M13 Clinical characteristics and management of patients presenting to the “Airways Clinic”; a specialised tertiary multi-disciplinary respiratory service

Abstract

IntroductionOur specialist service manages patients with vocal cord dysfunction (VCD), chronic cough (CC) and dysfunctional breathing (DB), and referrals have grown exponentially since we introduced this novel multi-disciplinary (MDT) model in 2006. The team comprises two severe asthma specialist physicians, two respiratory speech and language therapists (rSLT), a severe asthma nurse specialist, respiratory physiotherapist and clinical psychologist.AimsTo describe the clinical characteristics of those referred and assess utilisation of the multi-disciplinary structure.MethodsPatient demographics and clinical data were retrospectively collated from clinical records of patients referred between January and December 2014.ResultsThe service received 249 referrals. Excluding patients still in treatment or who failed to attend initial assessment, 141 complete data sets were available for analysis: 71% female; mean (range) age 55 (18–79) years. Assessment requests were for VCD (71%), CC (28%) or both (1%) and over half were from NW severe asthma centres or extra-regional specialist centres. The majority of referrals were from hospital consultants (72%), with the remainder from GPs (17%) and AHPs (11%). For VCD there was 73% agreement between the clinical suspicion on referral and nasendoscopic assessment. Approximately half had evidence of co-existent reflux (52%) and a third (29%) had nasal disease.The majority were seen by more than one member of the MDT team; all by a specialist physician and a rSLT, 43% by respiratory physiotherapy, and 7% clinical psychology.In the VCD cohort 64% had a previous asthma diagnosis and this was confirmed in the majority (93%) – 49(82%) were ≥Step 3 on BTS/SIGN guidelines; 43% were additionally referred for DB assessment; 78 flow volume loops were available and 31 (40%) were suggestive of extra thoracic inspiratory airway obstruction.Sixty-seven patients (48%) received rSLT management [median (range) 4(1–8) sessions] with a further 16(11%) scheduled to receive it post medical intervention. Of those who completed treatment, 63% had clinically improved presentation on discharge nasendoscopy.ConclusionsA large proportion of patients referred to a specialist service for patients with complex breathlessness require multi-disciplinary intervention. There is a significant incidence of VCD and DB in patients with severe complex asthma. Of those receiving rSLT interventions, outcome was extremely effective at reducing symptoms.

Dysfunctional breathing and reaching one’s physiological limit as causes of exercise-induced dyspnoea

“…This PDB can be constant or happen intermittently when provoked by a physical or psychological stress [ 17 ]. Dysfunctional breathing appears to frequently coexist with respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) [ 21 ], although the nature of the relationship (causal or coincidental) remains unclear. The mechanisms leading to such characteristically “abnormal” patterns of breathing are also unclear, although the condition does appear to be amenable to “breathing retraining” where it is possible to exert a level of voluntary control over the pattern and rate of respiration.…”

“…This clinic reports a significant number of their patients with severe asthma or chronic lung disease to also have PDB and/or vocal cord dysfunction. Despite a protracted history of symptoms in most, patients reported clinical improvement with multidiscip­linary team intervention addressing their dysfunctional breathing [ 21 ].…”