Transcript airways service preston

Providing a MDT approach to the
management of VCD and other
associated conditions
Airways Clinic Service
Preston
Siobhan Lillie – Specialist Respiratory SLT
Jemma Haines – Principal Respiratory SLT
Introduction
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Airways service/ team
How did it all start….?
Where to start with formulating a business
case…?
Diagnosis
SLT role
Future considerations
The Airways Service
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Tertiary referral centre
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Specialist care for individuals suffering from all forms
of respiratory insufficiency and/ or chronic cough
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Provides local/ national advice and education
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Developing centre of excellence for research and
development
The aim of Airways Service
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To improve quality of care delivered to patients
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To use MDT expertise to facilitate accurate,
expedited diagnosis
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To provide a forum for MDT therapeutic
interventions
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To develop as a research centre for prospective
study for both diagnosis and treatment
The ‘Airways’ Team
 2 Respiratory Consultants (Dr Vyas and Dr Fowler)
 1 Principal Respiratory SLT
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1 Senior Specialist Respiratory SLT
1 Specialist Clinical Psychologist
1 Senior Specialist Respiratory PT
1 Asthma Specialist Nurse
 2 Respiratory SN’s
 1 Respiratory HCA
 Administrative support
Current specialist service MDT
provision
UK
 Royal Preston Hospital joint ‘Airways Clinic’
 Birmingham Heartlands ‘Difficult Asthma Clinic’
 Royal Brompton, London ‘Respiratory Research Clinic’
USA
 National Jewish Centre for Immunology and Respiratory
Medicine
Australia
 John Hunter Hospital, Newcastle
The journey of service
development
The journey of service
development
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Identify a problem
Examine current evidence base
Examine current service provision
Identify key stakeholders
Collect evidence
Business case
Reflective practice
Evolution....
How did it all start….?
Date
Event
Sept 05
Jemma Haines joined as ENT service lead in
Chorley
Jemma had meeting with Dr Vyas in Preston
Jan 06
Feb/ Mar Jemma made general respiratory clinic
06
observations/ examined evidence
April 06
Airways clinic established (3 months unfunded )
April 07
Full business case submission
April 08
Business case successful
October
08
Nasendoscopy equipment arrived
How it started continued….
March
09
SLT 2 day post – part of MDT medical service
directorate
June 10
Nov 10
SLT full time post due to extent of workload and
based on referral evaluation data
Further business case submitted for further SLT,
Respiratory Physio, Respiratory nurse and Clinical
psychologist
Business case successful
Jan11
New SLT and Respiratory nurse started
Feb11
New Respiratory Physiotherapist started
April11
New Clinical Psychologist started
Sept 10
Developing the business case
Support application with:
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Evidence
Research
Money making
Money saving
Referral Process
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In house referrals
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Tertiary referrals
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Referred to respiratory consultants or directly
to SLT
Assessment
GP Referral/
tertiary referral
AHP Referral
Consultant
Referral
Respiratory Consultant & SLT joint
assessment in clinic, baseline measures
VCD diagnosed/
suspected
Referred for further
respiratory tests
Bronchoscopy/
Laryngoscopy
ENT Referral
SLT Therapy
Sp.Respiratory Nurse
Inhaler assessment &
technique review
Respiratory Physio
Assessment &
treatment for dysfunctional
breathing patterns
Joint MDT
working & liaison
Respiratory Consultant
& SLT review
Outcome measures
Clinical Psychology
Assessment & treatment
Discharge
SLT Role
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To work as part of the MDT to assist in diagnosing
and treating patients with upper airway respiratory
conditions (VCD, CC and HLS)
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To increase MDT awareness of symptoms
associated with VCD to facilitate appropriate
referrals
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To be involved in training & research advances,
linking with other respiratory centres
To set the context about VCD
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Vocal Cord Dysfunction (VCD) is a
respiratory disorder characterised by the
abnormal adduction (closure) of the vocal
cords upon inspiration, expiration or both,
leading to various obstructive airway signs
and symptoms.
(Soli and Smally, 2005, Vertigan, 2002 )
Comparison of ‘Normal and VCD
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Normally, when you breathe in, or inhale, the
vocal cords abduct allowing air to flow into your
trachea and reach your lungs.
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With VCD, the vocal cords adduct when you
inhale. This leaves only a small opening for air
to flow into your trachea.
Comparison of Normal and VCD
Signs and Symptoms of VCD
Cough
Changes in
voice
Throat tightness
VCD
Stridor
Wheezing
Chest tightness
Morris and Christopher 2010
Signs and Symptoms of VCD
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I feel like I’m being strangled/choking on air
Tightness in the throat
Tickle in the throat
Sensation of constriction in the larynx
Lump in the throat
Cough
Dysphonia
Key features of VCD
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Episodic (Acute intermittent attacks)
Presentation mimics asthma/other respiratory
disorders
Can be secondary to other respiratory
conditions
Often multiple investigations/
treatments/hospital admissions prior to
diagnosis
Aetiology
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A number of aetiologies have been proposed:
1)
2)
Psychological aspects
Upper airway sensitivity
(exertion)
Laryngeal irritants
(Coughing, smoke, inhaled irritants, temperature
change)
GORD (Carding, 2000)
3)
4)
But the cause still remains unknown…
Pathogenesis
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Exact pathogenesis of VCD remains uncertain
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Organic and non-organic causes have been identified
as precipitating factors (Ibrahim et al, 2007)
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Four mechanisms suggested in literature:
Laryngeal hyper-responsiveness
Altered autonomic balance
Direct stimulation of the sensory nerve endings in
upper or lower respiratory tract
Hyperventilation
1.
2.
3.
4.
Pathogenesis Hypothesis
(Ayres & Gabbott, 2002)
Initial inflammatory
insult
results in
Airway narrowing at
glottis or lower airways
Laryngeal
hyper-responsiveness
Short lived
Altered autonomic
balance
results in
Subsequent stimuli
induces presynpatic
reflexes
Persistent
Diagnosis of VCD
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Detailed history
Flexible nasendoscopy with challenge
Pulmonary Function Testing (especially
spirometry)
Provocation Challenge Testing
Flexible Nasendoscopy
Spirometry Flow Volume
Loops
NORMAL
VCD
Inspiratory limb truncation,
suggestive of extrathoracic
variable flow obstruction
Provocation Challenge Testing
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Inhaled irritants
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Perfume
Aerosols
Metacholine/histamine
Laryngeal challenge
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Pitch glides
Volume change
Laugh
Strong blow (imitating spirometry)
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Exertion (stairs/ treadmill)
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Cold temperatures
To set the context about
Chronic Cough
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Commonest symptom for which patients seek
medical advice (Schappert et al, 2006)
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Chronic cough is simply defined as ‘a cough that
persists for longer than eight weeks’
(Pratter et al 2006)
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20- 40% of chronic cough’s have no known
medical cause (Pratter et al 2006)
COUGH
Acute
< 3 weeks
Chronic
≥ 8 weeks
COUGH
Acute
< 3 weeks
Chronic
≥ 8 weeks
Responds to
Medical Treatment
(successfully
managed by
Anatomic Diagnostic
Protocol)
Non-responsive to
Medical Treatment
= Refractory/Idiopathic
Chronic Cough
(20% of cases, Pratter et
al, 2006)
Chronic Cough
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Acute cough is considered beneficial to the respiratory
system (Irwin et al, 2008)
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CC is considered to have no benefit to the respiratory
system or the body in general (Irwin et al, 2008)
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It is important to distinguish between CC that is
responsive to medical treatment and cough that is
refractory to medical treatment (Vertigan et al, 2006)
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Behavioural management of CC can break the cycle
(Vertigan et al, 2006)
Diagnosis of CC
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CC diagnostic protocol followed
CC check list completed
Flexible nasendoscopy with challenge
Pulmonary Function Testing (especially
spirometry)
Provocation Challenge Testing
Irwin et al
1998
Chronic cough checklist
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Cough has occurred greater than 8 weeks
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Patient is not on ACE inhibitors
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Patient has seen respiratory physician in last 8 weeks
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Patient has normal chest x-ray reported in last 8 weeks
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Patient does not have bronchiectasis
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Patient is not awaiting further respiratory investigations and/or results
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Patient has had an asthma diagnosis excluded after investigation
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Patient has had nasal disease excluded after investigation
Patient has had GORD excluded after investigation
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Patient has had non-asthmatic eosinophilic bronchitis excluded after investigation
Idiopathic Chronic Cough
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Nasendoscopy clip of
chronic cough –
circumferential
constriction, red and
inflamed
Spectrum of disorders
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In much of the literature it has found that CC and
VCD are linked (Irwin et al)
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CC and VCD are different manifestations of an
underlying condition (Irwin et al)
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The two conditions may manifest in a range of
clinical symptoms (Altman, 2001)
Spectrum of upper airway
symptoms
Vertigan, 2006
Associated symptoms and features
e.g. cough, dyspnea, dysphonia, globus
Pure
cough, no
VCD
Cough
more
severe
than VCD
Cough and
VCD of
equivalent
severity
VCD more
severe
than
cough
Pure
VCD, no
cough
Associated medical conditions
e.g. GORD, asthma, post nasal drip, hyperresponsiveness, psychopathology,
post viral, unknown
Co-morbidities of VCD and CC
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Asthma
Heightened Laryngeal Sensitivity
Chronic Cough
Laryngopharyngeal Reflux(LPR)/ Gastrooesophageal Reflux (GORD)
Rhinitis/ Sinusitis
Hyperventilation
Anxiety/Depression
(Vertigan et al, 2006)
SLT Assessment
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Full case history
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Questionnaires
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Nasendoscopy results
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Results of lung function tests
Patient Selection for SLT
therapy
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Is based on all assessment information
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Is reliant on:
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patient acceptance that condition can be treated
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Motivation for change
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Initial response to treatment
Case Study 1 : MC
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53 Yr old female
Referred with ‘progressive breathlessness’
Hx of Bronchial asthma – diagnosed 1994
Hx of anxiety and depression – HAD A4 D5
Hx of angio-oedema ( allergic to alcohol and bleach)
Medications: Seretide 250mcg, Salbutamol,
Levocetrizine, Prednisolone, Citalopram
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Minimal relief from inhalers
Case Study 1 :MC
Laryngeal symptoms:
Tightness
Pain
Tickle
Dryness
Globus
Dysphonia
Ache
Choking sensation
Triggers:
aerosols
talking
perfumes
laughing
Temp changes
exertion
Cold environments
Case Study 1 : MC
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Spirometry: Normal
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Allergy tests: Normal
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Chest X-ray: Clear
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Nasendoscopy: adduction on inspiration showing
VCD
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Circumferential constriction
Dysfunctional breathing pattern noted
Case Study 1 : MC
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Nasendoscopy of MC
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Audience participation
– what would we do
with this lady??
SLT overview for VCD
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Explanation of diagnosis
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Referral to PT and Psychologist
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Identification of triggers
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Emergency breathing strategies
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Laryngeal relaxation
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Diaphragmatic breathing
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Use own outcome measures no matter how simple
Database for service evaluations.
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Case Study 2: AK
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43 Year old female
Dry, tickly cough for > 6 months
No improvements with: OTC meds, inhalers or
antibiotics
Stopped ACE inhibitor
Possible LPR
Triggers:
perfumes
exercise
aerosols
stress
talking
dry/ crumbly foods
laughing
Case Study 2: AK
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Nasendoscopy:
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no signs of LPR, RSI = 5
Heightened laryngeal sensitivity
A-P constriction
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Spirometry: Normal
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Chest X-Ray: Normal
Case Study 2: AK
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Nasendoscopy clip of
AK
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Ideas – what should we
do for therapy?
SLT overview for CC
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Education
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Specific cough suppression strategies
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Breathing pattern retraining
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Vocal Hygiene Training
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Psychoeducational training
Case Study 3: AT
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17 Year old female
Breathing problems for 4 years
Elite swimmer
Breathing worsened at a swimming gala in Cyprus in
2009
Most ‘breathing attacks’ happen in the pool but also
when stressed with university work
Meds: Seretide, Salbutamol and Montelukast
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Do not help when swimming!!
Case Study 3: AT
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Laryngeal symptoms:
Tickle
Tightness
‘Closing up inside’
Dryness
Cough
Dysphonia
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Triggers
Heavy exertion
Coughing
stress
Case Study 3: AT
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Spirometry: Normal
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Chest X-ray: Normal
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Nasendoscopy: Static vocal cords in
adducted position suggesting VCD
Case Study 3: AT
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Elite VCD
nasendoscopy
VCD in athletes
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Education
Breathing techniques
Breathing retraining outside of sport
Breathing retraining whilst completing sport
Visual feedback
Acknowledge any external pressures/
anxieties which may need to be addressed
Airways clinic: audit
Year
2010
2011
2012 so far..
Num of
referrals
153
174
170
2012 so far….
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VCD referrals: 123 (72%)
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CC referrals: 47 (28%)
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Number confirmed VCD: 95/123
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Number of CC who also had VCD 13/47 (28%)
Airways clinic: audit
Psychology
Physio
SLT
Current SLT :
MDT approach
to VCD
29
48
95
Airways clinic: audit
6%
Post SLT: 2 month follow up
14%
17%
63%
Goals met - d/c
Long-term review
Non-complient
Onward referral
33 confirmed asthmatics with VCD who completed treatment,
65% had a reduction in their asthma medications
Summary
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Long journey
‘Suck up’ to the authoritative professionals
Support business case with evidence base
and up to date audits
Don’t take ‘No’ for an answer
Keep trying – it’s worth the hard work!!!
Discussion