Providing evidence-based care for adult patients with bronchiectasis.

Bronchiectasis is a long-term respiratory disease in which there is permanent bronchial dilatation, and it is associated with recurrent cough, sputum production and respiratory tract infections. The incidence and prevalence of bronchiectasis is rising, but it can be challenging to identify and manage this disease. The British Thoracic Society published its latest guideline for bronchiectasis in adults in 2019. This article outlines the main recommendations of this guideline to enable nurses to provide evidence-based care for adult patients with bronchiectasis.

Primary care implications of the British Thoracic Society Guidelines for bronchiectasis in adults 2019.

The British Thoracic Society (BTS) Guidelines for Bronchiectasis in adults were published in January 2019, and comprise recommendations for treatment from primary to tertiary care. Here, we outline the practical implications of these guidelines for primary care practitioners. A diagnosis of bronchiectasis should be considered when a patient presents with a recurrent or persistent (>8 weeks) productive cough. A definitive diagnosis is made by using thin-section chest computed tomography (CT). Once diagnosed, patients should be initially assessed by a specialist respiratory team and a shared management plan formulated with the patient, the specialist and primary care teams. The cornerstone of primary care management is physiotherapy to improve airway sputum clearance and maximise exercise capacity, with prompt treatment of acute exacerbations with antibiotics.

Updated BTS Adult Bronchiectasis Guideline 2018: a multidisciplinary approach to comprehensive care.

The new British Thoracic Society (BTS) Guideline for Bronchiectasis in Adults has been published. This article provides a summary of key highlights of the new BTS Guideline and covers who to investigate, what investigations should be carried out and a management strategy.

Adults miscoded and misdiagnosed as having pneumonia: results from the British Thoracic Society pneumonia audit.

A key objective of the British Thoracic Society national community-acquired pneumonia (CAP) audit was to determine the clinical characteristics and outcomes of hospitalised adults given a primary discharge code of pneumonia but who did not fulfil accepted diagnostic criteria for pneumonia. Adults miscoded as having pneumonia (n=1251) were older compared with adults with CAP (n=6660) (median 80 vs 78 years, p<0.001) and had more comorbid disease, significantly fewer respiratory symptoms (fever, cough, dyspnoea, pleuritic pain), more constitutional symptoms (general deterioration, falls) and significantly lower 30-day inpatient mortality (14.3% vs 17.0%, adjusted OR 0.75, p=0.003).

Procedural and short-term safety of bronchial thermoplasty in clinical practice: evidence from a national registry and Hospital Episode Statistics.

OBJECTIVE: Bronchial thermoplasty (BT) is a novel treatment for severe asthma. Its mode of action and ideal target patient group remain poorly defined, though clinical trials provided some evidence on efficacy and safety. This study presents procedural and short-term safety evidence from routine UK clinical practice. METHODS: Patient characteristics and safety outcomes (procedural complications, 30-day readmission and accident and emergency (A&E) attendance, length of stay) were assessed using two independent data sources, the British Thoracic Society UK Difficult Asthma Registry (DAR) and Hospital Episodes Statistics (HES) database. A matched cohort (with records in both) was used to estimate safety outcome event rates and compare them with clinical trials. RESULTS: Between June 2011 and January 2015, 215 procedure records (83 patients; 68 treated in England) were available from DAR and 203 (85 patients) from HES. 152 procedures matched (59 patients; 6 centres), and of these, 11.2% reported a procedural complication, 11.8% resulted in emergency respiratory readmission, 0.7% in respiratory A&E attendance within 30 days (20.4% had at least one event) and 46.1% involved a post-procedure stay. Compared with published clinical trials which found lower hospitalisation rates, BT patients in routine clinical practice were, on average, older, had worse baseline lung function and asthma quality of life. CONCLUSIONS: A higher proportion of patients experienced adverse events compared with clinical trials. The greater severity of disease amongst patients treated in clinical practice may explain the observed rate of post-procedural stay and readmission. Study of long-term safety and efficacy requires continuing data collection.

Mortality reduction in adult community-acquired pneumonia in the UK (2009-2014): results from the British Thoracic Society audit programme.

Community-acquired pneumonia (CAP) is a leading cause of death in the UK. In this analysis of 23 315 cases from the British Thoracic Society national CAP audit, an overall reduction in 30-day inpatient mortality over 6 years was observed-2014 compared with 2009 adjusted OR 0.86 (95% CI 0.68 to 1.08, p for trend 0.004). Significant increases in the proportions of patients who had (a) a chest X-ray and (b) the first antibiotic dose within 4 hours of admission were also observed (3.7% and 11.5% increases respectively). Further reductions in mortality may follow the 2016 National Institute for Health and Care Excellence Pneumonia Quality Standard.

Time to first antibiotic and mortality in adults hospitalised with community-acquired pneumonia: a matched-propensity analysis.

A matched-propensity analysis of national data from the British Thoracic Society community-acquired pneumonia audit was conducted (n=13 725). Overall, time to first antibiotic (TFA) was ≤4 h in 63%. Adjusted 30-day inpatient (IP) mortality was lower for adults with TFA ≤4 h compared with TFA >4 h (adjusted OR 0.84, 95% CI 0.74 to 0.94; p=0.003). Increasing TFA was associated with greater OR of 30-day IP mortality (p value for trend=0.001), but no TFA threshold was evident. Although we found an association between TFA and mortality, we cannot say whether this is causal or whether TFA might just be a quality measure for overall or other processes of care.

British Thoracic Society community-acquired pneumonia care bundle: results of a national implementation project.

In 2013, 16 U.K. hospital trusts participated in a quality improvement programme involving implementation of a community-acquired pneumonia (CAP) care bundle. High-level data were collected on 14,962 patients admitted with CAP; bundle implementation increased from 1% in October 2012 to 20% by September 2013. Analysis of patient-level data on 2118 adults (median age 75.3 years) found that in the bundle-implementation group, significantly more patients received antibiotics within 4 h of admission (adjusted OR 1.52, 95% CI 1.08 to 2.14, p=0.016) and 30-day inpatient mortality was lower (8.8% vs. 13.6%; adjusted OR 0.59, 95% CI 0.37 to 0.95, p=0.03).

UK trainee experience in interstitial lung disease: results from a British Thoracic Society survey.

Interstitial lung disease (ILD) is a growing field of respiratory medicine in which novel therapies are emerging. It is important that trainees gain competence and confidence in this area. To explore the training experiences of specialty trainees, we conducted a survey of their practical experience and confidence in diagnosing and managing ILD.

Admission via the emergency department in relation to mortality of adults hospitalised with community-acquired pneumonia: an analysis of the British Thoracic Society national community-acquired pneumonia audit.

OBJECTIVE: To determine the association between 30-day inpatient mortality and route of admission to hospital, for adults with community acquired pneumonia (CAP). METHODS: We studied 16 313 adults included in the British Thoracic Society (BTS) national CAP audit dataset. Comparisons were made between adults admitted via emergency departments (ED) with non-ED routes of admission, with regard to 30-day inpatient mortality. Secondary outcome measures were adherence to national CAP guidelines (time to first chest X-ray ≤4 h from admission; time to first antibiotic dose ≤4 h from admission; antibiotic choice; and antibiotic route of administration) by route of admission. RESULTS: Of adults hospitalised with CAP, 75.6% were admitted via ED; these adults had a greater prevalence of comorbid illness and higher disease severity in comparison with non-ED admissions. Adjusted 30-day inpatient mortality was similar for ED versus non-ED route of admission (OR 1.10, 95% CI 0.96 to 1.25). Admissions via ED were associated with faster processes of care (time to chest X-ray ≤4 h, adjusted OR 3.39, 95% CI 2.79 to 4.12; time to first antibiotic ≤4 h, adjusted OR 1.62, 95% CI 1.42 to 1.84) and greater use of intravenous antibiotics regardless of disease severity (adjusted OR 1.58, 95% CI 1.43 to 1.74). CONCLUSIONS: Adults with CAP admitted via EDs have more comorbid illness and greater disease severity compared to those admitted via non-ED routes. Following adjustment for these differences, 30-day inpatient mortality was not associated with route of admission.

Pleural procedures and patient safety: a national BTS audit of practice.

The BTS pleural procedures audit collected data over a 2-month period in June and July 2011. In contrast with the 2010 audit, which focussed simply on chest drain insertions, data on all pleural aspirations and local anaesthetic thoracoscopy (LAT) was also collected. Ninety hospitals submitted data, covering a patient population of 33 million. Twenty-one per cent of centres ran a specialist pleural disease clinic, 71% had a nominated chest drain safety lead, and 20% had thoracic surgery on site. Additionally, one-third of centres had a physician-led LAT service.

National BTS bronchiectasis audit 2012: is the quality standard being adhered to in adult secondary care?

A significant step towards improving care of patients with non-cystic fibrosis bronchiectasis was the creation of the British Thoracic Society (BTS) national guidelines and the quality standard. A BTS bronchiectasis audit was conducted between 1 October and 30 November 2012, in adult patients with bronchiectasis attending secondary care, against the BTS quality standard. Ninety-eight institutions took part, submitting a total of 3147 patient records. The audit highlighted the variable adoption of the quality standard. It will allow the host institutions to benchmark against UK figures and drive quality improvement programmes to promote the quality standard and improve patient care.

British Thoracic Society national bronchiectasis audit 2010 and 2011.

There have been two national British Thoracic Society (BTS) bronchiectasis audits from 1 October to 30 November in 2010 and 2011 in patients with non-cystic fibrosis attending secondary care. The first audit was soon after the publication of the BTS guidelines in July 2010 and both audits were based on the BTS guideline recommendations. We had 1460 and 2404 records in the 2 years respectively. The national audits highlight that the majority of guideline recommendations were not currently being adhered to and demonstrate the need for national quality standards, which are currently in preparation.

Primary care summary of the British Thoracic Society Guideline on the management of non-cystic fibrosis bronchiectasis.

The British Thoracic Society (BTS) has recently published a guideline for the management of non-cystic fibrosis (non-CF) bronchiectasis in children and adults. This paper summarises the key recommendations applicable to the primary care setting. The key points are: • Think of the diagnosis of bronchiectasis in adults and children who present with a chronic productive cough or unexplained haemoptysis, and in children with asthma which responds poorly to treatment; • High resolution computed tomography (HRCT) scanning is needed to confirm the diagnosis • Sputum culture should be obtained at the start of an exacerbation prior to initiating treatment with antibiotics; Treatment should be started whilst awaiting the sputum result and should be continued for 14 days; • Patients with bronchiectasis have significant morbidity. Management in primary care is aimed at improving morbidity, and includes; patient education, treatment and monitoring, as well as appropriate referral to secondary care including assessment for long term antibiotics.