The fight against lung disease

 

The Trust is a world leader in the diagnosis, management and treatment of lung disease. Patients from the UK and overseas are treated for the full range of respiratory disorders around the themes of: asthma and allergy; lung failure – including transplant, COPD and sleep and ventilation; lung infection and immunity; lung inflammation and cystic fibrosis; surgical oncology; and lung assessment – including sleep studies, lung function and physiology. 

We carry out over 2,000 treatments for respiratory failure each year, host Europe's largest centre for the treatment and management of cystic fibrosis and are the largest thoracic surgery unit in the UK, providing a full range of chest surgery, including for the treatment of lung cancer. Specialists at Royal Brompton see more people with breathing problems than any other unit in the country.

The Trust’s respiratory teams have always been very research active, in paediatric and adult medicine. We receive regular grant support from the Wellcome Trust, Asthma UK, the CF Trust, and the British Lung Foundation. Professor Andrew Bush is a principal investigator in the Medical Research Council/Asthma UK Centre for Allergic Mechanisms in Asthma (Imperial College and Guy’s/King’s/St Thomas’s hospitals), and is a senior investigator of the National Institute of Health Research. He has been cited more than 9,000 times, which places him among the top 10 respiratory scientists in Europe. Dr Jane Davies is co-principal investigator, with Dr Di Bilton, in the European CF clinical trial network centre based at Royal Brompton, which is one of only four such CF centres in the UK. Dr Davies is the clinical lead for the UK CF Gene Therapy Consortium, which is shortly to start the largest ever trial of gene therapy for children and adults with CF. The Trust’s respiratory consultants and academics lecture all over the world, usually giving more than 100 invited lectures each year.

Lung transplantation – a success story

Improved methods of handling donor lungs such as ex-vivo organ perfusion (where surgeons can re-condition donor lungs by pumping a bloodless solution containing nutrients, steroids and antibiotics through them inside a protected chamber, outside the body), and the use of non-heart-beating donors, has helped to increase lung transplant activity over the last two years. The Trust now has the most active lung transplantation programme in the UK, providing over a third of the nation’s lung transplants.

Revolutionary lung transplant surgery

In October 2010, Harefield Hospital was the first transplant centre in the UK to perform pioneering lung transplant surgery that dramatically improves recovery times and long-term wellbeing.

The new minimally invasive lung transplantation differs from established methods because it does not require surgeons to cut through the sternum to open the entire chest. Instead, organs are replaced individually via small incisions in the side of the ribcage. The benefits to patients include fewer wound complications and less bleeding and pain.

The landmark surgery was performed by Harefield’s director of transplantation, Mr André Simon, who also helped to develop the technique. He says: “It is still a major operation. However, as the sternum remains intact, this means much less post-operative pain and the patient is able to breathe for themselves within hours, generally spending one night in intensive care, as opposed to several days.”

Cystic fibrosis – patients from all over the south of England

Cystic fibrosis (CF) is an inherited, life-limiting disease, mainly affecting the pulmonary and digestive systems. The Trust has the largest paediatric cystic fibrosis clinic in Europe and the only larger clinic is our adult service. Co-location with adult services allows seamless transition in this as in all other respiratory diseases. Being based within a specialist hospital gives CF patients access to not only the very best in respiratory treatment, but also to often life-saving care provided by co-located services, such as our anaesthetic team and intensive care unit.

We are a world leader in the development of new treatments, diagnostic services and training. As the only unit south of Liverpool able to offer a nasal potential difference test to diagnose cystic fibrosis, we receive referrals from throughout the south of England, Wales and Ireland for this investigation, while also training investigators from CF units throughout Europe.

CF outreach services – working to keep patients out of hospital

Homecare service

The Trust’s CF service offers specialist nursing and physiotherapy to young CF patients at home, providing flexible, joined-up care between the hospital, the family and local services.

Homecare visits offer monitoring and assessment between routine appointments or following a course of antibiotics, physiotherapy offering advice on airway clearance techniques and exercise, and support following diagnoses and new treatments. The visits also offer families the undivided attention of a health professional away from a busy ward or clinic in the security and privacy of their own home. The homecare team complements the services offered by local health professionals and works closely with them. School visiting to educate and train staff is available at the request of parents and carers.

Adult CF outreach service

Continuing care for adults is offered by our adult CF outreach service, which aims to help patients maximise their independence, while maintaining their treatment programme. The outreach team, comprising specialist nurses and physiotherapists, provides a holistic service – examining patients, carrying out routine investigations, making clinical decisions and prescribing medication. As well as supporting conventional hospital treatment at home (e.g. intravenous antibiotic therapy, non-invasive ventilation), they also provide practical, emotional and social support for new diagnoses, transition from paediatric care, employment and educational issues, pre and post natal care, waiting for lung transplantation and end of life. During 2010, an innovative phone clinic was established providing advice and support for all CF patients.

Pulmonary rehabilitation - service reaches out

Harefield Hospital’s pulmonary rehabilitation service has gone from strength to strength since it was set up by consultant chest physician, Dr William Man, and his team two years ago. It is now the largest single-site service in the UK.

The service helps people with long-term lung diseases, such as chronic obstructive pulmonary disease, build up their muscle strength, improve their breathing and quality of life as well as increase their physical performance.

Dr Man says: “We receive about 400 new referrals every year from many different PCTs in west London, Hertfordshire and Buckinghamshire. As our programme is run by a specialist team of highly trained specialist physiotherapists, we are able to treat a wide range of patients with complex lung disease, including those who have had lung transplants or major surgery for lung cancer”.

The programme is supported by the National Institute for Health Research – Dr Man’s research team works closely with the hospital team so cutting edge developments are incorporated into the clinical service to provide the best possible care. “Recent research from our team shows that pulmonary rehabilitation shortly after leaving hospital for a worsening of the lung disease can reduce future hospital readmissions. This shows the enormous potential benefits for our patients and the NHS,” he says.

Patients referred to the service complete a pre-course assessment and are given a bespoke exercise programme. This is carried out in a state-of-the art gym under the supervision of an experienced team of physiotherapists.

The programme lasts eight weeks and is made up of two-hour sessions twice a week, which includes the exercise programme and education talks designed to improve self-management and increase understanding of their lung problems.

Dr Man says: “We have seen excellent results from the programme. More than 90 per cent of referrals have noticed feeling better or much better after completing pulmonary rehabilitation. This is in people who are already receiving the best possible combination of medications for their lung problem”.

“However, provision of pulmonary rehabilitation services is patchy around the country and many centres such as ours have to serve a wide geographical area. To help make it easier for patients to gain access to our services, we have started a community programme near Hayes in Middlesex. This will be run by our specialist physiotherapists using portable equipment in a local community centre. We are aiming to provide high quality specialist care for our patients on their doorsteps.”

Asthma

Trust experts treat more children and adults with severe asthma – unresponsive to standard inhalers, and requiring frequent hospital treatment – than anywhere else in the country. The asthma and allergy teams care for patients with serious allergies – from hayfever to food and drug allergies.
For asthma, the majority of patients are referred from consultants at district general hospitals, while for allergy, patients come from a variety of sources including primary care, because of the largely unmet medical need. There are only two centres in London, for a population of almost eight million.

Occupational asthma

Royal Brompton Hospital, in partnership with the National Heart & Lung Institute, runs the busiest clinical service in the UK for the investigation and management of occupational and other environmental lung diseases. Patients are referred from all parts of the UK for NHS treatment and care. The department has pioneered the investigation of occupational asthma for the past 20 years and runs one of the few laboratories in Europe that specialises in occupational and environmental allergen testing.

Occupational asthma refers to asthma that is caused or worsened while working in particular jobs where allergens are present, most commonly flour, eggs, mammals, latex and seafood but can also be caused by agents that a worker might come into contact with in industries such as spray painting, hairdressing, metalwork, construction, dentistry etc.

This form of asthma rarely responds to standard asthma treatment and usually results in major disruption to a patient’s employment.

Professor of occupational and environmental respiratory disease, Paul Cullinan, and his team, are currently involved in extensive research concerning egg allergy, laboratory animal allergy and baker’s asthma.

They also run regular postgraduate short courses and workshops.

Lung cancer care

The Trust provides specialised care for patients with suspected or diagnosed cancer affecting the chest (thoracic oncology). Patients can expect a whole care package from our multidisciplinary team who work with them and their families to help them choose the best treatment option and assess any needs they might have.

A comprehensive patient service
With a multidisciplinary (MDT) team that includes clinical nurse specialists, thoracic surgeons, respiratory physicians, oncologists, histopathologists, radiologists, palliative care specialists and rehab and therapies professionals, patients benefit from the support of having often national and international experts in one place.

Dr Alison Leary, Macmillan lead cancer nurse at the Trust, says: “Patients are referred to the Trust for different reasons and at different points in their cancer journey. This may be for a diagnostic procedure or curative lung cancer surgery, both of which are highly specialised. The surgical team also performs palliative surgery to improve a patient’s quality of life, which includes helping to alleviate symptoms such as shortness of breath in people living with more advanced cancers. Other very specialist areas include radio frequency ablation, laser surgery, sternal replacement or reconstruction and chest wall reconstruction.”

Most of the Trust’s work is tertiary, therefore the majority of patients are referred from other centres around the country. Colleagues work in close partnership with neighbours at the Royal Marsden, Chelsea & Westminster and Mount Vernon hospitals, meaning patients can expect a seamless and speedy transfer for further treatment where needed – or choose to be referred to a hospital closer to home if preferred. Specialised cases are regularly referred to the team for opinion and treatment, including the diagnosis of unusual chest problems related to conditions such as leukaemia and bone marrow transplantation. A variety of cases are discussed at MDT meetings, which are often attended by specialists from other trusts who are seeking our opinion on their case.

Key facts and figures

• We treat around 500 confirmed cancers each year but also provide a diagnostic service for people with suspected cancer that is much higher – these patients often need the emotional support or care co-ordination offered by our multidisciplinary team.
  
  
• The sarcoma team at Royal Brompton Hospital is the designated exclusive provider of thoracic sarcoma surgical services for the London and South East England, which serves a population of 18.5 million and is the largest sarcoma network in the UK. This came about as the result of the "Improving Outcomes for Patients with Sarcoma" NICE guidance, focusing on centralisation of treatment for these rare cancers to centres with accumulated expertise and a track record of excellent results.
  
  
• Patients travel from all over the country to be treated by our cancer and supportive care team.

Video assisted (VATS) lung resection

In an exciting development for the treatment of lung cancer, video assisted (VATS) lung resection techniques have now been established within the surgical service.

Most resections for lung cancer – removing lung tumours – are performed through an open incision for access into the chest cavity. But for some patients, VATS lung resection offers a suitable alternative that is less invasive as the operation is performed using a series of smaller incisions with video assistance (also known as keyhole surgery).

Evidence to date shows VATS lung resection is already achieving impressive results, with patients who undergo the surgery experiencing less pain and a shorter hospital stay after their operation.

A UK first

In June 2010, a new specialist ‘Lung Laser’ theatre was opened at Royal Brompton, which incorporates the latest technology in lung surgery and the first surgical laser of its kind in the UK. It uses a special wavelength laser beam to remove tumours from patients’ lungs, with minimal damage to neighbouring healthy lung tissue.

The lung laser can be used in tumours of all kinds, including colonic cancers and sarcomas, enabling surgeons to perform complicated lung surgery with greater benefits for patients. These include:

• Targeting and removing individual tumours, significantly improving the patient’s chances of survival.
  
  
• Enabling the eradication of deep-seated and multiple tumours without the need to remove a major section of the lung, preserving lung function and preventing post-operative breathlessness, which improves the patient’s quality of life.
  
  
• Removing multiple tumours faster, therefore reducing the time that patients spend under a general anaesthetic.
  
  
• Eradicating cancer tissue while at the same time sealing surrounding lung tissue, reducing the risk of internal bleeding or air leak from the lung, which can lead to a prolonged post-operative stay.

Mr George Ladas, senior consultant thoracic surgeon at Royal Brompton Hospital, who leads the project, has already performed more than 65 lung laser procedures with excellent results, many of these in patients who were previously declared inoperable in the UK and abroad.

The lung laser was funded by generous donations from the Portnoi family and the theatre is named after Mr Jack Portnoi, who is a patient of Mr Ladas.