Sharon Mitchell

Respiratory health in a total very low birthweight cohort and their classroom controls.

AIMS: To compare the respiratory health and function at 8 to 9 years of age of a total population based cohort of 300 very low birthweight (VLBW) children with that of two classroom controls (n = 590) matched for age and sex. STUDY DESIGN: Cohort study with controls. SETTING: Schools throughout Scotland. RESULTS: The VLBW children were more likely than their peers to use an inhaler, to be absent from school, and to be admitted to hospital because of respiratory illness. They were significantly shorter than their classroom controls, but even after adjusting for differences in height, the VLBW children had reduced forced vital capacity (FVC); this was associated with a history of prolonged ventilation (> 28 days) and pneumothorax in the neonatal period. There were no significant differences between the groups in forced expiratory volume in one second (FEV1)/FVC but twice as many (7.9% v 3.7%) of the VLBW children had ratios < 70%, denoting obstructive airways disease. Poor expiratory function was associated with neonatal respiratory distress syndrome, prolonged ventilation, and the need for > 40% oxygen. Exercise induced airway narrowing was increased in VLBW children (odds ratio = 2.0; 95% confidence interval 1.2 to 3.4) and was very little changed by adjustment for inhaler use and exposure to cigarette smoke. CONCLUSIONS: As in other low birthweight cohorts, respiratory morbidity was increased. Unlike previous studies, FVC was more affected than expiratory function in this VLBW population. Our findings support the hypothesis that poorer lung function is associated with very low birth weight, but not with intrauterine growth retardation.

Harmonising spirometry education with HERMES: training a new generation of qualified spirometry practitioners across Europe

“Hundreds of millions of people of all ages suffer from preventable chronic respiratory diseases and respiratory allergies in all countries of the world… accounting for 4 million deaths annually” 1. The considerable toll of respiratory diseases in terms of quality of life, disability of patients and indeed premature death 2 underlines the importance of spirometry in the detection and monitoring during the management of respiratory disease. Yet, in the past two decades, there have been specific concerns of under-utilisation in screening 3, lack of training 4 and misdiagnosis based on inaccurate results 5, 6 which only serve to document the inadequacies in spirometry practice not only within Europe but on a world-wide scale. An abundance of reports 2–8 has propelled quality issues in the practice of spirometry to centre stage and consequently introduced a number of quality improvement strategies. High-quality spirometry relies on three key determinants: 1) documented guidelines in spirometry, 2) access to quality spirometers, and finally, 3) trained and qualified spirometry practitioners 9. To some degree, the ERS/ATS guidelines in standardisation of spirometry 10 and availability of affordable spirometers across medical settings have directly addressed these first two factors. Further efforts implemented in the US by NIOSH (National Institute for Occupational Safety and Health), in several European countries, as well as across New Zealand and Australia through ANZSRS (Australian and New Zealand Society of Respiratory Science) have produced comprehensive training structures with supporting documents and certification criteria to endorse health professionals with a qualification to practice high-quality spirometry. There is some evidence which consistently shows that competence in spirometry is the key to quality services 7, 11, 12, but access to such training and assessment is relatively limited. Adopting HERMES (Harmonising Education in Respiratory Medicine for European Specialists) as …

Sleep HERMES: a European Core Syllabus in respiratory disorders during sleep

The clinical characterisation and description of the obstructive sleep apnoea–hypopnoea syndrome (OSAHS) and related syndromes were mainly revealed by several epidemiological studies conducted over the past fifty years. These highly prevalent syndromes affect about 9% of middle-aged men and 4% of women. These syndromes have serious medical and social consequences, such as cardiovascular or metabolic diseases, and even premature death. Consequently, respiratory sleep medicine (RSM) evolved and has progressed rapidly within the sleep medicine field over recent decades. New diagnostic and therapeutic techniques have appeared in response to an increasing number of patients and clinical interventions. The research progressed to focus not only on the clinical and pathophysiological but also the genetic and molecular aspects of these syndromes [1–6]. Nevertheless, the literature in the field does not provide any clear consensus on diagnostic classification and assessment. No harmonised standards of training exist across Europe for respiratory sleep medicine. The European Respiratory Society (ERS) provided external and postgraduate courses but the requirements and expectations in the field were not being fulfilled. There was a need for a project supporting both the teaching and certification. For this reason, ERS supported an application for a Sleep Harmonised Education in Respiratory Medicine for European Specialists (HERMES) Task Force project which aimed at establishing common standards in respiratory sleep training and education, in an adaptable framework which can be extended across Europe. HERMES was a project established in 2005 to provide documentation for the training and certification of adult respiratory specialists. Since 2005, the HERMES framework has been adapted for projects including paediatric respiratory medicine, critical care medicine and the development of the European Spirometry Driving Licence (spirometry). Within the HERMES model, a process of establishing consensus standards for training largely follows four key phases (fig. 1). In line with this …

A core syllabus for post-graduate training in respiratory physiotherapy

Physiotherapy contributes significantly to improving quality of life for patients with respiratory disease [1, 2]. Physiotherapists specialised in dealing with respiratory pathology and its associated problems are not only central in the delivery of pulmonary rehabilitation but also provide strategies and techniques for exercise testing, airway clearance, breathlessness management, mobility and function improvement and pain management [2]. Published evidence-based recommendations have paved the way for standardised practice [1–6] while also unravelling the extended scope of responsibilities of the respiratory physiotherapist [7]. The breakdown of traditional roles and allocation of new responsibilities is not confined to the respiratory physiotherapist within healthcare systems. Team-based healthcare and interprofessional treatment of patients is prevalent in the provision of care across the globe. New methods of healthcare delivery indicate that tasks are entrusted to those deemed competent to perform them [8]. It has therefore been necessary to train allied health professionals to take over parts of clinical care [9]. Mobility of the healthcare workforce has been at the forefront of discussion among healthcare providers and policy makers [10]. We now live in a “global village” [11], the consequence of which has seen a marked increase in health professionals completing part of their training and work experience abroad [10]. In this transition to international healthcare, more and more institutions, countries and regions will need standards to meet public, patient and healthcare provider expectations. This reform in medical practice is thus motivated by the breakdown of traditional roles and responsibilities within the healthcare system [12], increasing trends towards mobility [13] and more complex patient needs. These motivators for change have emphasised a new reality for healthcare systems bounded by a skilled healthcare …

Sleep HERMES: a European training project for respiratory sleep medicine

The clinical characterisation and description of the obstructive sleep apnoea/hypopnoea syndrome (OSAHS) and related syndromes have been revealed by several epidemiological studies conducted in the late 20th and 21st centuries. These highly prevalent syndromes affect about 9% of middle-aged males and 4% of females. These syndromes have serious medical and social consequences, such as cardiovascular or metabolic diseases and even premature death. Consequently, respiratory sleep medicine has evolved and progressed rapidly within the sleep medicine field over the last decades. New diagnostic and therapeutic techniques appeared in response to an increasing number of patients and clinical interventions. The research progressed to focus not only on the clinical and pathophysiological, but also on the genetic and molecular aspects of these syndromes [1–4]. Nevertheless, the literature in the field does not provide any clear consensus on diagnostic classification and assessment. No harmonised standards of training exist across Europe for respiratory sleep medicine. The European Respiratory Society (ERS) conducted a survey in 2010 to enquire about the structure and organisation of training in different countries within Europe. National experts in the field of respiratory sleep medicine from 21 different countries were consulted. They were first asked about the duration of training in respiratory disorders during sleep. A huge diversity in training organisations and durations was revealed. Across 18 collected responses, it was observed that nine countries do not have any specific training for the specialty. Those countries are Luxembourg, Belgium, Denmark, Greece, Sweden, Poland, Cyprus, Ireland and the UK. On the contrary, training is organised in the Czech Republic, Germany, Romania, Spain, Lithuania, Finland, Austria, the Slovak Republic and Lithuania but could last from 1 week to 12 yrs. Moreover, except for the UK and the …

ERS European Spirometry Train-the-Trainer programme: good trainers are made, not born

The most commonly used pulmonary function test is spirometry. This test measures how much air you can breathe in and out and how quickly you can move air out of your lungs. Spirometry is a powerful tool for the diagnosis and monitoring of asthma and COPD and its use is recommended by international guidelines for asthma and COPD [1–3]. The updated NICE guidelines of 2010 state that all health professionals managing patients with COPD should have access to spirometry and must be trained and competent in its use and interpretation. The increased availability of spirometers has led to improved access in primary care. Spirometry appears to be a simple test; however, it depends upon the quality of equipment and patient cooperation and, foremost, requires highly trained and competent staff to perform and evaluate the test correctly. Many European countries have shown a growing interest to regulate the quality of spirometry education. The American Thoracic Society/European Respiratory Society (ERS) Task Force on Standardisation of Lung Function Testing [4] recommends a standard training similar to the National Institute for Occupational Safety and Health-approved spirometry programme in the USA, which includes the fundamentals of spirometry standards and hands-on training. Competency is demonstrated by passing a written and practical examination in the presence of an experienced instructor. To assess the current situation of spirometry training in Europe, an online survey was carried out in 2008 by the ERS. This survey showed that, due to a lack of well-structured training opportunities, 94% of the respondents identified a need for standardised training courses. The results of this survey launched the European Spirometry Driving Licence (ESDL) HERMES (Harmonised Education of Respiratory Medicine in European Specialties) project. The aim …

“Education is the passport to the future”: enabling today’s medical teachers to prepare tomorrow’s respiratory health practitioners

“ If we are to achieve results never before accomplished, we must expect to employ methods never before attempted ” Sir Francis Bacon 1561–1626. British aviators Alcock and Brown made the first transatlantic flight in 1919 – In 2013, the total number of flights in Europe was 9.5 million. In July 1969, Apollo 11 Commander Neil Armstrong landed on the moon – today you can book your flight to space online with Virgin Galactic. Throughout the 1990s, medical education was transformed as a direct consequence of more complex patient needs and the reorganisation of healthcare delivery. Medical education refers to the educational process required to prepare the medical professional for entry into practice as well as provision of educational activities for lifelong learning. This educational process is aimed at physicians, nurses, technicians, physiotherapists, scientists and other related professions who deliver care to the patient and public. Today’s medical professional is bound by demanding healthcare systems [1–3], internationalisation of localised diseases [4], shorter more intense training periods and dependence on medical technology [5]. Global funds, trade and networks are all examples of initiatives that demonstrate our entry into an international, mobile era. In 1993, the European Council (EU) council directive 93/16 stipulated that those EU nationals holding an EU primary or specialist medical qualification were to be allowed to practice within any EU country [6]. We are aware that many European countries are heavily reliant on foreign-trained medical staff to support their medical systems [7]. Patient tourism has also warranted attention [8], as more and more patients opt to cross international borders in search of treatment. The European Respiratory Society (ERS) International Congress welcomes respiratory health professionals from all over the world. As a provider of continuous …

Respiratory Sleep HERMES: new considerations in project development

The respiratory sleep HERMES task force: Wilfred de Backer, Paolo Palange, Anita Simonds, Stefan Andreas, Johan Verbraecken, Winfried Randerath, William Donic, Renata Riha, Mary Morrell, Ha Trang, Patrick Levy, Walter Mc Nicholas, Marisa Bonsignore Launched in 2009, the European Respiratory Society (ERS) Respiratory Sleep HERMES project aimed to design and implement core educational activities supported by a network of initiatives to standardise training and education in respiratory sleep medicine (fig. 1). Figure 1 The HERMES structure for developing standardised training and education in specialist areas of respiratory medicine. Using the framework established by HERMES, the project task force has begun to move through each development phase successfully publishing a syllabus of what a respiratory sleep specialist should know [1], and supporting these modules through the publication of the ERS Handbook of Respiratory Sleep Medicine [2]. Perhaps the greatest challenge of the HERMES initiative is the application of a standardised methodology to medical specialties that are in essence different. To date, seven HERMES projects have been launched (fig. 2). The training characteristics vary from skills-based training, services-based training and sub-specialty or tertiary-based training. For each project, all healthcare professionals are considered from medical physicians and multidisciplinary teams to non-medical practitioners. Figure 2 HERMES Project family 2005–2012. The purpose of this editorial is to revisit how the …

Doctors on the move: a European case study on the key characteristics of national recertification systems

Objectives With increased cross-border movement, ensuring safe and high-quality healthcare has gained primacy. The purpose of recertification is to ensure quality of care through periodically attesting doctors’ professional proficiency in their field. Professional migration and facilitated cross-border recognition of qualifications, however, make us question the fitness of national policies for safeguarding patient care and the international accountability of doctors. Design and setting We performed document analyses and conducted 19 semistructured interviews to identify and describe key characteristics and effective components of 10 different European recertification systems, each representing one case (collective case study). We subsequently compared these systems to explore similarities and differences in terms of assessment criteria used to determine process quality. Results Great variety existed between countries in terms and assessment formats used, targeting cognition, competence and performance (Miller’s assessment pyramid). Recertification procedures and requirements also varied significantly, ranging from voluntary participation in professional development modules to the mandatory collection of multiple performance data in a competency-based portfolio. Knowledge assessment was fundamental to recertification in most countries. Another difference concerned the stakeholders involved in the recertification process: while some systems exclusively relied on doctors’ self-assessment, others involved multiple stakeholders but rarely included patients in assessment of doctors’ professional competence. Differences between systems partly reflected different goals and primary purposes of recertification. Conclusion Recertification systems differ substantially internationally with regard to the criteria they apply to assess doctors’ competence, their aims, requirements, assessment formats and patient involvement. In the light of professional mobility and associated demands for accountability, we recommend that competence assessment includes patients’ perspectives, and recertification practices be shared internationally to enhance transparency. This can help facilitate cross-border movement, while guaranteeing high-quality patient care.

Development of a syllabus for postgraduate respiratory physiotherapy education: the Respiratory Physiotherapy HERMES project.

Best practice in the diagnosis and management of patients with respiratory conditions is now a multidisciplinary effort [1, 2]. Physiotherapists engage in many aspects of the care of patients with respiratory diseases. Across a range of diseases, ages and settings, they carry out highly specialised treatments related to mucus clearance, breathing exercises, invasive and non-invasive mechanical ventilation, exercise training and rehabilitation, as well as reintegration of patients with respiratory disorders. Their tasks span from the neonatal intensive care unit to the palliative care unit of geriatric patients. Over the past decades, respiratory physiotherapists across the world have published research in all these fields feeding into the evidence base that underpins much of the care provided by these professionals. Physiotherapy practice has also evolved over the past few decades. Self-referral by service users (patients) is now possible in approximately half of the European member states of the World Confederation on Physiotherapy [3]. This requires highly trained health professionals capable of assessing, treating, referring and reintegrating patients. In patients with respiratory conditions, this is often performed in the context of a multidisciplinary team. The Respiratory Physiotherapy HERMES project aims to standardise treatment of patients within and beyond Europe http://ow.ly/L1e72