Improved survival following ward-based non-invasive pressure support for severe hypoxia in a cohort of frail patients with COVID-19: retrospective analysis from a UK teaching hospital.

Since the outbreak of COVID-19 in China in December 2019, a pandemic has rapidly developed on a scale that has overwhelmed health services in a number of countries. COVID-19 has the potential to lead to severe hypoxia; this is usually the cause of death if it occurs. In a substantial number of patients, adequate arterial oxygenation cannot be achieved with supplementary oxygen therapy alone. To date, there has been no clear guideline endorsement of ward-based non-invasive pressure support (NIPS) for severely hypoxic patients who are deemed unlikely to benefit from invasive ventilation. We established a ward-based NIPS service for COVID-19 PCR-positive patients, with severe hypoxia, and in whom escalation to critical care for invasive ventilation was not deemed appropriate. A retrospective analysis of survival in these patients was undertaken. Twenty-eight patients were included. Ward-based NIPS for severe hypoxia was associated with a 50% survival in this cohort. This compares favourably with Intensive Care National Audit and Research Centre survival data following invasive ventilation in a less frail, less comorbid and younger population. These results suggest that ward-based NIPS should be considered as a treatment option in an integrated escalation strategy in all units managing respiratory failure secondary to COVID-19.

Using individualised cognitive behavioural therapy as a treatment for people with COPD.

BACKGROUND: COPD is a common progressive and debilitating medical condition. Mental health difficulties, such as anxiety and depression, have been reported in 25-50% of all patients with COPD. Interventions that reduce anxiety and depressive symptoms may affect COPD outcomes. Little data exists on the effect of managing these psychological difficulties in this group. METHOD: We studied the effects of a respiratory nurse-led cognitive behavioural therapy programme in 10 patients with COPD, assessing goal achievement, Hospital Anxiety and Depression Scale scores and medical admission rates. RESULTS: We used CBT in 10 patients with COPD across a range of severities. All 10 patients completed the CBT programme, with an average of four sessions (range 2-13). The mean score in the anxiety domain fell from 10.6 (range 6-15) before CBT to 3.8 after the intervention (range 1-7; p < 0.001). Similar improvements were seen in the depression domain, with a mean score before CBT of 10.9 (range 2-17), falling to a mean score after treatment of 5.2 (range 3-12; p < 0.001). A statistically significant reduction in the number of admissions was seen, with a mean of 1.1 admissions (total 11) before CBT to a mean of 0.2 admissions (total 2), p = 0.02. CONCLUSION: In this non-randomised study, a programme of individualised CBT in patients with COPD resulted in marked improvements in psychosocial impairment and a significant reduction in service use.

Bronchial hyperresponsiveness and the bronchiolitis obliterans syndrome after lung transplantation.

Because bronchial hyperresponsiveness has been linked to the bronchiolitis obliterans syndrome (BOS), we determined PD(20) methacholine (PD(20(M))), PD(15) hypertonic saline (PD(15(HS))) and their dose-response slopes (DRS(M) and DRS(HS)) in 8 single and 18 double lung transplant recipients within 1 year of lung transplantation and examined the relationship to bronchoalveolar lavage cell profiles and subsequent development of BOS. Twenty-two patients (81%) had a positive methacholine and 6 (25%) a positive hypertonic saline challenge. A positive PD(15(HS)) was associated with an increased risk for BOS at 2 years (odds ratio 12.6, 95% confidence interval 1.3-123.5, p < 0.05), and time to BOS was significantly and negatively related to DRS(HS) (r = -0.5, p < 0.05) - that is, the greater the response, the shorter the time to BOS. Interestingly, DRS(HS) correlated positively with recipient:donor total lung capacity ratio (r = 0.5, p < 0.05), but there was no relationship between either challenge result and airway inflammation. Methacholine hyperresponsiveness is common after lung transplantation but is not prognostic, whereas response to hypertonic saline may reflect recipient:donor size matching and provide useful information regarding the potential for BOS development.