic characteristics, socioeconomic status, did spirometry, and determined the level of asthma control according to the Global Initiative for Asthma (GINA) classification. We calculated the prevalence of controlled, partially controlled, and uncontrolled asthma. We also per-formed a proportional-odds ordinal logistic regression analysis with asthma control level as the dependent variable among the sub-sample of adoles-cents and adults for whom socio economic data were available.Results: Control level could be assessed for 272 subjects (97% of sam-ple, mean age 43.9 years, s.d. 21.0, 59.3% female). Of these, 67 (24.6%) were controlled, 109 (40.1%) were partially controlled, and 96 (35.3%) were uncontrolled. The Table shows the results of the regression analysis among the adolescent and adult asthmatics (n=232). The only two factors associated with the level of control were gender (p=0.05) and whether the patient was born in Canada (p=0.03). However, there was no association between these two factors (p=0.78 for gender, p=0.43 for place of birth) and asthma control among children (n=33) in the univariate analysis.ConClusion: Our results obtained from a random sample in BC showed a substantial lack of asthma control. There was no difference in the level of asthma control between sexes in children. However, among adoles-cents and adults, females had greater risk of poorer control. Our results may help policy makers with strategies for targeting populations to achieve bet-ter asthma control.

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16USE oF ComplEmEntARy AnD AltERnAtiVE thERApiES in pAtiEntS With ASthmA: pREliminARy RESUltS FRom A pRoSpECtiVE StUDymohsen Sadatsafavi1, Roxanne Rousseau2, larry D lynd1, Carlo A marra1, Wan C tan2, J mark J Fitzgerald2

1Faculty of pharmaceutical Sciences; 2Faculty of medicine; University of British Columbia, Vancouver, BCintRoduCtion: Asthma patients are using complementary and alter-native therapies (CATs) in the management of their asthma. As part of an ongoing study, we prospectively documented participant reported use of CATs.MetHods: We recruited participants 1-85 years old from two geographic locations in BC using random digit dialing (RDD). Inclusion criteria were a physician diagnosis of asthma and use of at least one asthma-related health care resource in the past 5 years. We collected information on demographic characteristics, use of CATs, and performed a lung function test. Participants were categorized based on the level of asthma control (defined per GINA 2006 including lung function results). We compared the demographic information and asthma control of users and non-users of CATs.Results: For 280 participants (99% of recruited sample) the data on CATs use was complete (mean age 43.6±20.4, 60.5% female) with 75 sub-jects reporting any CAT (26.8%) use. Common CATs were breathing exercises, and herbal medicines (11.1% each) and dieting (5.7%). Homeopathy was the least common form of CAT (1.8%). Among partici-pants reporting use of CAT compared to non-CAT users there were no significant differences with age (p=0.44) and gender (p=0.33). There was a significant inverse association between use of AT and asthma control: among the users of CAT, asthma was fully controlled in 16.9% while in non-users it was fully controlled in 30.1% (p=0.03) according to GINA guidelines.ConClusions: Randomly selected participants showed poor asthma control where the use of CAT was high. The inverse relationship between the use of CAT and asthma control could be due to the complementary role of CAT among patients whose asthma is difficult to control despite medications, a substitute role among patients who are not willing to adhere to conventional therapies for their asthma, or even a potentially casual role in worsening asthma.Financial support: Funding was obtained from the GlaxoSmithKline Collaborative Innovative Research Fund (CIRF).

17Do hAiRDRESSERS ExpERiEnCE moRE RESpiRAtoRy SymptomS thAn non-hAiRDRESSERS?Shamara Sinnatamby1,2, Dennell mah1, Jeremy Beach1, Dilini Vethanayagam1

1Department of medicine, Faculty of medicine and Dentistry, University of Alberta, Edmonton, AB; 2Department of Environmental Studies, york University, toronto, onintRoduCtion: Hairdressers may complain of general (headaches, dizziness) and respiratory (shortness of breath, cough, wheeze) symptoms with exposure to chemicals such as hair bleaches, dyes and styling products. As hairdressers are frequently exposed to chemicals, this suggests a possible association between the hairdressing occupation and asthma. This study aimed to investigate this association through the administration of a ques-tionnaire to a group of hairdressers and a group of retail workers.MetHods: We conducted a cross-sectional study in the Edmonton area. Hairdressers and a comparison group of retail workers were chosen by con-venience sampling and asked to complete a questionnaire which included questions about respiratory symptoms (and whether symptoms were experi-enced at work or not at work), family history of asthma, exposure to hair bleaches and dyes, asthma/allergy history and smoking history. Subject demographics including age, gender, education, occupation, years in cur-rent occupation were also recorded.Results: 55 hairdressers and 52 retail workers participated. The average age of the hairdressers was 29 years, the majority (85%) were female.

Hairdressers interviewed had spent a mean of 8.8 years working in the industry. Average age of the retail workers was 23 years, the majority were female (67%). Retail workers had spent an average of 3.2 years in their occupation. There were statistically significant differences with hairdresser reporting more shortness of breath (p=0.04), cough (p<0.01), and dizziness (p<0.01) than retail workers. There were no differences in asthma or allergy history between the two groups. More hairdressers than retail work-ers reported eczema/dermatitis (p<0.01), but none of the hairdressers reported this developed after starting work in the industry.ConClusions: Significantly more respiratory symptoms were reported by the hairdresser group. There was no significant difference between the groups in reported asthma or allergies, while a difference in the prevalence of eczema/dermatitis may not be work-related.Funding: No external funding

18ASthmA AnD CopD pAtiEntS’ CARE gApS At EmERgEnCy DEpARtmEnt DiSChARgECristina Villa-Roel1,2, mohit Bhutani3, Jennifer Victor1, Stephanie Couperthwaite1, Brian h Rowe1,2

1Department of Emergency medicine; 2School of public health; 3Department of medicine, University of Alberta, Edmonton, ABRationale: Asthma and (chronic obstructive pulmonary disease) COPD patients who present to the Emergency Department (ED) usually lack adequate ambulatory disease control. There is limited information regarding the pharmacologic or non-pharmacologic needs of these patients at discharge. This study aimed to evaluate patients’ needs concerning the ambulatory management of their respiratory conditions after ED treatment and discharge.MetHods: Over 11 months, 108 adult patients with acute asthma or COPD, presenting to a tertiary care Alberta Hospital ED and discharged after being treated for exacerbations were enrolled. Using a standardized form, charts were reviewed by trained data abstractors to identify care gaps.Results: Overall, 67 asthmatic and 41 COPD patients were enrolled. More patients with asthma required education on spacer devices (57% vs 32%; p=0.02). Most asthma (93%) and all COPD patients denied written action plans; however, asthma patients were more likely to need adherence counselling (51% vs 32%; p=0.08) for preventer medications. More patients with asthma required influenza vaccination (72% vs 37%; p=0.001); pneumococcal immunization was low (34%) in COPD patients. Only 22% of asthmatics reported ever being referred to an asthma educa-tion program and 20% of the COPD patients reported ever being referred to pulmonary rehabilitation. At ED presentation, 33% of the asthmatics were assessed to require the addition of inhaled corticosteroids (ICS) and 15% required the addition of ICS/long acting beta-agonist (ICS/LABA) combination agents. Conversely, 32% of COPD patients were assessed to require the addition of long acting anticholinergics (LAAC) while most (85%) were receiving preventer medications. Finally, 32% of COPD and 27% of asthma patients required smoking cessation counselling.ConClusions: Overall, we identified various care gaps for patients presenting to the ED with asthma and COPD. There is an urgent need for high-quality research on interventions to reduce these gaps.Funding: Department of Emergency Medicine, University of Alberta; GlaxoSmithKline (GSK).

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19pREVEnting ASthmA ExACERBAtionS With A ShoRt CoURSE oF oRAl StERoiDS At thE EARliESt Sign oF UppER RESpiRAtoRy tRACt inFECtionS: pREliminARy RESUltS oF An ongoing poliCy tRiAlB Wilkinson1,2,3, R Jimenez-mendez1,2,3, g groeneweg1,2,3, A Smith1,2,3, R goldman1,4, B Carleton 1,2,3

1Faculty of medicine, Department of paediatrics, University of British Columbia; 2pharmaceutical outcomes programme, BC Children’s hospital; 3Child & Family Research institute; 4Emergency Department, British Columbia Children’s hospital, Vancouver, BCRationale: Emergency department (ED) visits due to asthma exacer-bations account for a significant burden on health services, and affects the quality of life of patients and families. As much as 80% of these exacerba-tions are caused by upper respiratory tract infections (URTIs). Despite being recommended in clinical guidelines, prescribing a short course of oral steroids at the earliest signs of a URTI is still not widely accepted.MetHods: Repeated users of ED services with a diagnosis of asthma exacerbation are randomized either to receive a filled prescription of oral steroids with detailed instructions on how to use them at the earliest sign of their next URTI, or are provided with the standard of care upon depar-ture from the ED. Follow up interviews are conducted to determine quality of life and the occurrence and frequency of any asthma exacerbations and/or URTI symptoms.Results: We have enrolled 60 patients, with 19 in the intervention group. 6 patients in this group have used the provided oral steroids and were able to avoid further ED or Physician visits. A higher quality of life was reported also in this patients and families. Several factors have been identified as barriers: the believe that the families will not be able to cor-rectly administer the oral steroid, that oral steroids will be administered but not followed up with correctly, and that there is no value in providing access to a medication when there is no active exacerbation.ConClusions: We have documented the efficacy of this intervention, and its positive impact on the quality of life for both patients and families. Some barriers that contribute to the difficulty in widely implementing this strategy into practice had been identified. Further research is necessary to quantify the improvement in quality of life, and to record barriers in uptake by different stakeholders.

CopD / oSA Clinical mpoC / ASo – Clinique

20KlEARWAytm oRAl AppliAnCES FoR pEDiAtRiC pAtiEntS With REtRUDED mAnDiBlESh Chen1, K yagi1, hiroko tsuda2, F Almeida3, A lowe1

1Department of oral health Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BC; 2 general Dentistry, Kyushu University hospital, Fukuoka, Japan; 3Department of oral Biological & medical Sciences, Faculty of Dentistry, University of British Columbia, Vancouver, BCRationale: The KlearwayTM appliance was designed to open the air-way by gradual advancement of the mandible. It has been used successfully for adult patients with obstructive sleep apnea and/or snoring. The func-tional effects of KlearwayTM on mandibular growth in pediatric patients with retruded mandibles have not been investigated. This preliminary study assessed how KlearwayTM could be utilized as a functional appliance.MetHods: Patients were selected to participate from the undergraduate orthodontic program at UBC. The criteria for each patient were: patients with mixed dentitions, significant overjets, growth remaining, well aligned lower incisors upright over basal bone and good lower face heights. The baseline data included study models, cephalometric & panoramic X-rays, together with intra-oral & extra-oral photos. In addition, a sleep question-naire was administered at baseline. A customized KlearwayTM was fabri-cated for each patient and a portable sleep monitor (Watch-Pat) was used

on the insertion night. Patients were advised to wear KlearwayTM at night only. The patients were treated by monitoring and/or adjusting KlearwayTM

on a monthly basis. Follow-up records were obtained to verify the craniofa-cial changes and sleep quality.Results: No patients discontinued therapy due to appliance discomfort. Some 18 patients (8 girls and 10 boys) completed Phase I treatment. The average baseline age was 12 years 0 months. The Angle’s classification transitioned to Class I in 16 patients and Class III in 2 patients. The over-jet was significantly decreased from 7.0±2.4 mm to 3.0±2.3 mm (p<0.001). The overbite was decreased significantly from 59.4±23.6% to 28.1±19.4% (p<0.001). There were no significant findings in questionnaire scores and sleep analysis.ConClusions: KlearwayTM is a suitable functional appliance for pedi-atric patients who exhibit retruded mandibles. This preliminary study did not confirm any significant changes in children’s sleep.

21EFFECt oF An intEgRAtED CARE AppRoACh With SElF-mAnAgEmEnt in pAtiEntS With CopDA Joubert, i ouellet, i Drouin, C lombardo, F paquet, D Beaucage, J Bourbeaumontreal Chest institute, mcgill University health Centre; Respiratory Epidemiology and Clinical Research Unit, mcgill University, montreal, QCBaCkgRound: Most successful integrated care approaches include interdisciplinary care team and self-management preparation emphasizing the patients’ central role in managing their chronic disease.oBjeCtive: To assess success of a customized self-management program (www.livingwellwithcopd.com Password: copd) with case management in COPD patients with increased disease severity from a COPD clinic i.e., patients’ use of the Action Plan in the event of an exacerbation.MetHods: Amongst patients who were followed in the COPD clinic program at the Montreal Chest Institute, 100 patients were randomly selected (50 in 2006 and 50 in 2009). The intervention includes an inte-grated care approach where the case manager plays a central role. An important component of the program is the self-management preparation including the written action plan. Data were collected from chart review over one year period: 2005-2006 and 2008-2009. Information included patient characteristics, nursing case management activities and action plan outcomes. Success of acute exacerbation self-management was defined with respect to: 1) patient behavior, i.e., patient’ use of the antibiotic and/or prednisone in the event of an exacerbation; 2) complication of exacer-bations, i.e., health services use such as emergency room visits and hospital admissions.Results: Overall patients had FEV1 of 1.0L in 2006 and 0.85L in 2009. In 2005-2006, 71% of patients used an action plan with self-administered prescription at least once compared to 87% in 2008-2009. The action plan for an exacerbation was used successfully in 53% of the events in 2006 and 64% of the events in 2009. In 2008-2009 only 5% of the events required an ER visit compared to 14% in 2005-2006.ConClusion: Despite the fact that patients had a more severe disease in 2009 as compared to 2006, they used their action plan in the event of an exacerbation more successfully and they had less visits to the ER.Financial support: Unrestricted educational grant from GSK.

22thE impACt oF polyphARmACy on thE oUtComES oF pUlmonARy REhABilitAtionEric Kaplovich1, Roger S goldstein2, Robert g Varadi21Faculty of medicine, Undergraduate medical Education, University of toronto; 2Department of Respiratory medicine, West park healthcare Centre, toronto, onPolypharmacy, defined as the use of an excessive number of medications, has been associated with increased morbidity and drug side effects in sev-eral medical conditions. Although prevalent among patients with chronic lung diseases, its impact on pulmonary rehabilitation (PR) is unknown. We hypothesized that patients with polypharmacy enrolling in PR would

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experience less marked improvements in quality of life and exercise capac-ity than those without.This retrospective cohort study included 299 patients (75% with chronic obstructive lung disease) who participated in a 6-week inpatient PR pro-gram in 2009-2010. Charts were reviewed for demographics, pulmonary function, exercise tests, symptoms and health status measures. All self-reported medications, including both prescription and over-the-counter products, were noted. Health status and exercise measures were repeated at program completion. The primary study outcome was change in the total Chronic Respiratory Questionnaire (CRQ) score.Results: The median number of medications used was 10. Patients had severe lung disease (FEV1 44±21% predicted) and 23% required supple-mental oxygen at rest. Patients with polypharmacy (using ≥10 medica-tions) were older (70 versus 67 years, p=0.02) and had poorer baseline exercise tolerance (6-minute walk distance 257 versus 309 metres, p<0.01; self-paced endurance walk time 14 versus 18 minutes, p<0.01) than those without. Polypharmacy did not influence the post-rehabilitation change in CRQ (mean total CRQ score increased by 1.5 versus 1.3 units, p=0.17) or exercise tolerance (6MWD increased by 58 versus 54 metres, p=0.59), even when adjusted for age, sex, baseline lung function and exercise capacity.ConClusion: Polypharmacy did not adversely affect the improve-ments in health status or exercise tolerance following PR and should not prevent enrolment in PR.Financial support: None.

23RESpiRAtoRy SymptomS ASSoCiAtED With ChRoniC ConDitionS Among thoSE With AnD WithoUt ASthmA oR CopDJoshua Allan lawson1, punam pahwa2, Shelley Kirychuk, Chandima Karunanayake, Donna Carole Rennie3, louise hagel, James Dosman; on behalf of the Saskatchewan Rural health Study (SRhS) Research group 1Department of medicine; 2Department of Community health and Epidemiology; 3College of nursing, Canadian Centre for health and Safety in Agriculture, University of Saskatchewan, Saskatoon, SKBaCkgRound and Rationale: Some chronic conditions may result from similar mechanisms suggesting the investigation of disease inter-relationships. We sought to determine if respiratory symptoms were more common among adults with chronic conditions and to examine this association among those with and without asthma or COPD.MetHods: We conducted a cross-sectional survey as part of the Saskatchewan Rural Health Study in 2010. Questionnaires were mailed to households in rural Saskatchewan. One adult per home provided informa-tion regarding each adult living in the home. There were 8261 adults from 4624 households (52% participation) included. Using descriptive statistics and multiple logistic regression, we examined the associations between reported diagnosed chronic conditions (diabetes, stroke, cardiovascular, chronic bronchitis, and sleep apnea) and respiratory symptoms (wheeze, cough, and phlegm) after adjusting for potential confounders and stratify-ing by history of doctor-diagnosed asthma or COPD.Results: The respondents’ mean age was 56 years (SD=16 years) with 51% of the population being female. As expected, there was a higher preva-lence (p<0.001) of reported wheeze, cough, and phlegm among those with a history of asthma or COPD (9.6% of the population). After adjustment, when there was no history of asthma or COPD, there was increased risk of wheeze associated with cardiovascular disease, chronic bronchitis and sleep apnea; increased risk of cough associated with each chronic condition except diabetes and; increased risk of phlegm with stroke, chronic bronchitis and sleep apnea. Among those with a history of asthma or COPD, respiratory symptoms were only associated with chronic bronchitis.ConClusions: Cardiovascular disease and stroke were associated with respiratory symptoms but only in the absence of asthma or COPD. Presence of these symptoms along with a non-respiratory chronic condition may result from common pathways, possibly inflammatory in nature, and may proceed more serious chronic lung disease.Financial support: Canadian Institutes of Health Research (MOP: 90002)

24pERCEiVED nEEDS oF CopD pAtiEntS FRom DiFFEREnt illnESS SEVERitiES ARoUnD thE AppRoACh to ADVAnCE CARE plAnningA Joubert, m nguyen, J Chamber-Evans, i Drouin, i ouelletmontreal Chest institute, mcgill University health Centre, montreal, Quebec, QCBaCkgRound: COPD’s unpredictable illness trajectory makes it diffi-cult for patients to plan for the end-of-life (EOL). In studies, there is no clear consensus on what the needs for EOL would be, or under which con-ditions advance care planning (ACP) can be best approached with COPD patients. A DVD was developed in the province of Quebec as a tool for facilitating ACP.oBjeCtive: The primary purpose of this study is to better understand the perceived needs of COPD patients from different illness severities around the approach to advance care planning (ACP). The secondary purpose is to investigate the usefulness of a DVD in meeting the needs of COPD patients at the Montreal Chest Institute.MetHods: A qualitative descriptive design is used to obtain rich data from 12 patients, four from each MRC categories 3, 4 & 5. Participants are recruited at the COPD clinic at the Montreal Chest Institute and are inter-viewed about their perceived needs on ACP. After viewing the DVD they participate in a second interview about their perceptions of it’s usefulness for approaching ACP.Results: To date, 10 out of 12 patients were interviewed. So far, illness severity is not indicative of the amount of preparatory measures made for EOL. Half of the participants preferred ACP to be done sooner rather than later, while the other half did not want to have EOL approached at all until the very end. Moreover, no major differences in perceived needs appear between groups of illness severity. Regarding the DVD, subjects mainly appreciated patients’ testimonies.ConClusion: It seems that health professionals cannot rely on illness severity when initiating ACP with COPD patients and must remain sensi-tive to their personal values. A standardized approach to ACP may not be ideal. Rather, a patient-centered tailor-made approach would be more appropriate.Financial support: None

25EVAlUAting impACtS oF A nEW CopD oUtREACh pRogRAm (inSpiRED)graeme m Rocker1,2, Joanne young1, A Catherine Simpson1, Jillian Demmons1, Wendy Conrad1

1Division of Respirology, QEii health Sciences Centre (QEii hSC); 2Faculty of medicine, Dalhousie University, halifax, nSRationale: At the QEII HSC, COPD accounts for ~ 300 admissions per year, costing ~ $3 million annually. Current models of care, focused primarily on acute care, are failing with significant costs to patients, fami-lies, and systems. INSPIRED is a new evidence-based outreach program introduced to address gaps in care by providing holistic, hospital-to-home services for those living with advanced COPD. Services include: disease self-management education, creation of “action plans” for management of acute exacerbations, provision of psychosocial-spiritual support, and engagement of patients/family caregivers in advance care planning discussions.MetHods: For quality assurance purposes, a mixed-methods approach was used to evaluate the program’s initial phases. Patients (P) and family caregivers (FCG) were interviewed and completed quantitative measures for health-related quality of life and dyspnea intensity (P), anxiety/depres-sion and hope (P; and FCG) before and after completion of the program. Interviews focused on the experience of living with advanced COPD, per-ceived gaps in care, and hopes for/views about INSPIRED. Using hospital databases, we also tracked patients’ COPD-related use of acute care ser-vices (number of ER visits and hospital admissions) from one year pre-program enrollment to 6 months following enrollment.Results: From February to June of 2011, 27 patients were enrolled. Preliminary themes emerging from interviews suggests participants greatly

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appreciated the program and felt: 1) more confident in managing COPD-related symptoms, 2) less anxious/stressed, and 3) willing to discuss goals of care including those related to end-of-life. Changes to length of stay (LOS/Bed Days), ER visits, and estimated cost savings are outlined in Table 1.

Table 1.Pre

INSPIRED n=27

12 months

Post INSPIRED

n=27 Evaluation

at 3 months

Post INSPIRED

n=27 Evaluation

at 6 months

Cost savings

Post INSPIRED

n=27 Projected at 12 months

Cost savings

Projected at

12 monthsER visits (n) 105 8 16 32Admissions (n) 57 4 8 16LOS/Bed Days 679 78 96 $487,000* 192 $974,000** Based on estimated cost of one bed day = $1000

ConClusions: Carefully planned chronic disease management initia-tives can yield significant cost savings and decrease burdens for those living with advanced COPD.Financial support: Pilot program: Hybrid funding. Program evaluation: Lung Association of Nova Scotia.

26USing opioiDS to tREAt REFRACtoRy DySpnEA in ADVAnCED CopD: EARly inSightS FRom A CliniCAl tRiAlgraeme m Rocker1,2,3, Jillian Demmons1, margaret Donahue1, Joanne young1, A Catherine Simpson1, paul hernandez1,3, Robert horton2,3 1Division of Respirology; 2Division of palliative medicine, QEii health Sciences Centre; 3Faculty of medicine, Dalhousie University, halifax, nSRationale: A 2011Canadian Thoracic Society (CTS) clinical prac-tice guideline recommends opioids as a treatment for refractory dyspnea in patients with advanced COPD. However, experience with opioids in this setting remains limited and patient/family caregiver experiences are mostly unknown. We designed a clinical trial (NCT00982891) to further under-stand the experiences of those living with advanced COPD when opioids are added to optimized conventional treatment.MetHods: We conducted semi-structured interviews with patients (P)/family caregivers (C) before, at 2 months, and 4-6 months after initiating opioid therapy in addition to optimized conventional treatment. Interviews were recorded, transcribed verbatim, and analysed using interpretive description methodology. We also collected ratings of dyspnea, health-related quality of life (HRQoL) and how helpful (or not) participants found opioid therapy.Results: 38 patients have enrolled over 18 months, 28 (74%) have completed the trial (7 withdrawals, 3 deaths). Patient data at 2 weeks (n=31), 2 months (n=25), 4-6 months (n=20), describe opioids to be either very helpful (32%, 40%, 55%) or somewhat helpful (48%, 48%, 40%) respectively. Dyspnea intensity (Numerical Rating Scale 6.16 vs 4.76) and HRQoL (CRQ 3.4 vs 4.4) improved significantly (p<0.05) from baseline to 6 months respectively. Preliminary interview findings suggest opioids: 1) improve QoL; 2) provide a new sense of hope for the future; and 3) that positive impact of opioids may wane over time for some.ConClusions: Opioids, when carefully initiated and titrated, appear to be a helpful and acceptable intervention for refractory dyspnea with benefits sustained over months. Findings support recent CTS recommen-dations regarding opioid prescribing for refactrory dyspnea in advanced COPD.Financial support: Canadian Institutes of Health Research

27pRotEomiC SignAtURE in plASmA oF ChRoniC oBStRUCtiVE pUlmonARy DiSEASE SUBJECtS CAn DiFFEREntiAtE FREQUEnt ExACERBAtoRS FRom non-ExACERBAtoRSKaren Sherwood1,2,3,4, Virginia Chen3, zsuzsanna hollander1,2,3,5, Janet Wilson-mcmanus3, Bruce miller6, Bruce m mcmanus1,2,3,5, Christoph h Borchers7, Raymond ng1,2,3,8, Scott J tebbutt1,2,3,4, Don D Sin1,2,3,4

1James hogg Research Centre, St paul’s hospital, University of British Columbia; 2institute for hEARt+lUng health; 3nCE CECR pRooF Centre of Excellence; 4Department of medicine, Division of Respiratory medicine, University of British Columbia; 5Department of pathology and laboratory medicine, University of British Columbia, Vancouver, BC; 6glaxoSmithKline plc, Collegeville, USA; 7genome BC proteomics Centre, University of Victoria, Victoria; 8Department of Computer Science, University of British Columbia, Vancouver, BCRationale: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in Canada and may affect up to 3 million Canadians. COPD exacerbations are difficult to predict. To identify COPD subjects susceptible to exacerbations, and thus help COPD disease man-agement, we aimed to discover a plasma proteomic profile that is predictive of frequent exacerbations.MetHods: A total of 166 subjects who had zero or one exacerbations in the year previous to enrollment were selected from the ECLIPSE cohort for the proteomics analysis. Of these, 107 were included for discovery (34 frequent exacerbators (FE) and 73 non-exacerbators (NE)) and 59 were included for validation (21 FE and 38 NE). Plasma samples were analyzed using iTRAQ-MALDI-TOF/TOF mass spectrometry. Data were interrogated using ProteinPilot™. Moderated robust t-test was used to determine dif-ferentially expressed proteins (p<0.1), which were used to build a classifier model using Elastic Net. Area under the receiver operating characteristic curve (AUC) and Net Reclassification Index (NRI) were used to compare the discriminative power of the panel with that of FEV1 and GOLD stage. UniProtKB was used to determine biological functions and canonical pathways.Results: Eleven proteins were identified as significantly under-expressed in FE compared to NE samples. Of these, 4 proteins were included in the biomarker panel. The proteomic biomarkers were able to predict who will have frequent exacerbations in the next 3 years as well as FEV1 or GOLD stage (AUC = 0.71 versus 0.73 and 0.57 and NRI of −0.02 and 0.17 rela-tive to FEV1 and GOLD stage respectively). UniProtKB suggests that the majority of these proteins are involved in biological processes such as cil-ium biogenesis, angiogenesis and innate immunity.ConClusions: Using an unbiased approach, we have identified dif-ferentially expressed proteins in plasma that separates COPD patients who will exacerbate from non-exacerbators. A protein biomarker panel has been constructed which performs similarly to FEV1 and GOLD stage as a predictor of future exacerbations.Financial support: PROOF Centre of Excellence

28DiABEtES mEllitUS AnD pUlmonARy FUnCtion in hoSpitAlizED pAtiEntS With ACUtE ExACERBAtion oF CopDCarmen A Sima1, Satvir S Dhillon1, and pat g Camp1,2

1 James hogg Research Centre, University of British Columbia, providence heart + lung, St paul’s hospital; 2Department of physical therapy, University of British Columbia, Vancouver, BCRationale: Chronic Obstructive Pulmonary Disease (COPD) is an important cause of morbidity and mortality in elderly people, and multiple comorbid conditions significantly contribute to the burden of this disease. Diabetes Mellitus (DM), as a comorbid condition, is inconsistently associ-ated with worse pulmonary function in COPD. In addition, corticotherapy and antipsychotic medication commonly used by COPD patients can affect blood glucose. This study investigates the relationship between DM

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and pulmonary function in patients hospitalized for an acute exacerbation of COPD (AECOPD). Secondary objectives include assessing the relation-ships between DM and typical COPD characteristics and treatments.MetHods: The charts of 88 patients with an AECOPD, admitted to St Paul’s and Mount St Joseph’s Hospitals between January 2008 and December 2010, were reviewed. The data included anthropometric charac-teristics, respiratory function, blood tests, presence of comorbidities, and prescribed treatment. A stepwise multivariate analysis was performed to assess the effect of DM on pulmonary function in AECOPD patients, adjusting for age, presence of cardiovascular disease, and smoking history.Results: The mean age of AECOPD patients was 70±11 years with a 2:1 male/female ratio. FEV1 was 39±16% predicted. DM and cardiac dis-eases were present in 24% and 66% of patients with AECOPD, respec-tively. Body mass index (BMI) and casual glycemia were significantly higher in the diabetic group (33.7±9.5; 10.3±4.7 mmol/L) than in the nondiabetic group (24.2±6.7; 7.2±1.4 mmol/L). There was no difference in lung function between the two groups. Although corticotherapy and antip-sychotic medication use was prevalent, there was no association between these therapeutic interventions and diabetes.ConClusions: The findings of this study suggest that DM does not influence lung function in elderly people with AECOPD; instead other factors may play an important role in this detrimental association.Financial support: None disclosed

29pREVAlEnCE oF UnRECognizED oStEopoRoSiS Among CopD pAtiEntSAshley Smith, David Kendler, mark FitzgeraldDepartment of medicine, University of British Columbia, Vancouver BCBaCkgRound: COPD and oral glucocorticoids (OCS) are established risk factors for osteoporosis (OP) and fragility fracture. OP is underdiag-nosed and undertreated in these patients.aiM: To evaluate the prevalence of low bone density and fragility fracture among patients with COPD seen in a Vancouver respirology clinic.MetHods: We invited COPD patients over 65, who had not had a bone density test in the prior 2 years, to participate in our observational study. Patients were attending a respirology clinic and all had a diagnosis of COPD. We collected spirometry and historical risk factors for OP includ-ing prior fracture and oral corticosteroid (OCS) use. We performed Bone Mineral Density by Dual Energy Xray Absortiometry (DXA) of hip and spine, Vertebral Fracture Assessment (VFA) and chemistries including serum 25-OH Vitamin D.Results: The initial 15 patients (10 male and 5 female) exhibited all stages of COPD, mild COPD was diagnosed in one patient, moderate in four patients and 10 exhibited severe COPD. All but two patients were on inhaled combination therapy. OCS use was reported for 6 patients in the prior year. Normal bone density (T-score >−1) was found in one of the patients and osteopenia (T-score −1 to −2.5) was diagnosed in 4 patients. OP by DXA was found in 10 patients and VFA revealed vertebral fractures in 8 of these patients.ConClusion: COPD patients attending a respirology clinic have many risks for fragility fracture, including OCS use. They have a high likelihood of having low bone density and spine fracture. Guidelines encouraging the routine evaluation of bone health in COPD patients are required.Funding: There has been no financial support for this project.

CopD Exercise therapythérapie par l’exercice en CopD

30FEASiBility AnD ACCEptABility oF A CommUnity-BASED mAintEnAnCE ExERCiSE pRogRAm FoR pEoplE With CopDmarla K Beauchamp1,2, Susan Francella3, Debbie Rolfe4, Barbara E gibson5, Roger S goldstein2,5,6, Dina Brooks1,2,5

1graduate Department of Rehabilitation Science, University of toronto; 2Respiratory medicine, West park healthcare Centre; 3Etobicoke olympium, 4lawrence S Bloomberg Faculty of nursing, 5Departments of physical therapy and 6medicine, University of toronto, toronto, onRationale: Pulmonary rehabilitation (PR) improves exercise capacity and quality of life in individuals with COPD. However, following comple-tion of PR, benefits diminish over time such that outcomes return to pre-intervention levels within 12 months. The purpose of this study was to describe the development, implementation and acceptability of a commu-nity-based maintenance exercise program for people with COPD post-PR.MetHods: A community-based exercise program was developed in partnership with the City of Toronto, Parks and Recreation. Individuals with COPD who recently completed PR were recruited to participate in a twice weekly exercise program at a local community centre supervised by a trained fitness instructor. The transition from hospital-based PR to the com-munity centre was facilitated by a Physiotherapist. To explore patient per-ceptions of the program, three focus groups were conducted with 12 patients with COPD who had participated in the program for greater than six months. Focus groups were conducted by an experienced facilitator using a semi-structured interview guide. Interviews were audiotaped, transcribed verbatim and analyzed for recurring themes.Results: Analysis of the data revealed four main findings: 1) Participants overwhelmingly endorsed the benefits of the program, particularly with respect to perceptions of improved functioning and endurance; 2) The main barriers to participant attendance were related to exacerbations, fatigue, weather and mood; 3) Attendance enablers were the existence and structure of the program, and feelings of accomplishment and improved quality of life; and 4) The most frequently cited recommendation was to expand the number of locations in which the program was held.ConClusions: The findings of this study suggest that participants found this intervention to be beneficial and recommended expansion to other sites. The potential value of community-based maintenance exercise programs for people with COPD warrants further exploration.Financial support: Marla Beauchamp is supported by the Canadian Institutes of Health Research and Dina Brooks is supported by a Canada Research Chair.

31phySiCAl ExERCiSE, oUR toolClarisa Boim, Fernanda monti, Sandra Chiervo, miguel Storni, marta Cortiñazhospital de tórax Dr Antonio A Cetrángolo, Universidad nacional de Buenos AiresRationale: The fitness results in Pulmonary Rehabilitation are not always completely achieved. This is the consequence of the subject with COPD characteristics and the available resources. However through our expe-rience we were made to see the improvement in quality of life in our patients.MetHods: Between January 2010 and May 2011 we implemented a multidisciplinary Respiratory Rehabilitation Program, designed in three Stages: 1) initial assessments 2) general aerobic endurance, global and segmental strength, and flexibility during 32 sessions under supervised twice a week stimuli; and 3) reassessment. During the program 102 patients were interviewed: 32 patients (31%) completed all 3 stages. Of these patients, 15 (46,87%) were female and 17 (53,12%) were male; 32 (100%) had COPD. According to the GOLD classification, 16 patients (50%) were stage II , 11 (34,37%) stage III and 5 (15,62%) stage IV. Mean age was 66 years [SD ±7,4] and FEV1 was 1.25 l. [SD ±0,57]. Regarding BMI, 5 patients (15,62%) were underweight, 9 patients (28,12%) had normal

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weight, 10 (31,25%) were overweight and 8 (25%) were obese.Results: Patients were reassessed upon completing the 32 sessions. CRQ results showed improvements in all four domains: Dyspnea, 21 patients (65,62%); Fatigue, 26 patients (81,25%); Emotional Function, 21 patients (65,62%) and Mastery 17 patients (53,12). As for the 6MWT, 18 patients (56,25%) achieved the MID (54 mts). Fourteen patients did not: 93% had improved in Fatigue, whereas 50% had improved in Dyspnea; 8 patients had a 6MWT >80% of predicted values per Enright’s formula, 2 had peripheral polyneuropathy affecting the lower limbs and 1 depressive syndrome.ConClusions: According to our experience, compliance improved over the last years (25% in 2004 vs. 31% currently). In our groups, the female population with COPD increased 50% over the last years. Patients are being referred at earlier GOLD stages, probably due to an increased promotion of PR. A review of patients show that over 50% are overweight. The improvement in the Fatigue domain (81,25%) – that implies an improvement in fitness – allows us to infer that the basis training was sat-isfactory, whereas the results of the 6MWT suggest the specific training was insufficient, although this could be due to the characteristics of this 14-patient population, and also to the fact that bicycles were used instead of treadmills for the GAE training.

32ECCEntRiC CyClE ExERCiSE FoR pAtiEntS With SEVERE CopD: tRAining AppliCAtion AnD FEASiBilityRiany de Sousa Sena1, Jacinthe Baril1, Danielle Soares Vieira Rocha2, Ruddy Richard3, helene perrault1, tanja taivassalo1, Jean Bourbeau4

1mcgill University, montreal, QC; 2Department of physiotherapy/Federal University of minas gerais, Belo horizonte, Brazil; 3Department of Sport medicine and Functional Explorations, Clermont-Ferrand, France; 4Respiratory Epidemiology and Clinical Research Unit, montreal Chest institute, montreal, QC Rationale: Considering that with eccentric training patients can sustain more muscle overload for a similar ventilatory demand, this train-ing may be ideal for severe COPD patients who may not otherwise achieve intensities sufficient to induce physiological adaptations in skeletal muscle. However, evidence regarding the feasibility of high intensity eccentric exercise for COPD patients is lacking.oBjeCtives: To examine the feasibility of a high-intensity eccentric cycling protocol for patients with COPD and to compare the effects of CON and ECC cycle on patients’ aerobic capacity (peakVO2).MetHods: In this pilot randomized control trial, 8 male patients with severe COPD (Age 67±6 years; FEV1 of 44±9 %predicted) were randomly assigned to either a CON (n=4) or ECC (n=4) cycling protocol over a course of 10 weeks. In order to monitor muscle injury, levels of serum cre-atine kinase were measured throughout the training period. The study was approved by the institutional ethics review board and all patients signed a informed consent.Results: Subjects in the ECC group reached an average of 160±55 watts at 80±1.12% of peak heart rate while patients in the CON group exercised at 66 ± 16.6 watts at 92±1.7% peak HR. Scores of dyspnea for the ECC group were significant lower (median [IQR], 1.9 [1.7-2] compared with those in the CON group (median [IQR], 2.8 [2.4-2.9]; p<0.05), but no significant differences were found for the for leg fatigue between the two groups (median [IQR], CON, 3.0 [2.5-3.2]; ECC, 2.6 [2.4-2.7]). Levels of creatine kinase remained within the normal range after 5 and 10-weeks of training. Additionally, increases in peak VO2 were detected in both groups (ECC = 28%; CON=21%; p>0.05), although not statistically significant (p>0.05)ConClusion: Preliminary results showed that high intensity eccentric cycle exercise is feasible for patients with severe COPD. However, in this ongoing research, more patients have been included to investigate the potential benefits of eccentric training on the maximal exercise capacity of COPD patients.Financial support: Riany de Sousa Sena is a PhD candidate supported by Edith Strauss fellowship in Rehabilitation Science.

33FACtoRS ASSoCiAtED With loW Six minUtE WAlK DiStAnCE in ADVAnCED CyStiC FiBRoSiSSatvir S Dhillon1,2, Robert D levy3, pearce Wilcox4, Carol Storseth5, isabelle Castell5, pat g Camp1,6

1James hogg Research Centre, University of British Columbia, providence heart + lung institute; 2UBC Faculty of graduate Studies; 3BC transplant Society; 4University of British Columbia Adult Cystic Fibrosis program, St paul’s hospital; 5VCh pre-transplant Assessment, Solid organ transplant Clinic; 6University of British Columbia Department of physical therapy, Vancouver, BCRationale: Cystic fibrosis (CF) patients are referred for lung trans-plantation (LTx) assessment when they have a 2-3 year mortality risk greater than 50% and/or poor level of function as indicated by various measures, such as the 6 minute walk test (6MWT). It has been suggested that patients who walk less than 400m in the 6MWT should be listed for LTx. There is little understanding regarding the factors associated with low 6MWT for advanced CF patients.MetHods: The medical records of a sample of CF patients referred for LTx assessment were reviewed. Patient demographics, lung function, Lung Allocation Score (LAS), blood chemistry, heart rate and oxygen saturation at rest and during exercise, and anthropometric data was compared between patients with a 6MWT <400 m (Group A) or >400 m (Group B).Results: Data from 20 patients (65% male) were collected. The mean(SD) 6MWT in Group A was 306.3(59.9) m; Group B 489.6(101.3)m. There was no difference in age, body mass index, LAS, PCO2, or PO2 between the two groups (p>0.05). Despite having similar lung function (Group A FEV1 % predicted: 29.1(5.1)%; Group B 27.4(10.6)%; p=0.65) and BMI (Group A 20.9(2.3)kg/m2; Group B 20.3(3.3) kg/m2; p=0.64), Group A had a significantly higher maximal heart rate during 6MWT (132.6(11.5) bpm compared to 109.7(19.6) bpm; p=0.04). The Group A resting heart rate was also elevated (102.4bpm), however this was not sig-nificantly different than Group B (88.6 bpm).ConClusions: The elevated maximal heart rate during 6MWT in CF patients who achieved a distance of less than 400 m may indicate a poor level of fitness in this group, and provides important information for the design of a prospective study on fitness and activity in these patients.Financial support: None disclosed.

34ARm ElEVAtion AnD CooRDinAtED BREAthing StRAtEgiES in pAtiEntS With SEVERE ChRoniC oBStRUCtiVE pUlmonARy DiSEASE (CopD)thomas E Dolmage1,2, tania Janaudis-Ferreira2, Kylie hill2,3, Shirley price4, Dina Brooks2,5, Roger S goldstein1,2,4,6

1Respiratory Diagnostic & Evaluation Services; 2Respiratory medicine, West park healthcare Centre, toronto, on; 3School of physiotherapy and Curtin health innovation Research institute, Curtin University, Western Australia; 4Respiratory Rehabilitation program, West park healthcare Centre; 5Department of physical therapy; 5Department of medicine, University of toronto, toronto, on BaCkgRound: Hyperinflated patients with severe COPD breathe against a high elastic load which increases further during the ventilatory demand of physical activity. Arm activities are especially demanding. Some pulmonary rehabilitation programs instruct patients to exhale while raising their arms whereas others recommend the opposite. The aim of this study was to determine the effect of co-ordinating breathing with arm movements on arm lift tolerance. We hypothesized that coordinating inspiration with arm elevation would increase the endurance time of a rhythmic lifting task.MetHods: Participants with COPD and resting hyperinflation com-pleted two separate (low and high intensity) rhythmic constant load arm elevation tasks to intolerance (tlimit) before and after attending four “teaching” sessions (intervention). All patients were taught to extend expiration to achieve an expiratory: inspiratory ratio of 2:1. Participants were randomly assigned a group taught to lift during: 1) inhalation; 2) exhalation; 3) without constraint (sham).

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Results: 29 participants (FEV1 [SD] = 36 [16] %predicted, FEV1/FVC = 34 [12] %; TGV = 172 [39]) completed the study. There was a significant effect of GROUP on the change in tlimit (p<0.001) regardless of whether the test was done at low or high intensity (p=0.37). The ∆tlimit in the ‘exha-lation’ group was significantly greater than the ‘sham’ group at both low (difference [95%CI] = 281 [41 to 520] s) and high (difference = 214 [82 to 345] s) intensities. There was no difference in ∆tlimit between the ‘inhala-tion’ and ‘sham’ groups.ConClusion: Teaching patients with COPD to coordinate exhalation with raising their arms increases the endurance time of a rhythmic lifting task. Coordinating inhalation with raising their arms does not affect endur-ance time. Therapists teaching arm lifting activities should co-ordinate them with exhalation to improve task endurance.Funding: Canadian Respiratory Health Professionals (CRHP)

35inVEStigAtion oF A SimplE mEthoD to SEt thE WAlKing SpEED FoR thE ASSESSmEnt oF AmBUlAtoRy oxygEn in pAtiEntS With ChRoniC lUng DiSEASEthomas E Dolmage1,2, Rachael A Evans2, nina malek2, lauren o’Brien2, Roger S goldstein1,2,3

1Respiratory Diagnostic & Evaluation Services; 2Respiratory medicine West park healthcare Centre; Department of 3medicine, University of toronto, toronto onintRoduCtion: Guidelines for assessment and qualification for ambulatory oxygen vary. A constant-speed endurance walk is the most responsive test. Conventionally its speed is individualized using an incre-mental walk test; an alternative is the average speed (s6MWT) of the six minute walk test (6MWT). We evaluated a simpler, less demanding, method to estimate the individual endurance speed.oBjeCtives: To determine the point between patients’ usual (susual) and fast (sfast) walk speed resulting in the highest proportion of ‘ideal’ results for the assessment of ambulatory oxygen.MetHods: A chart review was conducted including all patients with chronic lung disease assessed for ambulatory oxygen where the susual and sfast were measured. The control (air) test speed was guided by their s6MWT. The ideal endurance time (tlimit) was defined as 5 to 16 min based upon Ontario’s Home Oxygen Program criteria.Results: 35 patients (mean [SD]: age = 70 [9] y; 6MWT distance = 336 [121] m; end exercise SpO2 = 81 [7] %) were included. The s6MWT, susual and sfast were 56 [20], 53 [15] and 72 [17] m•min-1, respectively. The speed of the control endurance walk test, breathing air, was 67 [16] m•min-1 resulting in a tlimit 5.6 [3.3] min. There was a poor relationship between s6MWT and tlimit (r=0.22; p=0.23); 40 % of tests resulted in an ‘ideal’ tlimit. Referring to the susual and sfast as 0 and 100 %, respectively, the mean endurance speed occurred at 79 [20] %. The majority of ‘ideal’ tests occurred at 65 to 85 % between susual and sfast.ConClusion: The 6MWT was of little help to the administrator in achieving a tlimit within the most responsive range. In contrast, the usual and fast walks provide a quick, simple, effective and inexpensive approach to estimating the speed for assessing ambulatory oxygen.

36homE-BASED ExERCiSE pRogRAmming in pUlmonARy REhABilitAtion: A CASE REpoRt oF A nEW AppRoAChRay Down, Jamie FarrellEastern health pulmonary Rehabilitation, St John’s, nlRationale: Home-based pulmonary rehabilitation is recommended as an equally effective alternative to hospital-based programming. Exercise training is an essential component of a pulmonary rehabilitation program. Eastern Health Pulmonary Rehabilitation launched an individualized, direct-to-home exercise pilot project in 2010.This case report outlines a new approach of home-based exercise program-ming for a patient with chronic obstructive pulmonary disease (COPD) at our site.MetHods: A 58 year old male with severe COPD, previous hospitaliza-tions due to COPD exacerbations, functional limitations due to shortness

of breath, and motivation to improve his physical status was entered into the direct-to-home exercise project. He attended nine, one-hour visits with a physiotherapist consisting of a physician supervised exercise stress test, physical assessment, exercise set-up, bi-weekly follow-up appoint-ments, and final evaluation after twelve weeks of exercise. Exercise pre-scriptions were individualized based on patient functional goals, clinical assessment findings, and practice guidelines. Pre and post-program out-come measures included Incremental Shuttle Walk Test (ISWT), Chronic Respiratory Questionnaire – Self Administered Individualized Format (CRQ-SAI), Modified Medical Research Council Dyspnea Scale (MMRC), Berg Balance Scale (BBS), Body Mass Index (BMI), and Waist to Hip Ratio (WHR).Results: Significant improvements in functional aerobic capacity (+ 240m ISWT with a 38% increase in predicted peak oxygen uptake) and health related quality of life, particularly related to dyspnea ratings with functional activities (+2/7 CRQ-SAI and −2/5 MMRC) were observed. No significant changes were seen in BBS (+2/56), BMI (−1), or WHR (−0.03).ConClusion: Direct-to-home exercise programming in pulmonary rehabilitation may present a safe, effective, and feasible alternative for patients with COPD who are motivated to improve their functional status.Financial support: No funding

37hoW ShoUlD WE mEASURE ARm ExERCiSE CApACity in CopD? A SyStEmAtiC REViEWtania Janaudis-Ferreira1,2, marla K Beauchamp1, Roger S goldstein1,2,3, Dina Brooks1,2

1Respiratory medicine, West park healthcare Centre; 2Department of physical therapy; 3Department of medicine, University of toronto, toronto, onBaCkgRound: There are no recommendations on how to measure arm exercise capacity in individuals with chronic obstructive pulmonary disease (COPD). The objectives of this study were to: (i) synthesize the literature on measures of arm exercise capacity in individuals with COPD; (ii) describe the psychometric properties and the target construct of each measure and (iii) make recommendations for clinical practice and research.MetHods: Studies conducted in COPD that included a measure of arm exercise capacity were identified after searches of 5 electronic databases (MEDLINE, CINAHL, EMBASE, Physiotherapy Evidence Database and Cochrane Library) and reference lists of pertinent articles. One reviewer performed data extraction and two assessed quality of studies that described measurement properties using the Consensus-based standards for the selec-tion of health measurement instrument.Results: Of 654 reports, 41 met the study criteria. Five types of arm exercise tests were indentified: arm ergometry, ring shifts, dowel lifts, prop-rioceptive neuromuscular facilitation, and activities of daily living (ADL) tests. Four studies assessed measurement properties of the Unsupported Upper Limb Exercise test (UULEX), 6-minute Pegboard and Ring test (6PBRT), a test involving weight shifts and the Grocery Shelving Task (GST). Validity studies were of fair to good quality, whereas reliability studies were of poor quality.ConClusions: Arm ergometry may be best for measuring peak sup-ported arm exercise capacity and endurance, while the UULEX, 6PBRT and GST may better reflect ADL and should be the tests of choice to mea-sure peak unsupported arm exercise capacity (UULEX) and arm function (6PBRT and GST).

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38SKElEtAl mUSClE AtRophy iS ASSoCiAtED With phySiCAl FUnCtion in pEoplE With CopDpriscila Robles1,2, Dina Brooks1,2, Roger goldstein1,3, Ali naraghi1,4, marshall Sussman1,4, larry White1,4, Sunita mathur1,2

1Respiratory medicine West park healthcare Centre; 2graduate Department of Rehabilitation Science; 3Department of medicine, University of toronto; 4University health network, toronto, onRationale: Skeletal muscle dysfunction in chronic obstructive pulmo-nary disease (COPD) includes the loss of muscle mass and muscle strength, which may account for impaired mobility and lower physical activity levels.oBjeCtive: To compare skeletal muscle size in people with COPD to healthy controls using magnetic resonance imaging (MRI) and to correlate it with measures of muscle function and physical activity.MetHods: Seven individuals with moderate to severe COPD and seven control subjects underwent T1-weighted MRI to obtain maximal muscle cross-sectional area (CSAmax) of the quadriceps, hamstrings, dorsi- and plantar-flexors. Isometric and isokinetic peak torque of the same muscle groups, six-minute walk distance (6MWD) and physical activity levels using a questionnaire (PASE score) were also assessed.Results: People with COPD and controls were matched for age (72±6.7 vs 69±9.3 yrs), sex (3 males, 4 females) and body mass index (25±6.2 vs 25±4.6 kg/m2). Compared with controls, people with COPD had 30% and 25% lower CSAmax of the quadriceps hamstrings and plan-tar-flexors respectively (p=0.01and p=0.03) whereas muscle strength was 60% lower in people with COPD for both muscle groups (p=0.009). 6MWD was lower in people with COPD (248 m vs 639 m; p=0.02); how-ever, no difference was observed between groups for PASE score. Correlations were observed between CSAmax of the quadriceps and plan-tarflexors with peak torque (r=0.87 and r=0.83; p=0.001), 6MWD (r=0.79 and r=0.79; p=0.02) and PASE scores (r=0.58 and r=0.53; p=0.04).ConClusion: Muscle atrophy was observed across thigh and calf muscles of individuals with COPD and was associated with muscle strength, 6MWD and physical activity. Functional impairments in muscle strength were more profound than muscle atrophy and may be associated with poor muscle quality in people with COPD.

39phySiCAl ACtiVity pRoFilE in lUng tRAnSplAnt CAnDiDAtES With intERStitiAl lUng DiSEASE UnDERgoing pUlmonARy REhABilitAtionlisa Wickerson1,2, Sunita mathur2, polyana mendes2, Denise helm1, lianne g Singer1,3, Dina Brooks2

1lung transplant program, toronto general hospital; 2Department of physical therapy, University of toronto; 3Department of medicine, University of toronto, toronto, onRationale: Individuals with advanced interstitial lung disease (ILD) present with significant limitations in exercise capacity; however little is known about their levels of physical activity (PA). Pulmonary rehabilita-tion is recommended for lung transplant candidates, but its impact on daily activity has not been described. The objectives of this study were 1) to measure levels of daily PA in lung transplant candidates with ILD 2) com-pare levels of PA on rehabilitation days and on non-rehabilitation days and 3) explore the relationship between PA and muscle strength, functional exercise capacity and health-related quality of life (HRQOL).MetHods: A prospective cross-sectional sample of 24 lung transplant candidates with ILD underwent measurements of daily PA, quadriceps force (QF), functional exercise capacity (6-minute walk test (6MWT)) and HRQOL (Medical Short Form (SF-36) and St. George Respiratory Questionnaire (SGRQ)).Results: Lung transplant candidates with ILD were inactive taking 2736±1612 daily steps and spending 6.8±10 minutes in moderate intensity PA per day. Participants took significantly higher steps (3784 vs. 2103 steps, p<0.001) and spent more time per day in moderate intensity PA (11.8 vs. 4.2 minutes, p<0.001) on rehabilitation verses non-rehabilitation days. There was a moderate correlation between daily steps and the 6MWT

(r=0.57, p=0.004) and QF (r=0.5, p=0.02), as well as a moderate correla-tion between moderate intensity PA and the 6MWT (r=0.56, p=0.005).Conclusions: Lung transplant candidates with ILD have very low levels of PA corresponding to a third of the values of the general population. They can participate in a rehabilitation program and structured exercise increases their daily PA.Financial support: ORCS and CRHP

40EnERgy EConomy oF WAlKing With A WhEElED AmBUlAtoRy AiD (RollAtoR) in pAtiEntS With ChRoniC oBStRUCtiVE pUlmonARy DiSEASE (CopD)Kylie hill1,2,3,4, thomas E Dolmage1,5, lynda Woon1, Dina Brooks1,2, Roger S goldstein1,2

1Department of Respiratory medicine, West park healthcare Centre; 2Department of physical therapy and medicine, University of toronto, toronto, on; 3School of physiotherapy and Curtin health innovation Research institute, Curtin University; 4lung institute of Western Australia and Centre for Asthma, Allergy and Respiratory Research, University of Western Australia, perth, Western Australia, Australia; 5Respiratory Diagnostic and Evaluation Services, West park healthcare Centre, toronto, onRationale: Probst et al. (Chest 126: 1102, 2004) reported that, when using a rollator, patients with COPD increased their distance walked in 6 min along with increased oxygen uptake and ventilation. It was difficult to appraise economy (mechanical work to total energy expenditure) because the main determinant of the energy demand, speed, varied between condi-tions; hence, the authors concluded that rollator use improved distance by increasing ventilatory capacity and/or economy.oBjeCtive: To determine whether walking with a rollator improved the energy economy in patients with COPD. The hypothesis was that oxygen uptake, at the same speed, would be lower (improved economy) when walking with a rollator.MetHods: Subjects completed 2 walks, (with and without a rollator) at individually set and constant speeds. At least 24 h later they repeated the session for a total of 4 walks. Energy expenditure was estimated from mea-sured oxygen uptake using a telemetric system. Since mechanical work was kept constant (speed) during each walk, differences in economy were reflected in differences in energy expenditure in metabolic equivalents (METS).Results: Ten subjects completed the study. Attainment of a steady state was confirmed during every walk. There was no effect of day (p=0.23) on energy expenditure. There was no significant difference (0.0 [−0.4 to 0.3] METs) in energy expenditure with (3.6 [2.9 to 4.3] METS) or without (3.6 [2.9 to 4.3] METS) the rollator.ConClusion: Rollator use does not acutely affect walking economy in patients with COPD. A better understanding of how people with COPD benefit from rollator use may facilitate their design and prescription.suppoRt: Dr Brooks is supported by a Canada Research Chair and Dr Goldstein by the NSA Chair in Respiratory Rehabilitation Research

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general lung Diseases Basic Sciencemaladies pulmonaires générales – Science

fondamentale

41inFlAmmAtoRy RESponSES ARE QUAlitAtiVEly, BUt not QUAntitAtiVEly, SimilAR BEtWEEn AiRWAy AnD monoCytE-DERiVED mACRophAgESturki Alahmadi1, nurlan Dauletbaev2, Kassey herscovitch2, moishe liberman3, larry C lands1

1Respiratory medicine, montreal Children’s hospital, mcgill University health Centre; 2Research institute of mcgill University health Centre; 3ChUm Endoscopic tracheobronchial and oesophageal Centre (CEtoC), Division of thoracic Surgery, Université de montréal, montreal, QCRationale: Airway macrophages (AM) are key airway innate immunity cells. Their inflammatory responses are often studied to gain insights into dys-regulated airway inflammation. Retrieval of AM requires bronchoalveolar lavage (BAL), an invasive procedure. Macrophages can also be derived through in vitro maturation of peripheral blood monocytes; however, the similarities of inflam-matory responses between these macrophages types are unclear. We asked whether monocyte-derived macrophages (MDM) would exhibit inflammatory responses qualitatively and quantitatively similar to AM.MetHod: To address this, we sampled AM (n=7) by BAL from intact lungs of patients undergoing cancer staging. AM were allowed to rest for 24 hours prior to stimulation. Blood monocytes (healthy volunteers; n=5) were iso-lated using Ficoll, purified by adherence to plastic, and cultured for 2 weeks in the presence of Macrophage Colony-Stimulating Factor to promote matu-ration. Both cell types were then stimulated for 1 hour with Lipopolysaccharide (LPS) or Interleukin (IL)-1β. Inflammatory responses in both macrophage types were gauged by production of IL-8 (ELISA) 4 hours after stimulation.Results: In both AM and MDM, both LPS and IL-1β up-regulated IL-8. However, in both macrophage types, LPS was far more potent in stimulating IL-8, compared with IL-1β (p<0.05; all comparisons). We further observed that, while the pattern of IL-8 response was similar between AM and MDM, AM demonstrated weaker IL-8 responses to both LPS (~7 fold increase in IL-8 vs. ~40 fold in MDM) and IL-1β (~1.3 fold increase vs. ~15 fold in MDM).ConClusion: AM and MDM exhibit similar patterns of inflammatory responses. However, these responses are weaker in AM, possibly indicating their senescence or desensitization. MDM may cautiously be used as sur-rogates for AM in studies focusing on patterns of inflammatory responses.Financial support: This work was funded by the Cystic Fibrosis Foundation

42Utilizing nEAR inFRARED SpECtRoSCopy AnD inDoCyAninE gREEn DyE to EStimAtE RESpiRAtoRy AnD lEg BlooD FloW DURing ContinUoUS ExERCiSEpaolo B Dominelli1, William R henderson1,2, Jordan A guenettea, Donald Eg griesdale2,3, Jordan S Querido1, Robert Boushel4, A William Sheel11School of Kinesiology; 2program of Critical Care medicine; 3Department of Anesthesiology, pharmacology and therapeutics, University of British Columbia, Vancouver, BC; 4Department of Biomedical Sciences & Department of Anaesthesia Faculty of health Sciences, University of Copenhagen, Copenhagen, DenmarkRationale: Measurement of regional blood flow to the respiratory muscles has traditionally been invasive and impractical in exercise settings. The blood flow index (BFI), a minimally invasive method using indocyanine green dye and near infrared spectroscopy (NIRS), allows assessment of within subject changes in regional blood flow and can be performed during dynamic exercise. This study assessed the regional BFI to the vastus lateralis muscle and the superficial respira-tory muscles in the seventh intercostal space during exercise.MetHods: Seven healthy subjects (28±6 yrs) cycled continuously at incrementally more difficulty stages to exhaustion. To determine the BFI, a bolus venous injection of ICG was performed during the final minute of

each workload and the dye concentration was detected by emitting and receiving optodes secured to the skin. Ensemble averaged trans-pulmonary pressure-volume loops were integrated to determine the mechanical work of breathing (WOB). Data presented are means ± SE.Results: At maximal exercise intensity, oxygen uptake was 56±6 ml•kg-1•min-1, ventilation was 120±8 l•min-1 and the WOB was 323±35 J•min-1. Respiratory muscle blood flow index (RMBFI) increased linearly until ~65% of maximum work, whereafter it plateaued and declined. RMBFI was statistically lower at maximal exercise than at the two highest submaximal stages (p=0.04 and p<0.001, respectively) despite an increased WOB. The BFI to vastus lateralis displayed a similar pattern and was statistically lower at maximal exercise than at the two highest submaximal stages (p=0.04 and p<0.001, respectively).ConClusion: These findings suggest that there is competition between the respiratory and locomotor muscles for blood flow during sub-maximal and maximal exertion in healthy humans.

43UnDERStAnDing thE RolE oF REACtiVE oxygEn SpECiES in AlVEolAR FoRmAtion oF nEonAtAl RAt lUngSJamal mobin 1,3, A Keith tanswell1,2,3

1lung Biology programme, physiology & Experimental medicine, hospital for Sick Children Research institute; Departments of 2paediatrics and 3physiology, University of toronto, ontario, onRationale: Reactive oxygen species (ROS), including lipid hydroper-oxides (LOOH) and superoxide (O2•−), play a critical role as second mes-sengers in many physiological processes, including lung cell DNA synthesis in response to growth factors. Unpublished studies in our laboratory have demonstrated that ROS can both stimulate (at low concentrations) and inhibit (at high concentrations) DNA synthesis by primary cultures of fetal lung cells. In this study we speculated that the increase in arterial partial pressure of oxygen at birth (from approximately 20 to 70 mmHg in the human) may induce low-level LOOH formation, which triggers postnatal alveolar formation from secondary crests in the neonatal rat.MetHods: Air-exposed neonatal rats were either uninjected or received daily subcutaneous injections of DPPD, a LOOH-scavenger, in corn oil or corn oil alone from days 1-6 of life. The effects of DPPD on lung growth were assessed by DNA synthesis, and by lung morphometry. Immunohistochemistry and Western blot were used to assess the effect of DPPD on growth factors known to mediate alveologenesis. DNA synthesis was also assessed for kidney sections.Results: Treatment with DPPD resulted in a significant increase in tis-sue fraction, a significant reduction in both secondary crests/mm2 and secondary crests/tissue ratio, and a significant reduction in BrdU-positive cells/mm2, BrdU-positive secondary crests/mm2 and BrdU-positive sec-ondary crests/tissue ratio. However, treatment with DPPD did not cause a significant change in lung volume. Parenchymal thickening was associated with decreased numbers of apoptotic cells and decreased expression of the proapoptotic cleaved caspases-3 and -7. DPPD did not cause a change in DNA synthesis of kidneys.ConClusions: LOOH play a critical role in postnatal alveolar forma-tion in neonatal rats and exposure to DPPD results in an inhibition of physiological apoptosis, which contributes to the parenchymal thickening observed in the resultant lung injury.Financial support: CIHR

43Ail-17A poSitiVE CEllS in thE lUngS oF pAtiEntS With hypERSEnSitiVity pnEUmonitiSSimon hasan1,2, Carol gwozd1,2, Abrar Alansary1,2, Kerri Johannson2, margaret mary Kelly1,2,4

1Airway inflammation Research group; 2Departments of physiology and pharmacology; 3medicine; 4pathology & laboratory medicine, University of Calgary, Calgary, AB Rationale: Hypersensitivity pneumonitis (HP) is an interstitial lung disease resulting from the repeated inhalation of a variety of aerosolized

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antigens. A marked pulmonary inflammatory response results, with increased numbers of lymphocytes, macrophages, mast cells and neutro-phils present. A pro-inflammatory cytokine, interleukin(IL)-17A, has recently been shown to be central to the development of HP in an experi-mental animal model, but it is unknown if it is produced in the lung in the human disease. The commonest cells producing IL-17A in several other pulmonary inflammatory disorders have been reported to be lymphocytes. oBjeCtives: To determine whether IL-17A is produced in the lung in HP and if so, which cells are responsible.MetHods: Human lung biopsies with a confirmed diagnosis of HP (n=8) as well as healthy control lungs (n=4) were obtained. Initially IL-17A immu-nohistochemistry was performed and positive cells were identified. Subsequently, double immunofluorescence was performed to determine which cell type was producing IL-17A, using tryptase (mast cells), CD3 lymphocytes), CD68 (macrophages) and myeloperoxidase (neutrophils). Results: We found numerous cells staining strongly for IL-17A in the lungs from patients with HP, in contrast to very few in the control lungs. The majority of cells producing IL-17A were mast cells followed by neutro-phils. These were the same cell types positive for IL-17A in the control lungs, although in much fewer numbers. We found scanty macrophages weakly positive for IL-17A in the HP group, with < 1% of IL-17A positive cells consisting of lymphocytes.ConClusions: This is the first report, to our knowledge, describing the presence of IL-17A positive cells in the lungs of patients with HP. The major cell types were mast cells and neutrophils, with a minute contribu-tion from lymphocytes. The role of these IL-17A positive cells in HP needs to be explored further.Financial support: Funded by Alberta Innovates & the Alberta Lung Association. Simon Hasan received a Calgary Laboratory Services Summer Studentship and a Markin USRP Scholarship

44A pREliminARy ASSESSmEnt oF thE FUngAl miCRoBiomE in thE lUngm Sze1, pA Dimitriu2, JV gosselink1, Wm Elliott1, mm moore3, S Adam4, J Friedman4, y zhao5, R Varhol5, D miller5, A he5, R moore5, i Birol5, WW mohn2, DD Sin1, S hayashi1, JC hogg1 1James hogg Centre for Cardiovascular and pulmonary Research, University of British Columbia, St paul’s hospital/providence health Care; 2Department of immunology and microbiology, University of British Columbia, Vancouver; 3Department of Biological Sciences, Simon Fraser University, Burnaby; 4BC Clinical genomics network; 5BC genome Science Centre, Vancouver, BCBaCkgRound: Several studies have shown that a bacterial micro-biome exists below the larynx; however, whether or not fungi reside within the lung microbiome has not been established. In severe COPD, airways are infiltrated with inflammatory immune cells that form tertiary lymphoid organs consistent with adaptive immune responses (NEJM 350:2645-53,2004). To determine whether fungi provide a source of persistent anti-gens that drive this adaptive immune response in severe COPD, a pilot study using unbiased massively parallel sequencing and quantitative PCR was used to detect fungal DNA.MetHods: DNA from peripheral lung tissue from a healthy smoker control (2 samples) and a COPD GOLD 4 patient (5 samples) was ana-lyzed using the 75 based, pair-end tag sequencing (Illumina). Numbers of fungal genomes relative to human genomes were calculated from the respective numbers of reads. Following sequencing, non-smoker (n=8), smoker (n=8), COPD GOLD 4 (n=8), and cystic fibrosis (n=8) lung tissue was quantified for fungal specific ribosomal internal transcribed spacer 1 to 2 DNA by qPCR using A. fumigatus as a reference for the standard curve. Sterile water was used as the negative control.Results: Sequence analysis showed an average of 39.7 fungi/1000 human cells was found in the samples from the COPD GOLD 4 individual and 38.9 in those from the smoking individual. Compared to the bacteria in these same samples (Am J Respir Crit Care Med 183; 2011:A1017) the fungi were higher (P < 0.05). qPCR confirmed the presence of fungi in the larger sample group. All sample groups were significantly higher than the negative non-template control (P<0.05).

ConClusion: These preliminary results support the presence of small amounts of fungal DNA within the human lung microbiome and it is pos-sible that foreign antigens derived from this source could provide antigens capable of driving an adaptive immune response in severe COPD.supported by: NIH # 5P50HL084922, 5P50HL084948, 1R01HL95388 and CIHR # CIF-97687

45thE lUng tiSSUE miCRoBiomE in CopDm Sze1, pA Dimitriu2, JV gosselink1, Wm Elliott1, WW mohn2, DD Sin1, S hayashi1, JC hogg1 1UBC James hogg Research Centre for Cardiovascular and pulmonary Research, St paul’s hospital/providence health Care; 2Department of immunology and microbiology, University of British Columbia, Vancouver, BCRationale: In severe COPD airways are infiltrated with inflammatory immune cells that form tertiary lymphoid organs consistent with an adap-tive immune response (NEJM 350:2645-53, 2004). Hilty et al. (PLoS One 5(1):e8578, 2010) demonstrated that human lungs contain a diverse microbiome. To determine whether bacteria within the lung microbiome might provide a source of antigens to drive the adaptive immune response in severe COPD, we utilized qPCR to quantify the abundance of bacteria, and terminal-restriction fragment length polymorphism (TRFLP) and 454 pyrotag sequencing to determine community composition.MetHods: DNA was obtained from banked lung tissue from 8 non-smokers, 8 smokers, and 8 COPD GOLD 4 patients. Lung tissue from 8 cystic fibrosis (CF) patients served as positive controls and sterile water as negative controls. The DNA was analyzed by qPCR of the bacterial 16S rRNA gene and the number of bacterial genomes was normalized to the number of human cells based on the RPP40 gene. The 16S rRNA gene was also analyzed by TRFLP and 454 pyrotag sequencing. The pyrotag sequenc-ing was analyzed using principle coordinate and indicator species analysis.Results: The bacteria/1000 human for all groups were greater than the negative control (P<0.001). TRFLP analysis showed three distinct bacte-rial communities: one for the smokers and non-smokers, another for the CF patients, and the third for COPD GOLD 4 patients. The 454-based analy-sis confirmed these results and showed that negative controls formed their own group separate from the others. Indicator species analysis identified four OTUs that were associated with the COPD GOLD 4 group (P<0.05). These OTUs aligned with bacteria in the genus Lactobacillus or Burkholderia.ConClusion: These results confirm the presence of a microbiome in human lungs and suggest that changes within this microbiome could pro-vide foreign antigens capable of driving an adaptive immune response in very severe COPD.supported by: NIH # 5P50HL084922, 5P50HL084948, 1R01HL95388 and CIHR # CIF-97687

46pnEUmACUlttm-Ali: An impRoVED mEDiA FoR mUCoCiliARy DiFFEREntiAtion oF pRimARy hUmAn BRonChiAl EpithEliAl CEllSSamuel J Wadsworth1, michael J Riedel2, Andrea Eskandar Afshari2, Sharon A louis2, Delbert R Dorscheid1 1UBC James hogg Research Centre, providence heart + lung institute, St paul’s hospital; 2StEmCEll technologies inc™, Vancouver, BC Rationale: The human airway epithelium is a complex mucociliated structure that can be recapitulated in vitro by growing primary human bronchial epithelial cells (HBECs) in air-liquid interface (ALI) culture. Current ALI methods often result in poor mucociliary differentiation that does not mimic the in vivo human airway. We have developed a serum-free medium (PneumaCultTM-ALI) that provides consistent and improved differentiation of HBEC cultures.MetHods: HBECs from six normal donors were obtained from Lonza or the International Institute for the Advancement of Medicine. Initial HBEC expansion was performed in BEGM (Lonza). Cells at passage 3 were

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seeded onto porous tissue culture inserts in either BEGM-based medium or PneumaCultTM-ALI. Cells were grown to confluency in submerged cul-ture, and then cultured at ALI for 21 days. Trans-epithelial electrical resistance (TEER), morphological characteristics, and expression of key proteins were measured weekly post-ALI.Results: ALI cultures grown in PneumaCultTM-ALI demonstrated stable TEER values that were consistently higher than inserts alone. At day 21 post-ALI, cultures grown in PneumaCultTM-ALI have a significantly increased proportion of ciliated (66% vs. 52%) and mucous-producing (30% vs. 20%) apical cells compared to BEGM-based media, and a significant decrease in non-differentiated apical cells (4% vs. 28%). Mean cilia length was significantly increased in PneumaCultTM-ALI cultures (6µm vs. 3µm). E-Cadherin and ZO-1 were expressed on the plasma membrane at equal levels in both culture conditions while expression of Muc5AC and cilia basal body protein were significantly increased in PneumaCultTM-ALI cultures. Furthermore, PneumaCultTM-ALI cultures responded to IL-13 treatment with goblet cell hyperplasia as assessed by PAS staining and Western blot.ConClusions: PneumaCultTM-ALI is a novel defined media that provides consistent and improved mucociliary differentiation of primary HBECs in ALI cultures, creating a physiologically relevant model system for in vitro human lung epithelial cell research.Funding sources: The National Sanitarium Association, StemCell Technologies Inc.

Knowledge translation / Critical Care / general Clinical

Application du savoir / Soins critiques / général – Clinique

47impACt oF RApiD inVEStigAtion CliniC on timElinESS oF lUng CAnCER DiAgnoSiS AnD StAgingn Ezer1,2, J Dallaire1, K Schwartzman1,2, AV gonzalez1,2

1mcgill University health Centre; 2Respiratory Epidemiology and Clinical Research Unit, montreal Chest institute, mcgill University health Centre, montreal, QCRationale: Lung cancer guidelines recommend prompt investiga-tion and initiation of therapy. Diagnostic assessment units have been shown to decrease time to diagnosis for certain solid tumors; few studies have quantified their impact in lung cancer patients.MetHods: We evaluated the impact of a Rapid Investigation Clinic (RIC) on the timeliness of lung cancer diagnosis and staging at the McGill University Health Centre (MUHC), from February 2010 to June 2011. Within the RIC, investigation is conducted by a respirologist and a nurse clinician. A protocol based on recent guidelines is recommended. Priority is given to invasive procedures that allow simultaneous diagnosis and staging. Patients are subsequently referred to a multidisciplinary lung cancer clinic for therapeutic decisions. Controls were patients with a confirmed diagnosis of lung cancer, investigated outside the RIC at the same institution.Results: A total of 145 lung cancer patients were investigated at the RIC compared to 103 patients in the control group. The mean age of RIC patients was 67 years, and 69 years in controls. NSCLC was diagnosed in 128 RIC patients (30% stages I-II; 70% stages III-IV) and 95 control patients (40% stages I-II; 60% stages III-IV). SCLC was diagnosed in 17 RIC patients and 8 controls. The median delay from first contact with an MUHC physician for suspected lung cancer (t0) and tissue confirmation was 28 days (mean 38 days) in the RIC and 32 days (mean 56 days) in the non-RIC patients. The average number of invasive diagnostic and/or staging procedures was similar in the two groups. Median delay between t0 and first medical or surgical treatment for lung cancer was 73 days (mean 78 days) for the RIC and 78 days (mean 104 days) for the non-RIC patients.ConClusion: A Rapid Investigation Clinic improves delays of lung cancer diagnosis and staging.Financial support: Direction Québécoise du Cancer and MGH Foundation

48oUt oF BREAth: ADVAnCE CARE plAnning AnD EnD oF liFE CARE initiAtiVES in pUlmonARy REhABilitAtionSusan m haskellSt Clare’s mercy hospital, St John’s, nlRationale: 89% of patients with advanced lung disease desire infor-mation on advance directives. They also desire end of life discussions during periods of stable health. Yet, there are barriers between these patients and their doctors which lead to a lack of communication on these subjects. Consequently, outpatient clinics and Pulmonary Rehabilitation (PR) programs offer an ideal opportunity to address such needs. This poster will demonstrate Eastern Health’s initiatives in the area of advance care planning (ACP) and end of life care in PR with Chronic Obstructive Pulmonary Disease (COPD) clients and their families.MetHods: A variety of methods including the utilization of pastoral care personnel, customized education sessions, The COPD Toolkit, Professional Development Education, as well as awareness campaigns and tools have been employed to meet ACP and end of life care needs.Results: Patient feedback was consistent with the suggestion that ACP may actually decrease anxiety and depression in patients with chronic disease as it addresses two great concerns – loss of control over their lives and fear of becoming a burden to their families. Over the past year, The COPD Toolkit’s modified Advance Care Planning/Living Will educational session ranked a score of 4 or higher (on a scale of 1-7, where 1 is not very useful and 7 is extremely useful) amongst 95% of respon-dents. Resources such as the National Advance Care Planning day and Speak Up Wallet cards have been successful in getting people talking.ConClusions: Entering into discussion with COPD patients and their families about end of life matters is a worthwhile learning process. Clients and families appreciate such frank discussion and practical advice. Possible future considerations for enhanced ACP education include Clinical Pastoral Education for our team, continued knowledge translation activities, and follow up services to clients and families (as resources allow).

49ACUtE ExACERBAtion oF intERStitiAl lUng DiSEASE ASSoCiAtED With ConnECtiVE tiSSUE DiSEASE: REpoRt oF tWo CASES AnD REViEW oF thE litERAtURERohin malhotra, Rebecca Kruisselbrink, gerard Coxhamilton health Sciences; St Joseph’s healthcare; mcmaster University, hamilton, onThe management of patients with acute exacerbations of interstitial lung disease is medically and ethically challenging. Professional guidelines to assist decision-making are not currently available.We present two cases. The first was a 35-year old woman diagnosed with mixed connective tissue disease and biopsy-confirmed non-specific inter-stitial pneumonia. She developed respiratory failure requiring intubation two months after lung biopsy. Workup revealed no reversible trigger; despite aggressive treatment with steroids, cyclophosphamide, and even-tually Rituximab, she succumbed to intractable hypoxia. A second patient was a 58-year old woman with rheumatoid arthritis. Six months of worsening dyspnea led to a diagnosis of usual interstitial pneumonia based on high-resolution CT scan. Although referred for transplant con-sideration early in her course, she developed hypoxic respiratory failure requiring non-invasive ventilation within months of diagnosis. Workup was negative; empiric antibiotics, anticoagulation, and steroids were administered, and she was transferred to the transplant center. She dete-riorated shortly after transfer, was intubated, and died five days later.Interstitial lung disease comprises a heterogeneous group of disorders sharing clinical, radiographic, and pathological features. Idiopathic pul-monary fibrosis has a median duration of three years; there is no proven successful treatment. Acute exacerbations are common; outcomes are poor, and mechanical ventilation is often futile. In contrast, connective

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e49Can Respir J Vol 19 No 3 May/June 2012

tissue disease-associated ILD is believed to have a better prognosis and be more responsive to therapy. Our experience shows, however, that sudden, devastating exacerbations do occur in this group, and there is a marked paucity of published data regarding the best approaches to management and prognostication in this situation.Through these case reports and literature review, we summarize current teaching on the clinical course and prognosis of CTD-associated ILD as compared to idiopathic pulmonary fibrosis, focusing on the acute, hypoxic exacerbation. We identify clinical features that may be prognos-tic indicators in acute exacerbations. Our goal is to assist physicians car-ing for acutely ill ILD patients through management recommendations for a devastating disease process guided by little published data, and fraught with difficult decision-making.

50CliniCopAthologiCAl ConFEREnCES in thE Canadian RespiRatoRy JouRnal: A nEW FoRmAt FoR mAximizing thE EDUCAtionAl VAlUE oF CASE REpoRtSgeorge Rakovich1, Katherine thain2, Brian Vukusic3, peter D paré4 1University of montreal, montreal, QC; 2University of British Columbia - James hogg Research laboratories, Vancouver, BC; 3pulsus group inc, oakville, on; 4University of British Columbia, Vancouver, BCBaCkgRound: There is a decreasing interest in publishing case reports, due to a perception that case reports are not a valid or reliable source of scientific information. On the other hand, case presentations are recognized as a useful form of CME and are used on a regular basis as a learning tool in residency education, usually in the form of multi-disci-plinary clinico-pathological conferences. These are often high-quality presentations rich in educational content, which are seldom given an opportunity for publication.The potential educational value of case reports has received little attention, and the few journals that continue to publish case reports do so without any clear learning objectives. Therefore, we believe that there is an opportunity to improve the educational content and value of case reports.oBjeCtives: To develop and implement a new format for case reports in order to focus content and maximize educational value of cases pub-lished in the Canadian Respiratory Journal (CRJ).MetHods: We have described a new format for case reporting that relies on 1-2 focused learning objectives, a CanMEDS competency objec-tive and a brief pre-post test which would allow readers to be automati-cally credited with CME points through CRJ’s online system.In order to enhance educational content, we have also initiated a col-laboration with Canadian chest medicine and thoracic surgery programs that will create a pathway for publishing cases presented by trainees at local clinico-pathological conferences.ConClusion: The new format will be evaluated by a formal online survey 1 year following its implementation. We are hopeful that it will increase the appeal and educational value of case reports published in CRJ, and it may represent a useful model for the future publication of case reports in biomedical journals.

51non inVASiVE VEntilAtion on ACUtE AnD ChRoniC CARE UnitS: iS it SAFE?Julie Dallaire, Sandra Dial, Franceen Browman, lorine Jean-marie, odile Begin, Chantal Souligny, Constance Reidmcgill University health Centre, montreal , QCThe goal is to present the clinical pathway for the management of patients with acute respiratory failure, chronic respiratory failure and pal-liative care with Non Invasive Ventilation (NIV) on acute and chronic care units. It is generally recognized that Non Invasive Ventilation (NIV), is mainly initiated and used in monitored settings such as in ICU. However, at the Montreal Chest Institute (MCI), McGill University

Health Centre (MUHC), because of our expertise and specialization in respiratory care as well as increasing needs for ventilation assistance in our population, this mode of ventilation is used in non-ICU settings such as acute care wards. Concerns arose regarding the quality and safety of the care provided to these patients. For this reason an interdisciplinary committee was created to develop and to institute guidelines to maximize safe administration of NIV on the ward.oBjeCtives oF tHe CoMMittee: 1-To develop guidelines regarding use of NIV in the institution, 2-To determine optimal monitor-ing standards for care of the patient on NIV, 3- To tailor the treatment plan according to the patient’s needs as determined by the health care team, 4-To craft a NIV flow sheet to be used both by Nursing and Respiratory Therapy to facilitate the documentation of the patient’s con-dition and his/her management. 4- To prevent mistakes. 5- To communi-cate the guidelines to all members of the MCI health care team.MetHods: We have developed a 3hours training module; we adver-tised the implementation of the protocol with poster throughout the institution; we set up a NIV promotional booth.Results: pre-implementation there was 137 patients have been trans-ferred to the MCI with NIV. From those patients, 9 have been transferred to the ICU. In 2010, post-implementation, 70 patients have been trans-ferred to the MCI with NIV and from those patients, 7 have been trans-ferred to the ICU.ConClusion: With the implementation of the NIV protocol, the ICU attending is immediately consulted when a patient needs NIV (acute respiratory failure), and less patients were accepted in our institu-tion when they were unstable (135 in 209 vs 70 in 2010).Funding: No financial support.

52pEDiAtRiC SiCKlE CEll DiSEASE AnD AiRWAy hypERREACtiVity: pREVAlEnCE in ASymptomAtiC pAtiEntSnatalie Shilo1, nancy Robitaille2, yves pastore2, Denis Bérubé3, Sheila V Jacobs3, Sharon Abish4, larry lands1

1the montreal Children’s hospital, mcgill University health Centre, Department of pediatric Respiratory medicine; 2hôpital Ste Justine, Université de montréal; Department of pediatric hematology/oncology; 3hôpital Ste Justine, Université de montréal; Department of pediatric Respiratory medicine; 4the montreal Children’s hospital, mcgill University health Centre, Department of pediatric hematology/oncology, montreal, QCRationale: Asthma is a negative prognostic factor in sickle cell dis-ease (SCD). Yet children with SCD are not routinely screened. Possibly, a significant number of children with SCD, who do not have a recent history of acute chest syndrome (ACS) or respiratory complaints, do have AHR, but remain undiagnosed. Potentially, the window for delay-ing the progression of lung disease is being missed. Methacholine chal-lenge testing could examine whether the prevalence of AHR is under recognized in this sub-group of clinically asymptomatic patients, and if routine screening for asthma is thus indicated in this population.MetHods: Children with SS, SC, and Sb0-thalassemia disease between the ages of 8-18 years are being enrolled. Subjects with asthma, or on bron-chodilator, inhaled corticosteroid, or leukotriene antagonist therapy, are excluded. An ACS episode should not have occurred over the past year, necessitated a blood transfusion, or required a PICU admission. Subjects with a vaso-occlusive episode or respiratory infection within the past 30 days, or a blood transfusion within the past 90 days, are excluded.All subjects perform a methacholine challenge. A methacholine chal-lenge is positive if the FEV1 decreases by ≥20% in response to <4mg/ml methacholine.Results: To date, three patients have been enrolled. All had a posi-tive methacholine challenge test.ConClusions: The goal is for a total of 50 patients to be enrolled. Our preliminary results suggest that AHR is under recognized in children with SCD who have not had a recent history of respiratory complaints.Financial support: The Montreal Children’s Hospital, McGill University Health Centre, Department of Pediatric Respiratory Medicine, Internal funds

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e50 Can Respir J Vol 19 No 3 May/June 2012

53thE Canadian RespiRatoRy JouRnal ComES oF AgE (18) AnD goES onlinE!Katherine R thain, peter pare1James hogg Research Centre, institute for heart and lung health, St paul’s hospital, Vancouver, BCBaCkgRound: The Canadian Respiratory Journal (CRJ) was begun in 1994 and until 2001 was edited by Dr Norman Jones from McMaster. Between 2001 and 2011 the editor in chief was Nick Anthonisen from Winnipeg. Under their leadership the CRJ grew in stature and has become an important means of communication and education for the medical community in Canada and internationally. Until the beginning of May 2011, all submissions were in hard-copy paper form. Beginning in May of 2011, at the age of 18 years, the CRJ went to an online only sub-mission system.oBjeCtives: To compare differences in demographics and statistics of submissions after the changeover from paper-only to online-only submissionsMetHods: We have performed descriptive statistics to examine the differences in the types of manuscripts that were submitted during the paper-only era and have been submitted since the start of the current online-only submission processes. In addition, we have compared various parameters such as the differences in time-to-publish between the two processes as well as the time from submission to review, from submission to acceptance and the statistical differences between Canadian and International submissions.Results: There are significant differences in article types, number of submissions and countries of origin between the two submission formats. For example, 70% of paper-only submissions were received from within Canada but since transition to online-only submissions this has completely reversed with 70% of submissions being received from international sources.ConClusion: Many differences exist between a paper-only and an online-only submission system. It remains to be seen how these difference will affect the impact factor of the Journal.

e51Can Respir J Vol 19 No 3 May/June 2012

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BBaril J . . . . . . . . . . . . . . . . . . . . .32Beach J . . . . . . . . . . . . . . . . . . . .17Beaucage D. . . . . . . . . . . . . . . . .21Beauchamp MK . . . . . . . . . . 30,37Begin O . . . . . . . . . . . . . . . . . . .51Bérubé D . . . . . . . . . . . . . . . . . .52Bhutani M . . . . . . . . . . . . . . . . .18Birol I . . . . . . . . . . . . . . . . . . . . .44Boim C. . . . . . . . . . . . . . . . . . . .31Borchers CH . . . . . . . . . . . . . 4,27Boulet L-P . . . . . . . . . . . . . . . . 4,7Bourbeau J . . . . . . . . . . . . .9,21,32Boushel R. . . . . . . . . . . . . . . . . .42Brooks D. . . . . . 30,34,37,38,39,40Browman F. . . . . . . . . . . . . . . . .51Bwititi PT . . . . . . . . . . . . . . . . .11

CCamp PG . . . . . . . . . . . . . . . . . .28Camp PG . . . . . . . . . . . . . . . . . .33Carleton B . . . . . . . . . . . . . . 13,19Carlsten C . . . . . . . . . . . . . . . . . .7Castell I . . . . . . . . . . . . . . . . . . .33Chamber-Evans J . . . . . . . . . . . .24Chapados I . . . . . . . . . . . . . . . . . .1Chapman K . . . . . . . . . . . . . . . . .9Chen H . . . . . . . . . . . . . . . . . . .20Chen V . . . . . . . . . . . . . . . . . . .27Chuang J . . . . . . . . . . . . . . . . . . .9Conrad W . . . . . . . . . . . . . . . . .25Couperthwaite S . . . . . . . . . . . .18Cowie R . . . . . . . . . . . . . . . . . . . .9Cox G . . . . . . . . . . . . . . . . . . . .49

dD’urzo A. . . . . . . . . . . . . . . . . . .10Dallaire J . . . . . . . . . . . . . . . 47,51Dauletbaev N. . . . . . . . . . . . . . .41Davoine F. . . . . . . . . . . . . . . . . . .1Demmons J. . . . . . . . . . . . . . 25,26deSousa Sena R . . . . . . . . . . . . .32Dhillon SS . . . . . . . . . . . . . . 28,33Dial S . . . . . . . . . . . . . . . . . . . . .51Dimitriu PA . . . . . . . . . . . . . 44,45Dolmage TE . . . . . . . . . . .34,35,40Dominelli PB . . . . . . . . . . . . . . .42Donahue M . . . . . . . . . . . . . . . .26Dorscheid D . . . . . . . . . . . . . . . 2,3Dorscheid R . . . . . . . . . . . . . . . .6Dorscheid DR. . . . . . . . . . . .5,8,46Dosman J . . . . . . . . . . . . . . . . . .23Down R . . . . . . . . . . . . . . . . . . .36Doyle CC . . . . . . . . . . . . . . . . . .12Drouin I . . . . . . . . . . . . . . . . 21,24

eElliott WM. . . . . . . . . . . . . . 44,45Éthier C . . . . . . . . . . . . . . . . . . . .1

Evans RA . . . . . . . . . . . . . . . . . .35Ezer N. . . . . . . . . . . . . . . . . . . . .47

FFarrell J. . . . . . . . . . . . . . . . . . . .36FitzGerald J . . . . . . . . . . . . . . . . .7FitzGerald JMJ . . . . . .4,16,29,9,15Francella S . . . . . . . . . . . . . . . . .30Freue GVC. . . . . . . . . . . . . . . . . .4Friedman J . . . . . . . . . . . . . . . . .44

gGarvey NJ . . . . . . . . . . . . . . . . .11Gauvreau GM . . . . . . . . . . . . . 4,7Gibson BE . . . . . . . . . . . . . . . . .30Goldman R . . . . . . . . . . . . . . . .19Goldstein RS . . . . . . . .9,38,22,30, . . . . . . . . . . . . . . . . . . 34,35,37,40Gonzalez AV . . . . . . . . . . . . . . .47Gosselink JV . . . . . . . . . . . . 44,45Greene CD. . . . . . . . . . . . . . . . .14Griesdale DEG. . . . . . . . . . . . . .42Groeneweg G. . . . . . . . . . . . . . .19Guan J . . . . . . . . . . . . . . . . . . . .11Guenettea JA. . . . . . . . . . . . . . .42Guttmann A . . . . . . . . . . . . . . .11Gwozd C . . . . . . . . . . . . . . . . 43A

HHackett T. . . . . . . . . . . . . . . . . . .5Hagel L. . . . . . . . . . . . . . . . . . . .23Halayko AJ. . . . . . . . . . . . . . . . . .2Harkness H. . . . . . . . . . . . . . . . .12Hasan S . . . . . . . . . . . . . . . . . 43AHaskell SM. . . . . . . . . . . . . . . . .48Hayashi S . . . . . . . . . . . . . . . 44,45He A. . . . . . . . . . . . . . . . . . . . . .44Helm D. . . . . . . . . . . . . . . . . . . .39Henderson WR . . . . . . . . . . . . .42Hernandez P. . . . . . . . . . . . . . 9,26Herscovitch K . . . . . . . . . . . . . .41Hill K . . . . . . . . . . . . . . . . . . 34,40Hiroko T . . . . . . . . . . . . . . . . . .20Hirota J. . . . . . . . . . . . . . . . . . . . .5Hogg JC . . . . . . . . . . . . . . . . 44,45Hollander Z . . . . . . . . . . . . . . . .27Horton R . . . . . . . . . . . . . . . . . .26

jJacobs SV . . . . . . . . . . . . . . . . . .52Jamal M . . . . . . . . . . . . . . . . . . .43Janaudis-Ferreira T. . . . . . . . 34,37Jean-Marie L . . . . . . . . . . . . . . .51Jimenez-Mendez R . . . . . . . . 13,19Johannson K . . . . . . . . . . . . . 43AJoubert A . . . . . . . . . . . . . . . 21,24

kKam SHY . . . . . . . . . . . . . . . . . . .4Kaplovich E . . . . . . . . . . . . . . . .22Karunanayake C. . . . . . . . . . . . .23Kelly MM. . . . . . . . . . . . . 14,43AKendler D. . . . . . . . . . . . . . . . . .29Kirychuk S . . . . . . . . . . . . . . . . .23Knight D . . . . . . . . . . . . . . . . . . .5Kruisselbrink R. . . . . . . . . . . . . .49

lLands L. . . . . . . . . . . . . . . . . . . .52Lands LC . . . . . . . . . . . . . . . . . .41Lawson JA . . . . . . . . . . . . . . . . .23Leigh R. . . . . . . . . . . . . . . . . . . .14Leung C . . . . . . . . . . . . . . . . . . . .3

Levy RD . . . . . . . . . . . . . . . . . . .33Liberman M . . . . . . . . . . . . . . . .41Lombardo C . . . . . . . . . . . . . . . .21Louis SA . . . . . . . . . . . . . . . . . .46Lowe A. . . . . . . . . . . . . . . . . . . .20Lu Y . . . . . . . . . . . . . . . . . . . . . .11Lynd LD . . . . . . . . . . . . . . . . 15,16

MMah D . . . . . . . . . . . . . . . . . . . .17Malek N . . . . . . . . . . . . . . . . . . .35Malhotra R. . . . . . . . . . . . . . . . .49Maltais F. . . . . . . . . . . . . . . . . . . .9Marcinuik DD . . . . . . . . . . . . . . .9Marra CA. . . . . . . . . . . . . . . 15,16Marta C . . . . . . . . . . . . . . . . . . .31Mathur S . . . . . . . . . . . . . . . 38,39McManus BM . . . . . . . . . . . . . .27Mendes P . . . . . . . . . . . . . . . . . .39Meng TW . . . . . . . . . . . . . . . . .14Miguel S. . . . . . . . . . . . . . . . . . .31Miller B . . . . . . . . . . . . . . . . . . .27Miller D . . . . . . . . . . . . . . . . . . .44Mitchell JP. . . . . . . . . . . . . . . . .12Mohn WW . . . . . . . . . . . . . 44,45Monti F . . . . . . . . . . . . . . . . . . .31Moore MM. . . . . . . . . . . . . . . . .44Moore R . . . . . . . . . . . . . . . . . . .44

nNagel MW . . . . . . . . . . . . . . . . .12Naraghi A . . . . . . . . . . . . . . . . .38Ng R. . . . . . . . . . . . . . . . . . . . . .27Nguyen M . . . . . . . . . . . . . . . . .24

oO’Brien L . . . . . . . . . . . . . . . . . .35O’Byrne PM . . . . . . . . . . . . . . . 4,7O’Donnell DE . . . . . . . . . . . . . . .9Oosthuizen JL . . . . . . . . . . . . . . .4Ouellet I . . . . . . . . . . . . . . . . 21,24

pPahwa P . . . . . . . . . . . . . . . . . . .23Pallot F . . . . . . . . . . . . . . . . . . . . .1Paquet F . . . . . . . . . . . . . . . . . . .21Pare P . . . . . . . . . . . . . . . . . . . . .53Paré PD . . . . . . . . . . . . . . . . . . .50Pastore Y . . . . . . . . . . . . . . . . . .52Perrault H. . . . . . . . . . . . . . . . . .32Price S . . . . . . . . . . . . . . . . . . . .34Proud D . . . . . . . . . . . . . . . . . . .14

QQuerido JS . . . . . . . . . . . . . . . . .42

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s

Sadatsafavi M. . . . . . . . . . . . 15,16Sandra C . . . . . . . . . . . . . . . . . .31Saunders A. . . . . . . . . . . . . . . . . .8Schwartzman K . . . . . . . . . . . . .47Sheel AW. . . . . . . . . . . . . . . . . .42Sherwood K . . . . . . . . . . . . . . . .27Shilo N. . . . . . . . . . . . . . . . . . . .52Sima CA . . . . . . . . . . . . . . . . . .28Simpson AC . . . . . . . . . . . . 25,26Sin DD . . . . . . . . . . . . . 9,27,44,45Singer LG. . . . . . . . . . . . . . . . . .39Singh A . . . . . . . . . . . . . . . . . . 4,7Singhera GK . . . . . . . . . . . . .5,6,8Sinnatamby S. . . . . . . . . . . . . . .17Smith A . . . . . . . . . . . . . .13,19,29Souligny C . . . . . . . . . . . . . . . . .51Stelmack GL . . . . . . . . . . . . . . . .2Storseth C . . . . . . . . . . . . . . . . .33Stukel T . . . . . . . . . . . . . . . . . . .11Sussman M. . . . . . . . . . . . . . . . .38Sze M . . . . . . . . . . . . . . . . . . 44,45

tTaivassalo T . . . . . . . . . . . . . . . .32Takhar MK. . . . . . . . . . . . . . . . . .4Tan WC . . . . . . . . . . . . . . .9,15,16Tanswell AK . . . . . . . . . . . . . . .43Tebbutt SJ . . . . . . . . . . . . . .4,7,27Thain K . . . . . . . . . . . . . . . . . . .50Thain KR . . . . . . . . . . . . . . . . . .53Traves SL . . . . . . . . . . . . . . . . . .14

uUnruh H . . . . . . . . . . . . . . . . . . .2

vVaradi RG . . . . . . . . . . . . . . . . .22Varhol R. . . . . . . . . . . . . . . . . . .44Vethanayagam D . . . . . . . . . . . .17Victor J . . . . . . . . . . . . . . . . . . . .18Villa-Roel C. . . . . . . . . . . . . . . .18Vukusic B . . . . . . . . . . . . . . . . . .50

WWadsworth SJ . . . . . . . . . 2,3,8,46White L . . . . . . . . . . . . . . . . . . .38Wickerson L. . . . . . . . . . . . . . . .39Wilcox P . . . . . . . . . . . . . . . . . .33Wilkinson B . . . . . . . . . . . . . . . .19Wilson-McManus J . . . . . . . . . .27Woon L . . . . . . . . . . . . . . . . . . .40Wu Y . . . . . . . . . . . . . . . . . . . . . .1

XXing M . . . . . . . . . . . . . . . . . . . . .2Xu J . . . . . . . . . . . . . . . . . . . . . . .6

yYagi K . . . . . . . . . . . . . . . . . . . . .20Yamamoto M . . . . . . . . . . . . . . . .7Yang JS . . . . . . . . . . . . . . . . . . . . .8Young J . . . . . . . . . . . . . . . . . 25,26

ZZhang T . . . . . . . . . . . . . . . . . . .13Zhao Y . . . . . . . . . . . . . . . . . . . .44

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