Annual General Meeting of the Irish Thoracic Society - IJMS | Irish ...

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SESSION THREE ONE
ANNUAL MEETING OF THE IRISH THORACIC SOCIETY • 11 - 12 November 2005 • WESTWOOD HOUSE HOTEL, GALWAY
ANNUAL MEETING OF THE IRISH THORACIC SOCIETY • 11 - 12 November 2005 • WESTWOOD HOUSE HOTEL, GALWAY
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SESSION
SESSION THREE ONE
3.9
Alpha 1 Antitryspin Deficiency National Targeted Detection
Programme
Introduction
Alpha 1 antitrypsin (AAT), a serine protease inhibitor,
is a glycoprotein synthesised chiefly in the liver and
is the most important antiprotease in the lung. AAT
deficiency is a hereditary autosomal codominant
disorder, resulting from mutations in the AAT gene,
and classically presents with emphysema in youngto
middle-aged adults and liver disease in childhood
and occasionally in adulthood. The most common
phenotype presenting with clinical evidence of AAT
deficiency is the Z phenotype, resulting in decreased
levels of circulating AAT due to retention of the
aberrantly folded protein in the liver. It is unclear
whether the MZ phenotype confers increased risk
for disease. Demographic studies indicate that AAT
deficiency is under-diagnosed and prolonged delays
in diagnosis are common. World Health Organisation
guidelines advocate targeted detection programmes
of patients with COPD and asthma.
Results
500 individuals with COPD or asthma attending
3.10
the respiratory outpatients clinic in Beaumont
Hospital were screened. A combination of serum
AAT measurement by radial immuno-diffusion (RID),
AAT phenotyping by isoelectric focussing, and AAT
genotyping by PCR identified 15 ZZ, 53 MZ, 39 MS,
7 SZ, and 1 SS patient.
Conclusions
The percentage of deficiency alleles was higher than
anticipated from studies in other populations. The
S variant, common to the Iberian Peninsula, was
detected with unusually high frequency. Several other
rarer phenotypes were also identified. Further analysis
will reveal whether these phenotypes predispose
individuals to lung disease. Increased awareness and
understanding of AAT deficiency will prevent the
continuing under-diagnosis of this condition.
Acknowledgements
Alpha 1 Foundation Ireland and Department of
Health and Children AAT Targeted Detection
Programme.
Registration to initiation of NPPV – analysis of the time
factor in identifying suitable patients with COPD
T Carroll, C Taggart,
C O’Connor,
R Costello, SJ O’Neill,
NG McElvaney
Dept of Respiratory
Research, RCSI Building,
Beaumont Hospital,
Dublin
3.11
Audit on non-invasive ventilation (NIV) and its
effectiveness in an exacerbation of chronic obstructive
pulmonary disease (COPD)
Introduction
The British Thoracic Society (BTS) published guidelines
on the use of (NIV) in 2002 (Thorax 2002: 57: 192-211).
On introducing this service in June 2004, we wished
to determine its effectiveness of the Harmony Bipap
machine (Respironics Inc), and the compatibility of our
service with the BTS guidelines.
Method
We preformed an audit on all patients that received
NIV from June 04 to May 05, using the NIV audit sheet
from the BTS guidelines.
Results
Number of patients treated were fifteen, with two
requiring a second application of NIV, (F=4,M=11).
Diagnosis; 80% had COPD, 6% had COPD and asthma
and 6% had COPD and obesity. Number of chest
x-rays preformed prior to initiation = (Yes-16 + No-
1).Arterial blood gases (ABG) prior to initiation = (Y-17
+ N-0).ABG’s preformed pre-discharge = (Y-12 + N-5).
Spirometery preformed pre-discharge = (Y-6 + No-11).
Documentation of informed consent and action to
taken if NIV fails = (Y-6 + No-11). Average length of
stay of those treated with NIV = 12.5 days, and those
receiving conservative treatment prior to the NIV
service = 18.3 days. Benefits of NIV = (Y-13 + No-4).
Final outcome was fourteen were discharged home,
one was a bridge to mechanical ventilation and two
died a few days later. Follow up as an outpatient = (Y-6
+ No-9).
Conclusions
Marked improvements for patients treated with
NIV. Reduced hospital stay and morbidity. Less need
for intubations and it proved cost effective. Some
of the recommendations made are; Proper written
documentation regarding consent, prognosis
and options if NIV fails. Early initiation of NIV. All
patients followed up at outpatients. A new proforma
based on the BTS guidelines. Induction for all new
Junior Doctors on NIV and the use of the Harmony
machine.12 monthly updates on NIV for all nurses and
physio’s on medical ward. Changes to be considered;
Dedicated respiratory beds with specialised nursing
staff. An ABG analyser for medical ward. Domiciliary
NIV service to be considered for the future
TA Howe, JR Williams,
G Shivashanker,
M Jadoon, F Hardoo
Medical ward, Erne
Hospital, Enniskillen,
Co Fermanagh
Introduction
For successful outcome NPPV has to be considered
early in the course of respiratory failure before severe
acidosis develops and early identification of suitable
candidates for NPPV is essential. The purpose of
this audit is therefore, to determine the time factor
on the appropriate and effective use of the service.
Furthermore the study examined the usefulness
of the Manchester Triage System (MTS) to identify
patients with acute exacerbation of COPD who need
non-invasive ventilation.
Methods
All COPD patients who were treated with NPPV
between Jan. 2000 and Dec. 2003 were included.
Time intervals from registration to ventilation, triage
category and index ABG were analyzed. Non-COPD
patients, those who need immediate intubation and
adjuvant to weaning and those on home NPPV
were excluded.
Results
A total of 107 patients (with COPD as their primary
diagnosis) out of 147 episodes of acute respiratory
failure in 131 patients treated with NPPV were
analyzed. 47 (44%) were males and 60 (56%) females
with mean age of 66 years.
The average time interval between registration and
triage was 12minutes. According to MTS only 39%
were in category 2 and 59% were given low priority
(category 3 or above).
The mean time interval to see a doctor and for
respiratory consult (ventilation) were 82 minutes
and 26 hours respectively. From the time of index
ABG 28.5% of cases were ventilated after 29 hours.
Average length of hospital stay and duration of
ventilation were 22 days and 7.45 days respectively.
13 patients admitted through out-patients stayed
in hospital for an average of 17 days and needed
ventilation for an average of 3.6 days.
Conclusion
There is significant delay on initiation of NPPV. This
might be the reason for the prolonged hospital
stay and duration of ventilation. Patients admitted
through out-patients had a shorter on ventilation
and shorter hospital stay. The MTS, which is proved
to be sensitive, has failed to identify COPD patients
who needs non-invasive ventilation and needs to be
reviewed. Including ABG as part of the triage system
should improve the sensitivity to identify this group
of patients early.
S Asgedom, L Clancy
St. James’s Hospital,
Dublin
3.12
Results post initiation of an out-patient pulmonary
rehabilitation programme
Introduction
Despite being proven worldwide, pulmonary
rehabilitation programmes are still not widely
available to COPD patients in Ireland. In 2004, the
Respiratory Assessment Unit launched a pulmonary
rehabilitation programme.
Method
Patients attended twice weekly for eight weeks,
for one hour of exercise, and an education talk. Pre
and post programme individual out-patient assessments
consisted of medical history, resting values
of heart rate, respiratory rate, oxygen saturation,
BORG breathlessness scale, medical research council
dyspnoea scale (MRCD), and inhaler technique assessment.
Patients performed a six-minute walk
test, three-minute step test, and pulmonary function
tests including inspiratory muscle strength testing.
Patients completed a hospital anxiety and depression
scale (HADS), and a St. Georges Respiratory Diseases
Questionnaire (SGRQ). An anonymous patient satisfaction
survey was returned at the end of the programme.
Results
Three classes enrolled to date (39 patients in total),
with 32 patients (82.1%) completing the eight weeks.
Analysis of results showed significant increases in
6-minute walk test (p