Let’s read an article a month – April 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. I share the title and associated link with my followers to encourage clinicians to read more articles, stay up to date, and continue to grow.

The objective of this month’s paper is to  “discover whether there is any difference for Trelegy as compared with multiple inhalers use for adherence, symptoms, medication beliefs, and medication attitudes” (p45).

Chronic obstructive pulmonary disease patients’ experience using Trelegy as compared with other inhalers

By Hyfaa Mashaal, Joshua Fogel, Najia Sayedy, Ruchi Jalota Sahota and Jagadish Akella.

Can J Respir Ther Vol 58. Published online at https://www.cjrt.ca on 25 March 2022

Link to the article: https://www.cjrt.ca/wp-content/uploads/cjrt-2021-041.pdf

A few notes about this article

  • This article provides a quick review of COPD and Trelegy ( Fluticasone furotate, umeclidinium and vilanterol) (pp 44-45).
  • I was surprised to see that there was an increased reported symptoms with Trelegy, and no difference with inhaler adherence when compared to the other medication groups (p 46).  
  • Very important to mention that this is a small sample study. The authors do state that different findings were observed with larger sample size studies;  Check out number 27 and 28 items under the reference list:
    • 27. Yu AP, Guérin A, Ponce de Leon D, et al. Therapy persistence and adherence in patients with chronic obstructive pulmonary disease: multiple versus single long-acting maintenance inhalers. J Med Econ 2011;14(4):486–96. doi: 10.3111/13696998.2011.594123.
    • 28. Brandstetter S, Finger T, Fischer W, et al. Differences in medication adherence are associated with beliefs about medicines in asthma and COPD. Clin Transl Allergy 2017;7:39. Doi: 10.1186/s13601- 017-0175-6. 

Happy reading and learning,

Farzad Refahi

April 1st, 2022


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 – March 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 article is about COPD and COPD exacerbation. The authors describe the objectives of this paper as following: 

 The first objective of this study was to evaluate whether the data from the ECLIPSE and SPIROMICS studies support the presence of an individual-specific, underlying AECOPD rate which is stable over time. The second objective was to explore, based on the findings from the first objective, the randomness of observed AECOPD counts in a 12-month period, in order to determine the suitability of this factor for phenotypic classification.


Should the number of acute exacerbations in the previous year be used to guide treatments in COPD?

By: Mohsen Sadatsafavi, James McCormack, John Petkau, Larry D. Lynd, Tae Yoon Lee, Don D. Sin

European Respiratory Journal (ERJ) 2021 57: 2002122; DOI: 10.1183/13993003.02122-2020

Link to the journal ERJ: https://erj.ersjournals.com/content/57/2/2002122?etoc

Direct link to the article (pdf):  https://erj.ersjournals.com/content/erj/57/2/2002122.full.pdf

Reasons I enjoyed reading this article

  • It makes you appreciate the complexity involved in predicting future COPD exacerbation.  It is not as simple as looking at a patient’s number of exacerbations in the previous year.
  • The ECLIPSE and SPIROMICS studies are looked at and comments are made about the “difference” in findings.  
  • It is always nice to see the work of Canadian clinicians and researchers! 

Read the article and let me know what you think!  What are the factors used by your organization to predict and prevent future COPD exacerbations? 

Happy learning and reading!

Farzad Refahi

March 28, 20201 


Let’s read an article a month – November 2020

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://erj.ersjournals.com/content/erj/56/2/2000418.full.pdf

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

This month I found a great piece to share with you.  This one falls under COPD. The objective of this paper is to “ assess the role of sensitisation on clinical outcomes in COPD using a large Asian cohort recruited across three countries, and, for the first time, assess the influence of environmental allergen exposure using a metagenomics sequencing approach.” (p2).

Environmental fungal sensitisation associates with poorer clinical outcomes in COPD

By:  Pei Yee Tiew, Fanny Wai San Ko, Sze Lei Pang, Sri Anusha Matta, Yang Yie Sio, Mau Ern Poh, Kenny J.X. Lau, Micheál Mac Aogáin, Tavleen Kaur Jaggi, Fransiskus Xaverius Ivan, Nicolas E. Gaultier, Akira Uchida, Daniela I. Drautz-Moses, Huiying Xu, Mariko Siyue Koh, David Shu Cheong Hui, Augustine Tee, John Arputhan Abisheganaden, Stephan C. Schuster, Fook Tim Chew, and Sanjay H. Chotirmall

European Respiratory Journal 2020 56: 2000418; DOI: 10.1183/13993003.00418-2020 https://erj.ersjournals.com/content/56/2/2000418?etoc

Commonly used abbreviations in this article include home dust mite (HDM) and Global Initiative for Chronic Obstructive Lung Disease (GOLD).

When it comes to restriction to environmental sensitivities, asthma is the first in my mind.  This article reminded me that people with COPD may also benefit from the identification of their sensitivities and in turn limiting their exposure to them.

Top 3 Reasons why I enjoyed this article

>> Individual care. There are so many variances in personal experiences with diseases. This article is an example of this.  “Sensitisation responses and their respective allergen profiles exhibit geographical variation, largely determined by climate, environment, genetics, cultural and social practices and account, at least in part, for the variable reports in the COPD literature“ (p9).

>> I value the effort by these authors to exclude asthma/ACOS patients as it increases the value and accuracy of their study.

>>  How caring for patients, especially those prone to exacerbations may take indoor and outdoor irritants into consideration:  “… we observe that the outdoor and indoor (home) environment serves as an important reservoir of fungal allergen exposure translating to sensitisation responses to outdoor air fungi in a subgroup of COPD patients. Indoor (home) environments demonstrating a higher fungal allergen burden associate with greater COPD symptoms and poorer lung function illustrating the importance of environmental exposures on COPD outcomes.” (p9)

This article is a great reminder of how we need to look at each patient as a person with a unique circumstance, genes, environments and living space.  With a better understanding of the impact of fungal allergen exposure in some patients with COPD, clinicians have more variables to assess and monitor. 

Happy learning and reading!

Farzad Refahi

November 1st, 2020


COPD Day 2017

November 15th is the World Chronic Obstructive Lung Disease (COPD) Day.  Based on a study by World Health Organization (WHO) in 2015, COPD is responsible for “5% of all death globally that year” (WHO. Nov 2016).   When it comes to care for COPD patients, many names come to mind; One of these dedicated individuals is Mrs. Sheery Tse.

Sheery is an active RRT who works and volunteers with COPD patients at Markham-Stouffville Hospital and Scarborough and Rough Hospital (Birchmount site).

The first time I met Sheery was in May of 2017 at a social event for COPD patients, where she was facilitating it on her own time.  She is passionate about her work and is full of energy.  She is praised and respected by her patients and colleagues as she truly cares and advocates for her patients.  To get to know her better, I sent Sheery few questions:

  • When did you first hear about the respiratory therapy field? What made you decide to become an RT?  I heard about being an RT when I did some volunteering at HSC. There I ran into a high school mate who was working as a RT. After spending some time with her and the team, I decided to apply to Michener for the respiratory technology course as it was called many, many years ago.


  • What are some of your memorable jobs/roles so far?  In an acute setting I was always more interested in helping patients in the ER, providing care so they may breathe easier and giving a quick education of their puffer needs was very rewarding.
    Now I love doing education whether it’s in the COPD clinic or at a healthcare office, seeing the patients understand their airway disease and why certain puffers work and how is rewarding.


  • What are your career goals? (and do you feel that you have accomplished them?)  Given my age and how many years I’ve been in their field, I feel I have accomplished most of what I set out to do. Starting the COPD clinics in Markham and Scarborough from scratch has been very rewarding.
    There are still a few goals I would like to see happen, a support group with just patients input and more exercise sessions available would be the biggies. Patients self-management at home is another area I would to see happen too.


  • How did you get involved with patient education (with COPD patients)?When Dr. M. Forse first came up with the idea of having a clinic for COPD patients, it sounded like something I would enjoy. I applied and was chosen as the educator. Now came the challenge, getting certified as an educator and quite trained.


  • How does a typical day look like for you?
    Don’t think there is ever a truly typical day. It could be as simple as setting up for the clinic with patients charts and assessing the patients to triaging all new referrals, returning phone calls and emails from patients to meeting with pharma reps to hear what’s new, studies and of course being the nosy educator what’s on the pipeline for puffers. In between that I also need to triage patients into the exercise programs we have and call to see if they are willing to come in and for afternoons or evenings. Tuesday’sWednesday’s and Thursdays, I try to go to the exercise classes to provide some support and answer any question the participants may have. I’ve been called the “spy” as I do inform the respirologists if there are concerns about the participants, including possible flare up and low sats. Through these interactions we have been able to prevent patients from being seen in ER when the respirologists could fax a script for them, or as simple as asking if they started their on-hold meds. Low sats often, if they are with ProResp, I could get a RT to come assess on the track, other vendors, I ask the patients to contact their 02 providers and ask to be reassessed and the respirologist is informed.


  • What are some of the challenges and joys of working with COPD patients?
    Joys is seeing the patients in a follow up visit tell us how well they are doing, having the patients return from a trip they did not think they would be able to go on because of their airway disease, seeing how well they’re exercising. Challenges is trying to convince the patients they need to use their maintenance puffers regularly, and the same with those on 02. Most often, they are so used to being deconditioned and breathless, they’ve adapted to do without. Smokers are the biggest challenge, getting them to even think about quitting is often a huge step. Cutting back with each follow up is rewarding to hear, telling us they’ve actually quit is even more so.


  • Based on your experience, what are some of the common struggles for COPD patients, and how can RTs better assist these individuals?
    The most common struggle, is self-management and deconditioning. They’re breathless so often they feel they can’t do much. Try is one of my favourite word to use at the clinic and at exercise classes. Knowing if and when they need to be seen is a biggie too. They really are independent and don’t want to bother their healthcare team and often end up getting worse and needing to be admitted.   Providing tools for them to figure out if it’s a simple cold, a flare up or more is something all healthcare providers need to give so they may manage their disease better and hopefully not get to the point they become very ill.


  • What are your thoughts on the latest 2017 COPD Guidelines and New Medications in the market? *
    New guidelines are constantly changing, latest is to decrease use of ISC with COPD patients unless they have at least one exacerbation a year to decrease the chance of getting pneumonia. When we first started the COPD clinic we had short acting puffers (Ventolin, Atrovent) ICS(Flovent) combo (Advair, Symbicort) and a LAAC(Spiriva) that just came on the market. Now we have choices, we can provide patients with the puffers they need in a device that is easier for them to use so compliance increases. There may be more I the future, good for the patients, more challenging for healthcare providers as we will need to know them, how they work and how to use them to provide better support for patients.


  • Any advice or final thoughts to share with RTs?
    Final words, healthcare is an amazing profession, there are many different streams available, even for RTs from in hospital, to clinics, to home care. Patients safety and wellbeing should be the most important thought in our work. Giving patients respect, support and information should be on going.
    The best review in the COPD clinic is when the patient comes in, and asks for a hug, calls you by your name and remembers what you said and did for them. At the end of the day, my hours spent volunteering means they get the support they need. From a simple support I have been given so much more I return from them. It is very rewarding, even in sadness when they pass. We have family call to let us know how much they appreciate all the support we gave to their loved ones.


Thank you Sheery for your dedication and hard work!

*To the readers of this post, please continue to refer to the guidelines and medication pathways provided by the facilities/organization you work at.  The answers provided my Mrs. Tse is to provide perspective and is not to replace the protocols provided by your employer or RT governing body.

Here are some useful resources I came across:

-Canadian Thoracic Society.  https://cts.lung.ca/guidelines

Alpha-1 antitrypsin deficiency targeted testing and augmentation therapy (2012)

-Managing dyspnea in patients with advanced chronic obstructive pulmonary disease  (2011)

-Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease (2010)


-The Lung Association. Various PDF documents to study, to print and to share.  https://www.lung.ca/lung-health/lung-disease/chronic-obstructive-pulmonary-disease-copd/resources


-RTSO- COPD. https://lungontario.ca/disease/copd/

-Global Initiative for Chronic Obstructive Lung Disease . https://cts.lung.ca/sites/default/files/documents/cts/1.%20CTS%20COPD%20Dyspnea%20Guideline%202011%20EN.pdf http://goldcopd.org/wp-content/uploads/2016/12/wms-GOLD-2017-Pocket-Guide.pdf


Farzad ‘Raffi’ Refahi
Nov 15 2017


-WHO. World Health Organization. COPD. Fact Sheet. November 2016.