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25th May 2023
Most patients presenting with breathlessness should have a diagnosis and comprehensive treatment plan in place with six months, a support tool published by NHS England to reduce variation in care says.
Breathlessness is associated with high use of healthcare services accounting for 4% of GP consultations and 5% of emergency department attendances, NHS England said.
Yet despite the burden to the patient and the NHS, delays to diagnosis and misdiagnosis are common, the toolkit notes.
This includes 58% of patients with COPD who present with respiratory symptoms for over five years before diagnosis, as well as 41% of patients with heart failure.
Patients with chronic breathlessness are likely to need multiple investigations and should be provided with self-management advice, have lifestyle issues addressed and support for mental health from the first presentation, the guidance states.
Timeliness is key with a proactive approach to reassessment rather than waiting for patients to keep highlighting their breathlessness, it says, and in a third of patients the cause will be multifactorial.
The guidance sets out diagnostic pathway for initial investigations of chronic breathlessness lasting more than eight weeks including ECG, spirometry and FeNO with suggestions for further tests should be diagnosis be unclear.
Referral to respiratory physician or cardiologist is the third step should other investigations provide no explanation, the pathway says.
‘If there is no obvious cause(s) for breathlessness after robust investigation, fitness and lifestyle factors should be addressed,’ the toolkit continues. ‘Consider referral for therapeutic interventions for alcohol reduction, weight management, physical activity improvement and psychosocial support.’
It notes the guidance is not intended to override clinical judgment in individual cases.
In its annual report on COPD care, Asthma and Lung UK said almost a quarter of patients wait five year or more before their condition is diagnosed and 12% of 6,500 patients surveyed had waited more than a decade.
Some community diagnostic centres have been piloting the use of a pre-diagnosis breathlessness pathway, the charity said, but this approach now needs to be rolled out nationally as a matter of urgency.
The goal would be for any patients presenting with breathlessness with no obvious diagnosis to be referred to a diagnostic hub to have an assessment by heart, respiratory and mental health experts before onward specialist referral and treatment where necessary.
Dr Daryl Freeman, Primary Care Respiratory Society committee member and associate clinical director at Norfolk Community Health & Care said: ‘The NHSE breathlessness pathway is an opportunity to fine tune primary care diagnosis of breathlessness and look at how they can develop their PCN hublets or refer into community based diagnostic hubs if they exist.
‘The algorithm is useful I feel and is particularly useful for allied health professionals looking after patients with new onset breathlessness.’
This story was originally published by our sister publication Pulse.
11th May 2023
Fergus Gleeson has long held an interest in MRI scanning techniques that use hyperpolarised xenon – an odourless gas – to detect early-stage lung disease. Here, he discusses his interest in xenon, how the gas works in practice and his latest research findings in relation to long-Covid.
In 2020, Fergus Gleeson, professor of radiology at Oxford University and consultant radiologist at Oxford University Hospitals NHS Foundation Trust, turned his attention to a small study of post-Covid patients. They were experiencing breathlessness several months after being discharged from hospital, despite CT scans that appeared to show their lungs were normal.
The findings from this small study prompted Professor Gleeson to widen the research to investigate possible lung damage in non-hospitalised, post-Covid patients who continue to experience breathlessness many months after infection.
He is the principal investigator of the EXPLAIN study, one of 19 projects to receive nearly £40m from the National Institute for Health Research to improve understanding of long-Covid, from diagnosis and treatment through to rehabilitation and recovery.
I’ve worked in the xenon field since 2007/08 to identify patients with obstructive lung disease and interstitial lung disease, as have other researchers, including Professor Jim Wild, who is the head of imaging and NIHR research professor of magnetic resonance at the University of Sheffield. [Indeed, Wild pioneered the method, development and applications of hyperpolarised xenon MRI used in the EXPLAIN study.]
Xenon is unique in its ability to measure gas transfer in the lungs. The MRI scanner is programmed to detect signal from polarised xenon. The oxygen in the normal air we breathe isn’t used because it does not give enough MRI signal. Xenon behaves just like oxygen, so radiologists can use it to observe how it moves from the lungs into the blood stream and highlight any areas where it is not flowing well between the airways, gas exchange membranes and capillaries in the lungs.
The patient lies in an MRI scanner on a magnet with a vest like coil around their chest and breathes in one litre of inert gas xenon through a plastic straw. It is possible to watch the physiology of a patient’s lungs in real time and see where the xenon might be held up, how fast it moves, whether it gets to the alveoli and from this assess how well the exchange of oxygen and carbon dioxide happens in the blood. The degree of gas exchange is colour coded with areas of more damaged lungs being darker or a different colour to areas with normal exchange.
The scan times may be very short, for example a single sequence may only require the patient to breathe in and hold their breath for 14-20 seconds. There’s no radiation exposure so it can be repeated over time to see whether the changes to the lungs improve. If the research proves to be clinically useful, the equipment could be set up in multiple regional centres in a relatively short space of time. All that is needed is a cylinder of xenon and the polariser – which is about the size of a large chest of drawers. The MRI scanner would also need to be modified to detect the signal from the xenon gas.
Ours is located in the radiology department at the Churchill Hospital in Oxford. There’s one in Sheffield University’s imaging department, one is being installed at University College Hospital London and one at Manchester University. There’s also a couple in Denmark, two in Germany, several in the United States and at least one in Canada.
Some people were complaining of persistent breathlessness and fatigue for many months after the Covid-19 infection, so we conducted a small study on patients aged between 19 and 69. None of them required intensive care or ventilation, and standard CT scans showed no significant lung damage. The hyperpolarised xenon MRI scans revealed signs of lung damage for a number of the patients who were reporting breathlessness.
We then broadened the study out to include non-hospitalised individuals who had tested positive for Covid-19 across a range of age groups. Now, there are many different arms of the study and we’re working with three other hospital sites: Sheffield, Manchester and Cardiff. Hundreds of thousands of people in the UK continue to experience symptoms months after having Covid-19, with breathlessness one of the most commonly reported symptoms.
We hope to identify what’s causing patients with long-Covid breathlessness and essentially give them answers as to how long they might have these abnormalities and whether they’ll get better.
We’re using hyperpolarised xenon MRI scans to investigate possible lung damage in long-Covid patients who have not been hospitalised with Covid-19 but who continue to experience breathlessness. The full study will recruit around 400 participants following on from our two initial pilot studies. The EXPLAIN study will include:
We detected significantly impaired gas transfer from the lungs to the bloodstream in long-Covid patients when other tests were normal. These patients had never been in hospital, did not have an acute severe illness when they had their Covid-19 infection, and some had experienced symptoms for a year after contracting it. The important questions that now need answering are how many patients with long-Covid will have abnormal scans, what the significance of the abnormality we’ve detected is, what the cause of the abnormality is and what its longer-term consequences will be. Once we understand the mechanisms driving these symptoms, we will be better placed to develop more effective treatments.
We need to complete recruitment and analyse the data, so we have some way to go before fully understanding the nature of the lung impairment that follows Covid-19 infection. However, the clinical-academic collaboration in EXPLAIN and other studies funded by NIHR are fundamental steps towards understanding the biological basis of long-Covid. This, in turn, will help us to develop more effective therapies.
19th May 2022
The ENO Breathe programme used by patients experiencing long COVID symptoms has been found to improve mental health scores and elements of breathlessness compared to usual care. This was the conclusion from the first randomised trial to evaluate interventions for patients with long COVID by a UK team of researchers from London.
A recognised consequence for some patients after an acute infection with COVID-19 is long COVID and which has been defined as new or ongoing symptoms 4 weeks or more after the start of acute COVID-19. A wide range of symptoms experienced by those with long COVID have been documented with the most frequently reported including breathing problems, fatigue, muscle weakness or joint stiffness, sleep disturbances, problems with mental abilities, and mood changes such as anxiety or depression. Furthermore, a review of studies has suggested in both acute and long COVID, the impact of infection on health-related quality of life is substantial. In a systematic review, researchers identified how music interventions were associated with clinically meaningful improvements in health-related quality of life.
The English National Opera has created the ENO Breathe programme, to help patients recovering from the effects of COVID-19 an,d for the present study, the UK researchers set out to determine whether the programme could improve both mental and physical aspects of health-related quality of life, as well as breathlessness, in patients with long COVID. They conducted a parallel-group, single-blinded, randomised trial to compare the ENO programme with usual care. Eligible patients were adults (> 18 years of age) and who were recovering from COVID-19 with ongoing breathlessness with or without anxiety for at least 4 weeks after their acute onset of symptoms. Individuals were randomised 1:1 to the ENO Breathe programme or usual care. The programme was individualised and designed to support people with breathlessness and/or anxiety by focusing on breathing, retraining through singing techniques and delivered online. It consisted of an introductory session followed by 6, once weekly sessions.
The primary outcome of interest was a change in health-related quality of life (HRQoL) from baseline to the end of the 6-week programme and which was assessed using the RAND 36-item short form survey instrument and in particular two summary measures, the mental health (MHC) and physical health components (PHC). A number of secondary outcomes were used including a visual analogue scale (VAS) for breathlessness on rest, walking, climbing stairs and running.
ENO Breathe programme and HRQoL
A total of 150 participants with a mean age of 49 (81% female) were randomised to either the ENO programme or usual care. Across the two groups, there was a mean of 320 days since the onset of their initial COVID-19 symptoms.
Compared to usual care, those allocated to the ENO Breathe programme had a greater improvement in the MHC (regression coefficient = 2.42, 95% CI 0.03 – 4.80, p = 0.047). However, there was no significant difference between groups for the PHC component (p = 0.54).
With respect to breathlessness, the only self-reported measure to significantly reduce was based on running (p = 0.0026).
The authors concluded that the ENO Breathe intervention could improve mental health wellbeing and one aspect of breathlessness and suggested that the programme might have a role in supporting patients with persisting long COVID symptoms.
Philip KEJ et al. An online breathing and wellbeing programme (ENO Breathe) for people with persistent symptoms following COVID-19: a parallel-group, single-blind, randomised controlled trial Lancet Respir Med 2022