Browsing by Author "Boulet, Louis-Philippe"
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Item Open Access Adult Asthma Consensus Guidelines Update 2003(2004-01-01) Lemière, Catherine; Bai, Tony; Balter, Meyer; Bayliff, Charles; Becker, Allan; Boulet, Louis-Philippe; Bowie, Dennis; Cartier, André; Cave, Andrew; Chapman, Kenneth; Cowie, Robert; Coyle, Stephen; Cockcroft, Donald; Ducharme, Francine M; Ernst, Pierre; Finlayson, Shelagh; FitzGerald, J Mark; Hargreave, Frederick E; Hogg, Donna; Kaplan, Alan; Kim, Harold; Kelm, Cheryle; O’Byrne, Paul; Sears, Malcolm; Markham, Andrea White; on behalf of the Canadian Adult Consensus Group of the Canadian Thoracic Society,BACKGROUND: Several sets of Canadian guidelines for the diagnosis and management of asthma have been published over the past 15 years. Since the last revision of the 1999 Canadian Asthma Consensus Report, important new studies have highlighted the need to incorporate new information into the asthma guidelines.OBJECTIVES: To review the literature on adult asthma management published between January 2000 and June 2003; to evaluate the influence of the new evidence on the recommendations made in the 1999 Canadian Asthma Consensus Guidelines and its 2001 update; and to report new recommendations on adult asthma management.METHODS: Three specific topics for which new evidence affected the previous recommendations were selected for review: initial treatment of asthma, add-on therapies in the treatment of asthma and asthma education. The resultant reviews were discussed in June 2003 at a meeting under the auspices of the Canadian Thoracic Society, and recommendations for adult asthma management were reviewed.RESULTS: The present report emphasises the importance of the early introduction of inhaled corticosteroids in symptomatic patients with mild asthma; stresses the benefit of adding additional therapy, preferably long-acting beta2-agonists, to patients incompletely controlled on low doses of inhaled corticosteroids; and documents the essential role of asthma education.CONCLUSION: The present report generally supports many of the previous recommendations published in the 1999 Canadian Asthma Consensus Report and provides higher levels of evidence for a number of those recommendations.Item Open Access Asthma Education and Management Programs in Canada(2001-01-01) Cowie, Robert L; Cicutto, Lisa; Boulet, Louis-Philippe; the Patient Education Program Committee, Canadian Network For Asthma Care,OBJECTIVE: To establish the number and type of asthma patient education programs throughout Canada.DESIGN: National survey.SETTING: Canada.METHODS: Over a three-year period, contact was made with individuals and groups offering educational services for patients with asthma. Education given as part of a physician's consultation or a pharmacist's dispensing of medications for asthma was not considered a patient education program for the purposes of the survey. Contact was initially established by asking staff from well known asthma programs to provide lists of other such programs in their provinces or regions. Asthma programs were also identified from notices presented at Canada's Third and Fourth National Conferences on Asthma and Education. Lung associations, lay organizations and industry representatives affiliated with the Canadian Network for Asthma Care helped to supplement the list. Once identified, each patient education program was contacted by telephone and by mail to complete a 26-item questionnaire about their program. The province of Quebec was not included in the survey because it already had a province-wide, structured asthma education program and register.RESULTS: Seventy-four asthma education and management programs were identified outside Quebec. Staff in these programs were registered nurses (n=46), respiratory therapists (n=48) and other health professionals (n=21). Forty-one programs stated that at least one member of their staff had been trained as an asthma educator. In 71 programs, the initial patient encounter was of at least one hour's duration. Physician referral was required by 41 programs. The province of Quebec has a joint asthma education program provided by 114 asthma education centres throughout the province under the umbrella of the Quebec Asthma Education Network (QAEN). This comprehensive program is provided in hospitals and community centres by specialized educators - nurses, pharmacists or respiratory therapists - to patients referred by their physicians.CONCLUSIONS: A three-year search for asthma education programs in Canada identified 74 patient education programs (outside Quebec) for an asthma population estimated to exceed 1.2 million. For the province of Quebec, an integrated asthma education program is provided through a network of 114 education centres - the QAEN. The present survey shows that there has been progress in establishing asthma education programs in Canada, although there are significant regional differences in the availability of such programs.Item Open Access Canadian Thoracic Society 2012 Guideline Update: Diagnosis and Management of Asthma in Preschoolers, Children and Adults(2012-01-01) Lougheed, M Diane; Lemiere, Catherine; Ducharme, Francine M; Licskai, Chris; Dell, Sharon D; Rowe, Brian H; FitzGerald, Mark; Leigh, Richard; Watson, Wade; Boulet, Louis-Philippe; Canadian Thoracic Society Asthma Clinical Assembly,BACKGROUND: In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and/or gaps in the previous guidelines.METHODS: Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS/long-acting beta2-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations.RESULTS: The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified.CONCLUSIONS: The present clinical practice guideline is the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee’s new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.Item Open Access Canadian Thoracic Society 2012 Guideline Update: Diagnosis and Management of Asthma in Preschoolers, Children and Adults: Executive Summary(2012-01-01) Lougheed, M Diane; Lemiere, Catherine; Ducharme, Francine M; Licskai, Chris; Dell, Sharon D; Rowe, Brian H; FitzGerald, Mark; Leigh, Richard; Watson, Wade; Boulet, Louis-Philippe; Canadian Thoracic Society Asthma Clinical Assembly,BACKGROUND: In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and/or gaps in the previous guidelines.METHODS: Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS/long-acting beta2-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations.RESULTS: The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified.CONCLUSIONS: The present document is an executive summary of the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee’s new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.Item Open Access Canadian Thoracic Society Asthma Committee Commentary on Long-Acting Beta-2 Agonist Use for Asthma in Canada(2010-01-01) Lougheed, M Diane; Lemiere, Catherine; Dell, Sharon; Ducharme, Francine; FitzGerald, J Mark; Leigh, Richard; Licskai, Chris; Rowe, Brian H; Bowie, Dennis; Becker, Allan; Boulet, Louis-PhilippeItem Open Access Canadian Thoracic Society Asthma Management Continuum – 2010 Consensus Summary for Children Six Years of Age and Over, and Adults(2010-01-01) Lougheed, M Diane; Lemière, Catherine; Dell, Sharon D; Ducharme, Francine M; FitzGerald, J Mark; Leigh, Richard; Licskai, Chris; Rowe, Brian H; Bowie, Dennis; Becker, Allan; Boulet, Louis-PhilippeBACKGROUND/OBJECTIVE: To integrate new evidence into the Canadian Asthma Management Continuum diagram, encompassing both pediatric and adult asthma.METHODS: The Canadian Thoracic Society Asthma Committee members, comprised of experts in pediatric and adult respirology, allergy and immunology, emergency medicine, general pediatrics, family medicine, pharmacoepidemiology and evidence-based medicine, updated the continuum diagram, based primarily on the 2008 Global Initiative for Asthma guidelines, and performed a focused review of literature pertaining to key aspects of asthma diagnosis and management in children six years of age and over, and adults.RESULTS: In patients six years of age and over, management of asthma begins with establishing an accurate diagnosis, typically by supplementing medical history with objective measures of lung function. All patients and caregivers should receive self-management education, including a written action plan. Inhaled corticosteroids (ICS) remain the first-line controller therapy for all ages. When asthma is not controlled with a low dose of ICS, the literature supports the addition of long-acting beta2-agonists in adults, while the preferred approach in children is to increase the dose of ICS. Leukotriene receptor antagonists are acceptable as second-line monotherapy and as an alternative add-on therapy in both age groups. Anti-immunoglobulin E therapy may be of benefit in adults, and in children 12 years of age and over with difficult to control allergic asthma, despite high-dose ICS and at least one other controller.CONCLUSIONS: The foundation of asthma management is establishing an accurate diagnosis based on objective measures (eg, spirometry) in individuals six years of age and over. Emphasis is placed on the similarities and differences between pediatric and adult asthma management approaches to achieve asthma control.Item Open Access Commentaire du Comité sur l’asthme de la Société Canadienne de Thoracologie au Sujet de I’utilisation des Bêta-2 agonistes à Longue durée d’action dans le Traitement l’asthme au Canada(2010-01-01) Lougheed, M Diane; Lemiere, Catherine; Dell, Sharon; Ducharme, Francine; FitzGerald, J Mark; Leigh, Richard; Licskai, Chris; Rowe, Brian H; Bowie, Dennis; Becker, Allan; Boulet, Louis-PhilippeItem Open Access Comparison of Once- with Twice-Daily Dosing of Fluticasone Propionate in Mild and Moderate Asthma(2000-01-01) Boulet, Louis-Philippe; Cowie, Robert L; Negro, Roberto Dal; Brett, Wade; Gold, Milton; Marques, Agostinho; Thorburn, William S; Stepner, Nate M; Bobson, ReidOBJECTIVES: Two 12-week, randomized, double-blind, parallel-group studies were performed to compare the efficacy and safety of once- and twice-daily dosing of fluticasone propionate (FP) in the treatment of mild to moderate asthma, considered to require the equivalent of either 200 or 500 µg of FP daily.PATIENTS AND METHODS: In study A, 461 patients with asthma received FP either 200 µg once daily or 100 µg twice daily. In study B, 443 patients with asthma received FP, either 500 µg once daily or 250 µg twice daily.RESULTS: In both studies, regardless of the treatment regimen to which patients were randomly assigned, small improvements over baseline were observed in morning peak expiratory flows (PEF) and forced expiratory volume in 1 s (FEV1) following 12 weeks of treatment. In study A, the mean morning PEF improved by 2.4% and 4.3% (once daily versus twice daily, P=0.008). In study B, the mean morning PEF improvement was 0.2% and 3.7% (once daily versus twice daily, PÃ0.001). For both studies, the increases observed in FEV1 were not significantly different between the two groups (P = not significant). The incidence of exacerbations of asthma and related events was 13% and 5%, respectively, in the patients with mild asthma for the once-daily group versus the twice-daily group; these exacerbations were 12% and 10%, respectively, in patients with moderate asthma. Otherwise, the incidence and types of adverse events were comparable for the two treatment regimens. Although twice-daily dosing demonstrated small but statistically significant improvements over once-daily dosing, patients of both groups generally maintained a good level of asthma control on both regimens according to current treatment guidelines. CONCLUSIONS: Twice-daily dosing of FP is more effective than once-daily dosing, although the latter can maintain asthma control in most patients.Item Open Access Effects of a Short Course of Inhaled Corticosteroids in Noneosinophilic Asthmatic Subjects(2011-01-01) Lemière, Catherine; Tremblay, Caroline; FitzGerald, Mark; Aaron, Shawn D; Leigh, Richard; Boulet, Louis-Philippe; Martin, James G; Nair, Parameswaran; Olivenstein, Ronald; Chaboillez, SimoneBACKGROUND: Noneosinophilic asthma has been regarded as a distinct phenotype characterized by a poor response to inhaled corticosteroids (ICS).OBJECTIVE: To determine whether noneosinophilic, steroid-naive asthmatic subjects show an improvement in asthma control, asthma symptoms and spirometry after four weeks of treatment with ICS, and whether they further benefit from the addition of a long-acting beta-2 agonists to ICS.METHODS: A randomized, double-blind, placebo-controlled, multicentre study comparing the efficacy of placebo versus inhaled fluticasone propionate 250 μg twice daily for four weeks in mildly uncontrolled, steroid-naive asthmatic subjects with a sputum eosinophil count ≤2%. This was followed by an open-label, four-week treatment period with fluticasone propionate 250 μg/salmeterol 50 μg, twice daily for all subjects.RESULTS: After four weeks of double-blind treatment, there was a statistically significant and clinically relevant improvement in the mean (± SD) Asthma Control Questionnaire score in the ICS-treated group (n=6) (decrease of 1.0±0.5) compared with the placebo group (n=6) (decrease of 0.09±0.4) (P=0.008). Forced expiratory volume in 1 s declined in the placebo group (−0.2±0.2 L) and did not change in the ICS group (0.04±0.1 L) after four weeks of treatment (P=0.02). The open-label treatment with fluticasone propionate 250 μg/salmeterol 50 μg did not produce additional improvements in those who were previously treated for four weeks with inhaled fluticasone alone.CONCLUSION: A clinically important and statistically significant response to ICS was observed in mildly uncontrolled noneosinophilic asthmatic subjects.Item Open Access Omalizumab in patients with severe asthma and persistent sputum eosinophilia(2019-04-03) Mukherjee, Manali; Kjarsgaard, Melanie; Radford, Katherine; Huang, Chynna; Leigh, Richard; Dorscheid, Delbert R; Lemiere, Catherine; Boulet, Louis-Philippe; Waserman, Susan; Martin, James; Nair, ParameswaranAbstract Omalizumab, a recombinant humanized monoclonal antibody targeting the IgE molecule, is the first biologic approved for moderate-to-severe allergic asthmatics, who remain uncontrolled despite high dose inhaled corticosteroid and bronchodilators. Steroid-sparing effect of omalizumab has not been demonstrated in asthmatics with persistent airway eosinophilia in a randomised controlled trial till date. From this double-blind, placebo-controlled, multi-centred, randomized parallel group design, we report that omalizumab is possibly inadequate to control sputum eosinophilia, and therefore may not have a steroid-sparing effect, especially in those maintained on oral corticosteroids daily. This needs to be confirmed or refuted in a larger trial, which may be a challenge with respect to recruitment, since there are currently three additional biologics available to prescribe. Trial registration Clinicaltrials.gov, NCT02049294, Registered 30th January 2014, https://clinicaltrials.gov/ct2/show/NCT02049294Item Open Access Pan-Canadian Respiratory Standards Initiative for Electronic Health Records (PRESTINE): 2011 National Forum Proceedings(2012-01-01) Lougheed, M Diane; Minard, Janice; Dworkin, Shari; Juurlink, Mary-Ann; Temple, Walley J; To, Teresa; Koehn, Marc; Van Dam, Anne; Boulet, Louis-PhilippeIn a novel knowledge translation initiative, the Government of Ontario’s Asthma Plan of Action funded the development of an Asthma Care Map to enable adherence with the Canadian Asthma Consensus Guidelines developed under the auspices of the Canadian Thoracic Society (CTS). Following its successful evaluation within the Primary Care Asthma Pilot Project, respiratory clinicians from the Asthma Research Unit, Queen’s University (Kingston, Ontario) are leading an initiative to incorporate standardized Asthma Care Map data elements into electronic health records in primary care in Ontario. Acknowledging that the issue of data standards affects all respiratory conditions, and all provinces and territories, the Government of Ontario approached the CTS Respiratory Guidelines Committee. At its meeting in September 2010, the CTS Respiratory Guidelines Committee agreed that developing and standardizing respiratory data elements for electronic health records are strategically important. In follow-up to that commitment, representatives from the CTS, the Lung Association, the Government of Ontario, the National Lung Health Framework and Canada Health Infoway came together to form a planning committee. The planning committee proposed a phased approach to inform stakeholders about the issue, and engage them in the development, implementation and evaluation of a standardized dataset. An environmental scan was completed in July 2011, which identified data definitions and standards currently available for clinical variables that are likely to be included in electronic medical records in primary care for diagnosis, management and patient education related to asthma and COPD. The scan, sponsored by the Government of Ontario, includes compliance with clinical nomenclatures such as SNOMED-CT® and LOINC®. To help launch and create momentum for this initiative, a national forum was convened on October 2 and 3, 2011, in Toronto, Ontario. The forum was designed to bring together key stakeholders across the spectrum of respiratory care, including clinicians, researchers, health informaticists and administrators to explore and recommend a potential scope, approach and governance structure for this important project. The Pan-Canadian REspiratory STandards INitiative for Electronic Health Records (PRESTINE) goal is to recommend respiratory data elements and standards for use in electronic medical records across Canada that meet the needs of providers, administrators, researchers and policy makers to facilitate evidence-based clinical care, monitoring, surveillance, benchmarking and policy development. The focus initially is expected to include asthma, chronic obstructive pulmonary disease and pulmonary function standards elements that are applicable to many respiratory conditions. The present article summarizes the process and findings of the forum deliberations.