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Physio respiratory care 'a jewel in the crown'

A physiotherapist who helped develop a service for patients with acute breathing problems says it is saving lives and reducing critical care admissions. Matthew Limb reports

Forty on-call physiotherapists are delivering a 24-hour non-invasive ventilation (NIV) service at Birmingham Heartlands hospital, part of Birmingham Heartlands and Solihull hospital trust. Since the service was set up last August, more than 100 patients with acute respiratory failure have been treated with NIV at the 1,000-bed hospital.

Lead physiotherapist Emma Gallagher, a senior I, said an initial audit of the service highlighted good results in decreasing mortality and intubation. 'We are saving lives, preventing admissions to the critical care unit and improving the quality of care in accordance with British Thoracic Society guidelines,' she told Frontline.

The multidisciplinary service, which also involves nurses, doctors and physiologists, was set up under a consultant respiratory and sleep physician, Dev Banerjee. He said the service had become 'one of the jewel's in the hospital's crown'.

The NIV service at Birmingham Heartlands is provided mainly by juniors and senior II grade physiotherapists. Although some had previous NIV experience, all 40 on-call physios took part in a training day and have regular updates to maintain competency. Before August 2004, NIV was delivered by medical registrars.

Physiotherapists have been able to develop their role, Mrs Gallagher said, by learning to take arterial blood gases, and prescribe oxygen and salbutamol, under patient group directives agreed by the trust. She told Frontline: 'Physiotherapists have raised their profile within the trust and further demonstrated their capabilities as autonomous practitioners.'

NIV is provided to patients with type II respiratory failure, typically present in conditions such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, chest wall disorders, neuromuscular and obesity hypoventilation.

It is administered using a mask that provides ventilatory support without bypassing a patient's upper airways. We use the NIV to prevent mortality and prevent patients going into intensive care. It can be put on anywhere in the hospital,' Mrs Gallagher said.

The physio then transfers the patient to the respiratory ward to continue treatment and monitoring. Physiotherapists apply NIV after carrying out respiratory assessments, performing blood gas analysis and deciding on pressure settings. Patients are then monitored to assess whether they are progressing or deteriorating.

Mrs Gallagher, who coordinates the service with Lisa Kenyon, a rotational senior II respiratory physiotherapist, said: 'We discuss any possible escalation of care with the team. You don't want to delay intubation if it is required.'  Results so far have shown a reduction in the number of intubations - insertion of endotracheal tubes - and mortality in COPD patients.

Mrs Gallagher said there was much research evidence already to support the effectiveness of NIV as a treatment. She hoped a future study would highlight how effectively physios can deliver and run a NIV service. 'That's the research we are looking into,' she said.

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