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Allergy, Immunology and Respiratory

Medicine
Orientation Manual

Compiled by
The Department of Allergy, Immunology
and Respiratory Medicine
&
The Director of Clinical Training
The Alfred Hospital
2015
1

CONTENTS
Page
Introduction ........................................................................................................................................ 3
Senior Staff ......................................................................................................................................... 4
Organisational Charts ......................................................................................................................... 5
Contacting Consultants for AIRMED .................................................................................................. 8
Weekend Consultants on Call for AIR 1,2,3 & 4 . .......................................................................... 9
Generic Objectives ........................................................................................................................... 10
Clinical Handover.............................................................................................................................. 11
Registrar/HMO timetable .. ............................. 12
AIR I Staff ................................................................................................................. 13
Learning Objectives ......................................................................................... 14
AIR 2 Staff ................................................................................................................. 15
Learning Objectives ......................................................................................... 16
AIR 3 Staff ................................................................................................................. 17
Learning Objectives ......................................................................................... 18
AIR 4 Staff ................................................................................................................. 20
Learning Objectives ......................................................................................... 21
Physiology Service Staff ................................................................................................................. 25
Learning Objectives ......................................................................................... 26

AIR 1 / LUNG TRANSPLANT SERVICE


Lung and Heart/Lung Transplantation Protocol ................................................................................ 27
Lung Transplant Guideline ............................................................................................................... 40

AIR 2 / CYSTIC FIBROSIS SERVICE


Protocol for admission of patients with acute exacerbation of CF ................................................... 83
Insertion of PICC lines in adult patients with CF at The Alfred ........................................................ 88

AIR 3 / GENERAL RESPIRATORY & SLEEP MEDICINE SERVICE


Non-invasive ventilation (NIV) for acute hypercapnic ventilatory failure .......................................... 90
Management of acute hypercapnic respiratory failure ..................................................................... 92
Referral Process for NIV . .................................................... 93
Non-Invasive Ventilation Referral Flow Chart .. ....................................................... 95
Treatment Aims and Limits ....................................................................... 96
Common Antibiotic Dosages . ................................................................................................ 97
Management of pleural effusion ....................................................................................................... 98
Pleural effusion: a clinical pathway . ......................................................................................... 99
Management of Spontaneous pneumothorax ................................................................................ 100
Chronic obstructive pulmonary disease (COPD) Management at The Alfred ................................ 101
Oxygen for the palliative care patient ............................................................................................. 106
Appendix A Palliative Oncology 114
Appendix B - Home oxygen therapy consent form ...115
Appendix C Inpatient Domiciliary Oxygen Therapy Referral and Assessment ... 116

Policy and Guidelines for Tracheostomy Care are available on The Alfred Intranet,
under keywords, type in TRACHEOSTOMY CARE

AIR 4 / ALLERGY, ASTHMA & CLINICAL IMMUNOLOGY SERVICE


Ward Management of Asthma ........................................................................................................ 118
Guidelines for Emergency Treatment of Asthma ........................................................................... 119
Emergency Anaphylaxis Protocol ................................................................................................... 120
Recent Onset Angioedema ... 121
Ultra Rush Protocol for Bee Venom ............................................................................................... 122

PHYSIOLOGY SERVICE
General Information ........................................................................................................................ 123
Introduction to the Lung Function Laboratory ................................................................................. 124
Interpretation of Lung Function ....................................................................................................... 127
Lung Function Request Slip ....................................................................................... . .128
2

INTRODUCTION

Welcome to the Department of Allergy, Immunology and Respiratory Medicine at The


Alfred. We hope you enjoy your rotation within our Department and gain a lot of
valuable experience whilst being part of our Team.

This booklet has been structured to assist you with any queries you may have as to
your role and responsibilities whilst in the Department and the functioning of the
Department overall as well as introducing you to some of our protocols.

Please do not hesitate to ask for assistance whenever you require it. We would be very
keen for you to become knowledgeable of and participate in all Service activities.

Your major points of contact will be your registrar and consultant (on ward service). If
you have any problems that cannot be resolved please speak with the Clinical Director,
Prof Trevor Williams, (Senior Admin Support, Edwina England ext. 62405).
3

ALLERGY, IMMUNOLOGY AND RESPIRATORY MEDICINE


SENIOR STAFF

Name Title Unit/Department Address Sal Ext Pager

Robyn Director Allergy, Immunology 5th Floor Prof 62251 Alfred Switch
O'Hehir and Respiratory 9076 2000
Medicine

Trevor Clinical Allergy, Immunology 5th Floor Prof 62405 4916


Williams Director and Respiratory
Medicine

Greg Snell Head Lung Transplant 5th Floor Prof 62867 4919
Service (Medical)

John Head Cystic Fibrosis 5th Floor Prof 62315 Mob: 0407
Wilson Service 335 632

Matt Head General Respiratory 5th Floor Prof 68398 4392


Naughton and Sleep Medicine
Service

Mark Hew Head Allergy, Asthma and 5th Floor A/Prof 63836 Alfred Switch
Clinical 9076 2000
Immunology Service
1st Floor,
Bruce Head Physiology Service Linay Prof 63476 5253
Thompson Pavilion
4

Department of Allergy, Immunology and Respiratory Medicine


Director
Business Manager
Monash Professor Robyn O'Hehir Liz Malinowski

Executive
Clinical Director Assistant/Admin
Prof Trevor Williams co-ordinator
Dearnne Halliwell

Senior Admin Senior Admin


Support Support
AIRmed 1&2 AIRmed 3&4

AIRmed 1 & 2 AIRmed 3 & 4


Administrative support Group Administrative support Group

Service Lead Service Lead Service Lead Service Lead Service Lead Service Lead
BRONCHOSCOPY Clinician Clinician AIR2 PHYSIOLOGY Clinician AIR3 Clinician AIR4
Prof Trevor Williams AIR1 CYSTIC Prof Bruce GENERAL ALLERGY, ASTHMA
LUNG FIBROSIS Thompson RESPIRATORY & & CLINICAL
TRANSPLANT Prof John Wilson SLEEP Prof Matt IMMUNOLOGY
Prof Greg Snell Naughton A/Prof Mark Hew

Staff Specialist Staff Specialist Staff Specialist Staff Specialist Head, Infection & Staff Specialist Fractional Staff
Respiratory Physician Respiratory Physician Respiratory Physician Respiratory Physician Immunity Research Respiratory Physician Specialists
A/Prof Glen Westall Dr Helen Whitford A/Prof Robert Stirling Dr Eli Dabscheck A/Prof Tom Kotsimbos A/Prof Belinda Miller

Staff Specialist Staff Specialist


Respiratory Physician Respiratory Physician
Dr Dominic Keating Dr Miranda Paraskeva
5

Department of Allergy, Immunology and Respiratory Medicine


Administrative Co-ordinator
AIRMed 1 & 2 Dearnne Halliwell
Administrative
Support Group

Senior Administrative Support


Edwina England

Emma Debbie Natalie


Farrant Kafaltis Moore
Merrilyn
Campbell
Valerie
Mahon Delene
Ross

Service Lead Service Lead Clinician Service Lead Clinician Service Lead
AIRmed 1 AIRmed 2 PHYSIOLOGY
BRONCHOSCOPY LUNG TRANSPLANT CYSTIC FIBROSIS SERVICE
Prof Trevor Prof Greg Snell Prof John Wilson Prof
Williams Bruce Thompson

Staff Specialist Staff Specialist Staff Specialist


Respiratory Physician Staff Specialist Felicity Libby Respiratory Physician Respiratory Physician
A/Prof Glen Westall Dr Helen Whitford Finlayson Francis A/Prof Tom Kotsimbos Dr Dominic Keating

Staff Specialist
Respiratory Physician A/Prof Bronwyn Allied Health Nursing
Dr Miranda Parakseva Levvey
l
6

Department of Allergy, Immunology and Respiratory Medicine


Administrative Co-ordinator
AIRMed 3 & 4 Dearrne Halliwell
Administrative
Support Group

Senior Administrative Support


Dina Pitsas

Carolina Maria
Castro Mastorakis
Delene Catherine
Ross Aubrey

Service Lead Clinician Service Lead Clinician


AIR3 AIR 4
GENERAL RESPIRATORY ALLERGY, ASTHMA &
& SLEEP MEDICINE CLINICAL IMMUNOLOGY
Prof Matt Naughton A/Prof Mark Hew

Staff Specialist Staff Specialist Staff Specialist


Respiratory Physician Respiratory Physician Respiratory Physician Fractional Specialist
Dr Eli Dabscheck A/Prof Belinda Miller A/Prof Robert Stirling
7

CONTACTING CONSULTANTS FOR THE DEPARTMENT OF ALLERGY,


IMMUNOLOGY AND RESPIRATORY MEDICINE
The Department of Allergy, Immunology and Respiratory Medicine admits all patients
with a primary respiratory problem. Specific inpatient units are:

AIR1 Lung Transplant Service (Medical)


Head: Prof Greg Snell

AIR2 Cystic Fibrosis Service


Head: Prof John Wilson

AIR3 General Respiratory and Sleep Medicine


Head: Prof Matthew Naughton

AIR4 Allergy, Asthma & Clinical Immunology Service


Head: A/Prof Mark Hew

The registrar on call for the Department should be contacted for all new admissions via
the switchboard.

The registrar should notify the consultant-on-call for each Service for all new admissions
and requests for consultation within 12 hours of notification.

The registrar must contact the consultant immediately if:


1) the admitted patient is seriously ill or unstable, being admitted to ICU or is an
unscheduled transfer from another institution.

2) deterioration in a patients condition occurs such that the patient becomes


seriously ill or unstable,
the patient is referred to ICU,
a code blue call is made,
the patient is to be sent to the operating theatre for surgery.
2a) Following a MET call the consultant on call should be informed in a timely fashion.

3) unexpected patient death.

4) urgent referral of a patient by another hospital Unit.

5) any other circumstance where the registrar seeks advice or clarification as to


treatment plans.

The roster for on-call consultant is kept in the office of the Department and in the hospital
switchboard. The consultant may be contacted at home or mobile telephone.

If the registrar has difficulty contacting the on call consultant, the service head of that unit
should be contacted.

Should the HMO have difficulty contacting the registrar they should contact the
consultant-on-call directly.
8

WEEKEND CONSULTANT-ON-CALL FOR


AIRMED SERVICES 1, 2, 3 & 4

There is one consultant-on-call for AIRMed Services 1, 2, 3 & 4 between 1700hrs on


Friday and 0800 on Monday morning. The weekend consultant will be notified to
Switchboard, Ward 5East and the Registrar on call for the weekend.

The consultant-on-call for AIRMed 1, 2, 3 & 4 will perform at least one weekend ward-
round with the registrar, usually starting between 08:00am and 10:30am on Saturday and
Sunday morning, or at another time by mutual arrangement.

A hand-over of responsibility should take place between each Service consultant and the
weekend consultant, usually on a Friday evening. Each individual Service will have
identified and rostered a consultant (usually the consultant on for the prior week) who
may be contacted by the weekend consultant for assistance, clarification of treatment
plans, or when it is desirable that a second consultant be in attendance. Service
consultant now will clearly identify inpatients that need to be seen by weekend
consultant.

The registrar rostered on for AIRMed for the weekend will liaise with the weekend
consultant if there are any problems. The weekend consultant will contact the consultant
designated by each Service should there be any difficulties requiring their input/expertise.

There will be an AIR1 consultant on call each weekend who will be on call for new
transplants and to review ICU patients.
9

GENERIC OBJECTIVES COMMON TO MEDICAL SPECIALTY


ROTATIONS

1. The further development of your skill in combining a comprehensive medical history


including all relevant risk factors and a thorough physical examination into a list of
differential diagnoses and then formulate a plan of investigation and management
based on this. This includes the institution of a discharge plan.

2. The further development of your role within a team of hospital professionals,


understanding and acknowledging the role each has to play towards patient care and
extending this to the local medical practitioner and the patient home carers as
necessary. This includes communication by a well-written comprehensive discharge
summary and/or oral communication as necessary.

3. The further development of your professional relationship with your patients including
empathy and understanding towards them and their relatives in the setting of an acute
or chronic illness.

4. Building on self directed learning and the access of literature to assist with
understanding of clinical problems and when called upon to present at clinical
meetings.
10

CLINICAL HANDOVER
Clinical Handover is defined as the transfer of professional responsibility and
accountability for some or all aspects of care for a patient, or group of patients to another
person or professional group on a temporary or permanent basis.(Australian Medical
Association, 2006)

The basic foundation of structured clinical communication at Alfred Health is ISBAR


(Identity, Situation, Background, Assessment and Request/Recommendation.)

The Medical Handover Task Tracker is a tool available in clinical areas and on the
intranet to assist in clinical handover communication.
http://intranet.alfredhealth.org.au/assets/contentFiles/295/MedicalHandoverTaskTracker.
pdf

All JMS staff are required to adhere to the relevant Alfred Health Guidelines regarding
Clinical handover, Discharge and Transfer including attendance at handover meetings
and utilising the Alfred Health approved handover, discharge and transfer tools.

The table below contains information on the handover process including location and
time for this specific clinical unit:
11
TIMETABLE/ROSTER
AIR 1 IP AIR 1 OP AIR 2 AIR 3 AIR 4 NIV Residents
Afternoon
Off
HANDOVER
9am Histopath meeting
AIR 1 CONSULT. CONSULT. CONSULT. CONSULT.
Monday CLINIC WR WR WR WR
AM REFER BRONCH 1130 Lab meeting
LIST
1230 Sleep meeting/ M+M (last Monday of month)
AIR 1 FU REFER PFTs AFTERNOON NIV clinic AIR 1
Monday CLINIC outpatients (report FRI) OFF (AIR4 cover) intern
PM
3pm Ultrasound round

Tuesday 815am Radiology Meeting


BRONCH REFER AIR 3 AIR 3 AIR 4
Tuesday LIST CLINIC CLINIC CLINIC
AM
1230 AIRMED Grand Round
Tuesday AIR 1 MDT AIR 1 MDT SLEEP CLINIC AIR 2
PM CONSULT. REFER PFTs HMO
WR (report Mon)

Wednesday 815 Registrar Teaching


Wednesday BRONCH BRONCH Pulm HTN AIR 4 REFER
AM LIST LIST Clinic Drug testing/
(alternating (alternating if clinic
with AIR1 Gen Med with
OP) AIR1 OP)
Weekly if Resp
APT
1pm Lung Cancer MDT
Wednesday AFTERNOON AIR 1 AFTERNOON (AIR 2 cover) PFTs REFER AIR 3
PM OFF CLINIC OFF (report TUES) ILD CLINIC Intern
(HMO cover) FORTNIGHTLY (CPET
supervision
AIR3
HMO)
8am Allergy Meeting
Thursday PFTs CF BRONCH AIR 4 CONSULTANT
AM (report Wed) CLINIC LIST CLINIC WR
REFER

1230 Gen Med Grand Round


Thursday CONSULT. AFTERNOON CF MDT + AFTERNOON REFER AFTERNOON AIR 1
PM WR OFF CONSULT. OFF (NIV cover) OFF HMO
(AIR 1 OP WR (HMO cover) AIR 3
cover) HMO

Heart-Lung Tx MDT
Friday AIR 1 CONSULT. CONSULT. BRONCH
AM CLINIC WR WR LIST
REFER
1130 AIR 3 MDT
1230 Physiology Meeting
Friday CONSULTANT PFTs REFER AIR 4
PM WR (report Thurs) CLINIC
12

Bronch Clinics PFT Referrals Other


lists reports
AIR 1 inpt 1 1 1
AIR 1 outpt 0.5 3 1 Follow up
outpatients
AIR 2 0.5 2 (Gen + CF) 1 1
AIR 3 1 2 (Gen + PH) 1 1
AIR 4 1 3 1 1
NIV 1 2 (NIV, sleep, ILD 1 1 Sleep reporting
fortnightly) CPET reporting
13
AIR 1 STAFF

The Lung Transplant Service (Medical)

Consultants Extension Pager


Prof Greg Snell (Service Head) 62867 4919
Prof Trevor Williams 62405 4916
A/Prof Tom Kotsimbos 62315 4766
Dr Helen Whitford 62867 4725
A/Prof Glen Westall 68241 4166
Dr Miranda Paraskeva 65743

Transplant Clinic Coordinator/Team Leader


Bronwyn Levvey 63829 4063
Rani Martin 63262 5631
Emilie Beattie 65497 4166
Kelina Attard 65497 6481

Senior Physiotherapist
Ben Tarrant 63450 5036
Louise Fuller 63450 4753

Transplant Counsellor/Social Worker


Jane Harris 62161 4843

Transplant Recipient Coordinator


Jamie Hobson 63258

Transplant Research Coordinator


A/Prof Bronwyn Levvey 63829 4063

Ward Staff
Registrar - Lung Transplant/pHT (AIR1) Reg 4266
Lung Transplant/pHT (AIR1) HMO
Lung Transplant (AIR1) HMO3 4334
General Medicine Registrar (AIR1)

Respiratory Care Coordinator


Kirstie Wilson 63677 5081

Secretarial Staff
Edwina England 62405
Debbie Kafaltis 62867
Emma Farrant 63045
Valerie Mahon 65735

Pharmacy
Steve Ivulich 62061 4159
14
AIR 1 Learning Objectives

This rotation offers you the opportunity to achieve the following objectives:

1. An understanding of the indications for lung transplantation and the psychosocial


factors that need to be considered.

2. An understanding of the pre-operative work up and preparation involved in patients


assessed for lung transplantation.

3. An understanding of the transplant procedure and its complications, intra and post
operatively.

4. An understanding of the principles of immunotherapy, counselling of the immune


suppressed patient and follow-up investigations.

5. An understanding of the principles of investigation and management of the febrile


immunosuppressed patient and opportunistic infections.

6. An understanding of the principles of assessment and management of pulmonary


hypertension.
15

AIR 2 STAFF

Cystic Fibrosis Service


Extension Pager
Consultants
Professor John Wilson (Service Head) 62315 mob: 0407 335 632
A/Prof Tom Kotsimbos 62315 mob: 0419 770 115
A/Prof Robert Stirling 62315 mob: 0421 079 290
Dr Dominic Keating 68895 mob: via switch
Dr. Alan Young mob: via switch

Ward Medical Staff


Registrar CF (AIR2) Reg) 4340
CF /Asthma & Allergy (AIR2&4) HMO 4942

CF Nurse Coordinators
Ms Felicity Finlayson/ Ms Elyssa Williams 63443 4647
Ms Vanessa Edwards mob: 0407 079 623

Clinic Coordinator
Libby Francis (Clinic appointments) 66960 4227

Psychologist
Mr Anthony Talbot 63805 4932

Senior Physiotherapist
A/Prof Brenda Button 63450 4601
Ms Lisa Wilson

Social Worker
Ms Mary Fantidis 63026 mob: via switch

Dietician
Dr Audrey Tierney
Ms Bhey Orwin 63063 4778

Occupational Therapist
Ms Anna Loughnan/Ms Alison White 63526 4037

Research Nurse / Telehealth


Ms Denise Clark 68590 6071

Secretarial Staff PA to Prof J Wilson


Mr Merrilyn Campbell 62315

Pharmacist 4661
16

AIR 2 Learning Objectives

This rotation offers you the opportunity to achieve the following objectives:

1. Proficiency in respiratory examination and an ability to interpret physical signs


correctly and within clinical context.

2. An understanding of respiratory function testing, arterial blood gas measurements and


the interpretation of results.

3. An understanding of cystic fibrosis, its inheritance, principles of management of acute


exacerbations (including anti-pseudomonal therapy) as well as follow up and long
term measures to optimise patient health.

4. An understanding of the use of evidence-based guidelines for the management of


cystic fibrosis.

5. An understanding of the psychosocial issues that may result in the setting of a


complex medical illness.

6. An understanding of management of common complications of cystic fibrosis in a


multi-disciplinary team setting.

7. An awareness of the importance of developing good therapeutic relationships to


improve outcomes in chronic illness.

8. An appreciation of the contribution of the specialist nursing and allied health team to
the long term management of cystic fibrosis.

9. To fulfil RACP training requirements, including PREP and other activities as indicated
in guidelines.
17

AIR3 STAFF

General Respiratory and Sleep Medicine Service


Extension Pager
Consultants
Prof Matthew Naughton (Service Head) 63843 0419770107
A/Prof Belinda Miller 63837 4706
Prof Michael Abramson 68398
Dr Eli Dabscheck 62769 4576
A/Prof Rob Stirling 68037 switch
Dr Dom Keating 65498
A/Prof Mark Hew 63836 0432922141

Ward Medical Staff


Registrar: Advanced Resp & Sleep trainee (AIR 3 and CF Reg) 4340
Registrar Advanced Resp & Sleep trainee (NIV and Sleep Reg) 5054
Registrar Advanced General Physician trainee (AIR 3 and CF Reg)
Registrar Basic Physician trainee (AIR3) 5151
Intern (AIR 3) 6244

Respiratory Care Coordinator


Kirstie Wilson 63677 5081

Sleep Laboratory Staff


Teanau Roebuck (Medical Scientist) 68089/63653
Sally Ho (Home Monitoring) 62113/63653 4720

Respiratory nurses/scientists
Catherine Buchan (Non-invasive Ventilation Nurse) 68090 4978
Jo Toghill (Non-invasive Ventilation Nurse) 63594 4978
Kerry Parker (Non-invasive Ventilation Nurse) 68090 4978
Brigitte Borg (Oxygen Therapy) 62821 4140
Matt McGee (Oxygen Therapy) 62821 4140
Caroline Kein (COPD Nurse) 68088 5556

Secretarial Staff
Dina Pitsas 68398
Carolina Castro 63770
Delene Ross 62327

Pharmacy 6167
18

AIR 3 Learning Objectives

General Objectives for the Intern Year

Consolidate and build on the theoretical knowledge you gained as an undergraduate


and learn to apply this knowledge to caring for your patients.
Develop a professional manner and attitude towards your patients, their relatives and
carers.
Work well within a team. Respect and communicate well with all the professionals
who contribute to providing the best possible patient care.
Develop strategies to deal with professional and personal pressures associated with
being a medical practitioner.

Each of the core rotations has its own set of specific learning objectives that will
contribute to your development as a medical practitioner.

At The End of Your Core Medical Term on the AIR 3 Service You Should Be Able
To:
(The objectives refer to patients with common respiratory presenting problems)

1. With guidance from your registrar and consultants, develop a patient principal
diagnosis, together with a list of differentials and formulate a management plan
including all relevant investigations based on:
a comprehensive patient history including:
relevant risk factors,
complications of illness,
past history,
drug allergies and or side effects,
any relevant social issues,
and correct clinical findings on physical examination.

In addition, apply evidence-based medicine principles where applicable to your


management of patients through accessing current relevant literature to assist in
understanding clinical problems and formulating the best possible management plans.

2. Document the clinical history, physical examination and management plan in the
hospital unit record as a detailed, accurate and legible record of the patient's status
on admission. Regularly write suitable progress notes identifying changes in principal
clinical problems, results of investigations, procedures performed and their
interpretation. Ensure that your notes adequately communicate patient management
and progress to other health professionals working with the patient.

3. Interpret results of common investigation appropriately, and in particular the correct


interpretation of arterial blood gases and respiratory function tests.

4. Develop understanding of the common therapeutic agents, their clinical uses and
doses, adverse effects and potential drug interactions, as applied to each of your
19

patients. This would in particular include the knowledge of bronchodilators, antibiotics


and steroids in the management of lung disease.

5. Develop an appropriate professional rapport with patients, their families, carers and
other members of the managing health care team, which will facilitate patient
management. Show due sensitivity to the special needs of an individual patient, such
as might arise in relation to palliative care, emotional distress, psychosocial disorder,
communication difficulties or ethnic beliefs. Develop a sense of responsibility and
professional ethics.

6. Play an active role in the multi-disciplinary health care team. Communicate clearly
and concisely the salient features of the clinical findings with an appropriate problem
list and management plan outline; understand the interactive roles of the various
health professionals in the management of each patient and work with them to
facilitate patient management.

7. Implement a discharge plan including appropriate follow up and addressing strategies


for maintaining optimal health. This includes a concise discharge summary that
communicates to the local medical officer the main admission/discharge diagnosis,
any complications, discharge medication and follow up arrangements.

8. Continue your medical education by asking relevant questions of your registrar and/or
consultant, receiving feedback in a positive way with the aim of continued
professional development, accessing literature, attending intern meetings regularly
and other hospital educational meetings when possible. When called upon, prepare
and professionally present a case presentation and discussion.

9. Understand the indications, methods and results of commonly performed tests to


investigate symptoms of dyspnoea (rest, exercise, sleep) and excessive sleepiness.

10. Understand the various treatment options for patients with ventilatory failure,
tracheostomy, oxygen, non-invasive ventilation (NIV) support.

11. Understand the interaction between drug therapy and control of ventilation.

12. Understand principals of heart disease in patients with lung disease.


20

AIR 4 STAFF

Allergy, Asthma and Clinical Immunology Service


Extension Pager
Consultants
A/Prof Mark Hew Service Head 63836 switch
Dr Ian Glaspole 62934 4914
A/Prof Robert Stirling 68037 switch
Dr Larry Light 62934
Dr Celia Zubrinich 62934
Dr Andrew Gillman 62934
Dr Robert Puy 62934
Dr Ryan Hoy 62934
Dr Paul Cameron 62934
Dr Eli Dabscheck 62769 4576
Dr Julian Bosco 63241
Dr Naghmeh Radhakrishna 62934
Dr Megan Howden 62934

Clinical Fellows

Allergy & Asthma Clinical Nurse Coordinator


Edward Weber 62286 5297

Clinical Research Nurses


Lorraine Baxter 63710
Karen Symons 66963 4589
Anita Hazard 63710 5756
Kirsten Deckert 63710

Medical Staff
Registrar (Allergy and Asthma (AIR4) Reg) 4742
CF, Asthma & Allergy (AIR2&4) HMO 4942

Respiratory Care Coordinator


Kirstie Wilson 63677 5081

Secretarial Staff
Maria Mastorakis 62934
Catherine Aubrey 62253

Pharmacy 6167
21

AIR 4 Learning Objectives

Allergy, Asthma & Clinical Immunology

By completion of a term in this Service, HMOs should be able to demonstrate skills in the
management of asthma and allergic conditions including:

1. To be able to assess a patient with acute and chronic asthma including the
performance and interpretation of:
eliciting a clinical history and signs
objective assessments of severity including peak flow readings and blood gas
measurements.

2. Identify patients in need of ventilatory assistance and know how to seek help.

3. In consultation with Registrars and Consultants:


manage asthma according to The Alfred Emergency Asthma Guideline
manage anaphylaxis according to The Alfred Anaphylaxis Guideline
manage patients admitted to the ward with asthma according to the Ward
Management of Asthma Guideline
formulate a discharge management plan for patients with asthma and
anaphylaxis from the Ward or Emergency Department including a written
Action Plan and EpiPen when indicated.

4. Participate in the ambulatory Asthma & Allergy Clinics and have some experience
of assessment and management of patients with:
allergic rhinitis
stinging insect allergy
urticaria
drug allergies

5. Be able to perform skin prick tests and have some understanding of their
indications and interpretation.

6. Know where to access reliable information on Asthma and Allergies and where
information suitable for patients might be found.

7. Participate in the management of patients with primary immunodeficiency


disorders.

8. Basic management of immunodeficiency


IgG administration
Complications: Bronchiectasis
Antibiotic
Causes
22

Advanced Physician Trainees in AIR4 will be either Respiratory advanced trainees or


Allergy and Clinical Immunology advanced trainees. They will participate as above but
will gain further experience and competence in the areas of:

1. Assessment and management of Asthma and Allergic diseases


2. The use of lung function testing in the assessment and management of asthma
3. Conduct and prescription of immunotherapy for respiratory and insect venom
allergies.
4. Assessment and management of adult immunodeficiency syndromes
5. Conduct of ultra-rush insect venom desensitisation
6. Conduct of food and drug challenge testing
7. Long-term management of anaphylaxis, including Action Plan and prescription of
an EpiPen.
8. Management of Angioedema, including hereditary angioedema
9. The conduct and use of Audit for ongoing quality improvement and maintenance
of clinical standards.
10. The development and conduct of a research project to be submitted to a national
or international meeting and written up for publication.
23

AIR3 & 4 Ward Cover

AIR3 and 4 inpatients are covered by a single consultant according to a


roster. For specialised Allergy or Sleep services or consultations, an on-call
consultant is identified on the roster who will be able to provide advice or care
for patients with highly specialised problems relating to these conditions.

Allergy and Asthma Consultant Clinics

These clinics are conducted on Tuesday and Thursday mornings, and


Wednesday and Friday afternoons. They are staffed by whole-time and
visiting consultants as well as specialist nurses in Asthma and Allergies.

The clinics offer;


Skin Prick Testing
Spirometry
Allergen Challenge testing
Case discussions at the conclusion of every clinic

Allergy, Asthma and Clinical Immunology Meeting

This is held at 8.00am on Thursday mornings in the 5 East Seminar room.

Allergy, Asthma and Clinical Immunology Specialist Nurse

The AIR 4 Service has a Specialist Nurse (Mr Eddie Weber) who is able to
assist with asthma education and the care of patients with primary
immunodeficiency diseases. The nurses can be contacted on Ext 62886 or
page 5297.

1 week in 4 spiro reporting.

Referrals to Allergy and Asthma Clinics

All referrals should be faxed to Ext 62245 and an appointment will be sent to
the patient. Dedicated referral forms are available (see below).
24

Drug Administration Protocols

There are many requests for Drug Allergy desensitisation to AIR4. All such
referrals should be seen by the Allergy and Asthma Registrar or referred to
Allergy and Asthma Clinics before proceeding. Protocols for the conduct of
Drug Allergy Desensitisation and administration of other specialised
medications such as Omalizumab and C1Esterase Inhibitor can be found on
the Hospital Intranet under Drugnet/Allergy, Asthma and Clinical Immunology.
25

PHYSIOLOGY SERVICE STAFF

Extension Pager
Service Head
A/Prof Bruce Thompson 63476

Clinical Consultant
Dr Eli Dabscheck 62769 4576

Lung Function Laboratory Reception 63476

Deputy Head/ Senior Respiratory Scientist


Brigitte Borg 63476

Domiciliary Oxygen Coordinator


Matthew McGee 63476 4140

Respiratory Scientists
Corrie Ingram 63476
Matthew McGee 63476
Pam Liakakos 63476
Mahesh Dharmakumara 63476
Souvanny Khov 63476
Matthew Ellis 63476
Joanne Avraam 63476

Research Staff
Kris Nilsen 63476

Secretarial Staff
Natalie Moore 63476
26

Physiology Service Learning Objectives

Registrars in advanced training will be attached to Physiology Service


throughout their appointment.

Advanced trainees will:

1) Interpret and report simple and complex respiratory function tests


conducted in clinical settings as per a reporting roster.

2) Assist in oxygen assessment clinics and be familiar with prescribing


guidelines and availability of long-term oxygen therapy.

3) Observe and interpret the results of high altitude simulation testing to


prescribe oxygen for patients undertaking air travel.

4) Participate in Respiratory Physiology meetings at 12.15pm on Fridays.

During specific attachments to Physiology Service, advanced trainees will:

1) Assist in the conduct, interpretation and reporting of exercise testing


2) Work with a respiratory scientist to perform complex tests of lung function
such as gas transfer measurements, lung volume measurements and tests
of respiratory muscle strength and to report on the results.
3) Work with a respiratory scientist to conduct and interpret and report
bronchial challenge tests
27

AIR 1: LUNG TRANSPLANT SERVICE

Greg Snell
Trevor Williams
Helen Whitford
Glen Westall
Miranda Paraskeva
28

LUNG TRANSPLANT STAFF DIRECTORY ....................................................... 29

TIMETABLES .........................................................................................332

INTRODUCTION ....................................................................................354

DONOR SELECTION CRITERIA ...................................................................365

RECIPIENT SELECTION CRITERIA ...............................................................376

DONOR RECIPIENT MATCHING ........................................................ 38


ICU MANAGEMENT . .......................................................................... 39
LUNG TRANSPLANT ASSESSMENT .............................................................432

INVESTIGATIONS...................................................................................465

ADMISSION FOR TRANSPLANT .................................................................476

ROUTINE INVESTIGATIONS WHILST IN HOSPITAL . ............................. 49


IMMUNOSUPPRESSION ..........................................................................510

MAINTENANCE IMMUNOSUPPRESSION .....................................................521

DEFINITIONS ........................................................................................532

REJECTION AND PRIMARY GRAFT DYSFUNCTION .........................................554

TREATING REJECTION.............................................................................565

INFECTION PROPHYLAXIS . ................................................................. 58


POST-TRANSPLANT INFECTION ................................................................632

AUTHORITY SCRIPTS FOR ANTIFUNGALS ....................................................654

BRONCHOSCOPY BOOKING FORM ............................................................668

STREAMLINE AUTHORITIES . .............................................................. 68


VACCINATION PRE and POST TRANSPLANTATION ......................................... 69

INPATIENT TEAM ..................................................................................732

IMPORTANT THINGS TO INCLUDE IN DISCHARGE SUMMARIES .......................743

OUTPATIENT REGISTRAR ......................................................................... 75


LUNG TRANSPLANT BLOOD TESTS & BRONCHOSCOPY TESTS AT BRONCHOSCOPY
VISITS .. 78
3 MONTH POST LUNG TRANSPLANT INVESTRIGATION CHECKLIST..79
29

12 MONTH POST LUNG TRANSPLANT INVESTIGATION CHECKLIST.. 80


ANNUAL POST LUNG TRANSPLANT INVESTIGATION CHECKLIST 81

LUNG TRANSPLANT STAFF DIRECTORY


PHYSICIANS:

Greg Snell Mobile via Switch

Trevor Williams Mobile via Switch

Helen Whitford Mobile via Switch

Glen Westall Mobile via Switch

Miranda Paraskeva Mobile via Switch

TRANSPLANT NURSING STAFF:

Bronwyn Levvey x 63829 P 4063

Rani Martin x 68896 P: 5631

Emilie Beattie x 65497 P: 4166

Kelina Attard x 65497 P: 6481

Lucia Massi x 68094 P: 6009

Transplant Nurse Mobile 0417 046 210

PULMONARY HYPERTENSION NURSING STAFF:

Christianne Manterfield x 62743 P:4642

Trudi Miller x 62743 P:5320

TRANSPLANT CO-ORDINATORS:

Jamie Hobson x 63258 0418760332

Aimee Henrickson x 62862 P: 4918

Laurie Keown P: 9154 0416082017


30

CARDIOTHORACIC SURGEONS:

David McGiffin Head Cardiothoracic Service

Silvana Marasco

Julian Gooi

Adam Zimmet

Justin Negri

Adrian Pick

CTHR Reg Oncall Phone 0409754186

Cardiothoracic Fax F:62317

AIR 1 REGISTRARS AND RESIDENTS:

AIR 1 Inpatient Registrar 4266

AIR 1 Outpatient Registrar 4334

AIR 1 HMO 6492

AIR 1 Intern 5203

ALLIED HEALTH:

Jane Harris Social Work X 62161 P: 4843

Steve Ivulich Pharmacy P: 4159

Ben Tarrant Inpatient Physio P: 5036

Lou Fuller Outpatient Physio P: 4753

Jackie Anderson Dietician P:

Kate Cummins OT P: 4477

ADMIN STAFF:

Edwina England x 62405

Emma Farrant x 63045

Debbie Kafaltis x 62867


31

Valerie Mahon x 65735


32

WARD 5E/ CLINIC 5B/ LUNG FUNCTION/ BRONCH SUITE:

Kirstie Resp Co-ordinator x 63677 P: 5081

M: 0428396174

5E Resource Nurse x 65291

5E x 63751

Jette Balthazar x 63846

Bronch Suite x 63846

Bronch Alfred Centre Theatre 1 x 60321

LUNG FUNCTION F:63434 x 63476

5B RECEPTION x 63600 / 68095

5B Fax F:63601/ 68087

5B Reception Mobile x 68794

OTHER USEFUL NUMBERS


RADIOLOGY/ PATHOLOGY:

Angio and Fluro x 62963

MRI x 60357

Nuclear Medical x 62432

Radiology F:60399 x 60357/60242

VAS LAB x 62444

Pathology x 63888

ADMISSIONS/ BED ASSIGNMENT:

Alfred @ HOME x 66985

Bed Assignment x 60235

MADU x 62771/44171

Outpatients 2nd Floor x 62025

Private Con Suite (GF) x 63795


33

MEETING TIMETABLES

Monday Tuesday Wednesday Thursday Friday


9:00 8:15 8:15 8:00 7:30
Histopathology Radiology Teaching Allergy Meeting Heart/ Lung
meeting meeting Transplant
Meeting

12:30 12:30 13:15 12:30 12:30


Sleep Meeting Respiratory Lung cancer General Medical Physiology
(M&M first Grand Round MDT Grand Round Meeting
Monday of AMREP AMREP
month)
14:00 14:00
AIR 1 Meeting Consultant ward
round

** Ward rounds will occur at times set by individual consultants and will change from week
to week.
**Friday PM ward round will occur every week.

BRONCHOSCOPY AND CLINIC TIMETABLE

Monday Tuesday Wednesday Thursday Friday


Bronchoscopy: Bronchoscopy: Bronchoscopy: Bronchoscopy: Bronchoscopy:
H.Whitford/ G.Snell G.Westall/ T.Williams AIR 3
M.Hew M.Paraskeva
9:15 9:00
Outpatient clinic Outpatient
5B Clinic
5B
13:30 13:30 14:00
Outpatient clinic Outpatient clinic Pre transplant
5B 5B Clinic
34

EARLY POST TRANSPLANT PATIENT TIMETABLE

Monday Tuesday Wednesday Thursday Friday


Gym Gym Gym
Clinic Education Clinic

MONDAY 9 AM HISTOPATHOLGY MEETING:


Inpatient Registrar to fax list to histopathology by Thursday PM before the
meeting.
List all patients with transbronchial biopsies and BX numbers (if available).

TUESDAY 8.15 AM RADIOLOGY MEETING:


Radiology Conference Room, 1st floor Radiology
List needs to be emailed to Dr Sam Ellis by 2PM Monday, S.Ellis@alfred.org.au
Send list of only patients with new radiology that needs to be reviewed.
Patients to be presented by team members present at meeting (registrar or
HMO)

TUESDAY 2PM AIR 1 MEETING:


5E Seminar room
Clinical meeting where all inpatients and problematic outpatients are discussed
Intern/ HMO to print two copies of patient lists
Inpatient registrar to present patients to team
35

INTRODUCTION

Lung transplantation (and heart/lung transplantation) offers a treatment option in


patients with end stage pulmonary and pulmonary vascular disease.

We have performed more than 1000 lung and heart/lung transplants over our years
of operation. Initially the most common operation was a heart/lung transplant but
with improving skills and technology, bilateral lung transplants are now more often
performed.

Although results have improved over the years, infections (opportunistic and
pulmonary) and rejection (especially Bronchiolitis Obliterans) remain serious
complications requiring constant post operative surveillance.
36

DONOR SELECTION CRITERIA


Donation after Brain Death Donor:
1. Brain death certified
2. Consent for organ donation from next of kin (and/or appropriate authority)
3. Age < 65 years
4. No history of chronic respiratory or malignant disease.
5. Not in high risk category for HIV or Hep C.
6. A history of asthma, aspiration, tracheostomy or smoking is not necessarily a
contraindication.
7. Chest x-ray (performed within the last 6 hours) showing minor or unilateral
changes only
8. Pa02 > 300 mmHg on Fi02 or 100% & 5 cm PEEP for > 15 mins.
9. Likely additional requirements:
Repeat CXR and ABG's as clinically appropriate
Bronchoscopy with washings and gram stain
For heart/lung transplantation there should be no history of cardiac disease
and the ECG should be normal

Donation after Cardiac Death Donor


a. As per above 2. b)- g)
b. No previous thoracic surgery
c. Ability of thoracic retrieval team to be onsite within hour
37

RECIPIENT SELECTION CRITERIA


For all Potential Recipients-
a. End stage pulmonary parenchymal or vascular disease with
anticipated survival of 12-24 months
poor quality of life

b. Age is a guide only; "biological age" is more important than chronological age.

c. Clinical status
No other major systemic illness
Diabetes is acceptable
Epilepsy not easily controlled during a Tacrolimus trial is not acceptable
Optimal nutritional state (BMI between 18-28 kg/m2)
Not intubated, on mechanical ventilation, or bed bound
6 minute walk test of > 150 meters
No active significant infection: (HIV, Hep C, Hep B, Pan-resistant bacteria
or fungi)
Minimum corticosteroid dose compatible with clinical stability.

d. Psychosocial
Adequate social support
No major psychiatric illness
Non-smoker > 6 months
38

Determining the type of transplant required:


a. Single lung transplantation
Pulmonary fibrosis (idiopathic and other)
Emphysema/chronic airflow obstruction

b. Double lung transplantation


Bronchiectasis/suppurative lung disease
Bilateral bullous emphysema (with very large cysts)
Idiopathic pulmonary hypertension and pulmonary hypertension
secondary to a correctable cardiac defect.

c. Heart/lung transplantation
Severe lung disease with marked left heart dysfunction
Secondary pulmonary hypertension with an un-correctable cardiac lesion
Complex congenital heart disease
39

DONOR RECIPIENT MATCHING


a. ABO blood group

b. Size
Lung Transplants sizing is based on:
1. Thoracic dimensions:
Compare donor & potential recipients thoracic dimensions as
measured on CXR.
Aim for transthoracic diameter and vertical height of right and left
lungs to be within 5 cms.

2. Total lung capacity


Based on comparison of donor predicted and recipients measured
and predicted TLC (a=age, h=height in cm).
Aim to match the recipient with a donor whos predicted TLC lies
between the recipients measured and actual TLC.
Aim to oversize single lung transplants a further 20% than would
be optimal for a double lung transplant.
o adult male TLC = (75.6h-18.5a-4690)/1000
o adult female TLC = (73.1h-16.3a-6280)/1000
o child male TLC = exp [(0.43xh2) + (0.014xaxh) + 0.11]
o child female TLC = exp [O.OO75xaxh3) + (1.18int (h)) +O.5]

Heart/Lung Transplants
Heart size will relate to donor weight: aim for donor weight > 85%
recipient weight.
Lung size matching as above.

CMV status: ideally match negative donor into positive recipient and positive donor
into the positive recipient.
40

ICU MANAGEMENT
Ventilation :
Extubate as soon as practical, although a re-implantation response may not
start for 24-48 hours post-transplant.
5cm PEEP is routinely used.
SLTx patients with emphysema may require differential lung ventilation via a
double lumen tube because of gas trapping in the native lung.
a. Gas trapping can be severe enough to compress the heart and
produce a clinical problem of cardiac tamponade.
b. The native lung may be ventilated with as little as 2 breaths per
minute.
Patients transplanted for pulmonary hypertension are likely to return to ICU
on VAECMO.

Inotropes/fluid balance:
Aim for dry lungs with a low CVP i.e. 7-9.
Support the circulation with inotropes rather than IV fluid.

Sedatives/analgesics:
Epidural catheters are routinely used for the "clam shell" incision of the
BSLTx.
Non-steroidal anti-inflammatory drugs eg: Aspirin, Indomethacin, Ketoralac
are contraindicated because of potential for severe nephrotoxicity.

Insulin:
if BSLs > 14 mmol/l (early consultation with the diabetes unit is encouraged.

Cystic Fibrosis:
Pancreatic enzymes should be started as soon as practically possible.

Aperients should be given early to avoid bowel obstructions


41

Lung Transplant Guideline


Haemodynamic Management in first 72 hours
Check Target MAP (usually 65 - 75 mmHg) RE-ASSESS AT LEAST
Check Target Cardiac Index (usually 2.2 2.5 l/min/m2) EVERY HOUR
Repeat BASIC CHECKS and check ventilator settings IF TARGETS
NOT ACHIEVED SEEK
SENIOR HELP
CVP 7 mmHg CVP > 7 mmHg

MAP Target If cardiac index > Target


MAP Target
If cardiac index > Target Wean adrenaline / noradrenaline
Wean adrenaline / noradrenaline Consider reduction of iv fluid rate
(If PaO2/FiO2<200 and pulse<100 (If PaO2/FiO2<300 & pulse<100)
consider Frusemide 20mg) consider Frusemide 20mg )

If cardiac index < Target If cardiac index < Target


Start Nitroprusside 10/min Consider Inodilator or Nitroprusside
Consider fluid challenge Rewarm patient if temp < 36OC
with 4% NSA (or blood if required)
Rewarm patient if temp < 36OC
MAP < Target
MAP < Target If cardiac index > Target
If cardiac index > Target Start Noradrenaline 2/min
Start Noradrenaline 2/min & titrate to target MAP
& titrate to target MAP
Consider fluid challenge if CVP 4 If cardiac index < Target
with 4% NSA (or blood if required) CONTACT SENIOR HELP
Start Adrenaline 5/min
If cardiac index < Target & increase by 2/min until target MAP
Rewarm patient if temp < 36OC Consider fluid challenge
Check drainage in ICCs Assess dynamic hyperinflation
Fluid challenge with & consider RR, Vt, Inspiratory time
4% NSA (or blood if required) Repeat CXR and consider TOE

For queries about this guideline please contact Judy Currey (0438 424831) or David Pilcher (0422 239366)
42

Lung Transplant Guideline


Respiratory Management (while intubated)
Management within guideline may be initiated by nurse or ICU registrar
Management outside of guideline to be initiated by ICU consultant

Record Observations
Perform BASIC CHECKS Calculate
PaO2/FiO2 ratio at
Calculate PaO2/FiO2 ratio 0,3,6,12,24,48,72 hr
Check target MAP & cardiac index & more if required
P.T.0. for haemodynamic management

FiO2 PaO2 PaO2/FiO2 ratio > 300


Wean sedation & reduce SIMV rate
0.3 30 45 60 100
Switch to Pressure support aiming tidal volume 8 ml/kg
0.4 40 60 80 120 Wean FiO2 to 30%
Wean PEEP to 5 cmH20
0.5 50 75 100 150 Wean Nitric Oxide by 5 ppm every hour
Consider extubation
0.6 60 80 120 180
0.7 70 105 140 210 PaO2/FiO2 ratio 200 300
0.8 80 120 160 240 Wean sedation & reduce SIMV rate
Switch to Pressure support aiming tidal volume 8 ml/kg
Wean FiO2 to 40%
PaO2/ Consider weaning PEEP and NO
FiO2 100 150 200 300 Consider extubation

BASIC CHECKS PaO2/FiO2 ratio 150 - 200


ET tube Repeat BASIC CHECKS
Reduce tidal volume to 6ml/kg
Check position of ET tube at teeth and
Maintain in SIMV
on chest X-ray Wean FiO2 to 60%
Increase PEEP by 2.5 cmH2O (up to max 10 cmH2O)

Suction catheter
Can you pass catheter down ET tube? PaO2/FiO2 ratio < 150
Check amount of sputum / blood CONTACT SENIOR HELP
Repeat BASIC CHECKS
Reduce tidal volume to 6ml/kg
ICCs Maintain in SIMV

Are ICCs swinging or bubbling? Consider - Nitric Oxide at 5ppm


- Increase PEEP by 5 cm H20
Is drainage <100 ml/hr ? (Recommend 15 cmH2O for double lung tx)
(Recommend 10 cmH2O for single lung tx)

Chest X-ray - Increase respiratory rate by 4 breaths


(Recommend 30 for double lung tx)
Check for pneumothorax, mediastinal (Recommend 16 for single lung tx)
shift and infiltrate.
Check for position of lines & tubes. Management to continue as per guideline until 72 hours post op
For queries about this guideline please contact Judy Currey (0438 424831)
or David Pilcher (0422 239366)
43

LUNG TRANSPLANT ASSESSMENT


Patients are assessed for lung transplantation via a three-day inpatient admission,
most commonly in the Alfred Centre.
This occurs from Wednesday through to Friday.

It is the primary responsibility of the AIR 1 HMO to:


Complete all admission paperwork
Take a comprehensive history and examination.
Facilitate the admission
Collate the results utilising available documentation and letters.
Identify any contraindications/ issues and
Prepare a a PowerPoint presentation using the existing template for the Friday
am meeting.

Patients will usually be presented one to two weeks following their assessment.
44

History:
1. History of presenting complaint
a. Date of diagnosis
b. Significant hospital admissions
c. Use of oxygen or NIV

2. Past significant medical history including:


a. Surgical history: in particular thoracic surgery
b. Pneumothoraces/ ICCs etc
c. Cardiovascular risk factors
d. History of malignancy inc. skin, prostate, breast, cervical

3. Document history of sensitizing events


a. Number of pregnancies
b. History of blood transfusion

4. Social history:
a. Who the patient lives with and who will be their carer
b. Dependents
c. Financial information: disability support pension, employed etc
d. What services are in place: home help etc

5. Cigarettes, ETOH and other occupational exposures:


a. Smoking: history, when the patient quit
b. ETOH
c. Other illicit drugs
d. Occupational exposures

6. Family history
a. Any significant medical history, particularly in those with inherited
disorders
b. Cardiovascular and malignancy
45

7. Preventative
a. Vaccine History
Fluvax, Pneumovax, Hepatitis B and dates
Hx of chicken pox or varicella vaccine
Gardisil in those < 28yo

b. In Females:
Pap smear in last 12 months
Mammogram if > 40yo

Examination:
Document brief examination of patient.

Arterial blood gas:


Must be completed on ROOM AIR on all patients
46

INVESTIGATIONS
These will be ordered by the co-ordinators.
The only responsibility of the HMO is to complete an ABG on ROOM AIR.

ABO blood group Fasting lipids


FBE + film Fasting glucose
UEC OGTT or HbA1C
LFTs TFTs
CMP B12 and Fe studies
Coags Vitamin D
SPEP Vitamin A and E (in CF patients)
IgA, IgM, IgG Quantiferon Gold
Serology: Urine:
Hep B, Hep C, HIV mcs

CMV IgG, EBV IgG 24 hour creatinine clearance

HSV IgG, Toxoplasma IgG

ABG on ROOM AIR Sputum mcs, fungal, AFB culture


Pulmonary Function tests: Radiology:
Spirometry (FEV1, FVC + CXR

bronchodilator) CT Chest

Static Lung Volumes (TLC, FRC, Quantitative V/Q scan

RV) DEXA

Diffusing capacity (DLCO)

Cardiology: Vascular:
ECG Carotid Dopplers (>50yo)

TTE Vascular studies

Coronary Angiogram if > 50yo

This will occur only if


patient is listed for lung
transplantation and will be
booked at first review
clinic following
presentation
47

ADMISSION FOR TRANSPLANT


RMO Responsibilities: In-hours AIR1 RMO; out-of-hours CTHR RMO

N.B. Pack containing most of what is required available on 5 East.

Patient Nil Orally

Record brief history and examination

Observations

Weight & Height

Urinalysis

CXR PA and LAT (on arrival in ED) if not done in previous 6 weeks.

ECG if not done in previous 6 months

Blood specimens:

Blood Tubes Required: (70ml blood)

Purple Top Tubes (10ml) x 2

Blue Top Tubes (3ml) x 1

Pink Top Tubes (3ml) x 1

Gold Top Tubes (10ml) x 2

Other Tubes that may be required:

If a repeat T & B Cell Cross Match is required - 2 Gold Top Tubes (20ml)

Tests to Request: (Bloods should be sent to pathology marked as urgent.)

FBE
48

Coagulation profile (INR marked urgent)

Cross match

o Packed Cells 3 units

o If on Warfarin: PRBC 3 units, FFP 300mls & Prothrombinex per weight

UEC and LFTs

Sputum if patient has a productive cough

CMV IgG & EBV IgG. Toxoplasmosis IgG

Hep B & C, HIV 1&2 and Baseline Save.

Chlamydia pneumonia

CMV Viral Load


49

MEDICATIONS (to be ordered by the admitting resident)

Pre-op immunosuppression:

Discuss immunosuppression plan with transplant co-ordinator or consultant on call

Tacrolimus 5mg if patient >50kg or 3mg if <50kg orally

o discuss with consultant if patient on voriconazole or bosentan

Azathioprine 3 mg/kg orally or Mycophenolate 500mg bd (as per consultant)

Antibiotics:

To cover organisms in donor and recipient, as per consultant instructions

Reversal of Anticoagulation:

If patient on Warfarin

o 3mg IV Vit K.

o Prothrombinex 40 units/kg rounded to nearest 500 units to be given


in theatre.

o Ensure anaesthetist is aware patient is on Warfarin.

**Contact "Transplant-Coordinator on Call" through the switch with any queries.


50

ROUTINE INVESTIGATIONS WHILST IN HOSPITAL:


Tacrolimus levels Daily in ICU
Then 3 x week once stability achieved

CXR Daily until ICCs removed then


weekly

Bronchoscopy and biopsy Day 14

All pts admitted with infection Sputum mcs, AFB, fungal culture

Resp virus PCR (if indicated)


51

IMMUNOSUPPRESSION
PRE-OPERATIVE:
Tacrolimus orally 5mg > 50kg or 3mg <50kg
Azathioprine 3mg/kg orally or Mycophenolate 500mg bd
Intra-operatively: Methylprednisolone 500mg IV on reperfusion of each lung

POST-OPERATIVELY:
+/- Basiliximab (at discretion of consultant on-call)
this will be given as a calcineurin sparing agent in those at risk of renal
impairment
20mg iv (or 10mg for children <35kg) at day 0 and day 4

1. Tacrolimus:
Intravenous tacrolimus as per protocol
Aim for level 10-12g/L
Change to oral (dose conversion 1:10) capsules or syrup when patient
stable and gut working.

2. Azathioprine or Mycophenolate:
Azathioprine 1mg/kg IV or oral per day
Dose adjust dependent on TPMT activity
Activity <5u/ml = then halve dose and watch WCC as patient may not
metabolise drug appropriately.
Mycophenolate commence 500mg bd aim to uptitrate to 1g bd if tolerated

3. Prednisolone/ Methylprednisolone:
75mg IV every 8 hours on return from theatre for 3 doses.
1mg/kg in 2 divided doses daily, weaning by 5mg every day until 20mg/day
20mg per day until discharge.
52

MAINTENANCE IMMUNOSUPPRESSION
Most patients will receive an immunosuppressive regimen of tacrolimus, azathioprine,
and prednisolone.
Once daily tacrolimus (Prograf XL) may be considered in patients receiving antifungal
azoles and requiring very low doses of tacrolimus, or in potentially non-adherent
patients in whom once daily dosing is preferred.

Month 0-3 3-6 6-12 >12

Tacrolimus trough level 10-12 8-10 4-8

Azathioprine 1.5mg/kg/day

Prednisolone (mg/kg/day) 0.25 0.2 0.15 0.10

CyA trough 250-300 200-250 100-200

CyA (C2) level 1200-1400 1000- 400-800


1200

MMF 0.5-1.5g po bd

Everlolimus level 4-8

Sirolimus level 4-8

If patient NBM or poor GI absorption consider change to iv immunosuppression:


CONVERSION:

DRUG ORAL TO INTRAVENOUS

TACROLIMUS 10: 1 1mg oral tacro = 0.1mg iv tacro

AZATHIOPRINE 1:1

MYCOPHENOLATE 1:1

PREDNISOLONE 1:1 (use methylpred iv)


53

DEFINITIONS
Acute rejection:
Definite = histological evidence of rejection (> grade 2) on TBBx.
Probable = a steroid responsive clinical syndrome in the absence of an alternative
diagnosis (including infection). Suggestive features include dyspnoea, fatigue,
fever, perihilar CXR changes, > 10% fall in FEV1 or an isolated BAL lymphocytosis >
25%.

Acute rejection grading system: (Stewart et al, J Heart & Llung Transplant 2008; 15:1-15)

0 Normal

1 Minimal acute

2 Mild acute

3 Moderate acute rejection

4 Severe acute rejection

Chronic rejection = obliterative bronchiolitis:


Definite = histological evidence of obliterative bronchiolitis on open lung biopsy or
the presence of histological features of obliterative bronchiolitis on transbronchial
biopsies in the setting of a compatible clinical picture (see below).
Probable = the presence of a syndrome of increasing exercise imitation and
dyspnoea marked by a progressive fall in FEV1 ( 20% from previous best
performance post-transplant). It is slowly progressive and steroid unresponsive
and occurs only in the absence of an alternative diagnosis.

Clinical staging of chronic dysfunction in lung transplants:


Bronchiolitis Obliterans Syndrome (BOS):

Grade Severity FEV1

0 No abnormality FEV1 > 80% of maximal achieved post Tx

1 Mild FEV1 65-80% of maximal achieved post Tx


54

2 Moderate FEV150-65% of maximal achieved post Tx

3 Severe FEV1 < 50% of maximal achieved post Tx

CMV pneumonitis:
Definite = if histopathology or culture show the presence of CMV in pneumonic
lung tissue obtained from open lung biopsy, TBBx, autopsy in an appropriate
clinical setting.

Probable = if an appropriate clinical picture (possible including dyspnoea, fever


lymphopaenia) and CXR infiltrates is associated with any of the following (and the
absence of any other obvious pathology).

Diagnosis:

o Positive characteristics CMV inclusions in BAL cells


o CMV PCR blood >1000 copies /ml
o CMV PCR BAL >10,500 copies/ml

CMV reactivation/infection:
Evidence of CMV replication regardless of symptoms
o CMV BAL >600 or CMV Blood >600

Airway Complications:
Dehiscence
Stricture
Malacia
Fibrosis
Granulation
55

REJECTION AND PRIMARY GRAFT DYSFUNCTION


Hyperacute Rejection:
Very rare.
Represents specific recipient preformed anti-donor antibodies.

Reperfusion Injury/ Primary Graft Dysfunction:


Pulmonary oedema picture.
Present early post-transplant; usually resolves over 2 to 3 days.

Acute Rejection:

Clinical Features: Dyspnoea and worsening exercise tolerance.

Low grade fever; malaise.

CXR: Pulmonary infiltrate; perihilar flare.

ABG Widened A-a gradient (Normal <15)

A= 150 PaO2 1.25PaCO2 (FiO2 21%)

PFTs Worsening airflow obstruction

Fall in DLCO

Bronchoscopy BAL - relative lymphocytosis with no other explanation

TBBx Mononuclear infiltrate of small vessels

Corticosteroid 24-48 hours post IV steroid pulse producing a significant


Response: clinical and objective improvement.

V/Q scan: SLTx only relative increase in perfusion to the non-


transplanted side.

HLTx Recipients: Usually presents as lung rejection

Cardiac rejection is rarely alone, but may present as


dyspnoea, peripheral oedema, increased CVP, enlarged
heart and decreased LVEF on GBPC or TTE
56

TREATING REJECTION
PULSE METHYLPREDNISOLONE:
Methylprednisolone: 10mg/kg/day IV X 3 days. (Maximum dose 1g/d)
Dose is at the discretion of the consultant
Can occur as an in- or out- patient depending on patient characteristics and risk factors
Can be administered via a peripheral line.
Consider CMV prophylaxis in high risk patients

ANTITHYMOCYTE GLOBULIN (ATG)


Indications:
Recurrent Acute Rejection or prevention of Acute Rejection when other
immunosuppression medications cannot be used.
Treatment of BOS

Mechanism of Action:
It inhibits the cell-mediated response by:
Altering the T cell function.
Decreasing antigen reactive T cells.

Administration of ATG:
Requires a PICC line as is sclerosing to veins.
CD2/3 level to be measured prior and then daily.
5 day course.
Aim to admit Monday Friday.
Patients to be admitted to 5E ONLY
CMV prophylaxis in all patients

Special Considerations:
Patient should not knowingly be placed in a ward situation with infective patients.
Be aware of increased risk of infection and monitor for signs and symptoms.
Ensure monitoring and resuscitation equipment is easily accessible.
57

Side effects:
Fever and chills. Hypotension
Leucopoenia, thrombocytopenia. Renal impairment.
Anaphylaxis. Rash, pain at injection site
Tachycardia Lymphadenopathy
Increased risk of infection
58

HORSE ATG
500 mg initial dose IV in equal volume normal saline over 6 hours
Daily CD2 + CD3 levels
Subsequent dosing based on CD2 + CD3 level (aiming for <100)
Pre-med 60 minutes before
Prior to FIRST DOSE:
Methyl pred 100mg IV
Phenergan 12.5mg IV
Paracetamol 1g orally
For SUBSEQUENT DOSES:
Methyl pred 25mg IV
Phenergan 12.5mg IV
Paracetamol 1g orally

RABBIT ATG
Contraindicated in patients with known hypersensitivity to rabbit protein.
Initial dose IV in equal volume normal saline over 6 hours
Daily CD2 + CD3 levels
Subsequent dosing based on CD2 + CD3 level (aiming for <100)
Pre-med 60 minutes before
Prior to FIRST DOSE:
Methyl pred 100mg IV
Phenergan 12.5mg IV
Paracetamol 1g orally
For SUBSEQUENT DOSES:
Methyl pred 25mg IV
Phenergan 12.5mg IV
Paracetamol 1g orally
59

INFECTION PROPHYLAXIS

CYTOMEGALOVIRUS (CMV)
Serostatus:
Serostatus of a lung transplant recipient is based on the serostatus of the donor and
recipient.
CMV mismatch (CMV R-/ D+): Is defined as a seronegative recipient who receives
seropositive organs.

CMV PROPHYLAXIS:
All patients receive iv Ganciclovir 5mg/kg 12 hourly for 14 days

CMV R+/ D+; CMV R+/ D- CMV R-/ D+ or EBV R-/D+


Day 0 14 Day 0 14
Ganciclovir 5mg/kg iv bd Ganciclovir 5mg/kg iv bd

> Day 14 PLUS


Valganciclovir 450mg bd
CMV hyperimmune 1.5 million units
Day 1, 2, 3, 7, 14, 21 and 28

> Day 14
Valganciclovir 450mg bd

NB: If patient is discharged prior to completion of CMV hyperimmune course arrange for
infusion to be given in Alfred Centre Day Unit.

Following 14 days of ganciclovir patients will be converted to valganciclovir 450mg


bd orally for at least 5 months
Only exceptions are those patients
CMV R-/ D- EBV R +/ D+: 3 months of prophylaxis
CMV R-/D- EBV R-/D- : no prophylaxis
EBV R-/ D+: lifelong prophylaxis
60

CMV DIAGNOSTICS AND MONITORING:


Surveillance bronchoscopy with transbronchial biopsy (CMV inclusion bodies) and BAL
(quantitative PCR) at 6, 9, 12 and 18 months post-transplant
Plasma CMV PCR at 6, 7, 8, 9, 10, 11, 12, 15 and 18 months post-transplant.
Or if clinically indicated.
Hypogammaglobulinemia (IgG <5g/dl) is a risk factor for late CMV disease (and other
infections).
A measure of total IgG should be performed at 3 and 12 months post lung transplant
in all patients.
Patients with documented hypogammaglobulinemia should be referred for
consideration of IVIg (Intragam) replacement therapy.
61

TREATING CMV INFECTION


AST Definitions
CMV active infection:
Evidence of viral replication (detection of CMV by PCR in blood or BAL, evidence of CMV
on histopathological specimens) regardless of symptoms.

CMV disease:
CMV disease is defined by evidence of CMV infection with attributable symptoms. CMV
disease can be subclassified into CMV viral syndrome or tissue invasive disease.

TREATMENT STRATEGIES:
CMV Viral Syndrome or Tissue Invasive Disease:
Diagnosis:
BAL or blood CMV PCR > 5,000 copies/ml
Tissue invasion: CMV inclusion bodies in transbronchial biopsy, colon biopsy, etc
Clinical suspicion: CMV DNAemia with either abnormal LFTs, diarrhoea or unexplained
bone marrow suppression
CMV syndrome: fever, malaise, leucopoenia, and thrombocytopenia
Treatment:
At least 2 weeks IV ganciclovir
Followed by 3 months secondary prophylaxis with valganciclovir (450mg bd)

Subclinical CMV:
Diagnosis:
Asymptomatic patient with CMV PCR 600-5,000 in either plasma or BAL.
Treatment:
Valganciclovir 900mg bd for 2 weeks.
62

EPSTEIN BARR VIRUS (EBV)


Primary EBV mismatch (R-/ D+) at high risk for Post-Transplant Lymphoproliferative
Disorder (PTLD).

Prophylaxis:
Ganciclovir 5mg/kg iv BD for 14 day
Followed by life long valganciclovir 450mg bd
CMV hyper-immune globulin iv on day 1, 2, 3, 7, 14, 21 and 28.

NB. if CMV R- / D- but EBV mismatch valganciclovir 1g tds can be used.

PNEUMOCYSTIS CARINII (PCP):


Commence prophylaxis at day 14
Bactrim DS tab orally on Monday/ Wednesday/ Friday.

If sulphonamide sensitive:
Pentamidine inhalations 300 mg monthly
Trimethoprim 150 mg daily orally
Dapsone 100mg daily (if G6PD negative)
63

POST-TRANSPLANT INFECTION

BACTERIAL INFECTIONS:
The aim is to cover known and likely donor & recipient organisms.
In CF recipients use IV antibiotics last effective.
if no known infection or risk group use Tazocin 4.5g tds
To continue until ICCs removed.

FUNGAL INFECTIONS:
Clinical syndromes:
Colonization:
Positive BAL culture or GM in the absence of symptoms or any change on CT scan of
the chest.

Tracheobronchitis:
Positive BAL culture in the presence of abnormal respiratory secretions and airways
AND absence of any change on CT scan of the chest.

Bronchial anastomotic infection:


Positive BAL culture with abnormal bronchial anastomotic site with relatively normal
looking airways AND absence of any change on CT scan of the chest.

Pulmonary Invasive Aspergillosis:


Positive BAL culture in the presence of symptoms or new radiological findings on CT
scan of chest.

Disseminated Invasive Aspergillosis:


Positive blood culture in the presence of symptoms or new radiological findings in two
non-contiguous parts of the body.
64

Risk factors for invasive Aspergillosis include


Pre or Post Transplant Aspergillus colonization
Only 30% of IA cases are in these patients
20-25% of lung transplant patients will be colonized with Aspergillus
Growth within 6 months before transplant confers increased risk
Augmentation of immunosuppression with ATG
Single lung transplant
Bronchial stents
Anastomotic dehiscence
Acquired hypogammaglobulinemia

Treatment of Aspergillus:
Aspergillus culture post operatively warrants treatment
Voriconazole 200 mg bd.
Decrease CNIs (tacrolimus/ cyclosporine) by 1/3 to when initiating the
voriconazole.
Monitoring:
Drug level checked one week following commencement.
Monitor LFTs and voriconazole levels weekly in first 4 weeks.
Treatment Duration:
Treatment duration at least 12 weeks
Alternative treatment strategies:
In patients intolerant to voriconazole or with history of photosensitivity or skin
malignancy use posaconazole.
Target levels:
VORICONAZOLE 1 - 5.5 mg/L
POSACONAZOLE >0.7 mg/L
65

AUTHORITY SCRIPTS FOR ANTIFUNGALS


66

BRONCHOSCOPY:
Timing of routine bronchoscopies:
Week 2, 6, 12
Months 6, 9, 12, 18 and 24
or as clinically indicated.

Technique:
IV sedation: Midazolam +/- Propofol
Intranasal oxygen, monitored with oximetry
Visual assessment of airway anastomoses
BAL from RML (or lingula on left)
approximately 40 ml return
Cytology: looking for viral cytophathic effect or, evidence of fungal hyphae
mcs, fungal culture, AFB
CMV VL PCR (months 6, 9, 12, 18 or as clinically indicated)
TBBx from RLL
aiming for a minimum of 5 reasonable tissue pieces.
All sent for histology
Request C4D staining if antibody mediated rejection is suspected
67

ORDERING BRONCHOSCOPIES
A booking form must be filled out for each patient (see next page)

Considerations:
Need for anaesthetist:
There is one anaesthetic list per week at the Alfred Centre (alternating
Tuesdays and Thursdays)
If an anaesthetist is required outside those times make a request to the OT
floor anaesthetist.

Need for isolation:


Active viral infection, MBL organism etc
Be aware that all patients are recovered together.
If there is evidence of or suspicion of a viral infection please alert bronchoscopy
staff and discuss need for isolation of patient or extra cleaning.
68

BRONCHOSCOPY BOOKING FORM


PATIENT DETAILS Name:
(Bradma)
UR Number:

DATE: PROCEDURE DATE:


HOME UNIT
PATIENT LOCATION
Ward (specify).. Outpatient
DISCHARGE
DESTINATION Ward Home
BOOKED BY (Name)
Consultant Registrar ..

INDICATION:

INFECTION CONTROL STATUS: Nil Isolated (Specify VRE, TB etc).

Urgency: <48h <7d <14d other(specify)

Time post Transplant: OR N/A


Procedure:
Bronchoscopy Argon plasma coagulation
Washings (site ) Suture Removal
Brushings (site ) Balloon dilatation
Endobronchial biopsy (site...) Linear EBUS
BAL Radial EBUS
TBBx
SPECIAL TESTS REQUIRED (eg Nocardia, C4d staining etc):

Procedure Checklist
YES NO REASON/EXTRA INFO
ANAESTHETIST REQUIRED
IMAGING AVAILABLE PACS
CD
ANTICOAGULANTS WITHELD
CONSENTED
FEMALE PREGNANT (specify)
PAEDIATRIC CASE
NB: For lung biopsy/TBBx, withhold anti-platelets 7d prior and warfarin 5d prior. Aim INR <1.5.
Copy to be faxed/emailed/given to Edwina or Dina in office.
69

STREAMLINE AUTHORITIES
Drug Reason Authority Quantity Repeats
number
Valganciclovir Prophylaxis of cytomegalovirus 3421 120 5
450 mg tablet, infection and disease in solid
60 organ transplant patients at risk
of cytomegalovirus disease

Tacrolimus Management of rejection in 3328 200 5


1mg, 0.5mg patients following organ or tissue
transplantation, under the
supervision and direction of a
transplant unit. Management
includes initiation, stabilization
and review of therapy as required

Tacrolimus 3328 100 5


5mg
Tacrolimus XL 3328 120 5
1mg
Tacrolimus XL 3328 60 5
5mg, 0.5mg
TOBI nebs Management of a proven 3842 56 2

Pseudomonas aeruginosa
infection in a patient with cystic
fibrosis

DRUGS THAT MUST BE DISPENSED AT THE ALFRED


Mycophenolate Sandoz Tacrolimus

Cellcept Tacrolimus XL

Biomag Ursodeoxycholic acid

Azithromycin
70

VACCINATION PRE and POST TRANSPLANTATION:


Pre Transplant Post-Transplant

Respiratory Vaccines

Influenza vaccine Yearly single dose Two doses (6-8 weeks apart),
yearly

To start 6 months post-tx

Pneumococcal Single dose if not previously given Consider conjugate


vaccine pneumococcal vaccine
followed by polysac vaccine
6-8 weeks later if not
previously given

Haemophillus NOT INDICATED


Influenza B

General Immunizations

Hepatitis B If non-immune, vaccinate using


accelerate schedule D0, 30, 60

Check Ab level post 3 doses +/- further


dose

Varicella If non-immune, 2 doses of vaccine 6 8


weeks apart
LIVE ATTENUATED VACCINE
Children: 1 dose NOT TO BE GIVEN POST-
TRANSPLANT
Not to be transplanted in 4 weeks
following vaccination

MMR Only if history and serology negative LIVE ATTENUATED VACCINE


NOT TO BE GIVEN POST-
Not to be transplanted in 4 weeks
71

following vaccination TRANSPLANT

POLIO Best pre-tx:

BOOSTRIX IPV

DTP Best pre-tx:

BOOSTRIX - IPV
72

Optional Immunisations pre-tx

HPV All women < 26yo; Consider for all


females

Rotavirus Not recommended LIVE ATTENUATED VACCINE


NOT TO BE GIVEN POST-
TRANSPLANT

Meningococcal C Not routinely given in adults

VACCINES NOT TO BE GIVEN POST TRANSPLANT

Varicella

MMR

Rotavirus

Oral Polio
73

INPATIENT TEAM
INPATIENT REGISTRAR:
Attendance of one bronchoscopy list (Tuesday)
Attendance of all clinical meetings
Attendance of one clinic per week (Monday PM)
Daily ward round with HMO and Intern
Ward rounds to start in ICU or ED
Review all sick and new patients as early as possible.
All patients to be seen daily
Responsible for reviewing and admitting new patients

AIR 1 HMO AND INTERN:


Attendance of all clinical meetings
Division of workload to be negotiated amongst HMO and Intern, depending on skills
and time management.
Completion of all paperwork including discharge summaries in a timely fashion.
If patient needs RFTs at next clinic ensure that they are booked.

CLINICS
All outpatient clinics are in 5B
It is important to be aware that most of our patients will not be regularly attending a
GP
As such all of their follow up is undertaken in the 5B clinic and as such please
investigate all other medical issues and set up plans.

There are hundreds of outpatients, with very complicated medical histories, but the
Transplant Nurses and Consultants know them all. If you have questions about anything,
ask them.
74

IMPORTANT THINGS TO INCLUDE IN DISCHARGE SUMMARIES

Admission and Discharge Date

Discharge diagnosis:

Past Medical History:


1. Bilateral or Single Lung Transplant (date)
CMV and EBV status
CMV reactivation ever
Colonisation:
Any major complications
a. Anastamotic problems
b. ECMO
c. Clots: PE/ arterial/ venous

2. Other comorbidities
Most important IHD, Diabetes (insulin/ no insulin), Anticoagulation (why/ how
long), CVA

Presenting Problem:
One two line description
Eg. LRTI, decreased FEV1, treatment of chronic rejection, CMV reactivation
And any complication: renal failure

Treatment and Progress Summary:


Main treatments in point form with details
1. Antibiotics: when they started what they were
2. IV ganciclovir: when it started
3. Change to orals when and what duration
4. Etc
75

Investigation results:
Delete the power chart generated ones
Dot point of anything important: New bug, DVT, abnormal imaging that is
important to admission, new renal failure

Discharge Medications: Accurate list

Discharge Plan:
This is for clinic the GP doesnt care and wont be doing any of it.
Antibiotics for how long?
When the next bloods are due?
When the next RFTs due?
What the plan was?
76

OUTPATIENT REGISTRAR
Clinics:
Attend post-lung transplant clinics Monday and Friday mornings and Wednesday
afternoon
And at other times if needed
Post-clinic meetings held after each clinic where all patients are discussed

Outpatient responsibilities:
Assist Lung Transplant Nurses
Nurses often receive > 20 phone calls a day from outpatients for medical advice or
other queries, and often need a doctors input
Timing of clinic r/v or ED/direct admission if unwell, or organizing acute
management at other health facilities
Arranging and following-up appropriate investigations
Liaison with other specialty teams for a quick opinion or to expedite outpatient
review
Arranging Outpatient procedures
Elective admissions.
MDU treatments, procedures, line insertions, plasma exchange etc

Follow up of outpatient investigations:


Chase outpatient investigation results and act on them
Bloods often taken by nurses at clinic for drug levels etc, and results not available
when seen in clinic
May need to discuss with doctor who saw the patient if clinic notes not available
Lung Transplant Nurses automatically chase outside blood results for your review.
Ask them nicely to chase any other specific tests.
77

Other Responsibilities:
Weekly bronchoscopy list (transplant patients)
Cover Inpatient Registrar during their bronch list and afternoon off
Assist inpatient team when time available
Helpful to familiarize yourself with the patients and their medical issues on the
ward before they transition to clinic

As per timetable:
Histopath meeting Monday 9 am
AIR1 meeting Tuesday 2 pm
Research meeting Thursday 9 am
Lung function reporting (you report Mondays tests)

There are hundreds of outpatients, with very complicated medical histories, but the
Transplant Coordinators and Consultants know them all. If you have questions about
anything, ask them.
78

Documentation:
Document clearly on Powerchart by direct entry
Outpatient clinic notes are found as below
Clinical Documents > Cardiothoracic OP >> OP and Short Stay Heart/ Lung Tx

Things that must be documented:


Dose changes
Acknowledgement of abnormal results
Changes to management plan
Any conversation with a patient leading to a change in management
79
80
81
82
83

PROTOCOL FOR ADMISSION OF PATIENTS WITH ACUTE EXACERBATIONS OF


CYSTIC FIBROSIS

Cystic fibrosis (CF) is the most common life-threatening, genetic disease amongst
Caucasians with 1 in 25 people of European decent carrying a single gene. The
incidence of CF is 1 per 2500 live births1. Despite being a multi-system disease,
the major cause of morbidity and mortality is due to progressive, chronic lung
sepsis. The current median survival is 38 years and is increasing with
improvements in therapy. For this reason, a disproportionate number of adults
have severe lung impairment and are also more likely than their paediatric peers to
have multi-organ involvement2. Of the 300 adults with CF who access health care
through the Cystic Fibrosis Service at The Alfred, approximately 40-50% of patients
require admission to hospital at some time during any year3.

The aims of treatment are to improve physiological, functional and emotional health
within the shortest possible length of stay and to achieve a sustainable clinical
improvement. Given that an acute exacerbation of cystic fibrosis is frequently
associated with a decline of up to 20% from stable baseline FEV1 and response to
treatment is highly variable between individuals, current practice is to continue
treatment until there is demonstrated clinical improvement. CF Service guidelines4
recommend minimum 10-14 days of intravenous antibiotic therapy, directed at
appropriate organisms, together with a program of CF specific medical, nursing
and allied health interventions5.

Where possible, admission will be planned in advance to obviate the need for
acute, emergency intervention.

All reasonable measures should be undertaken to admit adults with CF who are
judged by the CF Team to require specialist nursing for either physiological or
educational/emotional support, to Ward 5 East where advanced practice CF
nursing care is available and specific infection control measures6 can be
implemented. For patients who require intravenous antibiotic treatment with
minimal nursing and allied health intervention or support, other sites may be
appropriate eg. MDU/Medihotel, Alfred @ Home.

Severity of illness remains the most important determinant of both timing of


initiation, and site, of care delivery.

Admission criteria
Any of the following should prompt consideration of an inpatient course of
treatment:

1. A fall in FEV1 of greater than 10% from the patients best values in the
preceding 6 to 12 months.
2. Constitutional symptoms including fatigue, lethargy, loss of appetite, general
malaise.
3. Weight loss (fall in BMI of > 1kg/m2 over the previous 6 months).
84

4. Increase in sputum volume or consistency or change in colour (usually darker).


5. Increased cough or need to perform ACT (airway clearance therapy).
6. Sleep disturbance associated with cough or fever.
7. Increased dyspnoea on exertion with reduced exercise tolerance or prolonged
recovery time.
8. New infiltrates on chest x-ray.
9. Haemoptysis over 50ml in one episode or 200ml over 24hr.

All patients who have severe lung disease (FEV1 < 40% predicted) will be
advised to present to the Emergency Department if no bed becomes
available within 24 hrs of request.

Acute exacerbations of cystic fibrosis are frequently associated with haemoptysis,


lethargy, loss of appetite, features of respiratory distress (tachypnoea, tachycardia,
use of accessory muscles) as well as the physical signs of new or increased
crackles on chest examination, cyanosis or cor pulmonale.

Intravenous antibiotic therapy


The chosen regimen for intravenous antibiotic therapy in acute exacerbations of
cystic fibrosis is based on previously cultured organisms from sputum and their
specific sensitivity patterns. In over 90% of adult patients with cystic fibrosis,
Pseudomonas aeruginosa is likely to be found on sputum culture.

Mucoid strains of Pseudomonas aeruginosa are likely to be the most pathogenic


species and therapy should be directed towards these organisms. Other organisms
include MRSA requiring Vancomycin or Burkholderia cepacia requiring Ceftazidine.
Fungi such as Aspergillus fumigatus may also be found, and requires treatment
where allergic bronchopulmonary aspergillosis is suspected.

Two antibiotic agents are used for intravenous anti-pseudomonal therapy:

a. Tobramycin 8mg/kg per day as a single dose. The dose determined during a
recent admission is an appropriate starting point, to be modified with
Tobramycin levels twice weekly. Ideal levels should be 30 minutes post dose
less than 15mcg/ml and pre dose levels should be less than 2mcg/ml.

b. A second anti-pseudomonal antibiotic should be one of:

Timentin 3.1g 8 hourly


Ceftazidime 2.0g 8 hourly
Meropenem 500mg 8 hourly
Aztreonam 2.0g 8 hourly
Ciprofloxacin 200mg 12 hourly (if no other alternative)

Nebulised antibiotic therapy is not recommended for inpatient care where


intravenous therapy is available. All other antibiotic therapy (other than anti-fungal
treatment) should be ceased on admission.
85

Appropriate cover for atypical organisms may be added where clinically indicated.
The need to treat MRSA with Vancomycin should be discussed with the
Consultant-on-call.

During 2015, admitted patients will be eligible for recruitment to the CISTIC Study
(Continuous Infusion Strategy To Improve Clinical outcomes.) and should be
offered the opportunity to speak with Dr Katherine Langan, ID Physician and
Principal Investigator via the CF Coordinators with in 24 hrs of admission.

Nebulised bronchodilator therapy


Nebulised bronchodilators are used to dilate airways and improve clearance of
airway secretions. The usual dose is salbutamol 2.5-5.0mg with or without
ipratropium bromide 500mcg 6 hourly. For convenience these medications may be
mixed to minimise nebuliser time.

Alfa Dornase (Pulmozyme)


This is reserved for those patients who have previously qualified as outpatients
under the S100 scheme and who have bought their own supplies. The usual dose
is 2.5mg nebulised each morning following bronchodilator therapy and
physiotherapy.

Physiotherapy Treatment Program


The treatment program aims to improve musculoskeletal fitness during the course
of an admission. Inpatient physiotherapy is part of a co-ordinated program involving
other allied health specialists, with nursing and medical input to optimise gains
achieved during treatment. The program consists of twice daily sessions of chest
physiotherapy together with an exercise program in either the Department of
Physiotherapy or 5 East gymnasium.

Nutritional Assessment
Patients with acute exacerbations of cystic fibrosis frequently experience sudden
rapid weight loss.

Early nutritional assessment is vital to reverse this process. The aim of treatment is
to maintain a BMI (weight in Kg/height in m2) above 20. Frequently, the BMI falls
below 18 but with oral nutritional supplementation can be restored during
admission. Where the BMI does not rise above 18, consideration is often given to
the insertion of a percutaneous enterogastrostomy feeding tube (PEG).

Occupational therapy, social work and psychological supports


There are often psychological and work related issues surrounding an acute
admission to hospital. Specialists in occupational therapy and the social problems
of young adults are available to deal with specific issues on an individual basis.
Problems should be clearly documented and presented at the time of admission
and during weekly team meetings. Where appropriate, consultation with a liaison
psychiatrist may be sought. It may be appropriate to plan a family meeting involving
medical and nursing staff together with allied health personnel and the Cystic
Fibrosis co-ordinator.
86

Investigations
All patients should have the following:

Pulmonary function testing on or within 2 weeks prior to admission and


approaching discharge.
FBE on admission
Full biochemistry profile including renal and liver function tests, HbA1C, CRP
Chest x-ray on admission
Sputum microscopy and culture on admission and at Day 5-7 (specifically
requesting culture for B. cepacia)
Sputum AFB on admission
Tobramycin levels performed twice weekly
Overnight oximetry if FEV1 is 40 % of predicted normal or below
Other investigations may be performed after discussion with the consultant on
for ward duty.

Hospital-in-the-Home
Many patients are suitable for transfer to care under the Alfred @ Home program.
In general, they should be:
over the acute phase of their illness,
be physically and psychologically capable of administering their own antibiotics
and caring for their intravenous line
be geographically within the Melbourne metropolitan area (for RDNS visits)
compliant with the training requirements of Ward nursing staff and HITH.

An early referral to the HITH liaison nurse should be made as soon as suitable
patients are identified.

Discharge planning
After a period of intravenous antibiotic therapy (generally 10-14 days) patients may
be considered ready for discharge if an appropriate clinical response has been
achieved (10% improvement in lung function, resolution of fever and weight gain
above BMI of 18). Where appropriate resolution has not been shown, a further
course of therapy should be considered after changing the non-aminoglycoside
antibiotic.

Discharge planning issues should be considered early during the admission and
include:

HITH requirements
Psychosocial needs
Lung function testing
87

Nutritional assessment and ongoing management


Oxygen requirements and assessment if necessary
Other surgical needs including revision of intravenous access, the placement of
PEG feeding tubes and assessment for sinus surgery.

These issues should be discussed with the CF Nurse Coordinators in context of the
patients long term management. Pg: 4647 or Mob: 0407 079 623 (BH).

All admitted patients with cystic fibrosis (except post transplant) should be admitted
under AIR2 bedcard or joint bedcard and, where possible, to Ward 5 East. In
exceptional circumstances, patients deemed suitable on discussion with the team
(CF Nurse Coordinators or Consultant on ward service), may be admitted to
Fairfield House or Ward 2F.
88

INSERTION OF PICC LINES IN ADULTS WITH CYSTIC FIBROSIS


ATTENDING THE ALFRED

Record of Discussion between Dr Wa Cheung Radiologist, Prof John Wilson


Head CF Service, and Felicity Finlayson CF Coordinator.

ISSUE: Apparent increase in incidence of venous thrombosis associated with PICC


lines in CF patients as a result of 2 audits. [Rate of venous thrombosis in CF
patients ~5.6%, c.f. 3% of all patients who had a PICC inserted over a 10 month
period.]

Thrombosis is likely to be caused by trauma to the vessel wall. In people with cystic
fibrosis the factors which may contribute to increased risk of thrombosis include:

Patient - Coagulopathy
- Vascular occlusion (pre-existing)

Operator - Experience.

Technique - 4.0 (c.f 3.0) Fr lumen size of catheter


- Polyurethane (c.f. silicon)
- Powdered sterile gloves
- Lint from huck towels at threading
- Uneven sheath shoulder on dilator (some
operators use Jelco instead)
- Tip of catheter not in SVC
- Multiple attempts to pass line

Measures being undertaken to reduce future risk:


Patient - Prophylactic Clexane in those who have had
previous thrombosis
- Pre-insertion U/S of upper limb veins in those
who have had previous clots
- Test and correct for coagulopathies in those at
risk
- Consider portacath insertion if PICC problems
persist

Operator - Registrar (Resp 2) to become proficient in


PICC insertion
- Long lines to be inserted on 5th floor where
possible then to Radiology for X-Ray to check tip
position is in SVC
- PICC insertion under fluoroscopy by
experienced operator for patients requiring
access through deep veins
89

Technique - Use of 3.0 Fr lines as first choice


- Silicon catheters as soon as available

- Unpowdered gloves or rinsing of powdered


gloves with sterile water prior to procedure
- Use of new introducer kit when available from US
- Ensure tip is in SVC

Quality Assurance
- Prospective audit of outcomes
- Data collection tool not yet finalised

Group to reconvene when 20 PICC lines have been inserted using these
guidelines.
90

NON-INVASIVE VENTILATORY (NIV) SUPPORT FOR


ACUTE HYPERCAPNIC VENTILATORY FAILURE

NIV in Acute Inpatient Wards and ED - Decision Points

1. The patients need for NIV should be fully assessed by clinical review
together with arterial blood gas analysis.
2. Goals of treatment should be established before commencing NIV.

ED initiated NIV
Once commenced on NIV, the patient needs to be reviewed at 1 and 4
hours. If ongoing management with NIV is indicated, a referral to the NIV
service is needed. ED can make this referral, if referral by the parent unit is
likely to lead to unacceptable delay in ward transfer.

Ward initiated NIV


If a patient has had a MET call, then the patient will be reviewed by ICU.
When consultation and NIV equipment is requested by ICU, the patient will
be followed up by NIV service/AIRMed Registrar. Note that the NIV service
is NOT an emergency service; if NIV is needed urgently, ICU must liaise
with NIV service.
A direct referral to the NIV service can be made.
No equipment is released for use in the ward setting unless a referral is
made and authorisation is granted from NIV service/AIRMed Registrar, or
ICU Registrar in a MET CALL ONLY.
A patient who is on long term domiciliary NIV, and is using their own
equipment in hospital, and is admitted to a ward, must be referred to NIV
service. Such patients should use their own equipment when possible in ED
and on the ward.

Transfer of patients to Wards


A patient on NIV, transferred from ED or ICU to a ward, will be placed in a
ward most appropriate to their clinical needs. This will depend on the
patients overall clinical status and nursing needs, not purely on NIV needs.

Transfer of patients from ICU to wards


A patient being discharged from ICU with NIV should have a planned
discharge, during normal business hours. The patient should be referred to
the NIV service at least 24 hours prior to planned discharge, to allow for
stabilisation on a ward NIV machine while in ICU.
An exception to this guideline may be made when the patient is on NIV, is
otherwise stable and safe for ward discharge, and the ICU bed demand is
unacceptably high. The NIV service must still be notified prior to the patients
discharge.
All patients discharged from ICU with NIV will be followed up by the NIV
service.
91

Staffing Resources in Wards


NIV in itself is not necessarily a criteria for additional staffing resources.
However, each patient needs to be assessed on an individual basis.
The following criteria should be taken into consideration when discussing
the need for additional resources:
o Altered conscious state
o Unstable respiratory status and requirement for frequent assessment
of response to NIV therapy
o Awaiting ICU bed
o Poor compliance with mask or NIV
o Patients with tracheostomy
o Inability to remove mask independently

Patient attendants should not be used to supervise patients on NIV (as


per hospital policy).
A patient on NIV should be cared for by a Registered Nurse with the
appropriate level of knowledge and experience.

Anaesthesia Post-operative patients


When there is an unanticipated complication post operatively and patients
require ongoing NIV post operatively they should be referred to the NIV
service. Again any patient on NIV service equipment will be reviewed.

Decision to cease NIV and progress to palliative management


Decision to cease NIV should be consultant based and be in consultation
with the NIV service.
92

NIV in Acute Inpatient Wards and ED


Decision Points Flowchart

NIV therapy 1 hour 4 hour Referral for


initiated in ED Medical review Medical review AIRMed review,
Ongoing NIV consideration in
ward setting
Ward patient
requires
NIV therapy

Referral to NIV Service AIRMed team

In hours contact: Yes Referral to ICU


AIRMed/ NIV Registrar, An ICU patient?
& transfer to ICU
pager 5054 (0800-1700 Mon- Fri)
Respiratory Therapist, pager 4978
No
Out of hours contact: ICU patient on NIV
After hours the on-call AIRMed Registrar therapy for discharge
to ward
NIV therapy Referral to NIV
commenced on ward service

Assessment of Clinical Needs and Management Plan for Ward Patients with NIV

Patients should be cared for in the ward that best meets their clinical need*

NIV in itself is not a criterion for additional nursing resources

Criteria for consideration of additional nursing resources:


Altered conscious state
Unstable respiratory status and requirement for frequent assessment of response to NIV therapy
Waiting ICU bed
Poor compliance with mask
Patients with tracheostomy

A patient on NIV should be cared for by a Registered Nurse with the appropriate level of knowledge and
experience. Patient Attendants should not be used to supervise patients on NIV therapy.

A NIV management plan needs to be documented in the medical record and this should include when the
response to NIV therapy will be reviewed

*Exceptions to this may include: lack of NIV therapy experienced staff and complex respiratory
needs i.e. weaning from NIV requires expert Respiratory staff

Cessation of NIV therapy


Decision to cease NIV should be consultant to consultant and be in consultation with either ICU or
the NIV service AIRMED team depending on the context.
93

Referral process for NIV

Referrals from ED and ICU:


ED and ICU must refer to the NIV service any patient to be discharged from
their care who requires ongoing NIV or is likely to require NIV in the ward.
ED patients who will require NIV on the ward should refer to the NIV service
within 4 hours of commencing NIV at the medical review.
ICU patients who will require NIV on the ward should be referred at least 24
hours prior to ward transfer to facilitate changing to ward equipment.
All patients commenced on NIV on the ward by ICU team must be referred to NIV
service as soon as practicable post the MET call.

Referrals from medical and surgical wards:


Medical and surgical units considering the use of NIV for any patient outside ED or
ICU need to contact the NIV/AIRMed Registrar.
The NIV Registrar must also be notified via a medical referral of the following:
o Hypercapnic patients not going to ICU
o Patients requiring access to equipment (machines & masks) from the NIV
service

ICU Registrar can authorise NIV in a MET CALL ONLY. ICU Liaison nurse can
collect designated NIV machine from the NIV service located on 5East. ICU Registrar
must contact the on call AIRMed Registrar as soon as practicable post the MET call
to refer and to discuss management plan.

Referrals from the Cardiology/Cardiothoracic unit (Ward 3CTC):


The Cardiology/Cardiothoracic unit (Ward 3CTC) has a dedicated NIV machine for
use in 3CTC only. 3CTC nursing staff should not initiate the equipment use without
prior referral from NIV/AIRMed Registrar, Cardiology or Cardiothoracic Registrar.
3CTC nursing staff can set up their own equipment or call 5East for assistance if
required, and complete NIV request form and fax to Respiratory Therapist on fax
62535. The Cardiology or Cardiothoracic Surgery Registrar must contact the
NIV/AIRMed Registrar as soon as practicable to refer and to discuss the management
plan.

Liaison with ED, ICU and medical and surgical wards:


The NIV service refers to ICU any patient receiving NIV in the wards who is
deteriorating and may require admission to ICU.
For patients who are appropriate for ICU admission the ICU Registrar is to be
notified of the following:
o Potential ICU admissions of patients requiring NIV
o Failure to improve or deteriorating clinical status after commencement of
NIV
o Requirement for very high FIO2 i.e. greater than approximately 40-50% O2
or equivalent needed to maintain target oxygen saturation whilst on NIV
o Out of hours requests for initiation of NIV to assist the on call AIRMed
Registrar in clinical management

Where both AIRMed NIV service and ICU teams are involved in the patients care on the
ward, mutual agreement should be reached at initiation of NIV as to which team is
94

primarily in charge of the patients respiratory management. It is suggested as a guide


that if the patient is awaiting transfer to ICU, that the ICU team be primarily in charge,
and if the patient is to remain on the ward, AIRMed NIV Service be primarily in charge.

Arranging NIV during business hours:


Monday Friday, 0800-1700

AIRMed NIV Registrar pager 5054


Respiratory Therapist pager 4978
On medical referral the patient will be reviewed by the AIRMed NIV Registrar and the
Respiratory Therapist for the appropriateness of NIV.
We encourage nursing staff to contact the Respiratory Therapist or AIRMed NIV
Registrar should there be any concerns regarding NIV use.
Equipment will be issued and set up by the Registrar or Respiratory Therapist or 5E
Resource Nurse.
The NIV service will provide staff and patient education.
The patient will be reviewed daily or more frequently by the NIV Registrar and/or the
Respiratory Therapist.
A consultant round will be conducted twice weekly during the weekdays, once or daily
on weekends and more frequently as required, with documentation made in the
patients medical notes.
The Respiratory Therapist is available for ongoing education and clinical support of
medical, nursing and allied health staff.

Arranging NIV after hours:


Note: This is not an emergency referral service.
AIRMed on-call Registrar page via switch If an urgent response is required initiate a MET call.
5E Resource Nurse ext 63651 When NIV is started in association with a MET call, ICU Registrar
can authorise, and the designated met call only NIV machine can
be collected from NIV service located on 5East by ICU liaison
Parent unit refers with ABG result to AIRMed nurse. ICU Registrar must inform AIRMed NIV Registrar of NIV
Registrar on call. set up at met call.

Ward patient requires NIV Therapy AIRMed Registrar oncall provides 5 East Resource
Nurse with patient details, Indications for NIV
including ABGs, pressure settings mask type
AIRMed Registrar on call contacts 5 East and regime documents plan of management;
Resource Nurse requesting NIV initiation. pressure settings, type of mask aim for SpO2
and regime and monitoring required for NIV

NOTE: 5 East Resource Nurse will not release NIV equipment without authorisation from
AIRMed Registrar or the ICU Registrar during a MET Call only

5 East Resource Nurse complete NIV request form and


5 East Resource Nurse liaise with ward staff leave in box in 5E as a referral to the Respiratory
regarding NIV initiation (setup and monitoring) Therapist,
and education of patient and staff. NIV will be 5East Resource Nurse will document NIV set up details
initiated as soon as practicable (1hour is an including Indication, ABGS, pressure settings, mask fit,
acceptable time frame) SpO2 levels and aims, NIV regime and monitoring
required in the patients medical history.
95

Non-Invasive Ventilation Referral Flow Chart

Patients Initial
ED MET Call Ward ICU
Location Anywhere in hospital

NIV Service
Who Decides if ICU Doctor ( Medical referral
ED Doctor ICU Doctor
Patient Needs NIV? (at the MET call) required from parent
medical team)

Afterhours
NIV service 5 East Nursing
Who Applies NIV? ED Nursing Staff OR ICU LN nurse ICU Nursing
(i.e. provision & application provide NIV machine
NIV Service
of machine, and immediate Staff AIRMed NIV Reg MUST BE Staff
education of staff) INFORMED BY ICU REG AT
MET CALL

In-hours
Refer to NIV service

Who Assesses ED Doctor NIV Service ICU Doctor


Response to NIV? Requirement for
ICU Doctor
ICU doctor determines
admission to ICU or for
patient destination
NIV on ward should be
ICU doctor hands over
determined within 4
patient to AIRMed NIV
hours of admission to ED
Reg in AM

Planned ICU Ward


ED staff must refer within 4 hours of admission to ED
Destination ICU team to manage patients on NIV after a
After a MET call, ICU team must notify AIRMed NIV Reg as soon as
for Patient MET call.
practicable.
Resuscitation and Intubation Status must be
ICU must refer to NIV Service 24 hours before discharge from ICU
decided prior to ICU admission
Resuscitation and Intubation Status must be decided prior to transfer

Who is responsible for ICU Team NIV Service


ongoing management?

Contact Numbers:
NIV Service:
ICU Senior Registrar Page: 4731 Ext: 62622 NIV Registrar Page: 5054
ICU Liaison Nurse: Page: 5083 Respiratory Therapist Page: 4978
After hours on-call AIRMed Registrar page via switch
After hours 5East Resource Nurse ext 63651
96

Treatment Aims and Limits

All patients must have a discussion and documentation of their resuscitation and
intubation status prior to commencement of NIV. Discussion should be at the
consultant level. This documentation must address how potential failure of NIV will
be dealt with, whether escalation of care is indicated or whether NIV is the ceiling
treatment.

Patients should be classified based on:


Pre-morbid state
Severity of their physiological disturbance
Reversibility of their acute illness
Presence of relative contraindications and exclusion to NIV
Where possible, the patients Advanced Care Plan or known wishes

The classification should be recorded in the medical notes:


Needing immediate intubation and ventilation
Suitable for NIV and suitable for escalation to ICU/ intubation and ventilation if
needed
Suitable for NIV but not suitable for escalation to ICU/ intubation and ventilation
Not suitable for NIV but for full active medical management

Palliative and supportive care agreed as most appropriate management (Note: this may
include NIV for symptom relief)

KEY RELATED DOCUMENTS

Please refer to the NIV education resource for further information.

REFERENCES

Charter of Human Rights and Responsibilities Act 2006 (Vic) 1


97

COMMON ANTIBIOTIC DOSAGES

Oral antibiotics:
Amoxicillin/clavulanate 875/125mg twice daily (Augmentin duo forte)
Cefaclor 375mg BD
Cefuroxime 500mg BD
Ciprofloxacin 500mg BD.
Clarithromycin 250-500mg bd orally
Clindamycin 300-450mg four times daily
Erythromycin 500mg QID
Metronidazole 400mg two times daily
Roxithromycin 300mg daily

Intravenous antibiotics:
Benzylpenicillin 600mg-1.2gm (1-2 mega units) IV 4-6hourly
Cefotaxime 1gm 6-8 hourly.
Ceftazidine 1gm 8 hourly.
Ceftriaxone 1gm daily.
Cephalothin 1gm IV 6 hourly
Ciprofloxacin 400mg 12 hourly
Clindamycin 600mg 8 hourly
Di(flu)cloxacillin 2gm 6 hourly.
Erythromycin (IV) 0.5-1g 6 hourly
#Gentamicin 4-7 mg/kg daily, adjusting for renal function.
Imipenem 500mg 6hourly
Lincomycin 1.2gm 8 hourly
Meropenem 500mg IV 8 hourly
Metronidazole 500mg 12 hourly
Penicillin 600mg-1200mg 4-6 hourly.
Ticarcillin/clavulanate 3.1gm 4-6 hourly
#Vancomycin 1gm in divided doses

Dosing may need to take into acount patients weight


Antibiotic dosage and/or interval may require adjustment in renal impairement- please
check antibiotic guidelines.
# blood level monitoring is required.
NB. These guidelines are not intended to refer to immunocompromised patients.

In the penicillin allergic patient, contact parent unit for antibiotic regimen
98

British Thoracic Society pleural disease guideline. Management of Pleural effusions


2010 Hooper, C, Lee, Y and Maskell, N
99

Management of Malignant pleural effusion. BTS 2010 Roberts, M, Neville, E, Bernisford,


R, Antunes, G and Ali, N
100

Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010. MacDuff, A, Arnold, A Harvey, J
101

COPD MANAGEMENT AT THE ALFRED: July 2012

Indications For Hospital Admission


Clinical:
Severe dyspnoea (e.g. respiratory rate > 28) or marked increase in symptoms
Altered mental state
Underlying severe COPD
Multiple co morbidities, older age
Onset of new signs, such as new R heart failure
Arrhythmias, haemodynamic instability
Not responding to initial medical management
Inadequate home supports/not coping at home
Physiologic:
Respiratory acidosis (pH < 7.35)
Hypoxaemia needing oxygen therapy, or worsened hypoxaemia

Reasons For Acute Decompensation - Look for/Rule out:


Infection (bacterial, viral)
Oxygen toxicity
Bronchospasm
Gastro-oesophageal reflux, aspiration
Arrhythmia, myocardial ischaemia & heart failure
Drug side effects (particularly sedatives, opioids)
Pneumothorax
Pulmonary embolus
Pleural effusion
Lung cancer

Reasons For Chronic Decline


Ongoing cigarette smoking
Poor nutritional state
Depression, anxiety & poor home supports
Obstructive sleep apnoea
Poor treatment adherence/inhaler technique
Untreated co morbidities (e.g. L heart failure)

Clinical Assessment
Speech: sentences or phrases or words
Respiratory Rate,
Conscious state Altered mental state is a sign of severe exacerbation
Other signs of
asterixis
use of accessory muscles
pursed lips breathing
tachycardia
ty
tremor
Pulmonary examination:
Wheeze, hyperinflation, crepitations, effusion, stridor, uni vs. bilateral signs
Clubbing
Upper airway (nasal and oral patency - Mallampati, dental hygiene)
Sputum: volume, colour and ease of clearance
Hypercapnia note if acute, or acute-on-chronic. Note patients with COPD are prone to hypercapnia
with exacerbations even if previously normocapnic
NIV/CPAP note current use, home use, past use with exacerbations
Oxygen therapy current flow rate and O2 saturation
If on home oxygen therapy note usual flow rate, use, intermittent or continuous
Steroid (glucocorticoid) usage (oral vs. inhaled; acute vs. chronic)
Past lung function tests (especially FEV1)
102

Bronchodilator response (FEV1 12% and 200 ml post salbutamol or steroids)


Best recent FEV1
Historical change in FEV1 (eg over past 2 years)
Usual symptoms and activity limitations
Frequency of exacerbations/hospital admissions
Previous ICU admissions/intubations
Co morbidities, medications, any recent changes
Aetiology: Smoking, family, occupational, other history

All patients should have discussion and documentation of their resuscitation and intubation status prior to
admission. Discussion should be at consultant level. Documentation should address how potential
treatment failure will be dealt with and whether escalation of care is indicated.

Initial Investigations
Chest X ray film note hyperinflation, pneumothorax, pneumonia, heart failure
ABG (always record inspired oxygen concentration and try to use 25 g needle)
1. pH low with PaCO2 high: acute (or acute on chronic) respiratory acidosis/hypercapnic respiratory
failure (e.g. COPD with exacerbation)
2. pH low with PaCO2 normal/low: metabolic acidosis (e.g. diabetic ketoacidosis)
3. pH high with PaCO2 high: metabolic alkalosis with respiratory compensation (e.g. high dose
steroids, diuretic therapy, hypokalaemia)
4. pH high with PaCO2 low: respiratory alkalosis (a) normoxic: e.g. hyperventilation, CHF (b) hypoxic:
e.g. pulmonary embolus, ILD)
FBE- note polycythaemia, anaemia, high wcc, eosinophilia
Electrolytes, creatinine note electrolyte disturbances such as hyponatraemia (e.g. with duiretics, (e.g.
hypokalaemia due to steroids, -2 agonists), bicarbonate
Other blood tests as indicated (e.g. troponin, BNP, CK, lactate, glucose, theophylline)
ECG rhythm, rate, ischaemic changes
Sputum M/C/S if sputum purulent
Blood cultures if patient febrile

Other Investigations (To be considered)


CTPA if suspect PE
Sputum AFB x 3, sputum cytology x 3 if clinically indicated
Echocardiogram/gated blood pool scan to assess R and L heart function
High resolution CT scan (1-2 mm slice): to assess lung parenchyma (emphysema, pulmonary fibrosis,
bronchiectasis, bullous lung disease vs. pneumothorax)
Standard CT scan (1 cm slice): to assess for lung masses/ mediastinum etc
Throat swab for virology
Urinalysis for Legionella antigen (Legionella pneumophila serogroup 1) if CXR shows pneumonia
Atypical pneumonia serology if CXR shows pneumonia

Acute Management (Note average inpatient stay 5 days)


1. Non-Invasive Ventilation: see NIV guidelines on Intranet. Consider intubation, HDU/ICU referral if
indicated
2. Oxygen: Use controlled, low flow oxygen (consider low flow regulator). Aim SpO2 88-92% in patients
with COPD. See Oxygen guidelines on Intranet
3. Antibiotics:
Exacerbations with clinical sign of infection (bronchitis): amoxycillin or doxycycline, or Augmentin
Duo if resistant organisms suspected. Review past sputum results (e.g. Pseudomonas, MRSA) and
treat appropriately
IF Pneumonia: consult Antibiotic Guidelines:
Hospital acquired pneumonia: consult Antibiotic Guidelines

4. Bronchodilators
Initial salbutamol (preferably MDI with spacer, 400mcg (4 puffs), nebuliser if needed, 2.5-5mg),
repeat as dictated by clinical response, 1- 6 hourly and prn and ipratropium (MDI with spacer, 42-
84mcg (2-4 puffs), nebuliser if needed 250-500mcg) 6-8 hourly. Be aware of lactic acidosis with to
high dose -2 agonist
5. Systemic steroids
103

Prednisolone oral 30-40mg for 7-10 days (hydrocortisone 100 mg IV 6 hourly if unable to use oral
medications), shorter course may be appropriate in some patients
6. Heart Failure: diurese (consider spironolactone). Add vasodilator. Watch for tachycardia and hypoxia
induced diastolic heart failure
7. DVT/PE prophylaxis unless contraindication present

Ongoing Management
1. Pulmonary rehabilitation programme
2. COPD nurse assessment
Formulate COPD management plan
Review inhaler technique
Assess need for home supports
Consider Advance Care Plan
3. Physiotherapy assessment
4. Nutritional assessment
5. Smoking cessation advice (refer to Fletcher-Peto diagram). Offer nicotine replacement therapy if
current smoker
6. Optimise inhaler regimen - consider tiotropium, indacterol, Seretide, Symbicort etc.
7. Assess for anxiety/depression
8. Assess bronchodilator/ glucocorticoid reversibility status and add inhaled steroids. Wean oral steroids
only if required >3 weeks.
9. Assess bronchodilator delivery system Note MDI with spacer most effective delivery system most of
the time
10. Vaccination status (annual influenza vaccination, consider 23vPPV pneumococcal vaccination, see
Australian Immunisation Handbook for guidelines)
11. Assess ventilation during sleep
12. Assess for bridging home oxygen requirements (MUST be ex-smoker)
15+ hours per day via concentrator
PaO2 55 mmHg on air or PaO2 60 mmHg with pulmonary hypertension
Overnight oxygen if nocturnal hypoxaemia, SPO2 88% for >30% of study
Exertional via portable cylinders: requires exercise test
13. Assess suitability for bullectomy, lung volume reduction surgery, transplantation
14. Consider 1 antitrypsin levels
15. Consider theophylline
16. Assess for osteoporosis
17. Arrange outpatient follow-up, with lung function tests to assess severity of COPD. FEV1 60-80% pred.
(mild), 40-59% (moderate), < 40% (severe).

Other Diagnoses with similar presentations to COPD


1. Bronchiectasis
2. Asthma
3. Lung cancer
4. Congestive heart failure

Further Reading
Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2011. Available from:
http://www.goldcopd.org/
TSANZ/ALF COPDX guidelines. Version 2.30, December 2011. Available from:
http://www.copdx.org.au/
104
105
106

OXYGEN FOR THE PALLIATIVE CARE PATIENT

Guideline Title: Domiciliary Oxygen Therapy in the Palliation of


Oncology Patients

Campus: Alfred Health Control No.:


Category: AIRmed Related Policy No.:
Responsibility for Review: Rev.: 003
Date Approved: June 2013 Review Date: June 2017

GUIDELINES
These guidelines should be read in conjunction with the Domiciliary Oxygen Therapy Guideline
(Control No: BH0408) available on the intranet.

PURPOSE
The purpose of this guideline is to inform Alfred Health healthcare professionals of the process
for assessing and referring an oncology patient for consideration of domiciliary oxygen therapy as
part of their palliative care management.

CONTENTS:
1. General Information
2. Domiciliary Oxygen Therapy in the Palliation of Oncology Patients
a. Management of Dyspnoea in the Oncology Patient
b. Assessment for Domiciliary Oxygen Therapy
i. Inpatients
ii. Outpatients
3. Funding
4. On Approval
5. Oxygen Equipment Set Up
6. Ongoing Monitoring
7. Withdrawal of Equipment
8. Related Documentation
9. References
10. Appendices

Contact Details:

Domiciliary Oxygen Service


Department of Allergy, Immunology and Respiratory Medicine, The Alfred
Commercial Rd, Melbourne VIC 3004

Hours: 0830-1630 Monday Friday


Telephone: 9076 3476
Fax: 9076 3434
Pager: 4140
107

DOMICILIARY OXYGEN THERAPY SERVICE

The Domiciliary Oxygen Therapy Service at The Alfred administers home oxygen
therapy for all Alfred Health campuses. This is to ensure the appropriate provision of
equipment and management of patients requiring domiciliary oxygen therapy.
The Respiratory Consultant for the Domiciliary Oxygen Therapy Service will review all
referrals and approve oxygen therapy according to the guidelines set out by the
Department of Human Services. These guidelines are based on the Adult Domiciliary
Oxygen Therapy Position Statement of the Thoracic Society of Australia and New
Zealand.

Guidelines for home oxygen therapy are available on the intranet

Oxygen referral form is available on the intranet


108

1. GENERAL INFORMATION
The Domiciliary Oxygen Therapy Service at The Alfred administers home oxygen therapy
for all Alfred Health campuses. This is to ensure the appropriate provision of equipment
and management of patients requiring domiciliary oxygen therapy.
The Respiratory Consultant for the Domiciliary Oxygen Therapy Service will review all
referrals and approve oxygen therapy according to the guidelines set out by the
Department of Human Services. These guidelines are based on the Adult Domiciliary
Oxygen Therapy Position Statement of the Thoracic Society of Australia and New
Zealand. [1]
Further information can be found in Domiciliary Oxygen Therapy Guideline, available on
the intranet.

2. DOMICILIARY OXYGEN THERAPY IN THE PALLIATION OF ONCOLOGY


PATIENTS

Dyspnoea is a common, distressing symptom in palliative care, and can be difficult to


control. [2]

Domiciliary oxygen may be of help in managing this symptom in conjunction with other
medical and surgical treatments, management of psychological and social concerns and
support of the family and other carers.

Dyspnoea does not necessarily mean hypoxia, and oxygen therapy is not a panacea for
dyspnoea

Although there is limited evidence as to the benefits for those who are not hypoxic, some
studies show that oxygen therapy can improve quality of life for oncology patients
receiving palliative care and their families and carers [2-7]

The current guidelines of the Thoracic Society of Australia and New Zealand (TSANZ) [1]
focus on the use of oxygen therapy to increase survival. The use of oxygen therapy in
palliative care of the oncology patient may have a different emphasis.

In Victoria, funding is generally available to those meeting the criteria set out in the
TSANZ position statement (refer to Domiciliary Oxygen Therapy Guideline for details).
However, some oncology patients may not meet these criteria despite having significant
dyspnoea.

As with any therapy, there must be clear parameters to justify its prescription and all other
medical options should be considered prior to oxygen being considered.

a. MANAGEMENT OF DYSNOEA IN THE ONCOLOGY PATIENT

The course of dyspnoea varies with the different disease processes such as
malignancy, end-stage chronic obstructive pulmonary disease or motor neurone
disease. Management aims are to:
Relieve the discomfort and distress of the patient and caregivers.
Improve the disease process where this is possible and appropriate.

Dyspnoea in the palliative care setting generally has a mixed aetiology.

All reversible or treatable factors causing dyspnoea should be identified and


managed.
109

Other treatment options shown to be of benefit in the treatment of dyspnoea should


generally be implemented before the use of domiciliary oxygen [2, 5].

Staff should be familiar, and provide patients with, the Cancer Council of Victorias
Coping with breathlessness caused by cancer or cancer treatments leaflet. [8]

See Appendix A for management of dyspnoea in the palliative care patient

b. ASSESSMENT FOR DOMICILIARY OXYGEN THERAPY

IMPORTANT:
Check contraindications for oxygen therapy prior to commencing
assessment (refer to Domiciliary Oxygen Therapy Guideline).

Referrals for Domiciliary Oxygen Therapy should be made by a medical


officer.

i. INPATIENTS

WHERE HYPOXEMIA IS DEMONSTRATED

Refer to Domiciliary Oxygen Therapy Guideline and follow assessment pathway.

In the patient with a short prognosis (< 3 months), an oxygen saturation on room
air may be performed instead of ABGs provided that the patient does not have a
condition or co-morbidity for which hypercapnia is a risk.

WHERE HYPOXEMIA IS NOT DEMONSTRATED

Check the following conditions:

o Other treatments for dyspnoea have been trialled without success

o Patient gets good symptomatic relief using supplemental oxygen

o Likely prognosis of patient is less than three (3) months

If yes to all three, submit completed Inpatient Domiciliary Oxygen Therapy


Referral form detailing the above conditions. An oxygen saturation on room air
may be performed instead of ABGs provided that the patient does not have a
condition or co-morbidity for which hypercapnia is a risk.

Submission of a referral in this case does not automatically mean funding will be
provided and the Domiciliary Oxygen Service will ultimately determine approval for
funded oxygen in consultation with the referring unit.

Where a patient does not qualify for funded oxygen and is not a current smoker,
the patient or their family may wish to privately fund oxygen therapy and the
Domiciliary Oxygen Service can assist with organising this.
110

ii. OUTPATIENTS

Dependent on mobility of the patient, patients can be referred to the Oxygen Clinic
for assessment.

Where this is seen as too burdensome given the stage of the patients disease,
arterial blood gases can usually be arranged by the patients treating doctor
through a local pathology provider or an oxygen saturation on room air may be
performed instead of ABGs provided that the patient does not have a condition or
co-morbidity for which hypercapnia is a risk.

WHERE HYPOXEMIA IS DEMONSTRATED

Contact the Domiciliary Oxygen Service Co-ordinator to determine which funding


sources are available for the patient, so appropriate application and referral forms
can be completed

In some cases, processing of applications can take up to 1 month. Patients may


need to fund oxygen therapy during this time if alternate funding sources are not
available. The Domiciliary Oxygen Service can assist with set up of equipment
being funded privately.

WHERE HYPOXEMIA IS NOT DEMONSTRATED

Check the following conditions:

Other treatments for dyspnoea have been trialled without success

Patient gets good symptomatic relief using supplemental oxygen

Likely prognosis of patient is less than three (3) months

If yes to all three, submit completed Inpatient Domiciliary Oxygen Therapy Referral
form detailing the above conditions. An oxygen saturation on room air may be
performed instead of ABGs provided that the patient does not have a condition or
co-morbidity for which hypercapnia is a risk.

Submission of a referral in this case does not automatically mean funding will be
provided and the Domiciliary Oxygen Service will ultimately determine approval for
funded oxygen in consultation with the referring unit.

Where a patient does not qualify for funded oxygen and is not a current smoker,
the patient or their family may wish to privately fund oxygen therapy and the
Domiciliary Oxygen Service can assist with organising this.

3. FUNDING

Refer to Domiciliary Oxygen Therapy Guideline for standard sources of oxygen funding.

Additionally, some palliative care services may have access to oxygen equipment for
patients that do not meet the criteria of other funding bodies.

Funding is usually capped. Oxygen requirements above this cap may not be funded and
may require a patient co-payment.
111

4. ON APPROVAL

Patients will be provided with:


a prescription for oxygen therapy including the flow and number of hours per day of use
education and information sheets on the safe use of oxygen therapy
a consent form to sign, agreeing to the conditions under which domiciliary oxygen therapy
will be provided (see appendix C).

This information may be provided by:


The domiciliary oxygen service
The primary medical team
The palliative care team
a community palliative care healthcare professional

The originals of all consents should be forwarded to the Domiciliary Oxygen Service for
review, prior to forwarding to the patients hospital medical record.

5. OXYGEN EQUIPMENT SETUP

The funding body will be responsible for the organisation of equipment set up.

The Domiciliary Oxygen Service will assist with set up of privately funded equipment.

The supplying Oxygen Company will provide training in use and safety of equipment with
either the patient or a carer upon delivery of equipment.

6. ONGOING MONITORING

Monitoring of oxygen therapy will be dependent on:

The funding source requirements

Whether or not TSANZ criteria for domiciliary oxygen therapy are met when oxygen
therapy is implemented

As a minimum, oncology patients utilising oxygen therapy for palliation should be


reviewed by community healthcare professionals on a monthly basis for effectiveness of
oxygen therapy. This will be undertaken in the following ways:
Review of the clinical effectiveness
Pulse oximetry measurement on room air and on currently prescribed oxygen flow
Communication to the Domiciliary Oxygen Service via the prescribed communication
form.
Patients attending outpatient clinics should be monitored via the above process also.

7. WITHDRAWAL OF EQUIPMENT

Consider in those who do not appear to find oxygen therapy beneficial.

Those who do not appear to be adhering to safety guidelines will have home oxygen
removed.
112

In the event of the death of the patient. Community staff / primary care teams are
requested to notify the domiciliary oxygen therapy co-ordinator at their earliest
convenience so that collection of equipment can be arranged.

8. RELATED DOCUMENTATION
Domiciliary Oxygen Therapy Guideline Available on the Intranet
Inpatient Domiciliary Oxygen Therapy Referral and Assessment form available on the
intranet
Domiciliary Oxygen Therapy Consent form
Patient information Sheets / brochures
A guide to home oxygen therapy - Southern Melbourne Integrated Cancer Services
Coping with breathlessness caused by cancer or cancer treatments Cancer Council
of Victoria
Alfred Health Domiciliary Oxygen Service introduction
Alfred Health Domiciliary Oxygen Service Privacy information sheet
Alfred Health Domiciliary Oxygen Service Information and prescription sheet
Alfred Health Domiciliary Oxygen Service Safety Information sheet
Process algorithm Inpatient and community setting

9. REFERENCES
1. McDonald CF, Crocket AJ, Young IH. Adult Domiciliary Oxygen Therapy. Position
Statement of the Thoracic Society of Australia and New Zealand. MJA 2005; 182(12):621-
626.
2. Ben-Aharon I, Gafter-Gvili A, Paul M, Leibovici L, and Stemmer SM. Interventions for
Alleviating Cancer-Related Dyspnea: A Systematic Review. J Clin Oncol 2008; 26:2396-
2404.
3. Uronis HE, Abernethy AP. Oxygen for relief of dyspnea: what is the evidence? Current
Opinion in Supportive and Palliative Care 2008, 2:8994.

4. Currow DC, Agar M, Smith J, Abernethy AP. Does palliative home oxygen improve
dyspnoea? A consecutive cohort study. Palliative Medicine 2009; 23: 309316

5. Clemens KE, Quednau I, Klaschik E. Use of oxygen and opioids in the palliation of
dyspnoea in hypoxic and non-hypoxic palliative care patients: a prospective study.
Support Care Cancer 2009; 17:367377

6. Cranston JM, Crockett A, Currow D. Oxygen therapy for dyspnoea in adults. Cochrane
Database Syst Rev. 2008 Jul 16;(3):CD004769.

7. Philip J, Gold M, Milner A, Di Iulio J, Miller B, Spruyt O. A randomized, double-blind,


crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. J
Pain Symptom Manage. 2006;32(6):541-50

8. Cancer Council of Victoria. Coping With Breathlessness Caused by Cancer or Cancer


Treatments Leaflet. cancervic.org.au factsheets

9. Charter of Human Rights and Responsibilities Act 2006 (Vic) 2


113

10. APPENDICES
A. Management of dyspnoea in the palliative care patient

B. Consent form

C. Inpatient Domiciliary Oxygen Therapy Referral and Assessment Form


114

Appendix A

Palliative Oncology
Assessment of Dyspnoea and requirement for Home Oxygen
Oxygen therapy may be considered as part of the palliative care of a patient wit h advanced cancer. It is, however,
never a complete treatment. Assessment needs to be on an individual basis

Palliative asse ssment of patient


with
advanced cancer and dyspnoea
(Prognosis estimated 3 months)

Establish Likely Cause(s) of Symptom


Detailed history and examination
Appropriate investigations
Perform pulse oximetry
Assess and Manage
Pre-existing diseases (eg COPD, heart failure)
Exacerbating factors (eg anaemia, ascites, anxiety)
Additional factors (eg infection, pulmonary emboli)

Are there Reversible Factors?


Assess for specific therapeutic management:
Pleural effusion - drainage pleurodesis
Pericardial effusion - aspiration window YES Treat Reversible
Endobronchial disease - laser therapy, stenting, consider steroids Factors
Lymphangitis - consider steroids
In selected patients, specific anti-cancer therapy
may be appropriate for symptom control

NO

General Management of Dyspnoea


Explanation and reassurance to patient, family and carers
Advice on positioning of patient in bed
NO Re-Asse ss
Stream of air - fan or open w indow
Relaxation and anxiety control techniques Is dyspnoea improved?
Encourage adaptations in activities of daily living, lifestyle and patient/family expectations
In selected patients, a trial of medications YES
such as benzodiazepines or opiods may be considered

Ongoing Monitoring
Re-Asse ss YES NOTE: The treatment strategy may rapidly change in
Is dyspnoea improved? advanced cancer and will need frequent adjustment as
necessary
NO

Is the patient hypoxaemic?


Use pulse oximetry and/or ABGs on room air
SpO288% and/or PaO2 55 mmHg

YES NO

Complete home Consider referral for home oxygen


oxygen referral therapy. Discuss with Domiciliary
Oxygen Coordinator.

November 2009
115

Appendix B
HOME OXYGEN THERAPY CONSENT FORM

I, ,

1. Understand that funding of oxygen therapy is dependent on me meeting particular criteria set
out in guidelines written by the Department of Human Services, Victoria.
2. Understand that provision of oxygen to me will be reviewed on a regular basis to ensure that
it still provides appropriate benefit to me.
3. Understand that provision of oxygen to me may be withdrawn if there is no clinical benefit.
4. Confirm that I have received a prescription from Alfred Health for use of the oxygen
5. Understand that I must not smoke at any time or my oxygen therapy will be withdrawn.
6. Confirm that I will inform Alfred Health immediately if I intend to commence or re-commence
smoking.
7. Confirm that I have received, read and understood the information sheet Oxygen Therapy
Safe Use of Oxygen regarding the safe use of oxygen.
8. Confirm that I have had the risks of oxygen usage explained to me.
9. Understand that I must not store or use oxygen within 2 metres of a naked flame, due to the
danger.
10. Will report all losses, theft or damage of the home oxygen equipment to my oxygen supplier
immediately.

Signed: Date:
Patient (or legal representative if patient is incapable of consenting)

Signed: Printed:
Health care professional
Date:
Designation:
Where applicable:
I, , have translated the above information and
assisted with oral translation to the above patient in a language which he / she understands.
Language:
Signed: Date:
Printed:
116

Appendix C Dept of Allergy, Immunology and Respiratory Medicine


Inpatient Domiciliary Oxygen Therapy Referral and Assessment Form
Please see over page for further information regarding domiciliary oxygen therapy
This document acts as a referral for review in oxygen clinic post discharge, hence requires referrer details and signature
Patient Details ****** This section MUST be completed please print ******
clearly
Name Referring unit/Ward
DOB Referring Doctor
Gender Pager no
UR Number Provider no
Planned discharge
Home / hostel / special accommodation / nursing home
Address Next of Kin
Relationship
Telephone (H) Name
(M) Address
Is patient eligible for care through Veterans affairs?
If so, VX number Telephone (H)
(W/M)

Clinical Information c. ****** d. This section MUST be completed e. ******


Diagnosis and reason for application for domiciliary oxygen

Evidence of 1. Cor pulmonale Y N 4. Advanced non-pulmonary cardiac disease Y N


2. Pulmonary hypertension Y N 5. Nocturnal hypoxaemia Y N
3. Exercise-related hypoxia Y N 6. Terminal malignancy Y N

Is patient 1. Receiving maximal Y N 3. Well motivated Y N


therapy
2. clinically stable Y N Current smoking history

Test Results Date Date


Lung Function FEV1 (L) FEV1 (L)
(Optional) FVC (L) FVC (L)
FEV1/FVC% FEV1/FVC%

Arterial Blood Gases Rest /Sleep Exercise


****** Air O2 Air O2
(ABG on Date Date
Room air L/min L/min
compulsory) pH Rest SpO2
****** PaCO2 Min SpO2
PaO2 Rest HR
SaO2 Max HR
COHb Dist (m)
% Increase in exercise tolerance on O2
Haemoglobin g/dl Date

Current oxygen therapy flow Corresponding SpO2

Referring Doctors Signature: _____________________Date of Referral: _______________________


Please return completed form to Lung Function Laboratory, 1st floor, Linay Pavillion, The Alfred.Phone: 9076 2000,
pager 4140 or 9076 3476, Fax: 9076 3434 (please page 4140 to inform that fax has been sent)
117

Domiciliary Oxygen Therapy Service


Department of Allergy, Immunology and Respiratory Medicine, The Alfred
Hours: 0830-1630 Monday Friday
Telephone: 9076 3476
Fax: 9076 3434
Pager: 4140

Procedure for Assessment of Domiciliary Oxygen Therapy for Inpatients


Domiciliary Oxygen Therapy may be considered in patients with ongoing hypoxemia, most often related to COPD, who are
unable to be safely discharged home without oxygen
24 48 hours notice is required for discharge with domiciliary oxygen therapy (longer if discharge planned for over weekend or
Monday)
Referring Medical Officer to complete a Domiciliary Oxygen Therapy Referral and Assessment Form and fax to number at
bottom of form. Please note that incomplete forms will be returned.
The Respiratory Consultant for Domiciliary Oxygen Therapy will assess the patient according to the guidelines set out by the
Department of Human Services (see contraindications and indications for domiciliary oxygen therapy below).
Further information can be found in
Adult Domiciliary Oxygen Therapy Position Statement of the TSANZ (MJA 2005; 182(12):621-626)
Victorian Aids and Equipment Program Guidelines
Department of Veterans Affairs Guidelines for Oxygen Prescribers

Assessment For Continuous Oxygen.


Based on arterial blood gases on room air measured when patient is approaching end of admission. Please ensure adequate
washout time if O2 therapy in place prior to assessment. Admission ABG will not be accepted in most cases.

Assessment For Portable Oxygen.


Based on a walking assessment on air to determine degree of hypoxemia and then on oxygen to determine degree of
improvement in exercise tolerance.
Bookings: The Alfred: Contact the Domiciliary Therapy Service on above numbers
CGMC and SDMH: Physiotherapy services of the respective hospitals should be able to provide assessment.
Note: assessment for portable oxygen can be done as part of an oxygen clinic review one month after discharge.

Assessment For Nocturnal Oxygen.


Based on continuous overnight oximetry or polysomnography (Available at Alfred only)
Referrals/Bookings: Sleep/NIV service: Registrar - pager 5054 or Respiratory Therapist - ext 63770 or pager 4978

Assessment for Oxygen for Palliative Care


Will be assessed on case-by-case basis where patient has evidence of hypoxemia and life expectancy of less than three months

Contraindications for Domiciliary Oxygen Therapy:


1. Current smokers patients must have ceased smoking (preferably as an outpatient) >1 month prior to assessment
2. Patients who are breathless but have PaO2 60 mmHg on room air and do not desaturate on exertion.
3. Patients who have not had adequate treatment of other kinds that may improve oxygen transport.
4. Patients who are not motivated to use oxygen therapy according to prescription.

Indications for Domiciliary Oxygen Therapy:


Following optimisation of medical treatment and cessation of smoking (>1 month), oxygen may be given as:

1. Continuous (16+ hrs per day)


PaO2 55mmHg breathing room air, OR
PaO2 between 56 - 59 mmHg breathing room air with either:
1) pulmonary hypertension (evidence on echocardiogram, ECG)
2) documented right heart failure
3) polycythaemia HCT > 0.55
Please identify oxygen flow required to maintain SpO2 90-92% (PaO2 just greater than 60mmHg).
Note: repeat ABG on O2 therapy may be required in patients with hypercapnia on room air.

2. Intermittent
Exercise: Chronic respiratory disease with exertion limited by hypoxaemia (SpO2 88%). Objective improvement in exercise
capacity (usually 50%) needs to be demonstrated when breathing supplemental O2 for portable O2 therapy to be prescribed.
Portable oxygen will not be prescribed for breathless patients who do not demonstrate hypoxaemia.

Nocturnal: Where overnight polysomnography or oximetry demonstrates hypoxemia (SpO2 88%) for >30% of the night. Note
that alternatives to oxygen therapy such as non-invasive ventilation may also be considered in this patient group.

3. Palliative Care
Indicated to relieve symptoms in terminally ill patients with evidence of hypoxemia and life expectancy of less than three
months.

Re-assessment Requirements:
Where guidelines are met, domiciliary equipment will be supplied free of charge for 30 days post discharge. At this time, patient will
be reviewed in the Oxygen Clinic and if above criteria for oxygen therapy still met, an application for long term funding will be made to
the relevant funding body.
118
119
120
121

Recent Onset Angioedema:


*Angioedema is self limited, localised subcutaneous (or submucosal) swelling that may occur in isolation or
accompanied by urticaria, or as part of anaphylaxis.
It particularly affects areas with loose connective tissue such as:
Face Lips Mouth
Throat Larynx Uvula
Extremities Genitalia Bowel Wall (colicky abdominal pain)

*Angioedema is typically characterised by:


Progression over minutes to hours
Asymmetrical
Tendency not to involve gravitationally dependent areas

* Angioedema may be mast cell mediated eg allergic reactions to foods, insect stings. Generally there are
other signs and symptoms of mast cell mediator release, including urticarial rash, pruritus, bronchospasm,
hypotension and diarrhoea.

*Angioedema induced by bradykinin is typically not associated with bronchospasm or others signs of
allergic reactions. The generation of bradykinin and complement derived mediators causes increased
vascular permeability. The time course is more prolonged when compared to allergic triggers. In
bradykinin mediated angioedema, the swelling typically evolves over 24-36 hours and lasts for 2-4 days.
There is no clear relationship between the trigger and onset of symptoms. Angioedema is usually benign
although it can be life threatening if there is significant angioedema of the:
Larynx Upper airway Tongue

*It is important to consider medications that are not uncommonly associated with angioedema as an
adverse effect, particularly with an aging population and polypharmacy.

Medications associated with angioedema include more commonly:


Non steroidal anti inflammatory drugs (NSAIDS) including Aspirin
o Direct mast cell activation, class effect.
Angiotensin converting enzyme (ACE) inhibitors
o Bradykinin pathway; class effect
o Account for 20-30% of cases of angioedema in up to 1% of patients on ACEI
o Angioedema and/or dry cough can occur a number of years post commencement
Angiotensin II receptor antagonists (AIIR antags)
o Bradykinin pathway; class effect
o Incidence of 0.5% of patients

Other less common causes include:


Calcium Channel Blockers Oestrogens (including high dose OC) Opiates
Proton Pump Inhibitors Metoprolol Risperidone
Herbal medicines Statins Sertraline

*As bradykinin-associated angioedema is not an allergy, there is no diagnostic test. In the first instance, it
is recommended that the most likely causative medication is ceased and an alternative medication be
prescribed. It is important to note that angioedema may take several months to resolve post cessation
of the causative agent. Antihistamines and corticosteroids do not assist with resolution of the symptoms. If
these measures do not result in resolution of the problem re-referral to the Immunology Clinic should be
made.

*If significant airway oedema occurs with airway compromise then emergency hospital care should be
sought (Phone 000).

*Highly useful web-accessed sites, including LexiComp linked to UpToDate (www.uptodateonline.com),


Lexi-Interact and MIMS On-Line (http://www.mims.com.au/)
122

ULTRA RUSH PROTOCOL FOR BEE VENOM

DAY DOSE CONC VOL DATE TIME SIGN


DAY1 0.1mcg 1mcg/ml 0.1ml 0mts

1mcg 10mcg/ml 0.1ml 30mt

10mcg 100mcg/ml 0.1ml 1hr

20mcg 100mcg/ml 0.2ml 1:30

40mcg 100mcg/ml 0.4ml 2:00

60mcg 100mcg/ml 0.6ml 3:00

DAY2 50mcg 100mcg/ml 0.5ml 0 hrs

50mcg 100mcg/ml 0.5ml 1hrs

DAY14 100mcg 100mcg/ml 1ml

DAY35 100mcg 100mcg/ml 1ml

DAY63 100mcg 100mcg/ml 1ml

References:
1. Birnbaum J, Charpin D, Vervolet D. Rapid Hymenoptera venom immunotherapy:
Comparitive safety of three protocols. Clinical and Experimental Allergy 1993;23:
226-230 (Hollister Stier)

2. Brehler R, Wolf H, Kutting B, Schnitker J, Luger T. Safety of a two-day ultrarush


Insect venom immunotherapy protocol in comparison with protocols of longer
duration and involving a larger number of injections. Journal of Allergy and Clinical
Immunology 2000; 105: 1231-1235. (ALK)
123

PHYSIOLOGY SERVICE
GENERAL INFORMATION

The Physiology Service conducts the operation of the Lung Function Laboratory and
Domiciliary Oxygen Therapy Service.

In addition to an active clinical program supporting both internal and external referrals,
inpatients and outpatients, the Physiology Service participates in an active teaching and
research program.

The Physiology Service provides training for both undergraduate and post graduate
students, and interested healthcare providers, in the performance and interpretation of
lung function, and oxygen therapy.

The Physiology Service supports research external to the service, but has an established
self-initiated program as well.

The Physiology Service operates under the guidelines as set in the Policy and Procedure
manual located in the Physiology Service Folder of the AIRmed network drive. It is a
requirement that all Residents and Registrars are familiar with:
- Requesting of lung function tests
- Contraindications for lung function tests
- Interpretation and reporting of lung function tests
- Operation of lung function database
Please see the Head or Deputy Head of the Physiology Service for further information.
124

INTRODUCTION TO THE LUNG FUNCTION LABORATORY


Why measure lung function?
Lung function tests are performed as an aid to diagnosis, to provide an ongoing objective
assessment of pulmonary function including response to therapy, and to quantify the
degree of pulmonary disability. Furthermore, knowledge of lung function has important
applications including monitoring disease progress, establishing safe working conditions
in industry with respect to respiratory hazards, and in the evaluation of the effectiveness
of new drugs and therapies.

Patient Appointments
Appointments are made through the administrative support officer, either in person or by
phone. A signed medical request slip with adequate identifying patient information,
relevant clinical information and the test required must be provided. Note: tests will not
be performed in the laboratory without a signed request slip. Tests may also be
requested online via Powerchart. Please notify the laboratory if a patient requires an
interpreter so one can be arranged to be present during the test.

Suitability for testing


Subjects need to be cooperative and able to follow instructions. Most lung function tests
require a patient to sit unaided and to follow specific instructions in the performance of
breathing manoeuvres requiring maximal effort. Relative and absolute contraindications
exist for lung function testing, and these should be considered when booking a patient for
testing.

Contraindications include:
Abdominal, thoracic, neuro, ocular surgery in past 6 weeks.
Pneumothorax in past 6 weeks
Haemoptysis of unknown origin
Open pulmonary TB
Thoracic, abdominal or cerebral aneurysms
Angiogram in previous 24 hours
Transbronchial biopsy in previous 24 hours
Intercostal catheters in situ
Unstable cardiovascular status
Recent myocardial infarction
Recent pulmonary embolus

RANGE AND DESCRIPTION OF COMMONLY PERFORMED TESTS


1. Spirometry / Flow volume loop
Spirometry assesses the ventilatory function, or bellows function of the lung. Spirometry
may be performed as a relaxed or forced manoeuvre, though the forced manoeuvre
provides information regarding changes in volume with respect to time. Forced
manoeuvres can be displayed as volume-time or flow volume curves. Flow volume
curves provide additional information to volume time curves, particularly changes in
shape with ventilatory defects and assessment of test quality and are helpful in
identifying fixed or variable intra and extra thoracic upper airway obstruction. Flow-
volume curves are the usual measure made in the laboratory.
125

Spirometry is particularly useful in identifying obstructive lung defects and in assessing


airways reversibility following inhaled bronchodilator.

Spirometry is performed routinely in the laboratory and outpatient clinics. In special


circumstances, spirometry may be performed at the bedside.

Spirometry takes 15-30 minutes to perform, depending on whether or not an assessment


of reversibility is required.

2. Carbon Monoxide Transfer Factor (TLCO)


This test assesses the effectiveness of lungs to transfer CO across the alveolar capillary
membrane and into a chemical combination with haemoglobin in pulmonary capillary
blood. It is therefore a test of the functional integrity of the lung membrane and
pulmonary vascular bed. The surface area and thickness of the lung membrane and the
quantity of haemoglobin in the pulmonary vascular bed are important factors affecting the
magnitude of the transfer factor.

Smoking (of which carbon monoxide is a by-product) will lead to an underestimation of


TLCO. Subjects should be advised not to smoke in the 24 hours prior to testing.

The TLCO takes about 20 minutes to perform.

3. Lung Volumes
Whole body plethysmography (body box) is the usual method used to measure the total
lung capacity (TLC), functional residual capacity (FRC) and residual volume (RV) in this
laboratory. Body plethysmography measures the compressible volume of the lung and,
thus, includes the volume of poorly ventilated lung units.

Lung volumes are usually measured to confirm hyperinflation or restriction which the
physician may have suspected from the clinical examination, radiology or from the initial
spirometry test. This test takes up to 20 minutes.

In subjects without substantial airways obstruction, an indication of total lung capacity


can be obtained from the measurement of CO transfer factor. The alveolar volume (VA)
is obtained from the dilution of a vital capacity breath of a gas mixture containing a known
concentration of an inert gas in 10 seconds. VA considerably underestimates true total
lung capacity if significant airflow limitation is present.

4. Bronchial Provocation Test


Bronchial provocation tests assess the tendency for airways to constrict in response to a
direct or indirect stimulus.

The lung function laboratory performs indirect challenges. The airway narrowing that
occurs in response to an indirect challenge is due to mediator release from inflammatory
cells and neural cells in response to the stimulus.

Hypertonic aerosols (hypertonic saline, mannitol). The bronchial provocation agent is


delivered to the airways in aerosol form in cumulative doses and the provocation dose
required to cause a fall in FEV1 of 15% is used as an index of airway sensitivity.
126

Eucapnic voluntary hyperventilation test. May be useful for patients suspected of


exercised induced asthma or brochoconstriction. This test is the test endorsed by the
IOC for use of respiratory medications in sport. The subject hyperventilates breathing a
dry gas mixture containing a small amount of carbon dioxide (to prevent hypocapnia) for
6 minutes. Lung function is then monitored over the following 15 minutes to look for a
drop in FEV1. A drop in FEV1 of >10% is considered a positive response.

To maximise the sensitivity of bronchial provocation tests, it is important that the patient
cease taking certain medications (eg bronchodilator, antihistamines) for specific periods
prior to the test. Test preparation instructions are available from the Laboratory. The test
is only performed in the Laboratory and takes approximately 60 minutes.

5. Maximal Inspiratory and Expiratory Pressures


Maximal Inspiratory (MIP) and Expiratory (MEP) pressures provide an indication of global
respiratory muscle function. Measurements of respiratory muscle function are useful for
supporting a diagnosis and management of patients with neuromuscular diseases or
diseases and injuries that affect the diaphragm, intercostal, or accessory muscles.

6. Cardiopulmonary Exercise Test (Stage 1)


A staged exercise test may be performed in an individual whose symptoms are not
supported by standard resting lung function tests. They are also used for pre-operative
assessments.

Formal exercise testing is usually performed using an electrically braked cycle ergometer
in which the patient cycles as a set peddling rate. At minute intervals the effort required
to turn the pedals is progressively increased until the patient reaches his maximum
exercise ability. During the exercise test various indices are measured such as minute
ventilation, gas exchange, heart rate, and arterial oxygen saturation. The results provide
valuable information about the cardiopulmonary reserve and general fitness and can help
in distinguishing heart or lung disease as the cause(s) of breathlessness. This test takes
approximately 60 minutes. A doctor must be present during the whole test.

7. Altitude Simulation Test


This test is usually performed on patients who are planning to travel on commercial
aircraft and are considered to be at risk of hypoxemia during flight. The test requires the
patient to breathe a gas mixture with an oxygen partial pressure equal to that
encountered at the maximum cabin altitude during flight. The test is performed to
determine whether desaturation below 88% occurs and the oxygen supplementation
required to maintain oxygen saturations inflight. The test takes about 45 minutes.
127

INTERPRETATION OF LUNG FUNCTION

Registrars, scientists and respiratory physicians all participate in the reporting of lung
function (rostered). To promote consistent reporting between staff, guidelines for
interpretation have been written. These guidelines, as well as training for registrars, are
provided through the Physiology Service.

Reporting of Cardiopulmonary Exercise Tests (CPET)


In consultation with a scientist, the registrar supervising the CPET interprets the results
and writes the report.

The CPET is reviewed at the weekly Physiology Meeting (12.30pm Fridays) and the
report is finalised.

Reporting Process for Lung Function Results


It is a requirement of TSANZ accreditation that reporting and distribution of lung function
results occurs within 5 working days.

The process for reporting of lung function tests is as follows:

At completion of testing, the scientist enters results into the lung function database for
reporting.
Each day, the registrar rostered to report logs onto the database and, from the
reporting screen, reports results from the previous day (or in chronological order) from
the unreported results list. Training will be provided in the operation of the database
reporting system.
As each report is done, the report is saved to the approval list, which is then checked
by a senior scientist.
Once verified, the report is saved to the Sign Off list, for signing by a consultant.
Following sign off, reports are printed and distributed by the Administrative Support
Officer for the Physiology Service.

It is expected that reporting will be done on a daily basis to maintain the accreditation
requirements for reporting.
128

Lung Function Laboratory The Alfred


Department of Allergy, Immunology and Respiratory medicine Commercial Rd, Melbourne, Vic. 3004
The Alfred Hospital is a member of Bayside Health
Enquiries & Appointments: (03) 9076 3476
Facsimile: (03) 9076 3434

Patient details: (Block Letters) DOB: Tick ( ) where appropriate


Private
Surname: Given name: Sex:
Workcover
Address: Phone: ( ) H
TAC
P/C: ( ) W
Veteran Affairs
UR: Dept/Dr on Bed Card:
Bulk Bill
Ward: Classification(H/SM etc): OP Clinic:

Interpreter arranged: Y/N language:


Clinical Notes: Test Required (PTO)
Lung Transplant for review COPD Spirometry - Pre and/or Post bronchodilator
Cystic Fibrosis for review Asthma for review TLCO (Hb: ______ Date: __________ )
Other: Lung Volumes
Cardiopulmonary Exercise
Bronchial Provocation:
Relevant Drugs:
Other:
#
Patient Isolation Required on Arrival ( PTO)
Referred by: (Block Letters)
Copies to: URGENT *PTO Yes / No
Address: (Outside referral) Fax No:
Postcode:
Provider
Signature: Pager/Contact No: Date: No:
(Medical officer) (Essential)
129

DOMICILIARY OXYGEN THERAPY SERVICE

The Domiciliary Oxygen Therapy Service at The Alfred administers home oxygen
therapy for all Alfred Health campuses. This is to ensure the appropriate provision of
equipment and management of patients requiring domiciliary oxygen therapy.
The Respiratory Consultant for the Domiciliary Oxygen Therapy Service will review all
referrals and approve oxygen therapy according to the guidelines set out by the
Department of Human Services. These guidelines are based on the Adult Domiciliary
Oxygen Therapy Position Statement of the Thoracic Society of Australia and New
Zealand.

Guidelines for home oxygen therapy are available on the intranet

On the intranet homepage, click Policies & Guidelines in top left hand corner.
A new window will open running PROMPT
In the search field, type oxygen and click search
Scroll down results page to find:
Adult Domiciliary Oxygen Therapy
Domicilliary Oxygen Therapy In The Palliation Of Oncology Patients

The Domiciliary Oxygen Therapy referral form is available on the intranet