Multidisciplinary management of inducible laryngeal obstruction and breathing pattern disorder.

We provide an overview of the assessment and management of inducible laryngeal obstruction and breathing pattern disorder. We highlight the multidisciplinary team members involved and their essential roles within a complex breathlessness service. We discuss treatments initiated by physiotherapy and speech and language therapy, the importance of joint working, and discuss the high incidence of comorbidities and the association with other respiratory disorders. Educational aims: Inducible laryngeal obstruction and breathing pattern disorder are common causes of breathlessness.Inducible laryngeal obstruction is an inappropriate, transient, reversible narrowing of the laryngeal area that causes breathlessness and laryngeal symptoms.Breathing pattern disorder is an alteration in the normal biomechanical patterns of breathing that results in intermittent or chronic symptoms, which may be respiratory and/or non-respiratory.People with inducible laryngeal obstruction or breathing pattern disorder often have other comorbidities that will also need addressing.Multidisciplinary assessment and treatment is essential for comprehensive workup and holistic care.Timely assessment and diagnosis can prevent unnecessary medication use and hospital admissions and facilitate effective management of the condition using reassurance, advice, education, breathing retraining and vocal exercises.

Management of acute exacerbations of airways disease: advice for the non-respiratory physician.

Airways disease encompasses a number of conditions including asthma and chronic obstructive pulmonary disorder (COPD). In this article we describe the management of patients with acute exacerbations of airways disease.

The multidisciplinary team severe asthma day case assessment and its impact on patient care.

People with severe and difficult to control asthma can be a complex and heterogenous group of patients often with multiple comorbidities. Living with this disease imposes a huge physical and psychological burden upon the patient which requires a comprehensive, systematic and patient-focused assessment, using a wide range of clinical expertise from within the multidisciplinary team. This article describes a severe asthma systematic and multidimensional day case assessment, and the positive benefits that the authors perceive it offers for patient care. These benefits include a confirmed diagnosis, consideration of alternative diagnosis, enhanced adherence, medication optimisation, access to and gatekeeping of high-cost specialist medications, improved patient self-management skills and signposting to appropriate therapies. As a consequence, they believe that this facilitates better patient outcomes through a reduction in corticosteroid exposure, exacerbations and hospitalisation. This severe asthma multidisciplinary team day case approach offers more than just physical benefits when compared with the traditional medical model. Patient feedback reports an excellent patient experience, feeling listened to, understood, empowered and hopeful for the future.

Serum Inhaled Corticosteroid Detection for Monitoring Adherence in Severe Asthma.

BACKGROUND: Daily inhaled corticosteroids (ICSs) are fundamental to asthma management, but adherence is low. OBJECTIVES: To investigate (1) whether LC-MS/MS could be used to detect ICSs in serum and (2) whether serum levels related to markers of disease severity. METHODS: We collected blood samples over an 8-hour period from patients with severe asthma prescribed at least 1000 µg daily of beclomethasone dipropionate equivalent. Following baseline sampling, patients were observed taking their usual morning dose. Subsequent blood samples were obtained 1, 2, 4, and 8 hours postinhalation and analyzed by LC-MS/MS. Correlations between serum ICS levels and severity markers were investigated. RESULTS: A total of 60 patients were recruited (41 females; 39 prescribed maintenance prednisolone; mean age, 49 ± 12 years; FEV1, 63 ± 20 %predicted). Eight hours postinhalation, all patients using budesonide (n = 10) and beclomethasone dipropionate (15), and all but 1 using fluticasone propionate (28), had detectable serum drug levels. Fluticasone furorate was detected in 2 patients (of 4), ciclesonide in none (of 7). Low adherence by repeat prescription records (<80%) was identified in 43%. Blood ICS levels correlated negatively with exacerbation rate, and (for fluticasone propionate only) positively with FEV1 %predicted. CONCLUSIONS: Commonly used ICSs can be reliably detected in the blood at least 8 hours after dosing, and could therefore be used as a measure of adherence in severe asthma. Higher exacerbation rates and poorer lung function (for fluticasone propionate) were associated with lower blood levels.

SERVICE EVALUATION OF A CYSTIC FIBROSIS HOME INTRAVENOUS ANTIBIOTIC SERVICE PROVIDED BY A NHS FOUNDATION TRUST.

AIM: To evaluate carers' satisfaction with the current service for home reconstitution and administration of intravenous (IV) antibiotics to cystic fibrosis (CF) patients and identify ways of improving this service to reduce treatment burden. METHODS: A formative evaluation was conducted of all 17 carers who reconstituted and administered the IV antibiotics at home. This was carried out using a cross-sectional survey. A questionnaire of open and closed questions was sent first class with a pre-paid return envelope to the carers. This was followed by a reminder letter after the set return date. RESULTS: Thirteen carers responded giving a response rate of 76.5%. The carers had a mean of 2 children in the household with all having 1 child under the care of the paediatric CF team. They had been receiving IV antibiotics for a mean of 8 years and 7 months and had been administering them at home for a mean of 6 years and 1 month. The majority had administered the antibiotics in the last 3 months.Over half received their drugs from the hospital pharmacy, but one carer highlighted that they did not always receive a full supply of the treatment.Removing the reconstitution step by providing pre-prepared syringes could reduce treatment time by around 18 minutes. Overall this could mean a daily reduction in treatment time of almost two hours for a patient who is on two antibiotics three times a day. The majority of respondents stated that they would prefer pre-filled syringes.The carers felt that they received enough training and felt confident in reconstituting and administering the antibiotics. The majority felt that they should receive regular updates to their training and it was highlighted that they are reassessed at the start of each course. Most of the carers felt that they had an opportunity to discuss the IV antibiotics in the out-patient clinic with the doctors and the nurses but none of them would contact the pharmacist. They felt that they were appropriately contacted in advance to organise when the course would start and a proportion were contacting the nurses in advance to organise the treatment around their commitments. When they receive the antibiotics and sundries from the hospital pharmacy they are supplied with written directions for reconstitution and administration. However, the carers did not find these easy to understand. It was highlighted by one that they could not access advice at night.Overall the carers had a high level of satisfaction with the service. Some felt that it could be improved by easier access to advice, having blood tests done by community nurses and pre-filled syringes. CONCLUSION: Overall this cohort is satisfied with their current home IV service. Improvements could be made by: ensuring carers always receive 100% of all necessary supplies; better access to advice; easier to understand written information; access to blood tests in community; increased awareness of the pharmacist. The majority of carers would like pre-prepared syringes and these could greatly decrease the treatment time.