Respiratory Futures spoke to Pearlene Antoine-Pitterson, Assistant Professor in Cardiorespiratory Physiotherapy at University Hospitals Birmingham and Chair of the British Thoracic Society Critical Care and RFMV SAG. Pearlene shares how vital the multi-disciplinary respiratory team is in delivering critical care and Respiratory Failure Home Ventilation (RFMV) services, the challenges often faced and where she hopes the future of the specialty will head.
Also shared below are a few thoughts and tips from some of the members of the wider British Thoracic Society Critical Care and RFMV SAG on what working in the specialty is like, and tips for getting involved.
Can you tell us a little bit about how and why the multi-disciplinary respiratory team (MDT) is important in critical care and respiratory failure home ventilation (RFMV)?
When looking at a patient’s complexity, an MDT approach to collaborate and problem solve is required. This is because no patient is the same, each one with their own challenges requiring us all to draw from each of our experiences working collaboratively and learning from each other to help the patient to return to their home. It requires input from across the medical team, Respiratory Medicine, Critical Care and General medicine. Over the last decade across both respiratory medicine and critical care there has been an extension of the scope of Allied Health Professional’s (AHP) involvement in the management of patients requiring ventilatory support and across all professions Physiotherapists, Occupational Therapists, Speech and language therapists and Respiratory Physiologists to name a few. Working to provide support from front door services, rehabilitation, and community along the patient’s journey.
Our backgrounds and interests make our involvement in the care of these patients invaluable across their whole journey: from front door through to follow-up. The balance of acute and long-term care allows us to see the benefits critical care can have in the longer term to patients and their loved ones.
How are allied health professionals best involved in managing complex ventilation patients? Which roles are usually involved in this type of service delivery?
The roles are wide and varied and we cannot do each profession justice in this short article. Physiotherapists have a vital role in facilitating mechanical ventilation weaning, tracheostomy weaning, airway clearance and rehabilitation both during the inpatient phase and in the community. Occupational Therapists (Ots) can work in the ICU with delirium and supporting the patients return to the community whilst advising and providing therapeutic adaptations to the patient’s home environment and continued rehabilitation in the community. Palliative care teams are essential not only to support the patients and their relatives but also staff. Speech and Language Therapists (SLTs) are invaluable in their role to facilitate tracheostomy weaning and voice rehabilitation. They play a vital role in reducing delirium by empowering patients to communicate. This is not an exhaustive list of AHPs who work with both Critical care and RFMV patients. There are respiratory Clinical Nurse Specialists (CNS), Critical Care Outreach Team (CCOT), Pharmacists, Psychology teams, dietetics, respiratory physiologist, all form an integral part of the team.
What does the future of critical care and RFMV look like from a respiratory medicine perspective? Are there any particular developments happening in this space?
We are still learning lessons from COVID-19 and particularly the complications of weaning patients. In 2023 BTS, along with the Intensive Care Society, published a Model of Care for specialised weaning. From this document the hope is to guide professionals on the management of patients and promote equity of care.
Discussed at the 2023 BTS Summer Meeting, with the changes made to dual intensive care training there should be a good spread of physicians who are able to support both respiratory and critical care. From a trainee point of view there is the opportunity for medical professionals to understand the entire patient journey across critical care and respiratory care. This will help to further develop skills in the medical workforce supporting more staff to work in both critical care and respiratory medicine. There will need to be careful consideration of job plans to ensure that dual trained medics can work in both.
There are ongoing developments in remote monitoring and High-flow Nasal Oxygen (HFNO) and how these can benefit respiratory patients.
What does the future of critical care and RFMV look like from the perspective of weaning, and delivering critical care and ventilation for patients at home?
As a team we agree we need improved collaboration between services to support the transition of care of our patients. This is the time for every profession to be able to contribute to the rehabilitation and management of patients back to the community. From trainees to experienced team members there is the opportunity to contribute to patient management and quality improvement. There is a varied work force of AHPs, CNS and medical teams.
This is the time for every profession to be able to contribute to the rehabilitation and management of patients back to the community.
We should continue to advocate for patients across services, particularly supporting long-term ventilation patients in the community.
What are some of the challenges the MDT faces in delivering high quality critical/RFMV care?
Challenges to providing high quality care include resources, space, and finances. There are differences in service availability throughout the country, leading to healthcare inequalities. To ensure that services are sustainable there needs to be drive and action to ensure that the right resources, space and finances are available to work efficiently and effectively. Hopefully dual training will help with development of the medical work force across both respiratory and critical care.
There should be ongoing creation and development of Respiratory Support Units to ensure safe and effective delivery of ventilation. Improved collaboration between intensive care and respiratory departments is central to this.
Do you have any tips for those who may be looking for ways to improve their service delivery?
Ensure that there is a robust system to collect data on your service outcomes, this can then feed into improvement of service provision and identify areas for development.
- Talk to each other and work together to help to enhance the service delivery.
- Ensure that there is use of urgent care plans and patient passports as well as ensuring they are up to date and valid.
- Engage in BTS audits to show how your service is performing nationally.
What advice would you give to somebody who may be considering joining the MDT involved in critical care/ventilation?
On the BTS Critical Care and RFMV SAG we have a range of professionals across the MDT who work in critical care and ventilation. Below are a few thoughts and tips from some of the members of our group on what working in our specialty is like, and tips for getting involved.
Katie Burke (Respiratory and Intensive care medicine registrar)
- For trainees I would definitely recommend trying to spend some time with a home ventilation team to see what they do. Your critical care placement during training is a good opportunity to learn more about ventilation and weaning from multiple team members (nurses, physios, doctors etc)
- Why I like specialising in critical care/ventilation: It’s an interesting combination of both acute and longer-term care. By working in both respiratory and critical care I can be involved in multiple stages of patient care and see their progress.
Pearlene Antoine-Pitterson (Assistant professor in Cardiorespiratory Physiotherapy)
- To start a conversation with anyone who is involved with the Critical care and ventilation team. For physiotherapists, engage in critical care and respiratory as part of your rotation, spend time with any LTV team.
- Why I like specialising in critical care/ventilation: What I enjoy about this specialty is the ability to problem solve. From their acute presentation to supporting them on their journey back to community where possible.
Stephanie Mansell (Consultant Physiotherapist)
- Look to get involved with networks, from a physio perspective there is the ACPRC, CSP and SiLVA. From an education perspective there is the opportunities for BTS short courses and the European respiratory society.
- Why I like specialising in critical care/ventilation: I feel like I am making a difference to patients as and as a physio I feel like a really valued member of the MDT. I’m able to voice my opinion and it matters and makes a difference. It is a challenging environment and if you like to be challenged and constantly learning then this is a specialty for you.
Dhruv Parekh (Associate Professor)
- It is a rewarding specialty - you can make such a big difference even where there are times you may feel that you are not making a difference. With weaning patients, start to anticipate the patients’ needs sooner. There is a huge value from AHP’s with the management for patients and support for their return to the community.
Ben Jones (Consultant in Intensive Care & Respiratory Medicine)
- If you’re about the critical care and longer-term ventilation, then I’d suggest following a patient through their whole critical care patient journey. You’ll see in time the benefit the MDT can provide to our patients and whether it’s something you’d like to be a part of!
- Our backgrounds and interests make our involvement in the care of these patients invaluable across their whole journey: from front door through to follow-up. The balance of acute and long-term care allows us to see the benefits critical care can have in the longer term to patients and their loved ones.