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Oxford Handbook of Respiratory Nursing
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OXFORD HANDBOOK OF Respiratory Nursing
SECOND EDITION
Edited by
Terry Robinson
Respiratory Nurse Consultant, Harrogate District NHS Foundation Trust, North Yorkshire, UK
Jane Scullion
Respiratory Nurse Consultant, Glenfield Hospital, Leicester, UK
1
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First Edition published in 2008
Second Edition published in 2021
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Consultant in Respiratory and Intensive Care Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
Ch6: Acute respiratory distress syndrome (ARDS); Ch12: Lung cancer and mesothelioma; and Ch25: Smoking and public health
Elaine Baillie
Ambulatory Pulmonary Care Specialist, University Hospitals of Leicester NHS Trust, Leicester, UK
Ch19: Pulmonary embolism
Bernadette Donaghy
Advance Nurse Practitioner in Cystic Fibrosis, University Hospitals of Leicester NHS Trust, Leicester, UK
Ch10: Cystic fibrosis
Kayleigh Hawkes
Specialist Pneumonia Nurse, University Hospitals of Leicester NHS Trust, Leicester, UK
Ch17: Pneumonia
Sarah Johnstone
Pleural Diseases Nurse Specialist, University Hospitals of Leicester NHS Trust, Leicester, UK
Ch16: Pleural effusion
Ruth McArthur
Former Training Co-ordinator for Education for Health (Scotland) & Allergy clinical lead
Ch7: Asthma and allergies
Karen Payne
Bronchiectasis Nurse Specialist, University Hospitals of Leicester NHS Trust, Leicester, UK
Ch8: Bronchiectasis
Jacqui Pollington
Respiratory Nurse Consultant, Breathing Space, Rotherham, UK
Ch14: Oxygen therapy
Terry Robinson
Respiratory Nurse Consultant, Harrogate District NHS Foundation Trust, North Yorkshire, UK
Ch3: Anatomy and physiology; Ch4: Respiratory assessment; Ch5: Respiratory investigations; Ch9: Chronic obstructive pulmonary disease (COPD); Ch14: Oxygen therapy; Ch15: Pharmacology; Ch18: Pneumothorax; Ch20: Pulmonary hypertension; Ch27: The multidisciplinary team (MDT); Ch28: Flying, altitude, and diving; and Ch29: Glossary
Jane Scullion
Respiratory Nurse Consultant, Glenfield Hospital, Leicester, UK
Ch2: Why work in respiratory medicine; Ch11: Interstitial lung disease (ILD); Ch13: Obstructive sleep apnoea (OSA); Ch23: Palliative Care; Ch24: Pulmonary rehabilitation; Ch26: Sex, sexuality, and breathlessness; and Ch30: Useful contacts
Helen Thuraisingam
Lead Nurse and Clinical Nurse Manager, Tuberculosis Service, University Hospitals of Leicester NHS Trust, Leicester, UK
Ch22: Tuberculosis (TB)
Emma Tolley
Advanced Critical Care Practitioner, University Hospitals of Leicester NHS Trust, Leicester, UK
Ch6: Acute respiratory distress syndrome (ARDS)
Dhiraj D Vara
Diagnostic Project Manager in Planned care team in Leicester, Leicestershire and Rutland, Leicester, UK
Ch21: Non-invasive ventilation (NIV)
Covid-19
This Oxford Handbook for Respiratory Nursing was in the final stages of completion when the worst respiratory virus we have ever faced in our lifetimes, COVID-19, swept across the world. Taking lives, devastating our hospitals, and general practices we had to rapidly adapt and cope with new ways of working, whilst sending our vulnerable respiratory patients into lockdown. As respiratory practitioners, we learnt rapidly and on the job. What helped us were good public health values, hand hygiene, infection control, isolation, and the use and lack of personal protective equipment, always a news worthy topic. It is this return to basics that we should embrace and incorporate going forward.
We learnt that two of the three main symptoms of coronavirus—high temperature and new continuous cough—are similar to the symptoms seen in many other respiratory conditions. We learnt the importance of additional symptoms such as loss of smell (anosmia) and taste (ageusia). However, it is worth noting that the current evidence base for these is predominantly of poor quality, due mainly to the retrospective and cross-sectional nature of the included study designs. One of the potential negative impacts of the addition of acute loss of smell or taste to the list of symptoms that indicate self-isolation is the potential number of falsepositive cases. Olfactory disorders including acute anosmia frequently occur with common cold and influenza. There are likely to be many people who will display these symptoms but do not have coronavirus.
We learnt of the impact on our Black and Ethnic Minorities (BAME) patients and colleagues and of the importance of comorbidity such as diabetes and obesity on affecting outcomes. As time went on we realized that although the elderly were disproportionately affected COVID-19 was no respecter of age.
We learnt that we could use High flow oxygen, NIV and CPAP in type 1 respiratory failure with good effect and that the lung compliance in COVID-19 unlike ARDS is not stiff but compliant. We learnt the importance of proning to improve oxygenation, and of the physical effort this entailed in turning patient on to their fronts whilst still ensuring ventilation requirements.
We learnt the rapid introduction and importance of research and collaboration amongst our respiratory academics and scientists. We learnt the impact of new drugs. Remdesivir shortening lengths of stay in COVID patients but not in the most severe patients although the study was stopped before its anticipated end date due to the early findings so therefore not seen to out to its conclusion. We also learnt the importance of dexamethasone—a cheap and plentiful medication. The recovery trial found that dexamethasone reduced deaths by one-third in ventilated patients and by one-fifth in other patients receiving oxygen only. There was no benefit amongst those patients who did not require respiratory support. These results showed, 1 death would be prevented by treatment of around 8 ventilated patients or around 25 patients requiring oxygen alone.
We learnt to consult remotely, either by telephone or video consultation and realized that for many of our patients their new reality was the confines firstly of their houses and more latterly their gardens. As time went on we learnt the impotence of mental health, anxiety and depression, again a basic of good care recognizing the mind and the body. We learnt to queue and maintain social distancing and the value of face masks. We applauded essential workers but also those who helped to keep the NHS safe by sticking to self-isolation and maintaining good hygiene practices.
Going forward we will need to embrace our new ways of working and rely on good history taking and assessment as our access to aerosolgenerating procedures such as spirometry are greatly restricted to help us with diagnosis. Rehabilitation both physically and mentally for our patients will be paramount and we will have to work out how to deliver this.
Finally, we realized that our respiratory patients described in the following chapters still exist and we still have a duty to care for them. Our chapters stand as they did pre COVID-19 and will do post COVID-19.
Keep safe.
Overview and causes of respiratory diseases 2
Mortality and morbidity 4
Costs of respiratory disease 6
Overview and causes of respiratory diseases
Overview
• respiratory diseases are one of the most common forms of ill-health.
• they affect about 2.5 million in the United Kingdom (UK); approximately one in five.
• prevalence is highest in the North-West and South-West of england.
• Globally the UK is in the top 20 countries for lung cancer and chronic obstructive pulmonary disease (COpD) deaths.
• More women than men have a diagnosed lung disease, mainly due to higher pneumonia incidence; most other lung conditions are more common in men.
• there are more than 30 conditions that can affect the lungs and/or airways and impact on a person’s ability to breathe. these diseases are a leading cause of hospitalization and death.
• Major respiratory diseases include infective lung diseases such as tuberculosis and pneumonia; obstructive lung diseases such as asthma and COpD; restrictive lung diseases such as interstitial lung disease; pulmonary vascular diseases such as pulmonary hypertension and pulmonary embolism along with many others.
• respiratory health problems have a major impact on the daily lives of people everywhere, accounting for a significant amount of morbidity, disability, and mortality. people with lung disease can experience severe restrictions on their mobility and ability to undertake day-to-day activities, such as getting dressed or cooking a meal.
Causes of respiratory disease
While some respiratory diseases are closely related to smoking; COpD and lung cancer, for example, it is important to stress that there is a wide variety of other factors which impact on lung health. these include:
• Viral lung infections in childhood
• Inadequate lung development in childhood
• passive smoking
• air pollution
• Occupational exposure to materials such as dust, asbestos fibres, and other irritant particles
• poor nutrition
• Social deprivation including poor housing and homelessness
• Genetic factors.
the specific causes of the most common respiratory diseases will be discussed in the individual chapters in this book.
Mortality and morbidity
Mortality
respiratory disease is the second biggest killer globally after cardiovascular diseases. Out of 68 million deaths worldwide in 2020, .9 million will be caused by lung diseases. respiratory disease kills one person in five in the UK, and accounts for more deaths each year than coronary artery disease or non-respiratory cancer. Unlike other chronic diseases, deaths from respiratory disease do not appear to be falling.
Data from the World health Organization (WhO) shows that death rates from diseases of the respiratory system in the UK are higher than both the european average and the european Union (eU) average. this difference is particularly marked for females: death rates from respiratory disease for females in the UK are about three times higher than those for females in france and Italy.
a higher proportion of respiratory disease deaths are caused by social inequality than by any other disease. almost a half of all deaths (44%) are associated with social class inequalities, compared with 28% of deaths from ischaemic heart disease.
Men aged 20–64 employed in unskilled manual occupations are around 4 times more likely to die from COpD, and nine times more likely to die from tuberculosis than men employed in professional roles.
Mortality by type of respiratory disease
• respiratory cancers—3% of respiratory deaths
• pneumonia—25.3% of respiratory deaths
• COpD—26.% of respiratory deaths.
the remaining approximately 20% of deaths are caused by a range of respiratory diseases including cystic fibrosis, tuberculosis, and acute respiratory infections.
Morbidity
respiratory disease is the most commonly reported long-term illness in children and the third most commonly reported in adults. Many of the 2.5 million people with respiratory disease in the UK suffer considerable personal discomfort.
Incidence and mortality rates for those with respiratory disease are higher in disadvantaged groups and areas of social deprivation.
Lung disease has a multiple impact on patients and their carers, as well as the NhS. this impact on the NhS includes the following areas:
Inpatient hospital treatment
• there were over 842,000 inpatient admissions for respiratory disease in NhS hospitals in england during 20. this represents nearly 8% of all admissions.
• respiratory disease accounts for 6. million bed days, nearly 0% of all hospital bed days.
Consultations in general practice
• respiratory consultations are the most common consultation in general practice.
• Many respiratory diseases can effectively be managed in primary care.
• there are nearly 24 million consultations in general practice due to respiratory disease in the UK per year.
• Nearly one in five males and one in four females consulted a Gp for a respiratory complaint in the UK in 2004.
• the most commonly reported illnesses in babies and children are lungrelated—asthma is one of the commonest single causes of admission to hospital among children.
Drug treatment
• the respiratory formulary prescription cost (net ingredient) accounts for around 2% of the total cost of all prescriptions of £8.82 billion in england (206).
• Just about half of these were for bronchodilators used in the treatment of asthma and COpD, corticosteroids now account for over a quarter of respiratory drugs (% p.390).
Costs of respiratory disease
• Lung disease not only causes much individual suffering, but it also has a major economic impact. respiratory disease costs the NhS and society £ billion per year.
• 340 million consultations with Gps—at a cost of £3 billion to primary care.
• an estimated 700,000 admissions a year for respiratory disease in the UK—at a suggested cost of £496.4 million to secondary care.
• Just over £ billion spent on prescribed respiratory drugs.
• Lost productivity owing to sickness.
• these figures do not include days lost from self-certified sickness, and so they underestimate the true cost of respiratory disease.
• respiratory disease (most commonly pneumonia) accounts for nearly 700,000 annual hospital admissions (> 6. million bed days) in the UK.
Further reading
british Lung foundation. the battle for breath 206. british Lung foundation, London. available at: https://www.blf.org.uk/policy/the-battle-for-breath-206 NhS. the NhS Long term plan. available at: https://www.longtermplan.nhs.uk
Snell N, Strachan D, hubbard r, et al. burden of lung disease in the UK; findings from the british Lung foundation's 'respiratory health of the nation' project. european respiratory Journal 206;48: pa493.
trueman D, Woodcock f, hancock e estimating the economic burden of respiratory illness in the UK. available at: https://www.blf.org.uk/policy
Why work in respiratory nursing?
A career in respiratory medicine or thoracic surgery? 8
Desirable qualities for a respiratory nurse 9
How do I become a respiratory nurse? 10
What are the current job prospects? 11
A career in respiratory medicine or thoracic surgery?
Working in the specialty of respiratory medicine and thoracic surgery offers an interesting, diverse, and wide-ranging choice of excellent opportunities for an appealing and fulfilling career. the specialty includes over 30 different medical conditions of which some are common and some relatively rare so there is ample opportunity to subspecialize as well as to take a more generalist pathway. Nurses in this specialty are often members of a multidisciplinary team working with other specialist nurses, consultants, general practitioners, physiotherapists, occupational therapists, pharmacists, and respiratory technicians (% p.560). there are also many opportunities to direct and help the development of local services and care provision. Many nurses now cross the traditional boundaries of primary and secondary care working with patients wherever there is a perceived need.
For nurses working in the acute setting some hospitals have highly specialized respiratory units often providing regional services. However, in the majority of units a large proportion of the workload combines acute respiratory and general medicine.
It is generally recognized that respiratory conditions currently account for about a third of emergency admissions so the range of roles for nurses may encompass triage and front line assessment, care on respiratory or general wards, intensive or high-dependency care, and a range of specialist roles for immediate, early discharge and continuing care.
In the community nurses may work in walk-in centres, Gp practices, health centres and intermediate care settings, or in the patient’s own home in a variety of roles. Some nurses will undertake their own respiratory clinics while others will incorporate their respiratory work into more generalist clinics.
Desirable qualities for a respiratory
nurse
there are several personal qualities that are desirable for careers in respiratory nursing. Among these are:
• A good general medical knowledge and surgical knowledge if working with thoracic surgery patients
• A good knowledge of respiratory disorders
• Good communication skills
• the ability to work with other multidisciplinary team members
• the ability to work both within a team and often alone
• A willingness to explore new roles and boundaries
• An empathetic approach towards patients with chronic disorders, especially where therapeutic interventions are limited.
It is also essential that the nurse has a thorough understanding of the basic physiological and anatomical principles relating to the respiratory system, along with a fundamental knowledge of how different disease processes affect lung function (% p.82).
How do I become a respiratory nurse?
there are many ways in which a respiratory nursing post can be developed. these include undertaking relevant training courses and study days backed up by practical experience working with patients with respiratory problems. Joining the Association of respiratory Nurse Specialist (ArNS), the british thoracic Society (btS), or the primary Care respiratory Society (pCrS) can help with educational needs, peers support, and networking, as well as being an opportunity to share best practice. opportunities exist for education and further training both locally and nationally.
Further training courses at all levels from diploma to MSc in respiratory are offered by:
As well as the training centres, many local universities and colleges run respiratory courses and many respiratory nurses work as facilitators on these courses, sharing their knowledge with others. there are also many conferences specifically for respiratory disorders run through the ArNS, btS, and also the training centres and pharmaceutical companies.
What are the current job prospects?
there are many opportunities for nurses with an interest in respiratory medicine and thoracic surgery to work in a variety of settings and in a variety of roles. While some nurses are generalists many choose to have a subspecialty interest, such as asthma, chronic obstructive pulmonary disease (CopD), tuberculosis (tb), cystic fibrosis, interstitial lung disease (IlD), or lung cancer. Many nurses offer services such as smoking cessation, breathlessness management, counselling, and cognitive behavioural therapy (Cbt) and many are involved in or run pulmonary rehabilitation schemes (% p.516).
A wide pathway of careers exists for respiratory nurses from Staff Nurse, practice Nurse, Specialist Nurse, Nurse with a Specialist Interest, Nurse practitioner, lead Nurse, to Consultant Nurse. Clearly respiratory nursing offers many opportunities for nurses seeking a challenging and fulfilling career.
the current job prospects are extremely good and there are often advertised vacancies within the nursing press. pay scales vary enormously between jobs and between different areas of the country.
Useful addresses
Association of Respiratory Nurse Specialists (ARNS) Davidson road City Wharf lichfield
WS4 9DZ
telephone: 0543 44298
https://arns.co.uk
British Lung Foundation (BLF) 73–75 Goswell road london
eCV 7er
telephone: 020 7688 5555
https://www.blf.org.uk
British Thoracic Society (BTS)
7 Doughty Street london
WCN 2pl
Primary Care Respiratory Society (PCRS) https:/www.pcrs-uk.org
A Professional Development Framework for Respiratory Nursing BTS www.brit-thoracic.org.uk
