Respiratory Health - Q2 2023

“One

Dr Paul Walker, Chair, British Thoracic Society

Air pollution’s deadly toll on the UK’s health and daily needs

The scale is dramatic: the health impacts of air pollution, such as breathlessness, can be devastating to people’s everyday lives.

Air pollution’s deadly toll on the nation’s health is illustrated in Professor Chris Whitty’s recent report, showing it contributes to up to 43,000 premature deaths in the UK a year.

Air pollution can cause life-threatening conditions Toxic air causes new lung conditions and can also worsen the symptoms of those who already live with them. It can inflame the airways, causing coughing and the terrifying feeling of breathlessness as well as life-threatening flare-ups of conditions like asthma and chronic obstructive pulmonary disease (COPD).

In the most extreme circumstances, such as the case of Ella Adoo Kissi Debrah, exposure to high levels of dirty air can cause early death for people with lung conditions.

As one concerned London parent put it to me recently: “Dirty air is really affecting our family’s health — in particular, my daughter, whose asthma has been made worse by air pollution. There are days when the high levels of toxic air near her school mean she can’t do sports or play with her friends. It’s hard to explain to a child that the reason she can’t play outside is something as intrinsic to life as the air you breathe.”

This is unacceptable. That’s why we at Asthma + Lung UK are calling for urgent and bold government action to clean up the air and tackle this public health emergency head-on.

Government investment can promote clean air Tackling a problem as fundamental as the air we breathe requires the kind of bold government action that, so far, has been lacking. Transport is key in the fight for clean air, and our new plan sets out the steps that must be taken to ensure we win that fight.

The Government must help the poorest communities and those living with health conditions — whose lives are often most blighted by dirty air — to switch to cleaner means of transport. This is about helping the most vulnerable in society to switch to cleaner modes of transport, including less-polluting cars and active travel options like walking and cycling.

More government investment will help give people the financial incentives to make that switch. With more awareness, government action and the right targeted investment, we can apply the emergency brake on air pollution and save countless lives.

WRITTEN

Sarah Woolnough CEO, Asthma + Lung UK

“Air pollution affects you from your first breath to your last.”

Dr

Malcolm White, Clean Air Specialist, Global Action Plan

“We are seeing greater investment in supporting general practice to carry out the tests which have been shown to support the diagnostic process.”

Beverley Bostock RGN MSc MA QN Chair of the Respiratory Diseases Committee,

Advanced Nurse Practitioner, Mann Cottage Surgery

“People with cystic fibrosis are extremely vulnerable to lung infections.”

Dr

Lucy Allen Director of Research and Healthcare Data, Cystic Fibrosis Trust

It’s hard to

a child that the reason she

play outside is something as intrinsic to life as the air

breathe.

Severe asthma: the impact of inappropriate OCS use

or hospital physician ever informed me I would get debilitating side effects from OCS use. I was hesitant to ask questions of my healthcare professionals and eventually found out myself from other people in the community, my work with Asthma and Lung UK and self-education from podcasts. I wish I had known.”

How can we improve treatment for patients?

Severe asthma experts are advocating for a change in OCS treatment norms for patients with more severe forms of the condition.

There needs to be a two-pronged approach. Firstly, identification and referral to specialist centres need to improve. Dr Katherine Hickman, GP and Executive Chair of the Primary Care Respiratory Society, believes that patients who have had an acute asthma attack which resulted in OCS being prescribed should routinely be followed up with a GP review to assess the cause of the asthma attack and if any further management is needed. Current guidelines indicate that patients with suspected severe asthma, or those requiring two or more courses of OCS within 12 months, should be referred to a specialist centre for assessment — but experts acknowledge this rarely happens.

WRITTEN BY

Dr Nadia Malik PhD, Medical Affairs Manager, GSK UK

Oral corticosteroids (OCS) are anti-inflammatory medicines used to treat a range of conditions including asthma. Most people with asthma manage their symptoms with inhalers. Severe asthma is a condition that is inadequately controlled by inhalers, so regular courses of OCS tablets are often used to treat a severe asthma attack.

Dr Andrew Whittamore, GP with a respiratory interest, explains: “Oral corticosteroids are cheap and very effective for people struggling with their asthma; they can be lifesaving. However, it is clear that patients, healthcare professionals and the wider NHS must not be complacent about the regular use of oral corticosteroids and need to do more to safeguard patients against their side effects.”

Consequences of OCS treatment for asthma

Increasingly, specialists are questioning the wide use of OCS in patients with severe asthma. A report called ‘Do No Harm’ by Asthma and Lung UK, a charity fighting to transform lung health, states: “These

tablets can stop the symptoms, but they have devastating side effects in the short and long term on physical and mental health — from suicidal thoughts and insomnia to diabetes and kidney damage.”

An additional study suggests that people on regular OCS treatment are three times more likely to suffer from osteoporosis/osteoporotic fractures; more than twice as likely to suffer from pneumonia; and have a 1.34-fold greater risk of death.

5–10% of the UK asthma population is estimated to have severe asthma — equivalent to approximately 200,000 children and adults. However, the cost of treating these patients is four times higher than general asthma patients, driven by the cost of treating the side effects of OCS.

Listening to the patient

experience

Patients say that the cumulative negative outcomes of long-term OCS use are rarely discussed, and healthcare professionals often prescribe a course of OCS to manage an acute asthma attack without an objective, in-person review.

Val, a patient who shared their firsthand experience at a recent GSK summit on OCS use, says: “No GP

For years, OCS were the mainstay of treatment for patients with severe asthma, but we have recognised for many years that these cause multiple, serious side effects.

Secondly, specialists agree that better education among healthcare professionals about the side effects of inappropriate OCS use is needed. This can be coupled with patient education about the side effects of OCS to empower patients to self-advocate.

Focusing on alternative treatments for severe asthma

Prof Liam Heaney, Professor of Respiratory Medicine, concludes:

“For years, OCS were the mainstay of treatment for patients with severe asthma, but we have recognised for many years that these cause multiple, serious side effects. The challenge now is to identify patients who would benefit from much earlier intervention with appropriate treatments — such as biologics — to ensure optimal outcomes for this group.”

A long-term observational study by Price et al (https://doi. org/10.2147/JAA.S176026) published in 2018 on adverse outcomes from initiation of systemic corticosteroids for asthma produced findings suggesting an urgent need for reappraisal of when patients need specialist care and consideration of nonsteroid therapy.

Oral corticosteroids are cheap and very effective for people struggling with their asthma; they can be lifesaving.

Love your lungs: what it’s like to have cystic fibrosis and lung infections

Cystic fibrosis affects many organs and tissues within the body including the lungs, which become clogged with thick, sticky mucus, making it hard to breathe and clear away infection-causing bugs and particulates in the air.

People with cystic fibrosis are extremely vulnerable to lung infections, which can be hard to treat, hard to detect and resistant to antimicrobial medicines. These infections can be picked up from the environment or by coming into contact with other people with the condition. While these infection-causing bugs are usually harmless to people who don’t have CF, they can cause permanent lung damage for those who do.

Living with long-term lung infections

The bacterium Pseudomonas aeruginosa (P. aeruginosa) causes serious, long-term infections in the lungs of some people with CF. The bacterium is found in many natural and domestic environments including plants, soils and surface water — especially warm, moist environments. Environments such as hydrotherapy pools and jacuzzis have been reported as a risk for people with cystic fibrosis. Within the lungs of people with CF, P.aeruginosa infection can sometimes be kept under control by antibiotics.

However, if it takes root, it can become resistant to antibiotics and cause serious problems.

Candice King, involvement manager at Cystic Fibrosis Trust, shares her thoughts and experience living with the condition: “Having chronic pseudomonas lung infections means that, over the years, I’ve exhausted a number of antibiotics. Despite advances being made with modulator drugs — meaning many people with CF are living healthier lives — there are still plenty of people who can’t benefit from these, and lung infections can still cause serious lung damage. It’s important that research continues to make new advances and ensures everyone with CF can live a life unlimited.”

What are we doing about it?

Cystic Fibrosis Trust is funding several multidisciplinary research programmes to investigate how P. aeruginosa becomes so well adapted to live in the lungs of people with CF. With this knowledge, we hope researchers in the future will be able to develop better ways to detect and treat it. Research also is taking place to investigate the impact of pollution and air quality on the lungs of people with cystic fibrosis and their risk of infection.

We’re extremely grateful for every single donation we receive; we wouldn’t be able to fund research like this and achieve what we do without them. Visit cysticfibrosis. org.uk to find out more and see how you can get involved.

WRITTEN BY Dr Lucy Allen Director of Research and Healthcare Data, Cystic Fibrosis Trust

People with cystic fibrosis are extremely vulnerable to lung infections, which can be hard to treat, hard to detect and resistant to antimicrobial medicines.

Cystic fibrosis (CF) is an inherited genetic condition that affects over 10,900 people in the UK. The condition is caused by a faulty gene which controls the movement of salt and water in and out of your cells.

It’s important that research continues to make new advances and ensures everyone with CF can live a life unlimited.

How we can help people with lung conditions breathe more easily

One in five people in the UK will need treatment for a lung condition in their lifetime. Lung disease varies from asthma, one of the most prevalent medical conditions, to lung cancer, the biggest cancer killer.

Lung disease is associated consistently with breathlessness, a frightening and debilitating symptom, and is strongly linked to health inequality and deprivation, meaning the most deprived and vulnerable communities are most affected.

Healthcare for people with lung conditions in the UK

The British Thoracic Society (BTS) is an organisation of respiratory professionals who, throughout the four UK nations, are committed to improving the lives of people with lung disease. For years, respiratory specialists have published groundbreaking research and been at the forefront of innovation and improvement.

Lack of access to respiratory diagnostic tests is a key issue which prevents people from receiving an accurate, early diagnosis while the current extreme and intense pressure on primary care limits access further.

Nationwide access to respiratory specialists

If a person with a lung condition is treated by a respiratory specialist, they are more likely to have the correct diagnosis, receive the right treatment and experience fewer symptoms. They are also less likely to need hospital admission.

To deliver this, we need to train people to fill vacant posts and then grow the respiratory workforce. Respiratory teams are multidisciplinary and include doctors (consultants and specialty trainees), nurses, allied health professionals and healthcare scientists. There are shortages in all these professions.

Furthermore, respiratory specialists are already under pressure to deliver new services. They increasingly work in integrated care teams to deliver ‘hospital at home’ care and support primary care. They are setting up and working in new virtual wards to enhance acute respiratory care at home. Respiratory professionals are also managing the extended workload of the new Targeted Lung Health Checks, which screen high-risk people for early lung disease. All these initiatives will lead to better lung care. However, they have to be properly resourced, or they risk staff burning out and leaving the NHS.

Addressing the workforce shortage

In our 2022 Report, A Respiratory Workforce for the Future, BTS focuses on respiratory workforce shortage as our main challenge, and we work with organisations like Asthma + Lung UK and the Primary Care Respiratory Society to highlight this. Everyone has the right to live a normal life, free from the debilitating effects of lung disease. The only way to ensure this is to provide high-quality respiratory care underpinned by a planned and sustainable specialist workforce.

WRITTEN BY Dr Paul Walker Chair, British Thoracic Society

What impact does air pollution have on our brain and mental health?

Air pollution is the biggest environmental threat to our health, no matter who you are or where you live. Air pollution affects you from your first breath to your last, as the damage to our health can start in the womb and carry on through into old age.

Air pollution damages overall health

There is no safe level of air pollution, and the health effects of air pollution are complex. It increases the risk of many health conditions and makes some existing health problems worse. Individuals with heart and lung disease, children and the elderly are particularly vulnerable.

The relationship between air pollution and our health has been studied for decades. While the physical health impacts of air pollution — such as asthma, heart disease and cancers — are well documented, more researchers are beginning to understand how air pollution can affect the brain and the mind.

Link between air pollution and cognitive conditions

People who breathe polluted air are more likely to develop mental health and brain problems than those who breathe clean air. Research shows that there is an

association between air pollution and conditions including schizophrenia, depression, anxiety and mood disorders. It also leads to a more rapid decline in cognitive function, including an increased risk of developing dementia. One of the main culprits is particulate matter (PM). They are tiny pieces of solid or liquid substances that are inhaled as people breathe. When we breathe polluted air, these small pollution particles can enter through our lungs, into our bloodstream and reach the brain. It can cause inflammation and change the chemistry of our brain, negatively impacting our mental health.

Taking steps to clear the air

By taking clean air actions, like driving less, we not only protect our mental and brain health but also benefit our wider physical health and the environment around us. However, we can’t do it alone — the Government and industries need to make decisions that improve air quality for everyone. We must use our voices to fight for cleaner air. This Clean Air Day, we can all take simple steps to build a clean air future together — to protect our mental, physical and planet’s health. Any reductions in air pollution that we make can benefit our health and the local community.

WRITTEN BY Dr Malcolm White Clean Air Specialist, Global Action Plan

There is no safe level of air pollution, and the health e ects of air pollution are complex.

More researchers are beginning to understand how air pollution can a ect the brain and the mind.

Accessible tests make respiratory care and diagnosis easier for patients

Effective management starts with the correct diagnosis.

A significant proportion of respiratory care and diagnosis is undertaken by qualified specialist nurses and other healthcare professionals. This allows for more streamlined care management.

Respiratory conditions account for the majority of appointments in general practice and a high proportion of hospital appointments.1 A high level of further education and training allows specialist nurses and other healthcare professionals to investigate, diagnose and treat these conditions and discharge people from hospitals.2

Importance of diagnosis in respiratory care

Effective management starts with the correct diagnosis. We are seeing greater investment in supporting general practice to carry out the tests which have been shown to support the diagnostic process.

Taking a robust history is key to making any diagnosis, but examination and tests can help to confirm whether the person with respiratory symptoms (cough, wheezing, breathlessness, sputum production) has asthma, chronic obstructive pulmonary disease (COPD) or another condition.

These tests can include spirometry — which can identify abnormalities in airflow through the lungs — and fractional exhaled nitric oxide (FeNO) testing — which can demonstrate the presence of inflammation in the airways. Blood tests, X-rays and scans can also help to confirm or refute a suspected diagnosis.

Better diagnostic process with respiratory tests

Anyone carrying out diagnostic tests will have had specific training on how to carry out the test and/or interpret the result. The skill is to put together all the information — history, examination and objective tests — so that the clinician is confident that the diagnosis is correct.

The pandemic led to the cessation of many of these tests as there was a risk of spreading airborne infections. However, the situation is gradually returning to normal, and many practices are offering these routinely once more.

Information about the tests can be found from sources such as the Asthma + Lung UK website or through discussion with the clinical staff in the practice or hospital.

References

1. GBD Chronic Respiratory Disease Collaborators (2020). Prevalence and attributable health burden of chronic respiratory diseases, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet. Respiratory medicine, 8(6), 585–596. https://doi.org/10.1016/S2213-2600(20)30105-3

2. Patel I. (2021). Integrated respiratory care. Clinics in Integrated Care, 6, 100053. https://doi. org/10.1016/j.intcar.2021.100053

WRITTEN BY Beverley Bostock RGN MSc MA QN Chair of the Respiratory Diseases Committee, ARNS Advanced Nurse Practitioner, Mann Cottage Surgery

The pandemic led to the cessation of many of these tests as there was a risk of spreading airborne infections.

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