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Standardisation of care: towards a common goal

In addition to training, the management of specific conditions is also being standardised throughout Europe and across the world. The need for standardisation of management was illustrated by a paper published in 1998, which compared the management of a common respiratory infection in infancy (bronchiolitis) in many European countries and in the USA. The main factor linked to the length of stay in hospital was not severity of illness but the country in which the infant lived. A 2010 study of cystic fibrosis across Europe identified fewer individuals surviving to adulthood in non-EU compared with EU countries, and suggested that up to 50% of all cases of cystic fibrosis in non-EU countries were not being diagnosed (and by implication, not receiving appropriate treatment). The considerable variation between countries, and the desire to standardise PRM training, has driven the standardisation of treatment and investigation. Table 3 lists some of the areas in which guidelines have been established.

The investigation and management of several conditions has now been standardised. However, it is important to note that for most conditions, no internationally agreed guideline exists, and many of the guidelines that do exist are based on consensus (i.e. what is currently being done) and rarely on an evidence base (i.e. clinical trials). To take drug dose as an example, most antibiotic doses are based on studies performed in adults with the assumption that children are small adults; however, this is often not the case and generally children receive inadequate doses of medication. There is a pressing need for clinical trials in PRM and this has been recognised by the 2006 EU Clinical Trials Directive, which obliges the pharmaceutical industry to test new medications in children as well as adults.

Table 2 - Modules of the Paediatric HERMES syllabus. HERMES: Harmonised Education in Respiratory Medicine for European Specialists.

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Chapters

• Editors' introduction
• Foreword from the World Health Organization
• Foreword from the European Commission
• Promoting respiratory health in Europe
• The burden of lung disease
  • Introduction: the global perspective
  • Key points
  • Respiratory deaths in Europe
  • Figure 1
  • Figure 2
  • The impact on health services
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
  • The “iceberg of disease”
  • Figure 7
  • Recent trends
  • Figure 8
  • Figure 9
  • Figure 10
  • Future projections
  • Terminology and data
  • Data sources
• The economic burden of lung disease
  • Background
  • Key points
  • Methods
  • The cost of respiratory disease
  • Figure 1
  • Discussion
  • Further reading
• Genetic susceptibility
  • Introduction
  • Key points
  • Figure 1
  • Figure 2
  • Monogenic diseases
  • Complex diseases
  • Figure 3
  • Complex traits
  • Conclusions and future prospects
  • Further reading
• Early-life events
  • Introduction
  • Key points
  • Abnormal antenatal lung growth
  • Low birthweight
  • Prematurity and BPD
  • Figure 1
  • Tobacco smoke exposure
  • Viral infections in infancy
  • Wheezy bronchitis
  • Conclusion
  • Further reading
• Diet and nutrition
  • Introduction
  • Key points
  • Diet as a risk factor
  • Nutritional status and interventions
  • Clinical recommendations
  • Further reading
• Outdoor environment
  • Introduction
  • Key points
  • Pollution: composition/sources
  • Pathophysiological effects of air pollutants
  • Respiratory health effects
  • Long-term consequences
  • Figure 1
  • Respiratory disease in adults and children
  • Lung cancer
  • Figure 2
  • The importance of susceptibility
  • Relevance and outlook
  • Further Reading
• Occupational risk factors
  • Introduction
  • Key points
  • Figure 1
  • Exposure history and assessment
  • Latency between exposure and disease
  • Figure 2
  • Maximum workplace concentrations
  • Exposures and their effects
  • Further reading
• Passive smoking
  • Introduction
  • Key points
  • Harmful effects of SHS on health
  • Figure 1
  • Estimates of burden of disease due to SHS
  • Measurement of SHS
  • Health benefits of smoke-free legislation
  • Protection from exposure to SHS
  • Further reading
• Tobacco smoking
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Toxic effects of tobacco smoke
  • Disorders induced by tobacco smoking
  • Figure 2
  • Societal costs of smoking
  • Dependence on tobacco
  • Legislation and prevention of smoking
  • Figure 3
  • Pharmacotherapy for smoking cessation
  • Counselling for smoking cessation
  • Benefits of quitting smoking
  • Cost-effectiveness of smoking cessation
  • ERS guidelines on smoking cessation
  • Future developments
  • Conclusions
  • Further reading
• Indoor environment
  • Introduction
  • Key points
  • Indoor pollutants and health effects
  • Figure 1
  • Figure 2
  • Specific pollutants
  • Figure 3
  • Indoor air quality in schools
  • Figure 4
  • Interventions
  • Conclusion
  • Further reading
• Childhood asthma
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Causes/pathogenesis
  • Clinical manifestations and consequences
  • Prevention
  • Management
  • Prognosis
  • Future developments
  • Research needs
  • Further reading
• Adult asthma
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Causes/pathogenesis
  • Clinical manifestations
  • Figure 2
  • Figure 3
  • Prevention
  • Management
  • Prognosis
  • Future developments and research needs
  • Further reading
• Chronic obstructive pulmonary disease
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Figure 2
  • Figure 3
  • Causes/pathogenesis
  • Clinical manifestations
  • Prevention
  • Management
  • Prognosis
  • Future developments
  • Research needs
  • Further reading
• Cystic fibrosis
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Figure 2
  • Causes/pathogenesis
  • Clinical manifestations and consequences
  • Prevention
  • Management
  • Prognosis
  • Figure 3
  • Future developments
  • Research needs and unanswered questions
  • Further reading
• Bronchiectasis
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Causes/pathogenesis
  • Figure 2
  • Clinical manifestations and consequences
  • Prevention
  • Management
  • Prognosis
  • Future developments
  • Research needs
  • Further reading
• Paediatric respiratory diseases
  • Introduction
  • Key Points
  • Figure 1
  • Acute bronchiolitis
  • Figure 2
  • Figure 3
  • Perinatal respiratory diseases and BPD
  • Figure 4
  • Figure 5
  • Severe community-acquired pneumonia in children
  • Figure 6
  • Tuberculosis in children
  • Figure 7
  • Immunisation
  • Figure 8
  • Congenital respiratory disorders
  • General remarks
  • Further reading
• Tuberculosis
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Causes/pathogenesis
  • Clinical manifestations and consequences
  • Prevention and control
  • Management
  • Prognosis
  • Research needs
  • Future developments
  • Further reading
• Acute lower respiratory infections
  • Introduction
  • Key points
  • Figure 1
  • Influenza
  • Figure 2
  • Pneumonia
  • Figure 3
  • Figure 4
  • Figure 5a
  • Figure 5b
  • Figure 6
  • Prevention
  • Future developments
  • Further reading
• Lung cancer
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Figure 2
  • Figure 3
  • Causes
  • Prevention
  • Management
  • Prognosis
  • Figure 4
  • Future developments
  • Research needs
  • Further reading
• Acute respiratory distress syndrome
  • Introduction
  • Key points
  • Definition and diagnosis
  • Pathogenesis
  • Incidence and outcome
  • Treatment options
  • Future developments
  • Further reading
• Pulmonary vascular disease
  • Introduction
  • Key points
  • Figure 1
  • Figure 2
  • Pulmonary embolism
  • Figure 3
  • Figure 4
  • Pulmonary hypertension
  • Further reading
• Interstitial lung diseases
  • Introduction
  • Key points
  • Epidemiology
  • Figure 1
  • Figure 2
  • Causes/pathogenesis
  • Clinical manifestations and consequences
  • Prevention
  • Management
  • Prognosis
  • Financial burden
  • Figure 3
  • Figure 4
  • Research needs
  • Further reading
• Sleep breathing disorders
  • Introduction
  • Key points
  • Epidemiology
  • The pathophysiology of OSAS
  • Figure 1
  • Clinical manifestations and consequences
  • Prevention
  • Management
  • Figure 2
  • Figure 3
  • Prognosis
  • Obesity hypoventilation syndrome
  • Future developments and research needs
  • Further reading
• Occupational lung diseases
  • Introduction
  • Key points
  • Acute inhalation injuries
  • Occupational infections
  • Asthma
  • COPD
  • Interstitial lung diseases
  • Figure 1
  • Types of ILD
  • Lung cancer
  • Pleural disease
  • Figure 2
  • Figure 3
  • Prevention
  • Conclusion
  • Further reading
• Rare and orphan lung diseases
  • Introduction
  • Key points
  • Specific diseases
  • Diagnosis and support
  • Therapy
  • Future developments
  • Further reading
• Immunisation against respiratory diseases
  • Introduction
  • Key points
  • Influenza
  • Figure 1
  • Pertussis
  • Figure 2
  • Streptococcus pneumoniae
  • Figure 3
  • Tuberculosis
  • Figure 4
  • Developments and research needs
  • Further reading
• Principles of respiratory investigation
  • Introduction
  • Key points
  • History
  • Physical examination
  • Laboratory methods
  • Respiratory function tests
  • Figure 1
  • Imaging techniques
  • Figure 2
  • Figure 3
  • Invasive biopsy techniques
  • Figure 4
  • Further reading
• Principles of respiratory therapy
  • Introduction
  • Key points
  • Pharmacological therapy
  • Figure 1
  • Nonpharmacological therapy
  • Figure 2
  • Figure 3
  • Other forms of treatment
  • Further reading
• Pulmonary rehabilitation
  • Background
  • Key points
  • Definition
  • Rationale
  • Application
  • Outcome
  • Setting and content
  • What is needed?
  • Conclusion
  • Further reading
• Paediatric respiratory medicine
  • Introduction
  • Key points
  • Figure 1
  • Setting
  • Figure 2
  • Training
  • Standardisation of care: towards a common goal
  • Keeping up with developments
  • Conclusion
  • Further reading
• Respiratory intensive care
  • Introduction
  • Key points
  • The role of respiratory medicine in intensive care
  • Figure 1
  • Future prospects
  • Figure 2
  • Further reading
• Thoracic surgery
  • Introduction
  • Key points
  • Standards of care
  • Figure 1
  • Figure 2
  • Figure 3
  • Changing roles
  • The future
  • Further reading
• Medical respiratory specialists
  • Introduction
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6
• Allied respiratory professionals
  • Introduction
  • Key points
  • Respiratory technologists and clinical scientists
  • Figure 1
  • Figure 2
  • Respiratory physiotherapists
  • Respiratory nurses
  • Further reading
• Primary care practitioners
  • Introduction
  • Key points
  • Primary care practitioners
  • Primary care and chronic lung disease
  • A role for primary care practitioners
  • Conclusion
  • Further reading
• Specialist clinical training (HERMES)
  • Specialist training in respiratory medicine
  • Key points
  • Figure 1
  • Development strategy for educational standards
  • Figure 2
  • The HERMES projects: adult respiratory medicine
  • Figure 3
  • Figure 4
  • The other HERMES projects
  • Conclusion
  • Further reading
• ERS School and postgraduate education
  • Introduction
  • Key points
  • The HERMES projects
  • The ERS School web platform
  • Figure 1
  • ERS School Courses
  • School publications
  • Educational research seminars
  • Skills-based, hands-on learning
  • Strategic developments in the School
  • Further reading
• Respiratory research
  • Introduction
  • Key points
  • Fields of research
  • Advances in respiratory biomedicine
  • Conclusion
  • Further reading
• Respiratory journals and publications
  • Introduction
  • Key points
  • Figure 1
  • General medical journals
  • Types of journal article
  • Peer review in respiratory journals
  • Assessing quality and status of respiratory journals
  • Publication ethics
  • Advances in publishing
  • Open access
  • Publications of the ERS
  • Conclusions
  • Further reading
• Patient organisations and the European Lung Foundation
  • Introduction
  • Key points
  • The role of patient organisations
  • Figure 1
  • Pan-European patient organisations
  • Respiratory diseases
  • Figure 2
  • Challenges
  • The future
  • Further reading
• Recommendations and policy
  • Introduction
  • Key points
  • Approach
  • Policy context
  • Noncommunicable diseases
  • Tobacco
  • Air quality
  • Tuberculosis
  • Conclusion
  • Further reading