British Thoracic Society emergency oxygen audits.

The British Thoracic Society (BTS) guideline for emergency oxygen use in adult patients was commissioned by the BTS and developed in conjunction with 21 other colleges and societies prior to publication in 2008. One of the specific aims of the Guideline Development Group was to audit the use of oxygen in UK hospitals before the guideline was published and at intervals afterwards.

Emergency oxygen use in adult patients: concise guidance.

There is considerable controversy concerning the benefits and risks of oxygen treatment in many situations and healthcare professionals receive conflicting advice about safe oxygen use. The British Thoracic Society (BTS) has published up-to-date, evidence-based guidelines for emergency oxygen use in the UK in order to encourage the safe use of oxygen in emergency situations and improve consistency of clinical practice. The purpose of this concise guideline is to summarise the key recommendations, particularly concerning emergency oxygen use in the hospital setting.

Comparison of skin prick tests with specific serum immunoglobulin E in the diagnosis of fungal sensitization in patients with severe asthma.

BACKGROUND: It has been shown that patients with allergic bronchopulmonary aspergillosis (ABPA) and patients with severe asthma with fungal sensitization (SAFS) can benefit from antifungal therapy. It is not known whether allergy skin prick tests (SPT) or specific IgE tests are more sensitive in the identification of patients who are sensitized to fungi and who are therefore candidates for antifungal therapy. OBJECTIVES: To compare SPT and specific serum IgE tests for fungal sensitization in patients with severe asthma. METHODS: We have undertaken SPT and specific serum IgE tests to six fungi (Aspergillus fumigatus, Candida albicans, Penicillium notatum, Cladosporium herbarum, Alternaria alternata and Botrytis cineria) and specific serum IgE test for Trichophyton in 121 patients with severe asthma (British Thoracic Society/SIGN steps 4 and 5). RESULTS: Sixty-six percent of patients were sensitized to one or more fungi based on SPT and/or specific serum IgE results. Positivity to SPT and/or specific serum IgE was as follows: A. fumigatus 45%, C. albicans 36%, P. notatum 29%, C. herbarum 24%, A. alternata 22%, B. cineria 18%, Trichophyton 17% (specific serum IgE only). Concordance between the tests was 77% overall but only 14-56% for individual fungi. Twenty-nine (24%) patients were sensitized to a single fungus and seven (6%) were sensitized to all seven fungal species. Fifty percent of patients were sensitized to fungal and non-fungal extracts, 21% were sensitized only to non-fungal extracts, 16% were sensitized only to fungal extracts and 13% had no positive tests. CONCLUSION: This study is consistent with previous reports that fungal sensitization is common in patients with severe asthma. At present, it remains necessary to undertake both SPT and specific serum IgE testing to identify all cases of fungal sensitization. This may be important in the identification of patients with ABPA and SAFS who may benefit from antifungal therapy.

Audit of oxygen use in emergency ambulances and in a hospital emergency department.

BACKGROUND: Oxygen is widely used but poorly studied in emergency medicine, with a limited evidence base for its use in specific conditions. There are safety concerns about the underuse of oxygen in patients with critical illness and its overuse in conditions such as chronic obstructive pulmonary disease (COPD). A baseline audit was required to assess current practice prior to the introduction of new national emergency oxygen guidelines in late 2008. METHODS: The use of pulse oximetry and oxygen therapy was audited in patients brought by ambulance to the "majors" section of the emergency department (ED) in a university hospital. Oxygen therapy in the ambulance and the ED was subsequently documented. Oxygen use in ambulances was compared with Joint Royal Colleges Ambulance Liaison Committee (JRCALC) guidance and with subsequent patient management. RESULTS: The ambulance and ED records of 1022 patients were audited manually. Oxygen saturation (SpO(2)) was recorded for 90% of patients, 17% of whom had SpO(2) <94% at some time and 7% had SpO(2) <90%, including 33% of patients with COPD and 5.5% of patients without COPD. 34% of patients received oxygen in the ambulance and almost half of these had oxygen discontinued in the ED. Only 62% of ambulance oxygen use was in accordance with JRCALC guidance, but most "undertreated" patients were stable normoxaemic patients for whom guidance recommends high-flow oxygen. Only 58% of patients with COPD were correctly identified in the ambulance and 73% of these patients were treated with flow rates >4 l/min (equivalent to >35% oxygen). CONCLUSIONS: Oxygen use in ambulances is very common, equivalent to 2.2 million episodes annually in the UK. The quality of oxygen use is suboptimal, especially for patients with COPD. Emergency oxygen therapy will become simpler when new evidence-based UK emergency oxygen guidelines are published, and it is hoped that future audits will show better protocol adherence.

Late carmustine lung fibrosis. Age at treatment may influence severity and survival.

Previously, we have reported in 1990 that 35% of carmustine treated patients (6 of 17) who survived childhood brain tumors died of pulmonary fibrosis between 2 and 13 years after treatment. In addition, 8 patients studied in 1989 (13 to 17 years post treatment), had physiologic and biopsy or radiologic evidence of pulmonary fibrosis. We now report 3 more years of follow-up on these patients. Between 1989 and 1992, two more patients have died of pulmonary fibrosis, giving an overall mortality of 47%. Of the eight patients who died of pulmonary fibrosis, the median age at treatment was 2.5 years, whereas the nine long-term survivors had a median age at treatment of 10 years. All five patients treated below the age of 5 years have died of lung fibrosis. Analysis by the standard survival curve method indicated that patients treated at an age less than 6 years were more likely to die than those treated at an age older than 7 years (p = 0.03). Of the nine survivors, seven were observed over 3 more years. There was a gradual decline in mean forced vital capacity from 55% predicted (range, 44 to 81) to 51% predicted (range, 41 to 72) and total lung capacity fell from 65% predicted (range, 51 to 89) to 57% predicted (range, 47 to 77).

Systemic bioavailability and potency of high-dose inhaled corticosteroids: a comparison of four inhaler devices and three drugs in healthy adult volunteers.

OBJECTIVES: To compare the systemic bioavailability (assessed by cortisol suppression) of high-dose budesonide when given by four inhaler devices and orally. Also studied are the relative systemic potencies of three inhaled steroids (budesonide, fluticasone propionate, and beclomethasone dipropionate) when given by metered-dose inhaler (MDI) with a large volume spacer. DESIGN: Double-blind, crossover, placebo-controlled trial. PARTICIPANTS: Sixteen healthy, steroid-naive adult volunteers. METHODS: On separate occasions, each subjects took 4 mg of budesonide through the following devices: MDI alone, MDI with 750-mL. spacer, dry-powder inhaler and nebulizer; 4 mg of budesonide was also taken orally to assess the effects of GI absorption. For the drug comparison, each subject took 4 mg of budesonide, fluticasone, and beclomethasone, and 2 mg of budesonide and fluticasone by MDI and spacer. RESULTS: Greatest percent suppression (95% confidence interval) of 9:00 AM cortisol with budesonide was observed with MDI alone (73% [57 to 90]) and turbohaler (72% [58 to 86]) compared with MDI spacer (42% [22 to 64]) and oral administration (14% [+6- to -34]). Nebulized budesonide produced an insignificant rise in 9:00 AM cortisol level. The most suppressive drug (given by MDI spacer) was fluticasone at 4 mg (86% [82 to 91]) and at 2 mg (72% [59 to 85]). The least suppressive drug was budesonide at 4 mg (43% [22 to 64]) and at 2 mg (25% [3 to 47]). The effects of 4 mg of beclomethasone were intermediate (66% [49 to 82%]). CONCLUSIONS: The choice of delivery device for administration of budesonide can lead to important differences in systemic bioavailability. Fluticasone has greater systemic potency than budesonide or beclomethasone when given at microgram equivalent dosage. The systemic potency ratio of fluticasone propionate to budesonide in normal human volunteers in the present study is similar to the therapeutic potency ratio of the drug in asthmatic patients (approximately 2:1).

A long-term study of symptoms, spirometry and survival amongst home nebulizer users.

Although home nebulizers are widely used to deliver bronchodilator medication to patients with asthma and chronic obstructive pulmonary disease (COPD), the long-term benefits and hazards are unknown. The present authors have previously reported a prospective 12-month study of home nebulizer use involving 49 patients (15 asthma, mean forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) 1.3/2.1 1; 34 COPD, mean FEV1/FVC 0.7/1.8 1). Thirty-two of these patients were treated with long-term domiciliary nebulized bronchodilator treatment, the other 17 patients chose metered dose inhaler (MDI) therapy. The present paper reports the progress of these patients over 5 yr. Five-year survival was similar in both groups (nebulizer users 56%, MDI users 53%). Most deaths were due to respiratory failure (14 deaths) or lung cancer (four deaths). Survival was determined mainly by FEV1 (R = 0.54, P = 0.0001) and age (R = -0.47, P = 0.0007). Laboratory lung function tests (16 nebulizer users) showed that FEV1 and FVC were still higher than pre-nebulizer baseline measurements after 36 months of nebulizer use, but PEFR had fallen by 7%. Twenty-one of 23 surviving nebulizer users completed a questionnaire after 36 months of treatment. All used their nebulizer at least once per day and 20 of 21 patients reported that they still obtained full benefit from each nebulized treatment. The morning peak flow response to nebulized treatment was the same at baseline and at 36 months (48 1 min-1). All patients remained breathless (mean subjective score 4.8 on seven-point scale) but the subjective response to nebulized treatment was unchanged at 36 months. Tachyphylaxis did not develop among 13 patients who underwent repeated reversibility studies using 200 micrograms of salbutamol at 6, 12 and 36 months. It is concluded that home nebulizer therapy is safe and effective for a small number of carefully selected patients with severe asthma or COPD, who have been evaluated by a rigorous home nebulizer assessment protocol prior to commencing home nebulizer therapy.

Value and accuracy of cytology in addition to histology in the diagnosis of lung cancer at flexible bronchoscopy.

There is still disagreement as to the value and reliability of wash and brush cytology, in comparison with histology, for the diagnosis of malignancy at flexible bronchoscopy. The present study compares the yield and concordance of findings from the two modalities for visible tumours at flexible bronchoscopy. A single-centre study of 514 consecutive flexible bronchoscopy procedures, in which a lesion suspicious of cancer was seen and bronchial wash cytology, brush cytology and forceps biopsy samples were taken. All equivocal or suspicious results were taken as negative. An overall yield of 89.3% was achieved using a combination of all three tests. This was greater for endobronchial than submucosal (95% vs. 86%) tumours. Cytology alone diagnosed 17.7% of cases. Use of all three modalities allowed tumours to be differentiated between small and non-small cell types in all but 5/459 positive cases (98.9%). There were only 3/313 cases in which there was a difference in cell type (small cell vs. non-small cell) between the two modalities. We conclude that wash and brush cytology are valuable tools, in addition to forceps biopsy, at flexible bronchoscopy. All three tests should be performed routinely in cases of suspected malignancy.

Home nebulizers: can optimal therapy be predicted by laboratory studies?

Twenty patients (six severe asthma, 14 chronic obstructive pulmonary disease, COPD) were referred for consideration of domiciliary nebulized treatment. A double blind laboratory assessment demonstrated similar subjective and objective responses to nebulized salbutamol (5 mg), ipratropium bromide (IB) (0.5 mg) or a mixture of these medications in both groups of patients. The patients subsequently self-administered each treatment four times daily for one month. Fourteen patients requested long-term home nebulizer treatment (three salbutamol, four ipratropium bromide, seven mixture), and nine of these had their highest domiciliary peak flow recordings during home nebulizer treatment. However, subjective and objective laboratory assessments did not clearly predict the patients long-term choice of therapy in any case. There was little overall correlation between the laboratory response and the domiciliary response to treatment (Spearman correlation coefficient; subjective score, laboratory vs. home, r = 0.27, P = 0.03; peak flow response 30 min after treatment, laboratory vs. home, r = 0.31, P less than 0.02). The hospital study was also unreliable in predicting side effects during domiciliary nebulizer use. We conclude that prospective laboratory studies are of little value in the assessment of patients for home nebulizer therapy; these assessments must be made by carefully supervised domiciliary trials of nebulized treatment.

A long-term prospective assessment of home nebulizer treatment.

Forty-nine patients (15 asthma, mean FEV1/FVC 1.3/2.1; 34 COPD, mean FEV1/FVC 0.7/1.8) were referred for consideration of home nebulizer treatment. All were monitored for 2 weeks while using their usual inhaled treatment followed by 2 weeks using a 'Nebuhaler' spacer to deliver 1 mg of terbutaline and 80 micrograms of ipratoropium bromide (IB) four times daily. They then borrowed a System 22 nebulizer to self-administer salbutamol nebulizer solution (5 mg), IB unit dose vials (0.5 mg) or a mixture of these drugs four times daily for 1 month each. Both asthmatic and bronchitic patients had a significant rise in their mean daily peak flow rate (PFR) during home nebulizer treatment (P < 0.03) and the COPD patients also had a significant PFR rise during Nebuhaler treatment (P = 0.0004). The mean daily peak flow rates (PFR 1 min-1 were: baseline 179, Nebuhaler 195, salbutamol nebulizer 200, IB nebulizer 198, mixed nebulizer 216). Four patients failed to respond subjectively or objectively to either Nebuhaler or nebulizer treatment. Five patients responded well to Nebuhaler treatment and did not proceed to a home nebulizer trial. Eight further patients preferred Nebuhaler to nebulizer treatment or could not tolerate nebulizer treatment (two cases). Thirty-two patients requested home nebulizer treatment for long-term use (nine salbutamol, five IB, 18 mixture). Twenty-seven of these patients had an increased mean daily PFR (compared to their usual therapy) while using their chosen nebulized treatment. The mean increase in PFR for all 32 patients was 191 min-1 (11%).(ABSTRACT TRUNCATED AT 250 WORDS)

Prospective, placebo-controlled trial of 5 vs 10 days of oral prednisolone in acute adult asthma.

BACKGROUND: The optimal duration of oral steroid treatment in the management of acute adult asthma is unclear. We prospectively studied the effect of 5 vs. 10 days of oral prednisolone in patients with acute asthma requiring hospital admission. METHODS: Each patient received 40 mg of enteric-coated prednisolone daily for 5 days, followed by 5 days of 40 mg prednisolone daily (n=24) or placebo (n=20). All were given their usual inhaled asthma therapy including inhaled corticosteroids. Patients kept PEF and symptom diaries for 21 days. RESULTS: For the 5-day treatment group mean (95% CI) early morning PEF was 6 (-47,+36) l/min lower to day 21 (P=0.78). There was no evidence of differences in other PEF measures (morning post-bronchodilator, evening or worst of day). One patient in each group had an exacerbation requiring further oral steroids during the 21-day observation period. Asthma symptom scores were worse in the 5-day group on days 6-21 but the significance of this finding was uncertain, as a difference had emerged by day 5 (prior to trial entry). CONCLUSIONS: It may be possible to reduce the standard steroid course to 5 days in acute adult asthma, provided all patients receive inhaled steroids and a personal asthma management plan.

The Salford Asthma Register.

OBJECTIVES: The Salford Asthma Register was launched at the beginning of 1995 to record the details of all asthma patients in Salford, Greater Manchester, UK. DESIGN: An IT system was developed for the registration, annual review, audit and feedback of data to general practices on the status of their registered asthma patients. SETTING AND SUBJECTS: On joining the Salford Asthma Register, each practice submits a list of their current asthma patients to a central database maintained at Hope Hospital. Patients with chronic obstructive pulmonary disease (COPD) and children below one year of age are excluded from the register. MAIN OUTCOME MEASURES: An annual review sheet for every registered patient is generated by the database and returned to the practice. Asthma patients numbering 10,841 have been registered from 41 general practices covering 70% of the population of Salford. Of these, 2244 (20.7%) have had an annual review and 1545 (14.3%) have been recorded as resolved. All participating practices have received annual asthma reports comparing their asthma management with the district average. Most asthma measures (peak expiratory flow, daytime and nighttime symptoms) progressively deteriorated from the BTS Step 1 to Step 5. We were able to identify possible under-treatment in some patients in Step 1 and provide feedback to the practices concerned. Conclusions: In this observational study, we have shown that it is possible to establish a broad-based asthma database in an NHS district, which provides valuable feedback to the primary care team. We feel that this database and asthma monitoring methodology could be utilised elsewhere in the country. This could be an important tool in clinical governance.