“As a longstanding ORCS member and your current OLA Board Chair, I look forward to celebrating 30 years of outstanding education and networking opportunities at Better Breathing 2011.” Kelly Muñoz, RRT Chair, Ontario Lung Association

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Features

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OSA has a significant impact on morbidity and mortality . . 1

Sleep Apnea: The Not So Silent Killer

Better Breathing 2011

Anu Tandon, MD, FRCP(C), Division of Respirology, Sunnybrook Health Sciences Centre, University of Toronto

In this Issue Sleep Apnea: The Not So Silent Killer

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Register today . . . . . . . . . . . . . 3

Patients First – Towards an Ontario Lung Health Strategy Pledge your support . . . . . . . 7

Assessing the Risks of Residential Radon in Canada Radon is the second leading cause of lung cancer. . . . . . . . 8

Radon in our Homes Test your home . . . . . . . . . . . . 9

In the Spotlight Dr. Judy King receives the Meritorious Service Award . . 10

Around the Regions Regional group activities and plans . . . . . . . . . . . . . . . . . . . 11

Regular Columns Chair’s Message . . . . . . . . . . . 2 Editor’s Comment . . . . . . . . . . 2 Coming Events . . . . . . . . . . . . 3 Respiratory Articles of Interest . . . . . . . . . . . . . . . . . 12

www.on.lung.ca

bstructive sleep apnea (OSA) is a Burden condition that involves intermittent While there isn’t a breadth of information closure of the upper airway during pertaining to the prevalence of OSA in sleep, limiting airflow and leading to Canada, a large epidemiologic study oxygen desaturation as well as conducted in Wisconsin found a arousals from sleep (Figure 1). While prevalence of 4% in men and 2% in it can lead to sleepless nights, this women (1). In general, there is an increased particular condition also has incidence in men than women and the significant public health implications incidence increases with age. Although ANU TANDON and cardiovascular risks. Other types the reported incidence varies among of sleep disordered breathing include central studies, men are considered to have a 3-fold sleep apnea which can be defined as absence of increased risk of OSA compared to women (1). airflow due to lack of respiratory effort. Interestingly, studies in women have also shown an Common causes of central sleep apnea can increased incidence of OSA in postmenopausal include drugs such as opioids, and conditions women, with a 3-fold increase in incidence such as stroke and heart failure. For the scope of compared to their premenopausal cohorts (2). this article we will focus on obstructive sleep apnea. Risk Factors FIGURE 1 This figure illustrates normal breathing on the left followed by collapse of the upper One of the leading risk factors for obstructive airways setting the stage for an obstructive event. sleep apnea is obesity. Studies have consistently shown a link with the degree of sleep apnea measured by the Apnea-Hypopnea Index (AHI) and weight gain as well as showing an improvement in the degree of OSA with significant weight loss (3). As seen in Table 1, even a ten percent change in body weight can impact the degree of apnea seen. Other risk factors have included tonsillar hypertrophy, macroglossia, neuromuscular diseases such as

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UPDATE An official publication of the Ontario Respiratory Care Society, a section of The Lung Association 573 King Street East Toronto, Ontario M5A 4L3 1-888-344-5864 Fax (416) 864-9916 E-mail: [email protected] Internet: http://www.on.lung.ca

EDITORIAL BOARD CO-EDITORS Dina Brooks, PhD, MSc, BScPT Mika Nonoyama, RRT, PhD MEMBERS Pat Bailey, RN, MHSc, PhD Yvonne Drasovean, RRT Elizabeth Gartner, BScOT Libby Groff, RRT, BHA, CRE Therese Hawn, BScPT Lawrence Jackson, BScPhm Dale Stedman, RN Renata Vaughan, RRT Suzy Young, RN, MN, NP CHAIR, ONTARIO RESPIRATORY CARE SOCIETY Cathy Relf, BScPT CHAIR, ONTARIO LUNG ASSOCIATION Kelly Muñoz, RRT PRESIDENT & CEO, ONTARIO LUNG ASSOCIATION George Habib, BA, BEd, CAE DIRECTOR, ONTARIO RESPIRATORY CARE SOCIETY Sheila Gordon-Dillane, BA, MPA Opinions expressed in Update do not necessarily represent the views of The Lung Association nor does publication of advertisements constitute official endorsement of products and services.

ONTARIO RESPIRATORY CARE SOCIETY Vision Improved lung health through excellence in interdisciplinary respiratory care.

Mission Furthering excellence in the provision of interdisciplinary respiratory care through education, research, collaboration, provision of professional expertise and support for Lung Association efforts to improve lung health. 2

CHAIR’S MESSAGE “The answer my friend, is blowing in the wind, the answer is blowing in the wind....” f only it were that easy. But…the answers we seek for the prevention and treatment of lung disease take dedicated research and a strategy to get it done. The National Lung Health Framework has been put forward to guide our future efforts. Here in Ontario, we have taken bold strides towards an Ontario Lung Health Strategy with the OLA’s Patients First initiative and the Risk Analytica project. The OLA has engaged an expert panel of healthcare professionals and sought input from key stakeholders to explore the impact of lung disease in our province. Visit www.on.lung.ca to pledge your support for an Ontario Lung Health Strategy. It’s been an exciting three years and I’ve had the privilege of being a part of these latest OLA developments. Now it’s time to pass the baton and welcome Libby Groff as she takes over as Chair of the Ontario Respiratory Care Society.

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Libby has over 20 years of experience with the ORCS and will bring great leadership and enthusiasm to the society. I’d like to say a special thanks to Justyna Couto, Regional Representative for the ORCS Southwestern Ontario Region, who stepped down in order to pursue new career opportunities in Alberta. A warm welcome is extended to Andrew Bagnall, a Respiratory Therapist at London Health Sciences Centre, who has taken over as the new SWO Regional Representative. I must also thank Sheila Gordon-Dillane and Heather Wood for their outstanding support throughout my term as Chair of ORCS. Better Breathing promises to be another great conference thanks to the leadership of Michael Keim and the planning committee. I look forward to seeing everyone at our 30th Anniversary Better Breathing Conference and the 2nd annual Breathe gala in support of lung research in January! Best wishes in 2011.

CATHY RELF, CHAIR, ORCS

EDITOR’S COMMENT appy New Year to everyone! I hope everyone had a wonderful holiday season and is feeling refreshed about the start of another New Year. This issue of Update comes just before the 2011 Better Breathing Conference (January 27th to 29th), its 30th anniversary. It will be packed with exciting learning opportunities and a great way to network with others in the respiratory field. Don’t miss it! This issue brings us some interesting articles, covering a wide range of topics. Dr. Anu Tandon (Respirologist) has provided a description of obstructive sleep apnea (OSA) that includes burden, diagnosis, co-morbid risks and treatment. It is a must for those who want to learn about OSA in a succinct and wellinformed package. Next, Michael King (Epidemiologist) and Brian Stocks (Air Quality Manager at the Ontario Lung Association) report on the risks of radon exposure. Of special interest for us is the significant risk for lung

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cancer. Mr. King has provided a summary of these risks via a case study and evidence contained in literature and reports. Mr. Stocks supplements this article by promoting awareness and education about radon risk. I plan to go out and buy my test kit today! In addition to the wonderful articles, the In the Spotlight column features Dr. Judy King, a physiotherapist who will receive The Lung Association's Meritorious Service Award at the 2011 Better Breathing Conference. She is a long-term ORCS volunteer with many accomplishments – a most deserving recipient. As always, check out the Coming Events column to see pending seminars, workshops and conferences and Respiratory Articles of Interest for summaries of new evidence.

MIKA NONOYAMA, CO-EDITOR

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COMING

EVENTS BETTER BREATHING 2011: Celebrating 30 years of educating health care professionals egister today for Better Breathing 2011, scheduled for January 27 - 29, 2011 at the Toronto Marriott Downtown Eaton Centre hotel at 525 Bay St., Toronto. The ORCS program offers something for everyone who works in respiratory care. It also includes the ORCS Annual General Meeting including reports on the year’s activities and the election of a new ORCS Chair.

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Conference Highlights Thursday, January 27 • ORCS Respiratory Health Educators Interest Group (RHEIG) annual session with a presentation on Lessons Learned from the H1N1 Experience and workshops on Culturally Sensitive Patient Education, The Use of COPD Action Plans in Patient Self-Management, Learning Differences in Child Patient Education and The New Asthma Continuum. Friday, January 28 • Plenary Session Theme: Old Challenges, New Opportunities: Emerging Technologies in Respirology. Dr. James Mahony (Hamilton) will discuss Molecular Technology for Infectious Disease Diagnosis and Dr. David Manson (Toronto) will address State-of-the-Art Pulmonary Diagnostic Imaging. • ORCS and OTS joint scientific session, entitled What’s New in Lung Health?, featuring talks on Update: Pulmonary Fibrosis – Progress is Slow but it is Happening by Dr. Martin Kolb (Hamilton), Supportive Care Needs of Individuals with Lung Cancer by Dr. Margaret Fitch (Toronto) and Patient Can’t Breathe: Is it the Heart or the Lungs? – Puffers or Diuretics? by Dr. Sheldon Magder (Montreal); • Friday afternoon ORCS sessions addressing Advances in Allergies and Asthma by Dr. Harold

Kim (Kitchener), Obesity and Lung Disease by Dr. Robert Ross (Kingston) and Assessment and Management of Chronic Cough by Amin Thawer (Calgary). The ORCS Annual Meeting will be held during these sessions. • Friday ends with two exciting social events: an ORCS Reception featuring poster presentations and Just What the Doctor Ordered!, a reception sponsored by ProResp, featuring a live band. Both receptions will offer food stations and a cash bar and are included in your registration fee. Saturday, January 29 • On Saturday morning, select two of six concurrent workshops: Research Presentations, Exhaled and Nasal and Nitric Oxide Use in Airways Disease, The Quality Improvement and Innovation Partnership, Introduction to Qualitative and Quantitative Review Methodologies, Respiratory Therapies: A Naturopathic Medical Approach and Teaching a High Risk Skill Using High Fidelity Simulation: Suctioning as a Shared Competency. Several companies will offer sponsored sessions with a speaker. These include a Thursday luncheon, Friday and Saturday breakfasts, a Friday evening Case Challenge with dinner and a Saturday luncheon. Please visit www.on.lung.ca/bbc for the full program and on-line registration or call (416) 864-9911, ext. 256 for information or to register by telephone. Register today! ORCS Annual General Meeting January 28, 2011, 2:15 p.m., Grand Ballroom AB Toronto Marriott Downtown Eaton Centre Hotel

Become an ORCS member or renew your membership for 2011-2012 Individual $40; Student $25; RHEIG add $15 Call 1-888-344-5864 ext. 256 for information or visit www.on.lung.ca/orcs W INTER 2011 U PDATE

January 27-29, 2011* Better Breathing 2011, Celebrating 30 years of educating health care professionals, will be held at the Toronto Marriott Downtown Eaton Centre hotel. See article on this page. February 4-5, 2011 The Third Annual Ottawa Conference: State of the Art Clinical Approaches to Smoking Cessation will be held at the Fairmont Chateau Laurier Hotel. www.ottawamodel.ca. February 24-26, 2011 The IUATLD North American Region’s annual conference, Engaging Vulnerable Populations: Tools and Strategies to Halt TB, will be held at the Sheraton Vancouver Wall Centre Hotel, Vancouver, BC. Call (604) 731-5864. April 8-10, 2011 McMaster University’s 6th Annual Thoracic Cancer Conference will be held at Queen’s Landing Inn and Conference Centre, Niagara-on-the-Lake. www. OntarioThoracicCancer.ca. April 13, 2011 – 5:30 - 8:00 p.m. The ORCS Greater Toronto Region’s spring educational evening will be held at Southlake Regional Health Centre in Newmarket. Details to follow. April 28–30, 2011 The Canadian Respiratory Conference, A Breath of Fresh Air, will be held at the Sheraton on the Falls Hotel and Conference Centre, Niagara Falls, Ontario. www.lung.ca/crc. May 13–18, 2011 The American Thoracic Society annual conference, Where Today’s Science Meets Tomorrow’s Care, takes place in Denver, Colorado. www.thoracic.org. Continued on page 12

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Sleep Apnea: The Not So Silent Killer... Continued from page 1

ALS and endocrinopathies such as hypothyroidism and polycystic ovarian disease. A recent risk factor with emerging data has been cigarette smoking (4). TABLE 1 Mean Change in the Apnea-Hypopnea Index (AHI) by Weight Change Category

Signs and Symptoms Clinically, patients with obstructive sleep apnea can present with various symptoms. One of the most common presentations is that of increased daytime somnolence, nocturnal awakening and snoring. Reports of witnessed apnea and choking events by the patient’s bed partner often prompt referrals to sleep clinics as well. Many individuals can also give a history of difficulty with memory and concentration. Recent data has confirmed this with studies

looking specifically at cognitive function and brain morphology in patients with OSA both on and off treatment. Results indicate a significant improvement in both memory and attention as well as an increase in grey matter on MRI with CPAP therapy (5). Men are referred more frequently than women to sleep clinics and this discrepancy has been explained by differences in presentation. The Wisconsin Sleep Cohort study found that women with OSA were less likely to present with snoring and sleepiness but rather with headaches and increased daytime fatigue when compared to men (6). Diagnosis The gold standard for diagnosis of OSA is an overnight polysomnogram. This involves an overnight study where several pieces of information are obtained from electrical leads placed strategically on the body. The raw data accumulated is shown in Figure 2, which illustrates the classic pattern associated with obstructive apnea. The sleep pattern can be determined by monitoring the electrical activity in the brain and skeletal musculature, which reveals the various stages of sleep. Data from the electromyography (EMG) at leg and chin, electroencephalography (EEG) and electrooculography (EOG) shows staging of sleep into N1, N2, N3 and REM as well as periods of arousal. Respiratory measures

FIGURE 2 An epoch from a 52 year old diabetic with snoring and daytime somnolence. Note the obstructive events during REM sleep with persistent respiratory and abdominal effort but no nasal flow followed by the resuscitative breath and oxygen desaturation.

include thoracic and abdominal belts that measure movements during breathing, a nasal pressure transducer to detect airflow resistance and oximetry and possible transcutaneous CO2 monitoring to diagnose apneas and hypopneas. An obstructive apnea is defined as a complete cessation in breathing with maintained respiratory effort. The definition of a hypopnea is less clear but commonly accepted as a 30% drop in thoracoabdominal movement or nasal flow associated with a decrease in oxygen saturation of 4% from baseline lasting more than ten seconds. From a clinical perspective there is no difference pathophysiologically between and apnea or hypopnea so these are commonly lumped together to give you an apnea-hypopnea index (AHI). This index determines the severity of apnea where an AHI of 5-15 per hour is considered mild, 15-30 per hour is considered moderate and greater than 30 per hour is considered severe (7). Treatment Once a patient is diagnosed with obstructive sleep apnea, the next step is to decide whether a patient needs therapy and if so what type. Treatment often begins with lifestyle modification. Since one of the most important reversible risk factors is obesity, weight loss is highlighted as a significant treatment given it is one of the few options that can actually cure sleep apnea. Other lifestyle modifications include reducing alcohol intake close to bedtime to prevent any further relaxation of the dilator muscles and eliminating sedatives such as benzodiazepines before bedtime to prevent worsening of the apnea. If patients are suffering only from supine related OSA, preventive positional therapy such as sewing a tennis ball onto the back of a nightgown can be used. Once lifestyle changes have been addressed, three other options are available to control OSA. First-line therapy is Continuous Positive Airway Pressure (CPAP). This treatment involves a mask, either nasal or full face, which is connected to a device that pressurizes air and delivers it into the oropharynx. The air pressure, which can vary between 6 and 20 cm of H20, acts as a stent preventing closure of the upper airway from occurring at end expiration, thereby preventing apneas and hypopneas. Patients normally undergo a CPAP titration study in a sleep lab to Continued on page 5

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appropriately determine what CPAP pressure they require; however this may be done at home now that auto devices are becoming available. Once a pressure is determined, the patient is asked to use the device on a daily basis. Evidence has shown that a minimum of four hours per night is most beneficial for symptom control (7b). The benefits of CPAP have been consistently shown in the literature. Patients report improvement in OSA symptoms (8), improved quality of life and less sleep disturbance for the bed partner (9). Large studies in the United States have shown a significant reduction in accidents with use of CPAP as well as increased cost savings related to these events (10). Given the nature of the treatment, studies have been done looking at compliance rates. A study done in Canada prospectively looked at patients with a moderate to severe degree of sleep apnea and studied compliance data from 2 weeks to 6 months. All subjects underwent a teaching session where they were educated on CPAP use as well as its benefits. In the end it was found that at 6 months, approximately 78% of the individuals were wearing their CPAP for more than 4.5 hours with resulting decreases in their Epworth Sleepiness Score. Predictors of compliance were found to be increasing age, female gender and improvement in symptoms, which provided positive reinforcement. It should be noted the patients in this study received intense follow up and education which may have produced artificially elevated compliance rates (11). If anything, this study may have provided a model to achieve higher compliance rates. Perhaps frequent compliance checks as well as education sessions prior to starting CPAP may be the key to improving a patient’s experience. As shown, while most individuals tolerate this therapy quite well, there are some side effects that can reduce compliance. One of the initial hurdles is that of finding a mask that fits appropriately. Often patients have to try two or more masks to accomplish a proper seal with a high level of comfort. This is often remedied by working closely with the patient’s CPAP provider company and revisiting mask fitting periodically while on therapy. Another common complaint is that of mouth dryness while on therapy at night. This can often be addressed by increasing W INTER 2011 U PDATE

humidity of the device or assessing whether the patient is mouth breathing while on a nasal mask and would therefore require either a full face mask or a chin strap. Nasal congestion may be encountered by some patients and this can treated with nightly saline rinses, ipatropium or steroid based nasal sprays. The benefits of CPAP have been consistently shown in the literature. Not only do patients report improvement in symptoms resulting from OSA (8), but studies have also shown improved quality of life and less sleep disturbance for the bed partner (9). From a public health standpoint, patients with OSA have been shown to have a three times increased chance of motor vehicle collisions (10) and large studies in the United States have shown a significant reduction in accidents with use of CPAP as well as increased cost savings related to these events (12). If a patient suffers from mild to moderate obstructive sleep apnea with symptoms and is either unable to tolerate CPAP or prefers another therapy, an oral appliance is available. This device normally acts by advancing the mandible thereby increasing the cross sectional area and volume of the upper airway. There are certain groups of patients where this device is appropriate including those with mild or moderate obstructive apnea, those with increased supine apnea as well as those with lower body mass indexes. Side effects related to this treatment can include temporomandibular joint discomfort, headaches or gum irritation (13). A final treatment option available is surgery. This is normally performed by ENT surgeons and involves nasal surgery including a septoplasty, palatal surgery including an uvulopalatoplasty or hypopharyngeal surgery which can include a mandibular osteotomy with genioglossus advancement. While many surgeries may remedy simple snoring, studies have shown that uvuloplasty resulted in complete treatment of the apnea in only 50% of the population at one year and a significant increase in apnea at the end of the four year period when compared to other treatment modalities such as a dental device (14). For this reason, surgery is not normally recommended in those with severe apnea. In order to address the obesity risk factor, bariatric surgery has recently been added as a possible treatment of OSA. One

FIGURE 3 Adjustable gastric banding procedure as a form of Bariatric Surgery. Obtained from www.jeffersonhospital.org/TestsandTreatment.

of the more common procedures is gastric bypass which is a surgical procedure that combines the creation of small stomach pouches to restrict food intake and the construction of bypasses of the duodenum and other segments of the small intestine to cause food malabsorption. Another common procedure is gastric banding (Figure 3) where an inflatable silicone device is placed around the top portion of the stomach, via laparoscopic surgery, creating a small pouch above the stomach which fills quickly as food is eaten, then slowly empties into the stomach. Because the pouch fills so quickly, the satiety centre registers a full stomach thereby suppressing appetite. In general, studies have shown an approximate excess weight loss of 60%. Studies looking specifically at resolution of obstructive sleep apnea have also been promising given that obesity is the most significant risk factor for development of OSA. A recent systematic review indicated that approximately 85% of patients had either resolved or significantly improved their OSA with the procedure (15). What has yet to be determined is whether there are consistent improvements or resolution of OSA over time, which would be significantly related to patients having maintained weight loss. Not So Silent Killer Why is obstructive sleep apnea a “not so silent killer”? There have been a number of studies looking at the impact of OSA on certain co-morbidities such as hypertension, diabetes and cardiovascular disease. Given the significant overlap of obesity as a risk factor for OSA as well as all these Continued on page 6 5

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conditions it has often been difficult to prove an independent relationship. However, when examining causality of OSA and hypertension, the literature has been strong. Individuals with OSA are more vulnerable to the development of hypertension because they consistently have chronically elevated sympathetic tone due to repetitive apneas as well as alteration in baroreceptor reflexes. There have also been recent studies indicating OSA patients have underlying vascular remodeling that may also be causal in developing hypertension (15b). The Sleep Heart Health Study was a community based study of approximately 6132 subjects that looked specifically at cardiovascular consequences in those with OSA. This study showed an approximate two fold increase in development of hypertension in those with untreated severe OSA when adjusted for body weight (16). Similarly, treatment of severe OSA with CPAP in those with hypertension has shown an approximate drop of 10 mm Hg in mean arterial pressure from baseline (17). With respect to diabetes, studies have also shown a causal relationship where patients with OSA have increased insulin resistance due to recurrent hypoxemia and sleep fragmentation as well as hormone changes in leptin and adiponectin, both of which regulate caloric intake and appetite. In the Wisconsin Sleep Cohort, there were a significantly increased number of individuals with untreated moderate to severe OSA diagnosed with Type 2 diabetes when adjustments were made for sex, age and body habitus (18). After three months of CPAP use, OSA patients have also shown significant improvements in glucose control with improvements in Hemoglobin A1C levels (19). Finally, the risk for development of cardiovascular disease has been shown to be increased in those with severe OSA. Contributing mechanisms have included vascular injury and acceleration of atherosclerosis by hypoxemia, chronic sympathetic hyper reactivity, elevated fibrinogen and homocysteine levels and an increased risk of plaque rupture related to the repetitive episodes of increased intrathoracic pressure. A landmark study published in the Lancet in 2005 by Marin and colleagues (20) looked at a ten year follow up of those diagnosed with severe OSA both with and without treatment as well as those who were healthy and simple snorers. They found a significantly increased number of cardiovascular 6

deaths and non-fatal cardiovascular events such as myocardial infarction, stroke, cardiac bypass surgery or angioplasty in those with untreated severe OSA compared to those who were healthy or who had treated their OSA. As seen in Table 2, there was a significant cumulative incidence of both fatal and non-fatal events in the untreated severe apneic patients as opposed to either the simple snorers or those with treated severe apnea. These results are similar to other studies that have looked at similar end points (21). Summary In summary, Obstructive Sleep Apnea is a relatively common condition affecting approximately 4% of the general population with studies showing an increased incidence in certain cohorts including those with stroke and other cardiovascular disease. Although weight loss is the only reversible risk factor, many individuals require treatment with CPAP which has shown significant improvements in symptoms related to obstructive sleep apnea and in comorbidities related to OSA including diabetes and hypertension. While there are TABLE 2 Cumulative percentage of individuals with new fatal (A) and non-fatal (B) cardio-vascular events in each of the five groups studied.

side effects of treatment as well as factors that can reduce compliance, it is important as health care providers that we encourage its use and promote the benefits of not only treating this disease but also recognizing its significant impact on morbidity and mortality. References 1. Young T, Palta M, Dempsey J, et al. The occurrence of sleepdisordered breathing among middle-aged adults. N Engl J Med 1993; 328:1230-1235. 2. Dancey D, Hanly P, Soong C, Lee B, Hoffstein V. Impact of Menopause on the Prevalence and Severity of Sleep Apnea. Chest 2001; 120:151-155. 3. Peppard P, Young T, Palta M, Dempsey J, Skatrud J. Longitudinal Study of Moderate Weight Change and Sleep-Disordered Breathing. JAMA 2000; 284: 3015-3021. 4. Wetter DW, Young T, Bidwell T, Safwan Badr M, Palta M. Smoking as a Risk Factor for Sleep-Disordered Breathing. Arch Intern Med 10 October 1994; 154: 2219-2224. 5. Canessa N, Castronovo V, Cappa S, Aloia M, Marelli S, Falini A, Alemanno F, and Ferini-Strambi L. Obstructive Sleep Apnea: Brain Structural Changes and Neurocognitive Function Before and After Treatment. Am J Respir Crit Care Med 2010; doi: 10.1164/ rccm.201005-0693OC. E-published ahead of print October 29, 2010. 6. Young T, Hutton R, Finn L, Badr S, Palta M. The Gender Bias in Sleep Apnea Diagnosis: Are Women Missed Because They Have Different Symptoms? Arch Intern Med 1996; 156: 2445-2451. 7. Fleetham J, Ayas N, Bradley D. Canadian Thoracic Society guidelines: Diagnosis and Treatment of Sleep Disordered Breathing in Adults. Can Respir J 2006; 13: 387-392. 7b. Weever T, Maislin G, Dinges D, Bloxam T, George C, Greenber H, Kader G, Mahowald M, Younger J, and Pack A. Relationship between Hours of CPAP use and Achieving Normal levels of Sleepiness and Daily Functioning. Sleep 2007; 30: 711-719. 8. Monserrat J, Ferrer M, Hernandez L, Farre R, Vilagut. Effectiveness of CPAP Treatment in Daytime Function in Sleep Apnea Syndrome: A Randomized Controlled Study with an Optimized Placebo. Am J Respir Crit Care Med 2001; 164: 608-613. 9. Doherty L, Kiely J, Lawless G, and McNicholas W. Impact of Nasal Continuous Positive Airway Pressure Therapy on the Quality of Life of Bed Partners of Patients With Obstructive Sleep Apnea Syndrome. Chest 2003; 124:2209-2214. 10. George C et al. Reduction in MVC following treatment of Sleep Apnea with nasal CPAP. Thorax 2001; 56:508-512. 11. Sin D, Mayers I, Man G, and Pawluk L. Long-term Compliance Rates to Continuous Positive Airway Pressure in Obstructive Sleep Apnea: A Population-Based Study. Chest 2002; 121:430-435. 12. Sassani A. Findley L. Kryger M, Goldlust K, George C. Reducing Motor-Vehicle Collisions, Costs, and Fatalities by Treating Obstructive Sleep Apnea Syndrome. Sleep 2004; 27: 453-8. 13. Ferguson K, Cartright R, Rogers R, Wolfgang Schmidt-Nowara. Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review. Sleep 2006; 29: 244-262. 14. Walker-Engström M, Tegelberg A, Wilhelmsson B, and Ringqvist I. 4-Year Follow-up of Treatment With Dental Appliance or Uvulopalatopharyngoplasty in Patients With Obstructive Sleep Apnea: A Randomized Study. Chest 2002; 121:739-746. 15. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004; 292: 1724-1737. 15b.Dincer H and O’Neill W. Deleterious Effects of Sleep Disordered Breathing on the Heart and Vascular System. Respiration 2006; 73: 124-130. 16. Javier Nieto F, Young T, Lind B, Shahar E, Samet J, Redline S, D'Agostino R, Newman A, Lebowitz M, Pickering T for the Sleep Heart Health Study. Association of Sleep-Disordered Breathing, Sleep Apnea, and Hypertension in a Large Community-Based Study. JAMA 2000; 283: 1829-1836. 17. Becker H, Jerrentrup A, Ploch T, Grote L, Penzel T, Sullivan C and Peter J. Effect of Nasal Continuous Positive Airway Pressure Treatment on Blood Pressure in Patients With Obstructive Sleep Apnea. Circulation 2003; 107: 68-73. 18. Reichmuth KJ, Austin D, Skatrud JB. Association of Sleep Apnea and Type II Diabetes: a population-based study. Am J Respir Crit Care Med 2005; 172:1590-1595. 19. Babu A, Herdegen J, Fogelfeld L, Shott S, Mazzone T. Type 2 Diabetes, Glycemic Control, and Continuous Positive Airway Pressure in Obstructive Sleep Apnea. Arch Intern Med 2005; 165: 447-452. 20. Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoeahypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005; 365:1046-1052. 21. Peker Y, Hedner J, Norum J, Kraiczi J and Carlson J. Increased Incidence of Cardiovascular Disease in Middle-aged Men with Obstructive Sleep Apnea: A 7-Year Follow-up. Am J Respir Crit Care Med 2002; 166: 159-165.

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Patients First – Towards an Ontario Lung Health Strategy he Ontario Lung Association including its • Project the prevalence and burden of lung two professional societies, the Ontario disease in Ontario for the next 30 years; Respiratory Care Society (ORCS) and the • Provide a platform for evaluating and Ontario Thoracic Society (OTS), is playing a comparing proposed intervention strategies leadership role in advocating to the to mitigate the societal impact of lung Government of Ontario for an Ontario Lung disease; Health Strategy. As such, we have launched a • Generate a solid, evidence-based foundation number of new advocacy and communications upon which a strategic and comprehensive initiatives that we refer to as “Patients First”. plan of action can be built; and, Lung diseases have a major effect on • Reveal the risks of not taking action to the millions of people living in Ontario and affect community and policy makers in all ages – from birth to the end of life. government. Despite progress achieved over the years in both prevention and treatment, respiratory The report will be a key element in the diseases continue to have a devastating impact Ontario Lung Association’s long-range on both the physical and economic health of advocacy strategy for the development of an people living in Ontario, taking a huge toll in Ontario Lung Health Strategy. lost lives, lost economic productivity, and We are also developing a broader government relations strategy that began with costs to our health care system. But perhaps a successful Lobby Day at Queen’s Park on the most significant impact is on the longterm quality of life for individuals and From left to right: Bruce Cooke, OLA Board October 6, 2010. Our COPD Ambassadors, families who are affected by lung disease. Member; Libby Groff, ORCS Chair-Elect; along with OLA representatives, members of Everyone living in Ontario is at some level of George Habib, President and CEO, OLA; our Board and our professional societies met risk for respiratory disease, making Margaret McDougall, Team COPD with 23 individual MPPs and/or their staff to Ambassador; Kelly Munoz, OLA Board respiratory health everybody’s business. advocate for a comprehensive smoking Chair; Brenda Cunningham, Bruce Eyre, The Ontario Lung Association aims to cessation system, as part of a broader lung Team COPD Ambassadors. bring this compelling health issue to the health strategy for Ontario. The day ended forefront in the hearts and minds of with a reception for all MPPs including consumers and government policy makers. Our overarching goal is special guests, the Minister of Health Promotion and Sport, Hon. to improve lung health and prevent respiratory illness and disease Margarett Best, and one of our lung champions, Walter Gretzky. among Ontarians through the development of a comprehensive Another major component of our plan is an on-line stakeholder Ontario Lung Health Strategy, that: survey, which will provide us with an opportunity to gather input • Promotes respiratory health among Ontarians from health care providers and others in the field of lung health on • Accelerates investment in all areas of lung health research what they believe the top priorities should be for an Ontario Lung • Recognizes the importance of prevention, detection and early Health Strategy. The survey will use the National Lung Health intervention Framework activities as a base, yet provide people with an • Improves indoor and outdoor air quality in Ontario opportunity to give additional ideas. The results of the survey will • Includes a province-wide smoking cessation system offering a be integrated with the outcomes of the study – both critical variety of supports and assistance elements of a longer-term communications plan. • Ensures fair and equitable patient access to all proven and If you would like additional information about this initiative, effective classes of medication, devices and evidence-based please contact Andrea Stevens Lavigne at the OLA office at supports, that have been endorsed and supported by the Canadian 416-864-9911, x229, [email protected] or Sherry Zarins at Thoracic Society Respiratory Guidelines and/or medical experts 416-864-9911, x267, [email protected]. in the area of lung health.

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As a first step, we plan to draw attention to the seriousness of the problem with the release of a comprehensive “Life and Economic Burden Report”, specific to lung disease. The Ontario Lung Association is working with an independent, health policy consulting organization and a panel of subject matter experts to produce a base model that will detail the health and economic impact of lung disease in Ontario. This report will aim to: W INTER 2011 U PDATE

TO PLEDGE YOUR SUPPORT FOR A LUNG HEALTH STRATEGY FOR ALL ONTARIANS, PLEASE VISIT THE OLHS PLEDGE PAGE: www.on.lung.ca/olhs. 7

Assessing the Risks of Residential Radon in Canada Michael King, MSc, Epidemiologist, Resources, Research, Evaluation and Development Division, Sudbury and District Health Unit, Sudbury possible health effects of residential radon exposures The Story of Stanley incurred by members of the general population. The story of radon in homes began with one man. The relationship between radon and other health Stanley Watras was an American construction engineer outcomes, including other respiratory diseases, other working at the Limerick Nuclear Power Generating malignancies and reproductive effects, has also been Facility in Pottstown, Pennsylvania in 1984. One day, studied. Currently, there is insufficient evidence to support Mr. Watras set off a radiation dosimeter that had been radon as a causative factor in anything but lung cancer.2 installed at the plant to screen workers and identify any who had accidentally accumulated an unsafe dose of Quantifying the Risks of Residential Radon Exposure radiation at work. The fact that Mr. Watras set off this MICHAEL KING Radon is one of the most widely studied human alarm was particularly notable as, at that time, the plant was still under construction and there was no nuclear fuel on site. carcinogens, and was the first occupational lung carcinogen to be The U.S. Environmental Protection Agency (EPA) eventually identified. As early as the 16th century, elevated rates of determined that Mr. Watras had received a massive dose of respiratory disease (which later would be diagnosed as pulmonary radiation to all parts of his body, and that this was the result of malignancies) were observed in miners in the Erz mountain region exposure to elevated levels of radon gas in his home. The measured in Eastern Europe. The hypothesis that these might be linked to the radon concentration in his house was found to be 2,700 picocuries high radon levels found in that area was put forth in the 1920s.3 per litre (piC/L)i, roughly 700 times the level considered by the EPA This hypothesis was not universally accepted until the results of several large occupational cohort studies in miners were published to be acceptable (i.e., 4 piC/L). The Watras family was evacuated from their home, which then (see Table 1), which consistently showed a significant association underwent mitigation. After installing a radon-reduction system, between radon exposure and lung cancer. These findings were radon levels in the house tested below 4 piC/L, and the family was confirmed in a 1999 combined analysis of all 11 cohort studies by able to return to their home. They still hold the distinction of the U.S. National Research Council’s Committee on the Health having had the highest average household radon concentration ever Effects of Exposure to Radon (BEIR VI). The committee found that the relationship between radon and lung cancer was adequately recorded. described by a linear model with no threshold – meaning that there is no “safe” dose of radon.2 Radon: A Ubiquitous Human Lung Carcinogen Radon is a naturally-occurring decay product of uranium to which all humans are exposed. It is a colourless, odourless and tasteless TABLE 1 Miner Cohort Studies of Radon and Lung Cancer2 gas, which continuously seeps out of rocks, soil and ground water China New Mexico and into the surrounding air. Though outdoor radon levels are Czech Port Radium typically very low, concentrations can increase within enclosed Colorado Radium Hill areas from which the gas is not allowed to disperse. Ontario France Radon is radioactive. It decays naturally to elemental lead Saskatchewan (Beaverlodge) through a series of other elements, historically known as radon Newfoundland daughters but now often termed radon decay products or radon Sweden progeny. If inhaled, the continuing decay of these gases can expose Attempts to draw conclusions regarding the population-level cells of the lung to alpha, beta and gamma radiation. Of these, alpha radiation (referred to as alpha particles) is of primary impacts of radon on lung cancer based solely on data from occupational cohorts are impeded by the many differences between concern to due to its significant ability to cause cell damage. Radon has been classified as a Group 1 (i.e., known human) miners and members of the public in general. As such, numerous carcinogen by the International Agency for Research on Cancer case control studies have been conducted examining differences (IARC)1 – a classification supported by the weight of evidence between population-based lung cancer cases and appropriatelyfrom a large body of experimental and epidemiologic research. selected controls with respect to their historical residential radon Action has therefore been taken to reduce elevated radon exposures4,5, (see Table 2). Very few of these studies have reported concentrations found in underground mines. And beginning with a significant association. This is not surprising, given the the Watras case in 1984, concern has been raised regarding the challenges in retrospectively creating an accurate exposure profile for each study participant for both residential radon and its i The SI unit of radon concentration is the bequerel per cubic metre (Bq/m ), where a bequerel confounders over the relevant exposure window (i.e., 5-30 years is the equivalent of 1 nuclear disintegration per second. The U.S. measures radon in piC/L, 3

where 1 piC/L is roughly equal to 37 Bq/m3.

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Residential Radon in Canada... Continued from page 8 TABLE 2

Case-Control Studies of Radon and Lung Cancer4,5

NORTH AMERICA

EUROPE

New Jersey Winnipeg Missouri-I Missouri-II Iowa Connecticut Utah-South Idaho

Sweden (Stockholm) Sweden (national) South Finland Finland (national) Southwest England Italy East Germany West Germany Sweden (non-smokers) France Czech Republic

CHINA Shenyang Gansu

previous). Non-differential misclassification of exposure biases towards the null (i.e., no significant association). Given that the miner cohorts predict a small increase in lung cancer risk at population-level exposures, even a small amount of exposure misclassification can result in a loss of statistical power to detect a true significant difference between exposure groups. As with the miner cohorts, attempts have been made to increase the statistical power of the radon case control studies by combining them. The North American4 and European5 analyses each show a small yet significant increase in lung cancer risk associated with increasing residential radon exposure, consistent with that predicted from the miner data2 (see Table 3). Note that work is currently underway to conduct a combined analysis of all radon case control studies worldwide. TABLE 3

Comparison of Results, Major Pooled Analyses of Radon and Lung Cancer Risk

Study

Relative Risk per 100 Bq/m3 (with 95% CI)

North American Case Control Studies4 European Case Control Studies Miner Cohorts2

5

1.11 (1.00-1.28) 1.08 (1.03-1.16) 1.12 (1.02-1.25)ii

Radon Levels in Canada Radon concentrations in homes follow a log-normal distribution – that is, most homes will have concentrations at or near the average, which is low, while a very small number of homes will have very high radon concentrations. Health Canada is currently conducting a new cross-sectional survey of household radon levels in Canada. Preliminary results indicate that approximately 7% of Canadian homes have radon concentrations in excess of 200 Bq/m3, but also that this proportion varies widely between provinces and territories, from 23.5% of homes in Manitoba to 0% of homes in Nunavut (see Table 4). In Ontario, an estimated 4.9% of homes have elevated radon levels.6 The Impact of Radon on Population Health Taken together, the levels of population radon exposure in Canada and the associated increase in lung cancer risk are believed to cause ii This estimate is based on a linear model developed by the BEIR VI Committee using data on low-exposed miners whose exposures were similar to long-term residents of high-radon homes; models derived from the full range of miner data available produce similar risk projections.

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RADON IN OUR HOMES…

Helping your patients clear the air indoors Brian Stocks, BA, MEd, Air Quality Manager, Ontario Lung Association here is growing public awareness about the lung cancer risk posed by indoor radon, and as a health professional, you may be asked about it by your clients in the coming months. The Ontario Lung Association is partnering with Health Canada to raise awareness about the health effects of long-term exposure to radon gas and to promote the testing of homes. Radon is a colourless, odourless gas produced BRIAN STOCKS from the breakdown of uranium in rocks and soil. It can enter a home through tiny openings in floors and foundations and build up to dangerous levels. Long-term exposure to radon is the second leading cause of lung cancer in Canada. For smokers, the risk of developing lung cancer from radon exposure is even higher. Radon is found across Canada and any home can be at risk. The level of radon in a home depends on many things, including the amount of uranium in the soil, the number of entry points into the home, and the type and level of ventilation. Levels can vary between neighbouring homes and even within a home from day-to-day. The only way to know if a home has high radon levels is to test. Health Canada recommends long term testing, for a minimum of three months in the fall, winter and early spring, when doors and windows are typically closed. Testing is easy and inexpensive, and test kits can be purchased from major home supply stores such as Home Hardware, Home Depot and Wal-Mart. Test kits can also be ordered on-line from various laboratories. Enclosed with this edition of ORCS Update is a brochure titled Radon – Is It In Your Home? Information for Health Professionals. A brochure for consumers is also available should you wish to distribute copies to your patients. For further information, visit The Lung Association’s website, www.on.lung.ca/radon, or speak with a Certified Respiratory Educator by calling 1-888-344-5864. You may also call Health Canada at 1-800-O-Canada.

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Thank you Brian Stocks Brian Stocks retired from The Lung Association on December 31, 2010 after almost 30 years as Executive Director of the Windsor office and more recently, provincial Air Quality Manager. Brian has been a strong supporter of the work of the ORCS, speaking at our seminars about indoor and outdoor air quality issues in almost every region of the province and writing several articles on various aspects of air quality for our publications. A true clean air champion, Brian has the ability to make complex matters understandable and has consistently provided health professionals with resources and knowledge to advise their patients on environmental issues. On behalf of the ORCS, thank you Brian and best wishes for a happy and healthy retirement. We will miss you! – The Editors 9

Residential Radon in Canada... Continued from page 9 TABLE 4

Distribution of Canadian Homes, by Province/ Territory and Average Annual Radon Concentration, 2009-20106

Province/ Territory Alta.

Percentage of Canadian Homes, by Radon Concentration < 200 Bq/m3 200-600 Bq/m3

>600 Bq/m3

93.1%

6.5%

0.4%

B.C.

95.4%

3.9%

0.7%

Man.

76.5%

22.1%

1.4%

N.B.

83.0%

11.7%

5.3%

N.L.

94.7%

4.4%

0.9%

N.S.

91.8%

6.3%

1.9%

N.W.T.

96.0%

4.0%

0.0%

NU

100.0%

0.0%

0.0%

Ont.

95.1%

4.3%

0.6%

P.E.I.

95.5%

4.5%

0.0%

Que.

91.0%

8.3%

0.7%

Sask.

84.2%

14.2%

1.6%

Y.T.

84.1%

10.6%

5.3%

approximately 10-15% of new lung cancer cases each year. Radon is therefore the second-leading cause of lung cancer death in Canada7, next to smoking. To put this risk into context, for a nonsmoker, lifetime exposure to 800 Bq/m3 yields a risk of death from lung cancer that exceeds that from all accidental injuries (e.g., motor vehicle collisions, falls, drowning, fire, etc.) combined.7 Table 5 shows the impact of radon exposure upon a hypothetical individual’s lifetime risk of developing lung cancer, based on their smoking status.7 Radon has a larger relative impact on nonsmokers, due to their lower baseline risk. Still, the vast majority of lung cancers attributable to radon will occur in smokers. TABLE 5

Estimated lifetime lung cancer risks, by radon exposure level and smoking status7

Radon Exposure Scenario

Lifetime Risk of Developing Lung Cancer Smokers Non-Smokers

Lifetime exposure to 800 Bq/m3

30%

5%

Lifetime exposure to 200 Bq/m3

17%

2%

Baseline (ambient exposure)

12%

1%

Managing the Risk Radon is an important public health issue. Screening kits are inexpensive and readily available. In terms of risk reduction, mitigating high radon levels is far more cost-effective than other environmental remediation programs.8 But note that since most people live at low levels of radon exposure, and lung cancer risk is linear with radon exposure at low doses with no threshold dose, a majority of the lung cancer cases attributable to radon will result from chronic exposure to radon at levels that fall below the Canadian advisory guideline of 200 Bq/m3.2 To significantly reduce the burden of lung cancer from radon in Canada, simply screening for and reducing radon concentrations in excess of 200 Bq/m3 is likely not enough. 10

The differential effect of radon on the risks of smokers vs. nonsmokers is such that the single most effective intervention to reduce the burden of radon-induced lung cancer is to reduce rates of smoking. References 1. International Agency for Research on Cancer (IARC). 1988. Man-made Mineral Fibres and Radon. Lyon, France: IARC. P. 143. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. 2. U.S. National Research Council (NRC). 1999. Health Effects of Exposure to Radon (BEIR VI). Washington, D.C.: National Academy Press. 3 3. Jacobi, W. 1994. The History of the Radon Problem in Mines and Homes. Protection Against Radon-222 at Home and at Work. Pergamon Press; London, England. 4. Krewski, D., et al. 2005. Residential radon and Risk of Lung Cancer: A Combined Analysis of 7 North American Case-Control Studies. Epidemiology, 16(2):137-145 5. Darby, S., et al. 2004. Radon in homes and risk of lung cancer: collaborative analysis of individual data from 13 European case-control studies. BMJ, doi:10.1136/bmj.38308.477650.63 (published 21 December 2004). 6. Health Canada. 2010. Cross-Canada Survey of Radon Concentrations in Homes. http:// www.hc-sc.gc.ca/ewh-semt/radiation/radon/survey-sondage-eng.php. Accessed on December 1, 2010. 7. Health Canada. 2008. Radon: Is it in Your Home? Information for Health Professionals. HC Pub: 4181, Cat: H128-554E. Ottawa, ON: Her Majesty the Queen in Right of Canada, represented by the Minister of Health. 8. King, M. 2005. Managing Lung Cancer Risks Associated with Residential Radon Exposure in Canada. Graduate Thesis, University of Ottawa.

In the Spotlight: Dr.

Judy King

ongratulations to Dr. Judy King, who will receive The Lung Association’s Meritorious Service Award at Better Breathing 2011. Dr. King is a physiotherapist, researcher and educator in Ottawa and has been a dedicated volunteer for The Lung Association at the national, provincial and local levels and for the Ontario Respiratory Care Society regionally and provincially for almost 15 years. Since 2006, she has been the Chair of the ORCS Research and Fellowship Committee, on which she previously served as a member for ten years. In her role as Research Chair, Judy provided leadership for the publication of several editions of the annual OTS/ORCS Research Review and had her own Ph.D. research, on Literacy and Health, featured in the 2008 edition. She has chaired the Poster Presentation session at the annual Better Breathing conference for many years, encouraging novice researchers to participate and gain experience with this skill. For several years, Judy has been a member of the ORCS Education Committee and ORCS Eastern Ontario Regional Group Planning Committee. Locally in Ottawa, Judy has also participated in fundraising activities and assisted the BreathWorks COPD Maintenance program. Nationally, she has served on committees, including serving as President of the Canadian Physiotherapy Cardio-Respiratory Society, one of the organizations that became the Canadian Respiratory Health Professionals. Judy King participates in Lung Association activities with enthusiasm and a wonderful sense of humour, encouraging her colleagues at The Ottawa Hospital and students at the University of Ottawa to become involved and to develop their skills and knowledge as educators and researchers to improve the lives of people living with lung disease.

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Around the Regions: ORCS Educational Opportunities for You and Your Colleagues ll members of the ORCS who live in Ontario belong to one of seven regional groups. Each group has a regional representative who sits on the ORCS Provincial Committee. Through volunteer planning committees, chaired by the regional representative and supported by the ORCS staff, regional groups usually present one or more education programs in their region each year. Members and non-members are welcome to attend. ORCS members pay a reduced fee for all programs. Those paying the non-member fee at full day seminars receive a trial membership for the balance of the membership year (April 1 – March 31). In 2011, take advantage of a program in your own region or another part of the province.

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Eastern Ontario Region – Regional Representative: Jennifer Olajos-Clow, RN(EC), MSc, CAE The Eastern Ontario Region presents full day programs in Ottawa and Kingston and has also held educational evenings in Cornwall, Brockville, Pembroke and Perth. In 2010, a full day seminar, Inspiration through Education: Diagnosing and Managing Respiratory Diseases A to ZZZ, was held at the Holiday Inn Kingston on June 24. A full day seminar in Ottawa will be planned for the spring of 2011. Greater Toronto Region – Chair: Julie Porco, RRT, Provincial Representative: Dilshad Moosa, RRT, MHSc(c), CRE, Education Chair: Ana MacPherson, RRT, MASc, CRE The Greater Toronto Region has a more formal structure than the other groups with an Executive Committee elected annually. One member of the Executive Committee is appointed to the Provincial Committee. Another member chairs the group’s Education Committee. Most years, the group offers educational evenings in April and June (the latter session includes the group’s annual meeting) and a full day seminar in November. In 2010, evening sessions were held on April 15 and June 17. Topics included Preschool Asthma, the AIR Team in the Emergency Department, BOOP and an Interprofessional Approach to Chronic Disease Management. The Region’s annual full day seminar, Making Theory a Reality in Respiratory Care was held on November 4, 2010 at the Holiday Inn Toronto-Markham. Planning has begun for a spring evening program on April 13 at Southlake Regional Health Centre in Newmarket. An evening in June in Toronto will also be scheduled and planning will begin soon for the 2011 fall seminar. A separate Planning Committee, based in Barrie and chaired by Ginny Myles, RRT, organizes occasional programs in the Barrie/Orillia area to serve the northern part of the Greater Toronto Region. An educational evening program on Pneumonia: Community to Hospital and Back Again was held at Royal Victoria Hospital in Barrie on October 6, 2010. An evening session will be planned either in Barrie or Orillia for the fall of 2011. Southwestern Ontario Region – Regional Representative: Andrew Bagnall, RRT The Southwestern Ontario Region is based in London. In addition to offering annual full day seminars there, the group has also presented educational evenings in various locations throughout the region. In 2010, a full day program, Spring Inspirations, was held in London on W INTER 2011 U PDATE

June 10. A full day seminar will again be held in London in the spring of 2011 and evening sessions in Sarnia and/or Stratford are being considered. Many thanks to Justyna Couto, who was the Regional Representative for almost 10 years until she moved to Alberta last fall and welcome to the new SWO Regional Representative, Andrew Bagnall. South Central Ontario Region – Regional Representative: Karen Martindale, RRT, BA The South Central Ontario Region has several large centres including Hamilton, St. Catharines, Niagara Falls, KitchenerWaterloo, Guelph, Burlington and Brantford so programs rotate among various locations from year to year. A full day seminar is held in October each year and occasional educational evenings are offered. In 2010, the group held a full day program, Resp Fest: A Respiratory Care Update on October 21 in Cambridge. In 2011, a full day seminar will be held in Niagara Region. Essex/Kent Region – Regional Representative: Gillian Hueniken, Reg. PT The Essex/Kent Region includes Chatham-Kent, the City of Windsor and Essex County. Programs are held in Chatham and Windsor. In 2010, the group’s full day seminar, All You Need is Lungs, originally scheduled for October, was rescheduled and held on February 25 at the Serbian Centre in Windsor. An educational evening program on the topic COPD vs. Asthma was held at the Chatham-Kent Health Alliance on November 2. A full day seminar may be held in Windsor in the fall of 2011. Northwestern Ontario Region – Regional Representative: Shelley Prevost, RRT, MASc The Northwestern Ontario Region is based in Thunder Bay. The group held a full day seminar, Inspiration through Education in Thunder Bay on October 21, 2010 in conjunction with a meeting of Family Health Teams from Northwestern Ontario. An educational evening will be held in 2011. Northeastern Ontario Region – Regional Representative: Christina McMillan Boyles, RN, MScN The Northeastern Ontario Region is based in Sudbury, where the group offers a full day seminar every two years and educational evenings in alternate years. An evening session on Residential Radon Exposure and Influenza was held on October 13 at Laurentian University. In 2011, a full day seminar will held in Sudbury in the fall. With Appreciation! ORCS education programs would not be possible without the strong support of the many ORCS members who volunteer to serve on our planning committees, speakers (including many ORCS and Ontario Thoracic Society members) who volunteer their time and expertise to present at our programs and many pharmaceutical, home oxygen and medical equipment companies that provide financial support through exhibit fees and sponsorship contributions for the seminars. If you would like to volunteer to serve on a planning committee or speak at a seminar in your region, contact [email protected]. 11

Respiratory Articles of Interest Gershon AS, Guan J, Wang C, To T. Trends in Asthma Prevalence and Incidence in Ontario, Canada, 1996–2005: A Population Study. American Journal Epidemiology 2010; 172 (6):728-736. A population-based cohort study was conducted to estimate asthma prevalence and incidence trends in Ontario, Canada. Data was obtained from universal, population health administrative databases. Annual asthma prevalence, incidence, and all-cause mortality rates were estimated from 1996 to 2005. During this time, the prevalence of asthma increased by 70.5%. The age- and sex-standardized asthma prevalence increased from 8.5% in 1996 to 13.3% in 2005, a relative increase of 55.1% (P < 0.0001). Asthma incidence rates increased in children by 30.0% and were relatively stable in adults. Overall all-cause mortality decreased. The prevalence of asthma in Ontario has increased significantly, attributable, in part, to an increase in the incidence of asthma in children. Effective clinical and public health strategies are needed to prevent and manage asthma in the population. Park R & Krajewski A. Successful advanced directives through quality disease management. Healthcare Quarterly 2010; 13: 74-77. The benefit of advance care directives is shared by health care professionals and the general public. The authors of this commentary indicate that although there is a consensus regarding the potential value of these documents, only 10-30% of the public in the US, Canada and Australia have engaged in this form of end-of-life planning. They suggest, however, that there is “a problem translating the support for advanced directives into actual plans” (p. 74). This failure is attributed, in part, to the difficulty most individuals have of anticipating decontextualized end-of-life health realities; perceptions are commonly limited to the “heroics” associated with acute events frequently portrayed in the media. Park and Krajewski also stress that it is difficult to make informed choices without knowledge of “the benefit and burdens” of such care. They therefore present a model that ties the creation of advanced directives to specific chronic or progressive illness, integrating advance care planning into routine professional care. Their work, informed by Gill et al’s (2010) longitudinal study of 754 community-dwelling older persons living with chronic progressive illnesses such as lung disease in the rural US, acknowledges differences in illness trajectories. Most importantly, their model imbeds advance care planning and reassessment by health care professionals familiar with patients and their substitute decision makers’ normal professional practice. 12

Hynninen MJ, Bjerke N, Pallesen S, Bakke PS, and Nordhus IH. A randomized controlled trial of cognitive behavioral therapy for anxiety and depression in COPD. Respiratory Medicine 2010; 104: 986-994. The objective of this Norwegian randomized controlled trial was to compare the effect of cognitive behavioral therapy (CBT) in a group setting with the “enhanced standard care” on symptoms of anxiety and depression in COPD. Recruitment of participants was through an outpatient pulmonary clinic as well as through a newspaper advertisement. The sample size was n = 25 in CBT group and n = 26 in control group. Primary outcome measures were the Beck Anxiety Inventory (BAI) and Beck Depression Inventory-II (BDI-II). Secondary outcome measures were: St. George’s Respiratory Questionnaire (SGRQ), perceived health status, Pittsburgh Sleep Quality Index (PSQI, subjective sleep quality) and actigraphy (objective sleep efficiency). CBT was provided in small groups for 2 hours/week x 7 weeks, with additional encouragement to maintain gains through phone contact 1 and 3 months after. The control group received standard COPD care plus a phone call every 2 weeks during the 7 weeks assessing the level of symptoms. All participants were followed at 2 and 8 months post baseline. Primary outcome measures demonstrated CBT improved the symptoms of anxiety and depression in the treatment group and no significant change in symptoms in the control group. Secondary outcome measures showed small changes in both groups. Although the authors acknowledge the limitations of the study, the evidence supports the conclusion that CBT may significantly decrease levels of anxiety and depression in COPD patients and mental health should be considered as part of the medical treatment regime for COPD. Summarized by Larry Jackson, Pat Bailey and Elizabeth Gartner.

COMING EVENTS... Continued from page 3 June 9–12, 2011 The Canadian Society of Respiratory Therapists National Conference and Trade Show will be held in Quebec City. www.csrt.com. July 14-17, 2011 The Canadian Physiotherapy Association National Congress 2011 takes place in Whistler, BC. Pre and post congress courses of interest to Respiratory Health Educators may be offered. www.physiotherapy.ca. *For further information on ORCS programs, call (416) 864-9911, ext. 256 or 236, e-mail [email protected] or visit www. on.lung.ca/orcs Additional 2011 Course Schedules: For RespTrec/SpiroTrec courses, visit www.resptrec.org For OLA Provider Education courses, visit www.olapep.ca For CAMH TEACH programs, visit www.camh.net

REGISTER TODAY JANUARY 27, 2011 EGLINTON GRAND, TORONTO

Tulip Day Breath of Spring For more information on Tulip Day in your area please visit www.tulipday.ca

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