Position statement on integrated respiratory care published by BTS and PCRS

9th February 2024

The importance of integrated respiratory healthcare models that put patients at their centre has been outlined in a new joint position statement from the British Thoracic Society (BTS) and the Primary Care Respiratory Society (PCRS).

Aimed at all respiratory healthcare professionals across primary and secondary care, the position statement aims to improve health outcomes, tackle complex challenges and inequalities in the provision of healthcare, and prevent avoidable hospital admissions.

It highlights the common priorities shared by the BTS and PCRS and sets out a series of common goals to support the coordination of the multi-professional team and deliver high-quality, accessible care that considers physical and mental health, housing and social care.

The common goals focus on maintaining pathways of care that help to avoid unnecessary admission to hospital, advocating a whole-person approach to planning and delivering respiratory care, supporting improved outcomes and addressing health inequalities, and facilitating workforce recruitment, retention and capacity models.

These goals sit alongside each organisation’s own range of existing initiatives to support the provision of integrated care, they said.

The position statement also includes a five-part high level model for use by respiratory teams, detailing practical steps to help ensure the success of integrated respiratory healthcare: build relationships; identify funds; establish clear, identified goals; build the right team; and actively deliver the pathway.

Dr Paul Walker, chair of the BTS, said: ‘Integration of respiratory care is vital to optimally deliver health and social care in a system that is often disjointed and challenging for patients and carers to navigate. Not only is integrated respiratory care more efficient and productive it encourages sharing of skills, knowledge and insight.

‘This position statement encourages respiratory professionals and teams, across the healthcare landscape, to work better together to improve outcomes for patients.’

Daryl Freeman, chair of the PCRS’ Service Development Committee, associate clinical director primary care and GP in older people’s medicine in Norfolk, said: ‘It’s been an inspiration to be part of the BTS/PCRS joint working group delivering this statement.

‘I know that it will inspire clinicians, trusts and integrated care boards to design and deliver integrated care in their own regions and enable new implementers; giving them access to a document to which they can not only refer, but the support and experience of clinicians from BTS and PCRS who are either actively working in or developing integrated services.’

The BTS and PCRS represent and support all respiratory healthcare professionals working in the NHS across the UK.

The organisations hope that their collaboration on the position statement will help to ensure that tools, resources and education materials are shared widely across all members of the multi-professional respiratory team to the benefit of patients.

Liberation time from respiratory support similar for high-flow nasal cannula and CPAP in acutely ill children

24th June 2022

High-flow nasal cannula therapy is equivalent to continuous positive airway pressure for release time from respiratory support in children

The use of high-flow nasal cannula (HFNC) therapy as a first-line non-invasive respiratory support system appears to be non-inferior to continuous positive airway pressure (CPAP) for the time to liberation of respiratory support in critically ill children. This was the conclusion of a randomised trial by UK researchers.

Respiratory distress is common cause of paediatric intensive care unit admission and strategies to address oxygenation problems in critically ill patients with hypoxemic respiratory failure include use of simple oxygen equipment, use of non-invasive ventilation, or use of invasive ventilation.

Non-invasive mechanical ventilation procedures include CPAP whereas HFNC is considered as a cross over therapy from basic oxygen therapy to non-invasive ventilation. In a systemic review, HFNC was shown to reduce the rate of intubation, mechanical ventilation and the escalation of respiratory support.

However, whether or not HFNC is superior to other forms of non-invasive respiratory support such as CPAP with respect to the length of time required for such respiratory support in acutely ill children remains to be determined.

In a feasibility study in 2018 designed to compare HFNC with CPAP, it was concluded that such a trial would be possible. Following on from this initial study, for the present trial, the UK team set out to determine if HFNC was comparable to CPAP in terms of to the time to liberation from respiratory support in acutely ill children admitted to a paediatric critical care unit.

In their pragmatic, unblinded trial, the researchers randomised children 1:1 to receive either HFNC or CPAP although physicians were permitted to switch from HFNC to CPAP (or visa versa) where they felt it would be clinically appropriate.

The primary outcome of interest was the time from randomisation to liberation from respiratory support, defined as the start of the 48-hour period during which the patient was free from all respiratory support.

For their secondary outcomes, the authors focused on several outcomes including the duration of stay within the critical care unit, mortality and use of sedatives during non-invasive respiratory support.

HFNC therapy outcomes

A total of 573 children with a median age of 9 months (39% girls) were included and randomised to either HFNC (295) or CPAP. The most common reasons for intensive care admission were in the HFNC group were bronchiolitis (48.5%) or another respiratory condition (18.6%) and these proportions were similar in the CPAP group.

The median time to liberation of respiratory support in the HFNC group was 52.9 hours compared to 47.9 hours in the CPAP group and this difference was not statistically significant (hazard ratio, HR = 1.03, 95% CI 0.86 – 1.22).

For the secondary outcomes the use of sedatives during respiratory support were significantly less for children using HFNC (odds ratio, OR = 0.59, 95% CI 0,39 – 0.88), as was the mean duration of their critical care stay (mean difference = – 3 days) and the mean duration of hospital day (mean difference = -7.6 days).

The authors concluded that HFNC was non-inferior to CPAP with respect to the liberation of respiratory support.

Citation
Ramnarayan P et al. Effect of High-Flow Nasal Cannula Therapy vs Continuous Positive Airway Pressure Therapy on Liberation From Respiratory Support in Acutely Ill Children Admitted to Pediatric Critical Care Units: A Randomized Clinical Trial JAMA 2022