Anatomy and Neuroscience - Research Publications
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ItemJunior doctors' attitudes to opioids for refractory breathlessness in patients with advanced chronic obstructive pulmonary disease(WILEY, 2017-09)BACKGROUND: Refractory breathlessness is a common, distressing symptom in patients with advanced chronic obstructive pulmonary disease (COPD). The judicious, off-licence prescription of opioids, together with other management strategies, can improve breathlessness, however, internationally there is profound reluctance to prescribe opioids for breathlessness in COPD. AIMS: To understand Australian junior doctors' knowledge and attitudes regarding the management of refractory breathlessness and the role of opioids in COPD. METHODS: All junior doctors undertaking basic training in internal medicine in Victoria were invited to complete an online survey. Knowledge, willingness, and experience prescribing opioids to COPD patients with refractory breathlessness, were examined. RESULTS: Of the 243 responses received, most trainees (193, 86.5%) believed opioids have a role in treating refractory breathlessness in stable COPD outpatients, with 143 (64.1%) recommending morphine as first-line treatment for refractory breathlessness. One quarter (55, 24.7%) reported having themselves initiated an opioid and 102 (45.7%) had prescribed an opioid under senior supervision for management of breathlessness in COPD. Concern regarding adverse opioid effects was low, with 58 (26.0%) having no concerns prescribing an opioid to COPD patients. CONCLUSION: This is the first study of doctors to demonstrate high awareness, confidence, willingness and experience in prescribing opioids for the off-licence indication of refractory breathlessness in COPD. These findings differ significantly from attitudes reported overseas and are unexpected given the doctors surveyed were recently qualified. The low awareness of possible adverse events and limited insight regarding knowledge gaps is concerning and highlights the significant need for greater education in palliative care.
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ItemApproaches to palliative oxygen therapy in chronic obstructive pulmonary disease: a multi-national survey of specialists(WILEY, 2019-02)As palliative oxygen therapy (POT) is beneficial only to a minority of patients with chronic breathlessness, it is no longer routinely recommended. This multi-national, online survey of respiratory and palliative medicine specialists, with 440 participants, identified that prescription of POT has decreased over the past decade; however a sizeable proportion of doctors, particularly within palliative care, still support and recommend POT. Further education and research regarding the optimal management of chronic breathlessness are required.
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ItemAntimicrobial prescription in patients dying from chronic obstructive pulmonary disease(WILEY, 2019-01)BACKGROUND: Despite rising antimicrobial resistance, treatment guidelines for chronic obstructive pulmonary disease (COPD) exacerbations are frequently ignored. Patients with terminal conditions are often prescribed antimicrobials despite the goal of care to reduce burdensome treatments. The appropriate use of antimicrobials in patients who die from an exacerbation of COPD is unknown. AIM: To review antimicrobial prescription during the final admission in patients who died from an acute exacerbation of COPD. METHODS: A retrospective medical record audit was performed for 475 patients who died over 12 years (2004-2015). Patients were analysed within three groups: Group 1 - pneumonia on chest radiograph, Group 2 - infective exacerbation of COPD +/- raised inflammatory markers (white cell count, C-reactive protein) and Group 3 - non-infective exacerbation of COPD. RESULTS: A total of 221 patients died from COPD. The median age was 80 years, and 136 (60%) were male. Median respiratory function: forced expiratory volume in 1 s 0.8 L (41.0%), forced vital capacity 2.0 L (74.0%) and diffusing capacity for carbon monoxide 8 (40.5%). A total of 109 (49.3%) patients used home oxygen and 156 (70.6%) were ex-smokers. Of the cohort, 90.5% received antimicrobials. In Groups 1, 2 and 3, 68 (94.4%), 108 (92.3%) and 24 (75.0%) patients received antimicrobials respectively. Guideline-concordant therapy was administered to 31.7% of patients (Group 1: 79.2%, Group 2: 4.3%, Group 3: 25.0%), 60.2% of patients received ceftriaxone and 44.8% received azithromycin. The median duration of therapy was 4 days and 27.1% received antimicrobials at the time of death. CONCLUSION: Antimicrobials are overprescribed, and non-guideline antimicrobials are overused in patients who die from COPD. Further education of medical staff, regular medication reviews and the use of disease severity scores or clinical pathways may improve antimicrobial stewardship.
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ItemIndividualized breathlessness interventions may improve outcomes in patients with advanced COPD(WILEY, 2018-12)BACKGROUND AND OBJECTIVE: Many patients with advanced COPD experience refractory breathlessness and individualized breathlessness interventions may improve management of this complex symptom. The aims of this study were to develop, implement and assess the efficacy of a breathlessness intervention for patients with COPD and refractory breathlessness and to evaluate patient acceptability. METHODS: An individualized breathlessness plan, information leaflets, breathlessness education and a hand-held fan were offered to consecutive patients with severe COPD and refractory breathlessness attending a tertiary integrated respiratory and palliative care service. Validated dyspnoea, quality of life and anxiety/depression questionnaires were administered at baseline and after 6 weeks, with change in dyspnoea scores being the primary outcome measure. A subset of patients participated in a structured telephone interview to qualitatively assess the intervention. RESULTS: Twenty-six patients with severe COPD (mean forced expiratory volume in 1 s (FEV1 ) 38%) were included, with a mean age of 74 years. Mean modified Medical Research Council Breathlessness Scale score was 3.5. Anxiety and depression were common, being present in 38% and 35% of participants. At 6 weeks, there was a clinically significant improvement in breathlessness severity as measured by the Numerical Rating Scale. The subset of patients with anxiety/depression also saw significant improvement in all domains of the Self-Administered Standardized Chronic Respiratory Questionnaire (CRQ-SAS). Patients reported that the intervention was highly useful and acceptable. CONCLUSION: This feasibility study of individualized breathlessness interventions in patients with severe COPD and refractory breathlessness is the first to demonstrate a clinically significant reduction in dyspnoea scores, with high levels of patient acceptability.
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ItemAustralian childcare centres are too close to car parks exposing children with developing lungs to high levels of traffic pollution(WILEY, 2020-12)OBJECTIVE: To examine the co-location of childcare centres and their outdoor play spaces with car parks in Melbourne and Sydney, Australia. METHODS: The co-location of childcare centre outdoor play spaces and car parks was examined through measurement of horizontal and vertical distances using Google Earth Pro satellite imagery. RESULTS: One hundred and forty-two childcare centres were studied in Melbourne, with 133 accompanying car parks identified. Eighty-one (57.0%) centres had a significant size car park within 150 m and 43.7% had a car park within 100 m. Twenty car parks (15.0%) were found within 10 metres of childcare centres, of which 12 (9.0%) had more than 100 spaces. Twenty centres were examined in Sydney, with 31 associated car parks identified. Eighteen childcare centres (90.0%) had car parks within 150 m and 17 (85.0%) had car parks within 100 m. CONCLUSION: Australian childcare centres are located too close to car parks exposing children to pollution and likely impacting the development of chronic respiratory disease. Traffic pollution is an avoidable risk that must be considered when planning childcare centre location. Implications for public health: The co-location of childcare centres with large-scale car parks may have long-term impacts on the respiratory health of Australian children under the age of five.
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ItemIntegrated respiratory and palliative care may improve outcomes in advanced lung disease(EUROPEAN RESPIRATORY SOC JOURNALS LTD, 2018-01-01)The unaddressed palliative care needs of patients with advanced, nonmalignant, lung disease highlight the urgent requirement for new models of care. This study describes a new integrated respiratory and palliative care service and examines outcomes from this service. The Advanced Lung Disease Service (ALDS) is a long-term, multidisciplinary, integrated service. In this single-group cohort study, demographic and prospective outcome data were collected over 4 years, with retrospective evaluation of unscheduled healthcare usage. Of 171 patients included, 97 (56.7%) were male with mean age 75.9 years and 142 (83.0%) had chronic obstructive pulmonary disease. ALDS patients had severely reduced pulmonary function (median (interquartile range (IQR)) forced expiratory volume in 1 s 0.8 (0.6-1.1) L and diffusing capacity of the lung for carbon monoxide 37.5 (29.0-48.0) % pred) and severe breathlessness. All patients received nonpharmacological breathlessness management education and 74 (43.3%) were prescribed morphine for breathlessness (median dose 9 mg·day-1). There was a 52.4% reduction in the mean number of emergency department respiratory presentations in the year after ALDS care commenced (p=0.007). 145 patients (84.8%) discussed and/or completed an advance care plan. 61 patients died, of whom only 15 (24.6%) died in an acute hospital bed. While this was a single-group cohort study, integrated respiratory and palliative care was associated with improved end-of-life care and reduced unscheduled healthcare usage.
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ItemAttitudes to specialist palliative care and advance care planning in people with COPD: a multi-national survey of palliative and respiratory medicine specialists(BMC, 2018-10-15)BACKGROUND: Chronic obstructive pulmonary disease (COPD) guidelines recommend early access to palliative care together with optimal, disease-directed therapy for people with advanced disease, however, this occurs infrequently. This study explored the approaches of respiratory and palliative medicine specialists to palliative care and advance care planning (ACP) in advanced COPD. METHODS: An online survey was emailed to all specialists and trainees in respiratory medicine in Australia and New Zealand (ANZ), and to all palliative medicine specialists and trainees in ANZ and the United Kingdom. RESULTS: Five hundred seventy-seven (33.1%) responses were received, with 440 (25.2%) complete questionnaires included from 177 respiratory and 263 palliative medicine doctors. Most respiratory doctors (140, 80.9%) were very or quite comfortable providing a palliative approach themselves to people with COPD. 113 (63.8%) respiratory doctors recommended referring people with advanced COPD to specialist palliative care, mainly for access to: psychosocial and spiritual care (105, 59.3%), carer support (104, 58.5%), and end-of-life care (94, 53.1%). 432 (98.2%) participants recommended initiating ACP discussions. Palliative medicine doctors were more likely to recommend discussing: what palliative care is (p < 0.0001), what death and dying might be like (p < 0.0001) and prognosis (p = 0.004). Themes highlighted in open responses included: inadequate, fragmented models of care, with limited collaboration or support from palliative care services. CONCLUSIONS: While both specialties recognised the significant palliative care and ACP needs of people with advanced COPD, in reality few patients access these elements of care. Formal collaboration and bi-directional support between respiratory and palliative medicine, are required to address these unmet needs.