Let’s read an article a month – January 2022

The cropped screenshot of the first page of the article. It also includes the URL or link to the article.

Every month I read an open-access article. Then, I share the title and associated link with my followers. This is to encourage clinicians to read more articles, stay up to date, and continue to grow.

The coexistence of asthma and COPD: risk factors, clinical history and lung function trajectories

By: Alessandro Marcon, Francesca Locatelli, Shyamali C. Dharmage, Cecilie Svanes, Joachim Heinrich, Bénédicte Leynaert, Peter Burney, Angelo Corsico, Gulser Caliskan, Lucia Calciano, Thorarinn Gislason, Christer Janson, Deborah Jarvis, Rain Jõgi, Theodore Lytras, Andrei Malinovschi, Nicole Probst-Hensch, Kjell Toren, Lidia Casas, Giuseppe Verlato, Judith Garcia-Aymerich, and Simone Accordini on behalf of the Ageing Lungs in European Cohorts (ALEC) study

European Respiratory Journal 2021 58: 2004656; DOI: 10.1183/13993003.04656-2020

Link to the article: https://erj.ersjournals.com/content/erj/58/5/2004656.full.pdf

The reasons I found this article interesting 

A detailed study with around 20 years of medical history. A large number of individuals [14864, 9251 and 6122, respectively in ECRHS I, II and III who underwent clinical examinations, from 23 centres] (p4).  Useful observations were presented based on past asthma, current asthma, asthma + COPD, and COPD alone. A recommended article to students, new RRTs and even experienced clinicians.  There are many results, findings and conclusions that I cannot cover in a post. As always, I recommend that you read the full article for yourself.

”Lung function decline for subjects with asthma + COPD could have been mitigated by long-term anti-inflammatory treatment. “ (p9).

“The coexistence of asthma and COPD  seems to be a form of severe asthma with severe asthma with origins early in life, as opposed to COPD alone, which is more linked to adult exposures.”  (p10).

”…COPD without concomitant features of asthma seems predominantly linked to adult-life toxic inhalant exposures.  Exposure avoidance (e.g. through smoking cessation and reduction of pollution exposure in occupational settings) may be particularly beneficial against the development of the “pure COPD” phenotype…” (p10).

Happy reading and learning.

Farzad Refahi

January 01, 2022

Link to the blog post: https://respiratory.blog/lets-read-an-article-a-month-January-2022/

Let’s read an article a month – November 2021

The cropped screenshot of the first page of the article. It also includes the URL or link to the article.

Every month I try to read an open-access article. After reading the article, I share the title and associated link with my followers. This is to encourage clinicians to read articles, stay up to date, and continue to grow.

This paper investigated “causal associations to estimate the causal effects of fathers’ smoking initiation in prepuberty (generation G1) and grandmothers’ smoking in pregnancy (generation G0) on offspring’s lung function (generation G2) within the paternal line” (p2).

Prenatal and prepubertal exposures to tobacco smoke in men may cause lower lung function in future offspring: a three-generation study using a causal modelling approach

By: Simone Accordini, Lucia Calciano, Ane Johannessen, Bryndis Benediktsdóttir, Randi Jacobsen Bertelsen, Lennart Bråbäck, Shyamali C. Dharmage, Bertil Forsberg, Francisco Gómez Real, John W. Holloway, Mathias Holm, Christer Janson, Nils O. Jõgi, Rain Jõgi, Andrei Malinovschi, Alessandro Marcon, Jesús Martínez-Moratalla Rovira, José Luis Sánchez-Ramos, Vivi Schlünssen, Kjell Torén, Deborah Jarvis, and Cecilie Svanes.

European Respiratory Journal 2021 58: 2002791; DOI: 10.1183/13993003.02791-2020 

Link to the article: https://erj.ersjournals.com/content/58/4/2002791?etoc

Reasons you may find this article interesting:

  • Perhaps not surprising: “Fathers’ smoking initiation in prepuberty was associated with an increased risk for nonallergic asthma in offspring” (p9).
  • Interesting finding from the analyses of the collected data:  “fathers’ overweight onset before 15 years of age had a direct effect on nonallergic asthma in the next generation” (p9).
  • Lastly, check out one of their conclusions:

“Men who initiated smoking before 15 years of age may have offspring with lower lung function compared with men who had never smoked. Grandmothers’smoking in pregnancy may have a negative impact on their sons’ lung function, an effect that could be carried over to their grandchildren. These results support the concept that lifestyle-related exposures in male prepuberty and in pregnancy influence the health of future generations. ”


As always, I encourage you to read the article to learn about all the details.

Happy reading and learning,

Farzad Refahi

November 5, 2021


Let’s read an article a month – January 2021

The cropped screenshot of the first page of the article. It also includes the URL or link to the article.

Every month I try to read an open-access article. After reading the article, I share the tittle and associated link with my followers. This is to encourage clinicians to read articles, stay up to date, and continue to grow.

This month I found a great piece to share with you.  This one falls under asthma and biologic treatments. The objective of this paper is to “ [describe] the effects of alarmins and [discuss] the potential role of anti-alarmins in the context of existing biologics “ (p1 ).

Anti-alarmins in asthma: targeting the airway epithelium with next-generation biologics

By: C. M. Porsbjerg, A. Sverrild, C. M. Lloyd, A. N. Menzies-Gow and E. H. Bel 

European Respiratory Journal 2020 56: 2000260; DOI: 10.1183/13993003.00260-2020

Link to the article: https://erj.ersjournals.com/content/56/5/2000260

Reasons you may find this article interesting 

  • Great review of inflammatory pathways in asthma (beginning on page 2).
  • An in-depth discussion of targeting the alarmins using biological therapies (beginning on page 6).  
  • Useful visualization to help put things in perspective ( Figure 1 on page 3 and Figure 2 on page 7). 

While I recommend you check out this article, I need to give you a heads-up. If you are not as familiar with asthma inflammatory pathways, you may need to dedicate more time to this piece.  Personally, I had to come back to it a few times.

Happy learning and reading!

Farzad Refahi

January 1st, 2021

Link to the blog post: https://respiratory.blog/lets-read-an-article-a-month-january-2021

Let’s read an article a month – September 2020

Cropped screenshot of the first page of the article

Every month I try to read an open-access article. After reading the article, I share the tittle and associated link with my followers. This is to encourage clinicians to read articles, stay up to date, and continue to grow.

Link to the article: https://doi.org/10.1016/j.chest.2020.03.052

Link to the blog post: https://respiratory.blog/lets-read-an-article-a-month-september-2020/

This month I found a great piece to share with you.  This one falls under Asthma and Original Research. The objective of this paper is to “examine the proportion of participants with negative BDR testing who had a positive MCT (and its predictors) result and characteristics of MCT, including effects of controller medication tapering and temporal variability (and predictors of MCT result change), and concordance between MCT and pulmonologist asthma diagnosis.” (1st page of the article, p.479)

Performance Characteristics of Spirometry With Negative Bronchodilator Response and Methacholine Challenge Testing and Implications for Asthma Diagnosis

By: Janannii Selvanathan BSc, Shawn D. Aaron MD, Jenna R. Sykes, MMath, Katherine L. Vandemheen MScN, J. Mark FitzGerald MD, Martha Ainslie MD, Catherine Lemière MD, Stephen K. Field MD, R. Andrew McIvor MD, Paul Hernandez MD, Irvin Mayers MD, Sunita Mulpuru MD, Gonzalo G. Alvarez MD, Smita Pakhale MD, Ranjeeta Mallick PhD, Louis-Philippe Boulet MD, Samir Gupta MD 

Edition: VOLUME 158, ISSUE 2, P479-490

Link to the article: https://doi.org/10.1016/j.chest.2020.03.052

Common abbreviations used in this study and blog post include PFT= pulmonary function testing, BDR= bronchodilator response and MCT= methacholine challenge testing (p.479).

Reasons you may find this article interesting:

  • It is on asthma which impacts many individuals in the population (“the third most common chronic disease in adults” p.480).
  • This article involves many recognisable and respectable experts.  The authors of this study have also taken part in many other research projects as well.  For my Canadian followers, many of these authors work in Canada!  I have been lucky enough to attend and enjoy talks, in person and virtually, by Dr. Shawn Aaron, Dr. Gonzalo G. Alvarez and Dr. Samir Gupta. 
  • There were follow up testings to assess the accuracy and consistency of the findings.  
  • This article is an excellent reminder for clinicians who order these tests to properly instructs patients to prepare for PFT and MCT.  Variability in MCT results based on seasons, environmental allergies, and impacts of other medications are important considerations.
  • This is a well-written article.  There is a nice flow that guides the reader through the method and the reasoning behind those decisions.  The results, conclusions and reflections are also nicely done.

My reflections and thoughts after reading this article

If you have almost no time to read the full article: Firstly, make time as this is a great article.  Secondly, if you still don’t have time then check out the ‘Take-home Point’ on the second page of the article where authors have included a quick summary and conclusions from this article (p.480).

I am worried that many patients may go undiagnosed or misdiagnosed.  Asthma can be properly managed;  Prolonged uncontrolled asthma can lead to more frequent exacerbations but also permanent changes to the lungs.  

As respiratory health community and excerpts, we need to educate clinicians and patients so they get tested.  Also, we need to raise the minimum standard so testing gets performed by trained individuals who have access to proper, accurate and well-maintained equipment. In addition, we have to make sure these clinicians know how to interpret and follow up with patients correctly.   For example, not to just rely on a pre-spirometry.  In case post-spirometry was done, we need to have knowledgeable clinicians who don’t automatically exclude asthma when no significant improvement was evident.  We need clinicians who know the importance of MCT, and organizations to support the costs related to the testing.  Besides, we want clinicians to understand that there are factors that could impact the MCT outcomes. 6.9% of participants who initially had a negative MCT end up having a positive reaction in the follow-up testing and 55.6% of those who initially had a positive MCT end up having a negative one in the follow-up testing ( Figure 2B, p.484).   On the bigger image, it is essential to understand that PFT and MCT are not the ultimate answers and they are just assessment tools that need to be tied with other clinical assessments and evidence. 

What are your thoughts on this?

Happy learning and reading!

Farzad Refahi

September 1st, 2020


Who Are Respiratory Therapists?

I have heard this question many times and in various forms.  

Who is a respiratory therapist? What do respiratory therapists do? Where do respiratory therapists work?  

With the current COVID-19 situation, respiratory therapists have been mentioned frequently. This blog post is meant to be a very quick overview. If you have any questions feel free to contact me and get in touch with your respiratory therapy organizations. I usually write for clinicians, but this post is meant for everyone as everybody is impacted by COVID-19.  

Who are respiratory therapists?

“Respiratory Therapists are health care professionals who monitor, assess and treat individuals who have difficulty breathing”

-College of Respiratory Therapists of Ontario (https://www.crto.on.ca/public/what-is-respiratory-therapy/ )

How and why was the profession of respiratory therapy initiated?

The origin of this profession is from the second world war. It began as a technician role to reduce the workload of physicians and nurses. With a focus on the cardio-respiratory system, the role has evolved into a therapist and now includes various responsibilities.  

What are the roles and responsibilities of respiratory therapists?

To keep things simple, I am going to give you a few different scenarios. They are not referring to any specific patient or organization. The teams are made of many amazing and dedicated clinicians who will be omitted in these scenarios so we can focus on the RT role!

Here are three scenarios to put things in perspective:

Case One: Asthma Exacerbation

Mary, and her parents, had felt that her asthma was not fully controlled for a few days and the recent cold has made her breathing much more difficult. Today her mother took her to an emergency department (ER) due to the severity. In the ER, a respiratory therapist is called to initiate the nebulized Salbutamol and to re-assess the patient. Despite various interventions, Mary continues to deteriorate and the decision is made to assist Mary’s breathing with the use of a ventilator.  An RT places a breathing tubing in the trachea and attaches it to a unit that breathes for the patient (i.e. a ventilator). The RT continues to monitor and adjust the ventilator to optimize Mary’s breathing. When Mary’s condition improves, assistance from the ventilator is discontinued and the breathing tube is removed. Mary is now able to breathe on her own. Part of the discharge process, an RT sits down with Mary and her parents to discuss self-assessment and monitoring, and proper inhaler techniques. A follow-up appointment, in a couple of weeks, is scheduled for Mary at the Asthma Clinic.  In the Asthma clinics RTs perform a breathing test, called Spirometry, and provide patient education which includes understanding the disease, management, prevention and optimization in case things don’t feel like the norm. 

Case Two: COPD Exacerbation 

Michael ignores the worsening of his cough, chest tightness and difficulty breathing with even short distance walks. Today he finally decides to consult his family doctor. A decision is made for him to visit an ER. In the emergency department, various tests and treatments are done, and an RT is called to start supporting Micahel’s breathing (using a mask and a supportive unit called BiPAP). Michael’s breathing is optimized over the next day. He is transferred to the general ward for monitoring. Before discharge, an RT meets with Micahel for a smoking cessation conversation.  The RT also provides education about the need for ongoing oxygen. A follow-up Pulmonary Function Testing and respirologist/pulmonolgist consult are scheduled. An RT with a Home Oxygen Company/team would visit Michael to set up the equipment, perform assessments, and provide further education. During Pulmonary Function Testing, an RT walks Michael through various breathing tests. At the respirology/pulmonology visit, an RT may sit down with Michael to review the proper inhaler technique. Same RT may also provide a smoking cessation consult. A follow-up PFT and respirology/pulmonology visit are scheduled.  

Case Three: Mona and Baby Lisa – Labour and Delivery

Based on the assessments and monitoring of Mona, a difficult delivery is suspected. The team, including a respiratory therapist, is present in the delivery or operating room. Immediately after birth, RT and nurses perform the routine assessments and provide the required care. In this example, the RT puts a small “mask” on Baby Lisa’s nose to deliver a small amount of airflow or pressure.  This will help to keep the lungs open slightly longer, and in turn, make breathing easier for Baby Lisa. The RT, part of the team, transfers Baby Lisa to the intensive care unit for further monitoring. Baby Lisa’s breathing is optimized by adjusting the CPAP unit as required. Use of CPAP will be weaned off as Baby Lisa starts feeling better. If Baby Lisa requires even more support, the RT can use a breathing tube to establish a better pathway, and a ventilator to deliver a more controlled breathing support.

There is more…

Respiratory therapists are involved with other roles such as managers, researchers, teachers, inventor, remote support using the phone/video-chat, transport team, consultant, policymaker, in-hospital code blue/pink resuscitation teams, operating rooms, sleep labs, CPAP educators, and others. 

What can an RT do for someone with COVID-19?   

Respiratory therapists can be part of the team who does the initial assessment.  By applying nasal prongs or a mask, an RT can improve the body’s oxygen levels.  When needed and indicated, inhalers can be given to optimize breathing. Assistance in breathing can be provided using non-invasive, such as CPAP and BiPAP, and invasive measures (Ventilators). 

How to become a respiratory therapist?

Most clinicians in Canada complete their undergraduate studies and then apply for one of the many respiratory therapy programs in Canada. For the list of available programs in Canada, I will refer you to the website of the Canadian Society of Respiratory Therapists: https://www.csrt.com/rt-profession/#education.  The training usually involves two years of academic and simulation learning, and a final year of clinical placements.

How much do respiratory therapists get paid? 

Based on Payscale.com, the median hourly rate is $31.80 in Canadian dollars ( as of March 22, 2020, https://www.payscale.com/research/CA/Job=Respiratory_Therapist/Hourly_Rate ). As you can guess, the pay is higher with more years of experience, and with roles that entail more responsibilities and that in the acute care settings.

Where can I get more information about respiratory care and respiratory therapists?

On the national side, visit the Canadian Society of Respiratory Therapists: www.CSRT.com.  

On the provincial side visit the College of Respiratory Therapists of Ontario: www.CRTO.on.ca, and Respiratory Therapy Society of Ontario: www.RTSO.com.   

On a personal RT perspective, there is my website: www.Respiratory.Blog . In my interviews with different respiratory therapists, I try to share different perspectives and insights. Here is one example: Mieke Fraser’s post at http://respiratory.blog/mieke/ (published on October 25, 2017).

Thanks for your interest in respiratory care and respiratory therapists! Share this with others who may find it helpful!

Stay safe. Frequently wash your hands.  Practice social isolation.

Here is a PDF version of this post for ease of sharing:

Farzad Refahi
Photo of Farzad Refahi of www.Respiratory.Blog

Simulation lab for the PALS certification course.
Simulation lab – Part of the PALS certification course.