Polly Robinson on behalf of the trainee and student organisers

Tuesday 18th April 2023

9th King's John Price Paediatric Respiratory Conference 2023 - Auditorium

The overarching theme of the conference was set by the opening session. We were called to work with our patients as an interdisciplinary team to advocate against the impact of socioeconomic determinates of health on lung and life trajectories. This rippled and reverberated throughout the next three days.

Professor Brand highlighted the gap between our belief that we are sharing decisions with our patients and their lived experience. He then bridged this with a model that improves outcomes.

Rosamund Adoo-Kissi-Debrah CBE went on to pass the baton back to us.  Her joint campaigning with Professor Stephen Holgate led to a recognition of the impact of air pollution on children’s lives and lungs. Rosamund acknowledged that clinicians are often reluctant to campaign outside their perceived sphere. She illuminated our power as professionals to affect change that families can’t. It should not be the responsibility of those being affected by this tragedy to fix it, it should be our duty as clinicians to advocate against it.

This profoundly impacted me to overcome my natural reticence on social media, virtual platforms, and controversial issues. With the help of Mums for Lungs my family created a local petition to turn a parking space outside our inner-city flat into a community ‘parklet’ with air-pollution targeted plants. We supported the creation of a local ‘School Street closed to traffic. I gained the courage to advocate for the children in my local community as well as my patients in my professional role.

Professor Ian Sinha immediately picked up Rosamund’s baton. He highlighted that when schemes like cleaner temperamental biomass stoves fail, rather than insisting we should fix the women using them, we should fix the dodgy stoves. And, I would add, as with his recommendation to read ‘Invisible Women’, fix the male focused system. He shared the letter he had written to a local housing association with the family’s consent. It outlined the evidence that their home was harming their child’s health with potentially fatal consequences. The family had been highlighting this for years with no change. Professor Sinha’s letter was immediately escalated to the CEO. The family was moved to safe housing within a week.

This was the first in person conference in three years. The ripples of this spread with Professor Sinha’s PhD students working in the first paediatric clean-air clinic in the country at Alder-Hey being introduced from the balcony where they were watching as an invitation to contact them to learn more. The Royal London research fellows who are piloting an environmental clinic jumped at the chance as did most of the audience.

9th King's John Price Paediatric Respiratory Conference 2023 - Auditorium

Our students noted that “delegates expressed gratitude that the conference was in person”, they “seemed thrilled to socialise and meet with old friends, everyone seemed to mingle really well”. This inclusive atmosphere really impacted on the medical students. “Personally, I learnt so much it’s hard to even put into words. I felt part of a wider community of doctors, which I’ve never felt before. It was brilliant learning about the different career paths the delegates had taken and the experiences they’d had along the way”. “Up until now my identity in medicine has been that of a student, often losing sight of what I’m actually training to be because it feels quite distant. Being around so many passionate doctors made me feel part of that world”. “Another factor was feeling useful. Had I not had set tasks to do at the conference, I probably would have felt much more like an outsider. Having to talk to the delegates as part of my role broke down the insecurity that I would have ordinarily felt talking to people with much more experience than I”.

Boundaries were also broken between multidisciplinary specialities. The most popular and packed practical sessions on oximetry and spirometry were led by physiologists: Jonathan James, Natasha Liddle, and Paula Lowe. This integrated approach reverberated in other hot topics. Dr Chris Grime suggested that teenagers’ chronic sleep deprivation may be a key factor in their poor asthma control, setting the stage for CNS Emily McInnes sleep hygiene talk the next day.

Dr Indra Nareng joined from across the Atlantic in Canada to share how they were trialling using high flow nasal cannula oxygen to treat obstructive sleep apnoea, particularly in their teenage population. And building on new applications our course director Dr Kat Harman demonstrated how non-invasive ventilation could facilitate earlier neonatal discharges, prompting an in-person discussion about how experiences of this differed across the country and how this should best be taken forwards. This prompted me to learn more about how local LTV services could be delivered in our district general hospital (‘This hospital is close to my home’) and analyse our patient feedback to discover their next priority: locally delivered sleep studies – an issue which had generated intense discussion in Thursday’s poster session.

The impact of all this was hammered home in Professor Bush’s state of the art summary: Old before their time. Biopsychosocial factors starting with grandparents’ choices determine children’s lung function trajectories for life. COPD and lung cancer are not adult diseases, they start in utero and earlier. The decisions we make in not only how we manage our patients medically but how we work with them to change the environment in which they live determine their life course. This is a terrifying responsibility but also an amazing opportunity.

Inspired and overwhelmed by the end of the day we were extremely grateful that the hybrid conference model allowed delegates to socialise, meet up with old friends, and make new ones. This culminated in the annual faculty dinner that evening where an impromptu speech recognising the contributions of the late Professor Hans Bisgaard moved many.

Wednesday 19th April 2023

Reinvigorated with purpose and caffeine the second day of the conference highlighted in the words of our student organisers “a massive amount of science and the latest research in the field” for how we could affect the change called for. For the first time knowledge-based assessments for paediatric respiratory subspeciality trainees were incorporated into the programme as early morning sessions, allowing the consultants of the future to meet their training needs whilst educating and inspiring other early career trainees.

The auditorium was packed bright and early for Professor Chang who joined us from Australia to present her data on how childhood pneumonia can change your lung outcomes for life. This echoed throughout Thursday. Integrated discussions in the poster presentation sessions reflected the tertiary pulmonologists fear that not treating a wet cough ongoing for four weeks with antibiotics could lead to serious complications from persistent bacterial bronchitis. Whilst General Practitioners explained the dilemma of balancing the multiple coughing children they see daily with antibiotic stewardship. Our student organisers highlighted that this was one of the strengths of the conference and that really opening the floor up to the audience for certain talks would have increased the interactive aspect even further.

Throughout the day there was a strong emphasis on the psychological aspects for both our patients but also clinicians culminating in Professor Brand’s presentation on how to be happy and avoid burn-out. As Dr Seb Gray tweeted after Professor John Weinmann and Dr Christina Pearce’s talk – it is crazy that only five asthma clinics across the country have a psychologist  as part of their team, given their ability to work on concordance in paediatric asthma.

9th King's John Price Paediatric Respiratory Conference 2023 - Auditorium

Drs Chan, Samuels and Kenia highlighted the shifts in perception of how non-invasive ventilation can be used in neuromuscular disease, as we start seeing it not just as a palliative tool but potentially how early initiation can help active management in concert. Mirroring the difficult conversations raised by the Lung Transplant team on Thursday, especially as families and teams move from standard cystic fibrosis care to standard care plus. Josie Lodge epitomised the power of an integrated approach providing proactive community physiotherapy outreach for neuromuscular patients on NIV, preventing deteriorations, admissions and potentially even deaths.

Responding to the call of the conference opening session the cystic fibrosis symposium focused on those groups whose needs were not being served. Starting in the UK with those ineligible for highly effective modulator therapies, and thus currently underserved in CF research who as one centre’s analysis found are more likely to be older and identify as Pakistani. Then expanded more widely to the experience of paediatric cystic fibrosis patients in South Africa where this tragically may often be a post-mortem diagnosis.

As the conference’s opening session highlighted: inequalities compound. Dr Desai demonstrated how the percentage of those living with CF who identified as Asian was increasing. The number of this group engaged in clinical trials was not. This was despite an increased need for research as this group had a much higher frequency of genotypes ineligible for modulator therapies. To start addressing this the CF Trust’s diversity team had surveyed their patient involvement group’s demographics to discover how representative of the whole CF community they were. This session inspired me to present these concepts to my fellow regional paediatric trainees to challenge us to create a truly inclusive and representative research workforce who involve all of our patients in setting the improvement agenda.

Thursday 20th April 2023

The final day featured the long-awaited paediatric chest imaging course led by Dr Tom Semple and Dr Alistair Calder. The wealth of experience in the faculty soon became clear from their ability to get an entire auditorium of clinicians nodding their heads subconsciously to work out which way tracheal tubes moved on neck flexion then switch to the intricacies of imaging CPAMs and ILD without raising the ambient lighting. Being able to discuss all modalities within the same day highlighted the strengths and interplay of each: chest radiographs are excellent for tube and line placement, or pleural imaging, but to be sure of the underlying pathology of a white out, ultrasound is invaluable before a drain is inserted into a presumed collection that turns out to be tissue or the heart. It also highlighted the progress made in CT and MRI scanners resolution and speed which is of the essence in paediatrics, plus the options for immobilisation to avoid sedation and intubation which can completely change the appearance of the lungs.

9th King's John Price Paediatric Respiratory Conference 2023 - Auditorium

Ms Mira Osinibi kicked off the parallel stream to a packed lecture theatre as she described how best to tackle the epidemic of vaping in our young people. Ms Osinibi’s campaigning on this issue embodied Rosamund’s point, as the government has finally announced new legislation to curb vaping this month. She stimulated the next generation of students who also consider their patients’ perspective: “the talks on clean air and vaping in young people have definitely inspired me. I’d like to get more involved in public education and potentially do some research of my own in those areas. It would be interesting to look into young people’s attitudes towards vaping and cessation”.

Drs Spence, Brodlie and Radtke challenged us to think of those who may have been left behind as they talked about the ‘ten percent’ living with CF who may still progress to severe lung disease and consideration of transplant. Dr Brodlie’s decision to introduce the guidance through questions really broke through the audience’s reserve and allowed a discussion across the nations of complex cases, and the difficulty of predicting if life expectancy is under 2 years. A question Dr Radtke’s modelling is trying to address.

After our third cardiopulmonary workout of the day climbing the stairs to the 8th floor for lunch the physiologists took our breath away with a whistle stop tour of exercise physiology in children. Dr Zoe Saynor used technological advances to explain how children are closer to elite cyclists than other adults; they do not plateau but push to the maximum then suddenly stop. (An experience familiar to anyone who has interacted with a toddler). Dr Urquhart and Dr Radtke made the strong case for the importance of functional testing foregrounding what patients need to do to live their lives.

Again, one of the most stimulating sessions was the interdisciplinary and international discussions provoked by the poster presentations. It was heartening to see how many early career students and trainees were encouraged by the audience. National diversity in how and by whom sleep studies were conducted with differing strengths to the local approaches was echoed in the answers to the thorny question of who should be carrying out emergency reviews 48 hours after an asthma attack with the Australians leading the way.

Consensus was only reached on the need for more multidisciplinary team members and physiotherapists to enhance care. As our medical student reflected: “I particularly felt that there was absolutely no distinction between doctors, physiotherapists and nurses which was really great to see. I think it created a comfortable environment for all clinicians, whereas sometimes conferences may be too doctor heavy and other clinicians may feel under-represented’. This was echoed by Rachel Knight Lozano a paediatric physiotherapist and academic attending for the first time to present her poster on community respiratory health measures in children with cerebral palsy. Mrs Knight Lozano hadn’t previously heard of the conference, but revealed as soon as she shared her experiences with her MDT colleagues they all wanted to come too. For as our student summarised: “there was a little bit of everything for everyone”.

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