Respiratory Service Research Articles

Analysis of predictive factors for adverse effects of antituberculosis treatments

Objective? Anti-tuberculosis chemotherapy is likely to cause a number of serious side effects that require treatment to be stopped and the dose reduced. The aim of this study was to identify the risk factors that may increase the likelihood of developing adverse reactions to anti-tuberculosis drugs. Materials and methods. We conducted a descriptive cross-sectional study using a questionnaire, including 80 patients with active tuberculosis undergoing first-line anti-tuberculosis treatment at the Tuberculosis and Respiratory Diseases Control Service in Sidi Bel Abbes (Algeria). Results. The sex ratio F/M of our patients was 1.85 in favour of women, with a mean age of 36 years. Pulmonary involvement was present in 32.5% of cases and extrapulmonary involvement in 67.5%. These patients benefited from four-drug RHZE anti-tuberculosis therapy in 93.80% of cases. Adverse effects occurred in 76.25% of patients, of which 15.16% were serious adverse effects. Digestive disorders were the most common adverse event (33.1%), followed by arthralgia (18.4%), peripheral neuropathy (15.60%), skin disorders (15.60%), hematological disorders (7.5%) and liver disorders (5.7%). Univariate analysis showed that certain classes of self-medication had a significant effect on the occurrence of adverse reactions to anti-tuberculosis drugs (p=0.05). In addition, female sex was associated with joint pain (p=0.029) and nausea and vomiting (p=0.01). Co-infection was associated with hematological (p=0.021) and liver disorders (p=0.05), while digestive and skin disorders were associated with drug allergy and use of phytotherapy (p<0.05). Conclusion. Adverse effects of tuberculosis treatment are not uncommon and require rigorous clinical and biological monitoring to reduce treatment-related mortality and morbidity

P065 Breath of Fresh Data: Enhancing NIV Patient Care in State-wide Service

Abstract Background The Victorian Respiratory Support Service (VRSS) provides long-term management for patients with chronic respiratory failure. An expanding patient base (497 in 2000, 2,031 in 2024) necessitates service development. Integration of non-invasive ventilator (NIV) data from ResMed Airview™ (San Diego, CA, USA) presented an opportunity to review these data at a “whole of service” level. Aim To pilot a summarised, data visualisation system for the VRSS. Methods Airview™ data were ingested daily into the hospital data warehouse and queried. Categories of adherence were; average usage/month, days used/month and average leak/month. Hours of NIV use was categorised as sufficient, moderate, or insufficient (>6, 4-6, or <4 hrs/day), days used/month as sufficient or insufficient (<80%>), and mask leak (<24> L/min) as acceptable or excessive. Results This analysis included 748 patients. 557 patients had sufficient usage, but only 290 patients had both sufficient NIV usage and acceptable leak. Conversely, 107 patients had insufficient NIV use with 59 having both insufficient NIV usage and excessive mask leak. Discussion These data are consistent with previous literature suggesting that while poor NIV adherence may be observed in people who experience “excessive” leak, “excessive” leak as determined by manufacturer limits does not always align with inadequate NIV adherence.(1) Data such as these enable novel models for participant care, especially triaging of ongoing clinical needs, to be proposed. Conclusion The interactive report provides opportunities for comparison of real-life data with the literature and enables planning for trials of novel service models. 1. Jeganathan. BMJ Open Respir Res. 2021

Respiratory Therapy Leaders' Perceptions of Value of Respiratory Care Services.

Respiratory care departments are experiencing an increased need to demonstrate value in the care they deliver. Value efficiency is a concept that incorporates the value of individual treatments into the normal operations of a department. The purpose of this study was to describe respiratory care leaders' attitudes about the value of services provided by respiratory care departments. An electronic survey was distributed via social media, professional networks, and a manager work group. The survey was targeted to directors, managers, and supervisors of respiratory care departments. We asked questions related to value, services, and barriers to implementation of value efficiency. Data analysis was descriptive. We received 116 responses; 86% were from managers or directors. The 5 most valuable services delivered were invasive mechanical ventilation (82%), noninvasive ventilation or CPAP (71%), protocol-driven care (47%), code team (44%), and rapid response team (41%). The 5 least valuable services delivered by respiratory care departments were electrocardiograms (63%), stress testing (44%), lung expansion therapies (41%), sleep studies staffed by the respiratory care department (36%), and smoking cessation education (36%). The primary barrier to value efficiency was physician prescribing practices (68%). There was general agreement that physicians support respiratory therapy protocols (71%), value should be considered when evaluating respiratory care services (95%), and directing resources to more valuable services if possible (73%). Respondents did not agree that hospital administrators understand respiratory therapy workflow and full-time equivalent needs (35%) nor that hospital administrators would be supportive if we reduced services (18%). In a small sample of respiratory therapy leaders, there was limited consensus on what respiratory care services are the most and least valuable. Lack of consensus on high- and low-value services and physician prescribing practice were the primary barriers to value efficiency. Nearly all respondents felt value should be considered when evaluating respiratory care services.

Rural pharmacist and consumer perspectives of expanded pharmacy services to address inequity in accessing health services.

Australians living in rural and remote communities have inadequate access to health services, contributing to poorer health outcomes compared to their metropolitan counterparts. This study investigated consumers' and pharmacists' perspectives of expanded pharmacy services in rural and remote communities in Australia. It aims to identify the role of the pharmacist in addressing the inequity of access to healthcare through the provision of expanded services in rural and remote practice. A concurrent parallel mixed-methods study was undertaken in rural Western Queensland, Australia to include a survey of 167 consumers and in-depth interviews with 10 pharmacists. Quantitative data analysis employed descriptive statistics and chi-square tests, while qualitative data were analysed thematically against the constructs of the Diffusion of Innovations Theory. Consumers indicated that they would like to access weight management services (53%), whereas pharmacists thought it was important to offer respiratory clinics and services. Both pharmacists and consumers would like to see diabetes checks (30% and 56%, respectively) and vision, hearing, and ear checks (40% and 53%, respectively) implemented as services in community pharmacies. Most consumers (97%) believe pharmacists have the skills and knowledge to deliver expanded services and in doing so, they would improve the overall health of the community. Pharmacists reported staffing availability, workload and time constraints, cost, and jeopardizing inter-professional relationships as barriers to implementing expanded services. Consumers were supportive of pharmacists working to their full scope of practice to provide expanded services, whereas pharmacists, while open to the idea, highlighted that there were barriers to overcome.

Respiratory issues and current management in neuromuscular diseases: a narrative review.

Respiratory care is often embedded as a component of the overlapping management strategies in many patients with neuromuscular disease (NMD). Implementation of respiratory care strategies requires a sensitivity to the nature of the disease, the vulnerability during rapid eye movement (REM) sleep and complicating comorbidities specific to each patient. Care must adjust to progression of the disease as well as the comfort and preferences of the patient. Clinical presentations are usually heterogenous based on the specific NMD and overall course of the disease making diagnosis and respiratory care challenging. The aim of this review was to review the state-of-the-art evidence-based clinical practices and updates in the management of respiratory complications in patients with NMDs. We conducted a search on the PubMed and Medline databases using these keywords: secretions, neuromuscular disease, neuromuscular disorders, non-invasive ventilator, neuromuscular respiratory weakness, respiratory failure. The specified timeframe began from 1980 to 2024. Timely use of non-invasive ventilation and overall respiratory care is most important as emerging evidence shows some benefits with improved mortality in this group of patients. In some settings, comorbid complications that dictate need for airway management and oral diversion may have a more profound impact on mortality than the effectiveness of ventilatory support that are chosen. A multidisciplinary team approach to care has been shown to improve the quality of life and survival in these patients in centers of excellence. Patients should have the ability to access services provided by neurology, pulmonology, speech pathology, sleep medicine, cardiology and respiratory therapy services. The cornerstone for management of respiratory failure and sleep disordered breathing in NMD is non-invasive ventilation (NIV). Initiation of this support and other respiratory cares need to be timely, and patients may have very subtle symptoms during the early stages of the disease which makes it challenging in recognizing the onset of respiratory muscle stress and fatigue. Close attention to these symptoms as well as respiratory and radiologic parameters is essential for appropriate incorporation of these cares.

Provision of palliative care for people with chronic obstructive pulmonary disease: a narrative review.

Chronic obstructive pulmonary disease (COPD) is characterized by persistent and progressive airflow restriction and is the third leading cause of death and disability, globally. People with severe COPD generally experience long-term functional decline punctuated by periods of acute exacerbation. Symptom burden can be severe and debilitating, and typically includes breathlessness, cough, fatigue, pain, anxiety, depression, and overall reduced quality of life. Understanding current palliative care needs and provisions in this group is an essential step to expanding access in future. A narrative review of specialist and generalist (primary) palliative care provisions for people with COPD, with an emphasis on breathlessness symptom management. This paper aims to examine the current landscape of palliative care provision and highlight barriers and facilitators to palliative care access for people with severe COPD. People living with severe COPD, as well as the people who care for them, are routinely under-serviced in best-practice end-of-life care, despite having symptom burden that is comparable to that of people with advanced cancer. Barriers to palliative care in this group include lack of specialist palliative care resources, uncertainty surrounding prognostication, and poor recognition of need from both patients and clinicians. Routine early palliative care involvement, including integration of specialist palliative care into respiratory services and upskilling of other healthcare providers to adopt palliative care principals within usual care (primary palliative care), have been shown to improve outcomes indicative of high-quality end-of-life care in this group, including symptom control, place of death, and legal preparations. Ongoing integration of specialist palliative care and professional education for generalist and non-palliative care specialist healthcare providers in the recognition and management of unmet palliative care needs is required to increase capacity beyond traditional specialist palliative care models. Despite high level of symptom burden, many people with COPD miss out on palliative care. Expanding capacity of traditional specialist palliative care by upskilling generalist healthcare providers and integrating specialist palliative care into existing respiratory services is necessary to improve access for people with COPD.

Spatio-temporal modelling of referrals to outpatient respiratory clinics in the integrated care system of the Morecambe Bay area, England

BackgroundPromoting integrated care is a key goal of the NHS Long Term Plan to improve population respiratory health, yet there is limited data-driven evidence of its effectiveness. The Morecambe Bay Respiratory Network is an integrated care initiative operating in the North-West of England since 2017. A key target area has been reducing referrals to outpatient respiratory clinics by upskilling primary care teams. This study aims to explore space-time patterns in referrals from general practice in the Morecambe Bay area to evaluate the impact of the initiative.MethodsData on referrals to outpatient clinics and chronic respiratory disease patient counts between 2012-2020 were obtained from the Morecambe Bay Community Data Warehouse, a large store of routinely collected healthcare data. For analysis, the data is aggregated by year and small area geography. The methodology comprises of two parts. The first explores the issues that can arise when using routinely collected primary care data for space-time analysis and applies spatio-temporal conditional autoregressive modelling to adjust for data complexities. The second part models the rate of outpatient referral via a Poisson generalised linear mixed model that adjusts for changes in demographic factors and number of respiratory disease patients.ResultsThe first year of the Morecambe Bay Respiratory Network was not associated with a significant difference in referral rate. However, the second and third years saw significant reductions in areas that had received intervention, with full intervention associated with a 31.8% (95% CI 17.0-43.9) and 40.5% (95% CI 27.5-50.9) decrease in referral rate in 2018 and 2019, respectively.ConclusionsRoutinely collected data can be used to robustly evaluate key outcome measures of integrated care. The results demonstrate that effective integrated care has real potential to ease the burden on respiratory outpatient services by reducing the need for an onward referral. This is of great relevance given the current pressure on outpatient services globally, particularly long waiting lists following the COVID-19 pandemic and the need for more innovative models of care.

Clinical Interventions Following Escalations from a Continuous Respiratory Monitoring Service in Patients With Chronic Obstructive Pulmonary Disease.

Continuous respiratory monitoring can support integrated care for chronic obstructive pulmonary disease (COPD) patients, by coupling them with remote clinical personnel who triage patients in coordination with their health care providers. When deploying such services, there remains uncertainty surrounding outcomes when at-risk patients are proactively identified and escalated for provider evaluation. This study presents findings from a service deployed in a real-world COPD cohort by analyzing the clinical interventions made during in-person and telehealth pulmonary outpatient visits following remote escalations. A single-center, retrospective, observational study of real-world COPD patients at a multisite pulmonary practice was conducted. Patients who were enrolled in a continuous respiratory monitoring service for at least one year and were seen by a provider within 7 days of an escalation by the service (N=168) were included. To evaluate the potential impact of these escalations on provider and patient burden, medical charts from outpatient visits were manually reviewed and grouped into 6 categories based on the clinical action(s) taken by the provider. A total of 245 outpatient visits occurred from 168 patients within 7 days of escalation. Of the 245 visits, 206 (84.1%) resulted in clinical intervention and 163 (66.5%) resulted in treatment consistent with acute exacerbations of COPD. A total of 1.6% of the outpatient visits resulted in referral to the emergency department. Provider encounters occurring following the escalation of a patient from a continuous respiratory monitoring service consistently resulted in that provider administering a treatment to the escalated patient.

Real-world implementation of the National Early Warning Score-2 in an acute respiratory unit

IntroductionThe National Early Warning Score-2 (NEWS-2) is used to detect deteriorating patients in hospital settings. We aimed to understand how NEWS-2 functions in the real-life setting of an acute respiratory...

Influence of physical activity on the prognosis of COPD patients: the HADO.2 score - health, activity, dyspnoea and obstruction.

The aim of this study was to create a prognostic instrument for COPD with a multidimensional perspective that includes physical activity (PA). The score also included health status, dyspnoea and forced expiratory volume in 1 s (HADO.2 score). A prospective, observational, non-intervention study was carried out. Patients were recruited from the six outpatient clinics of the respiratory service of a single university hospital. The component variables of the HADO.2 score and BODE index were studied, and PA was measured using an accelerometer. The outcomes for the HADO.2 score were mortality and hospitalisations during follow-up and an exploration of the correlation with health-related quality of life at the moment of inclusion in the study. 401 patients were included in the study and followed up for three years. The HADO.2 score showed good predictive capacity for mortality: C-index 0.79 (0.72-0.85). The C-index for hospitalisations was 0.72 (0.66-0.77) and the predictive ability for quality of life, as measured by R2, was 0.63 and 0.53 respectively for the Saint George's Respiratory Questionnaire and COPD Assessment Test. There was no statistically significant difference between the mortality predictive capacity of the HADO.2 score and the BODE index. Adding PA to the original BODE index significantly improved the predictive capacity of the index. The HADO.2 score, which includes PA as a key variable, showed good predictive capacity for mortality and hospitalisations. There were no differences in the predictive capacity of the HADO.2 score and the BODE index.

The handheld fan for chronic breathlessness: Clinicians' experiences and views of implementation in clinical practice.

The handheld fan ('fan') is useful for chronic breathlessness management, however little is known about clinicians' implementation of the fan in clinical practice. To explore clinicians' experiences and views of fan implementation. A qualitative approach, using semi-structured interviews. Participants were purposively sampled from clinicians who had completed an on-line fan implementation survey and were willing to participate. A topic guide was developed using the Theoretical Domains Framework (TDF). Data were analysed using an inductive approach informed by the TDF. Twelve clinicians participated (doctors n = 4; nurses n = 4; allied health professionals n = 4) from respiratory and palliative care. Analysis generated three major themes: i) Clinician knowledge and skills in fan implementation, ii) environmental constraints on fan use and iii) clinician beliefs about the consequences of fan use. Implementation by clinicians was positively influenced by having a scientific rationale for fan use presented (mechanism of action). Clinicians believed that the fan relieved breathlessness and did not carry a significant infection risk. Opportunity for fan use varied across healthcare settings; key environmental influences were COVID-19 restrictions, lack of access to resources and funding to provide fans, particularly in acute and respiratory services. Clinicians commonly encountered scepticism among patients and colleagues who felt the fan was an implausible intervention for breathlessness. Implementation of the fan is motivated by clinician beliefs about patient-benefit, a scientific rationale to counter clinician and patient scepticism, and access to fans in clinic. Funding to allow patients to be supplied with and taught how to use a fan would support uptake. Research is needed to address concerns about infection risk.

The impact of regular, low-dose, sustained-release morphine for chronic breathlessness on caregiver burden: An exploratory analysis of the BEAMS trial

Background: Chronic breathlessness adversely impacts people with chronic obstructive pulmonary disease and their caregivers (family and friends), who may, in turn, experience significant burden due to their caregiving role. Sustained-release morphine may reduce chronic breathlessness in some patients, which may have an impact on caregivers’ perceived burden. Aim: To explore the impact on caregiver burden of active treatment of people with chronic breathlessness (modified Medical Research Council (mMRC) ⩾ 3) and chronic obstructive pulmonary disease (COPD) with regular, low-dose, sustained-release morphine within a multi-site, double-blind, randomised, placebo-controlled trial. Design: Exploratory analysis of self-reported caregiver burden at baseline and end of week 3 in a randomised, double-blind, placebo-controlled study. Caregiver measures included: demographics and perceived burden (Zarit Burden Interview 12-item short-form questionnaire). Patient measures included: worst breathlessness and FitBitR-measures. Setting/participants: All consenting caregivers of trial patient participants in a multi-site study recruiting from palliative care and respiratory services. Results: Caregivers (n = 49; 59% women; median age 68 years [IQR 50–75]) reported median baseline caregiver burden 12 [IQR 5–17], with 53% reporting high burden (⩾13). Eighty-four percent of caregivers reported no change in burden. In people whose worst breathlessness improved, caregiver burden moved in the same direction, though the correlation was not significant (rs = 0.25, p = 0.17). Conversely, caregiver burden worsened as patients’ minutes lightly active increased, with the correlation being significant (rs = 0.56, p = 0.04). Conclusions: Caregivers reported high levels of caregiver burden, but patients’ response to treatment in terms of their symptom and function may influence change in caregiver burden over a three-week period.

Partnership-based nursing practice framework for patients with advanced chronic obstructive pulmonary disease and their families-A discursive paper.

The increase in the number of people with chronic obstructive pulmonary disease (COPD) and the disease burden, has prompted concerted efforts to improve healthcare, particularly outpatient services. In line with these attempts the Partnership-Based Nursing Practice Theoretical Framework for People with COPD was developed to guide outpatient nursing care. The principal approach of the framework is a 'Dialogue' with the patients, which has four components: 'Establishing family involvement', 'Assisting living with symptoms' and 'Facilitating access to healthcare', with the primary goal being 'Enhancement of the health experience'. With new knowledge, research on the framework, and extensive experience in using it, a need arose to modify the framework to maximize its clinical utility. Discursive paper. A narrative review and critical reflection was conducted to revise the nursing practice framework via selected literature search from 2012 to 2022, research on the framework, and the authors' reflections on the clinical experience of using the framework. The nursing practice framework highlights capacities and possibilities that lie in the nurse-patient relationship. The overarching dialogue in the revised framework includes both patients and families. The action-related component 'Assisting living with the disease' was added to the framework to underscore the significance of attempting to understand what may lie ahead for patients and families. The other action-related components are as follows: 'Assisting living with symptoms' and 'Facilitating access to healthcare'. The primary goal remains unchanged: enhancing the 'Health experience'. Using the revised nursing practice framework in outpatient care may help to enhance the lives of people with COPD and their families, particularly at advanced stages of the disease. It may have transferability to other groups of people living with progressive diseases dealing with complicated health problems, and to reduce the usage of costly healthcare resources such as hospital care. The partnership-based nursing practice framework assumes an extension of conventional specialized respiratory service and embraces a comprehensive account for that which may influence the patient's health problems. This guidance, which holistically attends to patient-family needs of living with complicated and progressive health predicaments, is fundamental. It contributes to strengthening the disciplinary focus of nursing, interdisciplinary collaboration, person-family-centred quality nursing care and inspires research initiatives. Critical reflections and updates on nursing practice frameworks, such as this revision, are essential to advance nursing and healthcare. There is no direct patient- or public contribution.

Analisis Kualitas Website dengan Menggunakan Metode Webqual 4.0 dan Importance Performance Analysis

The development of technology, information and communication (TIK) is growing very rapidly and dynamically. Www.rsuppersahabatan.co.id, is a website owned by the government in the health sector provided by the Friendship Hospital as a form of service to the community in providing information and health services online. As a national respiratory referral center hospital and has a vision as a world-level hospital that has excellent respiratory services. Of course, many users access the website to seek information related to health service needs, training, education and research in the health and medical fields. Of course this is a challenge for Persahabatan Hospital to improve the quality of the website so that it can compete not at the national level but at the world level. The purpose of this study was to measure user satisfaction with the service quality of the Persahabatan Hospital website. The instrument used in this study was a questionnaire with a simple random sampling technique. In this study, the methods used were webqual and IPA methods. The webqual method consists of aspects of usability, information quality and interaction quality. The IPA method is used to analyze the level of suitability and gaps based on the level of satisfaction and expectations of the users.The results of calculating the IPA method can be described by the IPA matrix which consists of four quadrants. From the results of the analysis in this study, the largest gap (gap) is in the aspect of information quality with an average value of 0.41%.

O029 Clinical features and outcomes of patients referred to a Respiratory Failure service

Abstract Non-invasive ventilation (NIV) improves quality of life and mortality in patients with hypercapnic respiratory failure. We reviewed the last decade of long-term home NIV provision in a single centre via an observational retrospective study. Data were prospectively collected in a database. Anthropometric and demographic data were expressed as mean±SD. Indications for chronic home NIV were categorised into: neuromuscular diseases (NMD) [including motor neuron disease (MND)]; obstructive sleep apnoea/obesity hypoventilation (OSA/OHS); pulmonary disease; and others. Linear regression analysis was performed for the annual incidence by indication, and multivariate Cox regression performed compares MND mortality with other causes. 541 new patients (Age 60.8 ±17.1 years; 273 Female; BMI 33.4±13.9 kg/m2 (n=380)) were commenced on NIV between 2012-2022. Patient numbers increased by 2.3 (0.4-4.1) per year (slope, (95% confidence intervals); p<0.02). Indications for treatment included: 52% NMD (29% MND); 19% OSA/OHS; 19% pulmonary disease; and 10 % other causes. Average referral age, BMI and gender composition were stable over the time period. There was an increase in patients with pulmonary disease commenced on NIV of 0.6 (0.7-3.5)% per year (p<0.008), other indications for treatment were unchanged. 31.4% patients died (16.8% MND). Multivariate Cox regression analysis showed that a diagnosis of MND was associated with an increased likelihood of death (HR 11.42, p<0.0001). In the last decade, there’s been a gradual increase in patient numbers treated with chronic home NIV, with an increasing percentage of patients with pulmonary disease commenced on treatment. Mortality in MND patients on NIV is higher compared with other indications.

A Decade of Analysis of Unplanned Extubation Etiology in Trauma Patients Including the Impact of the COVID Pandemic.

Unplanned extubations (UEs) in injured patients are potentially fatal, but etiology and patient characteristics are not well described. We have been prospectively characterizing the etiology of UEs after we identified a high rate of UEs and implemented an educational program to address it. This period of monitoring included the years of the COVID-19 pandemic that produced high rates of workforce turnover in many hospitals, dramatically affecting nursing and respiratory therapy services. We hypothesized that frequency of UEs would depend on the etiology and that the workforce changes produced by the COVID-19 pandemic would increase UEs. This study was a prospective tracking and retrospective review of trauma registry and performance improvement data from 2012-2021. UE subjects were younger, were more frequently male, were diagnosed more frequently with pneumonia (38% vs 27%), and had longer hospital (19 d vs 15 d) and ICU length of stay (LOS) (12 d vs 10 d) (all P < .05). Most UEs were due to patient factors (self-extubation) that decreased after education, while UEs from other etiologies (mechanical, provider) were stable. Subjects with UEs from mechanical or provider etiologies had longer ICU LOS, higher mortality, and were less likely to be discharged home. The COVID-19 pandemic was associated with more total patient admissions and more days of ventilator use, but the rate of UEs was not changed. UEs were decreased by education with ongoing tracking, and UEs from patient factors were associated with better outcome than other etiologies. Workforce changes produced by the COVID-19 pandemic did not change the rate of UEs.

Non-invasive ventilation for people with neuromuscular disorders in Australia and New Zealand: a qualitative study of clinician perspectives.

To explore the experiences of Australian and New Zealand clinicians with respect to care pathways, their awareness and use of non-invasive ventilation guidelines, and their perspectives on delivering quality non-invasive ventilation services to people with neuromuscular disorders. Qualitative study; semi-structured focus groups and individual interviews with Australian and New Zealand clinicians who provide non-invasive ventilation services to people with neuromuscular disorders, recruited from participants at a 2017 sleep medicine conference. Interviews were conducted during 1 October 2017 - 31 May 2018. Major themes identified by an iterative, semantic, and inductive analysis. A total of 28 participants attended the four focus group sessions and five individual interviews; fourteen each from New Zealand and Australia, seventeen women and eleven men, eighteen physicians and ten other clinicians. Two major themes were identified: decision making for current practice, and resource constraints. Participants noted variable use of clinical guidelines and limited training to meet the needs of people with neuromuscular disorders who require non-invasive ventilation. They described a lack of dedicated funding, unstructured care pathways, equipment supply levels that do not meet need, low staff-to-patient ratios and staff shortages, and the inability to deliver quality multidisciplinary care. The need for clinical guidelines and service specifications was highlighted as requisite for reducing variation in clinical care. Systemic factors influence the needs-based provision of non-invasive ventilation for people with neuromuscular disorders. Development of clinical guidelines for Australia and New Zealand, dedicated funding for respiratory services for people with neuromuscular disorders, and specialist clinician training are important for equitable and high quality non-invasive ventilation care.

Qualitative evaluation of an integrated respiratory and palliative care service: patient, caregiver and general practitioner perspectives.

Objectives Integrated respiratory and palliative care services for people with advanced lung disease provide disease-orientated care until the end of life, alongside symptom management and discussions about future care. This study aimed to explore patient, caregiver and general practitioner perspectives of an integrated respiratory and palliative care service, to understand which components of the service were considered valued and effective. Methods We approached patients, caregivers and general practitioners, to participate in semi-structured phone interviews. A grounded theory approach guided data collection and qualitative analysis. Results Between July and December 2019, 10 patients, eight caregivers and five general practitioners completed interviews. The overarching theme was that of valuing integrated care - the provision of disease-orientated care along with palliative care. Four other major themes emerged: Valuing communication and engagement between patient, caregiver and healthcare professionals - who spoke of 'growing this plan together'; the delivery of person-centred care - where physicians 'actually listen and you are not treated like a number'; the reality of action plan use in serious illness - while many found plans 'certainly' do help, others described when they were simply 'too ill to do the action plan'; and finally, divergent preferences for discussions about future care - while some patients felt this subject was 'better left alone', caregivers consistently reported their preference was to 'make a plan.' Conclusion Consumer perspectives highlight the service was valued for delivering personalised care with high communication standards. Similar services should appreciate the usefulness and limitations of action plan use in advanced lung disease, and be sensitive to potential diverging preferences of the patient and caregiver when discussing future care.

A Comparison of Long-Term Outcomes in Patients Managed With Venovenous Extracorporeal Membrane Oxygenation in the First and Second Waves of the COVID-19 Pandemic in the United Kingdom.

Early studies of venovenous extracorporeal membrane oxygenation (ECMO) in COVID-19 have revealed similar outcomes to historical cohorts. Changes in the disease and treatments have led to differences in the patients supported on venovenous ECMO in the first and second waves. We aimed to compare these two groups in both the acute and follow-up phase. Retrospective single-center cohort study comparing mortality at censoring date (November 30, 2021) and decannulation, patient characteristics, complications and lung function and quality of life (QOL-by European Quality of Life 5 Dimensions 3 Level Version) at first follow-up in patients supported on venovenous ECMO between wave 1 and wave 2 of the COVID-19 pandemic. Critical care department of a severe acute respiratory failure service. Patients supported on ECMO for COVID-19 between wave 1 (March 17, 2020, to August 31, 2020) and wave 2 (January 9, 2020, to May 25, 2021). None. One hundred twenty-three patients were included in our analysis. Survival at censoring date (χ 2 , 6.35; p = 0.012) and decannulation (90.4% vs 70.0%; p < 0.001) was significantly lower in the second wave, while duration of ECMO run was longer (12.0 d [18.0-30.0 d] vs 29.5 d [15.5-58.3 d]; p = 0.005). Wave 2 patients had longer application of noninvasive ventilation (NIV) prior to ECMO and a higher frequency of barotrauma. Patient age and NIV use were independently associated with increased mortality (odds ratio 1.07 [1.01-1.14]; p = 0.025 and 3.37 [1.12-12.60]; p = 0.043, respectively). QOL and lung function apart from transfer coefficient of carbon monoxide corrected for hemoglobin was similar at follow-up across the waves. Most patients with COVID-19 supported on ECMO in both waves survived in the short and longer term. At follow-up patients had similar lung function and QOL across the two waves. This suggests that ECMO has an ongoing role in the management of a carefully selected group of patients with COVID-19.

Idiopathic pulmonary fibrosis in Soweto, South Africa: A descriptive study

Objectives: Idiopathic pulmonary fibrosis (IPF) is a specific form of age-related fibroproliferative interstitial pneumonia that is chronic, progressive, and carries a poor prognosis, with median survival of just 2.5–3.5 years from diagnosis. The exact etiology is unknown, but smoking is known to be risk factor. Symptoms and signs include progressive dyspnoea, cough, inspiratory “Velcro” crackles, and clubbing. At present, treatment options are limited; but include pulmonary rehabilitation, long-term domiciliary oxygen therapy, and the conditionally recommended pharmacological therapies pirfenidone and nintedanib. This study sought to describe the cohort of patients that attended the respiratory outpatient services at a tertiary-level hospital in South Africa during the period 2007– 2016. To the best of the authors’ knowledge, this is the first such descriptive study performed in Africa. Materials and Methods: This was a retrospective, descriptive, and record review, that included patients ≥18 years of age who fulfilled 2011 ATS/ERS/JRS/ALAT diagnostic criteria for IPF. Results: Data from 74 patients were used for analysis in this study, of which 60.8% were female. The mean age standard deviation was 64.4 (10.9) years and the majority (79.7%) were Black. Over half of the patients (40/74, 54.1%) were current or previous smokers, although there was no correlation between smoking history and age or baseline pulmonary function testing. All patients reported dyspnea, which was modified Medical Reseach Council (mMRC) Grade 3 or 4 in 80% of patients. High resolution computed tomography chest was reported as radiological usual interstitial pneumonia (UIP) in 72 patients (97.3%) and three patients underwent lung biopsy, all of which showed a UIP pattern. Fifty-eight patients (78.4%) had spirometry results available, with median forced vital capacity 67.3% of predicted; this was significantly higher in females. Median transfer factor of the lung for carbon monoxide was 39% predicted. Twenty-five patients (33.8%) received corticosteroids, of whom five (6.8%) received the prednisone-azathioprine-N-acetylcysteine regime. Three patients (4.1%) received nintedanib; two of whom showed slowing of decline in lung function, although no significant symptomatic improvement was reported. Mean duration of follow-up was 13.3 months, although females had significantly longer duration of follow-up than males. Conclusion: Despite a fairly small sample size and retrospective nature, this study contributes to the body of literature on IPF and highlights the need for additional studies in developing countries, particularly in Africa.