Respiratory Medicine

St. James's Hospital

St James Respiratory Medicine consists of five Respiratory Consultants who provide SJH with the following services

Patient Care

1. Two acute medical services, on a 1:9 on call
2. A dedicated in-patient Respiratory Consult service
3. Daily bronchoscopy service for diagnostic studies, including fluoroscopy, argon-plasma photo coagulation, brachytherapy and endobronchial ultrasound for accurate lung cancer staging.       
4. Pulmonary function laboratory, including cardiopulmonary exercise stress testing, mannitol challenge testing and routine PFT’s
5. Non-invasive Ventilation “unit” for management of unstable chronic lung disease patients
6. Sleep Disorder clinics and full Polysomnography by dedicated Respiratory technicians
7. Multi disciplinary lung cancer clinic
8. National Referral Centre for Tuberculosis operating both an in-patient and out-patient settings.
9. Respiratory Outreach service dedicated to maximizing patient performance and well being and minimizing in-patient admissions in advanced lung disease.
10.  Interstitial Lung disease out-patient clinic
11.  Asthma out-patient Clinic
12.   Pleural disease evaluation including Pulmonary delivered ultrasonography to provide safe and efficient management of both benign an malignant pleural diseases, seldinger placed Cook catheters for chest tube placement with minimal pain, and Abrams pleural biopsy.

Undergraduates who spend time in our department can expect to get first hand experience of management of such diseases as tuberculosis, lung cancer, COPD, asthma, sleep-disordered breathing and interstitial lung disease. For example, we see up to 100 TB cases a year and in excess of 400 cases of lung cancer per year, so the service is very busy. We follow over 200 sarcoidosis patgints in the OPD setting.  This makes St James's Hospital an outstanding place for the undergraduate to get hands-on experience.  Our undergraduates are encouraged to integrate themselves into our clinical teams and involve themselves in patient management during post-call ward rounds and in the out-patient suite. Those who are so inclined are encouraged to become involved in both clinical and basic science research endeavors. 

Tallaght University Hospital

The Professorial Respiratory Centre at Tallaght University Hospital treats and cares for adult patients with all forms of breathing related difficulties including, but not limited to

• Asthma
• Chronic Obstructive Pulmonary Disease
• Lung infection
• Pulmonary Fibrosis
• Disorders of sleep and ventilation, and
• Patients with lung cancer

Our team of consultants, specialist respiratory nurses, specialist respiratory physiotherapists and Pulmonary Technologists work hard to enable those with respiratory disease lead as normal a life as possible.

We care for many of our patients within Tallaght University Hospital, but also manage a 25 bed specialist Respiratory Rehabilitation Unit at Peamount Healthcare in Newcastle Co. Dublin.

We are proud to be the home of Ireland’s first National Centre for the treatment of Pulmonary Fibrosis. Lead by Professor Seamas Donnelly, this state of the art medical unit provides specialised care for patients. Its Specialist Nurse Service offers assistance and advice to GPs, patients, and to their families.

The Professorial Respiratory Centre offers specialised treatment for a wide range of breathing related disorders.

1. Severe Asthma and allied allergic and vasculitic respiratory disorders
   We have a special interest in caring for patients with severe asthma, respiratory allergy and pulmonary vasculitis. Our team of doctors, clinical nurse specialists and pulmonary physiologists treats a large cohort of patients with the main asthma phenotypes such as allergic asthma, eosinophilic asthma and aspirin-exacerbated respiratory disease. We have a therapeutic interest in Monoclonal Antibody Therapy, Bronchial Thermoplasty, and Allergen Immunotherapy. The Professorial Respiratory Centre is a member of the Tallaght Vasculitis & Allergy Group (TVAG). This interdisciplinary grouping of consultants is involved in the management of rare vasculitis and allergic lung conditions such as Churg Straus Syndrome, Wegener’s Granulomatosis, Hypereosinophilic syndrome, Anaphylaxis and Immunodeficiency. We run an active clinical research unit and are involved in multiple ongoing investigational studies into these conditions.
2. Pulmonary Fibrosis
   In our National Pulmonary Fibrosis Centre, we care for patients with Pulmonary Fibrosis referred nationally from Consultant and GP colleagues. One of the largest in Europe, we have a multidisciplinary team of specialist nurses, physiotherapists, pulmonary function specialists, pharmacists and medical doctors who look after referred patients. In addition, the Centre runs joint clinics with our Rheumatology and Nephrology colleagues. It supports the cutting-edge research which is ongoing within the Professorial Respiratory Centre and Trinity College Dublin, seeking to discover why people get Pulmonary Fibrosis, and trying to develop potentially novel therapies to treat the disorder.
3. Disorders of Sleep and Ventilation
   We help and treat patients with respiratory symptoms of Obstructive Sleep Apnoea (snoring, witnessed apnoeas, nocturnal arousals and daytime sleepiness). We investigate using inpatient full or limited sleep studies, or home overnight oximetry studies. We manage patient treatment with nocturnal continuous positive airway pressure (CPAP) in our 25 bed Respiratory unit in Peamount Healthcare. This includes therapy setup, titration, and monitoring.
   We also assist patients with ventilatory failure caused by a variety of conditions including obesity hypoventilation disorders, OSA/ COPD overlap syndrome, Kyphoscoliosis, Muscular dystrophies and Motor Neuron Disease.
4. COPD
   We provide acute management of patients with Chronic Obstructive Pulmonary Disease through the Emergency Department and the Acute Medical Unit in Tallaght University Hospital. We assist and support patients with Early Supported Home Discharge from Tallaght University Hospital through our special COPD Outreach service.
5. Lung Cancer
   Our Lung Cancer Service operates in conjunction with our sister service at St. James’s Hospital, Naas General Hospital and Peamount Healthcare. The Centre treats c.170 new cases of lung cancer per annum.

Comprehensive Summary of Teaching Undergraduates

Undergraduates are invited to admit patients when we are on-call and present them during post-call ward rounds. In addition, they get an opportunity to work up patients in clinics and discuss them with the attending consultant in the outpatients department. Students are actively involved during our bronchoscopy lists and are given responsibilities with respect to the outpatient work up’s of lung cancer and tuberculosis.

During a typical week with us, the undergraduate will attend a dedicated pulmonary conference (Tuesday), where academic discussion of cases occurs, in addition to a tumour board or multi-disciplinary team meeting on Monday morning. We also have a dedicated PFT interpretation session which the students are encouraged to attend and journal clubs/didactic talks (Thursday).

Curriculum Summary

The teaching goals of the Department of Respiratory Medicine are the development of scientific and clinical knowledge, clinical skills, and professional attitude in all students attached to the service.

Scientific and Clinical Knowledge

• Pulmonary physiology and anatomy
• Atmospheric gases
• Ventilation; Boyle’s Law etc.
• Gas exchange
• Ventilation and perfusion relationships
• Pulmonary pathophysiology
• Failure of ventilation (Type 2 Respiratory Failure)
• Failure of gas exchange (Type 1 Respiratory Failure)
• Pulmonary disease
• Obstructive airways disease
• Lung infection
• Pulmonary malignancy
• Sleep and chronic ventilatory disorders
• Interstitial lung diseases
• Pulmonary vascular disease
• Lung transplantation
• Specific therapies
• Oxygen therapy
• Supportive ventilation, both invasive and non-invasive
• Pharmacotherapy for specific diseases
• Indication for therapeutic procedures
• Interpretation of diagnostic studies
• Pulmonary function testing
• Cardio-pulmonary exercise testing
• Allergy testing
• Sleep studies
• Chest radiology
• Arterial blood gas and pleural fluid analysis

Clinical Skills

• Focused history-taking, with an emphasis on cardinal symptoms, timing of symptoms, and risk factors for respiratory disease.
• Clinical examination with a focus on the application of clinical anatomy, and the elimination of redundancy in examination.
• Interpretation of findings from history and examination to develop a logical pathological differential diagnosis.
• Performance of  diagnostic and therapeutic procedures

Professional Development

• Development of communication skills, relating to interaction with colleagues and patients.
• Awareness of basic medico-legal concepts such as confidentiality and consent.
• Accurate note-taking and record keeping

Students attached to the department of respiratory medicine are expected to take a full and active part in the care of patients under the care of the service.

St James's Hopital

The respiratory department is involved in the training of specialist registrars in respiratory medicine and general internal medicine. We provide a dedicated teaching session in this regard. The consultants are also actively engaged in specific tutorial sessions for all parts of the membership exam. Our unit gives the postgraduate trainee a unique opportunity to acquire skills in invasive bronchoscopy, tuberculosis management, COPD work up and interstitial lung disease. Like most aspects of postgraduate training, self motivation is the key component in taking advantage of the unique environment that SJH provides in developing diagnostic and procedural skills. Although many aspects of SPR training involve documentation, in SJH feedback is given monthly to sPRs as to their performance with each individual consultant. A unique aspect of SJH is that the trainee gets to work with all 5 respiratory physicians and can benefit from their unique skills and different approaches.

Tallaght University Hospital

The Professorial Respiratory Centre is an excellent place to learn. Medics work under the direct guidance of renowned respiratory consultants and are based in Tallaght University Hospital & Peamount Healthcare. They learn how best to treat and care for patients with Asthma, COPD, Pulmonary Fibrosis, Lung Cancer and Respiratory Sleep & Ventilation disorders. They gain experience working in the 10-bed ICU Unit in Tallaght, and in the 25-bed Respiratory Sleep & Ventilation Unit in Peamount.  Those with a special interest in research have the opportunity to seek admission to a three year research programme in Trinity College Dublin under the leadership of Professor Seamas Donnelly, Head of Medicine, Tallaght University Hospital & Trinity College Dublin.

Why did you choose Respiratory Medicine and Tallaght University Hospital?

"I was initially attracted to work in Respiratory Medicine as it is a perfect blend of clinical and practical skills; it is very tangible too. I found working on rotation in Tallaght a great learning experience. Everyone was friendly, and I received great support and guidance from consultant colleagues. Working in Intensive care as a part of the SpR rotation was invaluable, as was working in the Respiratory unit in Peamount Healthcare.It was a great opportunity for me to gain in-depth knowledge and experience in the management of ventilatory and sleep disorders."  

Dr. Chithra Varghese, Registrar

"Tallaght Hospital is a very friendly place to work. The Professorial Respiratory Centre provides a variety of experience and learning opportunities. I began my training in the Intensive Care Unit where I learned under supervision how to perform many practical procedures and care for critically ill patients. Starting off my SpR year in such an important area was a valuable experience.  I look forward to working in the Ventilation Unit in Peamount Hospital.  It will be a good opportunity for me to learn how to treat and care for patients with sleep disorders." 

Dr. Aoife O'Reilly, SpR Respiratory Medicine

The department is engaged in basic research as well as translational and clinical research. Current mature projects include many currently under way in the respiratory research laboratory located in the Institute of Molecular Medicine relating to Tuberculosis and Lung Cancer. Research on new bronchoscopic techniques for the staging of lung cancer, use of whole body MRI in the staging of lung cancer, interstitial lung disease and COPD biomarkers are also under way. As the CRC facility is developed at SJH future projects relating to investigation of the pathogenesis Pulmonary fibrosis and sarcoidosis will become operable at SJH.

The conjoint department of respiratory medicine at Tallaght / Peamount Hospitals has developed into an effective research unit over the past few years, which employs, research scientists and technicians, research co-ordinators, pulmonary physiologists, physiotherapists, specialist nurses.  Clinical research is an integral part of the higher training of NCHDs in respiratory medicine. Fortnightly dedicated research meetings are conducted with assessment of research progress in all fronts.

Since 1998, our department has developed an impressive repertoire of published clinical and lab based research.

Research - SJH

For further information on the below Research Project please view the Trinity Translational Medicine Institute website

Delayed Tuberculosis Paradoxical Reaction associated with TNF inhibitors
Tuberculosis  - The generation of new diagnostic tests.
Tuberculosis  - Improving our understanding of the host defence against tuberculosis.
Tuberculosis - Multi-centre trials with the TBNET.
Tuberculosis  -Understanding apoptosis of macrophages as a response to tuberculosis infection.
Tuberculosis - Investigating the transcriptomics of macrophage infection with TB. .
Lung Cancer - Transcriptomics as a new test for lung cancer.

Interstitial lung disease.-Involvement in the ILD research consortium of the Dublin Teaching Hospitals.
COPD.- Developing a new reproducible marker in COPD severity.
Lung Cancer - Bronchosopy techniques.
Lung Cancer - Defining the use of EBUS bronchoscopy in the staging of lung cancer

Research - Tallaght University Hospital

The Professorial Respiratory Centre at Tallaght University Hospital offers significant MD/PhD opportunities for top-class medical graduates from Ireland and abroad.  The research focus of the Department concerns inflammation and the regulation of the inflammatory response and translates to a variety of lung diseases including asthma, cystic fibrosis, lung cancer and pulmonary fibrosis.  In addition the Centre has significant collaborative research programmes relating to connective tissue diseases and rheumatology, atheroma and cardiac disease, haematology and bone marrow transplantation, inflammatory bowel disease and gastroenterology.  Research is undertaken at the Meath Foundation Research laboratories on the hospital campus and at Trinity Biomedical Science Institute (TBSI) in the city centre.  Further details may be found at :-  https://seamasdonnelly.wordpress.com.

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Clinical Trials, Physiological and Molecular Studies in Airway Disease

Clinical Trials

• Multiple phase 3 and 4 multicentre interventional trials in COPD and Asthma.
• International pharmaco-economic study the cost of asthma exacerbations.
• Study of resource utilisation for patients with COPD.

Physiological studies involving the Tallaght Hospital PFT lab

• Alternative objective parameters for assessing the symptomatic benefit of bronchodilators in COPD (2004)
• A comparison of a flow and a volume measurement in the assessment of reversibility in COPD patients (2004)
• A comparison of airway resistance and FEV1 as a measure of airflow obstruction (2004)

Cellular and molecular studies

• Investigation of cellular and molecular mechanisms of synergy between long acting β2 Agonists and inhaled steroids.
• Investigation of the role of the novel eosiniophil chemotactic molecule CCL-28 in asthma; in conjunction with NUI Maynooth.
• Investigation of the role of MIF allele in asthma; in conjunction with SVUH and Yale. 

Clinical Research

Non invasive ventilation

• Description of setting up of this service in acute exacerbations of COPD (AECOPD) at Tallaght Hospital.
• Establishing the cut off pH severity for instigation of NIV in AECOPD
• The use of NIV in patients with Chronic Hypoventilatory Respiratory Failure at Peamount hospital.

Lung Cancer

• A lung cancer audit at Tallaght University Hospital
• Bronchoscopy for the diagnosis and palliative treatment in patients with lung cancer.
• This research is now being extended to look at the role of EUS (endoscopic ultrasound) in the diagnosis and staging of lung cancer (See details below).

Intermediate Care & Pulmonary Rehabilitation (PR) in patients with severe COPD

• Muscle training improved outcomes in PR in COPD.
• Validation and quality assurance of the Active Inpatient Respiratory (AIR) Care programme operating between Tallaght Hospital and Peamount Hospitals. 

Public Health & Epidemiology

• “What GPs want from a Hospital Based Respiratory Service”.
• Multimorbidity in Primary Care:  Exploring the impact on respiratory illness; in conjunction with the department of Primary Care and Public Health, TCD.

Synergy Study

Background: We have developed a safe, reliable and reproducible method of sputum induction in asthmatics. We have demonstrated a clear difference between asthmatic and non-asthmatic individuals in terms of the cellular components of the induced sputum.

We have shown a dose-dependent improvement in the following end-points in asthmatic subject: FEV1, PFR variability, symptoms, induced sputum cellular viability and eosinophilia in asthmatic subjects.  The effects of FP 500μg was similar to 1000μg in terms of FEV1 whereas 1000μg was clearly more effective than either 500μg or 200μg in the suppression of variability of PFR, sputum cellular viability, sputum eosinophilia and symptoms.

The purpose of our study is to assess the  in vivo “synergy” of Salmeterol xinafoate/fluticasone propionate (50/250 BD) via a single Diskus inhaler (combination) versus salmeterol xinafoate (50 BD) and fluticasone  propionate (250 BD) via separate Diskus inhalers (concurrent treatment) on eosinophilic inflammation in the lungs of adult subjects >/= 18 years old who have moderate bronchial asthma.

Methodology:  At an initial screening visit, subjects will be given written informed consent and undergo spirometry and sputum induction. Subjects with an ability to expectorate sputum after hypertonic saline inhalation and a percentage of eosinophils in the induced sputum of >/= 3% will be randomised at a second visit to receive either combination or concurrent medication for a period of 8 weeks. After this period, at visit 4, subjects will undergo spirometry and sputum induction.

This study is currently in the patient recruitment phase.

Asthma: Local IgE Therapy

Local efficacy audit of Anti IgE therapy:

We have been using anti-IgE therapy for the treatment of selected patients with resistant allergic asthma in accordance with international guidelines. Our experience with Anti-IgE therapy in Tallaght hospital has corroborated international findings of reduction in exacerbation rates, hospitalization, reliever inhaler use, oral corticosteroid use and improvement in FEV1 with an overall 71% response rate.

The use of EUS in the disease staging

The use of endoscopic ultrasound with fine-needle aspiration (EUS-FNA) is well established in diagnosing and staging non-small cell lung cancer with positron emission tomography (PET) positive posterior mediastinal lymph nodes. The sensitivity of EUS-FNA ranges between 83 and 96 %. It is less invasive and has lower complication rates when compared to surgical staging of mediastinal nodes. This study aims to describe our initial experience of EUS-FNA in lung cancer.

EUS-FNA was used prospectively for the assessment of PET positive mediastinal lymph nodes between January 2007 and July 2008. When EUS-FNA did not show malignant invasion, a confirmatory mediastinoscopy was done. Endpoints were performance of EUS-FNA, morbidity and length of hospital stay.

23 patients underwent EUS-FNA during the study period for both diagnosis and staging. 20 patients had positive lymph node invasion and 3 had no evidence of malignant invasion on EUS-FNA. Negative cytology on the latter 3 was confirmed on mediastinoscopy giving EUS-FNA a sensitivity of 100% for the study period. It upstaged the disease in 15 patients.

EUS-FNA is reliable, non-surgical tool for mediastinal staging. It reduces the need for surgical staging procedures in lung cancer patients with suspected mediastinal involvement. The limitation of this study is the poor documentation of the lymph node stations that were sampl

Compliance in the Measurement of CURB-65 in Patients with Community Acquired Pneumonia and Potential Implications for Early Discharge

Paper Published in IMJ May 2008 Vol 101, N 5

Background: The CURB-65 community-acquired pneumonia (CAP) severity score is a convenient 5-variable disease-specific tool validated to predict mortality and the decision to admit.

Rationale: This prospective study seeks to determine (a) the accuracy CAP diagnosis; (b) the degree to which the CURB-65 score was being documented; and (c) the degree to which CURB-65 was being utilised as an admission and early discharge tool in the A&E Department in the evaluation of patients presenting with CAP.

Methods: A prospective audit of the use of CURB-65 criteria in patients admitted to Tallaght Hospital, Dublin with a diagnosis of CAP was carried out over a 5-month period between August and December 2006.

Results:  Of 45 patients referred with an admitting diagnosis of CAP, 28 were subsequently found to satisfy the criteria of CAP, an over diagnosis of 38%. Documentation of
CURB-65 was 7%; recording of core variables was 81% i.e. 4 out of 5 variables and confusion was the variable least likely to be documented. On re-scoring, 50% of patients had a score of 0 or 1 and a further 28% had a score of 2. We conclude that CAP is significantly over diagnosed; that the CURB-65 severity score is not being utilised and that between 50 and 78% of patients with CAP may be admitted unnecessarily. This study raises important issues in the current management of CAP in the Irish Healthcare system.

Prophylaxis of Venous Thromboembolic Disease: Enhancing Compliance
Venous thromboembolic disease (VTED) is a major cause of morbidity and mortality among hospital inpatients.  A variety of methods of prophylaxis have been shown to reduce incidence of VTED in medical patients. We sought to assess compliance with current international guidelines in a medical inpatient population in our institution, as well as the impact of a simple educational intervention at ward and emergency department level. 
Data was collected from acute medical and specialist wards on two separate dates, approximately a month apart. The management of 150 patients was assessed on each date. Following completion of the first survey, medical teams were informed verbally that their practice was being audited. Simultaneously, educational pamphlets and posters were placed in strategic locations on medical wards and in our A&E. 
At baseline, prophylaxis was indicated in 64% (n=96) of patients. Of these 48% (n=47) received appropriate therapy. Compliance was best among specialist disciplines such as stroke medicine. Acute medical teams fared less well. Among the post-survey cohort, prophylaxis was indicated in 61% (n=92), and prescribed in 58 (n=63%) (p=0.52 for comparison) of these.

Our results suggest that simple educational measures can improve compliance with established international guidelines.

Results
VTED Prophylasis Compliance
Rates of Compliance by Speciality
Rates of Compliance by Ward Type

Potential Impact of a Workplace Smoking Ban on Acute Medical Admissions in a Dublin Teaching Hospital
In light of the Irish workplace smoking ban of March 2004, we sought to evaluate any potential impact of this ban on medical emergency admissions. Data for acute medical admissions during the two year periods preceding and following implementation of the workplace smoking ban (i.e. January 2002 – December 2003, and January 2005 – December 2006) were obtained via the Hospital In-Patient Enquiry (HIPE) system.

We compared the proportion of admissions due to respiratory and cardiovascular disease in the two time periods. There was a statistically significant decrease in the overall proportion of admissions due to acute respiratory and cardiovascular illness following implementation of the workplace smoking ban. This effect was observed among smokers and non-smokers alike. There was a trend towards reduced respiratory admissions among non-smokers vs. smokers. 

• Respiratory and Cardiovasular Admissions
• Pneumonia, Asthma, COPD, 8P and PE levels 
• Insem, Stem, Unstable Angia, Stroke and TIA levels
• resp smokers, resp non smokers, cvs smokers and cvs non-smoker levels

We are currently compiling retrospective data pertinent to our affiliated intermediate care facilities with regards their impact in optimisation of patient care in the acute setting, facilitation of discharge and chronic disease management. The long term goal of this endeavour is the definition of new processes in chronic respiratory disease management strategy. This focuses on initiatives to facilitate the optimal management of respiratory patients, apart from sending them to A&E or OPD. We are looking at the impact of Peamount Respiratory Rehabilitation Unit, Hospital in the Home, C.I.T., Pulmonary Rehabilitation, and COPD Outreach.

St James's Hospital

Tallaght University Hospital

Naas Hospital