Respiratory care

Refractory Dyspnoea in Palliative Care: Implementing High Flow Oxygen Therapy AIRVO2 Into Palliative Care and End of Life Care in the Community (2025)

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Type of publication:

Conference abstract

Author(s):

*Raton M.; *Rowe N.; *Wood G.;

Citation:

American Journal of Respiratory and Critical Care Medicine. Conference: American Thoracic Society International Conference, ATS 2025. San Francisco, CA United States. 211 (no pagination), 2025. Date of Publication: 01 May 2025.

Abstract:

Palliative patients often present to secondary care settings with respiratory distress during the endstage of their disease. Conventional oxygen therapy alongside opioid therapy has widely been considered the treatment of choice for dyspnoea and symptom alleviation. With an increasing number of palliative patients and the national drive for service improvement, the Respiratory Team have identified an additional method to enhance current practice. Based on previous positive experience gained since 2013 from utilising High Flow Oxygen Therapy (HFOT) during the acute stages of respiratory disease, it was decided to extend this therapy to patients with chronic disease and palliative needs. The physiological and clinical benefits of HFOT include reduction in dyspnoea and decreased work of breathing, augmentation of respiratory drive, improved quality of life, and comfort level in this patient population. During work on the COVID cohort ward (March 2020- Dec 2021) AIRVO2 was used routinely as a first-line treatment in over 300 patients and continued in over 70 patients in the palliation/ End of Life (EoL) pathway. Since then, AIRVO2 in combination with lowdose opioids has been used in Palliative/ EoL care routinely. In 2022 the first discharge from the hospital was facilitated to continue optimised treatment. Benefits from HFOT in EoL/ Palliative usage should be focused on comfort and symptom control with optimised FiO2 requirements. We looked at three patients who were discharged from hospital on HFOT: two patients to the hospice and one home. With the combined HTOT and conventional palliative management, we observed a significantly decreased requirement of opioid use, leading to a reduction in side effects such as drowsiness or palliative sedation. This enabled patients to experience interaction with family and friends at the end of their life. On each occasion, good feedback has been received from the family, hospice, and patients. Extending HTOT usage to the community enhances best interest care for individuals and avoids abrupt termination of therapy initiated in the hospital. This prevents palliative patients with symptomatic breathlessness from having to compromise on either place of death or symptomatic breathlessness. HFOT usage out of the hospital decreases the number of readmissions with the focus on extended care in the community. Discharging patients to the community requires a clear advanced care plan and close cooperation within Multidisciplinary Team. Correct patients' selection for discharge on HFOT needs to be considered due to the limited FiO2 concentration delivery in the community.

DOI: 10.1164/ajrccm.2025.211.Abstracts.A4177

Improving patients’ understanding about pleural effusion management options (2025)

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Type of publication:

Conference abstract

Author(s):

*Maimuna Adamu, *Greenway Tammy, *Jennifer Nixon

Citation:

Future Healthcare Journal. 2025 Volume 12, Issue 2, Supplement, June 2025. Abstracts from Medicine 2025: The future of medicine. RCP annual conference.

Abstract:

Introduction and objective
Various treatment options are available for managing recurrent pleural effusions, each with its merits. These include: (1) symptomatic control with medication; (2) ambulatory repeated pleural aspiration; (3) inpatient chest drain and talc pleurodesis; and (4) home-based indwelling pleural catheters. British Thoracic Society (BTS) guidelines recommend that, in the context of malignant pleural effusion (MPE), ‘decisions on the best treatment modality should be based on patient choice’.1 There are different factors to consider in choosing a treatment option, such as symptoms, availability of resources, need for hospitalisation and risk of requiring further pleural interventions. In our Trust, this information was given to patients in an unstructured verbal context, with variation between each practitioner. The objective of our project was to provide information on the different pleural effusion management options in a standardised written format as a tool to help patients reach an informed decision about their preferred option.

Methods
This quality improvement project was conducted in two cycles using the plan–do–study–act (PDSA) methodology. The patient population included were those attending our weekly outpatient pleural list within a 3-month period, who already had a diagnosis of MPE or if the clinical details (history, examination or imaging) were highly suggestive of MPE. The first cycle involved assessing our current practice against the BTS guidelines for pleural disease. A telephone-based questionnaire was administered, assessing how much patients understood and retained about the different methods of pleural effusion management after attending the pleural list. Our intervention involved designing and producing a pleural effusion management options patient information leaflet (Fig 1). The leaflet included information about pleural effusions and each of the management options listed above, with illustrative diagrams. We received input from our Trust’s health literacy team to ensure that the information was written in a way patients could understand. The leaflet was then given to clinically appropriate patients attending the pleural list. The same questionnaire was repeated after the leaflet had been in use for 4 months, and pre and post-intervention results were compared.

Results
Fig 2 summarises the findings. At baseline (n=21), only 48% of patients felt they had enough information to choose their preferred management option if their pleural effusion recurred. None knew about the option of symptomatic management with medication. After the intervention (n=20), there was a significant improvement in understanding of the pleural effusion management options, with 95% of patients now satisfied that they had enough information to choose their preferred management option.

Conclusion
This project demonstrates the benefits of providing structured, written information to patients with recurrent pleural effusion. This intervention enhanced patient understanding and helped patients to make informed choices about their treatment options, in alignment with the BTS guidelines

DOI: 10.1016/j.fhj.2025.100412

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Mucus plugging and mucolytics in patients admitted with acute exacerbation of chronic obstructive pulmonary disease (COPD); investigating impact on short term mortality (2024)

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Type of publication:

Conference abstract

Author(s):

*Abugassa E.; *Bosher O.; *Makan N.; *Crawford E.; *Saleem M.A.; *Srinivasan K.; *Moudgil H.

Citation:

European Respiratory Journal. Conference: European Respiratory Society International Congress, ERS 2024. Vienna Austria. 64(Supplement 68) (pp PA3010), 2024. Date of Publication: 01 Sep 2024.

Abstract:

Background: Although mucus plugging occluding medium to large sized airways in COPD is associated with increased long term all-cause mortality, acute exacerbations require further investigation, particularly where, despite reducing morbidity and improving quality of life, long-term use of mucolytics remains controversial. Objectives were (1) to quantify chest CT evidence of mucus plugging, (2) relate findings to mucolytics, and (3) investigate mucus plugging association with short term mortality.

Method(s): Retrospective review of 100 patients admitted with exacerbation of COPD (105 admissions).comparative analysis by chi square (x2) and logistic regression, significant p<.05.

Result(s): Mean (SD, range) age was 74.7 (10.5, 41-97) years with 54% male; mean FEV1/FVC 55% with FEV1 1.2(0.59, 0.4-3.6) litres at 49% predicted. 23 were on long term oxygen (LTOT). Mean stay was 6.3 (1-41) days. 24 died in the first 6 months. Where a historical or admission chest CT was available (n=82), 12 (15%) had mucus plugging with mucolytics prescribed to 6 (50%) compared to 32/70 (46%) without plugging (x2 0.057, NS). 9/56 (16%) with mucus plugging vs 3/26 (12%) without (x2 0.2921, NS) had emphysema and 3/13 (23%) vs 9/69 (13%) without (x2 1.016, NS) bronchiectasis. Regression investigating mortality at 6 months showed adverse outcomes for male sex, lower FEV1, and LTOT.

Conclusion(s): 15% with acute COPD admissions have current or historical evidence of mucus plugging. Mucolytics are prescribed for 45% irrespective of prior CT radiology. Mortality (24%) at 6 months is high but not shown related to mucus plugging or reduced by mucolytics.

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Pleural infection presentation and timeline of events: Real-world data from a tertiary hospital in the UK (2024)

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Type of publication:

Conference abstract

Author(s):

Mannan S.; Waseem T.; Safwan N.; Ganaie M.;

Citation:

Pleural infection presentation and timeline of events: Real-world data from a tertiary hospital in the UK.

Abstract:

Background: Pleural infection remains a significant burden on mortality and morbidity in the Western world even with the advancement of clinical management.

Objective(s): This paper aims to study the clinical course of empyema thoracic patients managed in a tertiary hospital in the UK.

Method(s): We did a retrospective observational study of the hospital's electronic records of patients who were diagnosed and managed for empyema thoracic from January 2021 to December 2022.

Result(s): The total cohort was 104 empyema thoracic patients. The mean age was 60. The affected males were almost double than females (68 vs 36). We did a retrospective RAPID score of our cohort. The RAPID score could not be calculated for 35 patients due to the unavailability of pleural fluid data. High inpatient mortality (23%) was observed in the medium- risk (RAPID score 3-4) group and high 3-month mortality (25%) was observed in the high-risk (RAPID score 5-7) group. The majority of the patients were managed conservatively. No difference was noticed in the median length of hospital stay (11d) in all the risk groups. A high rate of (37%) surgical management was observed in the low-risk (RAPID score 0-2) group.

Conclusion(s): Our cohort's data comply with the predicted mortality risk of the RAPID score. We emphasize that RAPID score calculation can be a significant tool in the management of empyema thoracic patients.

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Is smoking associated with higher cardiovascular risk and increased unplanned acute medical attendance? A retrospective analysis from the Lung Cancer screening cohort (2023)

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Type of publication:

Conference abstract

Author(s):

Haider R.; Finn E.; *Zeb S.; *Bharwana F.; Fitzgerald A.; Iftikhar S.; Hussain I.;

Citation:

European Respiratory Journal. Conference: European Respiratory Society International Congress, ERS 2023. Milan Italy. 62(Supplement 67) (pp PA1345), 2023. Date of Publication: 01 Sep 2023.

Abstract:

Intro: Active smoking plays a crucial role in cardiovascular disease. We looked at the rate of attendance to primary and secondary care amongst current smokers with increased QRISK and CAT scores.

Methodology: Data were drawn retrospectively from electronic medical records from a large tertiary care hospital covering Staffordshire region over a one year period 2019-2020. Data was extracted from lung cancer screening cohort.

Result(s): The data comprised of 1232 patients (516 female, 716 male). Of these, 566 were exsmokers and 666 current smokers. Average age was 62 years. Analysis was done using ANOVA. This confirms that current heavy smokers, had an increased QRISK score >10 (p value <0.05, 95% CI 0.00 to 0.02). 1 year mortality in this group was 2.8%. Heavy smokers were not at an increased risk of attending primary care (p value 0.862) or at increased risk of unplanned secondary care admissions (p value 0.09) as compared to light smokers. Median length of hospital stay was 8 (0 – 16) bed days in heavy smokers as compared to 4 bed days (0 – 8) in ex smokers. Female ex smokers had fewer hospital attendances as compared to female current smokers, male current and ex smokers (p value <0.05, tests statistic 4.207). A high CAT score was documented as >20 denoting impact of COPD on patient's life. It was not identified as a predictor of increased attendance to primary or secondary care.

Conclusion(s): Heavy smokers have a higher economic burden on acute secondary care on account of higher number of bed days. Early smoking cessation intervention may help reduce attendance into secondary care.

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The continued burden of pleural mesothelioma; a review of 10 years experience at this hospital Trust (2023)

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Type of publication:

Conference abstract

Author(s):

*Gohir Q.; *Mcadam J.; *Crawford E.; *Bosher O.; *Saleem M.; *Srinivasan K.; *Moudgil H.;

Citation:

European Respiratory Journal. Conference: European Respiratory Society International Congress, ERS 2023. Milan Italy. 62(Supplement 67) (pp PA3444), 2023. Date of Publication: 01 Sep 2023.

Abstract:

Background: Prognosis with pleural mesothelioma depends not only on histological typing but also distribution of metastatic disease (including stage 4 with distant spread) and performance status. Analysing all patients presenting at his hospital Trust over 10 years, this work (1) reports the pattern of metastatic disease and, accepting the complex multi-modality approach to treatment, (2) relates findings to survival.

Method(s): Retrospective computer based analysis conferring with oncology and radiology records. 169 patients (84% male) with mean (range) age 74.4 (44 to 93) years.

Result(s): Respectively, performance status was 0 (16%), 1 (34%), 2 (26%), 3 (18%) and 4 (1%). 70% only had thoracic disease (pleural, pericardial, mediastinal, pulmonary) and 30% extrathoracic extension (chest wall/extrapleural, diaphragmatic, peritoneal/omental/ascites), liver/spleen/adrenal, spine and bone, and other (including brain and brachial plexus). Overall, 94% were diagnosed on tissue samples; where histology was clarified, 63% with epithelioid survived longer at (mean) 15 months compared to the 37% with 12.6 months for sarcomatoid or biphasic typing. Although active treatments often involved the complexity of multimodality, 34% had best supported care (usually worse performance status).

Conclusion(s): Findings highlight the aggressive nature of pleural mesothelioma confirming at least 30% had extrathoracic metastases and marginally improved outcomes with epithelioid histology.

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BTS Position Statement on Sustainability and the Environment: Climate Change and Lung Health (2024)

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Type of publication:

National guidance

Author(s):

Laura-Jane Smith, Henry Marshall, Thomas Medveczky, *Jennifer Nixon, Gerrard Phillips, Ravijyot Saggu, Lewis Standing, Ruth Wiggans, Alexander Wilkinson

Citation:

British Thoracic Society 2024

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The diagnosis and management of systemic autoimmune rheumatic disease-related interstitial lung disease: British Society for Rheumatology guideline scope (2024)

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Type of publication:
Journal article

Author(s):
Hannah, Jennifer; Rodziewicz, Mia; Mehta, Puja; Heenan, Kerri-Marie; Ball, Elizabeth; Barratt, Shaney; Carty, Sara; Conway, Richard; Cotton, Caroline V; Cox, Sarah; Crawshaw, Anjali; Dawson, Julie; Desai, Sujal; Fahim, Ahmed; Fielding, Carol; *Garton, Mark; George, Peter; Gunawardena, Harsha; Kelly, Clive; Khan, Fasihul; Koduri, Gouri; Morris, Helen; Naqvi, Marium; Perry, Elizabeth; Riddell, Claire; Sieiro Santos, Cristiana; Spencer, Lisa G; Chaudhuri, Nazia; Nisar, Muhammad K.

Citation:
Rheumatology Advances in Practice. 8(2):rkae056, 2024.

Abstract:
Interstitial lung disease (ILD) is a significant complication of many systemic autoimmune rheumatic diseases (SARDs), although the clinical presentation, severity and outlook may vary widely between individuals. Despite the prevalence, there are no specific guidelines addressing the issue of screening, diagnosis and management of ILD across this diverse group. Guidelines from the ACR and EULAR are expected, but there is a need for UK-specific guidelines that consider the framework of the UK National Health Service, local licensing and funding strategies. This article outlines the intended scope for the British Society for Rheumatology guideline on the diagnosis and management of SARD-ILD developed by the guideline working group. It specifically identifies the SARDs for consideration, alongside the overarching principles for which systematic review will be conducted. Expert consensus will be produced based on the most up-to-date available evidence for inclusion within the final guideline. Key issues to be addressed include recommendations for screening of ILD, identifying the methodology and frequency of monitoring and pharmacological and non-pharmacological management. The guideline will be developed according to methods and processes outlined in Creating Clinical Guidelines: British Society for Rheumatology Protocol version 5.1.

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Lung Ultrasound for Diagnosis of Primary Graft Dysfunction in Lung Transplantation Recipients (2024)

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Type of publication:
Conference abstract

Author(s):
O'Brien E.; Curry S.; Rubino A.; Barker A.; *Miller A.; Parmar J.

Citation:
Journal of Heart and Lung Transplantation. Conference: ISHLT 44th Annual Meeting and Scientific Sessions Prague Congress Centre. Prague Czechia. 43(4 Supplement) (pp S345), 2024. Date of Publication: April 2024.

Abstract:
Purpose: To determine if lung aeration scores calculated using LUS correlate with the identification and grading of PGD in lung transplantation recipients identified on bedside chest radiography (CXR) and PaO2/FiO2 as the reference standard. Method(s): This is a two-year, single-centre, prospective observational study investigating lung transplantation patients admitted post-operatively to Critical Care at Royal Papworth Hospital (RPH). LUS assessments to examine 12-lung regions were conducted at specified timepoints and scored retrospectively. Differences between LUS aeration scores for PGD and non-PGD were tested for and correlation of LUS score and PGD grading was assessed. Result(s): To date, data has been collected from 29 consecutive adult patients in 12 months. A total of 816 lung ultrasound clips have been collected for analysis. The mean aeration scores in PGD patients was higher than non-PGD (t(42) = 4.58, p < 0.001). PGD severity grading and LUS score shows a moderate positive linear association r(42) =.67, p < 0.01. Conclusion(s): This interim data analysis demonstrates exciting potential of LUS as an imaging modality in this cohort for PGD. This study is set to continue for a further 12 months, to allow for a larger sample size and further analysis of the utilisation of LUS in this cohort.