Climate Change for the Pulmonologist: A Focused Review.

Climate change adversely impacts global health. Increasingly, temperature variability, inclement weather, declining air quality, and growing food and clean water supply insecurities threaten human health. Earth's temperature is projected to increase up to 6.4 °C by the end of the 21st century, exacerbating the threat. Public and health care professionals, including pulmonologists, perceive the detrimental effects of climate change and air pollution and support efforts to mitigate its effects. In fact, evidence is strong that premature cardiopulmonary death is associated with air pollution exposure via inhalation through the respiratory system, which functions as a portal of entry. However, little guidance is available for pulmonologists in recognizing the effects of climate change and air pollution on the diverse range of pulmonary disorders. To educate and mitigate risk for patients competently, pulmonologists must be armed with evidence-based findings of the impact of climate change and air pollution on specific pulmonary diseases. Our goal is to provide pulmonologists with the background and tools to improve patients' health and to prevent adverse outcomes despite climate change-imposed threats. In this review, we detail current evidence of climate change and air pollution impact on a diverse range of pulmonary disorders. Knowledge enables a proactive and individualized approach toward prevention strategies for patients, rather than merely treating ailments reactively.

Bronchoscopy Teaching Without a Gold Standard: Attending Pulmonologists' Assessment of Learners, Supervisory Styles, and Variation in Practice.

BACKGROUND: Despite the growing role of simulation in procedural teaching, bronchoscopy training largely is experiential and occurs during patient care. The Accreditation Council for Graduate Medical Education sets a target of 100 bronchoscopies to be performed during pulmonary fellowship. Attending physicians must balance fellow autonomy with patient safety during these clinical teaching experiences. Few data on best practices for bronchoscopy teaching exist, and a better understanding of how bronchoscopy currently is supervised could allow for improvement in bronchoscopy teaching. RESEARCH QUESTION: How do attending bronchoscopists supervise bronchoscopy, and in particular, how do attendings balance fellow autonomy with patient safety? STUDY DESIGN AND METHODS: This was a focused ethnography conducted at a single center using audio recording of dialog between attendings and fellows during bronchoscopies, supplemented by observation of nonverbal teaching. Interviews with attending bronchoscopists and limited interviews of fellows also were recorded. Interviews were transcribed verbatim before analysis. We used constant comparative analysis to analyze data and qualitative research software to support data organization and thematic analysis. Education researchers from outside of pulmonary critical care joined the team to minimize bias. RESULTS: We observed seven attending bronchoscopists supervising eight bronchoscopies. We noted distinct teaching behaviors, classified into themes, which then were grouped into four supervisory styles of modelling, coaching, scaffolding, and fading. Observation and interviews illuminated that assessing fellow skill was one tool used to choose a style, and attendings moved between styles. Attendings accepted some, but not all, variation in both performing and supervising bronchoscopy. INTERPRETATION: Attending pulmonologists used a range of teaching microskills as they moved between different supervisory styles and selectively accepted variation in practice. These distinct approaches may create well-rounded bronchoscopists by the end of fellowship training and should be studied further.

The effects of a short-term physician training on smoking cessation in a university pulmonary department.

Objective: The objective was to evaluate the effect of a short physician training in smoking cessation on the physicians' performance of smoking cessation interventions. The effects on patients' cessation rates were analyzed as well. A further aim was to identify barriers for providing cessation interventions. The study was conducted in an acute care pulmonology department of a German university hospital. Methods: 24 physicians of the pulmonology department of a German university hospital received a two-hour training in smoking cessation. 109 pre- and 89 post-training group patients were compared with regard to the frequencies of received smoking cessation interventions (Ask, Advise, Assist) and three- and six-month abstinence rates. Physicians estimated their intervention frequencies and gave reasons for not providing cessation interventions. Results: In a multivariable analysis (p<0.05), the physicians' application of "Ask" (OR 3.28, 95% CI 1.13-9.53) and the six-month abstinence rates (OR 2.70, 95% CI 1.24-5.84) were significantly higher in the post-training group. The univariate analysis also showed a significant effect on "Assist" (OR 2.05, 95% CI 1.09-3.87). No significant effect was seen on "Advise to quit". Physicians overestimated their intervention frequencies and reported the patients' low motivation to stop, an oncological disease and palliative care situation as barriers to performing smoking cessation. Conclusion: A short physician training in a hospital department of pulmonology increases the use of guideline-based cessation strategies and may improve cessation rates. The findings show that hospital-based strategies such as physician trainings could be useful in the improvement of smoking cessation. Strategies for overcoming barriers for providing smoking cessation interventions are needed.

Characterization of Applied Forces and Torques During Rigid Bronchoscopy Intubation.

BACKGROUND: Rigid bronchoscopy intubation poses a significant risk of complication to patients from mechanical trauma. Despite the importance of precision in forces exerted by surgeons during intubation, no prior study has analyzed the overall forces and torques involved in rigid bronchoscopy intubation, and whether existing training modalities accurately replicate them. METHODS: A bronchoscope was equipped with a 6-axis load sensor to measure forces and torques applied during rigid bronchoscopy intubation. The device was applied to measure intubation forces in low-fidelity manikins and patients by interventional pulmonologists. RESULTS: Axial and lateral forces were measured during rigid bronchoscope intubation from the mouth to the mid-trachea. The mean axial/lateral forces recorded during manikin trials were 6.93/18.06 N, whereas those recorded during patient trials were 4.57/9.43 N. Average axial and lateral force application was therefore 51.6% and 92.6% higher in manikin, respectively. Applied axial torque averaged across all human trials was 130.5 N-mm compared with 78.3 N-mm for manikin trials, 40% lower in manikin than in human. Lateral torque application during manikin intubation showed greater variation in between trials and a greater range of SDs within trials. CONCLUSION: This was the first application of a rigid bronchoscope measurement device designed to measure forces applied at the handle. Force and torque discrepancies between manikin training and patient applications were found, indicating a possible mismatch between the haptic feedback received by physicians during rigid training and application. This inconsistency could be resolved via novel haptic training modalities and help increase atraumatic intubations.

Recent Advances in Interventional Pulmonology.

The field of interventional pulmonology has grown rapidly since first being defined as a subspecialty of pulmonary and critical care medicine in 2001. The interventional pulmonologist has expertise in minimally invasive diagnostic and therapeutic procedures involving airways, lungs, and pleura. In this review, we describe recent advances in the field as well as up-and-coming developments, chiefly from the perspective of medical practice in the United States. Recent advances include standardization of formalized training, new tools for the diagnosis and potential treatment of peripheral lung nodules (including but not limited to robotic bronchoscopy), increasingly well-defined bronchoscopic approaches to management of obstructive lung diseases, and minimally invasive techniques for maximizing patient-centered outcomes for those with malignant pleural effusion.

A Pilot Study of the Effect of an Educational Web Application on Asthma Control and Medication Adherence.

BACKGROUND: An Asthma Adherence Pathway (AAP) application, which is an Internet application that combines patient and clinician education strategies to promote adherence to asthma therapy, has been developed. OBJECTIVE: The primary objective of this pilot study was to evaluate the effectiveness of the AAP application with electronic adherence monitors on asthma control. Secondary objectives evaluated the effect of AAP and monitors on medication adherence, asthma symptoms, quality of life, psychosocial factors, and barriers to treatment. METHODS: Adult patients with asthma were randomly assigned either to intervention (n = 19) or control (n = 20) groups in this 3-month prospective study, and they completed the Asthma Control Questionnaire (ACQ). Intervention patients completed the AAP software and were given barrier-specific motivational interviewing adherence strategies and a SmartTrack device to monitor mometasone furoate/formoterol (MF/F) use. Clinicians in the interventional group received adherence management training. Interventional patients were given feedback regarding adherence findings at each visit. Treatment adherence was determined by the mean of 4 measures of doses taken over 3 months. Control patients were not monitored for MF/F adherence. RESULTS: The mean MF/F adherence in the intervention group was 81%. The intervention and control groups did not differ on the mean baseline ACQ. Thirteen intervention patients achieved the minimal important difference (defined as an improvement ≥0.5 units on the ACQ) compared with 6 control patients (P = .016). The intervention group showed greater improvement in the ACQ (0.75) than the control group (0.19) representing a moderate-to-large effect size of d = 0.638. CONCLUSIONS: The AAP was effective in promoting adherence and helped to improve asthma control. These findings provide preliminary validation of the AAP model.

Transesophageal approach to lung, adrenal biopsy and fiducial placement using endoscopic ultrasonography (EUS): An interventional pulmonology experience. Initial experience of the UCSF-FRETOC (fresno tracheobronchial & oesophageal center) study group.

BACKGROUND: Routine lung cancer surveillance has resulted in early detection of pulmonary nodules and masses. Combined endobronchial ultrasound (EBUS) and trans-esophageal endoscopic ultrasound (EUS) are approved methods for sampling lymph nodes or masses. Furthermore, EUS allows for adrenal sampling as part of staging, and can assist with fiducial placement for stereotactic body radiation therapy (SBRT). OBJECTIVES: Promote use of EUS by interventional pulmonologists in the United States when diagnosing and staging lung cancer or when placing fiducials. METHODS: All patients undergoing EUS and/or EBUS were serially entered into a prospectively maintained database. Only patients undergoing EUS guided lung and/or adrenal biopsy and/or fiducial placement were selected for analysis. All patients underwent a post-procedure chest radiograph and were followed outpatient. RESULTS: 20 of 39 patients underwent sampling of a suspicious lung mass. An adequate sample was obtained in 19 of 20 patients. In all 19 patients a definitive diagnosis was achieved (95%). In all 13 patients who underwent adrenal sampling, presence or absence of metastasis was conclusively established. 6 patients successfully underwent fiducial placement. In all 39 patients, no major procedure related complications were noted for a period of 30 days. One patient had a small pneumothorax that resolved spontaneously. CONCLUSIONS: EUS can be safely performed by a trained interventional pulmonologist for the diagnosis of lung, adrenal masses and placement of fiducials. We think that interventional pulmonologists in the United States involved in lung cancer staging should receive training in EUS techniques.

Thoracoscopy: Advances and Increasing Role for Interventional Pulmonologists.

Thoracoscopy is an increasingly common procedure that provides significant clinical information and therapeutic applications. The procedure allows the physician to biopsy the parietal pleura under direct visualization with high accuracy. In addition, one can drain pleural fluid, place a chest tube in a precise location, and perform poudrage pleurodesis. Medical thoracoscopy (MT) is carried out in the operating room or procedure suite under moderate sedation with spontaneous ventilation. In comparison, video-assisted thoracoscopic surgery (VATS) is performed under general anesthesia with single lung ventilation and through multiple ports in the operating room. MT is less invasive, has a comparable diagnostic yield, and may be better tolerated in high-risk patients. The indications, complications, and advances in thoracoscopy will be discussed in this article. In the era of rapidly evolving therapeutics for lung cancer, immune-modulation and ever-increasing risks of immunosuppression, MT will evolve and continue to play a pivotal role in the evaluation and research of pleuropulmonary diseases.

A Palliative Approach is Adopted for Many Patients Dying in Hospital with Chronic Obstructive Pulmonary Disease.

Severe chronic breathlessness in advanced chronic obstructive pulmonary disease (COPD) is undertreated and few patients access specialist palliative care in the years before death. This study aimed to determine if symptom palliation or a palliative approach were delivered during the final hospital admission in which death occurred. Retrospective medical record audits were completed at two Australian hospitals, with all patients who died from COPD over 12 years between 1 January 2004 and 31 December 2015 included. Of 343 patients included, 217 (63%) were male with median age 79 years (IQR 71.4-85.0). Median respiratory function: FEV1 0.80L (42% predicted), FVC 2.02L (73% predicted) and DLco 9 (42% predicted). 164 (48%) used domiciliary oxygen. Sixty (18%) patients accessed specialist palliative care and 17 (5%) wrote an advance directive prior to the final admission. In the final admission, 252 (74%) patients had their goal of care changed to aim for comfort (palliation) and 99 (29%) were referred to specialist palliative care. Two hundred and eighty-six (83%) patients received opioids and 226 (66%) received benzodiazepines, within 1 or 2 days respectively after admission to palliate symptoms. Median starting and final opioid doses were 10 mg (IQR = 5-20) and 20 mg (IQR = 7-45) oral morphine equivalent/24 h. Hospital site and year of admission were significantly associated with palliative care provision. Respiratory and general physicians provided a palliative approach to the majority of COPD patients during their terminal admission, however, few patients were referred to specialist palliative care. Similarly, there were missed opportunities to offer symptom palliation and a palliative approach in the years before death.

Association Between Chronic Obstructive Pulmonary Disease and Type 2 Diabetes: A Systematic Review and Meta-Analysis.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) has been associated with an increased risk of type 2 diabetes (T2D). However, the mechanisms linking COPD and T2D is not fully understood and contradicting results are reported in the literature. AIM: The aim of this study is to investigate whether COPD is associated with an increased risk of T2D. METHODS: A systematic review and meta-analysis of cohort and case-control studies were performed. Search for studies and data extraction was carried out by two authors independently. Study quality was assessed by NOS. Adjusted data were pooled using the random effects model to calculate summary odds ratios (ORs) with corresponding 95% confidence intervals (CIs). RESULTS: We identified four cohort studies and three case-control studies with a total of 1,369,560 participants of whom 42,716 were COPD patients. The quality of the studies was acceptable, with an average on 7.7 indicating overall good study quality. The meta-analysis on adjusted data from all seven studies showed that the COPD group had a higher risk of T2D compared with the non-COPD group: random effect OR = 1.17 (1.01-1.35), p = 0.03. No heterogeneity was found I2 = 0%. When including only studies diagnosing both COPD and T2D according to recommended guidelines the association did not remain statistically significant, OR =1.17 (0.96-1.42), p = 0.12. CONCLUSION: This systemic review and meta-analyses showed that the association between COPD and T2D might be influenced by the diagnostic method and should be further investigated in studies using diagnostic definition according to guidelines. Nevertheless, physicians should be aware of comorbidities in COPD patients.

Factors facilitating and hindering the intention to promote pulmonary rehabilitation for patients with COPD among respiratory therapists.

PURPOSE: Pulmonary rehabilitation (PR) is recognized as the chief non-pharmacologic management approach for patients with COPD, but is clinically under-utilized. In Taiwan, respiratory therapists (RTs) are one of the first-line health care providers who spend vast amounts of time with COPD patients in PR programs. To better enhance patients' knowledge of and participation in PR, it is necessary to understand how PR is viewed by RTs, as well as how these views influence their behavioral intentions toward promoting PR. This study applied the Theory of Planned Behavior (TPB) to investigate both the behavioral intentions and the influential factors surrounding PR in RTs. PATIENTS AND METHODS: This cross-sectional study used structured self-administered questionnaires at a national symposium for RTs to collect data on their knowledge, attitudes, subjective norms, perceived behavioral controls, and behavioral intentions with regard to promoting PR. Multiple linear regression analysis was used to identify significant factors affecting the intended promotion of PR by RTs. RESULTS: The response rate after excluding respondents with incomplete data was 88.1% (n=379). A majority of the participants were college graduates, aged over 30 years, and women. The respective percentage scores derived from questionnaires gauging the knowledge, attitudes, subjective norms, self-efficacy, and behavioral intentions components of total PR scores were 63.12%, 71.33%, 68.96%, 66.46%, and 80.29%. The factors significantly affecting RTs' intentions to suggest PR participation to COPD patients or encourage it were attitudes, subjective norms, and self-efficacy. The total model explained 22.5% of the variance in behavioral intentions. CONCLUSION: The results of the study suggest that RTs strongly intend to promote PR, but are hindered by insufficient knowledge, attitudes, and self-efficacy with regard to it. Applying TPB provided insight into which factors can be addressed, and by whom. For example, enhancing RTs' self-efficacy can be achieved through PR training via school curricula, further regular continuing education and/or courses, and practical experience.

SafAIRway: an airway training for pulmonologists performing a flexible bronchoscopy with nonanesthesiologist administered propofol sedation: A prospective evaluation.

Nonanesthesiologist administered propofol (NAAP) sedation for flexible bronchoscopy is controversial, because there is no established airway management (AM) training for pulmonologists. The aim was to investigate the performance and acceptance of a proposed AM algorithm and training for pulmonologists performing NAAP sedation. The algorithm includes using 3 maneuvers including bag mask ventilation (BMV), laryngeal tube (LT), and needle cricothyrotomy (NCT). During training (consisting of 2 sessions with a break of 9 weeks in between), these maneuvers were demonstrated and exercised, followed by 4 consecutive attempts to succeed with each of these devices. The primary outcome was the improvement of completion time needed for a competent airway. Secondary outcomes were the trainees' overall reactions to the training and algorithm, and the perceptions of psychological safety (PS). The 23 staff members of the Department of Pulmonology performed a total of 552 attempts at AM procedures (4 attempts at each of the 3 maneuvers in 2 sessions), and returned a total of 42 questionnaires (4 questionnaires were not returned). Median completion times of LT and NCT improved significantly between Sessions 1 and 2 (P = 0.005 and P = 0.04, respectively), whereas BMV was only marginally improved (P = 0.05). Trainees perceived training to be useful and expressed satisfaction with this training and the algorithm. The perception of PS increased after training. An AM algorithm and training for pulmonologists leads to improved technical AM skills, and is considered useful by trainees and raised their perception of PS during training. It thus represents a promising program.

Development of a Tool to Assess Basic Competency in the Performance of Rigid Bronchoscopy.

RATIONALE: Rigid bronchoscopy is increasingly used by pulmonologists for the management of central airway disorders. However, an assessment tool to evaluate the competency of operators in the performance of this technique has not been developed. We created the Rigid Bronchoscopy Tool for Assessment of Skills and Competence (RIGID-TASC) to serve as an objective, competency-oriented assessment tool of basic rigid bronchoscopic skills, including rigid bronchoscopic intubation and central airway navigation. OBJECTIVES: To assess whether RIGID-TASC scores accurately distinguish the basic rigid bronchoscopy skills of novice, intermediate, and expert operators, and to determine whether RIGID-TASC has adequate interrater reliability when used by different independent testers. METHODS: At two academic medical centers in the United States, 30 physician volunteers were selected in three categories: 10 novices at rigid bronchoscopy (performed at least 50 flexible, but no rigid, bronchoscopies), 10 operators with intermediate experience (performed 5-20 rigid bronchoscopies), and 10 experts (performed ≥100 rigid bronchoscopies). Participants included pulmonary and critical care fellows, interventional pulmonology fellows, and faculty interventional pulmonologists. Each subject then performed rigid bronchoscopic intubation and navigation on a manikin, while being scored independently by two testers, using RIGID-TASC. MEASUREMENTS AND MAIN RESULTS: Mean scores for three categories (novice, intermediate, and expert) were 58.10 (±4.6 [SE]), 78.15 (±3.8), and 94.40 (±1.1), respectively. There was significant difference between novice and intermediate (20.05, 95% confidence interval [CI] = 7.77-32.33, P = 0.001), and intermediate and expert (16.25, 95% CI = 3.97-28.53, P = 0.008) operators. The interrater reliability (intraclass correlation coefficient) between the two testers was high (r = 0.95, 95% CI = 0.90-0.98). CONCLUSIONS: RIGID-TASC showed evidence of construct validity and interrater reliability in this setting and group of subjects. It can be used to reliably and objectively score and classify operators from novice to expert in basic rigid bronchoscopic intubation and navigation.