Breathing easier

Robert Millett speaks to physios at a new ventilation unit and hears about the benefits of lung ultrasound.

Respiratory physiotherapists play a vital role in running a purpose-built ventilation unit, which opened Manchester earlier this month. The unit, which was developed over 10 years, will provide a new base for the long-term ventilation service at Wythenshawe Hospital, part of the University Hospital of South Manchester NHS Trust. Patients are likely to benefit from increased space, state of the art facilities and improved accessibility to the service.
Senior respiratory physiotherapist David Gavin is a member of the unit’s multidisciplinary team. He explains that the service helps to prepare people with chronic respiratory conditions to receive non-invasive and invasive ventilation in their homes. Non-invasive ventilation (NIV) uses a mask, or similar device, to give breathing support, whereas invasive ventilation procedures, such as a tracheostomy, bypass a patient’s upper airway.
The specialist service has provided NIV for inpatients and a community outreach programme since 1998, says Mr Gavin, but staff have worked in a temporary ward environment for the past four years. ‘Not having a purpose-built facility restricted the types of patients we were able to bring in,’ he says. ‘But with the brand new unit we will have 10 non-invasive ventilation beds dedicated for our use, which should improve our ability to take more referrals from clinics and from other hospitals.’
People referred to the service usually need long-term domiciliary NIV, and are classed as type 2 respiratory failure patients. ‘This means they have a high carbon dioxide and a low oxygen level and,’ says Mr Gavin. ‘So we ventilate to get their oxygen and carbon dioxide levels as near to normal as we possibly can.’
Respiratory failure can be associated with a broad range of conditions, including chronic respiratory diseases, neuromuscular diseases, chest wall deformities, sleep breathing disorders and obesity-related hypoventilation syndrome. Sue Pieri-Davies, a consultant physiotherapist, and medical consultant Andrew Bentley lead the service, which includes specialist physios, nurses, occupational and speech and language therapists, a gastroenterologist, a dietician and a psychologist.
The staff, who are split between an inpatient and community outreach team, assess people who need NIV or invasive ventilation at home. Patients are set up with equipment and provided with training in long-term secretion management techniques, such as cough assist therapy or lung volume recruitment. 
‘Initially we aim to correct respiratory failure, with attention to daily care and rehabilitation needs during the brief in-patient period,’ says senior respiratory physio Shelly Holme. ‘Then a lifelong clinic and community follow-up is provided after the first home visit, which is within two weeks of discharge.’

Multidisciplinary working

Mr Gavin says one of the service’s greatest strengths is the multidisciplinary joint working that occurs within both the inpatient and community teams.‘We do joint community visits so we can look at all aspects of a patient’s care from a holistic perspective,’ says Mr Gavin. ‘And on inpatients the physios work very closely with the nursing team, conducting joint assessments where appropriate, and we work alongside medical consultants and gastroenterologists.’ Clinical lead nurses Debbie Freeman and Debbie McCann head the community outreach service.
Ms Freeman says: ‘Our service has developed and worked towards the opening of this dedicated ventilation unit for well over 10 years and along the way we have developed an interdependent working partnership with our physiotherapy colleagues. What effect has this had? ‘First, our team are able to meet the needs of our patients with a responsive and individualised approach throughout all stages of the disease process. Second, the transferable clinical skills acquired by the nurses and physios has been shown to be beneficial in terms of patient outcomes and life-expectancy.’
She adds that a recent audit showed that the service’s length of survival for patients with motor neurone disease on NIV was significantly higher than the national average.

Benefits of the new unit

Prior to the new unit opening the service experienced a number of challenges. ‘We didn’t have any side rooms – so we couldn’t admit anyone who had an infection,’ says Mr Gavin. ‘Instead we had to try to get them a bed on an outlying ward, which wasn’t always easy to do.’
The previous, temporary unit also had restrictions on admitting obese people, due to the physical location of the ward. As a result, patients who were obese had to be treated with NIV in their homes or in other hospitals. But the new unit is equipped with side rooms, has adequate space and provides access for obese patients. The purpose-built ward is also equipped with ceiling hoist facilities, which Mr Gavin says ‘will make life easier for the physios to rehabilitate patients and for the nursing staff to get them in and out of bed’.
Another advantage is the service can accept patients who are ventilated via a tracheotomy, who would previously have stayed on the hospital’s intensive care unit, due to additional beds for specialist weaning. A combination of new equipment, better facilities and a ‘nicer ward environment’ are likely to enhance patient care and improve the flow of patients through the unit, says Mr Gavin – reducing the overall length of stay. ‘And because we have dedicated staff for the unit we will hopefully be able to improve not only their experience, but also their education and training of those patients.’
Development of the new unit came about due to a successful business case from service leads Ms Pieri-Davies and Dr Bentley, which helped to secure the funding and the physical space needed. ‘It was driven in direct response to the exponential and rapid growth of demand for home-based ventilation and the need to meet clinical guidance and specialised commissioning standards,’ says Ms Pieri-Davies. ‘Much persuasion and many battles have been fought along the way to the successful bid, which we are all very proud of – so never be deterred.’ fl 

More information

Lung ultrasound

Simon Hayward is a critical care physio at Blackpool Victoria Hospital, part of Blackpool Teaching Hospitals NHS Foundation Trust. For the last three years he has been using lung ultrasound to help inform his treatment options. ‘I was introduced to it by an intensive care consultant who thought it could benefit our physiotherapy assessment compared to a typical anterior-posterior chest X-ray,’ he explains.
As a result Mr Hayward helped organise a training programme for himself and five physiotherapy colleagues. The training began in January last year and was adapted from the Intensive Care Society’s ultrasound training course.
In comparison to chest X-rays lung ultrasound provides a number of benefits, says Mr Hayward. ‘On a chest X-ray conditions such as consolidation, pleural effusion, blood in the plural cavity and collapsed lung all look white - everything that has any sort of density just looks white,’ he explains. ‘But with lung ultrasound you can start to differentiate between fluid and solid tissue, or between air and even slightly different densities of tissue – so you can tell if you are looking at a pure pleural effusion or blood.’
Treatments can also be performed while scanning a patient, he adds.
‘So you can see how it’s affecting the person there and then, which chest X-rays and MRI can’t do.’
Mr Hayward advises physios interested in lung ultrasound to attend an introductory one-day course. 
‘Read the current papers available around physiotherapists’ use of lung ultrasound and try to find an experienced point-of-care-ultrasound (POCUS) mentor who could help you develop your skills.’
Robert Millett

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