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Lonergan B, Morgan C, Al-Raweshidy Y, Singh R. Choking as a cause of negative pressure pulmonary oedema (NPPE) in an older adult. Age Ageing 2021; 50:592-594. [PMID: 33128549 DOI: 10.1093/ageing/afaa217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Indexed: 11/14/2022] Open
Abstract
An 86-year-old female presented to the Emergency Department (ED) in respiratory distress after choking on a sandwich at home. Her family had noticed that she had had difficulty during and coughing after swallowing for several months. Her initial chest x-ray showed diffuse alveolar infiltrates in both lungs and blood tests showed normal white cells and C-Reactive Protein (CRP). She was started on intravenous antibiotics for presumed aspiration pneumonia and received 15 L of oxygen. However, the infiltration had dramatically improved, both radiologically and clinically, within 24 hours. She was diagnosed with negative pressure pulmonary oedema (NPPE) type 1 and made a rapid recovery. The Speech and Language Team diagnosed an impaired swallow and advised soft or bite-sized suitable foods. We discussed the ongoing risk of aspiration and long-term feeding options with the patient's family. We agreed on a conservative plan for 'risk feeding', given her frailty and co-morbidities, and began discussions on ceilings of care. This case aims to raise awareness of NPPE so that it can be diagnosed, investigated and treated promptly. Although seen most commonly by intensivists and anaesthetists, it is relevant to those on the acute medical take and geriatricians managing patients with swallowing difficulties.
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Affiliation(s)
- Bradley Lonergan
- Department of Geriatrics, West Middlesex University Hospital NHS Trust, West Middlesex Hospital, London SW10 9NH, UK
| | - Cerys Morgan
- Department of Geriatrics, West Middlesex University Hospital NHS Trust, West Middlesex Hospital, London SW10 9NH, UK
| | - Yasser Al-Raweshidy
- Department of Geriatrics, West Middlesex University Hospital NHS Trust, West Middlesex Hospital, London SW10 9NH, UK
| | - Ravneeta Singh
- Department of Geriatrics, West Middlesex University Hospital NHS Trust, West Middlesex Hospital, London SW10 9NH, UK
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Philip KEJ, Bennett B, Fuller S, Lonergan B, McFadyen C, Burns J, Tidswell R, Vlachou A. Working accuracy of pulse oximetry in COVID-19 patients stepping down from intensive care: a clinical evaluation. BMJ Open Respir Res 2021; 7:7/1/e000778. [PMID: 33361436 PMCID: PMC7759755 DOI: 10.1136/bmjresp-2020-000778] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 12/01/2020] [Accepted: 12/07/2020] [Indexed: 11/28/2022] Open
Abstract
Introduction UK guidelines suggest that pulse oximetry, rather than blood gas sampling, is adequate for monitoring of patients with COVID-19 if CO2 retention is not suspected. However, pulse oximetry has impaired accuracy in certain patient groups, and data are lacking on its accuracy in patients with COVID-19 stepping down from intensive care unit (ICU) to non-ICU settings or being transferred to another ICU. Methods We assessed the bias, precision and limits of agreement using 90 paired SpO2 and SaO2 from 30 patients (3 paired samples per patient). To assess the agreement between pulse oximetry (SpO2) and arterial blood gas analysis (SaO2) in patients with COVID-19, deemed clinically stable to step down from an ICU to a non-ICU ward, or be transferred to another ICU. This was done to evaluate whether the guidelines were appropriate for our setting. Results Mean difference between SaO2 and SpO2 (bias) was 0.4%, with an SD of 2.4 (precision). The limits of agreement between SpO2 and SaO2 were as follows: upper limit of 5.2% (95% CI 6.5% to 4.2%) and lower limit of −4.3% (95% CI −3.4% to −5.7%). Conclusions In our setting, pulse oximetry showed a level of agreement with SaO2 measurement that was slightly suboptimal, although within acceptable levels for Food and Drug Authority approval, in people with COVID-19 judged clinically ready to step down from ICU to a non-ICU ward, or who were being transferred to another hospital’s ICU. In such patients, SpO2 should be interpreted with caution. Arterial blood gas assessment of SaO2 may still be clinically indicated.
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Affiliation(s)
| | - Benjamin Bennett
- Critical Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Silas Fuller
- Critical Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Bradley Lonergan
- Critical Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Charles McFadyen
- Critical Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Janis Burns
- Critical Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Robert Tidswell
- Critical Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Aikaterini Vlachou
- Critical Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Philip KEJ, Lonergan B, Cumella A, Farrington-Douglas J, Laffan M, Hopkinson NS. COVID-19 related concerns of people with long-term respiratory conditions: a qualitative study. BMC Pulm Med 2020; 20:319. [PMID: 33298023 PMCID: PMC7724437 DOI: 10.1186/s12890-020-01363-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022] Open
Abstract
Background The COVID-19 pandemic is having profound psychological impacts on populations globally, with increasing levels of stress, anxiety, and depression being reported, especially in people with pre-existing medical conditions who appear to be particularly vulnerable. There are limited data on the specific concerns people have about COVID-19 and what these are based on. Methods The aim of this study was to identify and explore the concerns of people with long-term respiratory conditions in the UK regarding the impact of the COVID-19 pandemic and how these concerns were affecting them. We conducted a thematic analysis of free text responses to the question “What are your main concerns about getting coronavirus?”, which was included in the British Lung Foundation/Asthma UK (BLF-AUK) partnership COVID-19 survey, conducted between the 1st and 8th of April 2020. This was during the 3rd week of the UK’s initial ‘social distancing measures’ which included advice to stay at home and only go outside for specific limited reasons. Results 7039 responses were analysed, with respondents from a wide range of age groups (under 17 to over 80), gender, and all UK nations. Respondents reported having asthma (85%), COPD (9%), bronchiectasis (4%), interstitial lung disease (2%), or ‘other’ lung diseases (e.g. lung cancer) (1%). Four main themes were identified: (1) vulnerability to COVID-19; (2) anticipated experience of contracting COVID-19; (3) pervasive uncertainty; and (4) inadequate national response. Conclusions The COVID-19 pandemic is having profound psychological impacts. The concerns we identified largely reflect contextual factors, as well as their subjective experience of the current situation. Hence, key approaches to reducing these concerns require changes to the reality of their situation, and are likely to include (1) helping people optimise their health, limit risk of infection, and access necessities; (2) minimising the negative experience of disease where possible, (3) providing up-to-date, accurate and consistent information, (4) improving the government and healthcare response.
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Affiliation(s)
- Keir E J Philip
- National Heart and Lung Institute, Imperial College London, London, UK. .,Royal Brompton and Harefield NHS Foundation Trust, London, UK.
| | | | - Andrew Cumella
- Asthma UK and British Lung Foundation Partnership, London, UK
| | | | - Michael Laffan
- Asthma UK and British Lung Foundation Partnership, London, UK
| | - Nicholas S Hopkinson
- National Heart and Lung Institute, Imperial College London, London, UK.,Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Asthma UK and British Lung Foundation Partnership, London, UK
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Philip KEJ, Lonergan B, Cumella A, Farrington-Douglas J, Laffan M, Hopkinson NS. COVID-19 related concerns of people with long-term respiratory conditions: a qualitative study. BMC Pulm Med 2020; 20:319. [PMID: 33298023 DOI: 10.1101/2020.06.19.20128207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 11/30/2020] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic is having profound psychological impacts on populations globally, with increasing levels of stress, anxiety, and depression being reported, especially in people with pre-existing medical conditions who appear to be particularly vulnerable. There are limited data on the specific concerns people have about COVID-19 and what these are based on. METHODS The aim of this study was to identify and explore the concerns of people with long-term respiratory conditions in the UK regarding the impact of the COVID-19 pandemic and how these concerns were affecting them. We conducted a thematic analysis of free text responses to the question "What are your main concerns about getting coronavirus?", which was included in the British Lung Foundation/Asthma UK (BLF-AUK) partnership COVID-19 survey, conducted between the 1st and 8th of April 2020. This was during the 3rd week of the UK's initial 'social distancing measures' which included advice to stay at home and only go outside for specific limited reasons. RESULTS 7039 responses were analysed, with respondents from a wide range of age groups (under 17 to over 80), gender, and all UK nations. Respondents reported having asthma (85%), COPD (9%), bronchiectasis (4%), interstitial lung disease (2%), or 'other' lung diseases (e.g. lung cancer) (1%). Four main themes were identified: (1) vulnerability to COVID-19; (2) anticipated experience of contracting COVID-19; (3) pervasive uncertainty; and (4) inadequate national response. CONCLUSIONS The COVID-19 pandemic is having profound psychological impacts. The concerns we identified largely reflect contextual factors, as well as their subjective experience of the current situation. Hence, key approaches to reducing these concerns require changes to the reality of their situation, and are likely to include (1) helping people optimise their health, limit risk of infection, and access necessities; (2) minimising the negative experience of disease where possible, (3) providing up-to-date, accurate and consistent information, (4) improving the government and healthcare response.
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Affiliation(s)
- Keir E J Philip
- National Heart and Lung Institute, Imperial College London, London, UK.
- Royal Brompton and Harefield NHS Foundation Trust, London, UK.
| | | | - Andrew Cumella
- Asthma UK and British Lung Foundation Partnership, London, UK
| | | | - Michael Laffan
- Asthma UK and British Lung Foundation Partnership, London, UK
| | - Nicholas S Hopkinson
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Asthma UK and British Lung Foundation Partnership, London, UK
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Lonergan B, Wright A, Markham R, Machin L. Time-limited trials: A qualitative study exploring the role of time in decision-making on the Intensive Care Unit. ACTA ACUST UNITED AC 2019. [DOI: 10.1177/1477750919886087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Withholding and withdrawing treatment are deemed ethically equivalent by most Bioethicists, but intensivists often find withdrawing more difficult in practice. This can lead to futile treatment being prolonged. Time-limited trials have been proposed as a way of promoting timely treatment withdrawal whilst giving the patient the greatest chance of recovery. Despite being in UK guidelines, time-limited trials have been infrequently implemented on Intensive Care Units. We will explore the role of time in Intensive Care Unit decision-making and provide a UK perspective on debates surrounding time-limited trials. Methods This qualitative study recruited 18 participants (nine doctors, nine nurses) from two Intensive Care Units in North West England for in-depth, one-to-one semi-structured interviews. A thematic analysis was performed of the data. Results Our findings show time is utilised by Intensive Care Unit staff in a variety of ways including managing uncertainty when making decisions about a patient’s prognosis or the reversibility of a disease, constructing relationships with patients’ relatives, communicating difficult messages to patients’ relatives, justifying resource allocation decisions to colleagues, and demonstrating compassion towards patients and their families. Conclusions Time shifts the balance towards greater certainty in Intensive Care Unit decision-making, by demonstrating futility, and can ease the difficult transition for staff and families from active treatment to palliation. However, this requires clear and open communication, both within the Intensive Care Unit team and with the family, being prioritised when time is used in decision-making.
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Affiliation(s)
- Bradley Lonergan
- University Hospitals of Morecambe Bay (UHMB), Lancaster University, Lancaster, UK
| | - Alexandra Wright
- St Helens and Knowsley Teaching Hospitals, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Rachel Markham
- University Hospitals of Morecambe Bay (UHMB), Lancaster University, Lancaster, UK
| | - Laura Machin
- Lancaster Medical School, Lancaster University, Lancaster, UK
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Davies K, Lonergan B, Patel R, Bukhari M. Symptomatic patients with P369S-R408Q mutations: familial Mediterranean fever or mixed auto-inflammatory syndrome? BMJ Case Rep 2019; 12:12/7/e228858. [PMID: 31266757 DOI: 10.1136/bcr-2018-228858] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 51-year-old South African female of Ashkenazi Jewish descent was admitted with acute pleuritic chest pain, shortness of breath, fatigue and fever. She experienced vague abdominal and calf pains for 30 years. Her monozygotic twin was investigated independently for recurrent abdominal pain. Despite initially responding to antibiotics, treating suspected pneumonia, she developed recurrent fevers and pleuritic chest pain. After thorough investigation without significant findings, she re-attended days after discharge with similar symptoms. Familial Mediterranean fever (FMF) was suggested as she met diagnostic criteria and responded to colchicine, though FMF normally presents before 20 years old. Genetic testing showed no pathogenic mutations but heterozygous P369S and R408Q mutations. The significance of these mutations remains unclear, as they are found in asymptomatic patients, suggesting incomplete penetrance. She remains well, with full symptom resolution, but mixed auto-inflammatory syndrome may be a more appropriate diagnosis in symptomatic patients with both P369S and R408Q mutations.
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Affiliation(s)
- Kristen Davies
- Northumbria Healthcare NHS Foundation Trust, Northumberland, UK
| | | | - Rikesh Patel
- Salford Royal NHS Foundation Trust, Manchester, UK
| | - Marwan Bukhari
- Rheumatology, University Hospitals of Morecambe Bay, Lancaster, UK
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Kakkar A, Ahmed K, Lonergan B, Zainuddin P. Bedside buddies – an educational and pastoral teaching programme for year 2 medical students. Future Healthc J 2019. [DOI: 10.7861/futurehealth.6-2-s29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kakkar A, Ahmed K, Lonergan B, Zainuddin P. Bedside buddies - an educational and pastoral teaching programme for year 2 medical students. Future Healthc J 2019; 6:29. [PMID: 31572926 PMCID: PMC6752442 DOI: 10.7861/futurehosp.6-2s-s29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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