Improving the care of patients with acute respiratory failure on the standard hospital ward

Background Each year, more than 600,000 patients are admitted to NHS hospitals and treated for acute respiratory failure. This serious condition has a high mortality rate (30-50%) with 2.6 million deaths worldwide.

Four out of five of these patients use non-invasive respiratory support including high-flow nasal oxygen, non-invasive ventilation, CPAP, and awake-proning. However, using these technologies relies on a robust assessment of respiratory failure.

The National Confidential Enquiry into Patient Outcome and Death, and the Healthcare Safety Investigation Branch repeatedly highlight failings in treatment use for patients with acute respiratory failure on hospital wards.

Non-invasive respiratory supports fail three out of five patients leading to needing intubation and invasive ventilation in intensive care.

The COVID-19 pandemic further exposed these key problems showing we lack evidence-based clinical guidelines describing how to use these treatments.

We need to identify the best approach to assess patients with acute respiratory failure linking this to simple treatment guidance on effective use of non-invasive respiratory support.

In this fellowship, I will build on my previous research and address this important need, while undertaking a structured PhD research training. Aims 1.

Provide an evidence synthesis of assessment methods suitable for guiding non-invasive respiratory support for patients on hospital wards 2. Understand the acceptability of these methods for patients and expert clinicians 3.

Evaluate the utility of these methods to assess acute respiratory failure and identify patients' response to treatment defining the optimal treatment approaches 4.

Co-design a treatment algorithm with patients and clinicians to guide optimal use of non-invasive respiratory support for acute respiratory failure patients on hospital wards 5.

Explore usability of this treatment algorithm in a proof-of-concept study for acute respiratory failure patients on hospital wards Methods In a systematic review I will combine existing evidence identifying all plausible methods to assess acute respiratory failure patients. I will discuss these methods with international experts through a Delphi process to gain consensus.

I then will interview a maximum variation sample of 30 patients and clinicians, to understand their views and beliefs regarding tolerability and usability of these methods using thematic analysis.

I will evaluate the utility of these methods in a prospective observational study of 100 patients with acute respiratory failure.

I will combine learning from Work-packages 1-3 to co-design a treatment algorithm with patients and clinicians to optimise non-invasive respiratory support.

Finally, I will confirm usability of this treatment algorithm on hospital wards in a proof-of-concept study recruiting 24 patients with acute respiratory failure.

Timeline Months 1-12: Work-packages 1 and 2; months 13-24: Work-package 3; months 25-36: Work-packages 4 and 5; months 36-48: Finalise and submit PhD thesis. This allows for project over-runs and dissemination.

Impact and dissemination My work will define the methods to assess acute respiratory failure and guide use of non-invasive respiratory treatments throughout NHS hospitals wards.

I will disseminate my findings through scientific papers and presentations at national and international conferences, and relevant social media. I will work with patient researchers to ensure my work is widely accessible to patient audiences.