One in five people in Scotland live with a lung condition, varying from common conditions such as asthma, COPD and sleep apnoea to rarer conditions such as sarcoidosis.
They include conditions that can be managed long term such as bronchiectasis as well as conditions that are currently terminal such as mesothelioma. Following a diagnosis every condition needs prompt, effective treatment often requiring a multidisciplinary approach.
We have identified five lung conditions where improvements in the delivery of effective care can result in high-impact changes to people’s respiratory health. These are asthma; chronic obstructive pulmonary disease (COPD), bronchiectasis; interstitial lung disease (in particular IPF); and sleep apnoea.
Asthma
Asthma is a condition that affects 1 in 14 people in Scotland of any age. It is an important factor in repeated respiratory infections in children and causes breathlessness in adults. If undiagnosed or inadequately treated it can lead in the short term to potentially life-threatening asthma attacks and in the long term to irreversible damage to the airways.
Once a diagnosis of asthma has been achieved, information about asthma which is relevant, easy to understand and in an accessible format should be provided. Those diagnosed should all be provided with a personalised digital asthma action plan (which have been shown to prevent hospital admissions) and what to do in the event that their asthma becomes uncontrolled, including training in inhaler technique to make sure medicines are as effective as possible.
Chronic obstructive pulmonary disease (COPD)
COPD is a chronic progressive disease of the airways associated with high morbidity and mortality. It is largely managed in primary care but exacerbations (or sudden worsening) of symptoms) often result in admission to hospital. Secondary care is involved with providing increasingly more complex interventions such as domiciliary ventilation and assessment for referral to surgery. Regular inhaler and symptom reviews in primary care, smoking cessation support, self-management initiatives, long-term oxygen therapy and pulmonary rehabilitation programmes can all improve quality of life and reduce hospital admissions. As the disease progresses, accessing palliative care services can improve the quality of life of patients with advanced disease.
Bronchiectasis
Bronchiectasis is a condition characterised by chronic sputum production and frequent lung infections, often requiring hospital admission. People with a suspected diagnosis of bronchiectasis should have the diagnosis confirmed by chest computerised tomography (CT). Physiotherapy has a major role in its management, helping to reduce infections and hospital admissions.
Interstitial lung diseases (ILDs)
ILDs comprise a large number (over 150) of diverse conditions which primarily affect the lung’s smallest airways and alveolar air sacs. Whilst the cause of some ILDs is unknown, there is an overlap with occupational and environmental lung diseases such as coal and slate workers’ pneumoconiosis, asbestosis and farmer’s lung. It is known that some ILDs are caused by cigarette smoke and others may occur as a reaction to medication. Yet others occur in association with diseases such as rheumatoid arthritis.
Idiopathic pulmonary fibrosis (IPF), the commonest ILD, has shown a greatly increased prevalence over the past 20 years. The median survival for IPF is just three years – a prognosis that is worse than many cancers. Lung transplantation is sometimes the only treatment option to improve survival in some forms of ILD.
Sleep apnoea
Sleep apnoea is a fairly common condition affecting around 4–6% of middle-aged adults. If left untreated it causes daytime sleepiness, impaired vigilance and cognitive functioning, reduced quality of life and is associated with an increased risk of road traffic accidents. The latter risk is particularly important for professional drivers of HGVs and public transport vehicles. Early diagnosis and a prudent approach to treatment should form the basis for sleep apnoea interventions, ranging from lifestyle advice to continuous positive airway pressure (CPAP) therapy and home ventilation for moderate to severe cases.
Vaccinations for our lungs
Far too many people are dying from short-term respiratory illnesses such as flu and pneumonia, which in some cases could have been prevented by better uptake of the flu/pneumococcal vaccination. It is one of the most cost-effective ways of treating someone with a pre-existing respiratory condition and it saves lives. In 2018/19 only 44.6% of people with chronic respiratory disease had the flu vaccination, with younger people with asthma being far less likely to have the vaccination than older people with COPD. Over a quarter of Scots are unsure if they need to get a flu vaccination and one in ten believe the flu vaccination will give them flu, a poll commissioned by our charity found. We therefore believe that innovative solutions need to be found to help more people to access the vaccine.
Asthma + Lung UK Scotland are calling for:
- The expansion of flu/pneumococcal vaccination uptake through out-of-hours delivery/delivery in non-healthcare contexts (supermarkets, shopping centres, etc.).
- Better data to be published by Health Protection Scotland showing the uptake of the flu/pneumococcal vaccination for each different lung disease.
- The free flu/pneumococcal vaccination to be available to all people with asthma regardless of their treatment plan.
- More investment in research into respiratory viruses and how we develop new treatments or prevention strategies.
The right medication at the right time
Using medication properly is key to controlling symptoms so people diagnosed with lung disease can live their lives as they wish. Inhalers are a vital part of treating COPD and asthma but there are significant problems with their use. A recent systematic review suggests that three-quarters of people make errors using their inhaler devices and that this has not changed over 40 years. Adherence to inhaled preventative therapies is also poor.
Over-reliance on short-acting reliever inhalers is responsible for a high proportion of avoidable asthma deaths. It is likely that fewer than half of people with COPD using inhaler therapy and only 1 in 5 with asthma received an inhaler technique check in the last 12 months. It is vital that all relevant healthcare professionals are trained and upskilled in inhaler use and technique in order to do this effectively.
In addition, connected devices for asthma have been developed – particularly smart inhalers which can objectively track, monitor and prompt medication use. Smart inhalers could revolutionise care by managing long-term conditions at scale; enhancing supported self-management; supporting risk stratification; personalising care; reducing avoidable emergency admissions; and improving patients’ safety and quality of life.
Biologic treatments have transformed the lives for many with severe asthma. They work by blocking the activity of some of the immune system chemicals that trigger inflammation in the airways. NICE and Scottish Medicines Consortium (SMC) have approved some of these drugs for severe asthma treatment but just 30% of people with severe asthma are currently eligible for treatment, and of those eligible four-fifths have not yet got access. This means many people are still reliant on toxic oral steroids, which can cause diabetes, cataracts and osteoporosis.
Two anti-fibrotic drugs are available for IPF which can slow down disease progression, helping to improve quality of life. But under NICE guidelines they are only available to patients with lung function of between 50% and 80%, which means that patients in the early stages of disease and more advanced stages are not eligible.
Scotland could be the lead in developing better treatments for those with long-term lung conditions. Through collaboration with scientists across the UK to evidence the clinical utility, clinical validity, cost-effectiveness and care-pathway benefits of innovative diagnostic devices, the next Scottish Government can help to make sure that if you have a lung condition in Scotland you are not left behind the curve.
Asthma + Lung UK Scotland are calling for:
- Additional funding to support the implementation of the Respiratory Care Action Plan for Scotland, overseen by a national clinical lead.
- A dedicated innovation centre for respiratory research, bringing together academia, industry and NHS.
- A review of the GP contract to reverse the fall in the number of annual reviews and spirometry for people with asthma and COPD.
- The development of national databases of people with severe asthma and ILD, whose treatment would largely be secondary care focussed.
- An awareness raising campaign for ILDs to help healthcare professionals and the public spot the symptoms of the condition and improve earlier diagnosis.
- The inclusion of a dedicated respiratory chapter in the next Scottish Health Survey.
- Investment in community-based respiratory specialist nurses and allied healthcare professionals to support people in the community and prevent readmission to hospital.
- Health Boards to improve asthma care that is supported by digital innovation, ensuring data sharing across the NHS to improve asthma care, enabled by the latest digital innovations including smart inhalers.
- Investment in training and support for people living with lung conditions to enable them to engage with the NHS digitally.
- Investment in a tertiary service to support people living with severe asthma based on the hub and spoke model available for IPF. Severe asthma currently affects nearly 3.6% of people with asthma (roughly 10,656 adults in Scotland) and we want everyone who is eligible to have access to biologic drugs through reduced variation in severe asthma care for equitable access to this life-changing medication.
We are therefore calling candidates of the 2021 Scottish General Election to support the below pledge:
Additional funding is needed to support the implementation of the Respiratory Care Action Plan for Scotland, protecting and improving lung health across Scotland