Respiratory conference highlights from a nurse perspective
This supplement is funded by Boehringer Ingelheim Limited (BIL).
The views expressed are those of the authors, who have been offered an honorarium for their contribution. BIL have written this supplement with medical writing support from MediTech Media, based upon interviews with the authors.
Jane Scullion, Consultant Respiratory Nurse, University Hospitals of Leicester NHS Trust, Leicester Royal Infirmary
Samantha Prigmore, Respiratory Nurse Consultant, St George’s Hospital
This year marked the 29th European Respiratory Society (ERS) meeting, currently the biggest congress in respiratory medicine, with over 22,000 delegates from around the world attending a 5-day congress in Madrid. The cutting-edge of respiratory medicine was presented, with high-quality scientific and educational content evident throughout the congress. The main focus was on prevention, particularly smoking cessation and the impact of air pollution.1
We have summarised what we consider is most poignant to nurses and allied healthcare professionals (HCPs) from all backgrounds. We hope you find these key summary points of use in your future practice.
Taking centre stage: ILD
There are currently over 300 interstitial lung diseases (ILD), with only one in three cases having a known cause.2 A major focus of many of this year’s sessions was therefore centred on ILD.
Key discussions were based on ensuring our management strategies within ILD are disease-specific and that caregivers shouldn’t be using the same approaches used for the management of asthma or COPD.
A clinical trials session titled “ALERT: Abstracts Leading to Evolution in Respiratory Medicine Trials: Interstitial lung diseases and pulmonary hypertension”, primarily concluded that we shouldn’t be using a “one-size-fits-all approach” when assessing ILD. In general, clinical trials in ILD tend to use forced vital capacity (FVC) as the primary efficacy endpoint, as spirometry outcomes are often used for trials in asthma and COPD. However, we now know that for some patients, when being evaluated for treatment, their FVC may be preserved, and may not reflect or relate to their disease severity, impairment or progression, as indicated by diffusion lung capacity for carbon monoxide, for example. Therefore, we should also be looking at different markers and endpoints to assess ILD.
From attending the congress, we saw the large rise in interest across the range of ILDs. New trial data included those from INBUILD®, which was one of the first clinical trials to include patients with several different ILDs;3 RELIEF,4 which looked at interventions in progressive forms of fibrotic ILD; and a Phase II trial in patients with progressive fibrosing unclassifiable ILD.5
We predict that this interest in ILDs will continue to grow and will play an even larger role in the coming years.
Symptom identification: asthma
A focus of some of the sessions we attended at ERS was on the improved identification of symptoms in clinical practice.
In patients with severe asthma, excessive symptom burden and impaired quality of life (QoL) are still prevalent, despite standard of care.6 In one study, patients were assessed, and answered the query: “What is/are the biggest problem/s you experience as a result of your breathing problem?” The most important symptoms identified were breathlessness (39.0%), cough (10.3%) and limitations in activity (17.1%). It was shown that at least one of these symptoms was reported in 51.4% of participants. Results highlighted the need for new effective targeted treatments, but also the need to prevent severe asthma where possible, and to make efforts to uncover and to manage symptoms in these patients.
Whilst in clinical practice, we do currently seek to identify those symptoms commonly reported as problematic by patients, but by using patient-reported outcome or experience measures, we tend not to assess individual items, but rather we look at a composite measure of symptoms. The take-home message from this congress session is that we need to evaluate symptoms and domains independently and in more depth, as these individual symptoms are often manageable with non-pharmacological interventions, which we would be able to put into place in clinical practice.
“Cough is a troublesome symptom in asthma, but is not routinely assessed by clinicians.”
Although patients do identify cough as a troublesome symptom in asthma, and it has been recognised as a common and important symptom associated with poor disease control, it is not always routinely assessed by clinicians.6-8
Currently used questionnaires and measures of asthma control often don’t focus on cough as a symptom, despite the impact it has on QoL. Lack of management of cough may lead to poor symptom control and the overuse of corticosteroids.9 A study presented at ERS assessed the interplay between cough measures and asthma control.10 The findings highlighted a significant association between these factors and the major impact cough has on patients with severe asthma. Many presented with cough frequencies greater than 10 coughs per hour.
The findings from this poster session indicate we need to look at ways we can assess and measure cough as a separate treatable trait in asthma.
“72% of patients on Step 4 or 5 of GINA have not been referred.”
Another important issue discussed at the congress was missed opportunities for referral to specialist care in patients with asthma, with many patients in primary care with potentially severe asthma not being referred to a specialist severe asthma centre.11 The importance of referrals in asthma care was highlighted in a British evaluation of asthma deaths, with 19% of deaths associated with avoidable factors relating to referrals (including delays for failure to refer to specialist care), and the majority of people who died from asthma(57%) were not recorded as being under specialist supervision during the 12 months prior to death.12 Therefore, it is vital we appropriately manage our patients with asthma.
One study presented in the “Clinical approach to asthma management” poster session, looked at developing a protocol to identify these patients with severe asthma, which could help to reduce the numbers of missed cases. Of 202,557 patients retrospectively studied, 8% were found to have potential severe asthma (i.e. GINA 2018 Step 4 and ≥2 exacerbations OR at Step 5); of these, 72% were unreferred, with only 28% referred to specialist care at some point in the past.13
This issue was further assessed in a separate study, looking at under-referral of high-risk asthma patients to specialist care in England,14 despite the recommendation that patients should be referred to specialist care after commencing high-dose inhaled corticosteroids (ICS) or ≥3 courses of oral corticosteroids, as assessed in the National Review of Asthma Deaths in 2014.12 Although referrals had increased after the recommendations in 2014, three-quarters of patients remained unreferred.
Therefore, it’s essential we continue to improve our understanding of high-risk patients with severe asthma, and we need to be mindful of the importance of referring eligible patients to specialist care where appropriate.
Symptom identification: COPD
Breathlessness was also an important topic in COPD sessions, with several speakers finding new ways to depict how this feels for patients. A very interesting observation was that many languages do not have a word that translates easily to breathlessness, meaning many patients may complain of chest pain or similar to describe their feelings associated with lack of breath. This can obviously lead to misinterpretation and lost time when trying to diagnose the cause. A series of emotive paintings at this year’s conference also dramatically highlighted the haunting and overwhelming feelings that patients have about breathlessness and exacerbations. Exacerbations of COPD are associated with high morbidity, mortality and costs. Identifying methods to reduce all of these is important in the management of COPD.
The outcomes and costs of COPD can be influenced by patients’ health behaviours, and advance practice nurses (APNs) may be able to provide coaching and guidance to these patients to aid with their self-management. Various countries have utilised a nurse-led model of care. A study in Switzerland evaluated the needs of patients with COPD,15 and found there was often fragmented care and a need for greater coordination of transition between healthcare settings. It was suggested that APNs have the potential to play a unifying role in this approach.
In the same session, nurses were described as the “spider in the web” of integrated respiratory care, reaching out and coordinating care between the different disciplines.16 It was concluded that nurses are a key contact point who can aid the transition between healthcare settings (e.g. from the hospital to the home setting), demonstrating the crucial role they play in respiratory care.
“Smart shirt can accurately measure breathing and could be used to monitor lung disease.”
We were interested to see several studies report on the use of technology in the management of COPD.
One particular study of interest, that may allow for earlier intervention in COPD management in the future, impacting mortality, morbidity and costs, involved the use of a “smart shirt” in patients in the Netherlands.17
In the M-health/e-health I poster session, this novel approach was discussed, in which breathing activity was measured in healthy patients, by sensing movements in the chest and abdomen, and was proven to be accurate when compared with traditional testing equipment. Together with a mobile app, the smart shirts have measured breathing in healthy people whilst carrying out activities. However, the calibration factors could not be reapplied reproducibly, and therefore efforts will need to ensure these are improved. The hope in the future is to test in patients with COPD, potentially allowing for the monitoring of patients remotely, and identify early signs their condition is worsening, with the possibility of early intervention.
Furthermore, as part of pulmonary rehabilitation (PR) in patients with COPD, it’s recommended that patients should perform physical activity. In a study using a Fitbit Zip to assess physical activity during PR, adherence to the prescribed exercise intensity was achieved in 55% of time spent exercising across the 6 weeks of the study. Further strategies to improve adherence are needed.18
Sustainability and pollution
Another key area discussed at ERS was sustainability, pollution and reducing the carbon footprint; from sustainability and the carbon footprint of inhalers, to taxi drivers facing the highest levels of exposure to black carbon when compared with other types of drivers.19 With 91% of the world’s population living in areas of poor air quality,20 we need to consider the impact of this on respiratory diseases.
“91% of the world’s population live in places where poor air quality exceeds WHO guidelines.”
During the “Recent clinical advances in inhalation therapy” session we were particularly interested in advances related to the global warming potential (GWP) of inhalers – and why we should consider both the pros and cons of switching respiratory disease patients to inhalers with a lower GWP.
The implications of governments imposing targets for HCPs to switch to inhalers with a lower GWP, and the impact this may have, were discussed.
The argument against governmental regulation of prescribed inhalers was presented and discussed in this session, and the importance of putting clinical commitment to patients first and before all other considerations focused on.
In 2011, it was estimated that in the UK, 70% of our inhaler use was with pressurised metered-dose inhalers (pMDIs).21 Both soft mist inhalers and DPIs have a lower estimated product carbon footprint in comparison with pMDIs.21,22 On the other hand, although some patients may be considered as candidates to switch from pMDIs, we need to keep in mind that asthma control is extremely important, and if pMDIs are working optimally for patients, we shouldn’t be enforcing a change. In order to address this issue, industry is working to continue to improve and develop pMDIs and other low carbon footprint inhalers.
It is also important to note that some patients, for example young children, may only be able to use
pMDIs with a spacer, and therefore switching to inhalers with lower GWP is not always feasible in these patients. Furthermore, it was put forward that enforcing a change in inhaler could significantly impact the level of their asthma control.
Occupational risk of COPD
When considering causative factors in COPD, we often focus on smoking, yet occupational exposures may be just as important,23 as these may also be preventable causes of COPD. A recent study published in the European Respiratory Journal identified the high-risk jobs associated with COPD from a UK biobank of 94,000 patients. Of those evaluated, six occupations showed an increased COPD risk among never-smokers and never-asthmatics; including sculptors, gardeners, food and drink workers, plastic-processing workers, agriculture/fishing, and warehouse workers. It is therefore important that patients with COPD symptoms should be asked about their job history for better diagnosis and disease management.
Vaping-induced lung disease
With the current ongoing epidemic of e-cigarette-associated acute lung disease reported in the US, an intriguing and topical emergency session added to the programme at ERS included a panel discussion on vaping-induced lung disease. Discussions focused on: What are the clinical characteristics of these patients admitted for severe lung disease? How “safe” are e-cigarettes? Should we be advocating them?
During the session, a panel discussion took place on the potential causes of 53 reported cases of pulmonary disease associated with the use of e-cigarettes in Illinois and Wisconsin between July and August 2019.24 Possible links with lipid-based formulations, petroleum-based products and use of tetrahydrocannabinol have been suggested, although further testing is required.
Importantly, Public Health England advocates the use of e-cigarettes, when supported by a smoking cessation service (updated as of February 2019).25 In March 2018, the National Institute for Health and Care Excellence issued guidance to health and social workers and discussed the use of e-cigarettes, stating that supporting data suggest e-cigarettes are substantially less harmful to health than smoking but are not risk-free, with evidence in this area still developing, including that on the long-term health impact.26
Potential reasons were considered with regards to why England is the only country in the world that actively encourages the use of e‑cigarettes. ERS leaders commented in 2018, “Human lungs are made to breathe clean air and any substance inhaled long term may be detrimental,”27 and it seems this remains the view of the organisation, with reiteration that the ATS/ERS taskforce continues to actively not support the use of e‑cigarettes, and do not consider it to be a form of smoking cessation.
“Why is England the only country that advocates the use of e-cigarettes?”
We don’t yet know the long-term consequences of e-cigarette use, and it is paramount that continued vigilance and research in this area is undertaken.
Train the brain
We also attended a thought-provoking presentation in the “Epidemiology of childhood respiratory diseases” session. We don’t often consider the psychological aspects of respiratory diseases, especially not the potential impact upon parents and carers.
In a study looking at trends in referrals for specialist psychological support for children who require long-term ventilation, it was found that over 70% of referrals were in fact for parents.28 Interestingly, referrals for fathers are increasing in frequency, with feelings of guilt a common occurrence. Therefore, we must consider parental health in our clinical practice, particularly the important role fathers play in care, and provide them with the relevant support.
Psychological interventions in patients were also a popular topic at this year’s congress. The importance of cognitive behavioural therapy and mindfulness training as part of an integrated care approach to patients with lung disease was discussed, and it was stated that we must “train the brain, as well as the lungs”.
Other topics
As the GINA report has been updated this year, discussions in an evening session looked at these updates, bringing out the key focus on symptom relief and risk reduction.29 GINA no longer recommends short-acting β2‑agonist (SABA)-only treatment in Step 1, as this may increase the risk of severe exacerbations, and could have led to overuse of SABA. The addition of ICS could significantly reduce this risk, and GINA now recommends adults and adolescents with asthma receive symptom-driven or regular low-dose ICS-containing controller treatment.
Concluding remarks
Our experience at this year’s ERS congress was extremely useful as an insight into the topics of interest in the field of respiratory medicine, and we hope we have highlighted those areas that particularly resonate with HCPs. It was interesting to see the rise in interest in ILD, and there is an expectation this will have an even larger role at next year’s event. Sustainability and pollution were also popular themes, and the drive towards reducing the GWP of inhalers was a key discussion point. We were particularly interested in the debate on the use of e-cigarettes, and as we rapidly uncover new epidemiological data, we can see the potential impact these devices are having upon global health.
We hope you have enjoyed our reflections and summaries and that we have discussed key themes that may be of interest for your future practice.
References
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Date of preparation: October 2019 | SC-GB-00044