Background:Ramadan, observed by nearly 2 billion Muslims worldwide, involves fasting from dawn to sunset, which can present challenges for individuals with chronic respiratory diseases due to altered medication regimens and oral intake restrictions. This study aimed to synthesise current evidence and develop consensus recommendations for managing asthma, COPD, interstitial lung disease (ILD) and bronchiectasis during Ramadan. Methods:A comprehensive search of electronic databases including MEDLINE, Embase and Google Scholar was conducted following a pre-specified protocol (PROSPERO identifier number CRD42024532759) to identify studies on Ramadan fasting outcomes in individuals with chronic respiratory diseases. The findings informed consensus recommendations stratified by the risk of adverse outcomes using International Diabetes Federation and the Diabetes and Ramadan risk assessment criteria. An international expert group of medical and religious experts refined these guidelines, achieving consensus approval. Results:11 studies met the inclusion criteria, primarily addressing asthma and COPD, with no relevant studies on ILD or bronchiectasis. The studies indicated that fasting did not significantly impact hospitalisation rates or lung function tests in individuals with stable asthma and COPD. However, small sample sizes and methodological limitations restricted generalisability. 19 recommendations were developed to support patients considering fasting, emphasising pre-Ramadan consultations, individualised risk assessments, and adjustments to medication regimens. Conclusion:This systematic review highlights the need for larger, well-designed studies to understand Ramadan fasting implications across chronic respiratory diseases. The developed recommendations provide a structured approach to assess fasting risks, ensuring informed and safe guidance during Ramadan. Future research should address identified gaps, supporting evidence-based guidelines that reconcile medical and religious considerations.

Introduction Sub-optimal inhaler adherence undermines the efficacy of pharmacotherapy in COPD. Digitalised care pathways are increasingly used to improve inhaler-use behaviour remotely. This review investigated the feasibility and impact of remote electronic inhaler adherence monitoring (EIM) and intervention platforms on clinical outcomes in COPD. Methods A literature search was conducted and studies investigating maintenance inhaler use among people with COPD using digital technology were selected. Pairwise and proportional meta-analyses were employed with heterogeneity assessed using I2 statistics. When meta-analysis was not feasible, a narrative synthesis of outcomes was conducted. Results We included 10 studies including 1432 people with COPD whose maintenance inhaler usage was supported by digital inhalers and apps featuring audiovisual reminders and educational content with or without engagement with healthcare providers (HCPs). Inhaler adherence rate (AR) varied with calculation methods, but an overall suboptimal adherence was observed among people with COPD. HCP-led adherence interventions alongside EIM improved mean AR by 18% (95% CI 9–27) versus passive EIM only. Enhanced AR may reduce COPD-related healthcare utilisation with little impact on health-related quality of life and exacerbation rate. Despite encountering technical issues among 14% (95% CI 5–23%) of participants, 85% (95% CI 76–94%) found digital platforms convenient to use, while 91% (95% CI 79–100%) perceived inhaler reminders as helpful. Conclusion Digitalised interventions can enhance maintenance inhaler adherence in COPD but their overall effect on clinical outcomes remains uncertain. Further work is required to tailor interventions to individuals’ adherence behaviour and investigate their longer-term impact.

The British Thoracic Society (BTS) and Scottish Intercollege Guidelines Network (SIGN), as well as National Institute for Health and Care Excellence (NICE), have previously produced separate asthma guidance differing in some key aspects in diagnosis and management leading to confusion, potentially hampering guideline dissemination and uptake. While there are inherent challenges, the upcoming release of new joint BTS/SIGN/NICE asthma guidance presents an opportunity to assess guideline adoption and its impact on clinical practice. The use of prescription data via databases such as OpenPrescribing can be used as a surrogate for guideline adoption and potentially linked to clinical outcomes such as hospital episode statistics (HES). The potential recommendation for anti-inflammatory reliever therapy (AIR) and maintenance and reliever therapy (MART) with inhaled corticosteroid/formoterol combination therapy in the next iteration of UK asthma guidance will require the accurate coding for the respective therapeutic approaches on prescribing platforms in order to assess their impact in real-life clinical practice. This could then direct targeted measures to improve wider guidance adoption leading to better clinical care in asthma based on up to date evidence.

INTRODUCTION:Sub-optimal inhaler adherence undermines the efficacy of pharmacotherapy in COPD. Digitalised care pathways are increasingly used to improve inhaler-use behaviour remotely. This review investigated the feasibility and impact of remote electronic inhaler adherence monitoring (EIM) and intervention platforms on clinical outcomes in COPD. METHODS:A literature search was conducted and studies investigating maintenance inhaler use among people with COPD using digital technology were selected. Pairwise and proportional meta-analyses were employed with heterogeneity assessed using I2 statistics. When meta-analysis was not feasible, a narrative synthesis of outcomes was conducted. RESULTS:We included 10 studies including 1432 people with COPD whose maintenance inhaler usage was supported by digital inhalers and apps featuring audiovisual reminders and educational content with or without engagement with healthcare providers (HCPs). Inhaler adherence rate (AR) varied with calculation methods, but an overall suboptimal adherence was observed among people with COPD. HCP-led adherence interventions alongside EIM improved mean AR by 18% (95% CI 9-27) versus passive EIM only. Enhanced AR may reduce COPD-related healthcare utilisation with little impact on health-related quality of life and exacerbation rate. Despite encountering technical issues among 14% (95% CI 5-23%) of participants, 85% (95% CI 76-94%) found digital platforms convenient to use, while 91% (95% CI 79-100%) perceived inhaler reminders as helpful. CONCLUSION:Digitalised interventions can enhance maintenance inhaler adherence in COPD but their overall effect on clinical outcomes remains uncertain. Further work is required to tailor interventions to individuals' adherence behaviour and investigate their longer-term impact.

Introduction and Objectives Inhalers play a central role in the management of respiratory conditions, with 73 million inhalers used annually in the UK, a high proportion of which end up in landfill. If pressurised metered-dose inhalers (pMDIs) are discarded before they are empty, residual propellant leaks out into the atmosphere, which has an impact on the environment. Conversely, using an inhaler beyond the labelled number of doses has implications for disease control and/or patient safety. Therefore, we evaluated how patients determine when their inhaler is empty and how they dispose of old/unwanted inhalers. Methods A qualitative online survey was circulated to individuals with a respiratory condition who were currently prescribed an inhaler and/or to their carers. Results Data collected from 199 respondents between February and June 2023 showed that they were prescribed pMDIs (47.7%), dry-powder inhalers (25.6%) or both (26.1%); 85.4% were using at least one inhaler with a dose counter. Of 29 respondents using devices without a dose counter, 55.2% were not confident in identifying when their inhaler is empty. When all respondents were asked how they knew when their inhaler was empty, 24.6% responded that it was when they no longer received a dose; 22.6%, when it felt empty when shaken, and 19.1%, when it stops 'puffing'. Of 170 respondents with an inhaler with dose counter, 77.1% reported starting a new inhaler when the dose counter indicates zero; however, 20.6% carried on using the device beyond zero. When considering disposal of old/unwanted inhalers, 52.8% of respondents disposed of them irrespective of whether they were empty; 41.7% disposed of them in household waste and 27.1%, in household recycling. Many respondents reported a limited knowledge of recycling schemes. Conclusion Most respondents using devices without a dose counter were not confident in identifying when their inhaler was empty. Furthermore, many respondents who used inhalers with a dose counter continued to use them beyond 'zero'; this has implications for disease control and patient safety. There was a limited awareness of appropriate recycling mechanisms for inhalers. Taken together, there is a clear opportunity for educational initiatives for optimising device use and disposal. Please refer to page A289 for declarations of interest related to this abstract.

Background Asthma exacerbations requiring hospitalisation are treated with high-dose oral corticosteroids (OCS). However, increased cumulative OCS dose is associated with significant adverse effects. Guidelines suggest only tapering OCS to avoid adrenal insufficiency in patients whose OCS course exceeds 2 weeks, or who take maintenance OCS. There is no evidence that tapering OCS improves future exacerbation risk, although data is limited. Aims Compare OCS tapering after asthma exacerbation to guidelines, identify factors associated with OCS tapering, and investigate if tapering improves outcomes. Methods Firstly, asthma exacerbation discharge summaries from May to October 2021 at a large UK hospital trust were reviewed to establish clinician practice compared to national/international guidelines. Secondly, tapering OCS patients were matched to patients with abrupt OCS cessation by admission date. Taper and abrupt patient data were compared using hospital and primary care electronic health records. Results 44 of 318 (13.8%) asthma exacerbation episodes received tapering OCS. Median duration of highest dose OCS was not significantly different between taper (7 days) and abrupt (6 days) groups. 4/44 taper and 1/44 abrupt patients had an acute OCS course >14 days. 10/44 taper and 13/44 abrupt patients had received OCS within 14 days pre-admission. 13/44 taper and 4/44 abrupt patients were prescribed maintenance OCS. Overall, 17/44 (39%) taper and 6/44 (14%) abrupt patients met guideline criteria for OCS taper. Tapering OCS patients had a longer hospital admission (median [IQR] 4 [2–5] vs 1 [0–4] days; p=0.004) and more asthma admissions in the preceding 6 months (median [IQR] 0 [0–1] vs 0 [0–0]; p=0.004) compared to abrupt OCS patients. There was no difference in blood eosinophils. Median [IQR] days from completion of OCS to next exacerbation was no different between taper (69 [33–152]) and abrupt (71 [32–143]) groups (p=n.s). Mean (SD) total dose of OCS (Prednisolone) was 835 (305) mg in taper patients compared to 295 (136) mg in abrupt patients (p=<0.0001). Conclusion Clinicians often prescribe tapering OCS courses outside of guideline recommendations, possibly with the aim of reducing future exacerbation risk. Tapering OCS was not associated with increased time to next exacerbation, despite 2.8x total OCS dose exposure.

All inhalers have an environmental impact; the majority are not recycled, with many disposed of inappropriately through domestic waste. To assess the feasibility of a method for recovering and recycling inhalers, Chiesi Limited (Chiesi) set up and funded 'Take AIR (Action for Inhaler Recycling)', a 12-month pilot postal scheme facilitated by community pharmacies across Leicester, Leicestershire, and Rutland, and hospitals in Leicestershire. All inhalers were accepted in the scheme. The recovered pressurised metered-dose inhalers (pMDIs) were dismantled and component parts recycled where possible; the remaining propellant gas was extracted for reuse in refrigeration and air conditioning industries. Other inhaler types were incinerated in an 'energy-from-waste' facility. From February 2021 to February 2022, 20,049 inhalers were returned; most (77%) were pMDIs. So far, Take AIR has saved the equivalent of an estimated 119.3 tonnes of carbon dioxide emissions from entering the atmosphere. Our experience demonstrates the feasibility and effectiveness of a postal inhaler recovery and recycling scheme, which could be used as a foundation to build future initiatives.

Inappropriate use of inhalers (due to suboptimal adherence or prescribing) is associated with adverse outcomes in asthma. Despite this, patterns of inhaler prescribing and adherence are not routinely assessed on admission. This could lead to inappropriate treatment escalation and missed opportunities for patient education. To evaluate the feasibility and potential impact of a routine adherence report we collected data on primary care prescription issue over the previous year in 95 consecutive patients admitted with asthma using electronic records. The medication possession ratio (MPR) for preventer medication was calculated; a cut off of 75% considered sub-optimal adherence. The numbers of prescribed short-acting β2-agonist inhalers and oral corticosteroids were also recorded. Results were retrospectively reviewed for each patient alongside discharge medication to determine whether knowledge of adherence on admission would have identified inappropriate prescribing, better inform patient education, or may have prevented unnecessary treatment escalation. Adherence reports were completed for 84/95 (88.4%) patients (one died before discharge, 10 had inaccessible records). 29 patients had first been prescribed preventer medication during the current exacerbation (on or just before admission). Of these 18 had received ≥ 1 SABA prescription during the previous year, 11 of whom had evidence of a historical blood eosinophilia suggesting missed opportunities for ICS prescribing in at least 37.9%. Of the 55 patients taking preventer medication prior to the current exacerbation, 36 (65.5%) had suboptimal adherence; 10 of whom had their ICS dose increased on discharge, suggesting inappropriate treatment escalation in 27.8%. 42 patients had been prescribed excessive SABA (at least 3 inhalers a year, including 10 of those with optimal adherence to preventer medication). Overall, this suggests that the adherence report identified areas for patient education in 83.6% of those who had already been established on preventer medication. Patients with MPR <0.75 had a significantly shorter length of stay (1.3 v 2.7 days, p=0.01) suggesting less severe exacerbations which may have been prevented by improved adherence. A comprehensive asthma prescribing and adherence report is feasible for patients admitted with acute severe asthma, and is likely to improve patient education and appropriate prescribing in the majority.

Introduction and Objectives All inhalers have an environmental impact. The majority are not recycled, and many are disposed of inappropriately through domestic waste. All pressurised metered-dose inhalers (pMDIs) are manufactured with an overfill of medication; inappropriate disposal of pMDIs with residual propellant releases hydrofluorocarbon (a greenhouse gas) into the environment. To correctly dispose of inhalers, patients are currently required to return them to their community pharmacies; however, there is a lack of awareness and uptake of such schemes. To assess the feasibility of an alternative method for recovering and recycling inhalers, Chiesi Limited set up and funded Take AIR (Action for Inhaler Recycling), a postal recycling scheme. Methods Take AIR was a pilot, postal inhaler recycling scheme facilitated by community pharmacies across Leicester, Leicestershire and Rutland (LLR) and hospitals in Leicestershire. Patients prescribed inhalers were provided with pre-paid, pre-addressed envelopes that could be used to return inhalers to Grundon Waste Management Limited. All inhaler types could be returned. pMDIs were dismantled, with aluminium canisters crushed for smelting and plastic casings pelletised ahead of recycling. Remaining propellant gas was extracted for reuse in non-pharmaceutical items (e.g. refrigerators, air conditioning units). Using predictive modelling, carbon emission savings from recycled pMDIs were estimated. Other inhaler types were incinerated at an energy-from-waste facility. A qualitative survey of patients involved in Take AIR was also conducted. Results In the first 12 months, 5258 envelopes containing 20 004 inhalers were returned to the waste management company; most inhalers (77%) were pMDIs. During this time period, Take AIR saved the equivalent of an estimated 117.9 tonnes of carbon dioxide emissions from entering the atmosphere. The scheme has been well received by patients: 73% of respondents (n/N=36/49) stated that they were 'very satisfied' with it. Conclusion The Take AIR scheme demonstrates the feasibility and effectiveness of a postal inhaler recovery and recycling scheme, albeit from data limited to the LLR region over a relatively short term. This initiative may offer some advantages (e.g. postal collection and recycling and reuse of some inhaler parts) compared with previous schemes. Please refer to page A210 for declarations of interest related to this abstract.

BACKGROUND: Nonadherence in difficult-to-control asthma can be identified using 7-day FeNO suppression testing where patients take additional fluticasone via Diskus with an Inhaler Compliance Assessment (INCA) acoustic monitoring device attached, and self-measure FeNO at home. However, this is inconvenient for patients attending a tertiary center and limited by FeNO meter availability. It is not known if this approach alters clinical outcomes. OBJECTIVES: To examine patient acceptability and the effectiveness of replacing usual combination inhaled corticosteroid (ICS)/long-acting b2-agonist (LABA) therapy with a fluticasone/salmeterol Diskus 500DINCA for 28 days as the initial intervention, compared with the 7-day FeNO suppression test, and to explore clinical outcomes after INCA monitoring. METHODS: A service evaluation of FeNO suppression testing was undertaken in clinical practice. RESULTS: Twenty-one of 23 subjects offered replacement of their usual ICS/LABA with fluticasone/salmeterol DINCA as the initial intervention accepted and completed 28 days of monitoring. Fourteen (66.6%) patients reduced their FeNO by >42% (FeNO suppressors), accompanied by improvements in forced expiratory volume in 1 second, Asthma Control Questionnaire, and blood eosinophils, similar to the 7-day test (n = 74). Twenty-two of 62 (35.5%) FeNO suppressors progressed to biological therapy, compared with 24 of 33 (72.7%) nonsuppressors (P = .0006). FeNO suppressors taking maintenance prednisolone (n = 13) who did not receive biological therapy reduced the median baseline dose from 10 to 3 mg, with further reductions limited by adrenal suppression. CONCLUSION: Replacing existing inhaled therapy with fluticasone/salmeterolDINCA for 28 days is acceptable to the majority of people with difficult-to-control asthma and identifies prior medication nonadherence. INCA monitoring coupled with clinical support potentially improves patient adherence and asthma control, preventing unnecessary progression to biological therapy. (C) 2020 American Academy of Allergy, Asthma & Immunology

Lower respiratory tract illnesses with wheeze occur in around one-third of all pre-school children aged 1–5 years. They are among the most common causes of childhood attendances to emergency departments, accounting for almost 75% of all childhood admissions for wheezing in the UK​[1]​. Although admissions and acute presentations have fallen for school-age children with asthma, […]

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Introduction and objectives Currently three main classes of biologics are licensed for severe asthma treatment in the UK. These classes target IgE (omalizumab) and IL-5/IL-5R (mepolizumab/reslizumab and benralizumab). The stratification factors that identify response to omalizumab and mepolizumab beyond the licensing criteria are poorly understood in clinical practice. However, the GINA 2019 severe asthma guidelines advocate clinical stratification when >1 biologic choice exists. The study aim was to evaluate the clinical characteristics that can predict response to omalizumab and mepolizumab. Methods Over a prospective period (April 2017 to July 2019) we evaluated 105 patients initiated on biologic treatment (omalizumab n=27 [GINA 4=9, GINA 5=18 (oral corticosteroids (OCS) median (IQR):10 mg (10–15) and mepolizumab n=78 (GINA 4=13, GINA 5=65 (OCS:12.5 mg (10–15)] at a single severe asthma centre. Omalizumab response was assessed at 16 weeks as per NICE recommendations, and on-going response at one year; according to MDT defined response markers. Mepolizumab response was assessed based on NICE criteria at 1 year. We looked at the GINA 2019 treatment selection criteria (omalizumab: blood eosinophils ≥260 cells/µl, FeNO ≥20ppb, childhood-onset asthma and mepolizumab: higher blood eosinophils, more exacerbations in the previous year, adult-onset asthma (≥18 years), nasal polyposis) as baseline stratifiers of early and 1 year response using Receiver operator curve analyses (ROC). Results 35% of patients were eligible for both biologics based on baseline characteristics. When assessing response to biologics [R+ (responder)/R- (non-responder)]: we identified for omalizumab 80.8%/19.2% (16 weeks), 69.2%/30.8% (1 year) response rates and mepolizumab: 71.8%/21.2% (16 weeks), 75.9%/24.1% (1 year) response rates. None of the GINA 2019 baseline stratifiers were predictive of treatment response. The best predictor of response to omalizumab (AUC:0.810,p=0.054) and mepolizumab (AUC:0.746,p=0.006) was exacerbations in the previous year. Conclusions We have identified that >1:3 patients are eligible for more than one class of biologic. Treatment failure rates in this highly refractory population at 1 year were relatively high with between 20–30% of patients failing therapy. Only exacerbations in the previous year was a significant predictor of treatment response to both biologics. Therefore, more effective decision support tools are required to guide biologic prescribing in clinical practice.

The role of clinical nurse specialists (CNSs) in interstitial lung disease (ILD) is evolving in response to clinical guidelines and the growth of clinical research. The role is well established in the UK, although more ILD posts are needed to ensure supply meets clinical demand. This phenomenon is also happening across Europe. An appreciation of the similarities and differences between CNS and advanced nurse practitioners is important given the challenges in defining, developing and supporting this nursing specialisation. Globally, different models exist. In some countries charitable organisations take a leading role in supporting patients. Many European centres look to the National Institute for Health and Care Excellence guidelines and quality standards as a template to develop and evaluate the role of the ILD CNS. We present a UK perspective in the context of a government subsidised healthcare system to promote professional discussion and debate regarding the future of nursing practice in the ILD specialty. Key points ILDs are often complex and associated with significant mortality, morbidity and co-morbid conditions that require a technical healthcare skill set There is worldwide shortage of nurses, low retention rates and retirement of many skilled nurses Collaboration across the ILD interdisciplinary community is needed to safeguard the future of our professions and high-quality patient care The ILD interdisciplinary and nurse network has identified key priorities to help secure the future of the ILD clinical and academic nurse specialism Educational aims To explain the similarities and differences between clinical nurse specialists (CNSs) and advanced nurse practitioners (ANPs) in the context of ILD specialism To review contemporary nursing specialism in the UK’s government subsidised healthcare system To stimulate discussion and debate across the European/international respiratory community regarding the clinical and academic development of the ILD CNS To identify key priorities that will support collaboration across the ILD interdisciplinary workforce in clinical practice and research