“As Ontario’s leading lung health
organization, The Lung Association’s
FA L L 2 0 0 8
Features
In this Issue
Editorial
Bronchiectasis, an orphan
disease or a disease
orphaned by science . . .2
Better Breathing 2009
Update from the Chair
of the OTS Better
Breathing Committee . . .3
Breathe New Life Award,
2009-2010 . . . . . . . . . . .6
Career Scientist
Award . . . . . . . . . . . . . .7
How Physicians Can
Give a Voice to the
Backseat . . . . . . . . . . . .7
Mission Statement
To Promote Respiratory
Health through Medical
Research and Education.
The OTR can also be viewed
on-line at on.lung.ca/
Health-Care-Professionals/
Ontario-Thoracic-Society/
Ontario-Thoracic-Reviews.php
www.on.lung.ca
mission activities include being strong
advocates for tobacco-free environments.
In partnership with healthcare
professionals across the province,
we are taking a leadership role in
the Smoke-Free Vehicles legislation
that comes into effect January 2009.
Together, we are giving a voice to the
back seat, protecting children against
the harmful effects of second-hand
smoke in vehicles.”
George Habib, BA, BEd, CAE
President and CEO of the
Ontario Lung Association
V O L U M E 2 0 , N U M B E R 3
Bronchiectasis
David Hall, MD. Ph.D., Critical Care and Respiratory Medicine, St. Michael’s Hospital, Toronto;
Assistant Professor, Department of Medicine, University of Toronto
ronchiectasis (BXIS) has recently Classification
B been termed an orphan disease.1
However advances in chest imaging,
Bronchiectais is sometimes classified
based on its radiological appearance.
particularly the use of high resolution The clinical significance of this
computed tomography, have resulted in classification is not clear and there
increasing recognition of this condition. may be considerable overlap.
It is estimated that 110,000 individuals Cylindrical BXIS is typified by a
in the United States suffer from BXIS.2 failure of the airways to taper distally.
The decline in BXIS has been In cylindrical BXIS the airways are
attributed to the dawning of the DAVID HALL
smooth, which is in contrast to varicoid
antiobiotic era and effective childhood BXIS where the airways are irregularly dilated
immunizations for measles and pertussis. None with outpouchings. Saccular BXIS has focal
the less, in certain communities with poor access dilation of the distal airways and can have a
to health care such as isolated aboriginal honeycombed appearance. Unfortunately these
settlements in Australia or in some native descriptors are not very helpful clinically nor do
Alaskans, the prevalence remains high.3 they clarify the etiology of the BXIS.
The hallmark of BXIS is bronchial dilatation.
Plain chest radiography can suggest such Etiology
dilatation but lacks sensitivity. In the past the BXIS is associated with many different
presence of BXIS was confirmed by contrast conditions and presumably may occur for
bronchography, which has now been replaced by different reasons (see table 1). However, a
high resolution CT scanning. BXIS can be unifying theme seems to be inflammation, often
defined clinically as chronic cough with purulent as a result of infections. The inciting event that
sputum, physiologically with airflow obstruction, sets off the vicious circle of infections and
and anatomically with dilated airways. inflammation may not always be clear but the
As a broad division BXIS can be considered impaired mucous clearance and stagnation of
as cystic fibrosis (CF) related or non-CF related. secretions that occurs as a result of the airway
This article will focus on non-CF related BXIS. changes predisposes the individual to recurrent
BXIS is a heterogeneous condition and, unlike infections (see figure 1.). Simply having a severe
CF, there are very few centres of excellence. pulmonary infection or recurrent infections in
Consequently there are few high quality studies childhood may set the stage for bronchiectatic
of non-CF BXIS with mostly case series or changes.
retrospective analyses. Although they are Immunodeficiency states such as HIV or
different disease entities it is tempting to apply immunoglobulin deficiency predispose patients
the lessons learned in CF to non-CF BXIS. Continued on page 4
ONTARIO THORACIC EDITORIAL
REVIEWS
An official publication of the Ontario
Thoracic Society, Medical Section of
the Ontario Lung Association,
573 King Street East,
Toronto, Ontario M5A 4L3
(416) 864-9911 • Fax (416) 864-9916
E-mail: ots@on.lung.ca
Web Site: www.on.lung.ca
ONTARIO THORACIC SOCIETY
EXECUTIVE COMMITTEE 2008-2009
Dr. Shawn Aaron (Chair, RAC)
Dr. Christopher Allen
Dr. Steven T. Bencze (Chair, Education)
Dr. John N. Bertley
(OLA Board Rep/OTS Past Chair)
Dr. Brenda Butters (OLA Board Member)
Dr. Hedy Ginzberg (Medical Director, OTS)
Dr. John Granton (OTS Chair)
Dr. Thomas Kovesi
Dr. Christopher Licskai
Dr. Susan Moffatt
Dr. Elizabeth Powell (OMA Rep.)
Dr. Matthew Stanbrook
Dr. Hans Stelzer (OTS Chair-Elect)
ONTARIO THORACIC REVIEWS
EDITORIAL BOARD 2008-2009
Dr. Robert Hyland (Editor)
Dr. John Granton (Chair, OTS)
Mr. Dean Karakasis (Chair, OLA)
Dr. James Edney (Ontario Chapter, College
of Family Physicians of Canada)
Dr. Hedy Ginzberg (Medical Director, OTS)
Mr. George Habib (President and CEO, OLA)
Ms. Jeanne Castellanos (OTS Administrator)
Ms. Corrine Holubowich (Medical Librarian)
We gratefully acknowledge the
sponsorship of our sponsor
Nycomed for this issue.
www.on.lung.ca
2 O NTARIO T HORACIC R EVIEWS FALL 2008
Bronchiectasis, an orphan disease
or a disease orphaned by science
Elizabeth Tullis, MD, FRCPC, FCCP, Division Head, Respirology St Michael’s Hospital,
Respirology Division Director, University of Toronto, Medical Director, Adult Cystic Fibrosis
Centre, Associate Professor, Member and Chair, Education Committee (past)
t is difficult to determine the true Although trials of therapy are
I prevalence of bronchiectasis but it may
be more common than once thought.
scarce and of poor quality, treatment of
bronchiectasis can greatly improve a
Weycker et al estimates 52 cases per patient’s quality of life. It is not fair to
100,000 and as many as 200 cases per deprive a patient of therapy because of
100,000 in individuals over 75 years of lack of evidence-based treatments.
age.1 Certainly, every Respirologist faces Chronic cough and fatigue are
the challenge of managing these debilitating symptoms and the social
individuals. As David Hall’s article nicely stigma of cough productive of purulent
summarizes, the etiology of bronchiectasis ELIZABETH TULLIS sputum or hemoptysis often limits
has changed over time; in earlier years, the most patient’s activities. The treatment of bronchiectasis
common cause was localized bronchiectasis from can be initiated regardless of etiology. Chest
previous infections whereas nowadays non physiotherapy to aid in sputum clearance can
tuberculous mycobacteria (NTM) and increased have a major positive impact on quality of life by
recognition of other causes of bronchiectasis like allowing the patient to control when they cough
“mild” cystic fibrosis diagnosed in adulthood and and produce sputum. The physician needs to
primary ciliary dyskinesia (PCD) are more prevalent. refer patients to physiotherapists who are
The search for etiology is important as it may knowledgeable in the airway clearance
influence therapy (eg. NTM, immunodeficiency, techniques such as percussion, PEP mask, Flutter
Allergic Bronchopulmonary Aspergillosis device, active cycle of breathing etc.
(ABPA) and potentially alpha-1-antitrypsin The development of chronic infection with
deficiency), allow patients to link with support Pseudomonas aeruginosa coincides with
groups (eg CF and PCD), specialized centres of increased symptoms. Strategies borrowed from
excellence or take part in clinical trials. CF bronchiectasis, such as inhaled antibiotics to
Although cystic fibrosis (CF) results from a reduce bacterial burden, are often useful. An
single gene defect, the more than 1,500 CFTR important proviso is that individuals with CF
mutations result in a broad spectrum of disease. have increased drug metabolism and inhaled
Half of the 3,500 Canadians with CF will be aminoglycoside therapy rarely causes raised
homozygous for the deltaF508 mutation and serum levels but this is not the case with non CF
present in infancy or early childhood. However a bronchiectasis. Tobramycin solution for inhalation
portion of the remainder are compound (TOBI) at standard doses of 300 mg BID in an
heterozygotes of potentially “milder” mutations elderly non CF patient may cause systemic toxicity.
and thus are pancreatic sufficient and escape One of the factors improving survival for
diagnosis until adulthood. Of the adults followed patients with CF is care in specialized
in the Toronto Adult CF centre, 20% were multi-disciplinary centres which facilitates
diagnosed when they were over 18 years of age. participation in clinical trials of new therapies.
Likewise, PCD is easy to recognize in its classic Patients with bronchiectasis might benefit from
form of Kartagener’s syndrome, but the 50% of this comprehensive and optimistic approach to
patients who do not have situs inversus may not be management.
recognized. A high index of suspicion is required.
In spite of a thorough workup, in 15% of cases, an References
1. Weycker D, Edelsberg J, Oster G, Tino G. Prevalence and economic
etiology for the bronchiectasis will not be found. burden of bronchiectasis. Clin Pulm Med 2005;12:205–209.
OTS Grant in Aid Competition Deadline for 2009-2010
The deadline for registration is November 14, 2008 and the application deadline is December 9, 2008
at 4:30 pm. The grant guidelines and forms can be viewed at the OTS website, http://www.on.lung.ca/
Health-Care-Professionals/Ontario-Thoracic-Society/Grant-Application-and-Guidelines.php
Better Breathing 2009
Lung Health: Global Inspirations – Local Impact
JANUARY 30-31, 2009 – MARRIOTT TORONTO DOWNTOWN EATON CENTRE
UPDATE FROM THE CHAIR OF THE OTS BETTER BREATHING COMMITTEE
am pleased to give you a preview of Better Breathing 2009, Medicine”, will feature presentations on Pulmonary
I the annual conference of the Ontario Lung Association
and the Annual General Meeting of the Ontario Thoracic
Hypertension (Dr. Duncan Stewart, Ottawa Health Research
Institute; The Ottawa Hospital) and Cardiopulmonary
Society. The Planning Committee is very excited about Interactions between Sleep Apnea and the Failing Heart
the topics and speakers chosen for Better Breathing (Dr. Douglas Bradley, Toronto Rehabilitation Institute ).
2009. Plan now to attend the OTS Program, which offers The popular and entertaining Resident Case
an exciting series of lectures, lunch sessions and debates. Presentations, facilitated by Dr. Nha Voduc (Ottawa), will
The focus of the Friday morning Plenary Session is follow the Friday afternoon talks. The afternoon session
“Global Respiratory Medicine”. The objective is to concludes with the OTS Annual General Meeting.
explore the future of respirology in Canada (the West), and DR. MICHAEL FITZPATRICK On Saturday morning, return to the OTS Sessions for
in developing countries. We are very fortunate to have two highly the ever-popular and provocative debates: “Controversies in
regarded plenary speakers. Dr. Nicholas Anthonisen, Winnipeg will Pulmonary Medicine”, chaired by Dr. Charles George, London.
discuss “The future of Respirology in Canada”. Dr. Gonzalo Alvarez, This year's speakers will debate controversial statements including:
Ottawa will talk about Trends in Lung Health in the Developing World. A High PEEP Strategy is Beneficial in ARDS (Dr. Niall Ferguson
The mid-morning OTS/ORCS Joint Session, “What’s New in and Dr. Brian Kavanaugh); Pharmaceutical Industry funded
Lung Health” will feature two members of the Ontario Thoracic research cannot be trusted (Dr. Shawn Aaron, Ottawa and Dr.
Society and one member of the Ontario Respiratory Care Society. Matthew Stanbrook, Toronto) and The Treatment of Non-
Dr. Parameswaran Nair, Respirologist, Firestone Institute of Tuberculosis Mycobacteria is more than marginally effective (Dr.
Respiratory Health, St. Joseph’s Healthcare, will discuss Obesity Onofre Morán, Kingston and Dr. Theodore Marras, Toronto). You
and Asthma. Dr. Patricia Hill Bailey, a member of the Ontario should not miss hearing these entertaining (if polarized !!) debates.
Respiratory Care Society, will give an update on the End-of-Life At the request of OTS members, a respiratory researcher will be
Care in COPD. Dr. Kayvan Amjadi, an interventional respirologist highlighted during the Saturday morning session. We are delighted
in Ottawa, will complete the session with a discussion on to announce that Dr. Jim Lewis (University of Western Ontario,
Interventional Pulmonology - what’s missing? London), a renowned researcher and speaker, and an expert on surface
During lunch-time on Friday, attend the General Lunch with the tension forces in the lung, will give the research presentation.
exhibitors or select one of three “Lunch with a Professor Series”. I want to thank all the members of the OTS BBC 2009 Planning
One lunch session is Cardio-Pulmonary Exercise Testing Workshop Committee (Dr. John Bertley, Dr. Steven Bencze, Dr. Hedy Ginzberg,
(Dr. Christopher Parker, Kingston). A second lunch session will Dr. Sheri Katz, Dr. Christopher Licskai, Dr. Peter Macleod, Dr. Parameswaran
discuss assessment of patients with difficult airway disease; the Nair, Dr. Mitra Niroumand, Dr. Chris Parker, Dr. Mark Soth, Dr. Hans
Difficult Airways Workshop will be given by Dr. Peter Slinger, Stelzer, Dr. John Granton and Michael Keim) for their hard work in
Toronto General Hospital. The third session is the André Péloquin organizing this exciting roster of speakers and interesting topics.
Case Presentations from Community Respirologists and is dedicated Exhibitors will display their products and services and draw
to the memory of Dr. André Péloquin. The case presentations are prizes will be awarded throughout the conference. Watch for the
facilitated by Dr. Steven Bencze (Ottawa) and this year’s case presenters program brochure. Mark January 30-31st, 2009, on your calendar
are Dr. Marcus Newton (Owen Sound), Dr. David Schneidermann and register early!
(Ottawa) and Dr. Jacqueline Nemni (Guelph). Please book early for
the lunch-time clinical sessions as seating is limited. Michael Fitzpatrick, MD, FRCPI, FRCPC, D.ABSM
The Friday afternoon program, “State of the Art in Respiratory Chair, OTS Better Breathing Planning Committee, 2009

Mark your
calendars!

B ETTER B REATHING C ONFERENCE 2009

Lung Health: Global Inspirations – Local Impact
January 30-31, 2009 | MARRIOTT TORONTO DOWNTOWN EATON CENTRE

FALL 2008 O NTARIO T HORACIC R EVIEWS 3

Bronchiectasis... Continued from page 1
to pulmonary infection and there is an problems with cellular chloride handling.
association between these disease states As a result pulmonary secretions become
and BXIS. thick and tenacious and patients have
Another theme is one of poor clearance difficulty clearing them. In contrast,
of secretions as is the case in cystic fibrosis, patients with primary ciliary dyskinesia
primary ciliary dyskinesia, Young’s have abnormalities in the structure and/or
syndrome, Mounier-Kuhn syndrome, and function of their cilia. There are a variety of
Williams-Campbell syndrome. Although recognized ciliary abnormalities that are
impaired clearance of secretions is the evident on electron microscopy; most are
underlying problem in these diseases it structural but some “structurally” normal
occurs for different reasons. In cystic cilia may not be aligned properly. This
fibrosis a defect in the CFTR gene results in organelle not only requires that its internal
“machinery” be normal but also that the
TABLE 1 Causes of Bronchiectasis13 cilia are aligned such that they can beat in a
coordinated fashion in order to propel the
Postinfectious Conditions “mucociliary escalator”. An inability to
Childhood lower respiratory tract infections cough effectively also results in impaired
Granulomatous infections clearance of pulmonary secretions, which
Necrotizing pneumonias in adults
occurs in Mounier-Kuhn and Williams
Other respiratory infections
Campbell syndromes.
Primary Immune Disorders Infection with atypical mycobacteria
Humoral defects may result in BXIS or conversely
Cellular and/or mixed disorders bronchiectatic airways may predispose an
Neutrophil dysfunction individual to infection by these pathogens.
Other Right middle lobe or lingular BXIS in
Cystic Fibrosis elderly women with atypical mycobacterial
infection well described and referred to as
Alpha1-Antitrypsin Disease “Lady Windermere” syndrome. It is named
after the title character in the Oscar Wilde
Heritable Structural Abnormalities
Ciliated epithelium
play “Lady Windermere’s Fan”. Lady
Cartilage Windermere was portrayed as a fastidious
Connective tissue woman of the Victorian era, thus likely to
Sequestration, agenesis, hypoplasia suppress cough and avoid expectoration
Dwarfism Non-infectious inflammation may
also be the inciting event. This may be
Idiopathic Inflammatory Disorders the cause of BXIS associated with
Sarcoidosis
inflammatory bowel disease (IBD). The
Rheumatoid arthritis
Ankylosing spondylitis
association with rheumatoid arthritis (RA)
Systemic lupus erythematosus is less clear and a number of postulates have
Sjögren's syndrome been put forth including a predisposition to
Inflammatory bowel disease infection as a result of treatments for the
Relapsing polychondritis RA or the BXIS itself is the inciting factor
for the RA.
Inhalation Accidents Direct airway injury from inhalation of
Gastroesophageal reflux/aspiration pneumonia
noxious substances such as toxic metal
Toxic inhalation/thermal injury
Postobstruction
fumes or other toxic gases is also known to
Foreign body occur. This may result in BXIS due to
Tumors, benign and malignant infectious complications following the
Extrinsic airway compression exposure or due to direct damage of the
ciliated epithelium.
Allergic Bronchopulmonary Aspergillosis/Mycosis
Miscellaneous Diagnosis
HIV infection/AIDS Although clinical manifestations vary,
Yellow-nail syndrome most patients with BXIS suffer from
Radiation injury repeated respiratory infections, chronic
Adapted from Mason RJ, Murray JF, Broaddus VC, Nadel JA eds
cough and purulent sputum. The degree of
sputum production is variable but may be
4 O NTARIO T HORACIC R EVIEWS FALL 2008
copious. Patients may also complain of
hemoptysis, shortness of breath, chest pain,
or fatigue.
There may be changes on chest radio-
graph but this modality lacks sensitivity.
The classic changes include “tram-tracking,
which results from the failure of bronchi to
narrow as they progress distally and
manifests as the bronchial walls appearing
as parallel lines. The signet ring sign refers
to an enlarged airway and its adjacent
vessel. Normally the airway and vessel
should be of the same caliber. In BXIS the
enlarged airway has the appearance of the
“ring” and the vessel, the “gem”.
The sensitivity of high resolution
computed tomography (HRCT) has allowed
for the diagnosis of less severe forms of the
disease. The typical findings on HRCT
include: internal bronchial diameter greater
than the adjacent pulmonary artery, lack of
bronchial tapering, visualization of bronchi
within 1 cm of costal pleura, visualization
of bronchi abutting the mediastinal pleura
and bronchial wall thickening.4
Spirometry typically shows airflow
limitation with or with out a reduced forced
vital capacity. Reactive airways can be
demonstrated in as many as 40-70% of
BXIS patients based on response to inhaled
bronchodilators or methacholine challenge.
Treatment
The literature on the treatment of BXIS is
scant and the quality of the studies poor.
Treatment can be broadly divided into three
categories, prevention of exacerbations,
treatment of exacerbations, and treatment of
complications. Treatment options are aimed
at decreasing the bacterial load, enhancing
clearance of secretions, decreasing
inflammation, or removal of diseased lung.
With the exception of a few circumstances
(i.e. allergic broncopulmonary aspergillosis,
non-tuberculous mycobacteria) the treatment
of BXIS is not influenced by its etiology.
If sputum cultures are available,
antibiotic therapy should be directed at the
isolated pathogen or pathogens. In the
absence of cultures studies have shown the
most commonly isolated pathogens are H.
influenzae, P. aeruginosa, and Strep.
pneumoniae. The duration of treatment for
acute exacerbations is not well established
but common practice is to treat for a
prolonged course (i.e >10 days).
Continued on page 5
Bronchiectasis... Continued from page 4
FIGURE 1 Infection and inflammation, the vicious circle.
Even less well established is antibiotic
treatment of a patient who is not in an
exacerbation. A recent Cochrane database
review of 9 trials looking at prolonged
courses of antibiotics (ranging from 4
months to one year) in BXIS showed a
positive response rate.5 Exacerbation rates
however were not decreased. Included in
this meta-analysis were studies of
prolonged courses of macrolides and also
studies of nebulized antibiotics. Although
beyond the scope of this paper, it would be
interesting to see if the positive effect was
maintained if these latter trials were
excluded from the meta-analysis.
The role of macrolide treatment of CF
BXIS patients infected with pseudomonas
is well established with multiple studies
showing effects including improved FEV1
and decreased exacerbation rates. The
mechanism for this benefit is likely a
combination of anti-inflammatory and anti-
biofilm properties. The anti-inflammatory
properties of macrolides are well
established and they have been used
successfully in the treatment of diffuse
panbronchiolitis. A recent pilot study of
conventional treatment plus azithromycin
500mg twice weekly in 11 BXIS patients
showed a decreased incidence of
exacerbations as well as decreased sputum
volume compared to usual treatment.6
Subjects also reported increased energy and
improved quality of life while receiving
azithromycin. Although insufficient evidence
is available to date to justify an approach
where all BXIS patients are treated with
long term macrolide therapy, further
investigations are certainly warranted.
FALL 2008 O NTARIO T HORACIC R EVIEWS
Nebulized antibiotic therapy aimed at
chronic pseudomonas infection has been
successful in CF patients. Unfortunately
evidence for a similar approach in BXIS is
lacking. Results have been inconsistent and
it is difficult to determine a priori which
patients will tolerate treatment with inhaled
antibiotics. There are nonetheless reports of
improved quality of life and symptom
scores with inhaled tobramycin.7 It is
possible to nebulize tobramycin as either
TOBI® (a preservative free formulation
designed specifically for nebulization) or to
nebulize the intravenous formulation (off
label indication). However, the intravenous
formulation may theoretically result in a
higher incidence of bronchospasm which
may be alleviated by nebulizing a mixture
of tobramycin and salbutamol. The practice
in our institution is to administer the first
dose of nebulized tobramycin in a
controlled setting with pre and post
inhalation spirometry.
Steroids
It makes physiological sense that
interruption of the “vicious circle” of
infection and inflammation in BXIS may
stabilize the disease or improve lung
function. The use of anti-inflammatory
medications has been poorly studied. A
Cochrane database review of inhaled
steroids in BXIS found only 2 suitable
studies for review.8 Although there was a
trend towards improved lung function there
was no demonstrated effect on sputum
production, cough, wheeze or dyspnea.
More recently a randomized controlled trial
of inhaled fluticasone versus placebo
showed decreased sputum volume in the
fluticasone treated group.9 In the subgroup
of patients with sputum cultures positive for
pseudomonas there was also a significant
reduction in the frequency of exacerbations.
To date there is insufficient evidence to
support the use of systemic corticosteroids
in stable BXIS or exacerbations of BXIS.
Bronchial Hygeine
Patients with BXIS may benefit from chest
physiotherapy or postural drainage. Many
of the techniques for enhanced secretion
clearance have been better studied in CF.
Percussion, postural drainage, flutter
devices or positive end expiratory pressure
(PEP) masks have all been used extensively
with success in CF. Despite this a Cochrane
database review found no evidence to
support these interventions in non-CF
bronchiectasis.10
Mucoactive Agents
Inhaled agents to enhance clearance of
sputum such as Recombinant DNase,
hypertonic saline, and powdered mannitol
have also been studied. Mannitol, and
hypertonic saline are hyperosmolar agents
that act by both stimulating cough and
causing a liquid flux into the airways.
Mannitol is probably the best studied of the
hyperosmolar agents in BXIS. It has been
shown to be effective in enhancing
clearance of pulmonary secretions.11
Recombinant DNase has been
demonstrated to be beneficial in CF BXIS
but not in non-CF BXIS. In a well
conducted double blind, placebo controlled
multi-center trial of 349 adult patients with
idiopathic BXIS, DNase was found to result
in a statistically significant more rapid
decline in FEV1 compared to placebo and
an increased rate of pulmonary
exacerbations, although this did not reach
significance. Chest physiotherapy was not
controlled for in this study.12 It was
postulated that the predominance of lower
lobe BXIS in the idiopathic patients
compared to upper lobe predominance in
CF patients may have accounted for the
differences in these two groups. In upper
lobe disease gravity may enhance sputum
clearance. This points out some of the
potential downfalls in directly applying
evidence from CF to non-CF BXIS.
Continued on page 6
5
Bronchiectasis... Continued from page 5

Surgery cases of massive hemoptysis protection of questions surrounding the treatment of

Perhaps the only “cure” for BXIS is surgical
removal of the diseased lung. In very
localized disease, usually BXIS secondary
to airway obstruction or previous
pneumonia, or in the presence of very drug
resistant organisms surgery may be
considered. Similarly surgery may also be
considered for recurrent hemoptysis
eminating from a particular diseased lung
segment. Double lung transplantation
remains a viable option in some patients.
Bronchodilators
There are no good trials assessing the
efficacy of short acting or long acting
inhaled bronchodilators in BXIS. In the
absence of data to either support or dissuade
the clinician from their use, decisions are
best made on a case by case basis. Further,
if there are any other indications for the use
of these medications such as concomitant
chronic obstructive pulmonary disease or
asthma, their use can be justified.
Hemoptysis
BXIS is one of the more common causes of
major hemoptysis due to bleeding from
enlarged bronchial arteries. Hemoptysis in
BXIS usually indicates infection and
parenteral antibiotic treatment is warranted.
On the other hand inhaled antibiotics may
irritate the airways and should be avoided.
The emergency management of hemoptysis
in BXIS should generally be no different
than that due to other causes with the
exception of a few additional concerns. In
the airway is of paramount importance.
Identification of the bleeding site may be
inferred in patients who have very localized
disease, plain chest radiographs may also
suggest the bleeding site. In select patients
fiberoptic bronchoscopy can identify the
bleeding site but often the rate of bleeding
will exceed the suction capabilities of the
bronchoscope and visualization will be
impaired. Some of the techniques for
managing large volume hemoptysis
include; placing the bleeding lung in a
dependant position, selective intubation of
the non bleeding lung, placement of a
bronchial blocker or placement of a double
lumen endotracheal tube. In the event
conservative management is not successful
definitive management by bronchial artery
embolization or surgical intervention may
be necessary. If the patient is receiving
antibiotics checking the coagulation profile
may indicate a coagulopathy secondary to
vitamin K deficiency that can be readily
corrected.
Conclusion
The advent of HRCT has resulted in the
recognition of more cases of BXIS,
although many of these may be less severe
than those diagnosed in the past. A
diagnosis of BXIS should warrant
investigations to look for the cause followed
by the institution of a treatment plan aimed
at the specific cause where possible and
otherwise directed at the management of the
BXIS itself. There are many unanswered
BXIS and hopefully in the years to come
some of these will be answered by high
quality clinical trials.
References
1. Barker AF, Bardana EJ Jr. Bronchiectasis: update of an
orphan disease. Am Rev Respir Dis 1988; 137 969-78
2. King P, Holdsworth S, Freezer N, Holmes, P.
Bronchiectasis. Int Med J 2006; 36 729-737
3. Steinfort DP, Brady S, Weisinger HS, Einsiedel L.
Bronchiectasis in Central Australia: A young face to an old
disease. Respir Med 2007 Dec 15 [Epub ahead of print]
4. Muller NL, Fraser RS, Colman NC, Pare PD eds, Radiologic
Diagnosis of Diseases of the Chest 1st ed. Philadelphia, PA,
W.B. Saunders Company, 2001:488-9
5. Evans DJ, Bara AI, Greenstone M. Prolonged antibiotics for
purulent bronchiectasis in children and adults Cochrane
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6. Cymbala AA, Edmonds LC, Bauer MA, Jederlinic PJ, May
JJ, Victory JM, Amsden GW. The disease-modifying effects of
twice-weekly oral azithromycin in patients with
bronchiectasis. Treat Respir Med. 2005;4(2):117-22
7. Scheinberg P, Shore E. A pilot study of the Safety and
Efficacy of Tobramycin Solution for Inhalation in Patients with
Severe Broncheictasis. Chest. 2005; 127:1420-1426
8. Kolbe J, Wells A, Ram FS. Inhaled steroids for
bronchiectasis. Cochrane Database Syst Rev. 2000;(2):CD000996
9. Tsang KW, Tan KC, Ho PL, Ooi GC, Ho JC, Mak J, Tipoe
GL, Ko C, Yan C, Lam WK, Chan-Yeung M. Inhaled fluticasone
in bronchiectasis: a 12 month study. Thorax. 2005 Mar;60(3):239-43
10. Jones AP, Rowe BH. Bronchopulmonary hygiene physical
therapy for chronic obstructive pulmonary disease and
bronchiectasis. Cochrane Database Syst Rev. 2000;(2):CD000045
11. Daviskas E, Anderson SD, Eberl S, Chan HK, Bautovich G.
Inhalation of dry powder mannitol improves clearance of
mucus in patients with bronchiectasis. Am J Respir Crit Care
Med. 1999 Jun;159(6):1843-8
12. O'Donnell AE, Barker AF, Ilowite JS, Fick RB. Treatment
of idiopathic bronchiectasis with aerosolized recombinant
human DNase I. rhDNase Study Group. Chest. 1998
May;113(5):1329-34
13. Adapted from Mason RJ, Murray JF, Broaddus VC, Nadel
JA eds, Murray and Nadel's Textbook of Respiratory Medicine,
4th ed. Philadelphia, PA, Elsivier Saunders, 2005: 1253

“Breathe New Life Award” Recipient, 2009-2010

he OTS is pleased to announce the third recipient of the “Breathe New Life Award” is Richard Horner,
T PhD. Dr. Horner received his undergraduate degree with honors in Physiology from the University of
Sheffield, UK in 1986. He then completed his PhD at the University of London, UK in 1991 with research
investigating upper airway physiology in humans. Dr. Horner then did postdoctoral work investigating the
control of breathing and sleep in the Department of Medicine at the University of Toronto (1991-1994) and
performed further post-doctoral training in sleep and respiratory neurobiology at the University of
Pennsylvania (1994-1997) before returning to a faculty position at the University of Toronto. Dr. Horner is
currently a Tier 1 Canada Research Chair in Sleep and Respiratory Neurobiology, and Associate Professor
of Medicine and Physiology at the University of Toronto. His research uses in-vivo pre-clinical models to
determine: (i) physiological mechanisms underlying the control of breathing during sleep, (ii) determine
how commonly used drugs, such as sedative hypnotics and opioids, cause respiratory depression and (iii)
with this knowledge develop strategies to increase breathing during sleep and states of respiratory
depression.
The OTS would like to congratulate Dr. Horner and thank the OTS members for their donations to the
Top It Up! for Respiratory Research Fund and the OLA for contributing the additional funds to make this
DR. RICHARD HORNER third award possible.

6 O NTARIO T HORACIC R EVIEWS FALL 2008

Career Scientist Award How Physicians
Andrea Gershon, MD, MSc, FRCPC Can Give a Voice
C ongratulations to Dr. Andrea Gershon from the Ontario Thoracic
Society and the Ontario Lung Association for receiving the
to the Backseat
A Message from the Cindy Shcherban,
Ministry of Health and Long Term Care’s Career Scientist Award. This
award is given to outstanding scientists to research health services. OLA VP of Provincial Programs
Dr. Gershon completed her medical degree, residency, and
hildren across Ontario will soon be
fellowship at the University of Toronto where she trained in General
Internal Medicine and Respirology. She followed this with a Masters C breathing easier thanks to a new
provincial law and important support
of Science in Clinical Epidemiology from the University of Toronto
and then postgraduate research fellowships in health services research provided by The Ontario Lung Association.
at the Institute for Clinical Evaluative Sciences. DR. ANDREA GERSHON The provincial government recently
Her major research interests are the study of health outcomes and health services use in confirmed that the law banning smoking
individuals with respiratory disease. She is working to validate health administrative in cars with children under the age of 16 will
definitions of asthma, COPD, and TB in the population and is involved in a surveillance come into effect on Wednesday, January
initiative to measure the burden of these diseases in the Ontario population. She is also 21, 2009 during National Non-Smoking
the principal investigator of a study designed to determine the ‘real world’ effects of Week, also known as Weedless Wednesday.
COPD medications. To help ensure the transition to the new
Dr. Gershon is currently a Canadian Institutes of Health Research and Public Health law is smooth, the provincial government
agency of Canada funded postgraduate fellow. She is the recipient of a 2008 Ontario has tapped The Ontario Lung Association
Ministry of Health and Long Term Care Career Scientist award which will commence to lead the development and execution of
when her postgraduate fellowship is complete. In addition to her research, Dr. Gershon is a a social marketing campaign to educate
consultant for the Centre for Chronic Disease Prevention and Control of the Public Health Ontarians about the grave health dangers
Agency of Canada and a National Spokesperson for the Canadian Lung Association. associated with smoking in vehicles with
children under 16.
“We are incredibly excited to be
We are pleased to invite you to the 6th Annual partnering with the Ministry of Health

BBC Respirology Job Fair

Promotion on this significant public
health campaign,” said George Habib,
President and CEO of The Ontario Lung
To be held at Association. “Although the law will soon
require cars with children to be completely
The OTS Better Breathing Conference 2009 smoke-free, we are encouraging those who
At the Toronto Marriott Downtown Eaton Centre currently smoke in vehicles with children
525 Bay Street, Toronto M5G 2L2 under 16 to make this change now – on
Phone (416)597-9200 behalf of the health of their children.”
The Ontario Lung Association is
Reservations 1-800-905-0667
currently developing a multi-phased campaign
www.marriotteatoncentre.com
that will educate Ontario residents about
the increased health risks for children
Friday January 30, 2009 exposed to second-hand smoke in a car.
After the OTS Annual General Meeting for a wine and cheese reception and the Job Fair Designed to “give a voice to the backseat”,
5:00 – 6:00 p.m. the campaign will aim to speak on behalf
of children who are either too young or
All members are invited too scared to speak up for themselves.
This is an opportunity for you to advertise information about positions available in your centre The medical community, physicians in
(academic or community) to the Ontario Respirology residents. Tables will be available to set up particular, are in an advantageous position
flyers and brochures, if required. Informal mingling will provide an opportunity to meet the future to encourage their patients to refrain
graduates of the Ontario Respirology Programs. In addition, the Ontario Respirology Program
from smoking in vehicles when children are
passengers. To get involved, or to order
Directors will be available for discussion of your future manpower needs.
patient education materials, contact The
Please RSVP to Jeanne Castellanos, Ontario Thoracic Society Ontario Lung Association at www.on.lung.ca
(416)864-9911 ext. 254 or ots@on.lung.ca by Friday January 9, 2009 or call 1-888-344-LUNG (5864).

FALL 2008 O NTARIO T HORACIC R EVIEWS 7