Objective: The Wrightington, Wigan, and Leigh NHS Teaching Hospitals Foundation Trust (WWL) developed a novel virtual ward (VW) service that integrated with community and primary care, supported healthcare throughout a patient’s journey, and had a clinical workflow that could step-up or step-down care as needed. We described their VW and evaluated clinical outcomes, adherence, safety, and patient satisfaction. Methods: Retrospective, single-center study of patients admitted to the WWL VW service from January 14, 2022 to January 31, 2024. Clinical data collected by WWL in their database for patients admitted to the VW, were matched to data captured automatically by the Current Health (CH) platform linked to the CH remote monitoring kits assigned to patients on the VW. The CH kits enabled the VW care at WWL and included a wearable device for continuous vital signs monitoring, a blood pressure cuff, and tablet. Evaluation metrics included clinical scope, clinical outcomes, adherence, safety, and patient satisfaction. Results: There were 1835 admissions and a 93% match rate between the clinical and CH databases. About 38% of referrals were step-up (31% ambulatory care and 7% primary care) and 62% of referrals were step-down (100% inpatients). Most specialty referrals were from thoracic and acute medicine (77%). The median length of stay on the VW was 8 days [IQR 5-13], 209 (12%) admissions were escalated to the hospital, 179 (11%) escalated to the emergency department out of hours, and 29 (2%) signposted to urgent medical services. Adherence to the wearable device was 92%. There were 38 minor safety incidents (typically hypersensitivity reactions or administrative errors) and 17 expected deaths. About 94% of admissions rated the VW experience as “excellent” or “good.” Results were similar between step-up and step-down referrals. Conclusion: We have shown the VW service yielded acceptable clinical outcomes, was safe with no serious adverse events or negative impact on mortality rate. Patient adherence to the technology and satisfaction with the VW service were high. The VW service was innovative in its acceptance of a broad range of patients, expanding services beyond respiratory medicine, and in developing a step-up pathway, preventing some patients from ever taking up an acute bed in the hospital.

Background: The psychological and physical Health Related Quality of Life (HRQoL) in Interstitial Lung Disease (ILD) has been recognised as an important patient centred outcome by leading health organisations (Aronson & Suzuki, 2021). This led to this review to identify how the symptom burden is affecting the day-to-day life of this patient group. Methods: K-BILD questionnaire (Birring, 2012) was sent out to 134 patients attending a medium sized District General Hospital. 123 (91%) had Idiopathic Pulmonary Fibrosis, 7 Sarcoidosis, and 4 Hypersensitivity Pneumonitis to assess their HRQoL, with a response rate of 70%. Results: Overall, a mean of 59.94 (SD 7.45) of patients experienced on going psychological symptoms “most of the time”. 67.62 % (SD 16.26) of the patients in our cohort also experienced on-going physical symptoms “most of the time”. Conclusion: Majority of patients attending ILD clinic experience a significant burden of psychological and physical symptoms “most of the time” affecting their HRQoL. These unfortunately remain un-addressed in the traditional models of care. Psychological support delivered by experts at the time of diagnosis could be offered to these patients to bridge this gap. Holistic care models need to be developed to address this” care gap” in patients attending ILD clinics.

Objective To estimate continuous positive airway pressure (CPAP) length of treatment effect on survival of hospitalised COVID-19 patients in a medium-sized UK Hospital, and how this effect changes according to the patient’s comorbidity and COVID-19 route of acquisition (community or nosocomial) during the two waves in 2020. Setting The acute inpatient unit in Wrightington, Wigan and Leigh Teaching Hospitals National Health Service (NHS) Foundation Trust (WWL), a medium-sized NHS Trust in north-west of England. Design Retrospective cohort of all confirmed COVID-19 patients admitted in WWL during 2020. Participants 1830 patients (568 first wave, 1262 s wave) with antigen confirmed COVID-19 disease and severe acute respiratory syndrome admitted between 17 March 2020 (first confirmed COVID-19 case) and 31 December 2020. Outcome measure COVID-19 survival rate in all patients and survival rate in potentially hospital-acquired COVID-19 (PHA) patients were modelled using a predictor set which include comorbidities (eg, obesity, diabetes, chronic ischaemic heart disease (IHD), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD)), wave, age, sex and care home residency, and interventions (remdesivir, dexamethasone, CPAP, intensive care unit (ICU), intubation). Secondary outcome measure was CPAP length, which was modelled using the same predictors of the survival rate. Results Mortality rate in the second wave was significantly lower than in the first wave (43.4% vs 28.1%, p<0.001), although for PHA COVID-19 patients mortality did not reduce, remaining at very high levels independently of wave and CPAP length. For all cohort, statistical modelling identified CPAP length (HR 95% CI 0.86 to 0.96) and women (HR 95% CI 0.71 to 0.81) were associated with improved survival, while being older age (HR 95% CI 1.02 to 1.03) admitted from care homes (HR 95% CI 2.22 to 2.39), IHD (HR 95% CI 1.13 to 1.24), CKD (HR 95% CI 1.14 to 1.25), obesity (HR 95% CI 1.18 to 1.28) and COPD-emphysema (HR 95% CI 1.18 to 1.57) were associated with reduced survival. Despite the detrimental effect of comorbidities, patients with CKD (95% CI 16% to 30% improvement in survival), IHD (95% CI 1% to 10% improvement in survival) and asthma (95% CI 8% to 30% improvement in survival) benefitted most from CPAP length, while no significant survival difference was found for obese and patients with diabetes. Conclusions The experience of an Acute Trust during the COVID-19 outbreak of 2020 is documented and indicates the importance of care home and hospitals in disease acquisition. Death rates fell between the first and second wave only for community-acquired COVID-19 patients. The fall was associated to CPAP length, especially for some comorbidities. While uncovering some risk and protective factors of mortality in COVID-19 studies, the study also unravels how little is known about PHA COVID-19 and the interaction between CPAP and some comorbidities.

Background We evaluated the use of baricitinib, a Janus kinase (JAK) 1/2 inhibitor, for the treatment of patients admitted to hospital because of COVID-19. Methods This randomised, controlled, open-label platform trial (Randomised Evaluation of COVID-19 Therapy [RECOVERY]), is assessing multiple possible treatments in patients hospitalised for COVID-19. Eligible and consenting patients were randomly allocated (1:1) to either usual standard of care alone (usual care group) or usual care plus baricitinib 4 mg once daily by mouth for 10 days or until discharge if sooner (baricitinib group). The primary outcome was 28-day mortality assessed in the intention-to-treat population. A meta-analysis was conducted that included the results from the RECOVERY trial and all previous randomised controlled trials of baricitinib or other JAK inhibitor in patients hospitalised with COVID-19. The RECOVERY trial is registered with ISRCTN (50189673) and [clinicaltrials.gov][1] ([NCT04381936][2]). Findings Between 2 February 2021 and 29 December 2021, 8156 patients were randomly allocated to receive usual care plus baricitinib versus usual care alone. At randomisation, 95% of patients were receiving corticosteroids and 23% receiving tocilizumab (with planned use within the next 24 hours recorded for a further 9%). Overall, 513 (12%) of 4148 patients allocated to baricitinib versus 546 (14%) of 4008 patients allocated to usual care died within 28 days (age-adjusted rate ratio 0·87; 95% CI 0·77-0·98; p=0·026). This 13% proportional reduction in mortality was somewhat smaller than that seen in a meta-analysis of 8 previous trials of a JAK inhibitor (involving 3732 patients and 425 deaths) in which allocation to a JAK inhibitor was associated with a 43% proportional reduction in mortality (rate ratio 0.57; 95% CI 0.45-0.72). Including the results from RECOVERY into an updated meta-analysis of all 9 completed trials (involving 11,888 randomised patients and 1484 deaths) allocation to baricitinib or other JAK inhibitor was associated with a 20% proportional reduction in mortality (rate ratio 0.80; 95% CI 0.71-0.89; p<0.001). In RECOVERY, there was no significant excess in death or infection due to non-COVID-19 causes and no excess of thrombosis, or other safety outcomes. Interpretation In patients hospitalised for COVID-19, baricitinib significantly reduced the risk of death but the size of benefit was somewhat smaller than that suggested by previous trials. The total randomised evidence to date suggests that JAK inhibitors (chiefly baricitinib) reduce mortality in patients hospitalised for COVID-19 by about one-fifth. Funding UK Research and Innovation (Medical Research Council) and National Institute of Health Research (Grant ref: MC\_PC\_19056). ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial The trial is registered with ISRCTN (50189673) and [clinicaltrials.gov][1] ([NCT04381936][2]). ### Clinical Protocols ### Funding Statement UK Research and Innovation (Medical Research Council) and National Institute of Health Research (Grant ref: MC\_PC\_19056). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The trial is conducted in accordance with the Principles of the International Conference on Harmonisation-Good Clinical Practice guidelines and approved by the UK Medicines and Healthcare products Regulatory Agency (MHRA) and the Cambridge East Research Ethics Committee (ref: 20/EE/0101). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable. Yes The protocol, consent form, statistical analysis plan, definition & derivation of clinical characteristics & outcomes, training materials, regulatory documents, and other relevant study materials are available online at [www.recoverytrial.net][3]. As described in the protocol, the trial Steering Committee will facilitate the use of the study data and approval will not be unreasonably withheld. Deidentified participant data will be made available to bona fide researchers registered with an appropriate institution within 3 months of publication. However, the Steering Committee will need to be satisfied that any proposed publication is of high quality, honours the commitments made to the study participants in the consent documentation and ethical approvals, and is compliant with relevant legal and regulatory requirements (e.g. relating to data protection and privacy). The Steering Committee will have the right to review and comment on any draft manuscripts prior to publication. Data will be made available in line with the policy and procedures described at: . Those wishing to request access should complete the form at [https://www.ndph.ox.ac.uk/files/about/data\_access\_enquiry\_form\_13\_6\_2019.docx][4] and e-mailed to: data.access{at}ndph.ox.ac.uk [1]: http://clinicaltrials.gov [2]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT04381936&atom=%2Fmedrxiv%2Fearly%2F2022%2F03%2F03%2F2022.03.02.22271623.atom [3]: http://www.recoverytrial.net [4]: https://www.ndph.ox.ac.uk/files/about/data_access_enquiry_form_13_6_2019.docx

Aim:Interstitial lung disease (ILD), is a common manifestation of rheumatoid arthritis (RA) however it is not known whether serological markers correlate with radiological findings and lung physiology.Methods: We reviewed the HRCT and lung physiology (DLCO) of 48 patients who attended the joint rheumatology ILD clinic between 2014-2018 and compared CT findings to serology.Patients were subdivided into those with strongly positive serology and others.Results: 28 (58%) patients had strongly +VE serology (RF &anti-CCP).14(50%) had Usual Interstitial Pneumonitis (UIP), 4(14%) Nonspecific Interstitial Pneumonitis (NSIP), 1(4%) Fibrotic NSIP and 3(11%) had Bronchiectasis changes on HRCT.6 patients had other HRCT changes.Of those 20(42%) with mixed serology, 12/20(60%) had strongly positive RF.2(16%) had UIP pattern, 5(42%) NSIP and 2(16%) Fibrotic NSIP.41 (85%) had Full lung function tests.Of, the patients with strongly positive serology 60% had DLCO<50%.Conclusion:Based on these results, we conclude that patients who have strongly +v serology (BOTH RF +ANTICCP) more likely to have a UIP presentation on HRCT and moderately severe disease based on physiology.Those without anti-CCP positivity are more likely to have NSIP on CT with less severe physiological disease.

Introduction: Long Covid patients may have concerns about the impact of mRNA vaccines on their symptoms. Method: A short questionnaire was sent to users of a long covid service supporting an NHS Trust staff in Wigan 2 weeks following the conclusion of a mRNA vaccine first dose roll out. The questionnaire explored acceptance and compliance with the vaccine and any change in the symptoms at least 2 weeks following the vaccination. Results: 77 HCW were offered the vaccine. 10 respondents declined mainly because of concerns regarding worsening long covid symptoms. 67% of respondents did not experience any change in symptoms whilst 21% experienced improvement of symptoms. 12% experienced worsening of symptoms. Conclusion: mRNA vaccines can influence long covid symptoms. However, patients seemed to be twice more likely to experience improvement than worsening of symptoms. © This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Background Continuous positive airway pressure (CPAP) therapy is commonly used for respiratory failure due to severe COVID-19 pneumonitis, including in patients deemed unlikely to benefit from invasive mechanical ventilation (nIMV). Little evidence exists demonstrating superiority over conventional oxygen therapy, as acknowledged by current pragmatic guidelines, whilst ward-level delivery of CPAP presents practical challenges. Precedent studies have been limited by small numbers, subjective physician treatment-selection, and lack of a control group. We sought to compare clinical outcomes of oxygen therapy versus CPAP therapy in patients with COVID-19 who were nIMV. Methods The North West Collaborative Organisation for Respiratory Research (NWCORR), a trainee-led network, performed a retrospective multi-centre cohort evaluation. Patient inclusion criteria were: a clinical diagnosis of COVID-19, a treatment escalation plan of ward-level care, treatment at a hospital only providing one respiratory support strategy and clinical frailty score ≤6. Patients were cohorted according to respiratory support strategy, either being CPAP in accordance with national guidelines or oxygen therapy requiring FiO2 ≥0.4 for over 12 hours; who would therefore have been eligible for CPAP if treated at a CPAP cohort hospital. Logistic regression modelling, using generalised estimating equations to account for within-hospital clustering, was performed to compare 30-day mortality between treatment groups, accounting for important confounders. Results Seven hospitals provided data for 479 patients during the UK COVID-19 pandemic in 2020. Overall 30-day mortality was 75.6% in the oxygen group (186/246 patients) and 77.7% in the CPAP group (181/233 patients) (figure 1). A lack of evidence for a treatment effect persisted in the adjusted model (adjusted 30-day mortality odds ratio comparing CPAP to oxygen of 0.84, 95% CI 0.57–1.23, p=0.37). 49.8% of patients receiving CPAP-therapy (118/237) chose to discontinue it. Discussion This is, as far as we are aware, the first study comparing conventional oxygen therapy with CPAP in cohorts unaffected by physician selection. No survival difference was found between using oxygen alone or CPAP to treat patients with severe COVID-19 who were nIMV. A high patient-initiated discontinuation rate for CPAP suggests a significant treatment burden. Further reflection is warranted on the continued widespread use of CPAP in this patient group. Please refer to page A189 for declarations of interest related to this abstract.

Introduction There remains significant variation in treatment of COVID-19 associated respiratory failure. Although Continuous Positive Airway Pressure (CPAP) has shown to improve outcome in single centre studies, inclusion criteria for commencement of CPAP varies significantly (Ashish et al., 2020; Nightingale et al., 2020). This respiratory-led ward-level dedicated CPAP unit provided CPAP to COVID-19 patients through the 'second wave'. This study aims to evaluate the efficacy and appropriateness of CPAP for COVID-19 management in an elderly population. Methods This retrospective observational study included all patients aged 75 and over who received CPAP for COVID-19 infection, admitted to a district general hospital between 1 October 2020 and 16 February 2021. Fifty-seven patients were included. Data were collected from computerised clinical notes for analysis. Results Of 57 patients (39 male and mean age 80), 47 (82.5%) patients died during admission or within 5 days of discharge. 10 (17.5%) patients survived to discharge. Non-survivors had a median CFS of 4; IQR 3–5, as did survivors (median CFS 4; IQR 3–4). Non-survivors had a median of 3 (IQR 2–4) significant comorbidities, and survivors had 2.5 (IQR 2–3.8). Median P/F (PaO2/FiO2) ratio prior to commencing CPAP was 10.5 (IQR 8.4–12.6) for non-survivors and 14.4 (IQR 12.9–18.8) for survivors. The odds of death were 6.8 (p value <0.01) in those with a severe P/F ratio (<13.3). Conclusion This evidence indicates that CPAP used in patients aged 75 and over, particularly those with a severe P/F ratio prior to commencing CPAP, does not improve mortality. These findings can inform future decision-making and CPAP protocol development to potentially limit its use in this group. Further study of less invasive alternative management options, such as nasal high flow oxygen, is recommended.

Introduction and Objectives There is an ongoing need to increase trainees participation in research in order to equip tomorrow's consultants with the skills required to appraise and deliver innovation. Trainee research networks have been established in a range of specialities, resulting in high impact studies benefiting patients whilst involving and developing trainees. However, to date, there are only a few such initiatives in the respiratory community. Here, we describe the experience of a collaborative in the Mersey and North West regions. Methods Launched in February 2020, the North West Collaborative Organisation for Respiratory Research (NWCORR), has fostered collaboration between respiratory trainees from the Mersey and North West Deaneries to create high quality, multicentre research. This collaborative has been initiated with the support of National Institute of Health Research (NIHR) Clinical Research Network (CRN) Greater Manchester and supported by mentorship from research-active consultants in subspecialties relevant to its projects and Local CRN lead. The network now provides all trainees in clinical training a new pathway to gain valuable experience of research design and delivery through mentorship and networking as valuable part of specialty training. Results With 42 active members, NWCORR has undertaken three research projects with several projects planned. Over 1300 patients have been included across 13 hospitals, with 39 trainees gaining valuable research experience (see table 1). Trainees have led on all aspects of research projects from design to publication. Completed projects have significantly impacted the care of COVID-19 patients whilst engaging 39 trainees across 2 deaneries and have been published and/or presented to disseminate the results. Conclusions The experience of NWCORR reflects a high rate of trainee enthusiasm to participate in research alongside clinical training and highlights the potential of collaborative networks. It has enabled trainees who may not wish, or have the opportunity, for an 'out of programme' research post to develop research skills and interests. We believe NWCORR and other trainee research collaboratives can, and should, play a pivotal role in embedding a research culture into everyday practice, improve patient care and build early career researchers within the NHS.

Background: Continuous positive airway pressure (CPAP) therapy is commonly used for respiratory failure due to severe COVID-19 pneumonitis, including in patients deemed not likely to benefit from invasive mechanical ventilation (nIMV). Little evidence exists demonstrating superiority over conventional oxygen therapy, whilst ward-level delivery of CPAP presents practical challenges. We sought to compare clinical outcomes of oxygen therapy versus CPAP therapy in patients with COVID-19 who were nIMV. Methods: This retrospective multi-centre cohort evaluation included patients diagnosed with COVID-19 who were nIMV, had a treatment escalation plan of ward-level care and clinical frailty scale <= 6. Recruitment occurred during the first two waves of the UK COVID-19 pandemic in 2020; from 1st March to May 31st, and from 1st September to 31st December. Patients given CPAP were compared to patients receiving oxygen therapy that required FiO(2) >= 0.4 for more than 12 hours at hospitals not providing ward-level CPAP. Logistic regression modelling was performed to compare 30-day mortality between treatment groups, accounting for important confounders and within-hospital clustering. Findings: Seven hospitals provided data for 479 patients during the UK COVID-19 pandemic in 2020. Overall 30-day mortality was 75.6% in the oxygen group (186/246 patients) and 77.7% in the CPAP group (181/233 patients). A lack of evidence for a treatment effect persisted in the adjusted model (adjusted odds ratio 0.84 95% CI 0.57-1.23, p=0.37).49.8% of patients receiving CPAP-therapy (118/237) chose to discontinue it. Interpretation: No survival difference was found between using oxygen alone or CPAP to treat patients with severe COVID-19 who were nIMV. A high patient-initiated discontinuation rate for CPAP suggests a significant treatment burden. Further reflection is warranted on the current treatment guidance and widespread application of CPAP in this setting. (C) 2021 The Authors. Published by Elsevier Ltd.

Findings: Between 23 April 2020 and 25 January 2021, 4116 adults were included in the assessment of tocilizumab, including 562 (14%) patients receiving invasive mechanical ventilation, 1686 (41%) receiving non-invasive respiratory support, and. 1868 (45%) receiving no respiratory support other than oxygen. Median CRP was 143 [IQR 107-205] mg/L and 3385 (82%) patients were receiving systemic corticosteroids at randomisation. Overall, 596 (29%) of the 2022 patients allocated tocilizumab and 694 (33%) of the 2094 patients allocated to usual care died within 28 days (rate ratio 0.86; 95% confidence interval [CI] 0.77-0.96; p=0.007). Consistent results were seen in all pre-specified subgroups of patients, including those receiving systemic corticosteroids. Patients allocated to tocilizumab were more likely to be discharged from hospital alive within 28 days (54% vs. 47%; rate ratio 1.23; 95% CI 1.12-1.34; p<0.0001). Among those not receiving invasive mechanical ventilation at baseline, patients allocated tocilizumab were less likely to reach the composite endpoint of invasive mechanical ventilation or death (33% vs. 38%; risk ratio 0.85; 95% CI 0.78-0.93; p=0.0005). Interpretation: In hospitalised COVID-19 patients with hypoxia and systemic inflammation, tocilizumab improved survival and other clinical outcomes regardless of the level of respiratory support received and in addition to the use of systemic corticosteroids.

BACKGROUND:Recent reports suggest a higher incidence of COVID-19 infections among healthcare workers (HCW). However, information about the long-term complications affecting this population is lacking.AIMS:Investigation of long-term impact of COVID-19 in HCW.METHODS:Seropositivity for SARS-CoV-2 antibodies was evaluated for the majority of HCW in an English teaching hospital 2 months following the peak of COVID-19 first wave. A questionnaire investigating the long-term complications was sent through global e-mail to HCW 4 months following the peak of the wave enquiring about the persistent health issues still affecting them at that point.RESULTS:Out of 3759 subjects tested for SARS-CoV-2 antibodies, 932 were positive (24%). Forty-five per cent of 138 HCW responding to the questionnaire reported persistent symptoms with 32% struggling to cope 3-4 months following the peak of the wave. Moderate-to-severe fatigue stood out as the most disabling symptom (39%) but mild-to-moderate shortness of breath, anxiety and sleep disturbance were almost universal in the subjects still struggling with symptoms. Only 16% consulted their general practitioner (GP) about their symptoms with only 2% taking sick leave after recovering from the acute illness.CONCLUSIONS:Our data suggest that about a third of HCW who responded to the survey were still struggling to cope with the symptoms of what is now known as long covid several months after the acute COVID-19 infections. The overwhelming majority of this group seem to be reluctant to neither seek medical advice nor take sick leave.

ObjectiveTo evaluate the role of continuous positive air pressure (CPAP) in the management of respiratory failure associated with COVID-19 infection. Early clinical management with limited use of CPAP (3% of patients) was compared with a later clinical management strategy which had a higher proportion of CPAP use (15%).DesignRetrospective case-controlled service evaluation for a single UK National Health Service (NHS) Trust during March–June 2020 designed and conducted solely to estimate the effects of current care.SettingThe acute inpatient unit in Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust, a medium-sized English NHS Trust.Participants206 patients with antigen confirmed COVID-19 disease and severe acute respiratory syndrome admitted between 17 March 2020 and 3 April 2020 for the early group (controls), and between 10 April 2020 and 11 May 2020 for the late group (cases). Follow-up for all cases was until 11 June by which time all patients had a final outcome of death or discharge. Both groups were composed of 103 patients. Cases and controls were matched by age and sex.Outcome measureThe outcome measure was the proportion of patients surviving at time t (time from the positive result of COVID-19 test to discharge/death date). The predictors were CPAP intervention, intubation, residence in care homes and comorbidities (renal, pulmonary, cardiac, hypertension and diabetes). A stratified Cox proportional hazard for clustered data (via generalised estimating equations) and model selection algorithms were employed to identify the effect of CPAP on patients’ survival and the effect on gas exchange as measured by alveolar arterial (A-a) gradient and timing of CPAP treatment on CPAP patients’ survival.ResultsCPAP was found to be significantly (HR 0.38, 95% CI 0.36 to 0.40) associated with lower risk of death in patients with hospital stay equal to, or below 7 days. However, for longer hospitalisation CPAP was found to be associated with increased risk of death (HR 1.72, 95% CI 1.40 to 2.12). When CPAP was initiated within 4 days of hospital admission, the survival probability was above 73% (95% CI 53% to 99%). In addition, lower A-a gradient was associated with lower risk of death in CPAP patients (HR 1.011, 95% CI 1.010 to 1.013). The selected model (best fit) was stratified by sex and clustered by case/control groups. The predictors were age, intubation, hypertension and the residency from care homes, which were found to be statistically significantly associated with patient’s death/discharge.ConclusionsCPAP is a simple and cost-effective intervention. It has been established for care of other respiratory disorders but not for COVID-19 respiratory failure. This evaluation establishes that CPAP as a potentially viable treatment option for this group of patients during the first days of hospital admission. As yet there is limited availability of quantitative research on CPAP use for COVID-19. Whist this work is hampered by both the relatively small sample size and retrospective design (which reduced the ability to control potential confounders), it represents evidence of the significant benefit of early CPAP intervention. This evaluation should stimulate further research questions and larger study designs on the potential benefit of CPAP for COVID-19 infections. Globally, this potentially beneficial low cost and low intensity therapy could have added significance economically for healthcare provision in less developed countries.

SUMMARY Background Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatory actions. We evaluated the efficacy and safety of azithromycin in hospitalised patients with COVID-19. Methods In this randomised, controlled, open-label, adaptive platform trial, several possible treatments were compared with usual care in patients hospitalised with COVID-19 in the UK. Eligible and consenting patients were randomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once daily by mouth or intravenously for 10 days or until discharge (or one of the other treatment arms). Patients were twice as likely to be randomised to usual care as to any of the active treatment groups. The primary outcome was 28-day mortality. The trial is registered with ISRCTN (50189673) and clinicaltrials.gov ( NCT04381936 ). Findings Between 7 April and 27 November 2020, 2582 patients were randomly allocated to receive azithromycin and 5182 patients to receive usual care alone. Overall, 496 (19%) patients allocated to azithromycin and 997 (19%) patients allocated to usual care died within 28 days (rate ratio 1·00; 95% confidence interval [CI] 0·90-1·12; p=0·99). Consistent results were seen in all pre-specified subgroups of patients. There was no difference in duration of hospitalisation (median 12 days vs. 13 days) or the proportion of patients discharged from hospital alive within 28 days (60% vs. 59%; rate ratio 1·03; 95% CI 0·97-1·10; p=0·29). Among those not on invasive mechanical ventilation at baseline, there was no difference in the proportion meeting the composite endpoint of invasive mechanical ventilation or death (21% vs. 22%; risk ratio 0·97; 95% CI 0·89-1·07; p=0·54). Interpretation In patients hospitalised with COVID-19, azithromycin did not provide any clinical benefit. Azithromycin use in patients hospitalised with COVID-19 should be restricted to patients where there is a clear antimicrobial indication. Funding UK Research and Innovation (Medical Research Council) and National Institute of Health Research (Grant ref: MC_PC_19056).

Background Pulmonary fibrosis is a chronic respiratory condition with a poor prognosis and significant symptom burden, yet has traditionally been managed purely by respiratory physicians. It was the experience in the Greater Manchester town of Wigan that many patients with pulmonary fibrosis were not recognised to be in the last year of life and often presented to and ultimately died in hospital during their final illness. There were missed opportunities for improving symptom control, advance care planning (ACP) and achievement of preferred place of death (PPD). Methods A new service was established where a Palliative Medicine Consultant and clinical nurse specialist reviewed patients in a dedicated clinic running alongside the respiratory clinic. The monthly face to face clinic was complemented with a fortnightly telephone follow up clinic in-between. Symptom issues were addressed guided by Integrated Palliative care Outcome Scale (IPOS) completion, hand-held fans given out to help manage breathlessness, referrals considered to the local AHP-run palliative care out-patient centre and ACP and PPD discussed and recorded. Results Since December 2017, to date 36 patients with Pulmonary Fibrosis have been referred to the clinic. Three patients died prior to review. Of the 33 who have been assessed, 9 remain under active follow-up, 6 have been discharged to community palliative care services, 1 back to GP and 17 have died. Advance care planning was initiated in 26 patients (79%) and completed in 18 (55%). Of the 17 patients that died, all but two died out of hospital (88%), 11 in their own home/nursing home and 4 in hospice, significantly greater than national averages for non-malignant conditions. Conclusion The development of a hospital-based dedicated palliative medicine clinic for patients with Pulmonary Fibrosis has resulted in a majority of out-of-hospital deaths for this group of patients.

COVID-19 infection typically causes pneumonia with bilateral changes on Chest radiograph. There is significant hypoxia and use of oxygen for patients admitted to hospital is standard. The use of Continuous Positive Airway Pressure (CPAP) in patients with COVID-19 has now become established as a common clinical practice based on recent experience. It is given as part of “best endeavours” treatment in the absence of sufficient evidence to guide best practice. The use of CPAP as a step up in clinical care is now common but has a poor evidence base. Using routinely collected data, the use of CPAP as a supportive non-invasive ventilatory treatment is described in 35 patients with COVID infection. Patients given early CPAP and in particular within 48 hours of admission, are shown to have a better outcome (a significant probability of lower mortality) than patients who received late CPAP (more than 48 hours after admission). Although the analysis is affected by a small sample size, the results have shown good evidence that supports the early use of CPAP in patients with COVID-19 infection.

Azathioprine (AZA) is common treatment for connective tissue disease (CTD) related interstitial lung disease (ILD) which is reflected in the British Thoracic Society 2008 ILD guideline [1]. However, this is only a grade C evidence and no studies have reported the real-life effectives in this patient subgroup. An observational study of the effectiveness of AZA in CTD ILD was carried out by retrospective data collection of 30 patients seen in CTD – ILD clinic between January 2010 and December 2018. The mean age of patients was 62.79 (+/- 13 SD) years of which 16 (53%) were females with underlying CTDs (table 1). 16 (53%) patients continued AZA for a mean duration of 52 (+/- 18 SD) months. The FVC and DLCO were preserved in this group compared to those who did not [Mean FVC change: -1.630% (CI 0.95 = 0.284) vs -15.767% (CI 0.95 = 0.555), Mean DLCO change: -4.478% (CI 0.95 = 0.302) vs -14.233% (CI 0.95 = 0.689) respectively]. AZA was stopped in 16 patients due to toxicity (16%) or intolerability (27%). 2 were later re-started on AZA with good tolerance. Our single centre experience showed that FVC of patients with CTD related ILD, over a mean 50-month duration of therapy with of AZA, remained stable. This leads us to conclude that AZA is effective in treatment of CTD related ILD but prone to poor tolerability and systemic toxicity. Reference: [1] Wells AU, Hirani N. Interstitial lung disease guideline. Thorax. 2008 Sep 1;63(Suppl 5):v1-58.

Introduction: Studies have shown lung involvement in 7.5-17% of patients with Connective Tissue Diseases(CTD) 1. Lung manifestations may also precede systemic manifestation of CTD by 5-10yrs. Our objective is to study the radiology, serology, lung function, clinical features, treatment and disease progression of patients attending Joint Rheumatology and Chest clinic (JRCC) in our District General Hospital (DGH). Methods: JRCC are run once a month at Wrightington, Wigan and Leigh trust by a Rheumatologist and Chest Physician. 98 new patients attended this clinic in 4 years (2013-16). Clinical details of these patients were obtained from Electronic Patient Record. Results: Rheumatoid Arthritis(59.2%) is the most common type of rheumatologic disease with lung manifestation, followed by Lupus (10.2%) then Sclerosis (8.16%). Majority of patients were Females (62.2%) with average age 64.5 years. The most common Computerised tomography (CT) findings were Non Specific Interstitial Pneumonitis (40.8%), followed by Usual Interstitial Pneumonitis(20.4%), Bronchiectasis in (12.2%), CT was normal in 7.14% of the patients with CTD. The connective tissue screen serology was negative in 14.28% of the patients who were symptomatic. Out of all the patients 64 are stable,10 have worsening of the disease and 15 died. Conclusion: JRCC are generally run in Tertiary centres in the NHS. All these patients seen in our centre were managed locally thus emphasising that it is possible to run these specialised ILD services in DGH. Running a joint clinic in DGH can avoid referrals to tertiary hospitals and provide care for patients closer to home. Reference: 1. Fischer A et al An official ERS/ATS research statement EurRespir J. 2015 Oct;46(4):976-87