222 e-Letters

  • Change in NEWS from emergency department to medical ward in patients with COPD

    We read the article by Hodgson LE, et al with interest. The authors examined the performance of National Early Warning Score (NEWS) for patients with an acute exacerbation of COPD. A limitation to this study was that the electronic scores (ward-based) were used as first NEWS - as the (paper) observations within the emergency department (ED) could not be included. We have reviewed data from our Hospital Trust of patients admitted with exacerbation of COPD (n=111), to determine whether NEWS scores from the ED department (paper records) differed from the first observation recorded on subsequent transfer to the acute medical wards (Electronic Patient Records). Admissions direct to ICU or HDU were excluded. Wilcoxon rank test was used to compare NEWS scores from ED to ward. Results are median (IQR).
    NEWS in ED fell from 6 (4-8) to 4 (3-6) on the acute medical ward (P<0.0001) over a mean time interval of 377 (sd 182) mins. The change in NEWS was due to a reduction in scores for respiratory rate and heart rate. Improvement in score for oxygen saturations was offset by scoring for use of oxygen.
    Not including the NEWS at presentation could underestimate risk of mortality, and hence contribute to the reduced sensitivity of NEWS that was observed in patients with COPD. Alternatively, utilising the NEWS at presentation to ED may lead to lower specificity in a patient with rapidly improving physiology.
    Harmonisation of data collection between ED and the hospital...

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  • A validation of the National Early Warning Score to predict outcome in patients with COPD exacerbation - Author response

    We thank Cardwell et al for their thoughtful comments on our paper.[1] The two alternative scoring systems did not demonstrate improved discrimination or calibration in our large dataset of AECOPD admissions. The authors suggest employing the Salford-NEWS only in patients ‘at risk’ of hypercapnic respiratory failure however, this introduces a subjective element that may negate the benefits of an objective physiological scoring system. As we emphasised in what we believe was a balanced discussion, patients with COPD should be managed in the right place by specialists and on-going education is crucial to avoid potential harms associated with misinterpretation of the NEWS alluded to by Cardwell and colleagues. Our article adds evidence that suggested RCP thresholds would indeed lead to unnecessary callouts in such patients. However, as we proposed, rather than abandon a scoring system that provides the significant advantages of standardisation and familiarity, it is possible to individualise patient management. For example, lowering observation frequency in a patient who is clinically ‘stable’, not increasing oxygen delivery if the prescribed target saturation is achieved, or taking into account prior/baseline physiology when deciding observation frequency and whether a senior review is required. Indeed a senior review may be appropriate to interpret whether the patient is at risk of hypercapnic respiratory failure and be able to advise on appropriate targets and level of mon...

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  • Salford NEWS score used incorrectly in paper by Hodgson et al

    We read the paper of Hodgson and colleagues with interest.1 Unfortunately, we note that the Salford-NEWS system (observation chart based on target Oxygen saturation prescription) has been applied in this study to all patients with a diagnosis of acute exacerbation of COPD (AECOPD) whereas we proposed applying this system for all patients at risk of type 2 (hypercapnic) respiratory failure, a group which includes many but not all patients with AECOPD and a number of patients with other conditions.2 Around 86% of those prescribed the lower range of Oxygen saturation (88-92%) in Salford are COPD patients judged to be at risk of hypercapnia, the remainder have conditions such as morbid obesity, neuro-muscular disorders, or complex lung diseases.3 Given this key difference in rationale we suggest that the Salford-NEWS system has been inappropriately applied in this study; hence, the conclusions have to be interpreted with extreme caution.

    When comparing NEWS with Salford-NEWS, it is clear that none of the systems had acceptable sensitivity at score thresholds of 5 and 7, and the most consistently reliable result from using either of them is the negative predictive value, which was similar. It was also evident that Salford-NEWS had better specificity at 91% and 95% compared to 57% and 80% for NEWS at score thresholds of 5 and 7 respectively. Since the increased sensitivity in NEWS is achieved at the expense of high “callout” rates, and low positive predictive value (8%...

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  • Response to: A randomised controlled trial of CPAP vs non-invasive ventilation for initial treatment of obesity hypoventilation syndrome
    Mark E Howard

    Dear Editor, We thank Dr Mansell for her comments regarding our recently published trial. [1] We agree that there are different phenotypic variations within the obesity hypoventilation syndrome (OHS), although it remains to be determined whether OHS with co-existent obstructive sleep apnoea (OSA) responds differently to treatment in comparison to OHS without OSA. [2] Acknowledging that the presence and severity of OSA in...

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  • Comment on: A randomised controlled trial of CPAP versus non-invasive ventilation for initial treatment of obesity hypoventilation syndrome
    Stephanie K. Mansell
    Dear Editor,

    We read with great interest the article by Howard et al[1] and commend the authors on this excellent piece of work. However, we wish to raise several points for consideration of this work in a clinical context. Firstly, it is not clear whether the patients being treated were truly patients with obesity hypoventilation failure (OHS) or whether in fact they had hypercapnic obstructive sleep apnoea (OSA). There is in...

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  • Response to correspondence from Professor Lipworth
    Dale Umetsu

    We thank Professors Lipworth and Anderson for their very thoughtful comments in their response to our piece1, and for pointing out clear strategies for treating obesity-associated asthma without expensive therapies, e.g., with improved delivery of inhaled corticosteroids and/or weight reduction.

    It should be noted however, that the focus of the piece was on mechanisms by which obesity might cause asthma,...

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  • Obesity and asthma - do we need expensive therapies?
    Brian J Lipworth

    We read with interest the state of the art review by Umetsu on mechanisms by which obesity impacts asthma [1]. He has clearly outlined the extent to which molecular targets, both within allergic (T-helper 2 [TH2]) and non-allergic mechanistic pathways of asthma, need further evaluation and drug development for obese asthmatics. This was on the basis that current standard therapies for asthma such as inhaled corticoste...

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  • Authors' Response to: Prediction models for hypersensitivity pneumonitis
    Kerri A. Johannson

    We thank Dr. Lacasse and the HP Study Group for their correspondence regarding 'A diagnostic model for chronic hypersensitivity pneumonitis', and appreciate their thoughtful consideration of our work.(1) We agree that these two studies are complementary, and hope that both will serve to improve diagnostic accuracy in the evaluation of patients with suspected HP. We further concur that much work remains to be done to advan...

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  • Prediction models for hypersensitivity pneumonitis
    Yves Lacasse

    To the Editor,

    The diagnosis of hypersensitivity pneumonitis (HP) is difficult and often relies on an array of clinical symptoms and signs developed in an appropriate setting, with the demonstration of radiographic and tomographic abnormalities, serum precipitating antibodies against offending antigens, a lymphocytic alveolitis on bronchoalveolar lavage, and/or a granulomatous reaction on lung biopsies. Taken...

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  • Inspiratory Muscle Training - The need for multiple tests to assess effectiveness
    Ashwin Rajhan

    We would like to congratulate Bissett et al on performing a clinically important study in a challenging cohort of Intensive Therapy Unit (ITU) patients. Any information in assisting the weaning process of ITU patients is clearly very important and clinically very useful.

    It is interesting that Maximum Inspiratory Pressure (MIP) was used to assess the inspiratory muscle strength (IMS), one of the primary endpoint...

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