ORCID Profile
0000-0001-9148-196X
Current Organisations
University of Otago Wellington
,
Capital and Coast District Health Board
,
Asthma and Respiratory Foundation New Zealand
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Publisher: BMJ
Date: 12-09-2018
DOI: 10.1136/THORAXJNL-2017-211466
Abstract: Transcutaneous carbon dioxide (TcCO 2 ) monitoring is a non-invasive alternative to arterial blood s ling. The aim of this review was to determine the accuracy and precision of TcCO 2 measurements. Medline and EMBASE (2000–2016) were searched for studies that reported on a measurement of PaCO 2 that coincided with a measurement of TcCO 2 . Study selection and quality assessment (using the revised Quality Assessment of Diagnostic Accuracy Studies tool (QUADAS-2)) were performed independently. The Grading Quality of Evidence and Strength of Recommendation approach was used to summarise the strength of the body of evidence. Pooled estimates of the mean bias between TcCO 2 and PaCO 2 and limits of agreement with outer 95% CIs (termed population limits of agreement) were calculated. The mean bias was −0.1 mm Hg and the population limits of agreement were −15 to 15 mm Hg for 7021 paired measurements taken from 2817 participants in 73 studies, which was outside of the clinically acceptable range (7.5 mm Hg). The lowest PaCO 2 reported in the studies was 18 mm Hg and the highest was 103 mm Hg. The major sources of inconsistency were sensor location and temperature. The population limits of agreement were within the clinically acceptable range across 3974 paired measurements from 1786 participants in 44 studies that applied the sensor to the earlobe using the TOSCA and Sentec devices (−6 to 6 mm Hg). There are substantial differences between TcCO 2 and PaCO 2 depending on the context in which this technology is used. TcCO 2 sensors should preferentially be applied to the earlobe and users should consider setting the temperature of the sensor higher than 42°C when monitoring at other sites. PROSPERO CRD42017057450.
Publisher: Elsevier BV
Date: 07-2020
Publisher: Springer Science and Business Media LLC
Date: 15-07-2019
DOI: 10.1038/S41598-019-46751-2
Abstract: Identifying common patterns in capnography waveform abnormalities and the factors that influence these patterns could yield insights to optimize responses to sedation-induced respiratory depression. Respiratory state sequences for 102 patients who had a procedure in a cardiac catheterisation laboratory with procedural sedation and analgesia were developed by classifying each second of procedures into a state of normal breathing or other capnography waveform abnormalities based on pre-specified cut-offs for respiratory rate and end-tidal CO 2 concentration. Hierarchical clustering identified four common patterns in respiratory state sequences, which were characterized by a predominance of the state assigned normal breathing (n = 42 41%), hypopneic hypoventilation (n = 38 38%), apnea (n = 15 15%) and bradypneic hypoventilation (n = 7 7%). A multivariable distance matrix regression model including demographic and clinical variables explained 28% of the variation in inter-in idual differences in respiratory state sequences. Obstructive sleep apnea (R 2 = 2.4% p = 0.02), smoking status (R 2 = 2.8% p = 0.01), Charlson comorbidity index score (R 2 = 2.5% p = 0.021), peak transcutaneous carbon dioxide concentration (R 2 = 4.1% p = 0.002) and receiving an intervention to support respiration (R 2 = 5.6% p = 0.001) were significant covariates but each explained only small amounts of the variation in respiratory state sequences. Oxygen desaturation (SpO 2 90%) was rare (n = 3 3%) and not associated with respiratory state sequence trajectories.
Publisher: BMJ
Date: 07-2017
Publisher: European Respiratory Society (ERS)
Date: 07-03-2019
DOI: 10.1183/13993003.02058-2018
Abstract: “Treatable traits” have been proposed as a new paradigm for the management of airway diseases, particularly complex disease, which aims to apply personalised medicine to each in idual to improve outcomes. Moving new treatment approaches from concepts to practice is challenging, but necessary. In an effort to accelerate progress in research and practice relating to the treatable traits approach, the Treatable Traits Down Under International Workshop was convened in Melbourne, Australia in May 2018. Here, we report the key concepts and research questions that emerged in discussions during the meeting. We propose a programme of research that involves gaining international consensus on candidate traits, recognising the prevalence of traits, and identifying a potential hierarchy of traits based on their clinical impact and responsiveness to treatment. We also reflect on research methods and designs that can generate new knowledge related to efficacy of the treatable traits approach and consider multidisciplinary models of care that may aid its implementation into practice.
Publisher: Elsevier BV
Date: 05-2019
DOI: 10.1016/J.JAIP.2019.02.042
Abstract: Severe asthma is complex and heterogeneous ad hoc outpatient assessment can be suboptimal. Systematic evaluation improves outcomes and is recommended by international guidelines. Electronic templates improve physician performance and clinical processes, and may be useful in severe asthma systematic evaluation. We developed the Severe Asthma Global Evaluation (SAGE) electronic platform to streamline this process, via Research Electronic Data Capture (REDCap). It incorporates: a questionnaire battery for patient completion before clinical consultation asthma and comorbidity modules a clinical summary page in an asthma management module a nurse educator module a structured panel discussion record and an automatically generated report incorporating all key data. SAGE incorporates 282 clinician input fields, with a typical consultation requiring completion of 169. To streamline the process SAGE contains 34 autocalculations and 20 decision support tools. It incorporates all 95 core variables of the International Severe Asthma Registry, with which it is directly compatible. SAGE improves symptom control and exacerbations in patients with difficult asthma. In conclusion, we developed and validated an electronic platform that facilitates a comprehensive but streamlined systematic evaluation of severe asthma that is available for free download via REDCap. Its use enhances management of patients with severe asthma and facilitates audit and international research collaboration.
Publisher: Massachusetts Medical Society
Date: 23-05-2019
Publisher: Elsevier BV
Date: 09-2019
Publisher: Wiley
Date: 15-07-2019
DOI: 10.1111/ALL.13952
Publisher: BMJ
Date: 08-2022
DOI: 10.1136/BMJRESP-2022-001271
Abstract: In randomised controlled trials, as-needed inhaled corticosteroid (ICS)-formoterol reliever therapy reduces severe exacerbation risk compared with maintenance ICS plus short-acting beta 2 -agonist (SABA) reliever in adolescent and adult asthma, but results in slightly worse control of asthma symptoms, as measured by mean Asthma Control Questionnaire-5 (ACQ-5) score. To assess the levels and changes in asthma control for as-needed budesonide–formoterol versus maintenance budesonide plus SABA in post hoc analyses from the Novel START and PRACTICAL clinical trials. The number and proportion of participants at study end in each ACQ-5 category (‘well-controlled’, ‘partly controlled’ or ‘inadequately controlled’ symptoms), and in each responder category based on the minimal clinically important difference for ACQ-5 of 0.5 (improved, no change and worse) with as-needed budesonide–formoterol and maintenance budesonide plus SABA treatment were calculated. With last observation carried forwards, 189/214 (88.3%) and 354/434 (81.6%) of patients in the budesonide–formoterol group had ‘well-controlled’ or ‘partly controlled’ symptoms at the end of the study, vs 183/214 (85.5%) and 358/431 (83.1%) in the budesonide maintenance group, for Novel START and PRACTICAL, respectively. The proportion of patients whose symptom control was either improved or unchanged from baseline was 190/214 (88.8%) and 368/434 (84.8%) for budesonide–formoterol, vs 185/214 (86.4%) and 376/431 (87.2%) for maintenance budesonide, in Novel START and PRACTICAL respectively. There were no clinically important differences in the proportions of patients with ‘well-controlled’ or ‘partly controlled’ asthma symptoms, or proportions who improved or maintained their level of control, with as-needed budesonide–formoterol versus maintenance budesonide plus SABA.
Publisher: BMJ
Date: 27-07-2020
DOI: 10.1136/THORAXJNL-2019-214343
Abstract: An as-needed combination preventer and reliever regimen was recently introduced as an alternative to conventional daily preventer treatment for mild asthma. In a subgroup analysis of the PRACTICAL study, a pragmatic randomised controlled trial of budesonide–formoterol reliever therapy versus maintenance budesonide plus terbutaline reliever therapy in adults with mild asthma, we recently reported that about two-thirds preferred as-needed combination preventer and reliever therapy. The aim of this study was to determine the relative importance of attributes associated with these two asthma therapies in this subgroup of participants who indicated their preferred treatment in the PRACTICAL study. At their final study visit, a subgroup of participants indicated their preferred treatment and completed a discrete choice experiment using the Potentially All Pairwise RanKings of all possible Alternatives method and 1000minds software. Treatment attributes and their levels were selected from measurable study outcomes, and included: treatment regimen, shortness of breath, steroid dose and likelihood of asthma flare-up. The final analysis dataset included 288 participants, 64% of whom preferred as-needed combination preventer and reliever. Of the attributes, no shortness of breath and lowest risk of asthma flare-up were ranked highest and second highest, respectively. However, the relative importance of the other two attributes varied by preferred therapy: treatment regimen was ranked higher by participants who preferred as-needed treatment than by participants who preferred maintenance treatment. Knowledge of patient preferences for treatment attributes together with regimen characteristics can be used in shared decision-making regarding choice of treatment for patients with mild–moderate asthma. ACTRN12616000377437.
Publisher: European Respiratory Society (ERS)
Date: 06-02-2020
DOI: 10.1183/13993003.02073-2019
Abstract: Symptom-driven low-dose inhaled corticosteroid–formoterol is safe and effective in mild asthma and has been recommended as one of the preferred treatment regimens at steps 1 and 2 in the 2019 update of the Global Initiative for Asthma. However, there are no data on patient preferences for this regimen. A subgroup of participants in the PRACTICAL study (ACTRN12616000377437), a randomised controlled trial comparing symptom-driven budesonide–formoterol with maintenance budesonide plus as-needed terbutaline completed a survey on treatment preferences, satisfaction, beliefs and experience at their final study visit. 306 (75%) out of 407 eligible participants completed the survey. Regimen preference was strongly associated with randomised treatment, as were preferences for and beliefs about preventer inhaler use. Combination preventer and reliever as-needed therapy was preferred by 135 (90%, 95% CI 85.2–94.8%) out of 150 who were randomised to as-needed budesonide–formoterol, and by 63 (40%, 95% CI 32.7–48.1%) out of 156 who were randomised to maintenance budesonide. By contrast, twice-daily preventer inhaler with a reliever inhaler as required was preferred by 15 (10%) out of 150 of those randomised to as-needed budesonide–formoterol and 93 (60%) out of 156 of those randomised to maintenance budesonide. Satisfaction with all study inhalers was high. Of patients randomised to as-needed budesonide–formoterol 92% (n=138) were confident using it as a reliever at the end of the study. Although most participants preferred the regimen to which they had been randomised, this association was much stronger for those randomised to budesonide–formoterol as needed, indicating that most patients preferred as-needed corticosteroid–formoterol therapy if they had experienced it.
Publisher: Wiley
Date: 02-2021
DOI: 10.1111/IMJ.14806
Publisher: Elsevier BV
Date: 11-2021
Publisher: BMJ
Date: 08-2020
DOI: 10.1136/BMJOPEN-2020-037491
Abstract: Preference for asthma management and the use of medications is motivated by the interplay between lived experiences of asthma and patients’ attitudes towards medications. Many previous studies have focused on in idual aspects of asthma management, such as the use of preventer and reliever inhalers. The aim of this qualitative study was to explore the preferences of patients with mild-moderate asthma for asthma management as a whole and factors that influenced these preferences. A qualitative study employing qualitative descriptive analysis situated within a constructionist epistemology to analyse transcribed audio recordings from focus groups. Three locations within the greater Wellington area in New Zealand. Twenty-seven adults with self-reported doctor’s diagnosis of asthma, taking short-acting beta-agonists alone or inhaled corticosteroids with or without long-acting beta 2 -agonist, who had used any inhaled asthma medication within the last month. Four key areas described preferences for asthma management. Preferences for self-management: participants wanted to be in control of their asthma and developed personal strategies to achieve this. Preferences for the specific medications or treatment regimen: participants preferred regimens that were convenient and reliably relieved symptoms. Preferences for inhaler devices: devices that had dose counters and were easy to use and portable were important. Preferences for asthma services: participants wanted easier access to their inhalers and to be empowered by their healthcare providers. Participant preferences within each of these four areas were influenced by the impact asthma had on their life, their health beliefs, emotional consequences of asthma and perceived barriers to asthma management. This study illustrates the interaction of the lived experience of asthma, factors specific to the in idual, and factors relating to asthma treatments in shaping patient preferences for asthma management. This aids our understanding of preferences for asthma management from the patient perspective. Australian New Zealand Clinical Trials Registry (ACTRN12619000601134).
Publisher: Springer Science and Business Media LLC
Date: 30-09-2019
DOI: 10.1007/S10877-019-00391-Z
Abstract: Capnography monitoring is recommended for use during procedural sedation. This study examined associations between capnography waveform abnormalities and the onset of apnea. Capnography waveforms from a s le of 102 participants undergoing moderate procedural sedation with bolus doses of midazolam and fentanyl were analyzed using a mixed effects Cox model. Patients were at increased risk of apnea (classified as end-tidal carbon dioxide concentration of zero) while demonstrating a capnography waveform abnormality classified as hypopnea (more than 10% increase or decrease from baseline end-tidal carbon dioxide concentration) (Hazard Ratio 2.14 95% CI 1.75 to 2.62). Risk of apnea was not increased during capnography waveform abnormalities classified as bradypnea (capnography-derived respiratory rate less than 8 breaths/min) (Hazard Ratio 0.64 95% CI 0.33 to 1.25). These estimates were similar when apneic episodes were defined as only those that lasted more than 20 s duration. Deciphering which capnography waveform abnormalities should promote intervention (and therefore alarms to signal the event to clinicians) from those that do not is an essential step towards successful implementation of this technology into practice. Our results indicate that using information about the history of previous capnography waveform abnormalities may be a promising solution to assist prediction of apneic episodes.
No related grants have been discovered for James Fingleton.