Harrow on the Hill, United Kingdom
Harrow on the Hill, United Kingdom

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Price S.,Royal Brompton and Harefield NHS Foundation Trust | Uddin S.,Barts and the London NHS Trust | Quinn T.,University of Surrey
Current Opinion in Critical Care | Year: 2010

PURPOSE OF REVIEW: Successful resuscitation requires potentially reversible causes to be diagnosed and reversed, and many of these can readily be diagnosed using echocardiography. Although members of the resuscitation team routinely use adjuncts to their clinical examination in order to differentiate these causes, the use of echocardiography is not yet considered standard. The purpose of this review is to discuss the potential for echocardiography to aid diagnosis and treatment during resuscitation, together with some of the perceived challenges that currently limit its widespread use. RECENT FINDINGS: Many studies have demonstrated the value of echocardiography in the assessment of critically ill patients in the intensive care unit and emergency room settings, including more recently the use of focused echocardiography. This can be performed within the time frame allowed during the pulse check of the advanced life support (ALS) algorithm. ALS-compliant focused echocardiography can be taught to nonexpert practitioners such that high-quality cardiopulmonary resuscitation is not compromised while diagnosing/excluding some of the potential causes of cardiac arrest. SUMMARY: Persistent and worsening haemodynamic instability are regarded as clear indications for echocardiography. The focused application of this well established technique within the ALS algorithm provides the resuscitation team with a potentially powerful diagnostic tool that can be used to diagnose/exclude some of the potentially treatable causes of cardiac arrest as well as to guide therapeutic interventions. The impact of routine periresuscitation echocardiography on patient outcomes both for in-hospital and prehospital care remains an exciting avenue for future research. © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Chatwin M.,Royal Brompton Hospital | Bush A.,Royal Brompton and Harefield NHS Foundation Trust | Simonds A.K.,Royal Brompton Hospital
Archives of Disease in Childhood | Year: 2011

Background: There are widely discrepant views on the respiratory management of infants with spinal muscular atrophy (SMA) type I. Typically, management is palliative. Design: A descriptive study of interventions and investigations is reported that were offered to a cohort of 13 children with SMA type I referred to our centre. Interventions and investigations: included sleep studies, provision of non-invasive positive pressure ventilation (NIPPV) for ventilatory support/dependency and for physiotherapy and the use of mechanical insufflation/exsufflation (MI-E). Results: NIPPV was provided for the following indications: continuous positive airways pressure flow driver dependency (n=3), nocturnal hypoventilation (n=3), to enable successful extubation (n=2), in anticipation of respiratory decompensation (n=3), and oxygen dependency/decompensation (n=2). NIPPV and MI-E were used for successful protocol-led extubations (n=9) but not non protocol-led successes (n=3). NIPPV was essential for discharge home in patients with ventilatory dependency (n=7) and was used for palliation of respiratory symptoms (n=4). Chest wall shape improved with NIPPV. The parents of children who died (n=5) were positive about the use of these techniques. Conclusion: NIPPV can be used to facilitate discharge home, and MI-E is helpful in this group. This symptom and goal-directed approach can be used to inform medical decision making and to help parents make informed choices about the appropriateness of respiratory interventions in SMA type I.

Yusuf S.,McMaster University | Healey J.S.,McMaster University | Pogue J.,McMaster University | Chrolavicius S.,McMaster University | And 6 more authors.
New England Journal of Medicine | Year: 2011

BACKGROUND: The risk of cardiovascular events among patients with atrial fibrillation is high. We evaluated whether irbesartan, an angiotensin-receptor blocker, would reduce this risk. METHODS: We randomly assigned patients with a history of risk factors for stroke and a systolic blood pressure of at least 110 mm Hg to receive either irbesartan at a target dose of 300 mg once daily or double-blind placebo. These patients were already enrolled in one of two trials (of clopidogrel plus aspirin versus aspirin alone or versus oral anti-coagulants). The first coprimary outcome was stroke, myocardial infarction, or death from vascular causes; the second was this composite outcome plus hospitalization for heart failure. RESULTS: A total of 9016 patients were enrolled and followed for a mean of 4.1 years. The mean reduction in systolic blood pressure was 2.9 mm Hg greater in the irbesartan group than in the placebo group, and the mean reduction in diastolic blood pressure was 1.9 mm Hg greater. The first coprimary outcome occurred at a rate of 5.4% per 100 person-years in both groups (hazard ratio with irbesartan, 0.99; 95% confidence interval [CI], 0.91 to 1.08; P = 0.85). The second coprimary outcome occurred at a rate of 7.3% per 100 person-years among patients receiving irbesartan and 7.7% per 100 person-years among patients receiving placebo (hazard ratio, 0.94; 95% CI, 0.87 to 1.02; P = 0.12). The rates of first hospitalization for heart failure (a pre-specified secondary outcome) were 2.7% per 100 person-years among patients receiving irbesartan and 3.2% per 100 person-years among patients receiving placebo (hazard ratio, 0.86; 95% CI, 0.76 to 0.98). Among patients who were in sinus rhythm at baseline, there was no benefit of irbesartan in preventing hospitalization for atrial fibrillation or atrial fibrillation recorded on 12-lead electrocardiography, nor was there a benefit in a subgroup that underwent transtelephonic monitoring. More patients in the irbesartan group than in the placebo group had symptomatic hypotension (127 vs. 64) and renal dysfunction (43 vs. 24). CONCLUSIONS: Irbesartan did not reduce cardiovascular events in patients with atrial fibrillation. (Funded by Bristol-Myers Squibb and Sanofi-Aventis; ClinicalTrials.gov number, NCT00249795.) Copyright © 2011 Massachusetts Medical Society.

MacEira A.M.,Cardiac Imaging Unit | Mohiaddin R.H.,Royal Brompton and Harefield NHS Foundation Trust | Mohiaddin R.H.,Imperial College London
Journal of Cardiovascular Magnetic Resonance | Year: 2012

Systemic hypertension is a highly prevalent potentially modifiable cardiovascular risk factor. Imaging plays an important role in the diagnosis of underlying causes for hypertension, in assessing cardiovascular complications of hypertension, and in understanding the pathophysiology of the disease process. Cardiovascular magnetic resonance (CMR) provides accurate and reproducible measures of ventricular volumes, mass, function and haemodynamics as well as uniquely allowing tissue characterization of diffuse and focal fibrosis. In addition, CMR is well suited for exclusion of common secondary causes for hypertension. We review the current and emerging clinical and research applications of CMR in hypertension. © 2012 Maceira and Mohiaddin; licensee BioMed Central Ltd.

Yorke J.,University of Salford | Moosavi S.H.,Imperial College London | Shuldham C.,Royal Brompton and Harefield NHS Foundation Trust | Jones P.W.,St George's, University of London
Thorax | Year: 2010

Rationale: Dyspnoea is a debilitating and distressing symptom that is reflected in different verbal descriptors. Evidence suggests that dyspnoea, like pain perception, consists of sensory quality and affective components. The objective of this study was to develop an instrument that measures overall dyspnoea severity using descriptors that reflect its different aspects. Methods: 81 dyspnoea descriptors were administered to 123 patients with chronic obstructive pulmonary disease (COPD), 129 with interstitial lung disease and 106 with chronic heart failure. These were reduced to 34 items using hierarchical methods. Rasch analysis informed decisions regarding further item removal and fit to the unidimensional model. Principal component analysis (PCA) explored the underlying structure of the final item set. Validity and reliability of the new instrument were further assessed in a separate group of 53 patients with COPD. Results: After removal of items with hierarchical methods (n = 47) and items that failed to fit the Rasch model (n = 22), 12 were retained. The "Dyspnoea-12" had good internal reliability (Cronbach's alpha = 0.9) and fit to the Rasch model (χ2 p = 0.08). Items patterned into two groups called "physical"(n = 7) and "affective"(n = 5). In the separate validation study, Dyspnoea-12 correlated with the Hospital Anxiety and Depression Scale (anxiety r = 0.51; depression r = 0.44, p<0.001, respectively), 6-minute walk distance (r = -0.38, p<0.01) and MRC (Medical Research Council) grade (r = 0.48, p<0.01), and had good stability over time (intraclass correlation coefficient = 0.9, p<0.001). Conclusion: Dyspnoea-12 fulfills modern psychometric requirements for measurement. It provides a global score of breathlessness severity that incorporates both "physical" and "affective" aspects, and can measure dyspnoea in a variety of diseases.

De Benedictis F.M.,Salesi Childrens Hospital | Bush A.,Royal Brompton and Harefield NHS Foundation Trust
American Journal of Respiratory and Critical Care Medicine | Year: 2012

We review recent advances in the use of corticosteroids (CS) in pediatric lung disease. CS are frequently used, systemically or by inhalation. Their mechanisms of action in pulmonary diseases are ill defined. CS exert direct inhibitory effects onmany inflammatory cells through genomic mechanisms. There is a time lag before clinical response,andthewashout ofeffects isalsoprolonged.Prompt relief in some conditions, such as croup, may be related to airway mucosal vasoconstriction through a nongenomic mechanism. CS have proven beneficial roles in the treatment of asthma, croup, allergic bronchopulmonary aspergillosis, and subglottic hemangioma. In some conditions, such as bronchiolitis, cystic fibrosis, and bronchopulmonary dysplasia, their use is controversial andisnot recommendedroutinely. In other conditions, such as tuberculosis, interstitial lung disease, acute lung aspiration, and acute respiratory distress syndrome, CS are often used empirically despite the lack of clear evidence of their benefit.Newdrugregimens, includingthemoreflexibleuseof inhaled corticosteroids and long-acting b-agonists in asthma, the lack of efficacy of oral corticosteroids in preschool children with acute wheeze, the severe complications of systemic dexamethasone used to prevent bronchopulmonary dysplasia and thus more restricted use, and the beneficial effect of pulse high-dose intravenous methylprednisolone in patients with allergic bronchopulmonary aspergillosis or cystic fibrosis are among the major recent developments. There is concern about adverse effects, especially growth and adrenal suppression, induced by systemic CS in children. These have been reduced, but not eliminated, with the use of the inhaled route. The benefits must be weighed against the potential detrimental effects. Copyright © 2012 by the American Thoracic Society.

Wells A.U.,Royal Brompton and Harefield NHS Foundation Trust
Respiratory research | Year: 2013

Idiopathic pulmonary fibrosis (IPF), the most prevalent idiopathic interstitial pneumonia, is associated with a poor prognosis. An accurate diagnosis of IPF is essential for optimal management. The recent ATS/ERS/JRS/ALAT recommendations on the diagnosis and management of IPF were developed from a systematic review of the published literature. High-resolution computed tomography (HRCT) scanning has a central role in the IPF diagnostic pathway with formal designation of criteria for an HRCT pattern of UIP. In the correct clinical context, a UIP pattern on HRCT is indicative of a definite diagnosis of IPF without the need for a surgical lung biopsy. However, although the 2011 ATS/ERS/JRS/ALAT statement is a major advance, the application of guideline recommendations by clinicians has identified limitations that need to be addressed in future statements. Key problems include: 1) the lack of management recommendations for the highly prevalent clinical scenarios of probable and possible IPF; 2) the ongoing confusion about the diagnostic role of bronchoalveolar lavage (reflecting ambiguity in the current recommendation); 3) HRCT misdiagnosis by less experienced radiologists, increasingly recognised as a major problem; and 4) the lack of integration of clinical data, including the treated course of disease, in the designation of the diagnostic likelihood of IPF.

Cox F.,Royal Brompton and Harefield NHS Foundation Trust
Nursing standard (Royal College of Nursing (Great Britain) : 1987) | Year: 2010

This article, the first in a series written by pain nurse specialists, provides an overview of the nature, causes and structured management of acute, chronic and neuropathic pain. The differences between nociceptive and neuropathic pain, and treatment options are identified. The pain management service's roles are described in the context that a person's experience of pain is the result of biological, psychological and social factors. Future articles will explore the physiology and pharmacology of pain, how patients express pain and interventions for acute and chronic pain. They will also provide guidance on managing pain in challenging circumstances.

Royston D.,Royal Brompton and Harefield NHS Foundation Trust
Anaesthesia | Year: 2015

There is a considerable difference between the mechanism of action of the lysine analogues, tranexamic acid and epsilon-aminocaproic acid, and the serine protease inhibitor aprotinin. Aprotinin acts to inactivate free plasmin, but with little effect on bound plasmin, whereas the lysine analogues are designed to prevent excessive plasmin formation by fitting into plasminogen's lysine-binding site to prevent the binding of plasminogen to fibrin. Aprotinin is associated with a reduction in bleeding and transfusion requirements following major surgery, and has a dose-response profile, compared with no dose-response effect in the one study investigating tranexamic acid in cardiac surgical patients. Following its withdrawal in 2007, which is explained in detail in this review, the regulators have now licensed aprotinin for myocardial revascularisation only, which is relatively low-risk for bleeding. © 2014 The Association of Anaesthetists of Great Britain and Ireland.

Brill A.-K.,Royal Brompton and Harefield NHS Foundation Trust
Breathe | Year: 2014

Noninvasive ventilation (NIV) applied via different interfaces is increasingly used in the treatment of acute respiratory failure. One of the key factors determining the success of NIV is the choice of interface. Interface selection, fitting and handling can be challenging as NIV application can be complicated by discomfort, air leaks, skin damage or conjunctivitis. The aim of this article is to provide practical information on interface choice, technical aspects of mask fitting and prevention of mask-related problems during the acute delivery of NIV. © 2015, European Respiratory Society. All rights reserved.

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