PhysioUpdate 16th November 2021

In an exclusive Q&A interview with PhysioUpdate, Rachael Moses tells editor Ian A McMillan about her career highlights and what becoming president of the British Thoracic Society (BTS) means to her and the profession at large. Currently BTS president-elect, Rachael takes over the presidential reins at the society's annual general meeting later this month.

How will your physiotherapy background influence how you approach your presidency at the BTS?

I feel privileged to work as a consultant physiotherapist helping people with respiratory conditions. The autonomy that comes with working at consultant level allows me to practise both independently and offer my advanced skills and opinion as part of a wider specialist multidisciplinary team (MDT). 

Working autonomously means I have to assess, diagnose, treat and evaluate people living with often complex respiratory conditions. At times this can feel quite daunting, but I am well supported by excellent doctors, nurses, other allied health professionals (AHPs) and the wider MDT.

I think this is important and will support me as the BTS is a multi-professional member organisation. Being able to appreciate all of the professional groups that care for people living with respiratory disease is really important to me.                       

Is physiotherapy beginning to realise its potential on national, and even international, multidisciplinary platforms like this?

With so many physiotherapy role models today, there is so much inspiration for the current and next generation of physiotherapy leaders. Being a physiotherapist is integral to who I am and all I have achieved and will remain really important to me as well as being part of the wider AHP family. 

Personally, I am surrounded by physiotherapy role models. For example, in my role as national clinical speciality adviser for respiratory in the personalised care group at NHS Improvement, I work with Aimee Robson, deputy director, personalised care (clinical, workforce and quality) and Andrew Bennett, national clinical director for musculoskeletal MSK – both have physiotherapy backgrounds and are the first non-medics in their posts. 

There is also the wonderful Bev Harden who is our national Health Education England allied health professional (AHP) lead and a physio by background, and the same goes for Steve Tolan, AHP lead for London. 

We also have role models like Dr Melrose Stewart MBE who has been an international trailblazer on healthy ageing and was fundamental in the success of the Channel 4 TV programme ‘Old People’s Homes for 4 Year Olds’. 

And then there other examples, such as Uzo Ehiogu, who is leading the way in military, sports and exercise. Uzo has more letters after his name than me and is a huge inspiration.

What top three things will you aim to achieve as BTS president?

• understanding our membership.  Our current membership data aren’t accurate so we are looking to review this over the next year
• increase the diversity of professionals sitting on our specialist advisory groups, committees and board
• help to create a society in which everyone feels like they truly belong 

Working in a variety of roles outside of physiotherapy has really helped me to develop a number of skills I wouldn’t have developed otherwise, and I really recommend others to do the same if they can [Rachael Moses]

Tell us about your ‘day job’ and how you go about filling a number of demanding roles simultaneously

I currently work one day a week as the national clinical speciality adviser for respiratory in the personalised care group at NHS Improvement. I job share this with Mohan, a wonderful GP,  and we really complement each other. This role looks to advise policies, guidelines, pieces of work that are aligned to the respiratory priorities of the NHS long-term plan with particular reference to personalised care.

On the other four days each week I am head of clinical leadership development in the NHS Leadership Academy. I couldn’t have asked for a better job at this stage in my career. Having experienced the very best and worst of NHS leadership, I now have the opportunity to influence the leadership development of others is an incredible opportunity. 

I am so fortunate to be able to continue to work part time as a consultant physiotherapist and currently this is in third sector with charities including Medical Aid for Palestinians, which is very close to my heart.

My additional roles include being a member of the Chartered Society of Physiotherapy Council and honorary student president, but my term ends next month. I am also the multimedia editor of Thorax BMJ and co-chair HMV-UK, the national home mechanical ventilation networking group.

I would love to say being organised is instrumental in working in a number of roles but, to be honest, the key for me is knowing my deadlines and priorities and working from there. There really aren’t enough hours in the day so it’s the only way I can seem to work everything in alongside the day jobs!

Working in a variety of roles outside of physiotherapy has really helped me to develop a number of skills I wouldn’t have developed otherwise, and I really recommend others to do the same if they can.

What inspires and energises you?

I would have given a very different answer to this question over the years, but what always inspires me is seeing the impact of my work, interventions and initiatives on people. This can be patients, families, professionals and peers and the great thing now is as I have progressed in my career, the reach you have is greater than it was when working across a local system or team. 

I have worked in the NHS for over 20 years and feel honoured to say this: I work with the kindest, most compassionate and caring people who have dedicated their lives to others. 

This feeling has been even more profound over the last two years and, as hard as times are now, we will get through this together. It is this belief that gives me the motivation to continue wanting to be better and empower others to do the same. 

To find out more about the British Thoracic Society, visit: https://www.brit-thoracic.org.uk

Concerns about the infection risks linked to using non-invasive breathing techniques when treating patients with Covid-19 may be unfounded, according to two papers that were published online today (4 November) in Thorax.

Researchers argue that neither continuous positive airways pressure (CPAP) nor high-flow nasal oxygen (HFNO) produces any more air and surface viral contamination than using simple oxygen therapy.

In fact, they found that coughing is responsible for producing far more aerosol than CPAP or HFNO – both of which are currently categorised as ‘aerosol generating procedures’.

Though CPAP and HFNO are not defined as ‘invasive’, there have been concerns that they generated viral particles that could contaminate the air and nearby surfaces, thus requiring added infection control procedures. 

One option was to segregate patients while in another, healthcare workers used high-grade FFP3 masks to curb the risk of aerosol transmission – with both options having implications for healthcare costs and capacity.

Some researchers have shown that environmental contamination occurs with SARS-CoV2, but few have evaluated the impact of CPAP and/or HFNO in moderate to severe cases of Covid-19 – or found viable (infectious) virus, confirming a transmission risk to healthcare workers.

Patients divided into three groups

The researchers in the first Thorax paper divided 30 hospital patients with moderately severe Covid-19 – none of whom required mechanical ventilation – into three groups of 10. They were given either supplemental oxygen, CPAP, or HFNO. 

Each patient was swabbed for SARS-CoV2, and had three air and three surface samples collected from the immediate vicinity. Positive samples and those suspected of being positive were then cultured for biological viability.

Overall, 21 patients (70 per cent) tested positive for SARS-CoV-2 by PCR (polymerase chain reaction) swab. But only four air samples out of 90 (4 per cent) proved to be PCR positive.

Clinical surfaces were more contaminated than the air samples, and nearly half (14 or 4 per cent) of the patients had at least one positive or suspected-positive sample for viral particles from one or more of the three surface samples collected.

In total, 6 out of 90 (7 per cent) surface swabs tested positive for the virus: 5 out of 30 (17 per cent) floor samples (another four suspected); no table surface samples (another three suspected) and only one high-object surface sample (three more suspected).

Neither the use of CPAP nor HFNO nor coughing were associated with significantly more environmental contamination than supplemental oxygen use. Of the total of 51 PCR positive or suspected positive samples, only one from the nose and throat of an HFNO patient was biologically viable in cell culture.

Time to reassess relevant infection control measures

Evolving evidence ... should prompt an evidence-based reassessment of infection prevention and control measures for non-invasive respiratory support treatments [Rebecca L Winslow et al.]

The researchers, led by Rebecca L Winslow from the Department of Infectious Diseases and Tropical Medicine, University Hospitals Birmingham NHS Foundation Trust and the Epidemiology and Public Health Group at the University of Manchester, state that larger studies are needed to reliably inform pragmatic infection prevention control measures relating to the use of CPAP/ HFNO.

They add: ‘The evolving evidence from hospitalised patients with SARS-CoV-2 infection and the risks of occupational/nosocomial exposure should prompt an evidence-based reassessment of infection prevention and control measures for non-invasive respiratory support treatments that are currently considered “aerosol generating procedures”.’ 

'Over cautious measures' have been implemented

In a linked editorial, which has accepted for publication in the journal, researchers from the University of Bristol and North Bristol NHS Trust, point out: ‘This study adds to the mounting evidence that [the aerosol generating procedure] classification is unhelpful in defining risks of transmission. 

‘It has resulted in over cautious measures for certain settings, mandating full PPE for all intubations and preventing relatives visiting the sickest patients, whilst underplaying risk in others, such as coughing patients with early infection in admissions units or on general wards.'

Second study published in Thorax

A second study published in the journal also questions whether CPAP and HFNO merit categorisation as aerosol generating procedures. 

The researchers compared aerosol production from different oxygen delivery systems among 25 healthy volunteers and eight hospital patients who were infected with Covid-19. Aerosol production was measured while breathing, speaking, and coughing room air and then again while receiving CPAP and HFNO in an ultra-clean operating theatre.  

The amount of aerosol produced was highest while coughing; a single cough generated at least 10 times more aerosol than speaking or breathing. Aerosol production wasn’t increased in those receiving CPAP and any aerosols generated during HFNO came from the machine rather than the individual concerned. 

The researchers study conclude: ‘In summary, our data ... suggest that risk of SARS-CoV-2 infection is not due to CPAP or HFNO generating infective aerosols. This has implications for infection and prevention control policy since aerosol generation appears greatest from patients with Covid-19 who are coughing.’ 

CPAP and HFNO: what are they?

• CPAP delivers a steady level of pressurised air and oxygen through a hose and mask to assist breathing
• HFNO pumps oxygen at a high flow rate through two small tubes in the nose
• 17 per cent of people admitted to hospital as emergencies due to Covid-19 needed non-invasive respiratory support or mechanical ventilation (based on an ‘estimate’ relating to UK data gathered in 2020)

To see the full version of SARS-CoV-2 environmental contamination from hospitalised patients with COVID-19 receiving aerosol-generating procedures, visit: https://thorax.bmj.com/content/early/2021/11/01/thoraxjnl-2021-218035

To see the full version of Aerosol emission from the respiratory tract: an analysis of aerosol generation from oxygen delivery systems, visit: 
https://thorax.bmj.com/content/early/2021/11/01/thoraxjnl-2021-217577

A final version of Coughs and sneezes spread diseases – but do “aerosol generating” procedures? A final edited version of this editorial will appear on the journal's homepage in due course.