Vancouver General Hospital Pulmonary Embolism Response Team (VGH PERT): initial three-year experience.

PURPOSE: Clinical equipoise exists with the use of novel reperfusion therapies such as catheter-directed thrombolysis in the management of patients presenting to hospital with high risk pulmonary embolism (PE). Therapeutic options rely on clinical presentation, patient factors, physician preference, and institutional availability. We established a Pulmonary Embolism Response Team (PERT) to provide urgent assessment and multidisciplinary care for patients presenting to our institution with high-risk PE. METHODS: Data were retrospectively collected from PERT activations between January 2016 and December 2018. Chi square tests were used to determine differences in mortality across the three years of study. Logistic regression was used to evaluate 30- and 90-day mortality and occurrence of major bleeds between those receiving anticoagulation alone (AC) and those receiving advanced reperfusion therapy (ART). RESULTS: There were 128 PERT activations over three years, the majority originating from the emergency department. Eighty-five percent of activations were for submassive PE, with 56% of all activations assessed as submassive-high risk. Fifteen patients (12%) presented with massive PE. Advanced reperfusion therapy was used in 29 (23%) patients, of whom 25 (20%) received catheter-directed thrombolysis. There was an increased risk of major bleeding in the ART group compared with in the AC group (odds ratio [OR], 17.9; 95% confidence interval [CI], 4.1 to 125.0; P < 0.001), but no increased risk of mortality at 30 days (OR, 2.1; 95% CI, 0.4 to 9.1; P = 0.3). The 30-day mortality rate was 7.8%. CONCLUSION: We describe the first Canadian PERT, a multidisciplinary team aimed at providing urgent individualized care for patients with high-risk PE. Further research is necessary to determine whether a PERT improves clinical outcomes.

RéSUMé: OBJECTIF: Le concept d'équilibre clinique existe lors de l'utilisation de traitements innovants de reperfusion tels que la thrombolyse in situ (ou thrombolyse par cathéter) pour la prise en charge des patients se présentant à l'hôpital avec une embolie pulmonaire (EP) à haut risque. Les options thérapeutiques s'appuient sur la présentation clinique, les caractéristiques du patient, la préférence du médecin et la disponibilité institutionnelle. Nous avons mis sur pied une Équipe d'intervention en cas d'embolie pulmonaire (PERT - Pulmonary Embolism Response Team) afin de fournir une évaluation urgente et des soins multidisciplinaires aux patients se présentant dans notre institution avec une EP à haut risque. MéTHODE: Nous avons récolté rétrospectivement les données concernant les activations/alertes reçues par notre PERT entre janvier 2016 et décembre 2018. Des tests de chi carré ont été utilisés afin de déterminer les différences en matière de mortalité au cours des trois années de durée de l'étude. La régression logistique a été utilisée pour évaluer la mortalité à 30 et à 90 jours ainsi que la survenue de saignements majeurs entre les patients recevant uniquement un traitement anticoagulant (AC) et ceux recevant un traitement de reperfusion avancé (TRA). RéSULTATS: Il y a eu 128 alertes requérant l'activation de notre PERT en trois ans, la majorité provenant de l'urgence. Quatre-vingt-cinq pour cent des activations concernaient des EP submassives, et 56 % de toutes les activations ont été évaluées comme étant submassives à haut risque. Quinze patients (12 %) se sont présentés avec une EP massive. Un traitement de reperfusion avancé a été administré à 29 (23 %) patients, parmi lesquels 25 (20 %) ont reçu une thrombolyse in situ. Un risque accru de saignement majeur a été observé dans le groupe TRA par rapport au groupe AC (rapport de cotes [RC], 17,9; intervalle de confiance [IC] 95 %, 4,1 à 125,0; P < 0,001), mais il n'y avait pas de risque accru de mortalité à 30 jours (RC, 2,1; IC 95 %, 0,4 à 9,1; P = 0,3). Le taux de mortalité à 30 jours était de 7,8 %. CONCLUSION: Nous décrivons la première PERT canadienne, une équipe multidisciplinaire ayant pour but de prodiguer des soins personnalisés urgents aux patients avec embolie pulmonaire à haut risque. Des recherches supplémentaires sont nécessaires pour déterminer si une PERT améliore les pronostics cliniques.

Sex differences in the intensity and qualitative dimensions of exertional dyspnea in physically active young adults.

Understanding sex differences in the qualitative dimensions of exertional dyspnea may provide insight into why women are more affected by this symptom than men. This study explored the evolution of the qualitative dimensions of dyspnea in 70 healthy, young, physically active adults (35 M and 35 F). Participants rated the intensity of their breathing discomfort (Borg 0-10 scale) and selected phrases that best described their breathing from a standardized list (work/effort, unsatisfied inspiration, and unsatisfied expiration) throughout each stage of a symptom-limited incremental-cycle exercise test. Following exercise, participants selected phrases that described their breathing at maximal exercise from a list of 15 standardized phrases. Intensity of breathing discomfort was significantly higher in women for a given ventilation, but differences disappeared when ventilation was expressed as a percentage of maximum voluntary ventilation. The dominant qualitative descriptor in both sexes throughout exercise was increased work/effort of breathing. At peak exercise, women were significantly more likely to select the following phrases: "my breathing feels shallow," "I cannot get enough air in," "I cannot take a deep breath in," and "my breath does not go in all the way." Women adopted a more rapid and shallow breathing pattern and had significantly higher end-inspiratory lung volumes relative to total lung capacity throughout exercise relative to men. These findings suggest that men and women do not differ in their perceived quality of dyspnea during submaximal exercise, but subjective differences appear at maximal exercise and may be related, at least in part, to underlying sex differences in breathing patterns and operating lung volumes during exercise.

Inspiratory Capacity during Exercise: Measurement, Analysis, and Interpretation.

Cardiopulmonary exercise testing (CPET) is an established method for evaluating dyspnea and ventilatory abnormalities. Ventilatory reserve is typically assessed as the ratio of peak exercise ventilation to maximal voluntary ventilation. Unfortunately, this crude assessment provides limited data on the factors that limit the normal ventilatory response to exercise. Additional measurements can provide a more comprehensive evaluation of respiratory mechanical constraints during CPET (e.g., expiratory flow limitation and operating lung volumes). These measurements are directly dependent on an accurate assessment of inspiratory capacity (IC) throughout rest and exercise. Despite the valuable insight that the IC provides, there are no established recommendations on how to perform the maneuver during exercise and how to analyze and interpret the data. Accordingly, the purpose of this manuscript is to comprehensively examine a number of methodological issues related to the measurement, analysis, and interpretation of the IC. We will also briefly discuss IC responses to exercise in health and disease and will consider how various therapeutic interventions influence the IC, particularly in patients with chronic obstructive pulmonary disease. Our main conclusion is that IC measurements are both reproducible and responsive to therapy and provide important information on the mechanisms of dyspnea and exercise limitation during CPET.