PCRS Logo

The Primary Care Respiratory Society

Inspiring best practice in respiratory care


This website is for healthcare professionals only

PCRS Logo

 

The Primary Care Respiratory Society

Inspiring best practice in respiratory care

 Facebook LogoTwitter Logo

This website is for healthcare professionals only

Conference Abstracts

Conference Banner

PCRS Respiratory Conference 2020 Abstracts

At this year’s virtual conference, delegates will be able to view abstract posters and ask questions to authors in our virtual poster room.

Please also join our PCRS Research and Service Development Highlights session on 25th September at 1530-1615 for a presentation from Luke Daines on the winning conference abstract "A clinical prediction model to support the diagnosis of asthma in children and young people in primary care" (ID 239)


Conference Winning Abstract

Authors: Daines L, Bonnett LJ, Tibble H, Boyd A, Turner SW, Lewis S, Sheikh A, Pinnock H
Institution: University of Edinburgh
Presenter: Luke Daines
Category: Scientific Research Abstract
Aim
Making an accurate diagnosis of asthma can be challenging. We aimed to derive and internally validate a clinical prediction model to support health professionals in primary care weigh up the probability of an asthma diagnosis in children and young people presenting with symptoms suggestive of asthma.

Methods
We created a dataset from the Avon Longitudinal Study of Parents and Children (ALSPAC) enhanced with data from routinely collected health records. Individuals with at least three inhaled corticosteroid prescriptions in one year and a ‘specific’ asthma Read code were designated as having asthma. Potential candidate predictors were included if data were available in at least 60% of participants. Remaining missing data was handled using multiple imputation. The prediction model was derived using logistic regression. Bootstrap re-sampling was used to internally validate the model.

Results
11972 individuals aged <25 years (49% female) were included, of whom 994 (8%) had asthma. Model performance was good; after internal validation, the area under the receiver operating characteristic (AUROC) was 0.86 (Figure 1; 95% CI 0.85 to 0.87). The calibration slope was 0.99. The items included in the model were wheeze, cough, breathlessness, hay fever, eczema, food allergy, social class, maternal asthma, childhood exposure to cigarette smoke, previous prescription of a short acting beta agonist and the recording of lung function/reversibility testing in the past.

Conclusion
Information readily available from a patient’s electronic health records can support primary care clinicians weigh up the likelihood of a child/young person having asthma. Prior to implementation, we plan to externally validate the prediction model, develop it into a user-friendly clinical decision support software, and test the feasibility of the system in clinical practice.



Figure 1: Receiver operating characteristic curve for the asthma diagnosis model
Authors: Murphie P, Paton R, McGill S, Little S.
Institution: NHS Dumfries and Galloway
Presenter: Phyllis Murphie
Category: Best Practice / Service Development Abstract
Back ground: Our Sleep medicine service serves a population of 150,000 accross 2,500 square miles. People with OSAHS utilising CPAP therapy were required to attend D&GRI for initial new/review appointments, with those from the west of the region facing a 100 -150 miles round trip, representing a significant burden in terms of lost work productivity and the environmental impact of fuel consumption and carbon emissions for both service users and clinicians travelling to satellite clinics.
Methodology: In 2013 we implemented teleconsultation clinics in two sites - Newton Stewart, (100 mile/2 hour commute) and Stranraer (150 mile/4 hour commute) our rationale being that teleconsultation avoided clinicians travelling to deliver face-to-face clinics, and also avoided travel for service users.
Aims: Teleconsultation to reduce clinician/patient travel; reduce fuel consumption/carbon emissions, and free clinician time, whilst providing a person-centred, efficient, economical, safe and environmentally-friendly service.
Results/Outcomes: 25 teleconsultation clinics in Stranraer (258 people) and 23 in Newton Stewart (237 people) have been undertaken. Clinicians mileage saved with teleconsultation versus face-to-face clinics, was 5,950 miles equating to 1.63 tonnes reduction in carbon emissions. Clinician time saved equated to 144 hours, representing 36 clinical sessions. Results demonstrate significant benefits for clinicians, patients, and the environment. Published service user audits in 2015 and 2017demonstrated satisfaction with teleconsultation clinics compared to face-to-face consultations. We have seamlessly transferred to the NHS ‘Near Me’ platform facilitated by our extensive experience of remote consultation. We have demonstrated teleconsultation sleep clinic review offers a service model for person-centred, safe and efficient services, delivered closer to individuals’ homes. This represents value for service users, and with the advent of the COVID 19 pandemic in March 2020 further service access with home review using the NHS Near Me platform being a more sustainable future service model given local, and national, service pressures.

Authors: SD Perumal
Institution: Cardiff University
Presenter: Shakila Perumal
Category: Best Practice / Service Development Abstract
This poster is only available to Conference Delegates in the virtual platform.
Authors: SD Perumal, TJ Mc Donnell
Institution: Cardiff University
Presenter: Shakila Perumal
Category: Best Practice / Service Development Abstract
This poster is only available to Conference Delegates in the virtual platform.
Authors: Murphie P, McGill S, Stewart K, Watt B, Scott Y, Donachie F, Gysin J.

Institution: NHS Dumfries and Galloway
Presenter: Phyllis Murphie
Category: Best Practice / Service Development Abstract
Description
We developed a “spend to save initiative” which was approved in April 2018. Our Integrated Respiratory Team (IRT) provides a regional service over 2,500 square miles. We wanted to provide more early-supported (ESD) and same-day discharges, admission avoidance (AA) and better access to Pulmonary Rehab (PR). Geography is challenging when delivering ESD and AA remotely. The PR service had long waits with no service provision in the West and was heavily supported by the community Respiratory Nurses to the exclusion of other work.
Methodology
We recruited 2 Respiratory Nurse Specialists (RNS), 2 Physiotherapists and 2 Respiratory Health care support workers to expand the existing team. Three-hospital based RNS’s provided in-reach to both the Combined Assessment Unit (CAU) and ED supported by senior medical team. We increased community-based staff by six in October 2018, with PR service recruitment complete in 2019.
Aims/Objectives
We aimed to provide same day/ESD with 7-day follow and to develop an AA service for GP referrals and self-referrals, introducing novel technology (MORSE linked directly to the clinical portal) enabled care solutions.
Results/Outcomes
We anticipated the IRT would see people with COPD, however the service now supports people with Interstitial Lung Disease, those with ventilatory failure using home oxygen and NIV, and complex cases where humidification/oxygen therapy is needed. We developed skills including spirometry, blood gas sampling, CO2 monitoring, fitting NIV mask to manage a range of respiratory conditions. The organisation has lower admission rates and 28-day readmissions for asthma and COPD compared to national rates. This fits with local health informatics data. The PR service can provide rapid access for those referred post discharge, and the waiting list for PR had reduced significantly (less than 4 months) with 80 % increased capacity delivered across multiple sites. The mean length of stay reduced consistently up to 2019.
Authors: Moore S
Institution: The University of Sheffield
Presenter: Stephanie Moore
Category: Best Practice / Service Development Abstract
Introduction:
NICE recommends that ‘people with Asthma receive a structured review annually’(1). Annual Asthma reviews are designed such that patients can optimise their Asthma control. This audit aims to identify if every child (aged 5 – 16 years) diagnosed with Asthma at Darnall Primary Care Centre (DPCC) has had an annual Asthma review in the last 12 months.

Method:
A SystmOne search of all patients aged 5 – 16 years who had not been recorded as having their annual Asthma review in the previous 12 months (May 2017 – May 2018). Each patient record was reviewed to identify the following:
i) Time since last annual Asthma review;
ii) Most recent contact with a Healthcare Professional at DPCC;
iii) Number of hospital admissions due to Asthma exacerbations.

Results:
49 patients were analysed. 3 had attended their review in the last 12 months, but this had not been recorded.
i) 46 patients had not had a review in the last 12 months;
ii) Of these, 40 patients (87%) had contact with a Healthcare Professional at DPCC in the last 12 months;
iii) 2 patients were admitted to hospital due to Asthma exacerbations

Conclusion:
There have been missed opportunities to conduct Annual Asthma Reviews for patients with Asthma. Annual Reviews enable better control of Asthma symptoms, and form part of the QOF system. The benefits of increasing Asthma Review uptake are two-fold:
i) the patient will experience a better quality of life;
ii) ii) DPCC will gain QOF points, which will help to fund improvements in services, therefore improving the health of the population it serves.

Recommendation:
It is recommended that DPCC conduct Asthma reviews opportunistically. This will enable earlier identification of children with poorly controlled asthma, and prevent unnecessary hospital admissions. 

References
1. NICE Guidance: Asthma, Quality Statement 5: Review
https://www.nice.org.uk/guidance/qs25/chapter/Quality-statement-5-Review
Authors: Maroof SJ, Thava B, Milligan D
Institution: Reading Primary Care Response Hub
Presenter: Shwan Maroof
Category: Best Practice / Service Development Abstract
As the pandemic was evolving in its early stages it became apparently clear that primary care services could not continue to operate under its current format. There was an immediate push towards remote triaging in order to minimise transmission of the SARS-CoV2 virus, which led to several challenges within primary care. Locally, we recognised that most practices did not have the facilities to assess suspected COVID-19 patients safely which included a lack logistics for PPE provision as well as a vulnerable and fragile workforce. With this in mind, local practices collaborated in developing a purely voluntary ‘Primary Care Response Hub’, in only 9 days, to assess patients with suspected COVID-19 in order to help spread, more thinly, the anticipated pressures that might have fallen onto practices and our secondary care colleagues. At the same time the Hub was developing, our colleagues at the Royal Berkshire Hospital were establishing a virtual ambulatory care unit. We were approached with a view to standardising our assessment of COVID-19 patients onto a common pathway as well as introducing POCUS (point-of-care ultrasound) in our assessment, through teaching received by hospital colleagues. Within the first 7 weeks of operation, the assessment teams at the Hub had seen 641 patients of which 42% were diagnosed with suspected COVID-19. Only 13% of suspected cases required admission to hospital, with 2 patients ending up in ITU. POCUS increased diagnostic accuracy by 75% and we were able to manage the vast majority of patients in primary care, either directly from the Hub or through a virtual ambulatory care service. We feel that primary care has a significant role to play in COVID-19 by providing a safe outlet for accurate assessment without overwhelming our hospital services and minimising possible healthcare related transmission of the disease within primary care services.
Authors: Middleton A, Osborne K, Graham L
Institution: Homerton University Hospital
Presenter: Laura Graham
Category: Best Practice / Service Development Abstract
Background
There is a documented higher prevalence of respiratory disease within the homeless population (Lewer et al, 2019). With a high incidence of smoking (85%) and illicit drug use (35% regular crack cocaine user) (Groundswell, 2017), and known poor engagement with primary care services (Homeless Link, 2014), there is an increased risk of undiagnosed respiratory diseases.
Aim
To pilot a monthly respiratory health clinic alongside the North London Action for the Homeless (NLAH) lunch club, to evaluate need and engagement.
Method
A monthly respiratory health clinic was held alongside the NLAH Lunch Club. The clinic was run by Respiratory Nurse and Physiotherapist Specialists and offered lung health assessment and advice, which included handheld spirometry, inhaled medication advice (if appropriate) and smoking cessation advice.
Each clinic was 2 hours long. The remit of the clinic was introduced at the start of the lunch club and attendees were encouraged to drop-in as required.
Results
The clinic ran from August 2019 to February 2020, with 7 clinics held, and 21 attendees in total accessing the clinic.
Of those that were reviewed, the age ranged from 36 to 78 years old, 67% (n=14) were men, 71% (n=15) were current smokers, 24% (n=5) had a chronic lung disease. We performed hand held spirometry on 76% (n=16) and one attendee having evidence of obstruction. Of those attendees that were current smokers, 86% (n=13) engaged in smoking cessation discussions and were provided with information on accessing the local stop smoking service.
Conclusion
The pilot allowed an opportunity to explore how best to support the Homeless Population living in the borough and overall was positively received by those that accessed it. This clinic worked well because it was run alongside a local charity, highlighting the need to outreach to this community, rather than managing within existing pathways.
Authors: Osborne K, Graham L
Institution: Homerton University Hospital
Presenter: Laura Graham
Category: Best Practice / Service Development Abstract
Background:
The National Asthma and Chronic Obstructive Pulmonary Disease (COPD) Audit Programme (NACAP) aims to improve care and outcomes for patients admitted to hospital with exacerbation of COPD. A best practice tariff (BPT) is aligned to two key components of care; a Respiratory Review within 24 hours of admission and delivery of the COPD discharge bundle.
Monday to Friday, t Homerton University Hospital a Specialist Respiratory Review is available, via the Community Respiratory Team in-reach pathway. Service cover is variable, with admission avoidance often prioritised over in-reach when demand exceeds capacity, meaning that Homerton University Hospital has never achieved the BPT.
Aim: To evaluate if redesign of the Respiratory Nurse in-reach pathway would improve patient outcomes, reflected in achievement of the NACAP BPT.
Method:
In January 2020 City and Hackney Community Respiratory Team’s in reach pathway was redesigned. This involved recruitment of a static inpatient Respiratory Nurse, expansion to a 7 day service, remote monitoring of every patient admitted with an exacerbation of COPD, daily review of every of every ward list to check for COPD admissions, dedicated NACAP data entry clinical team and attendance of the daily Acute Care Unit (ACU) MDT.
Results:
Between January and March 2020 the NACAP COPD BPT was achieved in 77.1% of patients admitted with an exacerbation of COPD to Homerton Hospital. This is an overall improvement of 51.8% compared with the same period in 2019. In total 77.1% of patients received a respiratory review within 24 hour of admission and 95.3% of patients received the COPD discharge bundle.
Conclusion:
A dedicate Respiratory inpatient specialist role, was key to the achievement of the BPT. Consistency of service and data entry, as well as extending to a 7 day service prevented missed admissions over the weekend period, which was reflected in achievement of the BPT.
Authors: Osborne K, Graham L
Institution: Homerton University Hospital
Presenter: Laura Graham
Category: Best Practice / Service Development Abstract
Background:
The National Asthma and Chronic Obstructive Pulmonary Disease (COPD) Audit Programme (NACAP) aims to improve care and outcomes for patients admitted to hospital with exacerbation of COPD. A best practice tariff (BPT) is aligned to two key components of care; a Respiratory Review within 24 hours of admission and delivery of the COPD discharge bundle.
Monday to Friday, t Homerton University Hospital a Specialist Respiratory Review is available, via the Community Respiratory Team in-reach pathway. Service cover is variable, with admission avoidance often prioritised over in-reach when demand exceeds capacity, meaning that Homerton University Hospital has never achieved the BPT.
Aim: To evaluate if redesign of the Respiratory Nurse in-reach pathway would improve patient outcomes, reflected in achievement of the NACAP BPT.
Method:
In January 2020 City and Hackney Community Respiratory Team’s in reach pathway was redesigned. This involved recruitment of a static inpatient Respiratory Nurse, expansion to a 7 day service, remote monitoring of every patient admitted with an exacerbation of COPD, daily review of every of every ward list to check for COPD admissions, dedicated NACAP data entry clinical team and attendance of the daily Acute Care Unit (ACU) MDT.
Results:
Between January and March 2020 the NACAP COPD BPT was achieved in 77.1% of patients admitted with an exacerbation of COPD to Homerton Hospital. This is an overall improvement of 51.8% compared with the same period in 2019. In total 77.1% of patients received a respiratory review within 24 hour of admission and 95.3% of patients received the COPD discharge bundle.
Conclusion:
A dedicate Respiratory inpatient specialist role, was key to the achievement of the BPT. Consistency of service and data entry, as well as extending to a 7 day service prevented missed admissions over the weekend period, which was reflected in achievement of the BPT.
Authors: Osborne K, Graham L
Institution: Homerton University Hospital
Presenter: Laura Graham
Category: Best Practice / Service Development Abstract
Background:
The National Asthma and Chronic Obstructive Pulmonary Disease (COPD) Audit Programme (NACAP) aims to improve care and outcomes for patients admitted to hospital with exacerbation of COPD. A best practice tariff (BPT) is aligned to two key components of care; a Respiratory Review within 24 hours of admission and delivery of the COPD discharge bundle.
Monday to Friday, t Homerton University Hospital a Specialist Respiratory Review is available, via the Community Respiratory Team in-reach pathway. Service cover is variable, with admission avoidance often prioritised over in-reach when demand exceeds capacity, meaning that Homerton University Hospital has never achieved the BPT.
Aim: To evaluate if redesign of the Respiratory Nurse in-reach pathway would improve patient outcomes, reflected in achievement of the NACAP BPT.
Method:
In January 2020 City and Hackney Community Respiratory Team’s in reach pathway was redesigned. This involved recruitment of a static inpatient Respiratory Nurse, expansion to a 7 day service, remote monitoring of every patient admitted with an exacerbation of COPD, daily review of every of every ward list to check for COPD admissions, dedicated NACAP data entry clinical team and attendance of the daily Acute Care Unit (ACU) MDT.
Results:
Between January and March 2020 the NACAP COPD BPT was achieved in 77.1% of patients admitted with an exacerbation of COPD to Homerton Hospital. This is an overall improvement of 51.8% compared with the same period in 2019. In total 77.1% of patients received a respiratory review within 24 hour of admission and 95.3% of patients received the COPD discharge bundle.
Conclusion:
A dedicate Respiratory inpatient specialist role, was key to the achievement of the BPT. Consistency of service and data entry, as well as extending to a 7 day service prevented missed admissions over the weekend period, which was reflected in achievement of the BPT.
Authors: Osborne K, Graham L
Institution: Homerton University Hospital
Presenter: Laura Graham
Category: Best Practice / Service Development Abstract
Background:
The National Asthma and Chronic Obstructive Pulmonary Disease (COPD) Audit Programme (NACAP) aims to improve care and outcomes for patients admitted to hospital with exacerbation of COPD. A best practice tariff (BPT) is aligned to two key components of care; a Respiratory Review within 24 hours of admission and delivery of the COPD discharge bundle.
Monday to Friday, t Homerton University Hospital a Specialist Respiratory Review is available, via the Community Respiratory Team in-reach pathway. Service cover is variable, with admission avoidance often prioritised over in-reach when demand exceeds capacity, meaning that Homerton University Hospital has never achieved the BPT.
Aim: To evaluate if redesign of the Respiratory Nurse in-reach pathway would improve patient outcomes, reflected in achievement of the NACAP BPT.
Method:
In January 2020 City and Hackney Community Respiratory Team’s in reach pathway was redesigned. This involved recruitment of a static inpatient Respiratory Nurse, expansion to a 7 day service, remote monitoring of every patient admitted with an exacerbation of COPD, daily review of every of every ward list to check for COPD admissions, dedicated NACAP data entry clinical team and attendance of the daily Acute Care Unit (ACU) MDT.
Results:
Between January and March 2020 the NACAP COPD BPT was achieved in 77.1% of patients admitted with an exacerbation of COPD to Homerton Hospital. This is an overall improvement of 51.8% compared with the same period in 2019. In total 77.1% of patients received a respiratory review within 24 hour of admission and 95.3% of patients received the COPD discharge bundle.
Conclusion:
A dedicate Respiratory inpatient specialist role, was key to the achievement of the BPT. Consistency of service and data entry, as well as extending to a 7 day service prevented missed admissions over the weekend period, which was reflected in achievement of the BPT.
Authors: Barr K, Kenward A, Graham L
Institution: Homerton University Hospital
Presenter: Laura Graham
Category: Best Practice / Service Development Abstract
Background
Prior to the COVID-19 pandemic there was limited use of remote online Pulmonary Rehabilitation (PR) in Hackney. As the second most deprived Local Authority in England, barriers such as digital exclusion and platform access presented. However, COVID-19 brought the suspension of face to face (F2F) PR, expediting the need to deliver PR remotely, via the either two freely accessible online options or provision of a Home Exercise Programme (HEP).
Aim
To provide all patients assessed for PR in Hackney prior to COVID-19 with a remote PR programme delivered either online or via a written HEP, review uptake and understand if digital exclusion remained a barrier.
Method
Patients assessed prior to the COVID-19 Pandemic were offered either an online PR programme or a written Home exercise programme (HEP). Patients received weekly phone calls for six weeks to support the delivery of their programme, with non-engagement or completion leading discharge as per F2F PR.
Results
In total 74 patients were offered a remote PR programme, 51% (n=38) female, average age 66 years old (Range 40-92), and 80% (n=59) had COPD. 51% (n=38) chose an online option, 12% (n=9) HEP, 30% (n=22) declined either and 7% (n=5) were uncontactable. Of 38 provided an online option, 42% (n=16) subsequently decided that they would prefer a HEP, due reported difficulty with the platforms. In total <1% (n=2) have completed remote PR, 60% (n=28) are still enrolled and 36% (n=17) discharged having not completed.
Conclusion
Overall the uptake of remote PR in patients previously assess was poor, irrespective of delivery, online or HEP. Over half of patients had access to the technology, but digital literacy limited uptake and preference wait for F2F PR reported by many. Review of uptake of remote PR in patients previously not assessed for PR is now required.
Authors: Griffith A*; Lever A* and Hughes D**
* GlaxoSmithKline UK Ltd. (GSK)
** Interface Clinical Services Ltd. (ICS)
Institution: GlaxoSmithKline UK Ltd
Presenter: Alun Griffith
Category: Best Practice / Service Development Abstract
Interest in remote primary care has escalated by necessity during the COVID-19 pandemic. We report on a clinical audit of a COPD patient review service both before and during the lockdown period, alongside insights from HCP webinar education. This service is funded by GSK, developed by ICS and GSK and delivered as a service to medicine by ICS across the UK & NI to patients with COPD stratified according to recorded symptoms and exacerbations. Patient symptoms were assessed using MRC and CAT test scoring, a full history and inhaler technique when possible. Based on these assessments, pharmacists were then able to recommend appropriate non-pharmacological and pharmacological (at class level) interventions for GP review and approval.
The comparative audit periods for GP practices are January 2019 to March 2020 (37,884 patients) for face to face (FTF) clinics, and April and May 2020 (2,364 patients) for remote clinics. Key observations include: 1. Elevated (+7%) rate of remote patient encounters per day; 2. Improved (53% FTF, 70% remote) appointment offer acceptance; 3. A reduction in the frequency of clinical interventions.
Two educational HCP webinars were delivered in April and insight on “Best practice in delivery of remote consultations”. Webinars were attended by 1,323 participants, content and associated Q&A was made available offline. From webinar poll responders, 83% rated the content as valuable and 44% scored that their confidence to deliver remote consultations had increased. An analysis of the Q&A indicated that the 3 most popular broad topics were consulting skills, inhaler technique and patient questionnaires.

This work highlighted the value of a remote care for respiratory patients alongside providing insights on training needs. It offers a potentially efficient platform to improve patient choice and explore innovative approaches to patient access, not just during the pandemic but also in routine care.
NP-GB-FVU-ABST-200001 June 2020
Authors: Anderton N, Kenward A, Osei-Wusu J, Ryder M, Barr, K, Graham L
Institution: Homerton University Hospital
Presenter: Laura Graham
Category: Best Practice / Service Development Abstract
Background

It is estimated that 6% of the Hackney population speak Turkish, the second most commonly spoken language in the Borough. It has long been recognised Turkish speaking Patients referred to The ACERS Pulmonary Rehabilitation Service (PR) do not get the same benefits from the PR education programme, as other patients, due to sessions being delivered in English.


Aim

Is it feasible to deliver Pulmonary Rehabilitation Education in Turkish to measure improvements in disease specific knowledge and patient satisfaction.

Method

All Turkish speaking patients with a diagnosis of COPD, known to ACERS PR Service were invited to attend a 2 hour education session. Presentations based on the PR education programme, were delivered by the ACERs Team and translated by Turkish Advocate. Presentations included; What is COPD, managing a flare up, medication management, benefits of exercise, smoking cessation and managing anxiety related breathlessness. Patients were asked to complete a Lung Information Needs Questionnaire (LINQ) pre and post and a patient satisfaction questionnaire, both translated into Turkish.

Results

In total of 22 people were invited and 55% (n=12) attended, however none of the patients completed the LINQ pre and post fully. 75% (n=9) did completed a patient feedback questionnaire, 89% (n=8) found the session useful and 55% (n=5) stated they would recommended it to family or friends. 55% (n=5) felt they received enough information, however 45% (n=4) reported there was either too much or not enough. What is COPD and Medication Management, were the two most popular presentations.

Conclusion

It was feasible to run a PR education session in Turkish, with some improvement in patient satisfaction. However it identified high levels of illiteracy, limiting analysis of further gains. For future sessions, consideration of appropriate outcomes measures must be made to establish the true benefit of the session for this patient group.
Authors: Hutchinson A, Barbetta C, Galvin K, Twiddy M and Johnson MJ
Institution: University of Hull
Presenter: Ann Hutchinson
Category: Scientific Research Abstract
Aim: Chronic breathlessness is common in cardiorespiratory conditions and is frequently associated with emergency department (ED) presentation when the patient experiences acute-on-chronic breathlessness. Breathing Space is a concept combining patient coping, help-seeking and clinician responsiveness to breathlessness in addition to disease-management. We aim to explore whether Breathing Space may help explain the decision by patients with acute-on-chronic breathlessness to present to the ED.
Methods: Secondary mixed-methods analysis of patient self-report survey, case note and interview data. We used an in-depth case-history approach to synthesise these source data from eight representative patients who presented to the ED due to acute-on-chronic breathlessness. Patient-interview data were also linked with interview data from their family carers and clinicians.
Results: Secondary analysis of eight survey and case note reviews, combined with analysis of eight patient interviews (four with a carer) and six clinician interviews was conducted. The Breathing Space concept was useful in understanding the individual patient’s decision to attend the ED. Having a clinician who both understands the impact of breathlessness on their patient and offers ways of managing breathlessness in addition to treating the underlying disease seems to be important. Clinicians responsive to breathlessness were able to encourage a disengaged patient (with restricted Breathing Space) to move towards a more adaptive way of living with breathlessness (greater Breathing Space). The converse was seen when clinicians had a sole focus on disease-directed treatment.
Conclusion: The Breathing Space concept may be useful for clinicians caring for people with chronic breathlessness. Early assessment and management of the Breathing Space of the patient (and carer) may help improve the patient’s (and carer’s) quality of life and the management of acute-on-chronic breathlessness crisis.
Authors: Barnes-Harris M, Daniel S, Venkateswaran C, Hutchinson A and Johnson MJ
Institution: University of Hull
Presenter: Ann Hutchinson
Category: Scientific Research Abstract
Aim: A named and defined chronic breathlessness syndrome aims to help clinicians actively seek, and patients legitimately present with, persistent breathlessness, and to drive services and research. However, views from low to middle-income countries were
not included in the consensus process. We aimed to explore the views of physicians caring for patients with chronic breathlessness in a single tertiary hospital in South India regarding chronic breathlessness syndrome, its recognition and management.
Methods:
Secondary analysis of qualitative data collected during a service development project. Three focus groups discussing chronic breathlessness syndrome were conducted in English, audio-recorded, transcribed and subjected to thematic analysis.
Results: Fifteen physicians from oncology, palliative care, cardiology and respiratory specialties participated. Three major themes (Impact, Invisibility and Purpose) were generated. Findings mirrored those in high-income countries. Chronic breathlessness as defined, was seen
as prevalent with a major impact on patients, families and physicians. Non-palliative care physicians described therapeutic helplessness with poor awareness and/or ability to manage breathlessness accompanied by active avoidance. This helplessness, a perceived
lack of assessment tools and lack of access to palliative care contributed to the “invisibility” of chronic breathlessness. Most participants agreed with the name of chronic breathlessness syndrome. All agreed the definition and that systematic identification
would foster education regarding assessment and management, and support service development and research.
Conclusion: Chronic breathlessness syndrome is recognised in South India but, as in higher income countries, risks being invisible due to lack of awareness
of therapeutic interventions. A named and defined syndrome was seen as a way to improve identification and management.
Authors: Humphreys L, Hammond M, Brocklehurst G, Jones S, Hadcroft J, Jones L
Institution: Liverpool Foundation Trust (Royal)
Presenter: Linda Humphreys
Category: Best Practice / Service Development Abstract
The international pandemic, Covid-19, that threatened to overwhelm the NHS required rapid and innovative ways to support patients.
Liverpool Community Respiratory Team (CRT) is a well-established, multi-professional team supporting respiratory patients at home to safely avoid hospital admission/reduce hospital length of stay. CRT piloted a service to support patients with Covid-19 on discharge from hospital to ensure quality care was provided for patients during their recovery.
It was anticipated CRT would identify deteriorating patients early and facilitate hospital re-admission where indicated. Local telehealth provision was utilised, with patients being set up to measure their vital signs three times daily and be monitored remotely by a respiratory practitioner for 10-14 days. Sit to stand tests were used prior to hospital discharge to identify patient’s baseline oxygen saturations and a telephone questionnaire template was used to recognise early decline in respiratory function.
What was not anticipated was the high level of psychological distress patients expressed, with most patients reporting fearing for their life during their admission, a fear that often continued post hospital discharge. Frequently patients had witnessed multiple deaths and some had lost relatives to Covid-19. Validated questionnaires were used to assess anxiety and depression with emotional support provision by CRT and referrals to specialist psychological support as needed.
An exercise and diet program was introduced to increase confidence, promote muscle mass and assess for further rehabilitation. By discharge anxiety had measurably reduced and patient confidence and mobility was improved. All patients reported benefitting from the service.
In total 29 patients were supported, recruited from 2 local hospitals. 1 patient required readmission due to acute chest pain. All patients were referred for further pulmonary rehabilitation.
Covid-19 patient numbers have diminished but the experience has been extremely useful in preparing the team to respond effectively to a second wave of the pandemic.
Authors: Smalley KR, Aufegger L, Flott K, Mayer EK, Darzi A
Institution: Imperial College London
Presenter: Katelyn Smalley
Category: Scientific Research Abstract
Introduction:
Patients with long-term conditions engage in self-management (SM) to manage their disease progression. Bronchiectasis is especially well-suited to SM, as the cycle of infection and inflammation characteristic of that disease provides an opportunity for patients to become intimately acquainted with their symptoms and how best to manage them. Whilst the activities required to self-manage bronchiectasis are quite clear, the extent to which patients know and feel capable to engage in them has never been measured. In this study, we developed – with an expert panel of patients, clinicians, and policymakers – an assessment tool of patient SM ability.

Aim:
To develop a tool to measure bronchiectasis patients’ self-management ability

Methods:
We conducted a modified, three-round online Delphi with patients, clinicians, and policymakers (N=30) to develop an assessment tool that will enable us to test patients’ self-management ability. In Round 1, participants opined on key, relevant SM knowledge and skills, from a list derived from the literature and expert interviews. In Round 2, the panel reacted to sample questions for each content area proposed in Round 1, and revisions were made based on feedback. In Round 3, participants reviewed the revised assessment and confirmed the items to be included.

Results:
The final assessment tool consists of 20 multiple choice questions, of varying levels of difficulty. Domains include general health knowledge, bronchiectasis-specific knowledge, bronchiectasis management skills, and communication skills. There was a high degree of consensus about whether items should be included or omitted.

Conclusions:
In order to trust that patients can self-manage safely, it is critical to know that they possess the prerequisite SM knowledge and skills. The uses for assessment tool, which has been developed in consultation with key stakeholders, include – but are not limited to – predicting and measuring the benefits of SM education programmes and providing personalised support where necessary.
Authors: Kinley E, Pinnock, H, McClatchey K & Steed, L.
Institution: University of Edinburgh
Presenter: Emma Kinley
Category: Scientific Research Abstract
Aims: Supported self-management reduces the risk of asthma attacks, improves asthma control, and improves quality of life. Despite this, asthma results in approximately 6.3 million UK primary care consultations and 1,400 deaths each year.
Nested within the IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) programme of work, this study aims to observe asthma review consultations to assess healthcare professional’s (HCPs) patient-centred and behaviour change strategies to promote asthma self-management.

Methods: A mixed-method observational study will be conducted. Video recordings of a sub-sample of the IMP2ART UK-wide cluster-RCT practices (implementation n10; control n10) will be undertaken. Data collection will include face-to-face, telephone and video consultations.
Analytical methods will include:
- ALFA Toolkit Multi-Channel Video Observation to code and quantify types of speech.
- Patient Centered Observation Form & The Behaviour Change Counselling Index to assess patient-centeredness and behaviour change techniques used by clinicians.
- Clinician perceptions of asthma reviews will be explored using follow-up semi-structured interviews and analysed using thematic analysis.

Results: We anticipate that the IMP2ART strategies will enable health care professionals to embed supported self-management more effectively within asthma consultations.

Discussion: Insights from observing asthma reviews will add to the evidence that health care professionals should be provided with specific training skills to implement a motivating and patient-centred asthma review. This study will contribute to the IMP2ART process evaluation, adding to recommendations of how supported self-management of asthma should be delivered in practice.
Authors: Kinley E, Pinnock, H, McClatchey K & Steed, L.
Institution: University of Edinburgh
Presenter: Emma Kinley
Category: Scientific Research Abstract
Aims: Nested within the IMP2ART (IMPlementing IMProved Asthma self-management as RouTine) study, this work seeks to explore the delivery of supported self-management during remote asthma reviews (including telephone/video conferences). This Rapid Realist Synthesis will aim to:
• Identify and synthesis studies which explore remote asthma consultations and the delivery of supported self-management.
• Explore the context and mechanisms that have contributed to the delivery of supported self-management during remote asthma consultations.
• Produce recommendations and guidelines for best practice of delivery of support-self-management via remote consultations for people with asthma.

Methods: This review will be conducted using a Rapid Realist Synthesis approach. Several theories will be initially identified using existing literature to refine the purpose of the review and identify the review question. Programme theory formulation progresses as the evidence is identified, assessed, and synthesised, until an evidence-based saturation and conclusion has been reached. A realist synthesis is an iterative process whereby theory development can be changed and refined throughout the process. Essential expertise will be added by key stakeholders to ensure the theory aligns with experiences in practice, including input from the PCRS professional advisory group which will contribute to the development of the programme theory.

Results: This review will produce a concluding programme theory which explains causational claims between varying contexts and mechanisms. The revised theory will explain how supported self-management is delivered via remote consultation to ensure patients have the skills, knowledge, and confidence to manage their condition.

Discussion: This work will inform future roll out of the IMP2ART implementation strategy, adding evidence for a remote asthma toolkit, and providing HCPs with specific training and skills to implement supported self-management remotely.
Authors: P T White, G Gilworth, C Corrigan, M Thomas, PB Murphy, N Hart, T H Harries
Institution: King's College London
Presenter: Patrick White
Category: Scientific Research Abstract
Aim

Assess the withdrawal of ICS, prescribed outside guidelines, in COPD patients with mild or moderate airflow limitation.

Method

COPD patients with mild or moderate severity, no history of ≥ 2 moderate or ≥ 1 severe exacerbations or asthma, and using ICS (dose >400mcg beclomethasone diproprionate/day equivalent), were recruited by their GPs for ICS withdrawal. Electronic participant records, identified by algorithm, were reviewed followed by clinical assessment of those eligible. Participants were randomised to withdrawal from higher-dose ICS. Withdrawal impact assessed through measures of lung function (forced expiratory volume in first second–FEV1), quality of life (COPD Assessment Test–CAT), cellular and molecular biomarkers. Measures repeated at 3 and 6 months.

Results

392 (13%) patients with mild or moderate airflow limitation were identified for higher-dose ICS withdrawal from a COPD population of 2967. On individual record review, 15 had prior evidence of asthma. 228 were excluded for other reasons. 149 patients were invited for assessment. 61 attended. All agreed to randomisation. Eleven (18%) had new evidence of asthma on assessment (FEV1 variability >12% and >200ml). 40 were randomised to ICS withdrawal or continuation of whom 18 (45%) had new evidence of asthma after repeated spirometry over six months; 10 in withdrawal group and 8 in continuation group. Presence of a Th2 (asthma-like) inflammatory response in those with FEV1 variability was seen in significant associations between: FEV1 variability and raised fractional exhaled nitric oxide (FeNO) levels (p=0.009); FEV1 variability and combination of raised FeNO and symptom burden (p=0.01); FEV1 variability and combination of blood eosinophil count and symptom burden (p=0.005).

Conclusions

ICS withdrawal for COPD is feasible. Active assessment of COPD patients with mild or moderate disease on higher-dose ICS may identify those with airflow variability suggestive of asthma. Adoption of an asthma treatment strategy should be considered in these patients.
Authors: Doe G, Chantrell S, Williams M, Armstrong N, Hutchinson A, Evans R.
Institution: University of Leicester
Presenter: Gillian Doe
Category: Scientific Research Abstract
Aim: To describe experiences of people living with chronic breathlessness without a disease diagnosis during the COVID-19 pandemic.
Methods: As part of a wider mixed methods study (Breathlessness - DiagnosE Early in Primary care: Breathe-DEEP), semi structured interviews were undertaken with people referred for investigation of chronic breathlessness across ten GP practices. The interview guide included questions around experiences of breathlessness, healthcare interactions and the impact of COVID-19 pandemic. Telephone interviews were audio-recorded, transcribed, coded and reviewed by the study team using thematic analysis.
Results: Over six weeks during the UK lockdown for the COVID-19 pandemic, 20 participants were interviewed (12 female, mean age 65yrs). Five participants lived alone, two were working and three recently received a confirmed diagnosis for their breathlessness. None of the participants experienced COVID-19. Three key themes were identified.
1) Unintentional de-prioritisation of diagnosis by patients.
“I mean obviously you don’t want to be phoning the doctors, because they’re there only for emergency now”
2) Following UK ‘lockdown’ guidance for the general population, is this enough?
“So we don’t even know what we’re meant to be doing… we’ve not been diagnosed properly. So we’re stuck.”
“…if I get this, it’s going to be serious because I have problems breathing anyway.”
3) Impact of lockdown on coping strategies for managing breathlessness.
“Well, I’m stuck in with this isolation thing which is driving me mad. So consequently, I haven’t been out, I haven’t done anything. And I find the less you do, the less you can do.”
Conclusion: The existing unpredictable pathway to diagnosis for people living with chronic breathlessness has been further interrupted during the COVID-19 pandemic. There was concern around appropriate level of shielding due to not having a diagnosis. Patients and clinicians need to re-engage with the pathway to diagnosis and management of chronic breathlessness.
Authors: Jackson T, Flinn F, Rafferty, L, Ehrlich E, Fletcher M,
Institution: The University of Edinburgh
Presenter: Tracy Jackson
Category: Scientific Research Abstract
Aim:
Older adults are the fastest growing population in the UK, but asthma is often underdiagnosed, undertreated and poorly self-managed in this population. It is necessary to explore the experiences of older adult with asthma to identify areas of research that could improve quality of life. We aimed to explore the perceptions of older adults in the UK with asthma on how they manage their asthma, how this impacts their life and if their asthma has changed over the years.

Methods:
15 adults with GP diagnosed asthma, aged 60 years and over, from across the UK were interviewed by telephone. Interviews were audio-recorded, transcribed verbatim and thematically analysed. This study was co-produced with an Asthma UK Centre for Applied Research (AUKCAR) Patient and Public Involvement Lead and guided by the NIHR UK standards for Public Involvement in Research to ensure meaningful public involvement.

Results:
Themes clustered around impact of asthma, managing asthma, interaction with healthcare and understanding of asthma. Participants experienced increased physical, psychological and social impacts of asthma management as they aged which led to feelings of isolation. Ageism and a lack of empathy from health care providers were mentioned by the majority participants. Quality of care varied widely across the UK, however all participants had seen a GP or nurse for an asthma review in the previous 12 months. Competing multimorbidities and polypharmacy complicate treatment and provide increased difficulties for older asthma managing their asthma.

Conclusions:
Older adults experience increased challenges in managing their asthma due to increased multimorbidities, polypharmacy and ageism from healthcare providers. Results will be used to inform the research priorities of AUKCAR to develop and undertake research aimed at improving the lives of older adults living with asthma.
Authors: Hui CY, McKinstry B, Buchner M, Fulton O, Pinnock H for the A4A+ project team
Institution: The University of Edinburgh
Presenter: Hilary Pinnock
Category: Scientific Research Abstract
Aim: Traditionally, clinicians support patients to plan their self-management strategies during face-to-face consultations. In a new digital era, the Internet of Things(IoT) with artificial intelligence(AI) can provide personalised self-management support, typically following pre-determined rules to interact with people, called artificial narrow intelligence(ANI). In contrast, artificial general intelligence(AGI), or artificial super-intelligence(ASI) mimics human intelligence to create new ways to interact with users. Trust is needed if patients and clinicians are to adopt such systems. We explored the trust that patients’ and clinicians’ place(or not) in IoT systems with AI to support asthma self-management.

Methods: We interviewed a maximum variation sample of patients and clinicians recruited via social media and professional contacts and explored their perceived trust in IoT systems. Thematic analysis used the McKnight’s technology trust model(functionality, helpfulness and reliability). Descriptive analysis of an online questionnaire enabled triangulation of findings.

Results: We interviewed 12 patients, and 12(primary/secondary/community-based) clinicians who routinely care for people with asthma patients. Most patients considered that an IoT system could help support a wide range of self-management tasks, and wanted AI within the system to provide personalised advice. They believed an IoT system could log their asthma status and provide pre-set action plan advice triggered by their logs. However, they did not trust an IoT to generate new advice without involving their clinicians. Clinicians similarly trusted AI-based IoT systems to support agreed action plans(but not generate new plans) though they wanted clinical evidence before adopting IoT systems.

Conclusion: ANI-based IoT is regarded as a functional, helpful and reliable to monitor asthma following a pre-determined action plan, but neither patients nor clinicians were ready to trust AGI, ASI to develop novel advice without clinical oversight. Research is needed to ensure the use of AI in connected asthma systems does not outstrip the trust of end-users.