The patient population
Respiratory conditions are a major health problem in the UK. For example, World Health Organization statistics show that the UK has highest incidence of asthma in the world and chronic obstructive pulmonary disease (COPD) is the second most common cause of medical admissions. There is a higher mortality for patients with COPD and lung cancer in the UK than in comparable countries in the developed world. National audits (for example, LUCADA and COPD) have shown that there are better outcomes for respiratory inpatients if they are cared for in appropriately skilled and staffed respiratory units. Research has shown that UK healthcare professionals are likely to underestimate the survival potential of patients with exacerbations of chronic respiratory disease and this may lead to a reluctance to admit respiratory patients to critical care in the UK.
For many respiratory diseases there are environmental factors that influence disease prevalence. For example, prevalence rates for COPD and lung cancer are related to smoking and social deprivation. Tuberculosis (TB) prevalence is higher in areas with high levels of deprivation and in areas with an above average number of people born in countries with a high TB prevalence. These areas also experience significant problems with multidrug resistant tuberculosis. There is more information on factors affecting TB prevalence published by WHO and more on COPD and lung cancer by the British Lung Foundation.
Conditions such as lung cancer, mesothelioma and asbestosis are related to past exposure to asbestos and high levels are seen in populations who have historically had exposure to these agents (eg areas previously associated with heavy industry such as ship building, railways, steel production, mining or power generation). Pneumoconiosis is seen in former mining areas. Occupational asthma is particularly underdiagnosed. The HSE website has more information on work-related respiratory disease.
Other conditions such as obstructive sleep apnoea are more common in populations with a high BMI and rates are likely to continue to rise in line with the nation’s obesity epidemic.
Given the links between many common respiratory diseases and social deprivation it is important that respiratory services are designed to reach out to the communities they serve.
Respiratory physicians specialising in TB have worked for many years with specialist community teams to deliver networks of TB care. Increasing numbers of respiratory physicians now work in community respiratory teams. In turn, these teams work with primary care colleagues to improve care quality and reduce admissions from COPD and other conditions. Both TB and community respiratory services in particular need to be resourced to provide care to people who are homeless, have significant mental health issues or whose primary language is not English.
Prevention of disease
There is robust evidence that stopping smoking reduces the risk of developing COPD, lung cancer and many other diseases. Smoking also causes poor asthma control. Maternal smoking impacts negatively on fetal lung development and is associated with reduced lung function in adult life. COPD is a disease which is largely avoidable and robust measures need to be in place to deter smoking and exposure to secondary tobacco smoke. Every hospital should have a stop smoking service for both patients and staff. The BTS Stop Smoking Champions programme supports this objective. In 2013, the British Thoracic Society (BTS) developed the Case for Change in conjunction with NHSQI. This includes an online return on investment calculator which demonstrates how cost effective it is to provide in-hospital stop smoking services.
There are a number of other sources of evidence on prevention of respiratory disease:
- Influenza vaccination in at-risk groups reduces morbidity and mortality and should be provided for patients with chronic lung disease. NHS England also encourages all medical staff to have an annual influenza vaccination.
- Public Health England recommends TB screening of migrants from countries where TB is common as an important disease control measure.
- Guidance on the association between radon gas and lung cancer and how to reduce risk is available.
- Losing weight can benefit overweight patients with obstructive sleep apnoea
- How exposure in the workplace can lead to occupational lung disease.
- The links between air pollution and asthma, and COPD exacerbations are explored in this article, as well as a 2016 report by the Royal College of Physicians.
- The link between social deprivation and COPD/lung disease is explored.