CRD editor's corner archive: January-March.

Home ventilation in duchenne muscular dystrophy. The value of attention to detail

15 March 2022

Long term domiciliary non-invasive ventilation is highly effective in Duchenne Muscular dystrophy but requires a skilled and technically adept clinical team to support patients receiving home therapy. In this month’s journal Leotard et al. report obstructive events during expiration during ventilation in a number of patients attending their centre. There was a significant impact on overall sleep quality and a potential easy fix for the problem. Don’t mistake this for something that will only interest ventilation “nerds”! We suspect patients will thank their team for identifying the problem demonstrating again the value of attention to detail in managing complex respiratory disorders.

-Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease

Daily life for people with COPD. It’s all about taking part

5 March 2022

Patients with COPD often tell us how difficult it is to do the things they want to do because of their breathing problems but measuring “participation” objectively is often not undertaken. In the journal this month, D’Amore et al. report the factors determining participation based on the elements set out in the WHO’s definition of the construct. They found that reduced walking performance and psychological distress were the primary determinants of impaired participation. Perhaps it is the combination of the loss of physical capacity and its meaning to the patient that drives the impact on participation.

-Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease

Peak flow monitoring in COPD. Time for a throwback?

25 February 2022

Spirometry is the GOLD standard for the diagnosis of COPD but does not perform well as an assessment of disease burden and the COVID-19 pandemic has placed restriction on access as it carries an infection transmission risk. In the journal this month Cen et al. report the use of PEFR to predict and monitor exacerbations in a cohort of people with COPD. Perhaps surprisingly for those of us who have taught that peak flow does not have a role in the management of COPD, it appeared to perform quite well. Time for a rethink of our available technologies in the post COVID era?

-Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease

Remote support for PR during COVID-19. Necessary but not necessarily popular

23 February 2022

The proliferation of remote/web based means to communicate and support patients during periods of social distancing/lockdown has been well documented during the COVID-19 pandemic. How is this viewed by consumers of key services such as Pulmonary Rehabilitation? In this month’s journal Polgar et al. report that more patients are able to access such digital technologies compared with a pre-pandemic cohort. However, patients did not express greater enthusiasm for such communication/support methods emphasizing the ongoing value of face to face human contact.

-Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease

The perils of taxi-motorcycling in West Africa

22 February 2022

The growth of road traffic in low and middle income countries has been matched by a concerning growth in mortality and morbidity from road traffic accidents (RTAs). In the journal this month, Ade and colleagues report the prevalence of high OSA risk amongst taxi-motorcyclist drivers (offering an increasingly valued transport service) in Parakou (Benin). Although these risks did not appear to be higher than in non-taxi drivers, approximately a quarter were considered at risk of the condition and a fifth reported excessive daytime sleepiness. Worryingly, these risks correlated with previous RTA incidents as did consumption of sleeping tablets which was considerable. Clearly identifying and treating OSA through provision of diagnostic sleep studies and availability of CPAP could be an effective measure to reduce the burden of RTAs in the developing world.

-Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease

Measurement of cardiac output in pulmonary hypertension. Practicality over purism?

20 February 2022

The measurement of cardiac output (CO) is central to understanding the severity and prognosis of Pulmonary hypertension (PH) but is not easy to measure. In the journal this month Robertson et al. provide technical insight into how a surrogate measure of pulmonary blood flow - Inert Gas Rebreathing (IGR) – measures up to gold standard methods using cardiac catheterisation. The data suggest IGR offers useful information and whilst some will argue the two are not synonymous (we agree!), patients might value less burdensome tests to help understand their health problems.

-Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease

Obesity in COPD – weighing up the impact

5 February 2022

Understanding the impact of obesity in lung disease has presented a conundrum. In addition to the somewhat counter-intuitive prognostic benefit of being overweight or obese in COPD, researchers have documented a potential advantage of increased body weight in reducing hyperinflation. In the journal this month, Zewari et al. provide further insight by comparing weight bearing exercise performance between normal and overweight people with COPD. They confirm a reduction in hyperinflation but suggest this is offset by the disadvantage of carrying additional weight. Food for thought for weight management programmes…

-Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease

Exercise desaturation. Does the head rule the hand?

19 January 2022

Oxygen desaturation during exercise is an important assessment with clinical implications for example provision of ambulatory oxygen or estimation of prognosis in pulmonary vascular disease. Measurement method matters therefore, and in the journal this month Robertson et al. report differences between saturation recording from the finger and the forehead during performance of the 6MWT in people with respiratory disease. Values were higher for forehead measurements and although on average these differences were small, for some this could impact on clinical decision making. Rightly, the authors don’t advocate one method over another but the paper will help clinicians and physiologists understand the limitations of the tests they are doing.

-Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease

Adherence to guidelines in the management of AECOPD – it’s complicated!

18 January 2022

Disease management guidelines exist to help clinical teams deliver evidence based care but in many healthcare settings are inconsistently implemented. This is demonstrated again by Tsao and colleagues who present data from a single institution in the US on adherence to GOLD guidance on the management of acute exacerbation of COPD. Both the content and timing of therapy appears deficient in many cases and was associated with longer length of stay in hospital. Whether the therapy gap itself is responsible for this association is a matter for debate – perhaps this is simply a marker for more difficult cases where diagnosis is uncertain or some treatment options may be contra-indicated. Or perhaps lack of guidance adherence is linked to poorer quality care in other less measurable domains. Too many perhapses? Delving deeper with richer datasets and larger cohorts may enlighten but we salute the authors for raising the questions!

-Mick Steiner, Editor-in-Chief, Chronic Respiratory Disease