Perceptions and knowledge of lung volume reduction procedures for chronic obstructive pulmonary disease in the Republic of Ireland: A survey of respiratory healthcare professionals

1 Introduction

It is estimated that approximately 500,000 people are living with chronic obstructive pulmonary disease (COPD) in the Republic of Ireland (ROI) with 200,000 of these having moderate or severe disease [1]. The symptomatic burden of COPD can have a detrimental impact on health status, quality of life (QOL) and on an individual’s ability to complete daily activities independently [2, 3]. Frequent exacerbations accelerate the progression of the disease, as well as significantly increasing the risk of hospitalisation and mortality in COPD [4]. Lung volume reduction (LVR) is a management technique for end-stage emphysematous lung disease targeting hyperinflation by resecting or collapsing the worst affected areas of lung tissue, which contribute disproportionately to gas trapping and hyperinflation [5]. LVR techniques can improve exercise capacity, pulmonary function and QOL and prolong survival compared with medical management alone, in appropriately selected patients [6, 7]. The National Institute for Health and Care Excellence (NICE) guideline for the management of COPD gives a Grade A recommendation that patients with severe COPD should be assessed by a healthcare professional for suitability for bronchoscopic or surgical LVR procedures [8].

This recommendation is further supported in the national clinical guideline for the management of COPD as well as international guidelines [9, 10]. Despite this, less than 300 LVR procedures were completed in ROI, by the single LVR centre, between 2016 and May 2023. Given the size of the population with COPD, the pool of potentially eligible candidates is likely to be much larger than this meaning that many patients who may benefit are not being considered for these procedures [11, 12]. LVR procedures have been commissioned for use in the management of severe emphysema in the United Kingdom [13], but no such process is in place in ROI. NICE recommend that the first assessment for suitability for LVR would be completed by a general practitioner, physiotherapist, or respiratory nurse, either at the completion of pulmonary rehabilitation or at routine monitoring appointments [14].

It has been suggested that physicians are reluctant to refer patients for LVR procedures due to a perceived high risk of morbidity and mortality with limited benefit to patients [6]. However, this perception likely stems from the early results reported from the National Emphysema Treatment Trial (NETT), which was a large multi-centre trial in the United States of America (USA) that launched in 1996 [15]. Initial results from NETT studies reported high surgical and short-term mortality rates following LVR surgery [16]. However, NETT subgroup analysis showed improved survival and function in people with upper lobe predominant emphysema and low exercise tolerance compared with medical therapy alone [6]. Increased mortality was shown amongst people with non-upper lobe predominant emphysema [6]. There have since been significant advancements in surgical approaches and techniques and improved knowledge around patient selection for these procedures [17]. Appropriate patient selection is described in the NICE guideline for the management of COPD [8] and a more recent audit of current practice suggests that morbidity and mortality rates are significantly lower than early LVR studies reported [18].

In the United Kingdom, members of the British Thoracic Society (BTS) were surveyed regarding attitudes and access to LVR in 2013 [19]. The results of this survey indicated a lack of knowledge among members regarding the indications and referral process for LVR procedures. As well as this 48% of respondents were either unsure about or overestimated the risk of morbidity and mortality associated with the procedure. The response rate to this survey was extremely low at 2.6%, with only 65 completed responses from the 2,498 BTS members at that time. The authors speculated that the low response rate may be representative of the general lack of engagement with LVR as a treatment technique among respiratory healthcare professionals.

The national LVR service is based in the Mater Misericordiae University Hospital (MMUH), Dublin, which is the national tertiary referral unit for lung transplantation, with access to endobronchial valve and robotic LVR procedures. As there is only one LVR service in ROI, the barriers and facilitators for referral may differ from those identified in the BTS survey which included National Health Service (NHS) staff in Great Britain and Northern Ireland, across multiple providers of LVR services. As well as this, 95% of respondents in the BTS survey were physicians or surgeons, meaning that the results of that survey are not representative of all staff involved in planning the care of patientswith COPD.

The Irish Thoracic Society (ITS) is the official society for healthcare professionals involved in the care of people with chronic or acute respiratory disease in Ireland. The ITS membership pool includes respiratory physicians, thoracic surgeons, general practitioners, junior doctors, nurses, physiotherapists, and other allied health professionals. Currently little is known about the knowledge of the LVR referral pathway and criteria amongst these members. Therefore, this survey of ITS members aimed to explore respiratory healthcare professionals’ knowledge of the LVR referral pathway and criteria and to identify and understand any obstacles which are currently limiting referral and assessment for LVR procedures as well as any training needs which may exist.

2 Methods

3 Results

There were 84 respondents to the survey, 19.9% of the ITS distribution list. There were 30 (36%) physiotherapists, 24 (29%) consultant physicians, 16 (19%) nurses and 14 (17%) NCHDs (Table 1). Fifty-eight respondents (70%) reported over ten years’ experience in respiratory care. Almost half of respondents (41, 49%) are working in hospital inpatient settings with 24 (29%) working in specialist ambulatory care and 19 (23%) as specialist support for general practice. There were no responses from general practitioners or those working in general practice settings. One response was excluded as the respondent identified that they work in an NHS hospital outside of ROI.

4 Discussion

This is the first survey in Ireland to provide insight into the perceptions and knowledge of LVR procedures among respiratory healthcare professionals. Although most respondents were aware of the LVR service and identified the key benefits of LVR, there is uncertainty around the referral pathway and appropriate patient selection which may be affectingreferrals.

Differences were noted in responses between consultant physicians and other respondent groups, and also between different care settings. Referrals to the LVR service are generally made by consultant physicians, however, referrals are also accepted from specialist nurses, physiotherapists and NCHDs and therefore a good understanding of the eligibility criteria and referral pathway is important for all these groups.

The key benefits of LVR identified by respondents were reduced breathlessness, improved QOL, increased exercise tolerance and improved pulmonary function. The reported benefits in this survey are consistent with the published efficacy markers associated with LVR procedures [20].

The survey also aimed to uncover any obstacles which are limiting referral and assessment for LVR procedures as well as any training needs. A need for information about the referral pathway and criteria around patient eligibility and selection was identified. While the eligibility criteria for LVR procedures are outlined in the NICE (2018) guideline for the management of COPD [8], the results of this survey suggest that there is a need to disseminate the criteria to further support implementation in practice. There is potential to achieve this through the development and distribution of specific LVR educational resources and support to those working with patients with COPD.

There was a wide variety of responses provided about the main fears and concerns around referring patients for LVR procedures which made creating themes from the responses more difficult. However, the final themes were agreed by the research team to ensure that the results are representative of the responses provided. Respondents (13%) mentioned concerns about patients feeling disappointed if deemed not suitable for LVR procedures. This highlights the potential need for specific education around expectations or clinical psychology input during the assessment phase to help to manage patient expectations and support them through this process as has been incorporated into lung transplant assessment [21].

There have been significant surgical advancements, including minimally invasive techniques (video assisted thoracoscopic surgery, robotic and bronchoscopic LVR) and improved stapling technology, which have decreased the risk associated with the procedures [22]. Currently, in surgical practice, unilateral thoracoscopic or robotic approaches are favoured compared with open sternotomy or thoracotomy in the NETT study. These advances in surgical and bronchoscopic approaches to LVR as well as improved understanding of appropriate patient selection have made the procedures safer [19]. Despite this, surgical complications, infection, and death were still the most commonly cited fear or concern by respondents. Appropriate selection of suitable patients for LVR procedures was cited by 23% of respondents as a main fear or concern, while a lack of knowledge around LVR procedures was cited by 13% of respondents. Therefore, these could be factors affecting referrals for LVR procedures. Remote satellite assessment clinics supported by the LVR MDT in MMUH may be one method to reassure clinicians and address the concerns around complications and appropriate patient selection. The development of a regional network of LVR specialist sites with referral to the national unit in MMUH for high risk cases is another model which should be considered for LVR services going forward. These clinics could be developed along a similar model to the eight lung rapid access clinics nationally which offer direct access to assessment and diagnosis for suspected lung cancers. Either option would require appropriate staffing and infrastructure.

Although considered to be a costly intervention, long term data from NETT has shown LVR to be cost-effective compared with optimal medical management for people with COPD [23]. The cost of LVR was not cited as a concern by any respondent in this survey and it was the lowest priority for most respondents for inclusion in a training resource.

A response rate of 19.9% from this specialist group of clinicians is higher than the 2.6% response rate to the previous survey of BTS members in 2013 [19]. Nonetheless, future surveys to multiple healthcare professionals could be improved on with advertisement of the survey on social media platforms or at national conferences. Inclusion of profession-specific groups or clinical interest groups outside of the ITS may also have increased the potential pool of respondents. One limitation of this study is that there were no responses from general practitioners or general practice care settings. The ITS is a society for specialist respiratory healthcare professionals, and although general practitioners can be members of the ITS, this is not the ideal forum through which to access this professional cohort. Future research should focus on understanding the opinions of LVR amongst general practitioners through the Irish College of General Practitioners or a similar body. A full breakdown of the ITS membership pool by clinical role was not carried out and therefore it was not possible to identify potential differences between responders and non-responders. Additionally, this survey was specifically directed at respiratory healthcare professionals and patient perspectives were not captured. However, patients will be key stakeholders in the development of training resources and their experiences and voices will be explored at a later stage. Views of patients and their families may also help to identify further concerns or considerations which have not been reflected in this research.

As there is only one LVR service in ROI currently, up to date learning tools need to be explored to make education and training as accessible as possible nationally. Blended learning approaches have been shown to have consistently superior effects on knowledge outcomes compared with traditional learning approaches in health education [24]. Some options for this resource could include flash cards and infographics supported by online educational seminars and these have already been used by the ITS [25].

5. Conclusion

There is a real opportunity to enhance LVR services for people with COPD in ROI. This survey has provided data which can be used to assist in the development of national training resources for respiratory healthcare professionals targeted to the whole range of profession groups and levels of care. Educational resources must focus on patient selection and the referral criteria and pathway. The structure of LVR services nationally also needs to be reviewed. Collaboration is required between the LVR MDT and the National Clinical Programme for COPD, respiratory integrated care hubs, and specialist respiratory clinics nationally to ensure that all potentially eligible candidates for LVR procedures are being considered.

Further development of the national LVR service may require a team approach with leadership from a designated national coordinator for LVR in ROI, who in turn could facilitate education seminars locally around the country and improve links between local centres and the specialist LVR service.