Management Of Chronic Lung Disease Research Articles

Perspectives from patients with chronic lung disease on a telehealth-facilitated integrated palliative care model: a qualitative content analysis study

BackgroundChronic lung disease affects nearly 37 million Americans and often results in significant quality of life impairment and healthcare burden. Despite guidelines calling for palliative care (PC) integration into pulmonary care as a vital part of chronic lung disease management, existing PC models have limited access and lack scalability. Use of telehealth to provide PC offers a potential solution to these barriers. This study explored perceptions of patients with chronic lung disease regarding a telehealth integrated palliative care (TIPC) model, with plans to use findings to inform development of an intervention protocol for future testing.MethodsFor this qualitative study, we conducted semi-structured interviews between June 2021- December 2021 with patients with advanced chronic lung disease. Interviews explored experiences with chronic lung disease, understanding of PC, and perceived acceptability of the proposed model along with anticipated facilitators and barriers of the TIPC model. We analyzed findings with a content analysis approach.ResultsWe completed 20 interviews, with two that included both a patient and caregiver together due to patient preference. Perceptions were primarily related to three categories: burden of chronic lung disease, pre-conceived understanding of PC, and perspective on the proposed TIPC model. Analysis revealed a high level of disease burden related to chronic lung disease and its impact on day-to-day functioning. Although PC was not well understood, the TIPC model using a shared care planning approach via telehealth was seen by most as an acceptable addition to their chronic lung disease care.ConclusionsThese findings emphasize the need for a patient-centered, shared care planning approach in chronic lung disease. The TIPC model may be one option that may be acceptable to individuals with chronic lung disease. Future work includes using findings to refine our TIPC model and conducting pilot testing to assess acceptability and utility of the model.

Home-based respiratory support

This review provides an overview of home-based respiratory support modalities for patients with chronic lung diseases. It discusses the increasing use of long-term high-flow nasal cannula (LT-HFNC) and long-term non-invasive ventilation (LT-NIV) and their potential to enhance patient quality of life. This review addresses various types of respiratory failure and their respective treatments, emphasising the significance of monitoring and telemedicine in home care. This comprehensive review underscores the clinical relevance of these interventions in the management of chronic lung diseases.

Mobile heath applications for self-management in chronic lung disease: a systematic review.

The online version contains supplementary material available at 10.1007/s13721-023-00419-0.

Deep learning to estimate lung disease mortality from chest radiographs

Prevention and management of chronic lung diseases (asthma, lung cancer, etc.) are of great importance. While tests are available for reliable diagnosis, accurate identification of those who will develop severe morbidity/mortality is currently limited. Here, we developed a deep learning model, CXR Lung-Risk, to predict the risk of lung disease mortality from a chest x-ray. The model was trained using 147,497 x-ray images of 40,643 individuals and tested in three independent cohorts comprising 15,976 individuals. We found that CXR Lung-Risk showed a graded association with lung disease mortality after adjustment for risk factors, including age, smoking, and radiologic findings (Hazard ratios up to 11.86 [8.64–16.27]; p < 0.001). Adding CXR Lung-Risk to a multivariable model improved estimates of lung disease mortality in all cohorts. Our results demonstrate that deep learning can identify individuals at risk of lung disease mortality on easily obtainable x-rays, which may improve personalized prevention and treatment strategies.

A Preliminary Investigation of Mobile Respiratory Function Testing in Western Australian Communities

Although underutilized, spirometry is essential in the diagnosis and management of chronic obstructive pulmonary disease (COPD) and asthma. This study aimed to investigate a mobile (i.e., transportable) lung function testing (LFT) services in two metropolitan and two rural clinics in Western Australia. Individuals attending a mobile LFT clinic in 2021 were invited to complete questionnaires at baseline and after 6–8 weeks. Questionnaires were completed by 59/74 (79.7%) respondents (mean age 62.5 ± 14.2 years); most were female (35/59; 59.3%). A history of asthma was reported in 50.9% (30/59) and COPD in 18.6% (11/59) of respondents [13.6% (8/59) reported both]. At baseline, most (22/30; 73.3%) had asthma control test scores ≤19 (mean 16.6; range 8.0–25.0); at follow-up, 16/31 (51.6%) had scores ≤19 (mean score 18.0; range 6.0–25.0). Of the 11 diagnosed with COPD at baseline, the mean Clinical COPD Questionnaire and COPD assessment test scores were greater at follow-up (1.9 vs. 2.3; and: 10.3 vs. 14.7 respectively), reflecting worsening disease. Most participants (57/59; 96.6%) were satisfied with the LFT experience. The role of mobile LFT services to optimize the diagnosis and management of chronic lung disease and to minimize patient burden requires further investigation to improve short term patient outcomes.

ADVANCED-CARE PLANNING IN PULMONARY HYPERTENSION AND INTERSTITIAL LUNG DISEASE: NEEDS ASSESSMENT AND DEVELOPMENT OF A QUALITY IMPROVEMENT PROCESS

ADVANCED-CARE PLANNING IN PULMONARY HYPERTENSION AND INTERSTITIAL LUNG DISEASE: NEEDS ASSESSMENT AND DEVELOPMENT OF A QUALITY IMPROVEMENT PROCESS

Implementing evidence into practice to improve chronic lung disease management in Indigenous Australians: the breathe easy, walk easy, lungs for life (BE WELL) project (protocol)

BackgroundStrong evidence exists for the benefits of pulmonary rehabilitation (PR) for people with chronic obstructive pulmonary disease (COPD), however the availability of culturally safe PR for Aboriginal and Torres Strait Islander (Indigenous) Peoples is limited. The study aims to determine whether PR can be implemented within Aboriginal Community Controlled Health Services (ACCHS) to improve outcomes for Indigenous people with COPD.MethodsMulti-centre cohort study using participatory action research guided by the Knowledge-to-Action Framework. ACCHS supportive of enhancing services for chronic lung disease will be recruited. Aboriginal Health Workers (AHW) and the exercise physiologist (EP) or physiotherapist (PT) within these ACCHS will attend a workshop aimed at increasing knowledge and skills related to management of COPD and the provision of PR. Indigenous people with COPD will be invited to attend an 8-week, twice weekly, supervised PR program. Outcomes: AHW, EP/PT knowledge, skills and confidence in the assessment and management of COPD will be measured before and immediately after the BE WELL workshop and at 3, 6 and 12 months using a survey. PR participant measures will be exercise capacity (6-minute walk test (6MWT), health-related quality of life and health status at commencement and completion of an 8-week PR program. Secondary outcomes will include: number, length and cost of hospitalisations for a COPD exacerbation in 12-months prior and 12-months post PR; local contextual factors influencing implementation of PR; specific respiratory services provided by ACCHS to manage COPD prior to project commencement and at project completion. Repeated measures ANOVA will be used to evaluate changes in knowledge and confidence over time of AHWs and EP/PTs. Paired t-tests will be used to evaluate change in patient outcomes from pre- to post-PR. Number of hospital admissions in the 12 months before and after the PR will be compared using unpaired t-tests.DiscussionPulmonary rehabilitation is an essential component of best-practice management of COPD and is recommended in COPD guidelines. Indigenous peoples have limited access to culturally safe PR programs. This study will evaluate whether PR can be implemented within ACCHS and improve outcomes for Indigenous people with COPD.Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001337369, Registered 2nd September 2017 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373585&isClinicalTrial=False

Circadian molecular clock disruption in chronic pulmonary diseases.

The circadian clock is the biochemical oscillator with a near 24-h period that is responsible for generating the circadian rhythms in peripheral organs including the lung. Mounting evidence suggests that circadian clock disruption during chronic lung diseases plays an essential role in augmented oxidative stress, inflammatory response, metabolic imbalances, hypoxia/hyperoxia, mucus secretion, dysregulated autophagy, and alters pulmonary function. Here, we review circadian clock disruption and discuss candidate clock genes that are altered at the transcriptional or translational level in chronic pulmonary diseases. This review aims to provide the current knowledge and understanding of the circadian molecular clock disruption in chronic pulmonary diseases which will further advance the development of novel clock-based therapeutics in the future.

ĐẶC ĐIỂM LÂM SÀNG VÀ CHI PHÍ ĐIỀU TRỊ HEN PHẾ QUẢN TẠI ĐƠN VỊ QUẢN LÝ NGOẠI TRÚ BỆNH PHỔI MẠN TÍNH BỆNH VIỆN ĐA KHOA ĐỐNG ĐA NĂM 2020

Objectives: Describe clinical characteristics, costs of asthma treatment at the unit outpatient management of chronic lung disease at Dong Da General Hospital 2020. Participants and Methods: Descriptive-cross sectional study analysis on 61 patients diagnosed with asthma according to GINA 2020 at the Chronic lung disease management clinic of Dong Da General Hospital from January 2020 to December 2020. Results: The rate of bronchial asthma in women/men was 1.44 and the average age group was 63.75. Co-morbidities 54.1% allergic rhinitis, 1.6% atopic dermatitis, 27.9% hypertensions, 13.1% diabetes, 3.3% osteoporosis, 3.3% disease other medical conditions, and 0% had cardiovascular diseases. The proportion of patients who did not smoke accounted for 65.6% compared to 34.5% of patients who smoked. The most common clinical symptom was cough 75.4%, followed by dyspnea 63.9%, wheezing 57.4% and no other patient had any other symptoms. The cost for asthma treatment is 4.03 million VND/year, the cost for treatment for the group without exacerbations is 3.91 million VND/year. The cost for the group with the grant is 4.15 million VND/year. Conclusion: Asthma has diverse clinical features and the cost of asthma treatment is low in the group of patients without exacerbations compared with the group with exacerbations. Keywords: bronchial asthma, treatment costs

Management of chronic lung diseases in Sudan and Tanzania: how ready are the country health systems?

BackgroundChronic lung diseases (CLDs), responsible for 4 million deaths globally every year, are increasingly important in low- and middle-income countries where most of the global mortality due to CLDs currently occurs. As existing health systems in resource-poor contexts, especially sub-Saharan Africa (SSA), are not generally oriented to provide quality care for chronic diseases, a first step in re-imagining them is to critically consider readiness for service delivery across all aspects of the existing system.MethodsWe conducted a mixed-methods assessment of CLD service readiness in 18 purposively selected health facilities in two differing SSA health system contexts, Tanzania and Sudan. We used the World Health Organization’s (WHO) Service Availability and Readiness Assessment checklist, qualitative interviews of key health system stakeholders, health facility registers review and assessed clinicians’ capacity to manage CLD using patient vignettes. CLD service readiness was scored as a composite of availability of service-specific tracer items from the WHO service availability checklist in three domains: staff training and guidelines, diagnostics and equipment, and basic medicines. Qualitative data were analysed using the same domains.ResultsOne health facility in Tanzania and five in Sudan, attained a CLD readiness score of ≥ 50 % for CLD care. Scores ranged from 14.9 % in a dispensary to 53.3 % in a health center in Tanzania, and from 36.4 to 86.4 % in Sudan. The least available tracer items across both countries were trained human resources and guidelines, and peak flow meters. Only two facilities had COPD guidelines. Patient vignette analysis revealed significant gaps in clinicians’ capacity to manage CLD. Key informants identified low prioritization as key barrier to CLD care.ConclusionsGaps in service availability and readiness for CLD care in Tanzania and Sudan threaten attainment of universal health coverage in these settings. Detailed assessments by health systems researchers in discussion with stakeholders at all levels of the health system can identify critical blockages to reimagining CLD service provision with people-centered, integrated approaches at its heart.

Factors affecting healthcare pathways for chronic lung disease management in Vietnam: a qualitative study on patients\u2019 perspectives

BackgroundChronic obstructive pulmonary disease (COPD) and asthma rank among the leading causes of respiratory morbidity, particularly in low- and middle-income countries. This qualitative study aimed to explore the healthcare pathways of patients with chronic respiratory disease, and factors influencing their ability to access healthcare in Vietnam, where COPD and asthma are prevalent.MethodsWe conducted 41 in-depth interviews among patients, including 31 people with COPD, eight with asthma and two with asthma-COPD overlap syndrome. Participants were recruited at provincial- or national-level health facilities in two urban and two rural provinces in Vietnam. The interviews were audio-recorded, transcribed, and analysed using thematic analysis.ResultsPatients’ healthcare pathways were complex and involved visits to multiple health facilities before finally obtaining a definitive diagnosis at a provincial- or national-level hospital. Access to healthcare was affected considerably by participants’ limited knowledge of their respiratory conditions, the availability of social support, especially from family members, the costs of healthcare as well as health system factors (including the coverage of public health insurance, the distance to health facilities, and attitude of healthcare providers).ConclusionThe study demonstrated the need for improved access to timely diagnosis and treatment of chronic lung disease within the lower level of the health system. This can be achieved by enhancing the communication skills and diagnostic capacity of local healthcare workers. Health education programmes for patients and caregivers will contribute to improved control of lung disease.

Azithromycin and Co-Trimoxazole in Antimicrobial Prophylaxis: Special Emphasis on Primary Immunodeficiencies in Children

Patients with primary immunodeficiency diseases (PID) are prone to infectious, and they often determine the course of the disease. Antimicrobial prophylaxis for patients with PID includes co-trimoxazole, amoxicillin and macrolides. Co-trimoxazole is a widely used antimicrobial agent for pneumocystosis prophylaxis in immunocompromised patients, including patients with primary cellular immunodeficiency. Antiinflammatory effect of azithromycin made it a drug of choice in the management of chronic lung diseases in the patients with primary immunodeficiencies, especially in those with antibody deficiencies. Further randomised controlled studies are needed to define the optimal agent for all types of primary immunodeficiencies, its dose, duration of treatment, benefits and safety of long-term use.A recommendation for the prophylactic use of long-term therapy should consider the balance between benefits and risk of adverse events.&#x0D; Bangladesh Journal of Medical Science Vol.20(3) 2021 p.530-538

Barriers to enrollment in pulmonary rehabilitation in a private hospital in Brazil: a physician survey study

Introduction: Pulmonary rehabilitation (PR) plays a key role in the management of chronic lung diseases, but it remains largely underused worldwide. The aim of this study was to assess clinicians’ knowledge about PR and to identify the barriers they encounter when referring patients with medical insurance to PR in a private hospital in Brazil. Methodology: This was a survey-based cross-sectional study conducted in 2019 at a reference hospital in São Paulo, Brazil. Eligible participants were physicians registered with the following specialties: Internal Medicine, Geriatrics, Cardiology, Pulmonology or Thoracic Surgery. Results: We collected 72 responses. While 99% of participants recognized COPD as a potential indication for PR, interstitial lung disease, bronchiectasis and pulmonary hypertension were less often recognized (75%). Most participants (67%) incorrectly associated PR with lung function improvement, while 28% of cardiologists and 35% of internists/geriatricians failed to recognize benefits on mood disorders. Notably, 18% of participants recommended PR only to patients on supplemental oxygen and 14% prescribed only home physiotherapy, patterns more commonly seen among non-respiratory physicians. The 3 most perceived barriers to referral and adherence were health insurance coverage (79%), transportation to the PR center (63%) and lack of social support (29%). Conclusions: Financial, logistic and social constraints pose challenges to PR enrollment even for patients with premium healthcare insurance plans. Moreover, physician knowledge gaps may be an additional barrier to PR referral and uptake. Providing continued medical education, incorporating automatic reminders in electronic medical records and using telerehabilitation tools may improve PR referral, adherence and ultimately patient care.

Perspectives of Healthcare Workers, National and Regional Policy Stakeholders on the Management of Chronic Lung Disease in Five Sub-Saharan African Countries: Tale of a Vicious Cycle of Neglect

Background: Chronic lung diseases are among the top four non communicable diseases (NCDs), associated with 80% of premature mortality worldwide, debilitating health, and poor quality of life for survivors. Common risk factors for lung diseases include exposure to biomass fuels, environmental pollution, tobacco smoke, hereditary factors, and lower respiratory tract infections. Low-and-middle-income countries bear the biggest burden of chronic lung diseases, due to increasing exposures to risk factors, and weak health systems.To manage this rising threat, countries need to orient their systems towards chronic disease management, strengthen their primary healthcare systems even as they pursue universal health coverage reforms. This paper draws on the views and experiences of health systems actors to explore the current challenges to improving high quality, accessible care for chronic lung diseases.Methods: We explored the perspectives of policy stakeholders on management of chronic lung diseases in five Sub-Saharan African countries, Kenya, Malawi, Sudan, Tanzania, and Uganda. Data were collected between May 2018 and March 2019 through key informant interviews and in-depth interviews with government officials, representatives of non-governmental organizations supporting various health system functions, and healthcare workers of 36 healthcare facilities. Data were analysed using the framework approach.Findings: We identified intersecting vicious cycles of neglect of chronic lung health at both the strategic policy level and the healthcare facility level. At strategic policy level, low diagnostic capacity, weak recording and reporting systems limit the availability of reliable data on the burden of disease, which negatively affects inclusion in policy, and in turn budgetary allocations for diagnostic equipment, training, and medicines. At the service level, lack of budgetary allocations for equipment and training of staff, constrains diagnostic capacity, which, along with limited availability of appropriate medicines reduces service delivery quality and collection of appropriate data within healthcare facilities. These vicious cycles leave health systems ill equipped to respond to the rising burden of chronic lung disease, an issue that has been brought into sharp focus as countries plan for dealing with post COVID lung disease. Interpretation: 1. There is increasing recognition among policymakers that NCDs, including CLD are rising in LMICs.2. CLDs are under-diagnosed, under-reported and underfunded leading to a vicious cycle of invisibility and neglect at all levels of the health system.3. Appropriate diagnosis and CLD management require strengthening of the health systems, particularly at the primary healthcare level.Funding Statement: This research was funded by the National Institute for Health Research (NIHR (IMPALA, grant reference 16/136/35) using UK aid from the UK Government to support global health research.Declaration of Interests: None declared.Ethics Approval Statement: The Liverpool School of Tropical Medicine Ethics Committee approved these studies separately (Kenya: protocol 18-054; Uganda: protocol 18-037; Malawi: protocol M1803; Tanzania and Sudan; protocol 18-043). Additionally, each approved was by in-country committees.

Effect of an antimicrobial drug on lung microbiota in healthy dogs

Alterations of the lung microbiota (LM) are associated with clinical features in chronic lung diseases (CLDs) with growing evidence that an altered LM contributes to the pathogenesis of such disorders. The common use of antimicrobial drugs in the management of CLDs likely represents a confounding factor in the study of the LM. The aim of the present study was to assess the effect of oral administration of amoxicillin/clavulanic acid (AC) on the LM in healthy dogs (n = 6) at short (immediately after stopping AC [D10]) and medium-term (16 days after stopping AC [D26]). Metagenetic analyses were performed on the V1–V3 hypervariable region of 16S rDNA after extraction of total bacterial DNA from samples of bronchoalveolar lavage fluid (BALF). AC did not induce significant changes in BALF cellular counts or in the bacterial load or microbial richness, evenness and α-diversity, while the β-diversity was clearly modified at D10 compared with D0 (before AC administration) and D26 (P < 0.01). The relative abundance of Bacteroidetes and Proteobacteria increased at D10 (P < 0.01) in comparison with D0 and D26 (P < 0.01). The relative abundance of Firmicutes decreased from D0 to D10 (P < 0.01) and increased from D10 to D26 (P < 0.01), but was still lower than at D0 (P < 0.01). The proportion of Actinobacteria increased at D26 compared with D0 and D10 (P < 0.01). Significant differences between timepoints at the level of family, genus or species were not found. In conclusion, in healthy dogs, oral administration of AC induces significant changes in LM at the phyla level and in the β-diversity. Most changes normalize within 2 weeks after discontinuation of AC.

Health seeking for chronic lung disease in central Malawi: Adapting existing models using insights from a qualitative study.

BackgroundChronic lung diseases contribute to the growing non-communicable disease (NCD) burden and are increasing, particularly in many low and middle-income countries (LMIC) in sub-Saharan African. Early engagement with health systems in chronic lung disease management is critical to maintain quality of life and prevent further damage. Our study sought to understand health seeking behaviour in relation to chronic lung disease and TB in a rural district in Malawi.MethodsQualitative data was collected between March-May 2015, exploring patterns of health seeking for lung disease amongst residents of two districts in rural Malawi. Participants included those with and without lung disease, health workers and village leaders. Participants with a history of TB were included in the sample due to similarities in clinical presentation and in view of potential to cause long-term damage to lung tissue.ResultsOur findings are ordered around a specific model of health seeking devised by adapting previous models. The model and findings span three broad areas that were found to influence health seeking: understandings of health and disease which shaped whether, when and where to seek care; the care seeking decision which was influenced by social and structural factors; and the care seeking experience which impacted future care decisions creating ‘feedback loops’.DiscussionEfforts to improve effective and accessible healthcare provision for chronic lung disease need to address all the determinants of health seeking behaviour identified. This may include: enhancing the structural and financial accessibility of health services, through the strengthening of community linkages; improving communication between formal health providers, patients and communities around symptoms, diagnosis and management of chronic lung diseases; and improving the quality of diagnostic and management services through the strengthening of health systems ‘hardware’ (equipment availability) and ‘software’ (development of trusting and respectful relationships between providers and patients).

Adolescent age is an independent risk factor for abnormal spirometry among people living with HIV in Kenya.

As life expectancy of people living with HIV (PLWH) improves in low-income and middle-income countries (LMICs), the spectrum of HIV-related pulmonary complications may reflect a greater burden of chronic lung diseases as in high-income countries. We determined whether the risk of abnormal spirometry was greater among adolescent compared with adult PLWH at the Coptic Hope Center for Infectious Diseases in Nairobi, Kenya, and evaluated the role of other cofactors for abnormal spirometry. We prospectively enrolled adolescent and adult PLWH for this cross-sectional study. Data collection included standardized questionnaires, clinical assessment, and prebronchodilator and postbronchodilator spirometry. Adolescents additionally underwent noncontrast chest computed tomography. Multivariable logistic regression determined associations of adolescent age with abnormal spirometry, adjusting for cofactors. Of 427 PLWH, 21 (40%) adolescents and 64 (17%) adults had abnormal spirometry. Among adolescents, 80% had abnormal chest CTs, and 79% had at least one respiratory symptom. Adolescent age (adjusted odds ratio 3.22; 95% confidence interval 1.48-6.98) was independently associated with abnormal spirometry, adjusting for recent CD4, HIV clinical stage, low BMI, indoor kerosene use, smoking pack-years, and prior pulmonary tuberculosis. Additional important cofactors for abnormal spirometry included prior pulmonary tuberculosis (3.15; 1.70-5.58), kerosene use (1.77; 1.04-3.04) and smoking pack-years (1.05; 1.00-1.10). Adolescent age, prior pulmonary tuberculosis, and smoking pack-years were significantly associated with airflow limitation. Adolescent age was independently associated with increased risk of abnormal spirometry, particularly airflow limitation. Studies to improve prevention, detection, and management of chronic lung disease across the lifespan among PLWH are needed in LMICs.

The fascinating story of surfactant.

The fascinating story of surfactant.

Working smarter will help patients breathe easier

8 British Journal of Healthcare Management 2016 Vol 22 No 1 © 2 01 6 M A H ea lth ca re L td These services are sharing expertise and skills behind a common aim—to support patients, their families and carers and their communities better. Most management of chronic lung disease is in the community—and lung specialists must continue to spread their knowledge and expertise beyond the hospital gates. Ever since I became a consultant, the NHS has talked ‘a good game’ about the issue of integration—but Simon Stevens’ recent Five Year Forward View has really put the issue centre stage—to help shape the NHS of the future. It is not an option to stay as we are—if we did, the NHS would become completely overwhelmed by increasing numbers of older people with long-term conditions. So with limited NHS budgets it is vital that we find new ways of working that break down old barriers between hospital and community services. Two pieces of research presented at the society’s meeting really stood out in showcasing the health and economic benefits of integrated care.

Palliative Care in Advanced Lung Disease: The Challenge of Integrating Palliation Into Everyday Care

The tendency toward "either/or" thinking (either cure or comfort) in traditional biomedical care paradigms does little to optimize care in advancing chronic illness. Calls for improved palliation in chronic lung disease mandate a review of related care gaps and current clinical practices. Although specialist palliative services have their advocates, adding yet another element to an already fragmented, often complex, care paradigm can be a challenge. Instead, we propose a more holistic, patient-centered approach based on elements fundamental to palliative and best care practices generally and integrated as needed across the entire illness trajectory. To support this approach, we review the concept of primary palliative care competencies, identify vulnerability specific to those living with advanced COPD (an exemplar of chronic lung disease), and describe the need for care plans shaped by patient-centered communication, timely palliative responsiveness, and effective advance care planning. A costly systemic issue in the management of chronic lung disease is patients' increasing dependency on episodic ED care to deal with preventable episodic crises and refractory dyspnea. We address this issue as part of a proposed model of care that provides proactive, collaborative case management and the appropriate and carefully monitored use of opioids. We encourage and support a renewed primary care resolve to integrate palliative approaches to care in advanced lung disease that, in concert with judicious referral to appropriate specialist palliative care services, is fundamental to what should be a more sustainable systematic improvement in palliative care delivery.