A dedicated physiotherapy led clinic for the assessment and management of cough weakness in a complex home ventilation cohort.

Purpose

A service redesign was undertaken to reduce the wait for treatment amongst patients with cough weakness, thus at risk of respiratory tract infection (RTI) (Chatwin et al, 2018), previously reviewed within the general clinics of a large and complex adult home ventilation cohort at the regional centre.

The now well-established clinic dedicated to assessing and treating those with cough weakness is led by a rotational band 6 physiotherapist.

Patients may also receive this review during planned hospital admissions for assessment of Non Invasive Ventilation (NIV), during unplanned admissions, and within the urgent clinic.

We describe the characteristics of patients referred to the dedicated clinic and consider waiting times and treatments provided, making recommendations for further development. We are not aware that this is described elsewhere in the literature.

Approach

All patients reviewed in the dedicated clinic between 1st January 2018 and 31st December 2018 were included in the locally registered audit. Data was retrieved from the locally held clinic database

Outcomes

Patients were referred to the clinic based on subjective assessment and history; rarely based on Peak Cough Flow (PCF) assessment.

41 appointments were completed (26 male, ages 18 to 87 years, 8 NIV users), 27 initial assessments (IA) and 14 follow up (FU).

Average wait was 38 days for IA and 32 days for FU.

The most prominent diagnosis represented was Motor Neurone Disease (MND) accounting for 26 appointments.

At IA the average PCF was 185l/min (< 270l/min in 22 cases) and 3 patients recorded 0l/min.

A mechanical insufflator/exsufflator device, NIPPY® Clearway (BREAS, UK), was provided at IA in 13 cases.

All treatments were provided immediately.

At FU, unaugmented PCF on average was 141l/min (recorded in 4 cases). 8 patients required setting adjustment to increase treatment effectiveness, or treatment progression.
 

The dedicated clinic appears responsive to referrals and treatment provision, however PCF on IA is low and we would wish to provide cough management strategies at an earlier stage given the rapid deterioration which can occur in the most frequently referred patient group, and the vulnerability of those with cough weakness.

Implications

Subjective assessment and history are insufficient to identify cough weakness. Although not defined in the NICE guidance for the management of MND (2016), the patient group most often accessing the dedicated clinic, PCF must be undertaken regularly to prompt earlier referral and subsequent review within the dedicated cough management clinic. This supports best practice recommendations of PCF at each clinic review (Chatwin et al, 2018).

We now plan to train the general clinic nursing assistants to undertake PCF to increase regularity of recording.

Funding acknowledgements

No funding was received for the undertaking of this project.

Additional notes

This work was presented at Physiotherapy UK 2019