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Lungs

Please see below for the policies relating to lungs. To view the policy, patient leaflet and additional information, please click on the relevant heading.


 

  • Cough assist machines

    What are cough assist machines?

    The mechanical insufflator/exsufflator (MI-E/ Cough Assist machine) assists the clearance of bronchopulmonary secretions in those patients with an ineffective cough by the use of both positive and negative pressure.

    The MI-E (Cough Assist Machine) is a non-invasive therapy that safely and consistently removes secretions in patients with an ineffective ability to cough (measured by peak cough flow <270 l/m). The Cough Assist device clears secretions by gradually applying a positive pressure to the airway, then rapidly shifting to negative pressure. The rapid shift in pressure produces a high expiratory flow, creating an effective cough by significantly increasing peak cough flow, which improves airway clearance and removes bronchopulmonary secretions, thereby preventing and reducing respiratory tract infections.

    Respiratory function should be assessed in people with complex care needs by a Specialist Ventilation MDT that includes consultants with a special interest in ventilatory support/weaning, physiotherapists, specialist ventilation nurses.  The MDT may include palliative care and speech and language clinicians. 

    All patients being considered for a cough assist device should be discussed with the Local Respiratory Specialist Team, however ONLY the Specialist Ventilation MDT may assess and apply for funding for a cough assist machine for the patient. However, once funding has been secured, the local Respiratory Specialist Team may provide assessment, on-going monitoring and support to the patient. If annual funding renewal is required, then review with the Specialist Ventilation MDT will be required to ensure that use of the device remains clinically indicated in the patient.

    N.B the Specialist Ventilation MDT will need to be ratified by the CCG as an appropriate centre, with an appropriately skilled MDT prior to funding applications being accepted by the CCG.

    Benefits of cough assist

    • Removes secretions from the lungs
    • Reduces the occurrence of respiratory infections and the ensuing requirement for antibiotics
    • Supports a patient to avoid hospitalisation and need for intubation and tracheostomy
    • Recruits lung volume and prevents atelectasis
    • Decreases the risk of patient mortality
    • Safe, non-invasive alternative to suctioning
    • Easy for patients and caregivers to operate
    • Can be used with a face mask, mouthpiece or with an adapter to a patient's endotracheal or tracheostomy tube
    • Approved for home use in adults and children
    • Available in automatic and manual models

    Eligibility criteria

    The patient must be diagnosed with one of the following conditions:

    • Motor Neurone Disease
    • Spinal Muscular Atrophy
    • Spinal cord injury
    • Multiple Sclerosis
    • Guillain-Barre Syndrome
    • Post polio syndrome with respiratory impairment
    • Kypho-scoliosis
    • Syringomyelia
    • Other neuromuscular disease which is known to cause respiratory muscle weakness or upper airway functional impairment.

    AND

    In line with the above diagnosis the patient must also be unable to cough or clear secretions effectively:

    • PCF (Peak Cough Flow) less than 160 L/min OR
    • VC (vital capacity) below 1.1L in general respiratory muscle weakness, OR
    • Reduced Peak Cough Flow (PCF) of 270 l/pm or < 270 l/pm and have clinical symptoms or a weak cough and therefore require intervention necessary to clear bronchial secretions or infection

    AND

    The patient must be assessed and continue to be monitored by a specialist ventilation team with expert clinical knowledge and experience in the use of Cough Assist machines.

    AND

    Prior approval for funding must be sought for a cough assist machine to be provided in the community prior to the patient being supplied with a Cough Assist machine. For each patient funded with a Cough Assist Machine the provider should provide a written annual update by the specialist ventilation team to evidence that continuation of treatment is clinically effective before the next year of funding will be continued.

    Contraindications to treatment with a Cough Assist Machine

    The specialist ventilation team will individually assess each patient prior to commencing treatment with a cough assist machine and consider all contraindications before use.

    These could include:

    • Any patient with a history of bullous emphysema
    • Susceptibility to pneumothorax or pnuemo-mediastinum

    This means (for patients who DO NOT meet the above criteria) the CCG will only fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG.

  • Continuous Positive Airway Pressure (CPAP)

    Continuous Positive Airway Pressure (CPAP) is a small machine that pumps a non-stop supply of compressed air through a mask which keeps the walls of the throat open. The mask may either cover the nose or the noseand mouth. The compressed air helps to stop the throat from closing. It is considered the most effective therapy for treating severe cases of obstructed sleep apnoea/hypopneasyndrome and must always be worn when sleeping.

    Why is it used?

    Everyone breathes in oxygen from the air to stay alive. The oxygen goes into the blood through the lungs. When the body has used the oxygen, it produces carbon dioxide which is breathed out. This is called ventilation.Some people with severe lung problems are unable to breathe in enough oxygen and breathe out carbon dioxide which can lead to the lungs not working properly.

    Obstructive Sleep Apnoea Hypopnea Syndrome (OSAHS)

    Obstructive Sleep Apnoea Hypopnea Syndrome (OSAHS) is a condition where the muscles supporting the walls of the throat relax and narrow during sleep. This affects normal breathing and causes the airflow to be blocked for a few seconds or more. At times, the airflow can stop completely. It may also wake you up from sleep several times so breathingc an return to normal.

    Apnoea

    Apnoea is where the walls of the throat relax and narrow, usually during sleep, which affects normal breathing. It causes the airflow to be blocked for 10 or more seconds.

    Hypopnea

    This is a partial blockage of the airway that results in an airflow reduction of greater than 50% for 10 seconds or more.

    In some patients, OSAHS can cause extreme daytime sleepiness, and affect daily life including not being able to sleep, eat, walk or drive on their own. The condition is also associated with ageing, obesity and high blood pressure, which increases the risk of heart disease and stroke.

    Treatment:

    Treatment for OSAHS aims to reduce daytime sleepiness by reducing the number of episodesof apnoea/hypopnoea experienced during sleep. CPAP is most commonly used to help manage moderate or severe sleep OSAHS.

    Other treatments include lifestyle management such as losing weight, eating healthier, stopping smoking, decrease the amount of alcohol consumed and not taking sleep medicines.

    Eligibility criteria:

    The use of CPAP at home for OSAHS is restricted. Patients with moderate or severe symptomsof obstructive sleep apnoea hypopnoea syndrome must meet the following criteria to be approved:

    • Severe inability to function properly during the day which is impacting on the patient’sability to carry out activities of daily living
    • Lifestyle changes have not helped
    • Other relevant treatment options have not worked or are considered unsuitable
    • Have an Apnoea–Hypopnoea Index level between 15 to 30 or over.

    This means (for patients who DO NOT meet the above criteria) the clinical commissioning group (CCG) will only fund the treatment if an Individual Funding Request(IFR) application proves clinical need and the CCG supports this.

    Advice and further guidance:

  • Non-invasive ventilation

    Non-invasive ventilation (NIV) is an external treatment used to help people with severe problems with breathing. It involves wearing a mask connected to a machine (ventilator) which makes breathing in and out easier. It supports the muscles in the lungs to work properly, especially during the night.

    Why is it used?

    Everyone breathes in oxygen from the air to stay alive. The oxygen goes into the bloodthrough the lungs. When the body has used the oxygen, it produces carbon dioxide which is breathed out. This is called ventilation. Some people with severe lung problems are unable to breathe in enough oxygen and breathe out carbon dioxide which can lead to the lungs not working properly.

    Chronic Obstructive Pulmonary Disease:

    Chronic Obstructive Pulmonary Disease (COPD) is the name for a group of lung conditions that cause breathing difficulties. It includes: emphysema (damage to the air sacs in the lungs) and chronic bronchitis (long-term inflammation of the airways). Symptoms may includeconstant breathlessness, constant chesty cough with phlegm, frequent chest infections and constant wheeze. The breathing problems tend to get gradually worse over time and can limitthe patient’s normal activities.

    Causes of COPD

    COPD happens when the lungs become inflamed, damaged and narrowed. The main cause of COPD is smoking. However, it can sometimes affect people who have never smoke, however have had long term exposure to harmful fumes or dust. Damage to the lungs caused by COPDis permanent; however, treatment may help to slow down the condition.

    Treatments:

    Treatments for COPD include:

    • Smoking cessation to help patient with COPD to stop smoking
    • Inhalers and medications
    • Programme of exercise and education
    • Surgery or a lung transplant.

    COPD can result in patients being admitted to hospital and needing support to breathe through non-invasive ventilation.

    Eligibility criteria:

    Non-invasive ventilation for Chronic Obstructive Pulmonary Disease at home is restricted. To beconsidered the patient must have been reviewed by their specialist respiratory/ventilation teamto confirm they meet the following criteria:

    • The patient has a lowered lung capacity which has been measured by the specialist respiratory team

    AND

    • Blood tests show the patient is not breathing out enough carbon dioxide

    The patient must also have ONE of the following:

    • A reduced quality of life identified by symptoms consistent with sleep disordered breathing problems e.g. extreme daytime sleepiness, headache, confusion, increased shortness of breath, resting tremor

    OR

    • More than one condition affecting the level of oxygen in the blood which could lead to high blood pressure in the lungs or heart failure

    OR

    • Two or more hospital admissions over the past 12 months needing non-invasiveventilation treatment during the admissions to which the patient has responded well.

    This means the patient’s NHS commissioning organisation (CCG), who is responsible forbuying healthcare services on behalf of patients, will fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and the CCG supports this.

    Neuro-muscular disorders:

    Neuro-muscular disorders cause weakness of muscles which can lead to not being able to breathe properly. Patients with some of these conditions may need to use non-invasive ventilation (NIV) during the day and night to breathe more easily.

    Patients with one of the following conditions who also meet the eligibility criteria below will be considered for non-invasive ventilation treatment at home:

    Motor Neurone Disease

    Motor neurone disease (MND) is a rare condition that affects the brain and nerves. It causes muscles and nerves to become weak which worsens over time.

    Muscular Dystrophy

    Muscular Dystrophy, including Duchenne Muscular Dystrophy gradually causes the muscles to weaken, leading to an increasing level of disability.

    Multiple Sclerosis

    Multiple sclerosis (MS) is a condition that can affect the brain and spinal cord, causing a wide range of potential symptoms including problems with vision, arm or leg movement, sensationor balance.

    Post-polio syndrome

    Polio is a viral infection which most people would have fought off without even knowing they had it. Post-polio syndrome is rarely life-threatening, however some people may develop breathing and swallowing difficulties.

    Guillain-Barré syndrome

    Guillain-Barré (pronounced ghee-yan bar-ray) syndrome is a very rare and serious condition that affects the nerves. It mainly affects the feet, hands and limbs, causing problems such as numbness, weakness and pain.

    Syringomyelia

    Syringomyelia is where a fluid-filled cavity called a ‘syrinx’ develops in the spinal cord. This candamage the spinal cord and cause muscular problems.

    Tuberculosis (with respiratory impairment)

    Tuberculosis (TB) is a bacterial infection which generally affects the lungs. If not treated it can cause the lungs to stop working properly.

    Spinal Cord Injury

    A spinal cord injury is where damage has been done to any part of the spinal cord or nervesat the end of the spine. It can cause the muscles that help you to breathe to stop working properly.

    Other neuro muscular diseases which are known to cause muscle weakness and also affect breathing may be considered.

    Eligibility criteria:

    NIV for neuro muscular diseases at home is restricted. Patients with one of the neuromuscular conditions listed above must also meet the following criteria:

    Ventilation at night

    The patient must meet ONE of the following criteria:

    • Signs or symptoms of hypoventilation
    • Blood tests show the patient is not breathing in enough oxygen
    • Blood tests show the patient is not breathing out enough carbon dioxide.

    Daytime ventilation

    In addition to meeting the above criteria, the patient must also meet ONE of the following criteria:

    • Not being able to swallow properly due to shortness of breath, which is relieved byusing a ventilator
    • Unable to speak in full sentences due to breathlessness
    • Blood tests show the patient is not breathing in enough oxygen
    • Blood tests show the patient is not breathing out enough carbon dioxide
    • Symptoms of breathing difficulties whilst awake.

    This means (for patients who DO NOT meet the above criteria) patient’s NHS commissioning organisation (CCG), who is responsible for buying healthcare services on behalf of patients, will only fund the treatment if an Individual Funding Request (IFR)application proves exceptional clinical need and the CCG supports this.

    Advice and further guidance:

  • Pre-operative chest x-ray

    This guidance is produced by The Academy of Medical Royal Colleges (the Academy) as part of the Evidence-based interventions programme. It is based on recommendations from the Expert Advisory Committee and the National Institute for Health and Care Excellence (NICE).

    All guidance has been reviewed by the Birmingham and Solihull & Sandwell and West Birmingham CCGs’ Treatment Policy Clinical Development Groups (TPCDG). This was reviewed to establish if existing CCG policies were already in place which covered the proposed intervention / treatment in question.

    Where there was no current CCG policy for the area in question, the NHSEI policy has been implemented in full into the CCG’s Clinical Treatment Policy portfolio.

    Where there was a current CCG policy for the area in question, then the existing CCG policy has been reviewed by the TPCDG considering the NHSEI EBI policy rationale and evidence base.  A decision has then been taken by TPCDG based on the review as to the most appropriate policy for implementation by taking into account the healthcare needs of our local population.

    The aims of the Evidence Based Interventions programme is to ensure the quality and safety of patient care by, freeing up valuable resources such as time so that more effective interventions can be carried out, reducing harm or the risk of harm to patients, helping clinicians maintain professional practice, creating headroom for innovation, and maximising value and avoiding waste.

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