Emergency oxygen use in adult patients: concise guidance.

There is considerable controversy concerning the benefits and risks of oxygen treatment in many situations and healthcare professionals receive conflicting advice about safe oxygen use. The British Thoracic Society (BTS) has published up-to-date, evidence-based guidelines for emergency oxygen use in the UK in order to encourage the safe use of oxygen in emergency situations and improve consistency of clinical practice. The purpose of this concise guideline is to summarise the key recommendations, particularly concerning emergency oxygen use in the hospital setting.

British Thoracic Society emergency oxygen audits.

The British Thoracic Society (BTS) guideline for emergency oxygen use in adult patients was commissioned by the BTS and developed in conjunction with 21 other colleges and societies prior to publication in 2008. One of the specific aims of the Guideline Development Group was to audit the use of oxygen in UK hospitals before the guideline was published and at intervals afterwards.

Hospital at home for chronic obstructive pulmonary disease: an integrated hospital and community based generic intermediate care service for prevention and early discharge.

Recent randomized controlled studies have reported success for hospital at home for prevention and early discharge of chronic obstructive pulmonary disease (COPD) patients using hospital based respiratory nurse specialists. This observational study reports results using an integrated hospital and community based generic intermediate care service. The length of care, readmission within 60 days and death within 60 days in the early discharge (9.37 days, 21.1%, 7%) and the prevention of admission (five to six days, 34.1%, 3.8%) are similar to previous studies. We suggest that this generic community model of service may allow hospital at home services for COPD to be introduced in more areas.

Oxygen alert cards and controlled oxygen: preventing emergency admissions at risk of hypercapnic acidosis receiving high inspired oxygen concentrations in ambulances and A&E departments.

BACKGROUND: Appropriate resuscitation of hypoxic patients is fundamental in emergency admissions. To achieve this, it is standard practice of ambulance staff to administer high concentrations of oxygen to patients who may be in respiratory distress. A proportion of patients with chronic respiratory disease will become hypercapnic on this. OBJECTIVES AND METHODS: A scheme was agreed between the authors' hospital and the local ambulance service, whereby patients with a history of previous hypercapnic acidosis with a Pao2 >10.0 kPa--indicating that oxygen may have worsened the hypercapnia--are issued with "O2 Alert" cards and a 24% Venturi mask. The patients are instructed to show these to ambulance and A&E staff who will then use the mask to avoid excessive oxygenation. The scheme was launched in 2001 and this paper present the results of an audit of the scheme in 2004. RESULTS: A total of 18 patients were issued with cards, and 14 were readmitted on 69 occasions. Sufficient documentation for auditing purposes was available for 52 of the 69 episodes. Of these audited admissions, 63% were managed in the ambulance, in line with card-holder protocol. This figure rose to 94% in the accident and emergency department. CONCLUSION: These data support the usability of such a scheme to prevent iatrogenic hypercapnia in emergency admissions.

Increasing social and psychological information conveyed to General Practitioners after bad news consultations by use of separate letters from the Lung Cancer Nurse Specialist.

Multidisciplinary teams (MDT) now review all cases of lung cancer. These teams include a Lung Cancer Nurse Specialist (LCNS). These Nurses help support the patient and should facilitate communication and liaise with other services. The LCNS is present when the diagnosis is given to the patient but also usually spends time afterwards with the patient and their family. We postulated that a separate letter from the LCNS to the General Practitioner (GP) after the consultations would convey extra information to the GP. In 58 new lung cancer patients reviewed in the clinic, the LCNS and Physician independently wrote separate letters after the consultation in which the diagnosis of lung cancer was given. The GPs were asked by questionnaire about the usefulness of the letter from the LCNS. This letter was considered by the GP to provide extra information in: (i) 69% concerning the patients reaction to the diagnosis; (ii) 85% concerning who attended the clinic with the patient; (iii) 85% about what referrals were made to community services; (iv) 86% about who the patient was living with; (v) 81% about who the patients carers were; (vi) 81% information on the patients condition; (vii) 70% concerning the information given to patients about benefits. Ninety-seven percent of the GPs found the LCNS letter useful or very useful and 92% of the GPs thought that the information in the letter would be useful or very useful when they next saw the patient. Separate and independent letters from the LCNS after "bad news" consultation in lung cancer provides added useful information for GPs. Ninety-one percent of the GPs wanted the letters from the LCNS to continue.

Telemedicine for multidisciplinary lung cancer meetings.

According to recent UK guidelines on the management of lung cancer, all cases should be reviewed prospectively by a lung cancer multidisciplinary team (MDT) and a thoracic surgeon should be readily available to liaise with the MDT. However, there is a shortage of thoracic surgeons in the UK. Over a one-year period, 28 MDT meetings were held at a district general hospital in Southend, at which 62 patients were presented to a tertiary cardiothoracic centre in London, 80 km away, via ISDN videoconferencing at 384 kbit/s. The annual resection rate increased by 30% following the introduction of the telemedicine MDTmeetings, and the mean time from first being seen in the clinic to surgery was reduced from 69 to 54 days.We estimate that the telemedicine meetings saved over three working weeks of thoracic surgical time during the year.

Obstructive sleep apnea presenting as pseudopheochromocytoma: a case report.

Sudden arousal from sleep causes a transient surge in sympathetic nervous activity. Repeated arousals, as occur in obstructive sleep apnea (OSA), are well documented to cause a more prolonged sympathetic overactivity and consequent elevations in 24-h urinary catecholamine levels. We describe here a series of five patients, each presenting with a clinical and biochemical picture indistinguishable from that of pheochromocytoma. Thorough investigations have failed to find catecholamine-secreting tumor in any of these subjects, but all have been diagnosed with OSA. Primary treatment of OSA with nasal continuous positive airways pressure has led to normalization of systemic blood pressure and urinary catecholamines. Pseudopheochromocytoma is therefore a rare, but treatable, presentation of obstructive sleep apnea.

Cushing's syndrome secondary to inhaled corticosteroids mimicking HIV-associated lipodystrophy.

We report the case of an asthmatic man with HIV infection who was initially diagnosed with HIV treatment-associated lipodystrophy. Further investigations showed he had Cushing's syndrome secondary to 1600 microg of budesonide dry powder inhaler. Cushing's syndrome has not been reported previously on this normal dose of inhaled budesonide.

Diaphragm strength in acute systemic lupus erythematosus in a patient with paradoxical abdominal motion and reduced lung volumes.

Diaphragmatic weakness is reported as a common feature of the shrinking lung syndrome of systemic lupus erythematosus (SLE). However, in chronic stable SLE it has been shown that, despite poor performance of voluntary tests of diaphragm strength, twitch pressures obtained by stimulating the phrenic nerves are normal. We present a patient with acute SLE and pulmonary involvement who, despite having paradoxical abdominal motion and low maximal inspiratory pressures during voluntary manoeuvres, had normal diaphragm strength when assessed with magnetic stimulation of the phrenic nerves. Following immunosuppressive therapy symptoms and lung function improved, yet diaphragm contractility remained normal and unchanged. We suggest that this case supports the view that reduced diaphragm muscle contractility per se does not explain the small volume lungs and respiratory symptoms in patients with acute SLE.

Transverse myelopathy and radiculomyelopathy associated with pulmonary atypical Mycobacterium infections.

Myelopathy is a well recognised but rare association with Mycobacterium tuberculosis infection, but has not been described with atypical mycobacteria. We report two cases of disabling myelopathy in association with pulmonary infection by Mycobacterium kansasii and Mycobacterium malmoense; the myelopathy is presumed to be a para-infectious phenomenon.

Age and the treatment of lung cancer.

BACKGROUND: The average age of patients with lung cancer is increasing and there are large numbers of elderly symptomatic patients with this common disease. However, there are few data on how the treatment of this group differs from that of younger patients. METHODS: From 1 January 1990 information was collected for the Southend Lung Cancer Registry on all patients with a diagnosis of lung cancer in a geographically well defined health district of the UK with a population of 325,000. Every effort was made to find new cases from all departments of the hospital, including all clinical diagnoses, histopathological and cytological reports, and necropsies. All death certificates in the district were examined, irrespective of age, for any diagnosis of lung cancer. This therefore included any patient not seen by the hospital services. The differences in initial treatment have been analysed for three age groups: under 65, 65-74 years, and over 75. RESULTS: The 563 cases of lung cancer diagnosed during a 30 month period were included in the study, of whom 240 (43%) were aged over 75 years. The overall mean age was 71 years (range 31-95). The incidence of lung cancer in the general population was 69 per 100,000, but in men over 75 years of age it rose to 751 per 100,000. For all patients the active treatment rate (chemotherapy, surgery, or radiotherapy) was 49%, but for patients not reviewed by a chest physician (n = 86) it was only 21%. There were large differences in initial treatment between age groups. For patients with non-small cell lung cancer (NSCLC) reviewed by a chest physician, surgery was undertaken in 18% of those under 65, 12% of the 65-74 age group, and 2.1% of those over 75. For patients with small cell lung cancer (SCLC) reviewed by a chest physician, 79% of those aged under 65, 64% of the 65-74 age group, and 41% of patients aged over 75 received chemotherapy. In patients with NSCLC reviewed by a chest physician, chemotherapy was given to 21% under 65, 6.4% in the 65-74 age group, and none over 75. If no histological diagnosis was made 37% of patients aged under 75 and only 5.4% of those over 75 received either surgery, radiotherapy, or chemotherapy. Patients not reviewed by a chest physician were less likely to have had a histological diagnosis. Differences in treatment rates with age persisted even after allowing for performance score status at presentation. CONCLUSIONS: Lung cancer is a common disease in the elderly and, in our district, 43% of patients were aged 75 or over at presentation. Age alone appeared to be a major factor in influencing treatment choices, and treatment was more likely if histological confirmation was obtained. Further detailed analysis of the reasons for the differences is needed. Patients referred to chest physicians were more likely to have both histological confirmation and active treatment. This study supports the contention that all patients with a diagnosis of lung cancer, irrespective of age or condition, should be assessed by an accredited chest physician.

Hypokalaemic rhabdomyolysis: an unusual presentation of coeliac disease.

OBJECTIVE: To describe the clinical presentation and management of a patient with hypokalaemic rhabdomyolysis secondary to coeliac disease. DESIGN: Retrospective study. SETTING: Hospital based. PATIENT: A 60-year-old Caucasian man presenting with weakness caused by hypokalaemic rhabdomyolysis secondary to coeliac disease. INTERVENTIONS: Following the diagnosis by jejunal biopsy, the patient was treated with both intravenous and oral potassium supplements, and a gluten-free diet. OUTCOME MEASURES: Resolution of weakness and restitution of normal villous architecture following treatment. RESULTS: The patient's myopathy responded to the potassium supplements, his diarrhoea and histological changes resolved while on the gluten-free diet. CONCLUSION: Patients with coeliac disease may present with hypokalaemia in association with steatorrhoea. If potassium loss is rapid, rhabdomyolysis may occur. Coeliac disease should be considered a cause of malabsorption-induced hypokalaemic rhabdomyolysis.

Randomized trial comparing weekly versus 3-week chemotherapy in small-cell lung cancer: a Cancer Research Campaign trial.

PURPOSE: A randomized trial of chemotherapy, given on either a 1-week or a 3-week schedule, was performed in small-cell lung cancer (SCLC) patients. The aim was to determine if weekly scheduling produced survival superior to conventional treatment. PATIENTS AND METHODS: Four hundred thirty-eight patients with SCLC with either limited disease (LD; 276 patients) or good-prognosis extensive disease (ED; 162 patients) were randomized. Weekly chemotherapy was 12 alternating cycles of ifosfamide/doxorubicin and cis-platin/etoposide (PE), while 3-week treatment was six alternating cycles of cyclophosphamide/doxorubicin/vincristine (CAV) and PE. Thoracic irradiation was administered 3 weeks after completion of chemotherapy to LD patients who attained a complete response (CR) or partial response (PR). Patients were well matched for clinical characteristics and prognostic factors. RESULTS: Overall response was the same in both arms: 82.3% (39.4% CR) with weekly and 81.1% (36.9% CR) with 3-week treatment. The median survival (MS) durations were 10.8 and 10.6 months for weekly and 3-week chemotherapy, respectively. The 2-year survival rates were 11.8% and 11.7% in the weekly and 3-week arms, respectively. Received dose-intensity (DI) was 73.9% of projected for weekly treatment and 92.7% for 3-week treatment. Hematologic toxicity was the major dose-limiting toxicity for the weekly treatment. CONCLUSION: This trial excludes at 90% power a benefit of greater than 10% for 2-year survival for weekly treatment. The received DI was reduced to a greater extent with weekly treatment, mainly due to hematologic toxicity.