Nicholas Hart

• MB BS BSc PhD MRCP FFICM
• Lecturer at King's College London

Introduction Mechanical insufflation-exsufflation (MIE) is a commonly used therapy to augment secretion clearance in individuals with neuromuscular disease. There are no clear evidence-based guidelines on the settings that should be used in different diagnostic groups and how they should be titrated. We report on the settings used in the largest co...

Introduction Patients recovering from severe acute exacerbations of chronic obstructive pulmonary disease (AECOPD) have a 30-day readmission rate of 20%. This study evaluated the feasibility of conducting a randomised controlled trial to evaluate clinical, patient-reported and physiological effects of home high-flow therapy (HFT) in addition to usu...

Weaning from invasive mechanical ventilation is an important part of the management of respiratory failure patients. Patients can be classified into those who wean on the first attempt (simple weaning), those who require up to three attempts (difficult weaning) and those who require more than three attempts (prolonged weaning). The process of weani...

Rationale The impact of extracorporeal carbon dioxide removal (ECCO2R) on work of breathing and aeration in exacerbations of chronic obstructive pulmonary disease (AECOPD) is poorly understood. Objectives The study explores the impact of non-invasive ventilation (NIV) and ECCO2R on respiratory drive, effort and distribution of ventilation in AECOP...

Sniff nasal inspiratory pressure (SNIP) is used to assess respiratory muscle strength in neuromuscular diseases like amyotrophic lateral sclerosis (ALS). The effect of contralateral nostril occlusion and mouth sealing on SNIP measurement are unclear. 81 participants were included (16 healthy, 39 patients with limb-onset ALS and 26 patients with bul...

Once the nature and number of patients with Long COVID was more fully understood, UK secondary care developed services to investigate, treat and support these patients. We aimed to identify evidence for demographic health inequalities based on general practitioner (GP) Long COVID referrals to available secondary care services. Despite Long COVID de...

Rationale Findings from individual trials of physical rehabilitation interventions in critically ill adults have limited potential for meta-analysis and informing clinical decision-making because of the heterogeneity in selection and reporting of outcomes used for evaluation. Objectives The objective of this study was to determine a core outcome s...

Objectives Critically ill adults requiring artificial airways experience profound communication deficits. Studies of interventions supporting communication report disparate outcomes, creating subsequent challenges in the interpretation of their effectiveness. Therefore, we aimed to develop international consensus for a communication core outcome se...

Introduction Many people experience persistent symptoms for more than 12 weeks following SARS‐CoV‐2 infection, which is known as post‐COVID‐19 condition (PCS) or Long COVID (LC). PCS can impair people's quality of life and daily functioning. However, there is a lack of in‐depth research exploring the PCS patient journey, as well as gendered aspects...

Background Acute skeletal muscle wasting during critical illness is common and causes significant morbidity and functional limitation. Myofibre necrosis is a major histological finding but is often considered an unprogrammed by‐product of muscle inflammation. This study sought to evaluate if a form of programmed necrosis, necroptosis, is activated...

Chronic respiratory disease can exacerbate the normal physiological changes in ventilation observed in healthy individuals during sleep, leading to sleep-disordered breathing, nocturnal hypoventilation, sleep disruption and chronic respiratory failure. Therefore, patients with obesity, slowly and rapidly progressive neuromuscular disease and chroni...

Intermittent (or bolus) feeding regimens in critically ill patients have been of increasing interest to clinicians and scientists. Changes in amino acid, fat and carbohydrate metabolites over time might yet deliver other benefits (e.g. modulation of the circadian rhythm and sleep, and impacts on ghrelin secretion, insulin resistance and autophagy)....

Introduction and Objectives Neural respiratory drive (NRD) is central control of breathing maintained through the respiratory muscles, particularly diaphragm and intercostals. NRD can be measured by surface electromyography (EMG) of the second intercostal space parasternal muscles (EMGpara). It is closely correlated to the subjective measurement of...

Objective: To develop an expert-informed (including end users) recovery goal menu for adults recovering from critical illness applicable to the community/home setting. Research methodology/design: Stage 1 Item generation: iterative development of domains, sub-domains, and goals in consultation with former intensive care patients, family members...

Background: There is a significant burden of sleep disordered breathing (SDB) in patients living with severe and complex obesity undergoing pre-bariatric surgery assessment. This longitudinal observational study evaluated the burden of obesity hypoventilation syndrome (OHS) in this cohort of patients and the therapeutic compliance of patients comm...

Respiratory waveforms can be reduced to simple metrics, such as rate, but this may miss information about waveform shape and whole breathing pattern. A novel analysis method quantifying the whole waveform shape identifies AECOPD earlier. https://bit.ly/3M6uIEB.

Home mechanical ventilation (HMV) is a treatment for chronic respiratory failure that has shown clinical and cost effectiveness in patients with underlying COPD, obesity-related respiratory failure and neuromuscular disease (NMD). By treating chronic respiratory failure with adequate adherence to HMV, improvement in patient-reported outcomes includ...

Introduction: Home noninvasive ventilation (NIV), targeting a reduction of carbon dioxide with a combination of sufficient inspiratory support and backup-rate improves outcomes in patients with chronic obstructive pulmonary disease. The aim of this systematic review with individual participant data (IPD) meta-analysis was to evaluate the effects o...

Home non-invasive mechanical ventilation (HMV) with home oxygen therapy (HOT) in patients with persistent hypercapnia following an acute exacerbation of chronic obstructive pulmonary disease delays hospital readmission. The economic impact of this treatment is unknown. We evaluated the cost-effectiveness of HMV in the UK healthcare system using dat...

Background: Duchenne muscular dystrophy (DMD) is a neuromuscular disorder characterised by progressive muscle wasting impacting mobility, ventilation and cardiac function. Associated neuromuscular cardiomyopathy remains a major cause of morbidity and mortality. We investigated the effects of cardioprotective medications [angiotensin-converting enz...

Background Patients presenting with acute hypercapnic respiratory failure due to exacerbations of chronic obstructive pulmonary disease (AECOPD) are typically managed with non-invasive ventilation (NIV). The impact of low-flow extracorporeal carbon dioxide removal (ECCO 2 R) on outcome in these patients has not been explored in randomised trials....

Introduction and Objectives Inhaled corticosteroids (ICS) are frequently prescribed outside guidelines to COPD patients with mild/moderate airflow limitation and low exacerbation risk. This primary care trial explored the feasibility of identifying mild/moderate COPD patients taking ICS, and the acceptability of ICS withdrawal. Methods Open feasib...

Introduction and Objectives Neural respiratory drive (NRD) is central control of breathing maintained through the respiratory muscles, particularly diaphragm and intercostals. It is closely correlated to the subjective measurement of breathlessness in asthmatic and COPD patients (stable state and during exacerbation). NRD has been measured by surfa...

Excessive dynamic airway collapse (EDAC) leads to exertional and nocturnal supine dyspnoea, chronic cough and poor sleep, and is associated with a impact on quality of life (QoL). We sought to determine the effect of positive airway pressure therapy (PAP) on symptoms.We included patients with a computerised tomography (CT) or bronchoscopic diagnosi...

Introduction and Objectives Duchenne’s muscular dystrophy (DMD) is a neuromuscular disorder characterised by progressive muscle wasting impacting mobility, ventilation and cardiac function. Home mechanical ventilation (HMV) has led to improved respiratory outcomes, while the associated neuromuscular cardiomyopathy remains a major cause of morbidity...

Background Current guidelines recommend that patients with obesity hypoventilation syndrome (OHS) are electively admitted for inpatient initiation of home non-invasive ventilation (NIV). We hypothesised that outpatient NIV setup would be more cost-effective. Methods Patients with stable OHS referred to six participating European centres for home N...

Background Inhaled corticosteroids (ICS) are frequently prescribed outside guidelines to patients with chronic obstructive pulmonary disease (COPD) with mild/moderate airflow limitation and low exacerbation risk. This primary care trial explored the feasibility of identifying patients with mild/moderate COPD taking ICS, and the acceptability of ICS...

Management options for patients with COPD with persistent breathlessness can range from non- pharmacological, to pharmacological, to mechanical interventions. This case discusses a patient with severe COPD who was referred for lung transplantation; however, he was eventually managed with daytime non-invasive ventilation (NIV).

Background Inhaled corticosteroids (ICS) are frequently prescribedoutsideguidelines to COPD patients with mild or moderate airflow limitation and low exacerbation risk, despite little evidence of benefit and risk of adverse effects. This trial explored thefeasibilityof ICS withdrawalfrompatients with mild/moderate COPD in primary care. Methods Open...

for the RECOVERY-RS Collaborators IMPORTANCE Continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been recommended for acute hypoxemic respiratory failure in patients with COVID-19. Uncertainty exists regarding the effectiveness and safety of these noninvasive respiratory strategies. OBJECTIVE To determine whether eithe...

Introduction Patients with spinal cord injury (SCI) often require complex ventilatory management but limited data exist on this cohort of patients. We sought to characterise the cohort of SCI patients who have received mechanical ventilation at our tertiary ventilation centre. Methods A retrospective database evaluation of all patients referred to...

Introduction Physical activity (PA) and sleep quality are commonly impaired in COPD, are associated with increased exacerbation frequency, healthcare utilisation and death, and deteriorate during acute exacerbations (AECOPD). Their post-discharge trajectories following hospitalisation with AECOPD and associations with patient-reported and physiolog...

Introduction Post-polio syndrome (PPS) can affect patients decades after initial polio-virus infection and is characterised by new slow onset neuromuscular weakness, fatigue and pain. Hypoventilation is a feature when respiratory muscle weakness occurs. We assess the relationship between symptoms of PPS to diagnosed sleep disordered breathing (SDB)...

Introduction Patients recovering from severe acute exacerbations of COPD (AECOPD) have a 30-day readmission rate of 25%. High-flow therapy (HFT) improves mucociliary clearance, dead space washout and pulmonary mechanics in stable COPD. This study aimed to determine the feasibility of a Phase III randomised control trial (RCT) of home HFT to improve...

Introduction Deaths from severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection continue to increase in the UK. Patients with pre-existing comorbidities, including obesity and chronic respiratory disease, have been shown to be at increased risk of adverse clinical outcomes. The impact of COVID-19 on the survival of patients establis...

1 KCL-London (United Kingdom), 2 GSTT-London (United Kingdom) Post-Polio Syndrome (PPS) may affect patients long after their initial viral infection. There are limited data reporting the impact of PPS on sleep. We investigated the prevalence of sleep disruption and sleep disorders in a cohort of PPS patients. We analysed the data of a large tertiar...

1 Guys and St Thomas NHS Foundation Trust-London (United Kingdom), 2 Kings College-London (United Kingdom) Post-polio syndrome (PPS) is characterised by fatigue, pain and neuromuscular weakness often decades after the initial poliovirus infection. This retrospective study evaluated outcomes from the only British residential self-management programm...

Background Both continuous positive airway pressure (CPAP) and high-flow nasal oxygenation (HFNO) have been recommended for acute respiratory failure in COVID-19. However, uncertainty exists regarding effectiveness and safety. Methods In the Recovery-Respiratory Support multi-center, three-arm, open-label, adaptive, randomized controlled trial, ad...

Background: We sought to determine whether peaks in essential amino acid concentration associated with intermittent feeding may provide anabolic advantages when compared to continuous feeding regimens in critical care. Materials and methods: We performed a secondary analysis of data from a multicentre trial of UK intensive care patients randomis...

Background The optimal interface for the delivery of home non-invasive ventilation (NIV) to treat chronic respiratory failure has not yet been determined. The aim of this individual participant data (IPD) meta-analysis was to compare the effect of nasal and oronasal masks on treatment efficacy and adherence in patients with COPD and obesity hypoven...

Purpose: Acute muscle wasting is the most common complication of critical illness, affecting more than 50% of patients. To date, no interventionhas been found to be effective in reducing its development or associated morbidity and mortality. The use of intermittent feeding regimens and highdose essential amino acid concentrations have been proposed...

Introduction Non-invasive ventilation (NIV) is life-saving in exacerbations of COPD complicated by acute hypercapnic respiratory failure (AHRF). These episodes indicate advanced disease and patients who survive the acute episode show significant morbidity and high one-year mortality.¹ In this group, clinicians can be prognostically pessimistic abou...

Introduction In patients treated with non-invasive ventilation (NIV) for exacerbations of COPD (ECOPD), late failure, defined as recurrent respiratory acidaemia during NIV but after 24 hours following normalisation of pH, or relapse, defined as recurrence of respiratory acidaemia during admission but after 24 hours following cessation of NIV, are a...

Background Motor neurone disease (MND) is a relentlessly progressive, incurable neurodegenerative disorder that causes muscle weakness, disability, and mortality. Non-invasive ventilation (NIV) can improve quality of life and survival. Scarce data exists on the preferred location of the initial titration. Therefore, we sought to investigate the adh...

Introduction Conventional lung function testing involves forced expiratory manoeuvres which risk aerosolisation of respiratory droplets and nosocomial transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2/COVID-19). Between-patient decontamination procedures render routine testing impractical. Parasternal electromyography (EMG...

Physiological phenotyping using daily home-based assessments reveals early improvement in load-capacity-drive imbalance following #AECOPD and feasibility of home parasternal electromyography measurement, which tracks symptoms, health status and spirometry https://bit.ly/3o6I0Ty.

Introduction Acute exacerbations of COPD (AECOPD) complicated by acute (acidaemic) hypercapnic respiratory failure (AHRF) requiring ventilation are common. When applied appropriately, ventilation substantially reduces mortality. Despite this, there is evidence of poor practice and prognostic pessimism. A clinical prediction tool could improve decis...

Objectives: To investigate the prevalence of low skeletal muscle index (area normalized for height) and density, their trajectory of change, and to determine associations with clinical outcome in adults with severe respiratory failure requiring venovenous extracorporeal membrane oxygenation. Design: Prospective observational study. Patients: A...

Non-invasive ventilation (NIV) has revolutionized the management of acute respiratory failure in chronic obstructive pulmonary disease (COPD), and is targeted at reducing respiratory system load and work of breathing. Compared with invasive mechanical ventilation (IMV), NIV is associated with a shorter length of ventilatory assistance, reduced leng...

Weaning from mechanical ventilation is an important element of the care of a critically care patient. There are four elements to the liberation of a patient from invasive ventilation. Treating the underlying cause of respiratory failure is paramount. Once adequately treated, the patient should undergo frequent assessment for the readiness to wean....

Objective The trial objective is to determine if Continuous Positive Airway Pressure (CPAP) or High-Flow Nasal Oxygen (HFNO) is clinically effective compared to standard oxygen therapy in patients with confirmed or suspected COVID-19. Trial design Adaptive (group-sequential), parallel group, pragmatic, superiority randomised controlled, open-label...

Humidified high-flow therapy (HFT) is a noninvasive respiratory therapy, typically delivered through a nasal cannula interface, which delivers a stable fraction of inspired oxygen ( F IO 2 ) at flow rates of up to 60 L·min ⁻¹ . It is well-tolerated, simple to set up and ideally applied at 37°C to permit optimal humidification of inspired gas. Flow...

Background: Post-polio syndrome is characterised by symptoms of fatigue, pain and new-onset neuromuscular weakness, and emerges decades after the initial poliovirus infection. We sought to evaluate the only post-polio syndrome specific self-management programme in the United Kingdom. Methods: This was a retrospective study of patients who had co...

Background: Sleep-disordered breathing (SBD) can be associated with hypercapnic respiratory failure (HRF). Home Mechanical Ventilation (HMV) is the preferred long-term treatment for patients with chronic HRF. We reviewed the database of a large tertiary referral centre for HMV to study the long-term adherence to HMV in chronic hypercapnic patients...

Introduction: Although home non-invasive ventilation (NIV) is increasingly used to manage patients with chronic ventilatory failure, there are limited data on the long-term outcome of these patients. Our aim was to report on home NIV populations and the long-term outcome from two European centres. Methods: Cohort analysis including all patients...

https://erj.ersjournals.com/content/56/suppl_64/3085 Background: Neural Respiratory Drive Index(NRDI) is the product of the resting surface parasternal electromyogram(EMGpara) normalised to maximum respiratory manoeuvre and respiratory rate(RR). NRDI reflects respiratory load-capacity balance and can provide insight to disease severity, monitoring...

https://erj.ersjournals.com/content/56/suppl_64/3086 EMGpara non-invasively quantifies neural respiratory drive, which reflects respiratory muscle load-capacity. It provides insights into ventilation optimisation, monitors treatment response and predicts treatment success in certain settings. Acceptable inter-observer reproducibility of EMGpara an...

Background: Increasing numbers of critically ill patients experience a prolonged intensive care unit stay contributing to greater physical and psychological morbidity, strain on families and cost to health systems. Quality improvement tools such as checklists concisely articulate best practices with the aim of improving quality and safety; however...

Background The optimal non-invasive application of external positive end-expiratory pressure (EPAP) to abolish tidal-breathing expiratory flow limitation (EFL T ) and minimise intrinsic PEEP (PEEP i ) is challenging in COPD patients. We investigated whether auto-titrating EPAP, using the forced oscillation technique (FOT) to detect and abolish EFL...