Riina Richardson speaks on how to avoid exposure to moulds and Physio Phil Langridge gives us several exercises to do that are vital to maintain muscle in patients during long bed stays.

1. Support Meeting for
Aspergillosis Patients & Carers
LED BY GRAHAM ATHERTON
SUPPORTED BY
GEORGINA POWELL, DEBBIE KENNEDY & DEB HAWKER
NAC CENTRE MANAGER CHRIS HARRIS
AVOIDING MOULDS – RIINA RICHARDSON
NATIONAL ASPERGILLOSIS CENTRE
UHSM
MANCHESTER
Fungal Research Trust

2. Car Parking
£3 all day in the Nightingale Car Park (opposite
NWLC)
Leave note in your windscreen saying
North West Lung Centre Delegate

3. Programme
 1.30 Riina Richardson– Avoiding moulds
 1.50 Phil Langridge (Physio Phil)– Keeping strong on the
ward
 2.15 Carers Discussion
 What issues do carers want to talk about
 Private/public?
 2.30 Patients Discussion
 What issues do patients want to talk about
 Private/public
 2.45 Group discussion
 Issues of the day

4. How to avoid
exposure to fungi?
Riina Richardson
DDS, PhD, FRCPath
Consultant in Medical Mycology and Senior Clinical Research Fellow in
Infectious Diseases
University of Manchester, Institute of Inflammation and Repair and
University Hospital of South Manchester

5. Classification of fungi and fungal diseases
• >100,000 species of fungi but only <500 have been
associated with human disease and <100 can cause
infection in immunocomptetent hosts.
• Many human infections are caused by environmental fungi
acquired through inhalation, ingestion or trauma
• Others are caused by human commensals > opportunistic
endogenous infections.
• Most have worldwide distribution, others are endemic to
specific geographical regions.
• Some can spread from person to person

6. Fungal lifestyle preference is a biofilm
• Most fungi prefer biofilm lifestyle
• Biofilms are organised microbial communities that are innately
resistant to antimicrobials and host immune mechanisms.
• Biofilms are typically formed on an artificial non-shedding
surfaces
• Biofilm infections cannot be treated with antimicrobials alone.

7. Classification of fungal diseases
1. Superficial mycoses
2. Subcutaneous mycoses
3. Deep mycoses caused by opportunistic
pathogens
4. Systemic mycoses caused by opportunistic
pathogens
5. Systemic mycoses caused by primary pathogens
6. Allergic fungal diseases

8. Deep / systemic Superficial infection Hypersensitivity,
infection asthma
Weak Strong
Casadevall A, Pirofski LA. The damage-response framework of microbial pathogenesis.
Nat Rev Microbiol. 2003;1:17-24.

10. Aspergillus in the air!

11. What do moulds need to thrive?
organic matter + moisture + warmth

12. Moisture??

13. Organic matter?

14. Organic matter?

15. Organic matter?

16. Organic matter?

17. Organic matter?

18. Organic matter?

19. Fungal biofilms?

20. Person to person spread

21. How can fungi be avoided?
X
X
X

22. Ventilate!!!

23. Ventilate!!

24. Keep house clean and tidy!

25. Keep house clean and tidy!

26. Staying strong in hospital
Philip Langridge
Specialist Physiotherapist
15/03/2013

27. The problem :
• It is estimated that people in the hospital can
lose from two percent to five percent of their
muscle mass per day.
• This loss of muscle mass is of great concern
because it can lead to a decline in daily
functioning, falls, immobility, and an increase
in frailty

28. Curr Opin Clin Nutr Metab Care. 2010 January; 13(1): 34–39.
doi: 10.1097/MCO.0b013e328333aa66

30. Consequences of bed rest and immobility
• Cardiovascular
– ↓Exercise tolerance/ VO2 max
– ↓ Cardiac output
– ↓ resting and maximum stroke volume
– ↓ orthostatic tolerance
– Venous pooling
– ↑ resting heart rate
– ↑ venous compliance
• Haematologic
– ↑ deep vein thrombosis risk
– ↓ blood volume
– ↓ red blood cells

31. • Musculoskeletal
– Muscle atrophy (disuse atrophy)
– ↓mitochondria density/ ↓ aerobic enzymes
– Bone demineralisation/ osteopenia/ osteoporosis
• Pulmonary
– ↓ lung volumes and capacities
– ↓respiratory muscle strength
– ↑ risk for pneumonia/ pulmonary emboli

32. • Metabolic/ endocrine / electrolytes
– ↑ insulin resistance
– Hypercalcaemia / renal stone formation
– ↑ urinary excetion of sodium, calcium, and phosphorous
– ↓thermoregulation
• Psychiatric
– ↑ anxiety
– ↑agitation
– ↑ delerium
– ↑depression
• Nutrition
– Cachexia/ malnutition
– Obesity

33. A 30-Year Follow-Up of the Dallas Bed Rest and Training Study I. Effect of
Age on the Cardiovascular Response to Exercise
• Conclusions— Cardiovascular capacity declined over the 30-
year study interval in these 5 middle-aged men primarily
because of an impaired efficiency of maximal peripheral
oxygen extraction. Maximal cardiac output was maintained
with a decline in maximal heart rate compensated for by an
increased maximal stroke volume. Most notably, 3 weeks of
bedrest in these same men at 20 years of age (1966) had a
more profound impact on physical work capacity than did 3
decades of aging.

34. Barriers to exercise on the ward:
– Vigorous exercising whilst ill is a bad
idea!
– Especially
• if you are wheezy
• have a temperature
• low numbers of white blood cells
• fast heart rate
• low oxygen levels needing lots of oxygen
therapy to sort out
– There is an expectation to “take it easy,
rest and recover”. But……………..

36. What exercise can I do on the ward?
• Lying
– Static quads
– Inner range quads
– Straight leg lifts
– Static gluts
– Shoulder elevation
– Bridging
• Sitting
– Trunk rotation
– Shoulder elevation
– Knee extension
– Bottom walking
– Chair marching
• Standing
– Heel pumps
– Single leg stands
– Mini squats
– Hip ext
– Hip abduction

37. What equipment is there to hand?
• Water bottles (with lids) make
great weights
• Bed rails / tables for balance
• Physios may provide dumbells/ ex
pedals etc
• Stairs
• Wall
• Wear shoes/ sensible clothing
• Paper and pen (e.g. to plan what
you’re going to do and to chart
what you have done)

38. GOALS !!
• Specific
• Measurable
• Achievable
• Realistic
• Timed

40. General Top Tips Staying Strong in Hospital
• Have GOALS
• Whole body checklist (the basics)
– Lungs
• regular deep breaths, as much in as you can, hold for 5s
• +/- mucus clearance exercises
– Arms – reach for the skies, scratch your back
– Legs
• walk if possible. Even 2 steps will help
• If not, need bed/ chair exercises
– Back
• Get out of bed
• Simple stretches e.g. bridging/ knee rolling/ trunk rotation
– Neck
• Chin retraction, looking up at ceiling
• Speak to ward physio for help/advice

41. Now your turn!
• Sitting exercises
• Standing exercises
• Lying down Exercises
• Breathing exercises

42. Carer Support
www.nhs.uk/carersdirect
• Often neglected group – all attention given to
patient
• Highlighted by a recent email to the Yahoo
support group – an Australian man who has
watched his active wife become much less
mobile and unable to enjoy life as they did.
They have eventually found new ways to enjoy
their time together. Read the story at
http://patientswithaspergillosis.wikispaces.com
/From+a+carers+perspective

43. Carers UK

44. Private Conversation
This part of the meeting has been deemed to be
private – online visitors or those using Skype access
can chat between themselves during this section.

45. Carers how can we help?
Own online group?
Private??
Own part of the website
Information leaflets

46. Patients -
Own online group?
Privacy?
Expert Patient Organisation
Is there anything that carers should not know?
Anything you can’t tell your carer?
Counsellor?
What else?

47. Whole group
Gardening tips
Topics?
Questions?

48. Gardening for Asthmatics
Twelve keys to building your own asthma-friendly
garden (American Holistic Assoc. http://ahha.org/):
1.Plant lots of female trees and shrubs. Not only will these not shed
pollen, they will also trap a good deal of pollen that may float in from
somewhere else. Think of these female plants as nature's air cleaners.
2.Use only low-pollen or no-pollen lawns. In southern states, if you
have a common Bermuda grass lawn, consider replacing it with a newer,
more asthma-friendly hybrid Bermuda grass. 'Princess 77' is a new
Bermuda grass hybrid that can be planted from seed. It is next to pollen
free, grows very low and tight, and is especially good looking.

49. Gardening for Asthmatics
3. With OPALS™ 1 is best, 10 is worst. Use only plants with rankings
of 1 to 5. The more plants in your gardens that have rankings ranging from 1
to 3, the friendlier your place will be for anyone with allergies or asthma.
4. Remove any trees or shrubs with rankings over OPALS™ 7.
The woody landscape plants with rankings of 8 to 10 are all sure-fire allergy
triggers. You can live without them.
5. Replace high-pollen, asthma-triggering plants with their
opposites, female trees or shrubs. Other good replacements are
perfect flowered plants that are known to be very low pollen producers. These
will have good (low) OPALS™ rankings.
OPALS: Allergy-free Gardening: A Revolutionary Approach to Landscape
Planning [Paperback]
Thomas L. Ogren (Author) £58

50. Gardening for Asthmatics
6. Use only plants that are well adapted to your own area. If you
can find natives that have low allergy rankings, consider using them. Walk
around your neighborhood and see for yourself which kinds of plants seem to
be flourishing there and which trigger your asthma. For almost every kind of
plant used in landscaping, there is now a no or low pollen version.
7. Use a wide variety of plant materials. Diversity is good and
biodiversity always makes sense. The more diverse our gardens are, the fewer
problems we'll have with insects and molds.
8. Avoid plants with strong fragrances or odors, as they can
cause asthma. Don't plant jasmines or similar vines next to entrances or
exits and certainly don't plant them beneath bedroom windows.
9. To cut down on toxic mold spores, use rock or gravel
instead of bark for mulch. Flat stones or pavers also make good,
mold-free mulching materials.

51. Gardening for Asthmatics
10. To further eliminate mold spores, encourage wild birds to
visit your garden. Insect damage triggers outbreaks of mold, and wild
birds eat insects. Even the tiny hummingbirds actually eat a large number of
insects. Put up a hummingbird feeder!
11. Keep your plants healthy. This, too, will cut down on both pollen and
mold. When it is hot and windy, irrigate your garden or lawn. Fertilize
everything in the garden in the spring and fall. If plants are crowding each
other too much, thin them out. If tree branches overhead are putting your
whole yard in deep shade, consider having the tree thinned to let in more
light. Fresh air and light are the enemies of molds.
12. If a tree, shrub, vine or any other plant always looks sickly
or dirty, or always attracts bugs, then shovel prune it. That is,
dig it up and get rid of it. Replace it with something easier to grow. Don't get
caught up in having to spray insecticides all the time, as they, too, can easily
trigger asthma and allergies.

52. Compost Bags labelling
Contacted MP
Undersecretary of State for Public Health (Anna
Soubry MP) replied and turned down request
Few deaths (3 noted in press)
All had underlying health issues impairing immune
system (eg asthma, smoker & welding!)
 Notice on all bags is disproportionate – GP should
be warning those at risk.

53. Q&A
Questions?
Areas of interest online
Mycotoxins
Mouldy homes
Saline nebulisers and their effectiveness
Media portraying aspergillosis as easy to cure
Travel insurance (Staysure, Unique (asthmaUK),
http://www.moneysupermarket.com/travel-
insurance/pre-existing-medical-conditions/)

54. Travel
Please give full info about ALL your medical
conditions on your proposal. If you give only partial
truth and need to claim, your whole policy might be
made invalid and you won't get anything.
http://www.aspergillus.org.uk/newpatients/travel.h
tml

56. Thank You
“The best chance we have of beating this illness is to
work together”
Living with it, Working with it, Treating it
Fungal Research Trust