Respiratory Medicine - Salford Royal

The Respiratory Support Unit (RSU) here at Salford Royal was created as part of the Trust response to the second wave of the COVID-19 pandemic by joining forces from specialties in Acute Medicine and Respiratory Medicine covering H1 (MHCU) and H2 respectively to enable enhanced respiratory support to be safely delivered outside of the critical care environment. This innovative model of care has been nationally advocated by British Thoracic Society (BTS) and Get It Right First Time (GIRFT) programme review in December 2020.

The main purpose of the RSU is to provide higher levels of acute care for COVID-19 patients, predominantly using Continuous Positive Airway Pressure (CPAP) and High Flow Nasal Oxygen Therapy (HFNOT), as well as Bi-level Positive Airway Pressure (BiPAP) to non-COVID-19 patients and acutely unwell medical non respiratory patients who require level 2 care in a bespoke setting providing enhanced, timely appropriate care and at the same time reducing the burden on the Critical Care Unit (CCU). This has also meant that critical care admission can be reserved for patients who are deteriorating despite receiving enhanced respiratory support on RSU and those who are requiring invasive ventilatory support. 

In creating RSU, the teams across H1 and H2 worked innovatively and collaboratively together with support from CCU colleagues. Some of the developments achieved during this process include:

• Weekly MDT working group meeting was organised to discuss, manage, and monitor the logistical and the operational requirements in order to provide a consistent and sustainable safe environment and meeting the challenges created by the pandemic. This was a collaborative endeavour between Acute Medicine and Respiratory Medicine with support from critical care.
• Aerosol Generating Procedure (AGP) coordinator role was created in order to facilitate and support urgent transfer of patients who require respiratory support to RSU in a timely manner based on their clinical needs. The AGP coordinator provides 24 hours seven days a week cover and has oversight of flow between the RSU, critical care and the rest of the hospital and has played a crucial role in the success of this unit.
• Daily handover between RSU and CCU is established to closely collaborate the care delivered to the patients with severe COVID-19 pneumonitis.
• Seven days a week cover including separate NIV overnight consultant on-call rota was established.
• An enhanced respiratory support pathway to treat COVID-19 pneumonitis patients was drafted based on the latest BTS guidance and regularly updated.

The RSU currently provides a capacity of 20 beds (60% of total bed capacity) to deliver respiratory support to patients who require it. To deliver this, enhanced nursing cover with the required skills has been established by the senior nursing staff covering the RSU through up skilling nursing staff on H2 ward to deliver HFNOT which was vital to support CCU step downs. Ensuring the right nurse to patient ratio to provide level 2 care is vital for those patients requiring respiratory support given the pressure the hospital was under, bearing in mind the increased level of COVID-19 related sickness among the nursing staff.

January 2021 was the busiest month of the second/third wave with 167 RSU referrals being received of which 84% were admitted for either respiratory support or level 2 care. One third of the totally admitted patients were stepped down from critical care. 75% in total were discharged home and 70% of COVID-19 positive patients who were admitted to RSU did survive and were eventually discharged home.

This model of care will provide in the long term, the platform to cope with winter pressures and the ongoing presence of endemic COVID-19. When Salford Royal faces the seasonal increase in emergency visits, which are predominantly related to respiratory illness, the RSU will strengthen the ability of the hospital to meet these annual challenges.

A chest drain is a narrow plastic tube that is used to drain air or fluid from the chest cavity. Chest drain insertion is a procedure, which involves the placement of a drain into the patient’s chest cavity through the chest wall.

It is sometimes possible to perform a procedure called ‘simple aspiration’ to remove air or fluid from the chest insert of inserting a drain. This involves the use of local anaesthetic and a needle or small plastic catheter that is smaller than a chest drain. However, unlike a chest drain, the procedure may need to be repeated several times. Simple aspiration will not work if there is an ongoing air leak in the lung. A chest drain is usually required in this situation. The only other alternative would be immediate surgery under general anaesthetic.

If a patient decides not to have a chest drain and has a serious air leak, they may become more breathless and may lose consciousness if the air leak is not released. If the patient has fluid on their lungs (pleural effusion), their breathlessness will not improve until it is drained (by chest drain or aspiration) and it may become worse.

Patients having a chest drain inserted, will be offered the opportunity to have a pain killing injection about 30 minutes before the procedure and sedation immediately before it. During the procedure they will have a local anaesthetic injection around the area where the tube is to be inserted. A general anaesthetic is not required.

The insertion of a chest drain is a safe and uncomplicated procedure in the vast majority of circumstances. Some patients experience discomfort from the tube but this is usually easy to control with painkillers.

Chronic Obstructive Pulmonary Disease (COPD) 

Everyone with chronic bronchitis, most patients with emphysema and some people with chronic asthma have a chest condition described as ‘chronic obstructive pulmonary disease’.

Chronic bronchitis

This is a disease where the tubes in the lungs become irritated or inflamed. This is usually caused by smoking. The irritation can make the lungs produce a lot of phlegm. This in turn causes the tubes to become narrower and can partially block the airways causing coughing, breathlessness and wheezing.

Emphysema

With emphysema, the air sacs in the lungs are damaged. Again the main cause is smoking. With damaged air sacs, the oxygen cannot pass into the blood stream as it should. This means you have to breathe faster and deeper to get enough oxygen which makes exercise especially hard. With severe emphysema, you can be out of breath even when sitting still. In many cases, chronic bronchitis and emphysema develop together.

Chronic asthma

Some people with chronic asthma are also described as having COPD. This is because their condition causes irreversible obstruction of the airways due to inflammation and possibly phlegm. They may also suffer a cough and wheeze but usually more at night.

Pleural plaques

Pleural plaques are areas of thickening of the lining between the lung and chest wall. The plaques themselves are harmless - they do not cause any symptoms. However, in most cases they mean that you have been exposed to asbestos either in your work or occasionally in your home at some time in the past.

On average, the plaques appear in a chest x-ray about 20-50 years after a person has first been exposed to asbestos.

The plaques are not, in themselves, of any significance but they suggest that a person has been exposed to asbestos and may be at risk of other asbestos-related lung diseases such as mesothelioma (a tumour of the lining of the lungs) or asbestosis (a type of fibrosis or stiffening of the lungs) or occasionally lung cancer (especially in smokers).

Although these diseases can be serious, the risk of getting them is small. Asbestosis is very uncommon nowadays due to improved working conditions in recent years.

The main risk factor for lung cancer is cigarette smoking and many experts believe that the risk of lung cancer is very slight in patients with pleural plaques but no evidence of asbestosis. If you smoke you have a one in five chance of getting lung cancer over your lifetime. This may increase to about one in four if you also have pleural plaques. The risk of mesothelioma is very low. It ranges from about 0.5 to two cases per thousand people with plaques per year. A typical person with plaques diagnosed when aged about 55 would have a lifetime risk of mesothelioma of 1% to 4%. In other words the chances of NOT getting a mesothelioma in that person’s lifetime would be 96-99%.

Flexible bronchoscopy involves inspecting the breathing passages using a fine plastic telescope called a flexible bronchoscope. This procedure is usually recommended to look for an abnormality in the airways or to take samples of lung tissue or lung fluids.

Other tests such as x-rays may give some information about the lungs but only a bronchoscope can enable the doctor to see inside the breathing passages and to take samples. The procedure can be carried out by a surgeon under general anaesthetic but this is a more major procedure.

During the procedure local anaesthetic jelly is applied inside the nose and local anaesthetic sprayed on the throat. Patient will be offered the opportunity to have sedation before the test if they wish.

Bronchoscopy is a very safe procedure for most patients and our experience is that most patients report only mild discomfort from the test. Most patients are alert or lightly sedated at the end of the test.

Somebody dies from lung disease every five minutes in the UK.

In Greater Manchester, an estimated 4,500 people die from a smoking-related illness each year, a large proportion caused by lung disease. This equates to nearly 13 deaths every single day with many more people living with debilitating ill-health caused by lung disease.

Although the number of people smoking is reducing both in the UK and in Salford, in some parts of Salford 30% of people are smokers. This is having a big impact in reducing life expectancy in these areas, which is up to nine years lower for men and three years lower women than the England average.

The lung health of Salford’s population continues to perform a lot worse than the rest of the country. Before our Lung Health Check service was available there was no service in Salford that checked for early symptoms of lung disease. 

The Lung Health Check Service will spot lung disease earlier and get patients the right treatment to reduce the rates of premature death and disability from lung disease in Salford.  The checks aim to:

• Spot early signs of Chronic Obstructive Pulmonary Disease
• Spot the early signs of lung cancer
• Reduce late lung cancer detection
• Improve lung cancer survival rates
• Increase the number of people who quit smoking

The Salford Lung Health Check Service is a pilot for smokers and ex-smokers across Salford aged 55 to 74 years who will be offered an “M.O.T” for their lungs.

Letters will be sent to everyone registered with a Salford GP identified as a current smoker or ex-smoker inviting them to attend an appointment with a Respiratory Specialist Nurse. At this appointment, patients will be asked some questions and take part in some simple, non-invasive tests.

In addition, for anybody who wants to stop smoking, on-site specialist stop smoking advisors from Salford City Council’s Health Improvement Service (HIS) will speak to patients immediately after their appointment to provide advice and support them to quit.

The pilot begins in September 2019 in Walkden (covering eligible patients registered with GPs in the Walkden, Little Hulton, Boothstown and Worsley) before moving around the remaining neighbourhoods across Salford.

This Lung Health Check Service pilot also strongly supports the aim of the Greater Manchester Smoking Strategy to reduce the smoking rate across Greater Manchester to 13% by 2020. In Salford this equates to approximately 17,000 people quitting smoking.

If you have recently received a letter inviting you to book an appointment, please call 0161 206 1136 to book your free Lung Health Check. If you have any questions, please email Lung.Healthcheck@srft.nhs.uk.

You can also watch this short film featuring Salford Royal’s Consultant Respiratory Physician Dr Seamus Grundy, to talk through why the checks are important and what they entail.

Pleurodesis involves the introduction of liquid into the space between the lungs and chest wall. The purpose is to produce a reaction that will cause the lung to stick to the chest wall to prevent a recurrence of fluid or air in the pleural space.

The success rate for this procedure is approximately 80% but it may be higher or lower in particular circumstances.

If pleurodesis is not undertaken, the patient will be at increased risk of having a recurrence of their chest problem. It is possible to have a surgical pleurodesis under general anaesthetic.

Pleurodesis requires the presence of a chest drain. The majority of patients experience little or no discomfort from the procedure although it can cause irritation or pain. The chest drain is normally removed 24 hours after the procedure.