Respiratory Team Research Articles

Impact of a protocol-driven unified service for neonates with bronchopulmonary dysplasia.

AimA new specialised service for preterm infants with bronchopulmonary dysplasia requiring long-term oxygen therapy (LTOT) was established in 2007, led by the paediatric respiratory team, transitioning from neonatal-led follow-up. The new service included the utilisation of a clear protocol. Our objective was to review whether this service initiation led to a reduction of time in LTOT and hospital readmissions.MethodsWe performed a retrospective cohort study of infants born at <32 weeks’ gestation requiring LTOT in a single tertiary neonatal service. Cases were identified from hospital records, BadgerNet and a local database for two cohorts, 2004–2006 and 2008–2010. Data collected for infants requiring LTOT included demographic details, length of neonatal stay, time in oxygen and hospital attendance rates.ResultsThe initiation of the service led to an increase in the number of discharges in LTOT: 13.1% of infants born alive before 32 weeks’ gestation in comparison to 3.5% (p<0.001). However, the length of time in LTOT reduced from 15 to 5 months (p=0.01). There was no difference in hospital readmission rates (p=0.365).ConclusionsIn our experience the increase in neonates requiring LTOT is likely to be due to enhanced provision of overnight oximetry studies prior to discharge. Structured monitoring and weaning led to a shorter duration of home oxygen therapy.

Integrated respiratory and palliative care leads to high levels of satisfaction: a survey of patients and carers

BackgroundThe Advanced Lung Disease Service is a unique, new model of integrated respiratory and palliative care, which aims to address the unmet needs of patients with advanced, non-malignant, respiratory diseases. This study aimed to explore patients’ and carers’ experiences of integrated palliative care and identify valued aspects of care.MethodsAll current patients of the integrated service and their carers were invited to complete a confidential questionnaire by post or with an independent researcher.ResultsEighty-eight responses were received from 64 (80.0%) eligible patients and from 24 (60%) eligible carers. Most participants (84, 95.5%) believed the integrated service helped them to manage breathlessness and nearly all participants (87, 98.9%) reported increased confidence managing symptoms. One third of patients (34.4%) had received a nurse-led domiciliary visit, with nearly all regarding this as helpful.Most participants believed the integrated respiratory and palliative care team listened to them carefully (87, 98.9%) with opportunities to express their views (88, 100%). Highly valued aspects of the service were continuity of care (82, 93.2%) and long-term care (77, 87.5%). Three quarters of participants (66, 75.0%) rated their care as excellent, with 20.5% rating it as very good. Nearly all (87, 98.9%) participants reported that they would recommend the service to others.ConclusionsPatients and carers expressed high levels of satisfaction with this model of integrated respiratory and palliative care. Continuity of care, high quality communication and feeling cared for were greatly valued and highlight simple but important aspects of care for all patients.

Supported self-management model reduces hospital admissions in paediatric neuro-respiratory patients

Purpose: Lanarkshire paediatric respiratory team provide multidisciplinary care to a large number of children who have significant respiratory compromise as a result of neurorespiratory illnesses. As a group, these children are vulnerable to developing acute-on-chronic respiratory problems, usually infective in nature. Hospital admissions for such treatments are a frequent occurrence. Provision of care on an inpatient basis is expensive and carries considerable human costs for children and families. The aim of this project was to reduce hospital admissions in children with neurorespiratory illnesses by pro-actively managing their conditions in the home setting.

A Patient with Fukuyama Congenital Muscular Dystrophy Who Received Good Respiratory Care from a Respiratory Support Team

A Patient with Fukuyama Congenital Muscular Dystrophy Who Received Good Respiratory Care from a Respiratory Support Team

Indications, clinical outcomes and complications of 1,949 flexible bronchoscopies

ABSTRACTObjective To describe indications, clinical outcomes and complications of flexible bronchoscopy.Methods A descriptive observational study of bronchoscopies performed at the endoscopy service of Hospital Israelita Albert Einstein . Demographic (age, gender and origin) and medical (indications and results of endoscopy and diagnostic tests, such as biopsy collection, lavage, cytology and culture) data were analyzed. Electronic medical records with incomplete data or reporting interventional procedures were excluded.Results Over a three-year period (2013 to 2016), a total of 1,949 bronchoscopies were performed by respiratory endoscopy team and anesthesia specialists of the hospital. The mean age of patients was 57.7±21.9 years (range of 3 days to 99 years), with prevalence of males (56.4%). The procedures were mostly (86.3%) elective and 30.7% were carried out in the intensive care unit. Major indications for bronchoscopy were infection or secretion (42.4%), followed by suspected neoplasm (10.8%). Endoscopic changes were reported in 91.9% of cases, with more than one change described in approximately 6.9% of patients. Positive results were obtained via direct testing or culture in 36.3% and 53.9% of 1,399 bronchoalveolar lavages, respectively. The overall diagnostic yield (bronchoalveolar lavage and biopsy) was 72.6%. Mild adverse event rate was 7.2%. The rate of severe adverse events requiring additional intervention was 0.5% (pneumothorax, 0.4%; severe bleeding with patient death, 0.1%).Conclusion Lower airway endoscopy is critical for respiratory disease assessment, diagnosis and treatment. Flexible bronchoscopy is associated with good diagnostic yield and minimal inherent risk.

366. Pyrexia in the puerperium as first manifestation of systemic lupus erythematosus

We report the case of a 29 year-old Asian woman who presented 13 days post-normal vaginal delivery with pyrexia, tachycardia and feeling generally unwell referred to hospital by her general practitioner (GP). She had a background of recurrent urinary tract infections and recently had an uncomplicated vaginal delivery with normal observations immediately post-partum and an uneventful short hospital stay. She was a non-smoker. She was started on oral antibiotics by her GP. She had a septic screen and was commenced on intravenous antibiotics. She developed a cough with clear sputum. Her broad-spectrum antibiotics were changed on microbiology advice and Tamiflu was commenced. She had a multitude of investigations performed including blood tests, blood cultures and swabs, echocardiogram, electrocardiography (ECG), pelvic ultrasound scan, Computed tomography (CT) abdomen/pelvis scan and infectious diseases screen. Despite the antibiotics, her pyrexia persisted. Following review by the respiratory team, an auto-immune screen was performed. This was positive for ANA, SSA-60, chromatin and DsDNA. A diagnosis was made for systemic lupus erythematosus with nephritis as she also developed proteinuria and haematuria. She was then reviewed by a rheumatologist and commenced on corticosteroid treatment.

A Charter to Improve Patient Care in Severe Asthma.

Severe asthma is a subtype of asthma that is difficult to treat and control. By conservative estimates, severe asthma affects approximately 5–10% of patients with asthma worldwide. Severe asthma impairs patients’ health-related quality of life, and patients are at risk of life-threatening asthma attacks. Severe asthma also accounts for the majority of health care expenditures associated with asthma. Guidelines recommend that patients with severe asthma be referred to a specialist respiratory team for correct diagnosis and expert management. This is particularly important to ensure that they have access to newly available biologic treatments. However, many patients with severe asthma can suffer multiple asthma attacks and wait several years before they are referred for specialist care. As global patient advocates, we believe it is essential to raise awareness and understanding for patients, caregivers, health care professionals, and the public about the substantial impact of severe asthma and to create opportunities for improving patient care. Patients should be empowered to live a life free of symptoms and the adverse effects of traditional medications (e.g., oral corticosteroids), reducing hospital visits and emergency care, the loss of school and work days, and the constraints placed on their daily lives. Here we provide a Patient Charter for severe asthma, consisting of six core principles, to mobilize national governments, health care providers, payer policymakers, lung health industry partners, and patients/caregivers to address the unmet need and burden in severe asthma and ultimately work together to deliver meaningful improvements in care.Funding: AstraZeneca.

Assessment of a Domiciliary Integrated Pulmonary Rehabilitation Program for Patients with a History of Acute Exacerbation of Chronic Obstructive Pulmonary Disease: A Retrospective 12-Month Observational Study.

BackgroundIntegrated pulmonary rehabilitation (PR) in chronic obstructive pulmonary disease (COPD) may prevent acute exacerbations of COPD (AECOPD). The aim of this study was to evaluate the effectiveness, before and 12 months after, the use of an integrated PR program in patients discharged from hospital for AECOPD.Material/MethodsA retrospective observational clinical study included patients diagnosed with COPD who participated in a domiciliary integrated PR program that included a weekly phone interview supervised by a respiratory team. A six-minute walk test (6MWT), COPD assessment test (CAT), and the modified Medical Research Council scale (mMRC) were evaluated every three months.ResultsOf the 303 eligible patients, 267 patients (88.1%), with a mean age of 64.9±8.7 years, a mean FEV1 percentage predicted of 48.8±12.9%, successfully completed the 12-month study program and achieved a significant improvement in their clinical performance with a significantly reduced frequency of episodes of EACOPD (3.1±1.7 vs. 2.0±1.4) (p<0.001), a significant reduction in emergency department visits (2.5±1.5 vs. 1.2±1.1) (p<0.001), and significantly reduced episodes of hospitalization (2.0±1.2 vs. 1.4±1.2) (p<0.001). Significant patient benefits were found during the 12-month study, on CAT, mMRC, and patient well-being when compared with the end of the study after 12 months (p<0.001).ConclusionsA multidisciplinary integrated PR program maintained a significant clinical improvement, in patients with COPD by reducing episodes of AECOPD, CAT, mMRC, emergency hospital admissions, and improved patient well-being, for the duration of the program.

Reflections on integrated care from those working in and leading integrated respiratory teams.

The concept of integrated care has been advocated for many years to address some of the challenges faced by the NHS. This report examines the experiences of respiratory healthcare specialists working in an integrated role. Twelve qualitative telephone interviews were undertaken with a range of integrated respiratory specialists and their teams working in both hospitals and the community. A descriptive and thematic approach to data analysis was adopted.Participants were very enthusiastic about their roles and saw themselves as ambassadors for this new way of working. Several key themes were identified from the analysis which participants identified as barriers or enablers to the successful undertaking of an integrated respiratory specialist role. These included the participants’ previous work experience and background, the range of multi-disciplinary expertise within or needed for the team, the structure of the team leadership and the measurement of outcomes to evaluate the team. Participants identified the need for clear job descriptions and roles, shared training and standards and appropriate outcome evaluation. More research is needed to understand how these new ways of working are developing and how they can be evaluated.

The Community Respiratory Team - An enhanced trust wide service offering an integrated pathway for the effective management of patients with respiratory illness within primary care and community settings

The Community Respiratory Team (CRT) aims to: • Enhance quality of life and quality of care for patients • Improve the process of diagnosis and condition management • Reduce the number of hospital and GP appointments patients require • Reduce the likelihood of potential hospital admission Based on current evidence-based practice and in line with the principles outlined in Transforming Your Care (TYC), it was recommended that a change to the Trust service model was is required in order to ensure a more co-ordinated and effective service. Transforming Your Care is the programme aimed at changing Northern Ireland’s health and social care system. It is focussed on improving care provided, providing more care at home and less care in hospitals. Under TYC, Integrated Care Partnerships (ICPs) were established to drive improve Integrated working between Primary and Secondary Care services. Evidence indicated that all people with chronic respiratory disease should have access to a Community Respiratory Team that is operating at the interfaces between the Acute Hospitals and the community service and the primary care teams. The CRT was established in June 2015. Prior to the establishment of a CRT, patients with a chronic respiratory disease received care from a diversity of core services (Early Supported Discharge, Case Management, respiratory physiotherapy, respiratory nurse specialists e.g. for oxygen assessment and pulmonary rehabilitation). A multi-disciplinary group was established by the ICP to look at best practice in respiratory care and to examine how to best facilitate the shift to Community and Primary care services. This group identified the requirements to enhance the existing Teams in support of integrated respiratory care pathways. Redesign of existing services was led by a Clinical Co-ordinator and Specialist Nurse. This included networking with key stakeholders through workshops, education sessions with all 57 GP practices in the Western Area, benchmarking against successful integrated respiratory services regionally and nationally, team workshops/meetings to empower staff and encourage collaboration, and an Operational framework developed based on current evidence and up to date guidelines relevant to respiratory disease management. The Operational Plan was circulated trust wide prior to implementation. Timeline: June2015 to date Highlights: Total of 818 patients referred to Community Respiratory Team (August 2015 – March 2016) Total of 7827 face to face contacts (August 2015 – March 2016) 4019 bed days saved for COPD - based on LOS 6 days (August 2015 – March 2016) 739 admissions avoided (August 2015 – March 2016) 3132 telephone reviews (August 2015 – March 2016) The rate of unplanned admissions to hospital for all patients with COPD: 20% reduction. Sustainability and transferability: Well managed change is effective; this includes timely communication and relevant information sharing with all key stakeholders. The individual education sessions with each GP practice was a large resource of time and expertise, this was very worthwhile with excellent feedback in the project evaluation. There is evidence provided, in the feedback, from all groups that the CRT is a provision that has brought positive impacts for patients, professionals and the health service.

Automatic intratracheal suctioning system improved airway clearance of amyotrophic lateral sclerosis patients with tracheostomy-invasive ventilation

Background: We provide long-term medical care for neuromuscular disease patients as a neuromuscular-disease center hospital in Hokuriku area of Japan. We have also developed multidisciplinary care team for amyotrophic lateral sclerosis (ALS). Partly as a result of our support, about 25% of our ALS patients choose tracheostomy-invasive ventilation (TIV). So, management of ALS-TIV respiratory condition is the important part of our care. To reduce respiratory complications, our respiratory care support team (RST) began to apply automatic intratracheal suctioning system (AISS) since 2012.

Understanding the factors affecting self-management of COPD from the perspectives of healthcare practitioners: a qualitative study

Self-management is recognised as an essential criteria for the provision of high quality care for chronic obstructive pulmonary disease (COPD). The management of COPD is usually delivered by a wide range of healthcare practitioners. This study aimed to understand the factors affecting self-management of COPD from the perspectives of the different multidisciplinary healthcare teams involved in COPD care. Semi-structured interviews were conducted with participants from primary care, specialist respiratory and pulmonary rehabilitation (PR) teams. Purposive sampling and snowballing were employed in participant recruitment. All interviews were audio-recorded and transcribed verbatim and data were analysed thematically. A total of 20 participants (eight primary care practitioners, seven respiratory specialists and five PR practitioners) were interviewed until data saturation was reached. Participants identified a range of complex and interrelated factors affecting COPD self-management that were grouped into three broad categories—patient, practitioner and organisational/system-level factors. Patient-level factors were predominantly considered as barriers, with COPD knowledge and understanding, and the individual patients’ life circumstances/context being the most prominent issues. Practitioner-level factors identified were practitioners’ speciality, interest and experience in respiratory conditions as the overarching factor that influenced how self-management was understood and practiced. A number of organisational/system-level factors were identified by all practitioners, including inconsistency of referral pathways and the wide variations of different self-management planning tools. Factors affecting self-management of COPD across these three levels need to be tackled equally in order to improve the effectiveness of interventions and to embed and integrate self-management support approaches into routine practice.

The AREST CF experience in biobanking — More than just tissues, tubes and time

Research to further improve outcomes for people with CF is dependent upon well characterised, archived and accessible clinical specimens. The recent article by Beekman et al. published in Journal of Cystic Fibrosis summarised a scientific meeting at the 13th ECFS Basic Science Conference. This meeting discussed how well-annotated, clinical biobanks for CF could be established in Europe to meet the needs of therapeutic development. The Australian Respiratory Early Surveillance Team for Cystic Fibrosis (AREST CF) has conducted biobanking of CF research and clinical specimens since the late 1990s and is custodian of the most comprehensive paediatric CF biobank in the world that focuses on the first years of life. This short communication will describe the approach undertaken by AREST CF in establishing a clinical specimen biobank.

Respiratory Patients Breathing Life into the Canterbury Integrated Respiratory Service

A group of past pulmonary rehabilitation participants have joined together to form the Pulmonary Rehabilitation Consumer Group. They have been actively engaged in Canterbury’s respiratory service design and innovation since 2013. Telling their Story : Members of the Consumer Group meet monthly to give their opinion on how pulmonary rehabilitation and the wider respiratory service support patients to look after their own health. They discuss their own positive and negative experiences to a wide range of audiences and report to governance and working groups. They present their stories at regional and national conferences and workshops for clinicians, such as the South Island Respiratory Educators Forum (SIREF) and GP Continuing Medical Education. They attend and promote community exercise groups and have just started a weekly coffee group to provide support for all patients and carers who have an interest in respiratory issues. They led a walking train of people through the Christchurch Botanical Gardens for World COPD Day in 2014. The Chair of the group has won the Asthma and Respiratory Foundation Achiever Award for COPD 2016. They are advocates outside the clinical meetings they attend by joining every session of the community-based pulmonary rehabilitation programmes to support participants new to pulmonary rehabilitation. Aim : We’ve previously identified that a large proportion of our referred patients to pulmonary rehabilitation are not attending, or are not completing the programme. In 2015 the service received 604 referrals from health practitioners, of which 268 attended (>1 sessions) and 175 completed (attended >8 sessions) the programme. The governance group agreed to investigate issues of non-attendance. Highlights : Specialist and primary health care services typically lack direct feedback from patients. The Integrated Respiratory Service in Canterbury has found that by actively supporting a group of patients, increasing their health literacy and engagement in service design and delivery, we have achieved a higher level of understanding. We have become more focussed on outcomes, defining and measuring what we are delivering and reducing barriers to attendance. Through working with our consumer group and undertaking relevant research we have identified key issues facing community-based programmes. Lessons Learned : The Integrated Respiratory Service and its governance infrastructure are supportive and open to consumer input at every level. We only wish we had organised a group like this earlier in the community-based programme establishment. The benefits to the consumers, the respiratory nurse facilitator, the wider community respiratory team and Integrated Respiratory Service, and people in Canterbury with respiratory conditions, have been profound. The consumers feel they are contributing to their communities, as well as the health sector. They feel valued, because they are. “I read that lovely Maori woman’s story, and I thought, if she can do it, then so can I!” Pulmonary Rehabilitation Participant 2016

Air trapping in early cystic fibrosis lung disease-Does CT tell the full story?

Mosaic attenuation on expiratory chest computed tomography (CT) is common in early life cystic fibrosis (CF) and often referred to as "air trapping". It is presumed to be localized hyperinflation due to small airway obstruction. In order to test this assumption, we compared air trapping extent to lung volumes measured on CT in young children with CF. Children aged below 7 years undergoing inspiratory/expiratory CT were recruited from the Australian Respiratory Early Surveillance Team for Cystic Fibrosis cohort. Automated lung segmentation was used to determine functional residual capacity (FRC), total lung capacity (TLC), and their ratio (FRC/TLC). Structural lung disease (%Disease) and air trapping (%TrappedAir) extent were assessed using PRAGMA-CF. Lung clearance index (LCI), an index of ventilation heterogeneity, was measured. Linear mixed model analysis was used to determine associations. Seventy-three scans from 55 patients were obtained. %TrappedAir was associated with %Disease (0.19 [0.07, 0.31]; P = 0.003) and LCI (0.22 [0.04, 0.39]; P = 0.016), but not FRC/TLC (0.00 [-0.02, 0.02]; P = 0.931). CT mosaic attenuation is associated with CF lung disease, however it is not always accompanied by physiologic hyperinflation. Other pathologies may contribute to mosaic attenuation. A better understanding of these factors could guide future therapies.

The 8-Year Experience of the Florence Referral ECMO Center and Retrieval Team for Acute Respiratory Failure

Many extracorporeal membrane oxygenation (ECMO) centers for respiratory failure and ECMO mobile teams were instituted during the H1N1 pandemic. Data on transportation are scarce and heterogeneous. The authors therefore described the experience of their referral ECMO center for severe respiratory failure from 2009 to 2016 and gave a comprehensive report of transfers performed by their mobile ECMO team. Observational retrospective study. An intensive care unit (ECMO referral center) in a teaching hospital. One hundred and sixty consecutive patients with acute respiratory distress syndrome refractory to conventional treatment requiring veno-venous (VV)-ECMO. VV-ECMO implantation. In this series, the transferred patients on ECMO averaged 57%, with annual percentages ranging from 28% to 90% over the years. No adverse event was observed during transportation. A progressive increase in simplified acute physiology score (SAPS) values and in the use of norepinephrine were detectable (p = 0.048 and p = 0.037, respectively) as well as in neuromuscular blockers use (p = 0.004). Dual-lumen cannule were more frequently used in recent years (p < 0.001). The overall mortality rate was 40% (64/160), with no differences over the years or between transferred and local patients. Body mass index and pre-ECMO neuromuscular blockers and SAPS were independent predictors for early mortality (when adjusted for age). The workload of the authors' referral center and mobile team did not change, documenting that severe respiratory failure requiring VV-ECMO support is still a clinical need. No difference in mortality rate was detectable during this period or between transferred and local patients who were managed by the same team.

Training in multiple breath washout testing for respiratory physiotherapists

IntroductionThe development of multiple breath washout (MBW) testing in respiratory disease highlights the need for increased awareness amongst respiratory physiotherapists and a potential opportunity for professional development in the use of an important outcome measure for clinical trials. ObjectivesTo rationalise how MBW may be a useful assessment tool for respiratory physiotherapists and to describe a local MBW training and certification programme for physiotherapists. ResultsThe respiratory Multidisciplinary Team in the Belfast Health and Social Care Trust (BHSCT) identified a need for MBW testing to be available to facilitate clinical research and assessment. A 2day training programme consisting of prereading preparation, self-directed learning, theory presentations, practical demonstrations and hands-on practice was developed and delivered. All participants underwent a certification process. ConclusionWe have demonstrated the successful training and certification of clinical and research physiotherapists and encourage other respiratory physiotherapists to consider MBW test training.

Cost-effectiveness of antibiotics for COPD management: observational analysis using CPRD data.

It is often difficult to determine the cause of chronic obstructive pulmonary disease (COPD) exacerbations, and antibiotics are frequently prescribed. This study conducted an observational cost-effectiveness analysis of prescribing antibiotics for exacerbations of COPD based on routinely collected data from patient electronic health records.A cohort of 45 375 patients aged 40 years or more who attended their general practice for a COPD exacerbation during 2000–2013 was identified from the Clinical Practice Research Datalink. Two groups were formed (“immediate antibiotics” or “no antibiotics”) based on whether antibiotics were prescribed during the index general practice (GP) consultation, with data analysed according to subsequent healthcare resource use. A cost-effectiveness analysis was undertaken from the perspective of the UK National Health Service, using a time horizon of 4 weeks in the base case.The use of antibiotics for COPD exacerbations resulted in cost savings and an improvement in all outcomes analysed; i.e. GP visits, hospitalisations, community respiratory team referrals, all referrals, infections and subsequent antibiotics prescriptions were lower for the antibiotics group. Hence, the use of antibiotics was dominant over no antibiotics.The economic analysis suggests that use of antibiotics for COPD exacerbations is a cost-effective alternative to not prescribing antibiotics for patients who present to their GP, and remains cost-effective when longer time horizons of 3 months and 12 months are considered. It would be useful for a definitive trial to be undertaken in this area to determine the cost-effectiveness of antibiotics for COPD exacerbations.

Positive Influence of a Dedicated Vascular Access Team in an Acute Care Hospital

The benefits of reduction in central line-associated bloodstream infections at Banner Boswell Medical Center in Sun City, Arizona, include decreased expenses and increased efficiency, quality of care, and patient satisfaction; improved patient outcomes with proper device selection; 24 hours a day, 7 days a week specialized registered respiratory therapist and lines team availability; standardization of peripherally inserted central catheter and central venous catheter insertions, maintenance, and removal; better workflow; and resource and cost center centralization.

Managing respiratory disease.

The diverse and evolving role of a psychologist within a respiratory multidisciplinary team (MDT) is described, providing a working model for service provision. The rationale for appointing a psychologist within a respiratory MDT is presented first, citing relevant policy and research and outlining the wider psychosocial impact of respiratory disease. This is followed by an insight into the psychologist’s role by highlighting important areas, including key therapy themes and the challenge of patient engagement. The way in which the psychologist supports the collective aims and aspirations of respiratory colleagues to provide a more holistic package of care is illustrated throughout.