Real world experience of single use flexible bronchoscopy over six months in a tertiary centre

The development of single use flexible bronchoscopes (SUFBs) has accelerated in recent years, with the reduced risk of infectious transmission and reduced need for endoscopy staff particularly advantageous in the COVID-19 era. Despite complex cleaning systems for reusable flexible bronchoscopes (RFBs), disinfection is often inadequate with the consequent risk of cross infection. We trialled the routine use of The Surgical Company Bronchoflex © SUFB in a tertiary bronchoscopy service. 139 procedures were performed by five consultants from January to July 2021, with the main indications being infection (45%) and malignancy (32%). Most were performed in the endoscopy suite;eight procedures took place in the Intensive Care Unit, six at ward level and three in theatre as an adjunct to rigid bronchoscopy. SUFBs were used across a range of procedures including bronchoalveolar lavage, brushings, endobronchial biopsy, transbronchial needle aspiration, argon plasma coagulation, cryobiopsy and stent placement. 85% of procedures had no complications related to the use of a SUFB with a user satisfaction score of above 4/5 in 89% of cases (Figure 1). Issues with image quality (6%) or suction (5%) meant the reversion to reusable bronchoscope in some cases. Overall, the use of SUFBs has significant benefits in patient care with the ability to use the SUFB across a range of indications and procedures with high user satisfaction.

Portable HEPA filtration successfully augments natural-ventilation-mediated airborne particle clearance in a legacy design hospital ward.

As the severe acute respiratory syndrome coronavirus-2 pandemic has proceeded, ventilation has been recognized increasingly as an important tool in infection control. Many hospitals in Ireland and the UK do not have mechanical ventilation and depend on natural ventilation. The effectiveness of natural ventilation varies with atmospheric conditions and building design. In a challenge test of a legacy design ward, this study showed that portable air filtration significantly increased the clearance of pollutant aerosols of respirable size compared with natural ventilation, and reduced spatial variation in particle persistence. A combination of natural ventilation and portable air filtration is significantly more effective for particle clearance than either intervention alone.

Who’s talking about cystic fibrosis continued: the effects of the COVID-19 pandemic on the cystic fibrosis online landscape

Background: Due to COVID-19, we saw an increased usage of digital platforms for healthcare delivery. However, its effect on internet postings for CF during 2021 is unknown. Methods: CF key phrases were identified by a CF MDT and entered in Google Alerts and tracked for 6 months in 2021. Alertswere also created for Asthma, COPD and Lung Fibrosis. Data recorded for each alert includes the date, title, URL, category, country of origin;if a discussion, like/share took place. Thiswas then compared against previous data collected (2015, 2019). Results: The number of CF alerts recorded decreased (2021:1846– 2015:2742) while the number of blocked alerts increased (2021:325– 2015:89). Almost half of the CF alerts originated from the USA. In 2021, News was the most common category (33.96%) followed by Financial/ Marketing (25.73%) and Medical (21.07%). The most common category for 2015 was News (58.35%) and Financial/Marketing in 2019 (35.2%). The majority of CF terms experienced an increase in quantity, specifically alerts relating to CF pathogens or changing condition expectations, such as Pseudomonas (2021:718, 2015:149), CFLD(2021:428, 2019:865, 2015:37), and CF Pregnancy (2021:91, 2015:5). For the comparative lung conditions, in 2015 Asthma was the most common alert (985) followed by CF, COPD, and Lung Fibrosis. In 2019 CF (605) was the most common. In 2021, the quantity of alerts decreased for all conditions, with CF (316) and Asthma (336) being of similar magnitude. Conclusion: The landscape for CF internet postings continues to evolve. CF is discussed frequently online, with the focus of these discussions changing to news items in 2021. The increased frequency of specific CF terms may reflect changing expectations (e.g Pregnancy). The number of blocked alerts continues to increase, potentially reflecting different global GDPR practices. Online non-EU healthcare resources need to factor this into their practice to avoid potential correct information loss for EU patients.

Supported discharge for COVID-19

Aims Assessment of a supported discharge service for a cohort of patients admitted to Cork University Hospital with COVID-19 that were identified as being appropriate for remote patient monitoring. Methods Patients uploaded SpO2, subjective breathlessness scores, and temperature readings onto the PatientMpower application, and received a daily phone call from the physiotherapist. Readmission was triggered where appropriate. Patient satisfaction questionnaires were completed following service discharge. Results Over 12 weeks, 15 patients had a supported discharge. Readmission was triggered for 3 patients (20%). Compared to non-readmitted patient, readmitted patients had more abnormal SpO2 readings (9 (5.5-22.5) vs 1 (0-1), p= 0.022) and all 6 temperature spikes that occurred, but lower subjective breathlessness scores (3 (1-6) vs 4.25 (2-8), p = 0.003). Differences in mean abnormal SpO2% readings were not statistically significant. Conclusion A supported discharge service including remote monitoring and regular contact with healthcare professionals can facilitate safe, and timely discharges of select patient groups.

TeCC (TeleMedicine, Cystic Fibrosis, Corona-Virus) study in a previous telemedicine-naive centre: clinical challenges, outcomes, and user experience in the first six months of a global pandemic

Background: COVID-19 made it necessary to establish telemedicine as a first default for reviews in a previously telemedicine-naive clinic. Objectives: To establish and assess telemedicine in the first 6 months of COVID-19 pandemic. Methods: Utilising a multidisciplinary team (MDT) approach, we established a ‘Covid Pack’ of medical equipment (sent to each patient) and a suitable video conference platform to replicate the in-person clinic format. The virtual clinic was then rolled out (94 patients reviewed in the first 6 months). A retrospective chart review comparing patients’ clinical metrics pre- and post-rollout was then conducted. Usability and Acceptance were also measured with patients (p) and staff (s) via a number of standardised surveys: System Usability Scale (SUS), TeleHealth Usability Questionnaire (TUQ), IT Familiarity, and our own quality-survey. Results: The Covid Pack permits adequate spirometric assessment of patients (mean bias −2.5%). Preliminary data collected from 52 patients and 11 staff members show an overall positive response to our remoteclinics. The SUS received a median score of 90 (p) and 87.5 (s) out of 100. The TUQ received a total score of 6.52 (p) and 6.1 (s) out of 7, with ease of Use and Learnability as the highest-rated category in the TUQ (median 7, range 3.6–7) and Reliability as the lowest-rated category (median 5.33, range 2–7). The IT Familiarity questionnaire received an average median score of 1 (very familiar) from both groups. Qualitative data collected via a custom survey show that while patients and staff are positive to the convenience of the remote clinic, the facility for an in-person. face-to-face review remains important, as does good WiFi connection. Conclusion: Initial 6-month data are positive for the remote clinic as a first default during the pandemic. Preliminary data shows a positive trend for the usability and acceptance by all stakeholders, but it is not a replacement for physical clinics.

Who's talking about cystic fibrosis? The changing landscape of internet postings related to cystic fibrosis: a two-year comparative study

Background: Medical professionals are aware that patients continue to use the internet as a medical information source. With the advent of government campaigns to increase awareness of data privacy and information sources, we investigate how the landscape of internet postings has changed for CF and how this could affect patients seeking online medical information. Methods: Key phrases relating to CF were identified by a CF multidisciplinary team and entered in Google Alerts with prospective tracking for 6 months in 2015. Alerts were also created for 3 non-orphan lung diseases (asthma, chronic obstructive pulmonary disease and lung fibrosis). These steps were repeated again in 2019 and the data compared. Results: In 2015, Asthma received the highest mean number of alerts per day (31.7), followed by CF (16.1), then COPD (14.6), and Lung Fibrosis (5.1). This changed in 2019 where CF was the highest with 19.5, followed by Asthma (11.5), COPD (10.3), and Lung Fibrosis (7.4). In both years, the USA generated (56%) the highest number of alerts for CF. There was an increased number of blocked articles in 2019 (540). In 2015, News (58%) was the most common category for CF alerts, but this changed to Financial/Marketing (35%) in 2019. In 2015 there was a small number of Social Media alerts recorded for all lung conditions;however, in 2019, there were none for the comparative lung conditions and only 3 for CF. Alert frequency for CF-related terms also increased in 2019. Conclusion: The landscape for internet postings for CF has changed. CF is now more commonly reported than other lung conditions and the ‘business of CF’ is now more frequently reported online while content from the general public has decreased (or is private). Medical professionals need to remain vigilant and increase awareness of information-dilution by monetary based media. A limitation of this study is that it predated the COVID-19 pandemic and it is suggested that future works revisit this at an appropriate time.

Compassionate use triple therapy CFTR modulation (Kaftrio®) in severe disease. Single-centre, real-world clinical outcomes, safety and tolerability

Objective: Patients (F508del/F508del or F508del/MF) with severe CF (ppFEV1<40%) were not represented in the Phase 3 VX445 (Kaftrio®) [Table presented] clinical trials. We aimed to assess real-world efficacy, safety and tolerability in this cohort. Method: All patients with severe lung disease (ppFEV1<40%) attending our clinic eligible for Vertex's managed access programme who received treatment were assessed prospectively at 3 monthly intervals. Results: 7 of 8 patients remain on therapy. Irrespective of prior CFTR modulator therapy, notable improvements were observed (Table 1). After adjusting for time, there was a relative reduction of 68.89% IV and 21.43% PO antibiotic usage as well as a 66.9% reduction in hospital bed days. Improvements in CFQR-R and D domains and FACIT fatigue scores were observed. Patient 4 developed an erythematous diffuse rash on day 7 which resolved with antihistamines. No liver function abnormalities have been seen to date. Patient 6 died while on therapy due to multimorbidities including pulmonary embolism (Covid PCR and antibody negative), persistent pneumothorax and sepsis. Conclusion: This cohort demonstrates preliminary clinically meaningful real-world efficacy, safety and tolerability for patients (F/F, F/MF) with severe disease (ppFEV1<40%).

Virtual cystic fibrosis doctor: design, development, and user experience pilot study

Background: Patients often contact the cystic fibrosis (CF) multidisciplinary team (MDT) via phone to express health-related concerns in between the standard quarterly review. This often requires a phone evaluation before organising an unscheduled appointment. These sporadic interactions heavily affect available resources. This strain on resources will be further impacted when considering that data from the European CF registry predicts that there will be a 75% increase in the adult CF population by 2025. Furthering this, CF services are increasingly more strained now during the global Covid-19 pandemic. Objective: This research first sets about to design and develop a Virtual Doctor system based on the expertise of a MDT through multiple consultations. Next, pilot data pertaining to user acceptance and experience with using this novel technology is gathered. We therefore aim to investigate if the use of such technology can be beneficial in a specific clinical setting. Method: The final collaborative-design of the Virtual Doctor comprises several technical features and is primarily a voice synthesis system allowing the patient to interact with natural language. The virtual doctor asks the patient questions regarding their health concerns and can collect real-time clinical metrics such as FEV1, oxygen saturation, temperature. The patients’ responses and metrics are then compared to baseline values calculating a score which stratifies a response time from the CF team. This information is then collated in a report and sent to the CF team for action. Future works: Initial stress testing of the technical performance is now complete. Supportive visual media to improve coaching of using clinical devices have now been implemented in preparation for patient pilot testing which is currently ongoing. It is anticipated that a virtual system such as the Virtual Doctor will become more accessible and acceptable to patients, especially during the Covid-19 pandemic.

Effectiveness of a plasma treatment device on microbial air quality in a hospital ward, monitored by culture.

This study analysed the effectiveness of plasma treatment on airborne bacteria and surface counts during a 14-day intervention within a four-bedded bay in an adult respiratory ward at Cork University Hospital, Ireland. One-hundred-litre air samples were collected twice daily every weekday for 4 weeks, with settle plates and surface swabs. The plasma treatment did not have an effect on airborne bacteria and fungi that was detectable by culture. However, the possibility that culture-based sampling may be insufficiently sensitive to detect an effect, or that the duration of the study was insufficient for plasma treatment to affect a complex environment, cannot be excluded.

Containment of procedure-associated aerosols by an extractor tent: effect on nebulized drug particle dispersal.

BACKGROUND: Several medical procedures involving the respiratory tract are considered as 'aerosol-generating procedures'. Aerosols from these procedures may be inhaled by bystanders, and there are consequent concerns regarding the transmission of infection or, specific to nebulized therapy, secondary drug exposure. AIM: To assess the efficacy of a proprietary high-efficiency-particulate-air-filtering extractor tent on reducing the aerosol dispersal of nebulized bronchodilator drugs. METHODS: The study was conducted in an unoccupied outpatient room at St. James's Hospital, Dublin, Ireland. A novel real-time, fluorescent particle counter, the Wideband Integrated Bioaerosol Sensor (WIBS), monitored room air continuously for 3 h. Baseline airborne particle count and count during nebulization of bronchodilator drug solutions were recorded. FINDINGS: Nebulization within the tent prevented any increase over background level. Nebulization directly into room air resulted in mean fluorescent particle counts of 4.75 x 105/m3 and 4.21 x 105/m3 for Ventolin and Ipramol, respectively, representing more than 400-fold increases over mean background level. More than 99.3% of drug particles were <2 µm in diameter and therefore small enough to enter the lower respiratory tract. CONCLUSION: The extractor tent was completely effective for the prevention of airborne spread of drug particles of respirable size from nebulized therapy. This suggests that extractor tents of this type would be efficacious for the prevention of airborne infection from aerosol-generating procedures during the COVID-19 pandemic.

Pulmonary embolism and covid-19

Aims There is increasing concern amongst clinicians of a possible increase in venous thromboembolism (VTE) events in patients with COVID-19. There remains limited data defining the incidence of VTE in this population and thus also a paucity of research examining the impact of targeted treatment in patients with thrombotic complications. Methods We examined the number of symptomatic VTE events amongst proven COVID-19 patients admitted to a tertiary level academic hospital, over a one-month period. Patient characteristics, admission and discharge inflammatory and coagulation markers were included in the analysis. Results Sixty-one patients were identified. Twelve patients (19.6%) admitted with COVID-19 were treated for a suspected PE. Of these patients, 3 patients were discharged on anticoagulation, 3 died and 6 remain inpatients at the end of the study period. Discussion COVID-19 patients are at increased risk of VTE. This risk may extend beyond the period of admission. Further research examining the role of extending the duration of thromboprophylaxis in COVID-19 patients beyond hospital discharge is warranted. © 2020, Irish Medical Association. All rights reserved.