On 5th July was our second Student Panel meeting where we were fortunate enough to receive hands-on practical experience in the labs of the Chest Unit at King’s College Hospital! Our main point of interest today was to investigate measurements of inspiratory and expiratory muscle strength. The session started with all the members reintroducing ourselves to one another and speaking about what we study and what we would like to do in the future. It was great to catch up again and meet new members who I didn’t see at our last meeting! I made a load of new friends who gave me valuable tips regarding university and a career in medicine and science. These activities made us all feel very welcome again and very excited for the afternoon!
We were split into three groups depending on what we’d prefer to investigate and I chose to do respiratory muscle testing. My team’s practical was led by Brittany Best who is a current MSc student. Britt was extremely supportive and reassuring which made us find the practical easy and exciting to carry out. She started by teaching us the names and functions of the equipment which we were going to use; these included nose bungs, mouth pieces and a 3-chamber metal valve which we all used at some point of our practical. We also got to pop in to the other group’s rooms and see the cool stuff they were using such as an ECG! In my team, we performed measurements of inspiratory and expiratory muscle strength using the PImax, PEmax and SNIP technique. The PImax was much harder to carry out because we were not used to the equipment but also because it was so unusual to us! This made us think about how difficult a healthcare professional may find it to get accurate data from a patient’s results as patients can often be giggly or even find the unusual technique very awkward and hence will alter their breathing pattern, either purposefully or subconsciously. To obtain results, patients must suck air into their lungs through a mouth-piece. This may sound simple at first, however it quickly challenged our lung muscle ability when my partner was told to close one of the valves. It felt as though my lungs were about to burst because I couldn’t breathe in any air after a certain point due to the valve, but was generating a lot of pressure in my lungs! The SNIP test was much easier to do as it just involved sticking a nose-bung up your nose and breathing regularly with a little twist: give a powerful sniff after every third breath out. Although it isn’t the most fashionable way to gather results, it sure was easier!
Once we all had a chance to take on the roles of both a patient and the scientist, we each analysed our data to see if our values fell into the predicted range values. After a couple of attempts with Brittany reassuring us that it is tough when you’re new to it, we finally got the hang of it! Our values started looking normal as we got more used to the test.
Once we finished our practical, we then all discussed how these tests might be adapted to different patient populations including younger children or those on intensive care. We discussed about how someone on intensive care may not be able to breathe as they usually would and hence more invasive measures would be taken into consideration such as a technique which runs a tube through your nose and down the back of your throat which allows successful results to be collected. We also thought of the difficulties an individual may face due to weakened muscle strength such as those who suffer from motor neurone disease. The team spoke about how hard it must be for somebody’s biceps to always feel very painful and heavy as if a heavy bag was attached on to them! This made us reflect and contemplate about how difficult their home life could be, especially if they lived alone as simple everyday activities such as walking up the stairs could be a challenge to them.
The day was just as expected: very fun and factual! I always enjoy our student panel meetings as each meeting is different from the rest and always involves activities which I have never done before or even knew existed!
Huge thank you again to Dr Vicky MacBean and everybody else who works hard to make all our meetings amazing!
Sarah Ezzeddine, Year 12, Harris Academy Peckham
On the 7th of July, as part of the King’s College Muscle Lab Student Panel session, we looked at measuring lung function in two ways, Impulse Oscillometry and Spirometry.
Impulse Oscillometry involved measuring the patient’s tidal breathing over 90 seconds at a 5Hz resistance. We felt the procedure was simple, and once you get used to the noise of the machine, easy to get good readings from. We repeated the examination 3 times, layering the graphs to ensure our results were concordant. We saw a regular trace graph over a 90 second period.
Spirometry was a little more difficult to carry out; we recorded some tidal breathing first to ensure the patient was comfortable and ready, then the patient was asked to inhale as much air as possible into the lungs, then exhale as quickly as possible, all air from their lungs (we encouraged this through shouting as we found the first time round both patients didn’t expel as much air as they could!). This gave us a forced expiratory volume in 1 second value. We also repeated this examination to ensure out results agreed.
Both these tests are good in determining aspects of airway function, with Spirometry also giving FEV1 values and vital capacity, and Impulse Oscillometry giving tidal breathing patterns, however for patients with breathlessness which is a common symptom seen in the chest clinic, these tests could be difficult to carry out and gain accurate results, especially from Spirometry. Also young children may find this difficult to carry out, as it can take a while to get used to breathing with your mouth round the mouthpiece and with a nose clip. Overall it was a good experience to get some practical skills in the clinic and gain some valid result and values to analyse.
Estelle Thomas, Year 12, Harris Academy Crystal Palace
Students interested in the Science and Medicine field were recently granted the special opportunity to be a part of the King’s Muscle Lab advisory student panel which took place down the road from King’s College Hospital. Many of those were Year 12 and 13 students who like myself were from the ‘Harris Experience Advanced’ scheme along with some other students from JFS, Burntwood and Graveney schools who were lucky enough to be invited with us! This was the first gathering of the upcoming few for many of the students.
Upon arrival, we met 6 professionals in various fields including Doctors, Physiologists, Physiotherapists and Researchers. Each one gave a helpful presentation about their journeys into their professions and the various routes they took. Some were not as successful as others in their initial attempt. However, this broadened my insight into the very many similar pathways I could take other than Medicine including biomedical research. Our day was based around the broad topic of ‘Physiology’, the study of the functioning of the body, and specifically ‘Paediatrics’.
Soon after, we were assorted into groups with people we’d never met and each group was assigned a speaker to work with for 15 minutes. Here, we had the beneficial opportunity of asking questions that we were curious about. We discussed the differences between adults and children and their lung capacities. We then answered the question “Are children mini adults?” To my surprise, the answer was no. We also got the chance to share our future aspirations with them and gain useful tips and advice including upcoming work experience offers with the team which I am thrilled by!
As an aspiring neurologist, my favorite thing which we spoke about was the topic of brain diseases such as epilepsy, a neurological disorder which causes recurrent seizures in an individual. Also, learning about what causes the irregular brain wave signals which a sufferer experiences was fun. We deduced how factors such as other health conditions, race and age make developing epileptic seizures much more likely. Dr Harris also informed us about children he previously worked with in Uganda where the rate of death caused by open-fires is exceptionally high. Along with this, we brain-stormed the many difficulties a modern family with an epileptic child could face and the future issues which could arise.
Altogether, the experience was fascinating and a great success. Dr MacBean and her team organized it very well for us to feel welcomed and comfortable with one and other despite it being the first time seeing each other. (Side note: the snacks we munched on whilst being fascinated by the works of the respiratory system were lovely and a great aid for helping us absorb the new scientific content we learned.) It was not at all as difficult and fact-heavy as I initially expected it to be and turned out to be one of my favorite experiences so far this year. I will definitely be including this experience on my personal statement in future when I apply for Medicine, which I feel more content in doing after the Muscle Lab!
Special thanks to everybody who worked hard to provide us students with such an amazing experience!
Written by Sarah Ezzeddine, Year 12 Harris Academy Peckham
For those, like me, who love science it is natural to consider becoming a doctor. However, many students have very little idea what this involves and there are limited opportunities to find out more. So I was very grateful to be invited onto the King’s Muscle Lab panel. I went for the first time today and loved it. I have done the usual volunteering and work experience but this gave me a genuine insight into real life inside the NHS – how the moving parts all work together to produce better outcomes. Our panel were able to properly talk to the doctors and other healthcare professionals about their work which was a particularly valuable experience.
I’d never been on a student panel and had no idea what it involved but when I was sent the itinerary with a list of guest speakers I started to get excited! I arrived at King’s College London Institute of Psychiatry, Psychology & Neuroscience (is there anything they don’t do?!) with a few other keen scientists from my school. We were welcomed by Dr Vicky MacBean who introduced us to the ‘Muscle Lab’ and the visiting professionals and then we were off!
Each professional, a mixture of doctors, physiologists and physiotherapists, had fifteen minutes with their group of five to discuss a topic that incorporated everything from child physiology to ethics to care plans to early intervention. I was fascinated to see that so many professionals with such varied backgrounds were all working in the field of respiratory studies whether it was research or clinical. To see how all the healthcare professionals’ work fit together was particularly interesting and very reassuring for those on the panel who are trying to narrow down what they might want to do in the future. Whether you’re the person holding the spirometer measuring vital capacity or the person in the lab examining lung tissue you are part of a wider system that works with the primary focus of caring for patients. All the professionals that we met were at different stages of their career and yet all of them were genuinely enthused to be sharing their experiences with us.
The focus of the session was paediatrics and specifically how this differs to adult healthcare. It was emphasised that children are not just ‘mini adults’. Although all the students attending learnt a great deal it wasn’t like being in a class at school. The small group environment created an easy atmosphere for discussion where every idea was valued and we felt able suggest something that we weren’t necessarily sure was correct. We were guided by our experts but given the ability to be free thinkers.
I had an encouraging and inspiring experience at the ‘Muscle Lab’. It opened my eyes to the complexity of our comprehensive healthcare system which is particularly topical. Instead of leaving fearful for the future of the NHS I left energised by the passion and enthusiasm of those who are working to keep it going. Their desire to include the next generation in their work is admirable and I’m extremely lucky to have met such wonderful people with such passion for the respiratory system!
Post written by Tilly Roberts, Year 12 student at Graveney School, London
Systematic review and meta-analysis of health status questionnaires in bronchiectasis
A recent study regarding Bronchiectasis questionnaires was used to understand the quality of life of patients with a chronic lung disease called Bronchiectasis. These results were used to understand the connections between HRQOL (Health Related Quality of Life) and clinical measures, which are other tools we use to assess a disease. The aims of the study were to identify all the evidence and select the appropriate studies that can later be assessed in an unbiased and balanced way. The importance of collecting this data in this way is that it provides useful insights about the quality of life of patients from a personal point of view and helps the researchers understand the effectiveness of their clinical tools.
The searching and selection process using electronic databases were used to choose appropriate studies, for instance patients with cystic fibrosis (a genetic condition) were not chosen. The studies which were chosen were analysed to check for certain criteria that made sure their results were reliable. Then, a meta-analysis (a combination of various data assessments) was used to test how strong the connections between HRQOL and the clinical measures actually were. Out of the initial 1,918 studies first identified, 43 studies were used in the reviews and 38 ended up being chosen as suitable for the meta-analysis.
Results showed that there was a strong relationship between the HRQOL and subjective outcome measures such as fatigue (tiredness) in comparison to objective measures such as ability to exercise and how severe the Bronchiectasis was revealed to be on a CT scan.
Development and validation of the Bronchiectasis Health Questionnaire (BHQ): a new patient-reported outcome measure
There is an insufficient amount of questionnaires in relation to assessing the health status of someone with bronchiectasis. The questionnaires themselves are easy to understand and they give an idea of the patient’s perspective. A study was conducted to develop and confirm the value of the BHQ (Bronchiectasis Health Questionnaire). The BHQ is a new tool to measure the health status for patients with bronchiectasis. Questionnaires are needed for individual conditions due to the fact that every disease has its own causes and symptoms. This means that in order to help patients with different diseases questionnaires have to be adapted in order that the questions lead to suitable answers which can thus help those asking the questions to find answers that will lead to help for those taking part.
Patients who took part in the study were recruited from two outpatients clinics. The BHQ was developed by the introduction of item generation as well as item reduction. As well as this, the BHQ was developed by repeated testing and validation.
Two hundred and six patients took part in the study and completed a questionnaire with 65 questions. Fifty five of the questions were removed from the initial questionnaire to make the tool easy to use and more valid. The final version of the BHQ consisted of 10 items with a score between 0-100 with 100 being the best health status.
The BHQ generates a total score and general consensus. It can be used in clinical and research settings in order to assess the effect of bronchiectasis from the perspective of the patient who has the disease.
The objective assessment of cough frequency in bronchiectasis
Bronchiectasis is the abnormal widening of the bronchi or their branches, which causes a risk of infection. Cough is a common symptom of this condition and recent advances in technology in the monitoring of cough sound have enabled the assessment of cough frequency to be used to better understand various diseases. This study was aimed at quantifying cough frequency and by doing so investigating how the cough frequency affects the health status of individuals.
54 Bronchiectasis patients were assessed along with 35 healthy people (controls). The researchers measured their health status, cough severity, lung function and 24-hour cough. 24-hour cough was measured using a small portable audio recording device.
Data revealed that the cough frequency was high for patients suffering from Bronchiectasis meaning they coughed a significant amount more that healthy people. Additionally, patients with Bronchiectasis had impaired health status. Various factors associated with the objective cough frequency included sputum production (coughing up phlegm), the frequency of antibiotics for respiratory infections and older age. However, there was no good association between cough frequency and a common lung function test (spirometry).
Overall the studies revealed that questionnaires were a successful technique to provide results regarding the quality of life of those suffering from Bronchiectasis. This shows that a patient’s own perspective is very valuable in medical research and not only their physical condition!
This summarises the PhD research undertaken by Arietta Spinou, under the supervision of Surinder S Birring & Rachel Garrod. The summary was produced by Neta Fibeesh, Abi Mincer & Ma’ayan Dee, Year 12 student from JFS School, Harrow, as part of our departmental educational outreach programme.
Airways Obstruction and Pulmonary Capillary Blood Volume in Children With Sickle Cell Disease
Catherine Wedderburn, David Rees, Susan Height, Moira Dick, Gerrard F. Rafferty, Alan Lunt, Anne Greenough
Published in the journal Pediatric Pulmonology, published online July 10th 2013
Children with Sickle Cell Disease (SCD) often face many obstacles due to the changes the condition causes in the body’s red blood cells. SCD results in anaemia, which is when there is less haemoglobin in the blood to help carry oxygen around the body. As a result, the heart has to pump much harder in order to ensure that the tissues of the body receive enough oxygen. This increased work by the heart also raises the amount of blood in the lungs, in order to allow sufficient oxygen is absorbed from the air. Children with SCD also frequently experience ‘airway obstruction’, which is the narrowing of the airways that makes it then harder to breathe. Airway narrowing can be caused by asthma, where muscles in the airways constrict, or by other causes.
This research was used to investigate whether the increased blood volume in lungs is associated with the ‘obstruction’ of the airways. The researchers tested this through testing the difference in the airways before and 30 minutes after using a medication called a bronchodilator (the blue asthma ‘reliever’ inhaler) which relaxes the airway muscles, widening the airways. The study used measurements called spirometry, which tests the amount and speed of air that can be moved in and out of the lungs, and Impulse Oscillometry (IOS), which uses sound waves in order to assess the resistance of the airways (airway narrowing).
If the bronchodilator had a substantial effect, the researchers would be able to say that the airway obstruction was due to an asthma-type condition, as the inhaler would have relaxed the muscles and allowed air to move more easily through the airways. What the results showed, however, was that there was little change in the measurements of lung function after the inhaler was given. The researchers can therefore use this evidence to support the hypothesis that the airway obstruction in SCD may be due to increased blood volume in the lungs.
Therefore, this study suggests that treatment of non-asthma related airway obstruction in SCD patients could perhaps move away from bronchodilators and towards more effective treatments for the anaemia aspect of SCD such as blood transfusions. A great deal of further work is needed but this is a valuable insight into the a potential process underlying breathing problems in SCD.
This summary was produced by Morgan Walker, Year 13 student from Harris City Academy Crystal Palace, as part of our departmental educational outreach programme.
Neuromuscular electrical stimulation to improve exercise capacity in patients with severe COPD: a randomised double-blind, placebo-controlled trial
Matthew Maddocks, Claire M. Nolan, William D-C. Man, Michael I. Polkey, Nicholas Hart, Wei Gao, Gerrard F. Rafferty, John Moxham, Irene J. Higginson
Published in the journal Lancet Respiratory Medicine, published online December 14th 2015
Patients with severe COPD often have weak legs as breathlessness can limit their ability to be active. Normally, to combat this and other symptoms of COPD, exercise classes called Pulmonary Rehabilitation (PR) are carried out. However, more severely affected patients may struggle to do PR.
An alternative therapy was introduced, neuromuscular electrical stimulation (NMES), to COPD patients with more severe symptoms. NMES is when electricity is used to create muscle contractions, in this case in the thigh muscles. While NMES has been used to strengthen muscles in previous research, this trial is the first to explore the impact on daily activities and the first to investigate the longer-term impact of the treatment.
52 participants with very severe COPD took part in this trial over two years. Participants received 30 minutes of NMES to both sets of thigh muscles daily for 6 weeks; 27 were placebo (‘sham’ stimulation) and 25 received active NMES. The aim: to assess the effectiveness of NMES, as a therapy to be conducted unsupervised at home, and at aiding daily activities. The main measure of effectiveness in this trial was a test of how far participants could walk in 6 minutes.
The results of the walk tests strongly support the use of NMES for severe COPD patients, with the patients who received the active NMES being able to walk substantially further. During interviews active NMES participants expressed a greater ease in everyday tasks (such as climbing the stairs) and stated that they could carry out physical activities for longer. No participants reported any negative views. Unfortunately, the improvement provided by NMES quickly waned after the treatment had stopped. Therefore, all existing evidence suggests that NMES should not be considered a replacement for PR. NMES can be used as an extension to PR, and could be used when patients are unable to take part in PR programmes. In addition, the short duration of effect suggests that longer programmes need to be investigated. Nonetheless, this trial has shown that NMES is a practical home-based therapy, suited to patients with more severe symptoms and has gives suggestions for future research.
This summary was produced by Reef Ronel, Year 12 student from JFS School, as part of our departmental educational outreach programme.
Pulmonary function, CT and echocardiographic abnormalities in sickle cell disease
Alan Lunt, Sujal Desai, Athol Wells, David Hansell, Sitali Mushemi, Narbeh Melikian, Ajay Shah, Swee Lay Thein, Anne Greenough
Published in the journal Thorax, August 2014
Sickle Cell Disease (SCD) is amongst the most prevalent genetic diseases worldwide. Only being inherited if both of one’s parents carry a ‘faulty’ gene in their DNA, SCD affects the Haemoglobin molecules that carry oxygen in the blood, distorting the shape of the red blood cells into so-called crescent shaped ‘sickles’.
It has been shown previously that the majority of adults with SCD have changes in their lungs that can be found on a CT scanner, a high powered X-ray scanner that can create a detailed 3D image of the lungs, including airways and blood vessels.
This study showed that findings like particularly large blood vessels in the lung were linked to reduced lung function. This study aimed to show a link between these changes in the lung and the resulting changes in heart function that one can view on an ‘echocardiogram’ in the same group of patients. An ‘echocardiogram’ is a scanner used to observe the way in which the heart functions, from ultrasound waves ‘bouncing’ off the heart. It can view the structure of the heart and vessels, as well as blood flow. In SCD the heart has to pump more blood through the lungs in order to deliver enough oxygen to the tissues.
Adults with SCD were assessed using CT, echocardiography, and other lung function tests such as lung capacity, between the years 2009-2013. This same group of adults had previously been shown to have lung changes on CT scans between 2003-2005.
Whilst there was a large variety in the lung function of the 28 patients with altered lung features, it was demonstrated that lung structure changes seen on CT scans was related to the patients’ decline in lung function, and changes in the function of the heart displayed on echocardiogram tests. Importantly, the results of the study suggest that some of the changes found in the blood vessels between the heart and lungs may be able to explain the differences in the lungs found on CT scan and the decline in lung function. The results of this study help us to understand the complex relationships between heart, lung and blood vessel function in SCD.
This summary was produced by David Launer, Year 12 student from JFS School, Harrow, as part of our departmental educational outreach programme.
Airway and alveolar nitric oxide production, lung function and pulmonary blood flow in sickle cell disease
Alan Lunt, Na’eem Ahmed, Gerrard F. Rafferty, Moira Dick, David Rees, Sue Height, Swee Lay Thein, Anne Greenough
Published in the journal Pediatric Research, March 2016
Patients with Sickle Cell Disease (SCD) are often assumed to have asthma because they have ‘airflow obstruction’, which is when airways become narrowed and air is not able to move out of the lungs as quickly or easily as in healthy lungs.
Inflammation in the airways is one of the main features of asthma. Nitric Oxide (NO) is a substance that is produced by the airways when they are inflamed, so therefore can be used to measure the severity of asthma in a patient and find out how inflamed their airways are.
As well as being produced in the airways, NO is also produced in blood vessels, and helps to widen blood vessels.
People with SCD are anaemic, meaning they have less haemoglobin (a protein in the body that carries oxygen) so their cells cannot carry as much oxygen. In order to compensate for this, the heart beats faster and with more power to make sure enough oxygen is picked up from the lungs and delivered to the body.
This study looked at measurements of NO from the airways (representative of asthma) and the alveoli (representative of blood vessel widening), and compared it to lung function tests (to look at airway narrowing) and measures of pulmonary blood flow (how fast blood was circulating around the lungs).
The results showed that the airway NO was not raised, but that there was still airway narrowing occurring. There was a relationship between how fast blood was circulating through the lungs and NO from the alveoli. This might suggest that previous findings of high NO and airway narrowing resulted in a false assumption that SCD patients’ airway narrowing was down to asthma. This study suggests that the changes in heart and blood vessel function in SCD may have an effect on the airways.
This study was relevant in terms of contributing to medical research because it shows the airway narrowing in SCD patients may not always be down to asthma, so it therefore allows us to target other root causes of the problem.
This summary was produced by Ashleigh Francis, Year 13 student from Harris City Academy Crystal Palace, as part of our departmental educational outreach programme.