Effects of portable non-invasive ventilation on exercise tolerance in patients with COPD

Breathlessness is the dominant symptom that limits exercise tolerance in patients with COPD. Several ergogenic approaches have been employed to improve exercise tolerance in this population including bronchodilators, oxygen and heliox supplementation, intermittent exercise and non-invasive ventilation (NIV). Although application of NIV during exercise is beneficial for increasing exercise capacity in patients with COPD, there are several disadvantages that limit its wider application during exercise, including lack of compliance with the equipment, and the time required to set up and supervise the equipment in the setting of pulmonary rehabilitation. Recent advances in technology have facilitated the development of portable non-invasive ventilation (pNIV) devices aiming to alleviate breathlessness during activities of daily living. The VitaBreath (Philips, Respironics) was developed in 2016 as a portable, handheld, battery powered, bi-level, NIV device, providing fixed positive inspiratory and expiratory airway pressure support (IPAP:18 and EPAP: 8 cmH2O, respectively). Accordingly, this dissertation aimed to investigate the physiological effects of pNIV application during controlled laboratory exercise conditions and activities of daily living, in patients with advanced COPD. As the VitaBreath device is no longer commercially available, but similar devices may come to market, the present dissertation provides proof of concept on how pNIV can be applied intermittently during exercise in patients with COPD, and how to select patients most likely to respond to pNIV. This in turn may encourage the development of more suitable devices. Intermittent exercise was chosen to evaluate the effects of pNIV in comparison to the commonly adopted pursed lip breathing (PLB) technique, as this type of exercise allowed regular application of the pNIV device or the PLB technique during recovery periods. Patients retained the device for 3 months to investigate the acceptability, comfort and usability of the device during activities of daily living. Twenty-four COPD patients were randomised to perform two intermittent exercise protocols sustained at different work intensities (60% WRpeak for 6-min and 80% WRpeak for 2-min) alternated with 2-min rest periods. Within each intermittent exercise modality, patients performed two identical exercise tests using either pNIV or the PLB technique in a balanced order sequence, during the recovery phases of intermittent exercise. The findings of this study showed that with both intermittent protocols average endurance time was greater when pNIV was applied compared to PLB. Improvements in exercise tolerance were due to lower degrees of dynamic hyperinflation (DH) and breathlessness with pNIV compared to PLB. An important finding of the aforementioned study was that a subgroup of patients (8/24) failed to show a clinical important improvement in DH with pNIV compared to PLB and did not improve exercise tolerance. Analysis identified that these 8 patients experienced greater resting lung hyperinflation, greater exercise-induced DH and breathlessness, secondary to the adoption of a tachypnoeic breathing pattern with pNIV compared to PLB. Interestingly, these patients also reported less benefit from using the device at home, in terms of anxiety around breathlessness and recovery time from breathlessness. Considering the variation of response reported in the present thesis it is important that clinicians assess the response to pNIV on an individual basis. As with any new method, it was important to appreciate the physiological consequences of the acute application of pNIV on thoracoabdominal volume regulation and respiratory muscle recruitment (assessed by optoelectronic plethysmography), and central hemodynamic responses. Compared to PLB, acute application of pNIV was associated, in the majority of patients, with increased end-inspiratory and end-expiratory rib cage volumes and greater rib cage muscle recruitment, as well as decreased end-expiratory abdominal volumes reflecting reduced expiratory abdominal recruitment. Measurement of cardiac output revealed no adverse circulatory responses with the application of positive airway pressures provided by pNIV during the recovery periods. However, the pattern of thoracoabdominal volume regulation and respiratory muscle kinematics confirmed the findings of the original studies, thereby identifying responders and non-responders to pNIV. Interestingly, responders to pNIV exhibited greater recruitment of the expiratory abdominal muscles compared to non-responders, thereby facilitating them to combat end-expiratory rib cage dynamic hyperinflation effectively. When patients used the VitaBreath device during their daily physical activities, the majority of patients felt less anxious about becoming breathless and felt that their breathlessness recovered faster when using the device at home for 3 months. Moreover, almost all patients used the device at least weekly and all patients rated the ease of VitaBreath use to be between good and excellent. Additionally, most patients felt that using the device had benefited them and that they would recommend the device to other patients. The main disadvantage of the device was reported to be the high cost and its portability. The pNIV method provided fixed IPAP and EPAP. This represents a very important disadvantage of this particular pNIV device, which clearly mitigated the beneficial impact it had on some patients. Future research into pNIV devices should examine how best to identify patients who benefit from a pNIV method in everyday life. On-going development of auto-adjusted ventilators would facilitate a larger fraction of COPD patients to be physically active and experience a better quality of life

Teddy Bear Cabinet: Photography Exhibition at Northumbria Specialist Emergency Care Hospital, Northumbria Healthcare NHS Foundation Trust

The Teddy Bear Cabinet features a series of portraits of handcrafted teddy bears. The portraits resemble 19th century cabinet cards; an early form of photography, which was often displayed in glass cabinets. This practice evolved into the conventional family album. The teddy bears have been made from keepsakes such as baby clothes, muslins, pregnancy jumpers and baby blankets. The images represent familiar memories of nurturing in the elusive cabinet of stories of early motherhood. This work draws upon the Theory of Attachment, introduced by British psychologist John Bowlby in his book Attachment and Loss, published in 1969. This theory proposes that the mother-infant physical closeness and responsiveness during the early years of life is most crucial to emotional nurturing, cognitive development and lifelong mental health. This also endorses a "lasting psychological connectedness between human beings" (Bowlby, 1969). Dr Christina Kolaiti is a practising artist based in North Tyneside and senior lecturer in photography at York St John University, whose research over the past two decades has converged the fields of arts and healthcare. The exhibition has been organised by Northumbria Healthcare’s Bright charity. For the past 20 years Bright has developed an award-winning healing arts programme, which uses art to enhance the hospital environment for patients, visitors and staff. For information, see https://www.northumbria.nhs.uk

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

'Helping Hands' sculpture

This glass and steel sculpture, entitled ‘Helping Hands’ designed in collaboration with Colin Rennie, is made up of three separate shaped panels set at angles to each other to create an overall three dimensional organic and uplifted shape. The work represents healing/helping hands, raised up in a supplicant manner as if protecting a central space where healing and calm can be found. The work is made in waterjet cut, textured, laminated and toughened glass, set into a satin polished stainless steel base. The bases are welded to a thick galvanised steel base which is bolted into a reinforced concrete foundation

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic

Additional file 1 of Feasibility, acceptability, and fidelity of Physical Activity Routines After Stroke (PARAS): a multifaceted behaviour change intervention targeting free-living physical activity and sedentary behaviour in community-dwelling adult stroke survivors

Additional file 1: Appendix A. Stroke survivor interview guide. Appendix B. HCP focus group discussion guide. Appendix C. HCP pre- and post-training and protocol questionnaire Likert scores. Appendix D. Stroke survivor post intervention questionnaire Likert scores