Managing Shortness of Breath

Managing shortness of breath in patients with COPD, Interstitial Lung Diseases, Bronchiectasis. 

Live recording of hybrid meeting at 15 Clarke Street on 2nd December 2023. Apologies for technical problems during ZOOM recording.  Recording is much longer and contains the same slides as the above presentation. 

Lung Bulla

 Smokers may have shortness of breath because of chronic obstructive pulmonary disease or COPD.  The development of lung bullae in a smoker's emphysematous lungs may worsen breathlessness.  

Breathing Well is a choice.

To live we need to be able to breathe.  Breathing is natural and automatic.  Breathing well however is a choice because we need to exercise the respiratory muscles and also treat any underlying disease that causes airflow obstruction or impairment of gas exchange.  

There is a saying that goes; "when you can't breathe, nothing else matters".  How true!  

Managing Cough and Excessive Phlegm

 I have taken the liberty to split up the long virtual workshop on Managing Cough and Excessive Phlegm into several smaller video segments.  The segments contain information on how to perform home chest physiotherapy.  These videos are suitable for patients having chronic bronchitis, COPD, bronchiectasis, cystic fibrosis, lung infection etc.  

Heart failure with preserved ejection fraction.

This is an interesting topic. The ejection fraction is a measurement of left heart function obtained during echocardiography. The question is how does the heart fail when the measured EF is normal? 

Heart failure is an important cause of shortness of breath which has to be differentiated from lung causes of shortness of breath.  Often the distinction between the two conditions is not obvious clinically without further investigations. Relevant investigations include ECG, NT proBNP (blood test), echocardiography, chest x-ray and coronary angiography.  

Heart failure with preserved ejection fraction is a type of heart failure with normal or near normal ejection fraction and objective evidence of diastolic dysfunction.  

More than half of heart failure patients have heart failure with a maintained ejection fraction. The illness primarily affects the elderly, accounting for 4.9 percent of the population over the age of 60. It appears to be more common in women, and it is projected to become more widespread as people live longer. 

Link to this interesting article which I have read:

Heart failure with preserved ejection fraction | Radiology Reference Article | Radiopaedia.org

Feger, J., Worsley, C. Heart failure with preserved ejection fraction. Reference article, Radiopaedia.org. (accessed on 24 Mar 2022) https://doi.org/10.53347/rID-93980

Tracheostomy for Ventilated Patient

Doctors struggle to accurately predict which patients will require prolonged mechanical ventilation.  Doctors need a clear understanding of the nature and typical course of chronic critical illness.

Communication about chronic critical illness should begin before its onset and, ideally, as early as the initiation of mechanical ventilation (or even at decision-making about whether to initiate ventilation).  Doctors should inform not only of the risk of death in the ICU, but also the chance the patient might survive but remain dependent on the ventilator and other intensive therapies for a prolonged period. 

These initial discussions allow a longer time for doctors to “cultivate prognostic awareness” i.e. the capacity to understand prognosis and the likely illness trajectory and help patients and families prepare psychologically and practically for further developments.

Based on the available evidence, routine placement of tracheostomy prior to day 10 of mechanical ventilation is not indicated. General consensus is that a tracheostomy should be placed after day 10 if the patient is likely to require more than a few additional days of ventilation i.e. the patient will neither be liberated from the ventilator nor die in the near future i.e. the patient is chronically critically ill.

Benefits of tracheostomy include:

Improved patient comfort

Easier oral care and suctioning

Reduced need for sedation or analgesia

Reduced accidental extubation

Improved weaning from mechanical ventilation

Easier facilitation of rehabilitation

Earlier communication and oral nutrition

Facilitated transfer to lower level of care

Early Complications:

Bleeding

Air leak causing subcutaneous emphysema, pneumothorax, pneumomediastinum

 

Damage to the swallowing tube (esophagus)

 

Injury to the nerve of the vocal cords (recurrent laryngeal nerve)

 

Tracheostomy tube can be blocked by blood clots, mucus, or pressure of the airway walls.

Late Complications:

Accidental removal of the tracheostomy tube

 

Infection in the trachea and around the tracheostomy tube

 

Trachea may be damaged by pressure from the tube resulting in bacterial infections and scar tissue formation

Delayed Complications:

Thinning of the trachea from the tube rubbing against it (tracheomalacia)

B Lines in Lung Ultrasound

Lung ultrasound has come in vogue during the COVID pandemic.  LUS is simple to perform and can be readily done at the bedside.  LUS performed well, together with a proper clinical history and physical examination, can help clinicians reach a diagnosis quickly before needing to perform more extensive investigations like HRCT scans of the lungs.

Indentification of B line artifacts in the lungs can mean pulmonary oedema (heart failure), interstitial syndrome (interstitial lung disease), infections (viruses or bacteria) and ARDS (acute respiratory distress syndrome).

LUS is a useful screening tool at the bedside in ward or emergency room.  The ultrasound machine can also be used to scan other organs of the body (heart, blood vessels, liver, kidneys, etc) at the same sitting providing more useful clinical information.

Blue Bloaters

Blue bloaters is the name used to describe COPD (chronic obstructive pulmonary disease) patients who are overweight, puffed up, having difficulty breathing, lacking oxygen (hence the blue, cyanotic discolouration) and have leg swelling due to right heart faillure.  COPD is mainly caused by cigarette smoking.

These patients are hypoxic with low oxygen saturation and some with carbon dioxide retention.  The brain adapts and is reliant on the low oxygen in the blood to drive breathing.  As such, an overdose of oxygen, removing the hypoxic drive, will make them worse leading ultimately to deeper respiratory failure, carbon dioxide narcosis, respiratory arrest and death. 

Therefore, it is very important for caregivers to know exactly how much oxygen (litres per minute) to give to these COPD patients.  Some of these patients may only need to maintain their SpO2 at only 90% to 93% as they are used to these low oxygen to drive ventilation and to "blow out" the carbon dioxide. 

Please consult your doctor for medical advice and not to give too much oxygen to these COPD patients.  Arterial blood gas analysis is required to make a proper diagnosis for these patients. 

Plain Chest Xray

 A CT scan of the lungs will give better definitions than a plain chest x-ray.  However, CT scans are more expensive, needs an appointment and person will receive more radiation. 

Pulse Oximeter

 

The rising number of COVID-19 cases prompted me to create this explainer video on how to use the pulse oximeter correctly.  The normal oxygen saturation (SpO2) of a healthy person is between 95 - 100%.  It is important to monitor the SpO2 at least daily, better several times a day, for Category 1-2 patients undergoing home quarantine. 

One Minute Sit To Stand Test

 

The normal oxygen saturation or SpO2 of a healthy person is 95 – 100 %.  These numbers generally stay unchanged during moderate intensity exercises and may even increase a little, because one is breathing faster and deeper, resulting in better lung ventilation. 

During vigorous short-term exercise, like in soccer, you may notice a small drop in blood oxygen saturation of about 1 – 2 %. When you stop exercising, the SpO2 will return to your baseline reading quickly.

When a person complains of shortness of breath, the doctor will take down a medical history, perform a physical examination and may order some tests.  Diseases of the heart, lungs, kidneys or liver may present with shortness of breath. 

The most common functional impairment in patients with lung disease is impaired gas exchange. In the early stages of many lung diseases, the oxygen saturation is maintained or is normal at rest, but when the lung is challenged with increasing demand, like during exercise, the oxygen saturation may drop.

The 6MWT is used to assess the functional capacity of a person.  The 6MWT is also a simple test to evaluate gas exchange impairment during exercise.  It is widely used, and is considered the gold standard, to evaluate patients with chronic respiratory disorders like COPD and ILD.  However, it is not feasible to perform the 6MWT in many office-based practices, which generally, do not have the flat, straight 30-m corridor required for the test.

There is evidence in the literature, suggesting that the 1MSTST be used as an alternative to the 6MWT for measuring a person’s functional capacity and in detecting exercise induced gas exchange impairment.  Both tests have a good correlation, and the advantage of the 1MSTST is that it causes less hemodynamic stress for patients than the 6MWT. The 1MSTST is well tolerated, easy to perform, understood, and interpreted; and does not require special hardware.  The mean number of 1MSTST repetitions reported in the literature achieved ranged from 8 repetitions (patients with stroke) to 50 repetitions (young men). 

The 1MSTST has been validated for use in COPD and ILD of various aetiologies. 

There are many uses for the 1MSTST: 

The 1MSTST is used to identify subjects with low exercise capacity or preserved exercise capacity.

The 1MSTST is used to detect exercise-induced gas exchange impairment early in the course of ILD, before changes in resting DLco and PaO_2, hence making the early clinical diagnosis of ILD possible.  The resting DLco is a specific but an insensitive predictor of abnormal gas exchange during exercise. The DLco is the diffusing capacity of lung for carbon monoxide is a measure of the efficiency of lung gas transfer.

The 1MSTST is used to measure the effectiveness of a pulmonary rehabilitation programme as an improvement of three repetitions is consistent with physical benefits.

 A doctor or nurse should be present during the 1MSTST. 

To perform the 1MSTST place a chair of standard height (46 cm), without arm rests, against a wall to prevent the chair moving and person falling during the test. Seat the person upright on the chair with knees and hips flexed at 90°, feet placed flat on the floor and a hip-wide apart, with arms held stationary by placing the hands on the hips. The person is asked to perform repetitions of standing upright and then sitting down in the same position at a self-paced speed, safely and comfortably, as many times as possible for 1 minute. The person should not use the arms for support while rising or sitting. The person is permitted to rest during the one-minute period. 

The patient is given the following instructions:

“The purpose of the test is to assess your exercise capacity and leg muscle strength. The movement required is to get up from this chair with the legs straight and sit back continuing the repetitions as fast as possible within one minute. I will give you the countdown ‘3, 2, 1 Go’ as an indication to start and I will tell you when we are at the 15 remaining seconds. If required, you can make a break and resume the test as soon as possible”.

The patient should be able to perform a minimum of 5 repetitions.

The SpO2 and heart rate are noted before and immediately after the 1-minute test.  The SpO2 and hear rate are noted for a further 1 minute following the test, during recovery, as oxygen desaturation can continue for up to a minute after stopping the test.  The number of sit-stand repetitions are recorded for the first 1 minute of the test.

In early lung disease, a person at rest, may have a normal SpO2 of 95 – 100 %.  However, during exercise the SpO2 may drop because of increased oxygen demand and the presence of impaired gas exchange in the diseased lungs. 

POSITIVE TEST.  A SpO2 drop of 3% or more is considered a positive test.  A positive test may indicate the presence of lung disease which requires medical attention.

DO NOT perform the 1MSTST in the following situations.

1.      When the resting SpO2 is already abnormal at 94% or less.

2.      When the person is immobile or using walking aids.

3.      During advanced pregnancy.

4.      Following recent abdominal surgery or heart attack.Fo

F    STOP the 1MSTST when you notice the following:

1.      Feeling faint or giddy.

2.      Vision becoming dim or blur. 

3.      SpO2 falling more than 3% from baseline.  (Calculate the value before starting the test.  Example: when the resting SpO2 is 96%, stop the test when the SpO2 fall to 93% or lower.)

4.      Sensation of breathlessness which is severe or unbearable. 

5.      Occurrence of chest pain

You MUST CONSULT a doctor when the test is positive.

The 1MSTST is currently being evaluated for use in respiratory illnesses other than COPD and ILD. 

The IMSTST is being used in some EDs or emergency departments to quickly identify exercise induced oxygen desaturation caused by lung disease, so a decision can be made regarding patient discharge, with or without enhanced monitoring, or hospitalisation. 

 

COVID-19 Quick Facts

COVID-19 Quick Facts

Video Script:

Hello I'm Dr Leong.  Today's talk will be on COVID-19.

A Suspected Case of COVID-19 needs to fulfil 2 criteria. One is the Clinical Criteria and the other is the Epidemiological Criteria.  In the clinical criteria one has to have an acute fever and cough OR an acute illness with two or more of the following:  fever, cough, general malaise, fatique, headache, myalgia, sore throat, coryza, dyspnea, anorexia, nausea, vomiting, diarrhea or altered mental status.

In the Epidemiological Criteria the suspected case needs to have been in the following places within the last 14 days prior to symptoms and signs.  The case needs to have 1. stayed or worked in an area of high risk of transmission like in a close residentials example a nursing home or institutions like prison or immigration detention depot 2. stayed or travelled in an area with community transition or 3. worked in any healthcare setting.

A confirmed case is one who is tested positive RTK- Ag in areas of prevalence greater than 10% or cases tested positive with a molecular test, namely RT-PCR or a rapid molecular test.

This graph shows the probability of detection of SARS CoV2 over time. The incubation period of SARS Co V2 is about 5 days. Most infected persons will show symptoms or signs within 11 days of infection. During the onset of symptoms, RT- PCR testing will usually be positive. Before symptoms onset, RT-PCR testing can be negative even though the person is infective because of viral shedding.  After the onset of symptoms, the RT-PCR test can be positive for up to 3 weeks.  Commonly the infected person will no longer be infective to others after 14 days of symptom onset, even though the RT-PCR is still positive as the nasopharyngeal swabs contain detectable non-viable viral material. The infected person begins to develop antibodies to the virus after a week of symptom onset and the antibodies will be detectable at about the 2^nd week.  RT-PCR will likely be negative after the 3^rd week of symptom onset.

SARs CoV2 mutation and variants. This chart shows the variants of concern.  The Alpha, Beta, and Delta variants are present in Malaysia. The delta variant is of special concern as there is information suggesting increased transmissibility of the virus. There is also some suggestion of reduced neutralization of the virus by antibodies produced in our bodies by vaccination.  But it is too early to say if vaccines are compromised.

Dr Noor Hisham reported in the Malay Mail that the variants of concern like beta and delta are already present in Malaysia. 

Clinical stages of COVID-19 infection. There are five categories. Category 1 – asymptomatic. Category 2 - symptomatic but no pneumonia. Category3 - symptomatic with pneumonia. Category 4 - symptomatic with pneumonia and requiring oxygen. Category 5 – the critically ill with multi-organ involvement. Persons in Category 1 and 2 maybe opt for home quarantine. Whereas persons in Category 3 to 5 will need hospital admission.

Category 2 can be divided into mild and moderate. The moderate cases who have RED FLAG symptoms may need to be admitted to hospital for observation.  The RED FLAG symptoms are  - persistent or new onset fever, exertional dyspnea, chest pain, unable to tolerate orally, worsening lethargy, unable to ambulate without assistance, worsening or persistent symptoms such as cough, nausea, vomiting, or diarrhea, reduce level of consciousness. or reduced urine output in the last 24 hours.

Confirmed cases of COVID-19 can undergo home quarantine or be admitted to hospital for observation. Persons in Category 1 and 2, with mild symptoms, can undergo home quarantine. However should the Category 2 status change with RED FLAG symptoms they better be observed in  hospital.  Persons in Category 3 - 5 should be admitted to hospitals.

A person may undergo home quarantine if he fulfills the following criteria: For adults the person should be less than 40 years and without comorbidities; like diabetes, cardiovascular disease, chronic lung disease, chronic kidney disease, hypertension, or obesity.  The person needs to be able to ambulate without any assistance and also be able to self-administer medication.  The person should have no ongoing clinical needs, like hemodialysis, not pregnant and is not immunocompromised.

For pediatric patients, who are in Category 1, they should not have any comorbidity and with a suitable caregiver.  Children in Category 2 with mild symptoms should be more than two years old, with no comorbidities and with suitable caregivers.

The home condition should be suitable and the person must be able to adhere strictly to SOP.

Caregivers who are suitable should not be more than 60 years old, are not pregnant, without comorbidities, are not immunocompromised and with no disease considered high risk by health personnel.

The home should be suitable.  A telephone should be available at all times.  The isolation room should preferably have an attached bathroom.  The other occupants in the house are not immunocompromised and appropriate caregivers should be present in the house.

The person should be able to adhere strictly to SOP.  The person should stay at home, maintain physical distance with other household members and there should be no visitors.  The person must wear a mask, wash hands regularly and practice cough etiquette.  The person must be able to report health status to health care providers through MySejahtera App.  The eating utensils, tableware should be used exclusively for the person.

Vaccination

The national COVID-19 immunization program is on a voluntary basis, is free for all Malaysians and non-Malaysian residing in the country.  It is for everyone of age 18 years and above.  Currently the age has been extended to cover 12 years and above using the Pfizer vaccine.  The immunization target is to cover 80% of the Malaysian population.  We are currently in Phase 3 of the program.  The immunization program will be completing sometime at the end of this year. 

Portfolio of Vaccine in Malaysia are from the following manufacturers:  Pfizer, SinoVac, Astra Zeneca, Johnson and Johnson and CanSino. 

The Pfizer vaccine uses the mRNA technology.  The Astra Zeneca, Jansen, CanSino vaccines use the viral vector technology.  SinoVac is of the inactivated virus technology.

As of June the registration for immunization has reached almost 60% of the population in Malaysia. From the graph you can see the accelerated growth for vaccination.  There is an increase in demand by the population and vaccine roll out by the government.

Selangor, Sarawak, Kuala Lumpur and Putrajaya will reach vaccination target in August.  Labuan will reach vaccination target earlier in July.  Perak will reach the 50% target in September and full target by year end.

Vaccine adverse events are very uncommon. Of note with mRNA vaccines is heart inflammation (myocarditis and pericarditis)  This adverse event occurs several days after vaccination.  It mostly affect males, adolescent and young adults of 16 years and above. The presenting symptoms are chest pain, difficulty breathing and palpitation.  The Pfizer vaccine is a mRNA vaccine.  The occurrence of the adverse event is about 2 per 100,000 population, aged between 16- 39 years.

Another adverse event of concern is Thrombosis with Thrombocytopenia Syndrome. (TTS).  It occurs 4 to 30 days post vaccination.  TTS may present as cerebral venous sinus thrombosis.  The illness presents with severe headache, worse by lying down or bending over, and is associated with blurred vision, nausea and vomiting, difficulty with speech, weakness, drowsiness, or even seizures. 

There may even be unexplained bruising or bleeding.   Some may experience shortness of breath, chest pain, leg swelling or persistent abdominal pain.

The Astra Zeneca and Jansen vaccines are viral vector vaccines.  These adverse events are very rare with 2 - 4 events per million vaccinated.

Recovery Plan

The national recovery plan has 4 Phases.  There are 3 conditions to be met under each phase.  The conditions include 1. the number of daily cases 2. ICU bed availability and 3. The percentage of population vaccinated.

In Phase 1 only essential services are allowed.  In Phase 2, some economic sectors to reopen while the social sector remains closed.  In Phase 3, more economic sectors to reopened, the social sector is reopened gradually, Parliament and schools to reopened as well.  In Phase 4, there is full reopening of the economy.  Phase 4 is projected to occur sometime in November and December this year.

This chart shows the number of observed and forecast cases in the month of April and June. R0 is the basic reproduction number of an infection.  The rate of infection rises when the R0 is greater than 1 and declines when the R0 is less than 1.  We currently have a R0 of less than 1 with declining number of cases.

As you can see from this chart, there has been an increasing number of hospitals managing COVID-19 cases.  The number of ICU beds and ventilators have also increased.   

As such, with deceasing number of cases and increased number of ICU beds we can expect ICU bed utilization will decrease.

More than 10% of the population is already vaccinated.  We shall soon reach our 40% and 60% target soon and will help speed up our National Recovery Plan.

There is a very low risk of viral transmission from surfaces and outdoor activities. However there is a very high risk of viral transmission from gatherings in enclosed spaces,  like in offices, religious places, cinema halls, gyms and theaters.

Infection

The COVID virus is mainly transmitted via droplets and contact routes.  However airborne transmission is possible for example while performing aerosol generating procedures. There has been no report of faecal- oral transmission to date.

A viral dose of about 1000 virus particles is needed before a person becomes infected.  During normal breathing about 20 vp are shed in a minute.  While speaking about 200 vp.  Coughing and sneezing expel about 200 million vp into the air and these vp can remains in the air for hours in poorly ventilated environments.

The infectious dose is dependent on the number of virus particles multiplied by time.   

 

 

 

 

Check your blood oxygen level.

 Check your blood oxygen level regularly if you are unwell and under home quarantine for COVID-19 infection.  

Anti-Smoking Campaign

School students are warned about nicotine addiction and dangers of tobacco smoke. Video briefly mentions vaping and Hookah as well.

Perak Chest Society AGM 2020

Presided our first AGM virtually.  It was easy and convenient to meet in the cloud.  The audio visual was good.  Used ZOOM platform.  Was able to share screen and even annotate on the slides.  We were using the free version and was cut off after about 45 minutes into the meeting.  We restarted the meeting by sending another meeting link from ZOOM.  Not much of a hassle in reconnecting.  But best is to buy a license.  

ZOOM seems to be easier to use than Skype.  Can also schedule a ZOOM meeting via Microsoft Outlook. 

World TB Week 2018

Oxygen Concentrators for loan

The Perak Chest Society in partnership with Lahat Road YMCA is providing oxygen concentrators for loan.  The machines are located at 15 Clarke Street (15 Jalan Sultan Abdul Jalil).

All users are to fill in this document:

PERAK CHEST SOCIETY

178 - 180A  Jalan Pasir Puteh

31650 Ipoh, Perak

Tel: 05-2556302   Fax: 05-2432145 

__________________________________________________________________________________ 

HOME OXYGEN CONCENTRATOR LOAN PROGRAMME

Person or Patient who borrows oxygen concentrator (Users): 

Name: ………………………………………………………………………………………… 

NRIC No:  ……………………………………… 

Address: ………………………………………………………………………………………

                 ………………………………………………………………………………………

Date to return oxygen concentrator: ……….... / ………….. / …………...  

Signature: ……………………………………..

Terms of Agreement between Perak Chest Society and User: 

1.        The home oxygen concentrator loan programme is available to all members of the Perak Chest Society while in stock.  It must be recommended by a doctor and a referral letter is required.

2.        Oxygen therapy must be prescribed by a doctor.  The desired oxygen concentration, flow rate, frequency and duration of oxygen use must be made known and strictly adhered to.

3.        Users are to seek immediate medical advice if their condition worsen after using supplemental oxygen or if they develop side effects from oxygen therapy or while using the oxygen concentrator unit.

 4.        The oxygen concentrator is for medium term use only and must be returned to the Perak Chest Society within one month from the date of borrowing.  

 5.        Users are to use the oxygen concentrator in a proper manner and in accordance with the operating and maintenance instructions given.

 6         Users are not to make any alterations or remove any component from the oxygen concentrator.

7.        All Users must place a deposit of RM500.00.  Upon return of the oxygen concentrator in good working condition the User will be returned RM 400.00.  A charge of RM 100.00 is levied for servicing the machine upon return.  Should the oxygen concentrator be returned damaged the cost of repair will be further deducted from the deposit.
8.        The Perak Chest Society and its Board members will not be liable to the User for any injury, damage or death arising by reason of any defect in the oxygen concentrator or as a result of using the oxygen concentrator.

Witness:

Name: ………………………………………….

Signature: ……………………………………… 

Doctor:

Name: ………………………………………….

Signature: ……………………………………… 

Today’s Date:  …………… /………………/……………..

Publicise an Event

Some tips:

• Staple a card with information about the event onto existing handout tri fold brochures.
• Create photo flyers and hang them in places.
• Keep signs clear and uncluttered.
• Create custom countdown calendars to give away to generate  excitement and awareness.
• Create an oversized schedule of events and display it outside the venue several weeks before the event to help people get a sense  of what to expect.
• Talk up the event.  Call 3 -5 people outside your circle of friends to tell them about the event. Then seek their assistance to inform their circle of friends. 

How to write a grant proposal

First requirement is to identify and develop a project that supports the core mission.

Questions to be answered:

1. What do you want to do?
2. How much will this cost?
3. How long will it take?
4. Who will benefit from this project and how?
5. How does teh project fit within the mission of the organisation?

Prepare a good summary of the project followed by details.  Most people will just read the summary and decide whether to read on further.

Perak Chest Society will need a grant to purchase more oxgyen concentrators for loan.

Asthma Workshop 2016

An Asthma Workshop was held on Saturday 19th November for nurses from various private hospital in Ipoh.  The workshop started at 9.30 am and ended at 12 noon.  There were 33 participants.  The nurses were from KPJ ISH, Pantai Hospital Ipoh, Fatimah Hospital and Perak Community Specialist Hospital.  There were also several industrial nurses from local factories.

The objectives of the workshop were to:
1. Improve the understanding of Asthma Control and how to achieve it.
2. Encourage the use of peak flow meters and the Asthma MD app in monitoring asthma control.
3. Encourage the use of the Asthma Control Questionnaire.
4. Demonstrate the proper use use of MDI, DPI devices and spacers.
5. Encourage the setting up of asthma counselling teams in the hospitals
6. Train coaches for the Asthma Friendly School workshops.

Dr. Leong Oon Keong and Mdm Leong Yee Leng RN (who is currently doing her Masters in Nursing) were the trainers.

All nurses were given a Certificate of Attendance after the workshop.  They each earned 4 CPD points from the Lembaga Jururawat Malaysia.