Lynn McDonnell

British Thoracic Society guidelines for home oxygen use in adults

The British Thoracic Society (BTS) Home Oxygen Guideline provides detailed evidence-based guidance for the use of home oxygen for patients out of hospital. Although the majority of evidence comes from the use of oxygen in patients with chronic obstructive pulmonary disease, the scope of the guidance includes patients with a variety of long-term respiratory illnesses and other groups in whom oxygen is currently ordered, such as those with cardiac failure, cancer and end-stage cardiorespiratory disease, terminal illness or cluster headache. It explores the evidence base for the use of different modalities of oxygen therapy and patient-related outcomes such as mortality, symptoms and quality of life. The guideline also makes recommendations for assessment and follow-up protocols, and risk assessments, particularly in the clinically challenging area of home oxygen users who smoke. The guideline development group is aware of the potential for confusion sometimes caused by the current nomenclature for different types of home oxygen, and rather than renaming them, has adopted the approach of clarifying those definitions, and in particular emphasising what is meant by long-term oxygen therapy and palliative oxygen therapy. The home oxygen guideline provides expert consensus opinion in areas where clinical evidence is lacking, and seeks to deliver improved prescribing practice, leading to improved compliance and improved patient outcomes, with consequent increased value to the health service.

Effectiveness, Attendance, and Completion of an Integrated, System-Wide Pulmonary Rehabilitation Service for COPD: Prospective Observational Study

Abstract Pulmonary rehabilitation (PR) is one of the most effective treatments for COPD but not widely available. Uptake is poor and completion rates are low. In this integrated PR service we report on effectiveness, attendance, and completion of twice weekly rolling recruitment and once weekly cohort recruitment programmes in two hospital and five community PR sites. The hospital and two of the community programmes were ‘rolling’ recruitment twice weekly for 8 weeks. Three community programmes ran in once weekly cohorts for 8 weeks. Predictors of attendance, completion and effectiveness were sought. 1114 eligible COPD patients were referred. 812 (73%) attended assessment, 656 (59%) started and 441 (40%) completed. Significant improvements were seen in incremental shuttle walk test (ISWT) (mean 68.3 m; 95%CI 59.3–77.4), Chronic Respiratory Questionnaire self-report dyspnoea scale (CRQ-SR) (0.94; 0.80–1.07), Hospital Anxiety and Depression Scale anxiety (0.9; 0.5-1.2) and depression (1.1; 0.8–1.4) components, exceeding the minimum clinically important difference for ISWT and CRQ-SR. Twice weekly compared with once weekly programmes showed similar improvement. Patients were less likely to complete if they were deprived (4th quintile of deprivation 0.56; 0.33–0.94, 5th quintile 0.57; 0.34–0.85), reported MRC dyspnoea scale 4 (0.61; 0.37–0.97) or 5 (0.39; 0.16-0.93), or had been referred by their general practitioner (0.42; 0.24–0.74) (pseudo R2 0.103). PR is effective for COPD in real-world practice achieving results comparable to trials. Low rates of attendance and completion of PR were not explained by demographic characteristics, disease severity, psychological morbidity and source of referral despite the large number of participants.

BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults

### Principles of mechanical ventilation #### Modes of mechanical ventilation Recommendation 1. Pressure-targeted ventilators are the devices of choice for acute NIV (Grade B). Good practice points #### Choice of interface for NIV Recommendation 2. A full face mask (FFM) should usually be the first type of interface used (Grade D). Good practice points #### Indications for and contra-indications to NIV in AHRF Recommendation 3. The presence of adverse features increase the risk of NIV failure and should prompt consideration of placement in high dependency unit (HDU)/intensive care unit (ICU) (Grade C). Good practice points #### Monitoring during NIV Good practice points #### Supplemental oxygen therapy with NIV Recommendations 4. Oxygen enrichment should be adjusted to achieve SaO2 88–92% in all causes of acute hypercapnic respiratory failure (AHRF) treated by NIV (Grade A). 5. Oxygen should be entrained as close to the patient as possible (Grade C). Good practice points

Pulmonary rehabilitation and sleep quality: a before and after controlled study of patients with chronic obstructive pulmonary disease.

Background:Poor sleep quality is common in chronic obstructive pulmonary disease (COPD). It is associated with poor quality of life. Pulmonary rehabilitation (PR) improves quality of life, exercise capacity, and anxiety and depression. Its effect on sleep quality is uncertain.Aim:To determine whether PR improves sleep quality in COPD.Methods:A prospective controlled ‘before and after’ study of sleep quality in COPD patients attending a community PR programme was conducted. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). Lung function, disease-specific quality of life (COPD assessment test—CAT), exercise capacity (incremental shuttle walk test—ISWT), and anxiety and depression (Hospital Anxiety and Depression Scale—HADS) were measured. Change in sleep quality was compared with a COPD control group.Results:Twenty-eight participants completed PR. The control group comprised 24 patients. Prevalence of poor sleep quality (PSQI ⩾5) was 78%. There were no differences between observation and control groups in sleep quality, age or severity. Quality of life was strongly correlated with quality of sleep (r=0.64, P<0.001). PR improved the quality of life (CAT change 3.0; 95% CI, 0.7–5.3), exercise capacity (ISWT change (metres) 81.0; 15.3–146.6), anxiety (HADS score ⩾8: change 2.33; 0.45–4.22), and depression (HADS score ⩾8: change 2.90; 1.92–3.88). PR did not improve sleep quality (PSQI mean change 0.79; −0.35 to 1.93).Conclusions:PR did not improve sleep quality in COPD despite improving quality of life, exercise capacity, anxiety and depression. New strategies, independent of PR, are required to improve sleep quality in COPD.

British Thoracic Society/Intensive Care Society Guideline for the ventilatory management of acute hypercapnic respiratory failure in adults

The British Thoracic Society (BTS) published the guideline ‘The use of non-invasive ventilation in acute respiratory failure’ in 2002.1 This was in response to trials that had demonstrated that non-invasive ventilation (NIV) was an alternative to invasive mechanical ventilation (IMV) in life-threatening respiratory acidosis due to acute exacerbations of chronic obstructive pulmonary disease (AECOPD). It drew attention to evidence that, when NIV was used in the less severely unwell patient, it also limited progression to more severe respiratory failure.2 The trial also demonstrated the feasibility, of delivering NIV on general medical or admission wards that had enhanced support and when staff were provided with ongoing training. In subsequent years, NIV has been shown to deliver better rather than equivalent outcomes to invasive ventilation in AECOPD and better evidence has accumulated for the use of NIV in non-COPD disease in the intervening years. Repeated national audits have, however, raised concerns that expected patient benefit is not being delivered and have pointed to a number of process deficiencies.3–5 There is also the risk, in the absence of justifying trial evidence, that the preferred use of NIV in AECOPD might be extended to all hypercapnic patients, irrespective of circumstance or underlying disease process. That this is a real risk might be inferred from the BTS audits where the indication for NIV was not COPD in over 30% of cases.3 ,4 NIV development in the UK has been largely outside the organisational ‘umbrella’ of critical care. This may have adversely affected resource allocation and contributed to a lack of integration in NIV and IMV patient pathways. Other unintended consequences might be a restriction on access to invasive ventilation and delay in the development of extended applications of NIV, such as accelerating extubation and its use in the management of …

M25 Has the new contract delivered better ambulatory oxygen devices for patients? A London perspective

Background In 2012 changes in the home oxygen service (HOS) contract offered patients the potential to benefit from new technology designed to assist ambulatory oxygen (AO) use, such as liquid oxygen (LOX) and refillable cylinders (Homefill). Prior to the change in contract only three services were thought to be commissioned in London (serving approximately 10,000 HOS users, costing £10.5m), with many areas attempting to meet increasing demand with no increase in resources. Aim To determine the service provision, commissioning arrangement and assessment protocols for AO across London Establish an AO network across London Methods A telephone audit was carried out in January-March 2013 with all known oxygen assessment centres in London. Two clinicians used an agreed proforma, with email follow-up. The interview included questions regarding; commissioning/funding; location; access to service, referrals and pathway; assessment protocol; disciplines/grades; and integration with respiratory services. Results 34 interviews were performed across the 32 London boroughs. Key findings are: Access: Two boroughs had no service, some had multiple. Who: In 20 teams nursing staff assessed; 15 teams, physiotherapists; and 7 teams, respiratory physiologists. Where: 16 assessed in the hospital, 9 in the community and 7 in both. How: The majority (94%) performed the 6MWT, however teams that assessed in the home did not use validated reproducible exercise tests. Equipment for assessment: The majority had standard cylinders (88%); 53% had lightweight and conservers; and other devices were rarely (3–13%) available. Size: 16 services (47%) carried out less than 5 assessments per month. Funding: 47% have some arrangements in place, 29% had no funding or no service provided and 24% unclear. Integration: 67% were part of an integrated service, 18% stand alone, 12% unclear and 6% had no service. Conclusions Service provision for AO across London is varied, with no standardised referral pathway, assessment protocol and often limited range of equipment available for assessment. This raises concerns over access to services, clinical assessment skills/competencies and unsuitable prescriptions. Approximately half of the services have no or unclear funding arrangements and although the majority of services (67%) are integrated within a wider COPD/IRS there was no established network and many clinicians felt isolated.