Early identification of respiratory impairment in motor neurone disease
Respiratory function significantly predicts both survival and quality of life in people with Motor Neurone Disease (MND). Early referral to specialist respiratory services at the onset of symptoms is vital to facilitate decisions regarding respiratory management. Effective management of respiratory symptoms is likely to have a positive impact on the quality of life of the person with MND. Objective measures of respiratory function allow clinicians and patients to self-monitor respiratory symptoms at home. A challenge of working within a multi-disciplinary (MDT) community neurological therapy team was the lack of easy to use, accessible, accurate objective measures of respiratory function. We describe the development of the team's MND respiratory assessment, which aimed to improve early identification of people with respiratory impairment. A further aim was to improve the referral pathway between the community team and its local sleep and ventilation service.
The current NICE Motor Neurone Disease guidelines (2016) were reviewed in collaboration with the consultant respiratory physiotherapist at the local sleep and ventilation service, we identified measurement of peak cough flow (PCF) and pulse oximetry (SpO2) as the most accurate and user friendly objective measures to use within a community setting. New assessment paperwork was developed and included; subjective symptoms, PCF, SpO2 measurement alongside guidelines on how to interpret results. MDT teaching was arranged, ensuring all team members were competent to complete the respiratory assessment. Equipment was purchased so that every MND patient could be provided with a PCF device following initial assessment from the community team. Patients were encouraged to self-monitor their cough strength on a weekly basis.
Between March 2016 and March 2017 the team supported 22 individuals with MND, 16 of these patients underwent respiratory assessment. We identified nine patients with respiratory symptoms, resulting in four new referrals to the sleep and ventilation service whilst five patient's respiratory appointments were expedited. Six patients did not have an assessment carried out by the community team as physiotherapists were not present during the initial assessment. The assessments were carried out by physiotherapists (88%) and speech and language therapists (13%).
Cost and savings
This was a pilot study to assess the feasibility of non-respiratory specialists carrying out respiratory assessments as part of a collaborative and integrated working approach. Further work is required on potential cost benefits.
The new assessment and referral pathway has been successful at identifying patients with a changing respiratory status. This has resulted in earlier referrals to the sleep and ventilation service or enabled appointments to be expedited. The results highlight the majority of respiratory assessment was carried out by physiotherapists and not all of our patients had their PCF assessed by the team. Further work is required by the team to promote patient self-monitoring of symptoms and on-going refresher MDT training will be provided to increase utilisation of the assessment tool amongst other disciplines.
Developing an objective and user-friendly respiratory assessment assists MDTs in the early identification of respiratory symptoms. It improves access to specialist respiratory services and is an innovative way to integrate services.
Top three learning points
Working to explore a solution to our problem outside of our normal organisational boundaries was a positive experience and enabled the team to access a wider range of professional expertise and led to improved communication between services.
Services being open to working together and the ability of our Respiratory colleagues to support with education and training was key to the success of this project.
This pilot study demonstrates that it is feasible for a non-respiratory specialist MDT to carry out a respiratory assessment enabling improved access to specialist services. Uptake of the tool was better amongst Physiotherapist’s suggesting other health professionals may require more ongoing support and training.
This work was not funded.
This work was presented at Physiotherapy UK 2017.
For further information about this work contact Stephanie Mansell