Inside this issue:

‘How-to guide’ to Measurement Kate Cheema

1-2

Home NIV Jo Congleton

3-4

NIV - Patient Experience 5

New Poll - Home NIV services 5

Singing for Life –Project Report

Stephen Clift 6-7

Making it a dozen

12th Asthma Top Tip 8

World No Tobacco Day, News 9-10

June 2013

Edition 19 Breathing Matters Newsletter of the Respiratory Programme

Kent Surrey Sussex

Keeping up with Government strategy of moving away from targets to focusing on outcomes, Kate Cheema gives guidance on how to measure these. Those who attended our PR Network meeting on 13th April will have benefitted from Kate’s advice on collecting data to support pulmonary rehabilitation programmes, but the principles apply to other clinical settings and we hope the articles gives you something to ponder. The provision of Home NIV is increasing and is increasingly a locally delivered service so you are more likely to come across patients on this therapy. We thought it a good topic for this edition’s educational piece. The accompanying piece by one of Lisa Vincent-Smith’s patients gives a view from ‘the other side of the machine.’ And Julia Bott reports on the recent National Home NIV meeting at The Lane Fox Unit. Innovative ideas are always stimulating and we include a report on a feasibility study on Group singing for COPD carried out in the Kent area. It’s really good to get feedback (reassures us that some people read this) and we had a great sug-gestion for the 12th point in our ‘Asthma Out of Control Checklist’ from Alex Hough, Physiotherapist. Alex wins a bottle of bubbly, well done for making our list a neat dozen. We hope you find something of interest in this edition, if you do have any comments (good or bad, we can take it) you know where to send them to: Eva.Lazar@nhs.net

Continue on page 2

A ‘how-to’ guide to measurement Why Measure?

In a busy clinical environment it can

sometimes seem rather burdensome to

worry about measuring what you are

doing, rather than just doing it, but there

are two really good reasons why it is so

important:

1. If we strive to continuously improve

the service we deliver to patients then

we must measure it or otherwise we

don’t know if we’ve actually made any

improvement

2.In order to maintain an efficient and

financially viable service there are mini-

mum reporting requirements which

must be made in order to assess things

like value for money and meet the mini-

mum requirement of our commissioners

This short guide will give you some of

the basic pointers you will need to

make sure you record the information

you require. This isn’t an exhaustive

guide and should be seen as a ‘starter

for ten’.

Kate Cheema Specialist Information Analyst

Quality Observatory

be a core set of what you want to report

on further down the line. Thinking

about what you will eventually want to

report now could save a lot of time later.

Equally, thinking about what you don’t

need is as important; there is a tempta-

tion to collect everything you can think

of but this can often take up lots of time

recording data you don’t eventually

need.

How, who, and when?

It is worth spending a bit of time plan-

ning the how, who and when of record-

ing data. You may wish to ask yourself

the following questions:

▪ At what point in the care pathway do

you record data? At the point of care or

in a ‘batch’ at the end of the day from

casenotes? How often do you need to

report; monthly, quarterly?

▪ Who within the team will be collecting

or collating data? Is there just one per-

son or a group of people? Will they all

need access to the same files at the

same time?

Think ahead!

Before you do anything else, you

should plan what you actually need to

record. Whilst this may change slightly

over time as requirements change (for

example your commissioners require

additional information) there is likely to

Data Article

Page 2 Page 2

Tools you need:

The main point here is to remember that

data and information doesn’t have to be

complicated to be effective. You can

create a very useful and serviceable data

entry and analysis tool using a simple

Excel spreadsheet. It is beyond the

scope of this particular guide to go into

the detail but if you cover the following

then you’re well on the way:

▪ Have all you data in a single spread-

sheet, organised into columns, with each

column representing a ‘field’ or data item,

and each row representing one patient.

Don’t separate different years or pro-

grammes into different sheets, record that

kind of information in a column in the

spreadsheet.

▪ Learn how to do a pivot table. These

are incredibly powerful inbuilt tools within

Excel that allow you to ‘cut’ your data

however you see fit without having any

impact on the underlying data, no cutting

and pasting required. A good tutorial in

how to use these can be found at:

http://

spreadsheets.about.com/

b/2012/06/01/excel-2007-

pivot-table-tutorial-2.htm

▪ Ensure that you are able to create

charts; it is well known that information

presented graphically is much more po-

tent than tables of numbers. Again use

Excel’s substantial charting ability to cre-

ate simple charts of the data that’s most

important to you.

Planning the output:

Before you do any analysis or try to chart

anything, go back to your original plan of

what you needed to report. In this in-

stance less is more; showing a simple

dashboard of 5-6 key measures is far

more effective than creating a huge table

with everything in it. Have a think about

the message you want to convey and to

whom. For example if you are creating

something for internal team use that will

be very different from creating an activity

report for the local commissioners.

Again thinking things through at this

stage will make life less messy and re-

duce the overall time spent fiddling with

numbers.

▪ How will you record the data? Do you

already have a system in place to capture

it or do you require something extra? If

something additional is needed, can you

record the data electronically or is it collat-

ed from a paper-based system?

Thinking through these kinds of issues

now can help you to streamline the pro-

cess of data collection and reduce the

burden.

Basic rules for recording:

Now you have decided what you need to

record and how, there are some very sim-

ple rules that can be applied to your data

collection to help the next stage (reporting

and analysis) much simpler and also

much increase the accuracy of the data:

▪ Limit the amount of free-text items you

have; free text is notoriously difficult to

analyse effectively and different people

use it in different ways

▪ Make use of simple categories, for ex-

ample for diagnosis you might have

COPD, Bronchiectasis, Asthma, Sarcoido-

sis, Other. These can then be applied in a

uniform way by all people inputting the

data.

▪ If you have lots of categories, it is recom-

mended that you create a ‘data dictionary’

essentially a list of categories you use, for

others to use as reference

▪ If using Excel, make use of the data vali-

dation tools; these can help you create

rules to ensure that incorrect or invalid

data isn’t entered. Use drop down menus

to enable people to choose from a list of

options.

▪ Use a single date format throughout (e.g.

dd/mm/yyyy); use the validation tools to

enforce this if you are using Excel.

Data entry is easiest for the inputter, and

much easier to analyse, if it is at the low-

est level of aggregation, usually the pa-

tient. This may seem obvious but there

are many examples of people trying to use

aggregated (e.g. by month) data sets in-

correctly.

Showing the data…

How you choose to show your data will be

based on a range of factors:

▪ The audience you are creating it for

▪ The purpose it is to be used for

▪ Corporate style & preferences

▪ The story you want to tell with it

This final point is crucial; if you are trying

to tell a story of a continuously improving

service with loads to offer then you will

want to accentuate improvements over

time through the use of run (line) charts,

whilst if you wanted to make a point about

high referral rates from a particular prac-

tice then a bar chart with each practice

represented by a single bar would be best.

It is tricky to give absolute guidance on

presentation, given the variety of ap-

proaches but the following are most defi-

nitely top tips:

▪ Keep the display simple; try not to use

multiple lines on a single chart, they start

to look like spaghetti! As a rule of thumb,

try not to exceed three lines on a chart.

▪ If you are using multiple measures to tell

your story, see if you can get them on a

single page.

▪ Research suggests that colour is not

always the best way to indicate different

lines or bars on a chart so use it sparingly

▪ Avoid pie charts, if you have proportional

(%) data put it in a table instead

▪ Test your display on other people (‘The Granny Test’).

If they cannot see what you are trying to say then your audience may not either!

Simple display is often best

(name of location) PR completion rate

Educational Article Page 3

Home Non Invasive Ventilation

Acute Respiratory Failure

As we have discussed previously ventilation is an interven-tion that is appropriate when there is respiratory pump failure, manifest not only by a fall in arterial oxygen level but also by a failure of the lungs to clear carbon dioxide leading to a rise in pCO2. If this happens quickly (as in an acute exacerbation of COPD) this leads to acidosis as it shifts the equation be-

low towards the right.

Chronic Respiratory Failure

When pump failure occurs more slowly (over weeks and months) the buffering system of the blood means that the body is protected from developing acidosis by compensatory retention of bicarbonate by the kidneys (to ‘buffer’ or combine with the H+ ions) so the adverse effect of acidosis is avoided. However pCO2 still rises and this, in time, will lead to reduced cerebral function, drowsiness, morning headaches and fluid retention. (The mechanism of the fluid retention is not well understood despite the clinical syndrome of cor pulmonale recognized for many years. It is probably linked to the renin-

angiotensin system.)

Home NIV

Long term ventilation was first used in the polio epidemic and negative-pressure ventilators (such as the Iron Lung or Tank Ventilator) were used at home to manage chronic respiratory failure. It was not until the early 1980s that non-invasive posi-tive pressure home ventilators started to be used in this situa-tion. There are still a few home NIV patients on negative pres-sure devices (e.g. the cuirass device) but positive pressure NIV is the standard mode used now. Ventilation is lowest for all of us when we are asleep (respiratory rate falls as does tidal volume so the minute ventilation falls). This is why in the early stages of chronic respiratory failure the situation can be controlled by the patient using NIV overnight. If their condition worsens (this is inevitable in many of the conditions that Home NIV is used for) there will come a time when nocturnal NIV alone will not be sufficient to maintain pCO2 at a satisfactory level and there will be a requirement for NIV to be used for longer and longer. However many conditions are slowly pro-gressive or non-progressive (e.g. COPD and stable chest wall disease) and nocturnal NIV may stabilize pCO2 levels for

some time

Minute Ventilation (l/min) = Tidal Volume (L) x Respiratory Rate

Jo Congleton Consultant Respiratory Physician

Carbon dioxide (CO2) combines with water (H2O) to form carbonic acid (H2CO3), which in turn

rapidly dissociates to form hydrogen ions (acid)

and bicarbonate.

Any disturbance of the system will be compensated by a shift in the chemical equilibrium (Le Chatelier’s principle). When there is hypoventilation blood CO2 level rises as it is not cleared by the lungs and some of the excess combines with water to form carbonic acid. Some of the excess carbonic acid will dissociate to bicarbonate and hydrogen ions (H+). pH is the negative log of H+ concentration i.e. this shift of the equation to the right will cause the pH to fall until the body’s regulatory systems have time to kick in and compensate for

this change.

Acidosis leads to failure of tissue respiration reduced func-tioning of vital organs leading to further deterioration and then death if it is not reversed. In addition the rising CO2 level leads to CO2 narcosis contributing further to pump fail-ure. This situation requires rescuing swiftly with medication

and augmentation of ventilation.

Continue on page 4

Many of you will be familiar with the use of Non-Invasive Ventilation (NIV) in the context of acute exacerbation of COPD with hypercapnic

acidotic respiratory failure (see in BM 2012 October), however you are probably also aware that NIV is also used at home in some patients.

The use of this mode of treatment is likely to increase, in part because the size of the average person increasing!

This article gives an overview of home NIV and in particular indicates when you should be thinking about referring your patient

for consideration for home NIV. First a little refresher on acute and chronic respiratory failure:

Educational Article Page 4

This difference in outcome in differing conditions was demon-strated in a study of 180 patients over 5 years from the Brompton Hospital1 Fig 1. If the condition is largely non-progressive e.g. post pneumonectomy then the prognosis is excellent. If there is a progressive underlying condition (e.g. COPD) NIV will only be able to control ventilation for so long. Note that once hypercapnia develops in bronchiectasis this indicates a very poor prognosis despite ventilatory support. The NIV machines used are essentially the same as used for AECOPD but as there is a range of machines the Home NIV centres will aim to match the machine that best suits the pa-tient and their condition. Most will have a machine that they tend to use first line for patents but you will come across a range of machines and also interfaces. (The bit that

‘interfaces’ with the patient’s nose and or mouth).

Box 1

Respiratory Conditions Where Chronic Hypercapnic Respiratory Failure Occurs and Home NIV may be indicated

Neuromuscular Weakness MND / ALS

Muscular Dystrophies

Chest Wall Abnormalities Kyphoscoliosis

Post chest wall surgery

Reduced lung capacity Previous pneumonectomy Very Severe Airways Disease COPD Bronchiectasis Hypoventilation Obesity Related Hypoventilation Combination of above OSA + COPD i.e. ‘Overlap Syndrome

MND the evidence shows that NIV does not prolong life but can lead to improved symptom control if it is tolerated. (Bulbar problems mean that NIV is more difficult to use.) Alt-hough NIV is used frequently in patients with COPD the evi-dence for its role is rather lacking. Potential benefits could be reduction in hospital admissions by reducing severe exacerba-tions, improvement in symptoms of hypercapnia, and reducing mortality. To date convincing trial evidence on all of these points is lacking. I would strongly encourage you to consider supporting the HOT-HMV trial which compares the outcomes of LTOT vs Home NIV in patients with persistent hypercapnia following an exacerbation of COPD. This is an important question which needs answering and providing evidence is important when we try and make the case for Home NIV provi-

sion for patients. (See next page for entry criteria and contact details.)

It is important to consider the aim of NIV for each patient, see Box 2. There is evidence that supports some of theses situa-tions and conditions but lacking in others. There is good evi-dence that NIV prolongs life significantly in stable chest wall disease. There is evidence that NIV prolongs life in Motor Neurone Disease (MND) however if it is bulbar predominant

Continue on page 5

Nasal pillows type of interface

Figure 1. Probability of continuing nasal intermittent positive pressure ventilation; (NIPPV) in differ-

ent diagnostic groups. KS= kyphoscoliosis; polio =poliomyelitis; COPD = chronic obstructive pulmo-

nary disease; TB = tuberculosis.

Box 2

Aim of home NIV

Symptom control e.g. MND with predominant bulbar component

Reduction in admissions e.g. COPD?

Prolong Life e.g. Stable chest wall disease

Bridge to transplantation e.g. Cystic Fibrosis

When to think of home NIV

If your patient has a condition where pump failure may occur and is clinically deteriorating consider checking ABG to see if there is hypercapnia. Think of checking ABG if fluid retention is developing. Consider screening for respiratory failure in conditions known to progress e.g. MND. For neuromuscular conditions screen with FVC and mouth pressures and use these as a guide to arrange ABG or overnight assessment

with transcutaneous CO2 monitoring.

Educational Article

If significant hypercapnia is confirmed ensure that you and the patient understand what the aim of home NIV would be. If the patient would like to explore this further then referral to a centre providing home NIV for further assessment is ap-propriate. In the past these have been tertiary centres (for our region Royal Brompton Hospital or Lane Fox Unit) but there is a shift to providing this from local centres for non-complex cases or for patients who would find travel difficult – e.g. MND patients. (Ashford Kent and Guildford have been doing this for some time, Medway and St Peter’s Chertsey have started fairly recently). Technical back up arrange-ments need to be in place also a robust system for clinical

support for when there are unexpected problems.

HOT-HMV Trial

CXR of a patient who had a thoracoplasty for TB in 1948 when she was 19, developed respira-

tory failure and commenced on home NIV in 2002 and has remained well and stable since then.

References:

1. Outcome of domicillary nasal intermittent positive pressure ventilation in restrictive and obstructive

disorders. AK Simonds, MW Elliot Thorax 1995;50:604-609

2. Rationale for the use of non-invasive ventilation in chronic ventilatory failure. P M Turkington, M W Elliott Thorax 2000;55:5 417-423 3.The use of non-invasive ventilation in the management of motor neurone disease http://www.nice.org.uk/guidance/CG105

Main Inclusion Criteria

Acute hypercapnic exacerbation of COPD at least 2 weeks previously

Inpatient admission with acute hypercap-nic respiratory failure

>20 pack year history

FEV1 <50%

FEV1/FVC <60%

Chronic hypercapnia (PaCO2 >7kPa)

Chronic hypoxia: PaO2 <7.3kPa or <8kPa with secondary polycythaemia, pulmonary hypertension, peripheral oedema or signif-icant nocturnal hypoxia (SpO2 <90% for >30% sleep time)

Main Exclusion Criteria

Unable to wean off NIV prior to discharge (persistent hypercapnic respiratory failure with pH <7.30)

Post extubation or decanulation

BMI >35 kgm-2

Primary diagnosis of restrictive lung dis-ease causing hypercapnia

Development of worsening hypercapnic respiratory failure with acidosis during ini-tiation of oxygen therapy (ABG - pH<7.30 taken 2-4 hours after waking)

Unable to tolerate NIV (if given) during acute illness

Unstable coronary artery syndrome

Renal replacement therapy

This article scratches the surface of a complex and evolving subject.

For more information see the references below.

To discuss whether your patient is suitable, contact Gill Arbane, Project Coordinator, Lane Fox Unit, email: gill.arbane@gstt.nhs.uk

Breathing Matters

It was interesting to see the results of our poll on

pneumonia mortality. The question we posed was:

‘Are you persuaded that the

SEC EQ Pneumonia Programme has lead to

reduction in mortality of Community Acquired

Pneumonia treated in hospital?’

Here is the result:

67% thought yes

and 33% thought no.

Page 6

As Julia Bott mentions in her report on the

National NIV meeting (see the back page),

there was quite a debate about organisation of

Home NIV.

We would like your view

and this edition's question is:

Do you think Home NIV can be sat-

isfactorily run by local providers as

opposed to tertiary centres?

Click here to vote

poll

At first sight the machine is an underwhelming looking

machine with an easily forgettable name and of almost

Heath Robinson proportions; but first impressions can be

misleading. Let me explain: the main box resembles a

small attaché case from which projects the plastic tube-

at the end of which is the mask. It all looks somewhat

daunting but let me tell you that it’s all rather easy really!

Being unable to sleep at night had left me tired, unfo-

cused, lacking in appetite and challenged. To get a really

good night’s sleep seemed a far off dream! The unlikely

looking machine was to change everything.

My first night using the machine had its problems. My

wife had to fit the mask to my face and make the clip on

attachments work. Over the longer term I would want to

do this myself. Waking up in the middle of the night, with

something that you’d forgotten about, attached to your

face is also somewhat weird; but being calm and carrying

on works wonders. The steady rush of fresh air into my

The Breathing Machine

lungs was what I was

used to experiencing.

It was refreshing,

energy giving and

ensured that I slept

like the proverbial

baby. I now fit the

mask myself and

ensure that it’s work-

ing effectively before

going to sleep.

O.K., this machine ticked someone’s box somewhere-

but for me it was more than a ticked box; it was the

remedy to achieving a good night’s sleep and that

has ensured a massive lift in the quality of my life. I’m

energetic, focused and my appetite’s back. Above all I’m

up for the many challenges that each day brings!

Anon

This account was written by a patient of Dr Lisa Vincent - Smith (Consultant Respiratory Physician, Medway) about their experience of starting on home NIV.

As you will read this particular patient took to it fairly easily and derived good symptomatic benefit.

Breathing Matters

Group Singing for People with COPD

Evidence on the value of regular group singing for people with COPD has been published by researchers at Canterbury Christ Church University.

An observational feasibility study, conducted by the Sidney De Haan Research Centre for Arts and Health, recruited over 100 patients with mild to very se-vere COPD from across East Kent. They participated in weekly singing in one

of six groups over a period of ten months. The St. George’s Respiratory Ques-tionnaire (SGRQ) and two standard spirometry measures FEV1 and FVC (raw

scores and % expected values) were the principal measures.

To date three randomised con-trolled trials examining the value of singing lessons for small groups of patients with COPD have been reported in clinical settings – one in Brazil and two at the Royal Brompton Hospital in London. These studies showed that singing was an acceptable intervention for COPD patients and lead to improvement in self-reported health and quality of life, but no changes in objective measures of lung function or physical exercise capability. All three studies took place in clini-cal settings, involved small num-bers of patients and the groups ran over a short period of time. The Canterbury study in contrast assessed whether singing groups could be established in communi-ty settings and if patients with

COPD would maintain regular involvement over the course of a year. In addition it examined

Stephen Clift Professor of Health Education

Measure n Baseline End of

programme

Mean difference

(95% Cl)

p

value

FEV1 66 1.29 (0.49) 1.32 (0.51) 0.03 (-0.01; 0.58) 0.094

FEV1 %predicted 67 54.34 (20.45) 56.28 (21.98) 1.94 (0.58; 3.30) 0.006

FVC 64 2.43 (0.75) 2.54 (0.075) 0.11 (0.01; 0.20) 0.027

FVC% predicted 65 81.72 (22.60) 85.35 (21.70) 3.63 (0.28; 6.98) 0.034

Table 1

whether groups would be willing to come together for larger cho-ral workshops and public perfor-mances.

Comparisons between baseline measures and assessments after ten months of singing showed significant improvements in the Total and Impact aspects of the

Measure n Baseline End of programme Mean difference (95% Cl) p value

SGRQ total 71 48.71 (16.95) 45.42 (16.96) -3.29 (-6.14; -0.45) 0.024

SGRQ symptoms 71 59.16 (23.49) 56.04 (22.05) -3.13 (-7.35; 1.08) 0.143

SGRQ activities 71 65.46 (22.41) 63.33 (22.14) -2.13 (-5.44; 1.18) 0.204

SGRQ impact 70 35.65 (17.56) 32.21 (15.90) -3.45 (-6.77; -0.13) 0.042

MRC dyspnoea 68 2.68 (0.98) 2.54 (1.03) -0.13 (-0.34; 0.08) 0.210

EQ-5D utility score 65 0.71 (0.22) 0.75 (0.22) 0.04 (-0.01; 0.08) 0.152

EQ-5D VAS 65 66.61 (17.96) 68.86 (18.99) 3.24 (-1.2; 7.68) 0.150

SF-12 mental 65 53.48 (9.87) 54.99 (9.06) 1.50 (-0.90; 3.91) 0.216

SF-12 physical 65 28.91 (7.98) 28.82 (7.87) 0.09 (-1.14; 1.33) 0.082

SGRQ though the value did not reach the clinically significant change of 4 points (Table 1). There was no change in absolute FEV1 and FVC but there were sig-nificant improvements in FEV1%, FVC and FVC%, (as COPD is a progressive condition a decline in lung function would be expected over time, Table 2).

Table 2

Page 7

Continue on page 8

Breathing Matters

Qualitative feedback from partici-pants showed many patients re-porting improvements in their breathing, physical health and social and mental wellbeing.

Typical comments include:

‘Standing to sing helps posture, you think “upright” automatically as this gives maximum output from your lungs. The relaxation exercises do just that, and learn-ing to breathe bringing the mus-cles of the abdomen into play, as well as controlled exhalation, has helped me enormously.’

‘This is the first winter I have not had to call an ambulance or be on several lots of antibiotics and have taken only maintenance doses of steroids. This maybe a coincidence or it may be better because of the breathing help we have received.’

‘Helped mentally and physically. Somewhere to go with like-

minded people. Have not for the first time in five years been ad-mitted to hospital or casualty over the winter period. Opened up doors i.e. joining the (BLF) Breathe Easy group.’

‘I have enjoyed the project the singing has help me to under-stand how breathing and singing can help me to breathe better.’

In fact, all of the feasibility ques-tions were answered very posi-tively by the study.’

‘I believe that the project is teaching me how to understand my breathing and how to control it. This is very useful; it stops me hyperventilating when my breathing is under pressure i.e. climbing a steep hill.’

Having demonstrated that a com-munity-based singing interven-tion is possible to establish for patients with COPD, the next step in to undertake a pilot ran-

domised controlled trial. The Centre has recently submitted an outline proposal to the National Institute for Health Research, Health Technology Assessment programme for such a study in East Kent. If funding is secured, and the outcomes from the trial replicate the positive findings from the feasibility study, the next step would be a national multi-centre trial.

A report on the study, and documentary films are available from Isobel Salisbury, Sidney De Haan Research Centre for Arts and Health, Canterbury Christ Church University, University Centre Folkestone, Folkestone, Kent CT20 1JG. Email: Isobel.Salisbury@canterbury.ac.uk

Stephen Clift

Director Sidney De Haan Research Centre for Arts and Health Canterbury Christ Church University

Watch the film about the project:

http://www.youtube.com/watch?v=c0UK2X3i-FU

Page 8

Breathing Matters

Asthma Out of Control

A Dozen things to Check

1. Suboptimal inhaler technique: ALWAYS check inhaler technique before stepping up

inhaled therapy.

2. Adherence: Explore adherence in a non-

judgmental way using open questions

3. Wrong diagnosis: If a patient is not respond-

ing to treatment it is fundamental to review the basis for

diagnosis.

4. Vocal Cord Dysfunction: Some asthmat-

ics develop a pattern of breathing against semi-closed vocal cords that mimics the symptoms and signs of

asthma.

5. Occupational asthma: Always consider

this in adult onset asthma.

6. Nasal Disease: Treat the nose.

7. ASA (Aspirin Sensitive Asthma): Sampter’s Triad is aspirin sensitivity, asthma, and nasal

polyps.

8. Drugs: Especially ß blockers.

9. Allergy: Consider if asthma symptoms are linked

to allergen exposure.

10. ABPA one of the Asthma Plus conditions - check

the eosinphil count.

11. Churg Strauss Syndrome: check for

features of vasculitis.

12. And Making it a Dozen…

Hyperventilation Syndrome (HVS):

Hagman et al (2011) state that misdiagnosis of asthma

is common because hyperventilation syndrome and

asthma augment each other's symptoms and hypocap-

nia can cause bronchoconstriction (Lehrer et al 2008) or

chest discomfort on exercise (Hammo 1999). Gardner

(2004) found that 80% of patients presenting to an emer-

gency department with acute hyperventilation had good

evidence of asthma that was previously undiagnosed in

half of them, and Thomas et al (2001) found that a third

of women and a fifth of men diagnosed with asthma had

HVS. So-called ‘steroid resistant asthma’ raises suspi-

cions that there is a strong hyperventilation component

(Thomas 2003). Patients diagnosed with asthma may

bring on their hyperventilation syndrome symptoms eve-

ry morning when they test to see if they need their inhal-

er by taking a 'nice deep breath'.

Page 9

Breathing Matters

Best Suggestion to complete the dozen Many thanks to all of you who responded, the best 12th Tip was received from

Alex Hough, Respiratory Physiotherapist, and her prize is bottle of bubbly!

Congratulations!

Consider screening for HVS using the Nijmegen Questionnaire if your patient’s symptoms are not controlled on standard therapy?

Breathing Matters

WORLD NO TOBACCO DAY Virgin Care Surrey were asked to raise awareness of this day with all their staff through their regular newsletter ‘Something for the Weekend’ and they published this piece

below:

World No Tobacco Day (WNTD) was created by the Mem-ber States of the World Health Organization in 1987 to draw global attention to the tobacco epidemic and the preventable death and disease it causes. Every year, on 31 May, WNTD is celebrated, with a different theme to cover the broad range of measures within the WHO Framework Convention on Tobacco Control (WHO FCTC). The theme for World No Tobacco Day 2013 was: Ban to-bacco advertising, promotion and sponsorship. A compre-hensive ban of all tobacco advertising, promotion and sponsorship is required under the WHO Framework Con-vention for Tobacco Control (WHO FCTC) for all Parties to this treaty within five years of the entry into force of the Convention for that Party. Evidence shows that compre-hensive advertising bans lead to reductions in the num-bers of people starting and continuing smoking. Statistics show that banning tobacco advertising and sponsorship is one of the most cost-effective ways to reduce tobacco demand and thus a tobacco control “best buy”.

For more information click here

http://www.euro.who.int/en/what-we-do/health-topics/disease-prevention/tobacco/world-no-tobacco-day/2013-ban-tobacco-advertising,-promotion-and-sponsorship

Page 10

Adam Lewis from the NW Surrey Respiratory Care Team, Virgincare, handing a cheque to Mandy Molloy, a patient successfully completing

Adam’s PR programme

Local newspapers (Surrey Advertiser and Woking Informer) also published articles by Julia Bott (see below) about the health risks of smoking and the

benefits of quitting, highlighting the value of the simple

Chequebook Project ‘It Pays to Stop Smoking’

with a photo of one of the local community respiratory team handing a cheque to a patient.

Stop smoking

A No-smoking campaign is being launched by Virgin Care to coincide with the World No Tobacco Day.

The company, which manages community healthcare services in Surrey, supported the day today by en-couraging healthcare professionals to identify pa-tients who smoke.

The ‘It pays to stop smoking’ campaign devised by Pfizer works by helping health professionals make quick referrals to Stop Smoking Services (SSS) and features a chequebook for use as referral tool All the referrer has to enter is the patient’s name on the cheque. The cheque has contact details of the SSS plus a reminder of the benefits of stopping smoking.

The patient takes the cheque to their first appoint-ment. The smoking cessation service is sent the stubs so it knows who to expect.

Patients who still smoke and have developed a chronic obstructive pulmonary disease are being offered the cheques. Quitting at any time reduces the progression of this condition.

Please let us know what you did do in your area to raise awareness

Hold the date for the

Kent, Surrey, Sussex Stop Smoking Network Launch Event

on the 20th September 2013 Timing and venue TBC

News in brief

Report on the Home Mechanical Ventilation Conference

St Thomas’ Hospital, 31 May 2013

This is an annual, national event co-hosted by the Lane-Fox Unit, now in the capa-ble hands of Dr Nick Hart, and St James’ Hospital, Leeds HMV Unit, led by Dr Mark Elliott. The aim is to bring together clinicians from all professions with a common interest in HMV for sharing of information, best practice and ideas. It is always an interesting and valuable day, leaving one with new information and buzzing with ide-as how to improve your own service. This year was no exception: we heard presen-tations from doctors, nurses, physiotherapists and technicians; specialist and local centres, adult and paediatric, and there was plenty of time for questions, networking, discussion and debate; not to mention excellent refreshments! It was interesting to hear about the different models of delivering Home NIV e.g. out of Tertiary Centres, specialist secondary/teaching hospitals, or local DGH or integrated acute/community services.. (See our poll on page 6 to add to this debate). My big take home message was that the group was keen to pool our individual learning and agreed to collect data on outcomes for sharing. We therefore, in time, can identify the most clinically and cost effective model of care for different patients, which may depend on their needs. If you are not on the circulation list and wish to be, contact Nick Hart or his PA Carol Bridge @ the Lane-Fox Unit: Nicholas.Hart@gstt.nhs.uk ;

Carol.Bridge@gstt.nhs.uk, PA Tel: 020 7188 6115 Julia Bott Consultant Physiotherapist Clinical-Co Lead KSS Respiratory Programme

Guide to

Quality Assured

Spirometry Spirometry is one of the most common diagnostic tests per-formed in primary care but its quality can be very variable. As a result spirometry results cannot be relied on in around a quarter of all patients on GP COPD reg-isters. This step-by-step guide shows clinicians how to ensure that diagnostic spirometry performed in primary care and other settings is quality assured and provides valid results for patients. It details how spirometry should be per-formed, the interpretation and reporting of results and methods for quality assurance. The guide also illustrates common technical errors and offers a Top Ten Tips

for reporting spirometry results

Download the guide

South East Coast Regional NIV meeting, Tuesday 9 July 12.30-16.30 Rooms 1&2, Training & Development Centre, VirginCare, Guildford Road, Chertsey, Surrey KT16 0QA LUNCH followed by talks and discussion on: Workshops on the latest NIV equipment The new integrated NW Surrey service Update on Specialist Commissioning Management of patients with OHVS - Dr Nick Hart, Lane Fox Unit

To register, please contact

eva.lazar@nhs.net

BTS Winter Meeting 2013

Wednesday 4 to Friday 6 December 2013 Queen Elizabeth II Conference Centre,

Westminster, London Abstract submission is now open

Closing date : 23:59 on Thursday 25th July 2013

Join our Respiratory Network: www.networks.nhs.uk/nhs-networks/south-east-coast-respiratory-programme

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