Background: Lung cancer treatment has improved in recent years; with earlier disease detection via the 'Liverpool Lung Project', use of stereotactic ablative radiotherapy (SABR) and improved systemic therapeutics. Despite this the United Kingdom (UK) lags behind Europe in cancer outcomes. The 'wheel and spoke' structure of tertiary services may contribute to geographical variation in the provision of services, worsening outcomes for outlying populations. Aim: To assess the effect of distance to tertiary centre in lung cancer, at a UK three site Trust of District General Hospitals. Methods: This is a retrospective, observational study using UK national lung cancer audit data 2019-2021. All adult patients with biopsy proven lung cancer, or radiological diagnosis meeting criteria for radical treatment were included. Mesothelioma was excluded. Radical treatment candidates were identified, with distance calculated between patients' home address and relevant tertiary centre. Results: 1,633 patients were included. 413 received radical treatment, 273 surgery or SABR. Characteristics between sites (A, B, and C) were similar; mean age (73.3, 73.4, 71.9), performance status (0.89, 0.81, 1.14), and ratio receiving radical treatment (0.23, 0.25, 0.26). Proportion of patients receiving SABR or surgery decreased (0.81, 0.58, 0.51) as distance from tertiary centre increased. [Table 1] – Operative rates by distance to tertiary centre. Conclusion: Patients further from treatment centres were less likely to receieve curative treamtment.

Background Chest drain displacement is a common clinical problem that occurs in 9-42% of cases and results in treatment failure or additional pleural procedures conferring unnecessary risk. A novel chest drain with an integrated intrapleural balloon may reduce the risk of displacement. Methods A prospective randomised controlled trial comparing the balloon drain to standard care (12 F chest drain with no balloon) with the primary outcome of objectively defined unintentional or accidental chest drain displacement. Results 267 patients were randomised (primary outcome data available in 257, 96.2%). Displacement occurred less frequently using the balloon drain (displacement 5 of 128, 3.9%; standard care displacement 13 of 129, 10.1%) but this was not statistically significant (OR for drain displacement 0.36, 95% CI 0.13-1.0, Chi-squared 1 degree of freedom (df)=2.87, p=0.09). Adjusted analysis to account for minimisation factors and use of drain sutures demonstrated balloon drains were independently associated with reduced drain fall-out rate (adjusted OR 0.27, 95% CI 0.08-0.87, p=0.028). Adverse events were higher in the balloon arm than the standard care arm (balloon drain 59 of 131, 45.0%; standard care 18 of 132, 13.6%; Chi-squared 1 df=31.3, p<0.0001). Conclusion Balloon drains reduce displacement compared with standard drains independent of the use of sutures but are associated with increased adverse events specifically during drain removal. The potential benefits of the novel drain should be weighed against the risks, but may be considered in practices where sutures are not routinely used.

Introduction and ObjectivesElectronavigational bronchoscopy (ENB) facilitates the biopsy of small peripheral lesions in the lungs, otherwise inaccessible to conventional sampling techniques. It is most commonly performed under general anaesthetic in tertiary institutions. We sought to evaluate the ability to perform ENB under conscious sedation in a district general hospital.MethodsProspective data was gathered on the first 21 patients undergoing ENB between May 2019 and June 2020 using the Medtronic SuperDimension Navigation system. Neither cone beam CT nor fluoroscopy were used during the procedure. A lead operator performed all procedures assisted by another experienced consultant bronchoscopist. Patients were followed up for a minimum of three months, except for one who declined further review. A false negative was defined by either a subsequent biopsy proven cancer, or when treatment for cancer was given based on clinical and radiological suspicion despite a negative ENB biopsy.Results21 patients with suspected lung cancer underwent 22 day-case ENB procedures under conscious sedation with no significant complications (Table). In our case series ENB had a diagnostic yield of 76.2% (52.8% – 91.8%); sensitivity of 68.8% (95% CI 41.3% – 89.0%); a specificity of 100.0% (47.8% – 100.0%); a positive predictive value of 100.0%; and a negative predictive value of 50.0% (32.6% – 67.4%). These results are similar to the largest published trial of ENB (81.4% done under GA; 94.9% with adjuvant cone beam CT or fluoroscopy) which had diagnostic yield, sensitivity, and negative predictive value and of 72.9%, 68.8%, and 56.3% respectively. Eight patients (38.1%) had undergone a prior non-diagnostic biopsy, and all had a subsequent diagnostic ENB. In cases where a positive diagnosis was obtained the size of the target lesion (27 mm) was comparable with that of the case series as a whole (24 mm).ConclusionENB can be performed successfully in a district general hospital using conscious sedation and without reliance on cone beam CT or fluoroscopy, with diagnostic rates comparable with larger institutions under general anaesthesia.

AbstractObjectivesTo define the burden of nosocomial (hospital-acquired) novel pandemic coronavirus (covid-19) infection among adults hospitalised across Wales.DesignRetrospective observational study of adult patients with polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection between 1st March – 1st July 2020 with a recorded hospital admission within the subsequent 31 days. Outcomes were collected up to 20th November using a standardised online data collection tool.SettingService evaluation performed across 18 secondary or tertiary care hospitals.Participants4112 admissions with a positive SARS-CoV-2 PCR result between 1st March to 1st July 2020 were screened. Anonymised data from 2518 participants were returned, representing over 60% of adults hospitalised across the nation of Wales.Main outcome measuresThe prevalence and outcomes (death, discharge) for nosocomial covid-19, assessed across of a range of possible case definitions.ResultsInpatient mortality rates for nosocomial covid-19 ranged from 38% to 42% and remained consistently higher than participants with community-acquired infection (31% to 35%) across a range of case definitions. Participants with nosocomial-acquired infection were an older, frailer, and multi-morbid population than those with community-acquired infection. Based on the Public Health Wales case definition, 50% of participants had been admitted for 30 days prior to diagnostic testing.ConclusionsThis represents the largest assessment of clinical outcomes for patients with nosocomial covid-19 in the UK to date. These findings suggest that inpatient mortality rates from nosocomial-infection are likely higher than previously reported, emphasizing the importance of infection control measures, and supports prioritisation of vaccination for covid-19 negative admissions and trials of post-exposure prophylaxis in inpatient cohorts.Trial registrationThis project was approved and sponsored by the Welsh Government, as part of a national audit and quality improvement scheme for patients hospitalised covid-19 across Wales.Key MessagesWhat is already known on this topicWe searched PubMed and ISI Web of Science up until 31-December-2020 for studies reporting on patient outcomes following hospital-acquired infection due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We identified a range of case-definitions for hospital-acquired infection, based on timing of diagnostic testing 5 to 15 days following admission. The largest and only multi-centre study concluded individuals with nosocomial infection are at a lower risk of death from SARS-CoV-2 than those infected in the community, however, was performed early in the pandemic and utilised a conservative definition of nosocomial infection.What this study addsOur multi-centre observational study represents the largest assessment of clinical outcomes for patients with nosocomial covid-19 in the UK to date, and suggests the burden of nosocomial SARS-CoV-2 infection has been underestimated. Nosocomial-infection occurred in older, frailer, and multi-morbid individuals, and was consistently associated with greater inpatient mortality than amongst those who were infected in the community across a spectrum of case-definitions. Our findings support implementation of enhanced infection control measures to reduce this burden during future waves, especially given the recent emergence of novel viral variants with enhanced transmissibility. Furthermore, roughly half of the patients meeting the Public Health Wales definition of definite nosocomial SARS-CoV-2 infection had been admitted for 30 days prior to diagnosis, highlighting a potential window of opportunity for inpatient pre-exposure and/or post-exposure prophylaxis.

The burden of nosocomial SARS-CoV-2 infection remains poorly defined. We report on the outcomes of 2508 adults with molecularly-confirmed SARS-CoV-2 admitted across 18 major hospitals, representing over 60% of those hospitalised across Wales between 1 March and 1 July 2020. Inpatient mortality for nosocomial infection ranged from 38% to 42%, consistently higher than participants with community-acquired infection (31%–35%) across a range of case definitions. Those with hospital-acquired infection were older and frailer than those infected within the community. Nosocomial diagnosis occurred a median of 30 days following admission (IQR 21–63), suggesting a window for prophylactic or postexposure interventions, alongside enhanced infection control measures.

BackgroundClinical guidelines for asthma are available to UK clinicians but implementation is not straightforward. Diagnostic and treatment inadequacy contribute to patient morbidity and mortality and lack of adherence to guidelines is a component of this.AimThis qualitative study sought to explore and understand the use of asthma guidelines by primary care clinicians in two geographically bounded regions of Wales.MethodMultiple case study design was used. Data was collected using semi-structured interviews with a purposively sampled group of clinical staff from GP practices. Interview transcripts were thematically analysed to produce a detailed picture of practice.ResultsAsthma care in the studied areas operated as a social network of clinicians who often used guidelines as boundary objects. Practice and local service design was influenced and dependent on regular input from local secondary care providers. Clinicians looked to British Thoracic Society and Scottish Intercollegiate Guideline Network (BTS/SIGN) 2016 guidelines. There was limited use of National Institute for Health and Care Excellence (NICE) 2017 guidelines. Barriers to guideline recommended diagnostic asthma care included: lack of acceptability, financial costs and disempowerment of nursing staff.ConclusionThe findings from this study replicate and reinforce the findings of previous work. It is striking and concerning that the thematic outcomes of this study bear a strong resemblance to that which was demonstrated over a decade ago. The guideline-implementation gap in asthma diagnostics will likely persist unless there is significant restructuring, financial investment and greater empowerment of nursing staff in primary care.

Objective To test the hypothesis that administration of talc poudrage during thoracoscopy with local anesthesia is more effective than talc slurry delivered via chest tube in successfully inducing pleurodesis. Design, Setting, and Participants Open-label, randomized clinical trial conducted at 17 UK hospitals. A total of 330 participants were enrolled from August 2012 to April 2018 and followed up until October 2018. Patients were eligible if they were older than 18 years, had a confirmed diagnosis of MPE, and could undergo thoracoscopy with local anesthesia. Patients were excluded if they required a thoracoscopy for diagnostic purposes or had evidence of nonexpandable lung. Interventions Patients randomized to the talc poudrage group (n = 166) received 4 g of talc poudrage during thoracoscopy while under moderate sedation, while patients randomized to the control group (n = 164) underwent bedside chest tube insertion with local anesthesia followed by administration of 4 g of sterile talc slurry. Main Outcomes and Measures The primary outcome was pleurodesis failure up to 90 days after randomization. Secondary outcomes included pleurodesis failure at 30 and 180 days; time to pleurodesis failure; number of nights spent in the hospital over 90 days; patient-reported thoracic pain and dyspnea at 7, 30, 90, and 180 days; health-related quality of life at 30, 90, and 180 days; all-cause mortality; and percentage of opacification on chest radiograph at drain removal and at 30, 90, and 180 days. Results Among 330 patients who were randomized (mean age, 68 years; 181 [55%] women), 320 (97%) were included in the primary outcome analysis. At 90 days, the pleurodesis failure rate was 36 of 161 patients (22%) in the talc poudrage group and 38 of 159 (24%) in the talc slurry group (adjusted odds ratio, 0.91 [95% CI, 0.54-1.55]; P = .74; difference, -1.8% [95% CI, -10.7% to 7.2%]). No statistically significant differences were noted in any of the 24 prespecified secondary outcomes. Conclusions and Relevance Among patients with malignant pleural effusion, thoracoscopic talc poudrage, compared with talc slurry delivered via chest tube, resulted in no significant difference in the rate of pleurodesis failure at 90 days. However, the study may have been underpowered to detect small but potentially important differences. Question Is thoracoscopy with local anesthesia and administration of talc poudrage more effective than chest tube placement with local anesthesia and administration of talc slurry at inducing pleurodesis in individuals with malignant pleural effusion? Findings In this randomized clinical trial that included 330 patients, thoracoscopic talc poudrage, compared with chest tube insertion and talc slurry, resulted in no significant difference in the rate of pleurodesis failure at 90 days (22% vs 24%). Meaning Among patients with malignant pleural effusion, there was no significant difference in the rate of pleurodesis failure between the use of talc poudrage and talc slurry; however, the study may have been underpowered to detect small but potentially important differences.

Background: The burden of hospital-acquired (nosocomial) COVID-19 remains poorly defined with variation in case-definitions used for reporting and little publicly-available information concerning outcomes.Methods: We conducted a retrospective observational study of adult patients with a positive SARS-CoV-2 positive polymerase chain reaction (PCR) hospitalised across Wales between 1st March – 1st July 2020. An electronic survey was used to capture patient outcome following admission until 20th November. The prevalence and outcomes for nosocomial COVID-19 were assessed across of a range of possible case definitions.Findings: The study included 2518 patients from 18 major hospitals sites across Wales and collected outcomes on patients discharged up to 20 th November, representing approximately 60% of patients hospitalised. Inpatient mortality rates for nosocomial COVID-19 ranged from 38% to 42%, and remained consistently higher than patients with community-acquired infection (31% to 35%) across a range of case definitions. Nosocomial patients were older, frailer and multi-morbid population than those with community-acquired disease, even when categorised using a 2-day cut-off. Based on the Public Health Wales case definition of nosocomial COVID-19 infection, 50% of cases had been admitted for 30 days prior to diagnostic testing.Interpretation: This represents the largest assessment of clinical outcomes for patients with nosocomial COVID-19 in the UK to date. These findings suggest that inpatient mortality rates from nosocomial-infection are likely higher than previously reported, emphasizing the importance of infection control measures, and suggests opportunities for inpatient vaccination of vulnerable cohorts.Funding: Welsh Government, Respiratory Health Implementation Group, UK Coronavirus Immunology Consortium, Wellcome Trust Senior Fellowship (to IRH), WCAT Fellowship (to MJP).Declaration of Interests: We declare no competing interests.Ethics Approval Statement: This project constitutes the evaluation/audit arm of the National Pathway for Managing COVID-19 Infections in Secondary Care in Wales. As such, the requirement for formal ethical review or approval was not required

A 71-year-old man presented with breathlessness and visual disturbance. On examination of the chest, he had signs suggestive of a right-sided pleural effusion and a neurological examination yielded conjugate vertical gaze palsy. Subsequent investigations revealed pleural thickening and mesothelioma. His anti-Ma2 antibodies were positive indicating a paraneoplastic syndrome as the cause of the vertical gaze palsy.

Background The 2013 NHS England service specifications for severe asthma aimed to develop a limited number of high volume specialist hub centres. These centres would have a multi-disciplinary team (MDT) working to improve patient outcomes and reduce healthcare costs. In the North West we have developed a networked approach to specialised severe asthma services; the first Operation Delivery Network (ODN) for a chronic disease. Representatives from 11 NHS Trusts and a central hub undertake a monthly virtual MDT meeting with physicians, nurses, pharmacists, physiotherapists, clinical psychologists, speech and language therapists, and radiologists represented. All patients being considered for specialised treatments undergo MDT discussion for consensus approval of treatment. Aim To summarise the experience and case-mix encountered during the first 4 years of operation of our regional virtual severe asthma MDT. Methods We reviewed all cases discussed at the MDT between January 2015 and June 2018. Proformas are submitted via nhs.net accounts and data entered into a central database by MDT coordinator. All biologic proformas are pre-assessed by the ODN Pharmacist and Specialist nurse to ensure compliance with the NICE guidelines. Results During this period 41 meetings were held, with 933 cases discussed. Omalizumab was approved in 78% of cases submitted, BT in 39%, mepolizumab in 84% and reslizumab in 94%. The most common reasons for non-approval of omalizumab were insufficient steroid requirement, poor adherence and lack of allergy to perennial allergen. The most common reasons for non-approval to mepolizumab and reslizumab were poor adherence and lack of evidence of raised eosinophil levels within the stated 12 month period. The potential 5 year cost saving of high cost therapies not approved at the Central hub is estimated to be £7.5 million. Conclusion A multi-site virtual severe asthma MDT meeting facilitates expert care across a wide geographical area, ensures governance in the use of novel and expensive therapies, strengthens collaboration and aims to improve patient care. Reference Ryan D, et al. The UK's largest severe asthma multidisciplinary team meeting; experience from the first 18 months. ThoraxDec 2016:71(3);A5.

Introduction Antifibrotic medication (AFM) is indicated for the treatment of idiopathic pulmonary fibrosis (IPF), but medication related side effects can lead to early discontinuation of therapy in some patients. Factors that may predict intolerance of AFM are poorly described Methods Retrospective data from all patients from a single District General Hospital that had received AFM for IPF between January 2014 and March 2017 were analysed. Patients were defined at four months as either tolerant or intolerant of AFM determined by either continuation of treatment, or discontinuation of treatment because of medication related side effects respectively. Fisher’s exact test was used to compare age, body mass index (BMI) and Clinical Frailty Score (CFS) between the two groups. Frailty was defined as a CFS of ≥6 (scale 1–9 with a high score indicating greater frailty) Results 35 patients received AFM and 10 (29.4%) were intolerant of treatment at 4 months. Patients without frailty were more likely to be tolerant of treatment than those with frailty (86.4% versus 33.3%, p=.0074) Patients with a BMI in the upper three quartiles of the sample were more likely to be tolerant of treatment than those in the lowest quartile, but this trend did not reach statistical significance (80.7% versus 44.4%, p=0.081), and there was no difference in tolerance between patients over 80 years of age and younger patients (77.8% versus 75.0%, p≥0.99) Conclusions Frailty and low BMI may predict treatment intolerance with AFM in IPF, whereas age does not appear to influence this outcome. Clinicians should consider a patient’s frailty when considering this therapy. Further analysis of a larger dataset and a prospective study are warranted.

Background Severe asthma comprises 5% of all asthma, but over 50% of the asthma healthcare burden. With multi-disciplinary team (MDT) working there is potential to improve patient outcomes and reduce healthcare costs. In 2013 NHS England produced service specifications for severe asthma aiming to develop a limited number of high volume specialist centres. In the North West we have developed a networked approach to specialised severe asthma services; the first Operation Delivery Network for a chronic disease. Representatives from 11 NHS Trusts and a central hub undertake a monthly virtual MDT meeting, with physicians, nurses, physiotherapists, clinical psychologists, speech and language therapists, allergists, pathologists and radiologists represented. All patients being considered for specialised treatments undergo MDT discussion for consensus approval of treatment. Aim To summarise the experience and case-mix encountered during the first 18 months of operation of our regional virtual severe asthma MDT Methods We reviewed all cases discussed at the MDT between January 2015 and June 2016. Cases were submitted online via nhs.net accounts, and data entered into a central database managed by two MDT coordinators for MDT discussion. Results During this period 17 meetings were held, with 208 case-submissions representing 185 patients, mean (SD) 12 (7) discussions per meeting. Indications for case submission included proposals for use of omalizumab, bronchial thermoplasty (BT), and steroid-sparing therapies, and for the discussion of patients with complex clinical issues, often managed across multiple sites. Omalizumab was approved in 81% of cases submitted, and BT in 39%, with more of the latter requiring multiple discussions (30% versus 2%) The most common reasons for non-approval of omalizumab were insufficient steroid requirement, poor adherence, and lack of allergy to a perennial allergen. Thermoplasty was not approved or listed for re-discussion for a variety of reasons, including 10 (43%) that required further investigation. Conclusion We describe our early experience of a multi-site virtual severe asthma MDT meeting facilitating expert care across a wide geographical area. This ensures governance in the use of novel and expensive severe asthma therapies, strengthens regional collaborations and ultimately aims to provide better patient care.

Introduction There is limited information regarding long-term survival following Pulmonary Embolism (PE), and no data on survival of patients that have undergone CT Pulmonary Angiography (CTPA) but found to be thrombus negative. The positive rate of PE detection in patients undergoing CTPA is variable, ranging from 4.7–25.8% and there is a high reported incidence of incidental pathology discovered during this investigation. We sought to determine the comparative survival of patient undergoing CTPA that were thrombus positive compared with those without a PE. We also sought to determine the rate of PE detection and characterise the nature of incidental findings found in patients undergoing CTPA. Methods We retrospectively reviewed data on all CTPA investigations conducted between April 2010 and April 2012. All abnormalities reported on CTPA were reviewed and compared with previous imaging from the last 6 months to determine if they were new findings. Follow-up investigations and out-patient attendances were obtained for all new findings reported on the index CTPA, and 2 year mortality rates were established from regional registry data. Results Of the 1043 patients suitable for analysis, 241 (22.4%) were thrombus positive. The thrombus positive cohort consisted of 47.7% males compared with 40.7% in the thrombus negative group (difference 7.1% [-0.0 to 14.2, p = 0.52]). Survival at 2 years following CTPA was 67.6% in thrombus positive patients and 65.9% in thrombus negative patients with a hazard ratio of 0.96 (95% CI, 0.74 to 1.23, p = 0.721) (Figure). Incidental findings were detected in 51.1% of CTPA examinations including: consolidation/collapse (19.5%), effusion (16.7%), neoplasia (13.5%), lymphadenopathy (9.8%), heart failure (7.6%) and pulmonary nodules (6.6%). 47.7% of incidental findings were deemed significant as determined by the need for further follow-up of clinical intervention. Conclusion There is no difference in the 2 year mortality between thrombus positive and thrombus negative patients undergoing CTPA. Many incidental findings found on CTPA are clinically significant.

Introduction Referring suitable patients for Pulmonary Rehabilitation (PR) has formed part of the Quality and Outcomes Framework (QOF) reward for General Practitioners (GPs) in Wales since April 2013. Patients with Chronic Obstructive Pulmonary Disease (COPD) that have a Medical Research Council (MRC) dyspnoea score of 3 or above, or those with an MRC score of 2 and recently discharged from hospital for COPD are eligible. We sought to determine the impact of this change on the referral pattern to our PR programme, which traditionally had only accepted referrals from secondary care respiratory consultants. Methods A standardised form was prospectively designed and distributed to enable primary care providers to refer suitable patients to the PR programme. Data on patient demographics, respiratory diagnosis, co-morbid conditions, MRC dyspnoea score, exacerbation frequency and current medication were collected. Referring GPs were also asked to provide recent spirometry values for patients that were referred. An assessment was made based on the information provided as to whether the patient could be listed immediately for pulmonary rehabilitation, whether further assessment was required, or whether the referral was inappropriate. Results A sample of 250 GP referral forms out of a total of 545 were evaluated of which 51% of patients were male and the mean age was 69 years (range 31–90). 40.8% of GP referrals could be listed immediately for PR, 34.8% of referrals needed further assessment and 24.4% were inappropriate. 22.4% of all patients referred did not have COPD based on the spirometry results supplied. Compared with the baseline referral rate to PR from secondary care consultants, the rate of referral from GPs showed a sharp increase, particularly toward the end of the financial year (difference in slope -0.77 (95% CI -2.16 to 0.61) versus 9.53 (6.03 to 13.03), p < 0.0001) [Figure]. 36.8% of patients were found to be on off-label inhaled therapy for COPD. Conclusion The number of referrals to PR increased significantly following inclusion in QOF. The majority of the referrals from GPs either require further evaluation or are inappropriate. The spirometry data suggests there is a high misdiagnosis rate of COPD in primary care.

Mucus plugging plays a vital role in the pathophysiology of fatal and near fatal asthma as demonstrated in various postmortem studies. There is a paucity of published literature on how to manage mucus plugging in adult patients with refractory asthma exacerbation not responding to conventional therapies as compared with its paediatric cohort. We describe a dramatic improvement with the use of rhDNase, following bronchoalveolar lavage in an intubated adult female patient, with status asthmaticus refractory to conventional treatment.

Both the ongoing evaluation of training and the possible reduction in SpR training numbers makes it imperative to identify which SpR training posts offer the best educational value. Consultants may overestimate or overstate the training opportunities at their hospital. The JRCPTB “Post Assessment” form is rather non-specific and poorly used. The Respiratory STC in our region undertook to obtain feedback from respiratory SpR’s about the diversity and quality of training and educational supervision. A questionnaire was e-mailed to all SpR’s asking about training opportunities in clinical areas defined by the respiratory curriculum and the JRCPTB Respiratory PYA form; asking about exposure to a given service or specialty rather than just its presence in the hospital (e.g. domiciliary NIV, sleep medicine, thoracoscopy), and the quality of training in that area, (score 1–5, poor - excellent), and how they rated their educational supervision overall. Responses were to include posts previously and currently worked. Trainees sent 40 evaluations on the 14 training hospital in our region, (range 1–6 per hospital). A composite score for training opportunities was derived (maximum possible score for specialty and service areas 71). Scores for individual hospitals ranged from 17.3–43.6 (median 32) and the score for supervision at those sites ranged from 3.3–5 (median 4.3). Hospital identifiable results were tabulated and circulated firstly to trainers and later to trainees. Free text comments were handled more confidentially. Despite some reservations, (e.g. the perspective held by a junior SpR in completing the survey and a possible bias away from broad based DGH training), the STC regarded this as a useful exercise and the questionnaire will be modified by iteration and trainees will complete one after each post. Consultants will be asked to complete the same questionnaire for cross reference. Anecdotally, some units have already begun addressing some issue raised, perhaps in response to a need to “compete”. These results may motivate hospitals to improve their training of SpR’s as well as informing decisions on which posts should be retained and which should not.

The contribution of the alveolar compartment to exhaled nitric oxide (alveolar nitric oxide or CANO) can be calculated as a surrogate of distal inflammation. This value should be corrected for nitric oxide produced in the conducting airways which “back-diffuses” into the alveolar compartment (Corrected CANO). Impulse oscillometry (IOS) (Nava et al., Am J Respir Crit Care Med 168:1432–1437, 2003) is used to derive values for peripheral airways resistance. Twenty-four healthy volunteers, 21 severe asthmatics, 15 mild-to-moderate asthmatics, and 24 COPD patients were assessed with spirometry, impulse oscillometry, and fractionated exhaled nitric oxide. Compared to healthy volunteers, FENO was higher in mild-to-moderate and severe asthmatics: geometric mean fold ratios of 1.91 (P = 0.02) and 2.74 (P < 0.001), respectively. However, there was no difference for mild-to-moderate versus severe asthma. Ratios for CANO were not different for severe asthma versus COPD, but both were elevated compared to that of healthy volunteers [2.64 (P < 0.001) and 3.07 (P < 0.001), respectively] and mild-to-moderate asthma [1.95 (P = 0.04) and 2.28 (P < 0.01)]. However, after correction for axial diffusion, Corrected CANO was increased in COPD compared to severe asthma (geometric mean fold ratio 1.28, P = 0.04), mild-to-moderate asthma (1.34, P < 0.01), and healthy volunteers (1.28, P = 0.02), and there was no difference between other groups. R5 and RF were reduced in healthy volunteers versus mild-to-moderate asthma (P = 0.011 and P < 0.001 respectively), severe asthma (P = 0.002 and P < 0.001), and COPD (P < 0.001 and P < 0.001). Peripheral resistance (R5–R20) was not different for healthy versus mild-to-moderate asthma but was higher in severe asthma (P < 0.001) and COPD (P < 0.001). Correlations were observed between R5–R20 versus FEF25–75 (r = 0.71, P < 0.01), CANO (r = 0.44, P < 0.01), and Corrected CANO (r = 0.24, P < 0.01). CANO and IOS provide additional information to traditional measures of spirometry and tidal nitric oxide. Previous data reporting elevated alveolar nitric oxide in severe asthma may reflect back-diffusion of nitric oxide from the conducting airways into the alveolar compartment. Corrected CANO and IOS may prove to be useful noninvasive measurements of small-airways disease.