Purpose of the studyTo measure the number and distribution of crackles in patients with idiopathic pulmonary fibrosis (IPF) and assess how this relates to measures of disease severity.Study designFourteen patients with IPF had both the number of crackles per litre of lung volume and lung function measured every 3months for 1year. Crackle counts were expressed according to position (upper and lower zones) and whether they occurred during inspiration and expiration.ResultsAt baseline, crackle count per unit volume was higher at the bases than the apices and higher during inspiration than during expiration. There was a significant relationship between lung function and number of crackles per unit volume. Upper zone crackles during inspiration (crackle count vs forced vital capacity (FVC): r=0.69, p=0.007) and lower zone crackles during expiration (crackle count vs FVC: r=0.55, p=0.04) demonstrated the strongest relationship with lung function.ConclusionsNumber and distribution of crackles in IPF relate to physiological measures of disease severity. Inspiratory lower zone crackles were universal and extensive but the presence, hence, development of inspiratory upper zone crackles and expiratory lower zone crackles correlated with measures of poorer lung function. The presence or appearance of these assessed using chest auscultation provides a clinician with simple measure of disease severity, and possibly progression, prompting further physiological assessment and review of treatment.

Objectives To assess the interactive experience of first year medical students attending the leadership and management course hosted by a British Army Reserve Field Hospital developed in partnership with Liverpool University. Methods 244 students submitted a 1000-word structured reflective learning assignment about their reaction to, learning from and any behaviour and attitude changes as a result of, the training. The assignments were thematically analysed to identify how aspects of the training had impacted upon the students' understanding of leadership and teamwork. Their comments relating to the army were analysed to gain insight into their views and experience of the training. Results Students were surprised at how enjoyable and useful they found the course. Initially they expressed scepticism about what they could learn in an army-based environment. However, the training, particularly command and planning tasks, helped them appreciate and understand the different skills individuals can bring to a team environment, and the importance of everyone contributing. While some students were challenged by aspects of the course, with support and encouragement from team-mates and the army personnel, they learned they could achieve more together. Conclusions Teaching leadership and management skills to medical students is a challenge which can be effectively addressed by adapting and developing army training resources. Students overcame initial scepticism about participating, and learned a lot about themselves and each other. In addition, the army developed a better understanding of the doctors of the future. The expertise of the army in delivering this training was crucial to its success as the medical school could not have provided this experience unsupported.

Clinical leadership has been reported as one of the major underlying causes of poor patient care in the NHS.[1] Medical educators now face the challenge of introducing practical leadership training...

Medical EducationVolume 50, Issue 5 p. 568-569 Really Good Stuff Medical students learn about leadership from the army John Earis, John EarisSearch for more papers by this authorJayne Garner, Corresponding Author Jayne GarnerCorrespondence: Jayne Garner, School of Medicine, University of Liverpool, Room 2.17, Cedar House, Ashton Street, Liverpool L69 3GE, UK. Tel: 00 44 151 795 4246; E-mail: jayneg@liverpool.ac.ukSearch for more papers by this authorDiane Haddock, Diane HaddockSearch for more papers by this authorVikram Jha, Vikram JhaSearch for more papers by this author John Earis, John EarisSearch for more papers by this authorJayne Garner, Corresponding Author Jayne GarnerCorrespondence: Jayne Garner, School of Medicine, University of Liverpool, Room 2.17, Cedar House, Ashton Street, Liverpool L69 3GE, UK. Tel: 00 44 151 795 4246; E-mail: jayneg@liverpool.ac.ukSearch for more papers by this authorDiane Haddock, Diane HaddockSearch for more papers by this authorVikram Jha, Vikram JhaSearch for more papers by this author First published: 13 April 2016 https://doi.org/10.1111/medu.13018Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume50, Issue5May 2016Pages 568-569 RelatedInformation

Non‐technical summary Cough is the commonest symptom for which people seek medical advice and has significant impact upon quality of life. Moreover ineffective coughing is associated with significant morbidity and mortality. A better understanding of cough mechanics is important for dealing with the complications of both excessive and impaired cough. This study investigates how the mechanical changes during coughing are influenced by the amount of air inhaled prior to coughing (operating volume), examining chest and abdominal motion, pressures and flow. We have shown that operating volume is the most important determinant of the flow achieved and volume expelled during single voluntary coughs and peals of voluntary coughs. Coughs within a peal appear to have a different motor pattern, producing similar pressures and flows but more rapidly than single coughs and therefore may be more efficient. Future studies investigating cough mechanics should control for the influence of operating volume.

Cough is a common presenting symptom in patients with Idiopathic Pulmonary Fibrosis (IPF). This study measured cough rates in IPF patients and investigated the association between cough and measures of health related quality of life and subjective cough assessments. In addition, IPF cough rates were related to measures of physiological disease severity and compared to cough rates in health and other respiratory conditions.

Introduction: The primary aim of this study was to evaluate the ability of radiologists to accurately estimate pneumothorax and pulmonary haemorrhage during percutaneous co-axial. cutting needle CT-guided lung biopsy.Methodology: Patients undergoing cutting needle lung biopsy during the study period were identified; the path taken by the cutting needle marked on each pre-biopsy staging CT scan. Each scan was then reviewed independently by two thoracic radiologists blinded to clinical details and complications; pneumothorax and pulmonary haemorrhage risk estimated with a percentage Visual Analogue Scale.Results: In 134 patients, pneumothorax occurred in 24%. The radiologists differed in the estimation of pneumothorax risk in 55% (74 episodes). When pneumothorax risk was estimated <20% by radiologists 1 and 2, 16% and 14% of biopsies resulted in pneumothorax; where risk was estimated at 20-49%, pneumothorax incidence rose to 33% and 31%; where risk was deemed >= 50%, pneumothorax rate was 87% and 100%. Pulmonary haemorrhage occurred in 4%; estimated haemorrhage risk for biopsies complicated by haemorrhage did not differ significantly from where haemorrhage did not occur.Conclusion: Radiologists differ markedly in the estimation of pneumothorax risk for a patient undergoing co-axial lung biopsy. Identifying individual patients developing pneumothorax was only possible when risk was estimated at >= 50%. Pulmonary haemorrhage was uncommon and difficult to predict accurately. (C) 2008 Elsevier Ltd. All rights reserved.

The stethoscope has long been a powerful symbol of the physician. This article describes a stethoscope that was presented as a prize to an outstanding student, Mr Bampton, by his eminent teacher Dr James Hope (1801–41) in 1837. The extraordinary journey of this prize stethoscope that eventually found its way to North Wales and into the hands of the Liverpool physician, Robert Coope (1892–1972), is outlined. Its subsequent importance and symbolism to the Thoracic Society and the British Thoracic Society is emphasized.

INTRODUCTIONBlind percutaneous pleural biopsy has traditionally been performed to investigate the etiology of exudative pleural effusion in which the initial thoracentesis has been nondiagnostic. In view of the increasing use of image-guided and thoracoscopic pleural biopsies, this study examines the role of blind Abrams pleural biopsy in the investigation of pleural effusion in a large urban hospital.METHODPatients undergoing blind Abrams needle biopsy between January 1997 and 2003 were identified from the hospital pathology database. The case notes and pathology records of these patients were analyzed retrospectively. All patients had presented to respiratory teams with an exudative pleural effusion and had initial nondiagnostic thoracentesis.RESULTSSeventy-five patients undergoing blind biopsy were identified. Pleural tissue was obtained in 59 biopsies (79%), with no statistically significant difference in pleural yield between respiratory specialist registrars (equivalent to pulmonary fellows in training) and senior house officers/preregistration house officers (equivalent to junior residents and interns, respectively) performing the biopsy (chi(2) test, p = 0.43). When up to three samples were obtained per episode, sufficient pleural tissue was obtained in 18 of 25 patients (72%) compared to 80% (32 of 40 patients) in whom four to six samples were taken (chi(2) test, p = 0.55 [not significant]). For all diagnoses, blind biopsy had a sensitivity of 38%, which rose to 43% when reviewing patients in whom sufficient pleural tissue was obtained (for malignant diagnosis alone, sensitivity values were 43% and 51%, respectively; specificity, 100%; negative and positive predictive values, 51%). No fatalities were reported, and pneumothorax was seen in eight patients (11%), with only two patients requiring specific intervention.CONCLUSIONSBlind Abrams needle biopsy obtaining pleural tissue was diagnostic in approximately 50% of patients presenting with malignant effusion in the sample, and can be performed safely by all grades of medical staff with due attention to technique and supervision. The data support the continued use of the Abrams needle in the investigation of malignant pleural disease.

Background The relationships between objective cough rates, cough reflex sensitivity, subjective estimates of cough frequency, and cough-related quality of life in patients with COPD are poorly understood. Subjects Twenty-six patients with stable COPD who complained of cough (76.9% men; mean ± SD age, 68.7 ± 6.9 years; mean FEV1, 54.2 ± 12.0% of predicted; median smoking history, 42.4 pack-years [range, 13 to 135 pack-years]). Methods Subjects performed a cough challenge test, ambulatory daytime and overnight sound recordings, scored the severity of cough (0 to 5 score and visual analog scale) for each recording period, and completed a cough-specific quality of life questionnaire (CQLQ). Coughs were counted manually and quantified in terms of cough seconds per hour (cs/h): the number of seconds within the recording that contain cough. Results Overall median time spent coughing was 7.5 cs/h (range, 2.7 to 23.1 cs/h; daytime median, 12.4 cs/h [range, 3.3 to 40.4 cs/h]; overnight, 1.9 cs/h [0.0 to 19.0 cs/h]) [p = <0.01]. Median log concentration of citric acid eliciting five coughs (C5) was − 0.9 mol/L (range, − 1.5 to 0.0 mol/L). Day time but not overnight time spent coughing was significantly correlated with log C5 (log C5 r = − 0.49, p = 0.02, and r = − 0.20, p = 0.37, respectively). Subjective cough scores and visual analog scales were moderately associated with objective time spent coughing: daytime (r = 0.37, p = 0.03, and r = 0.41, p = 0.03) and overnight (r = 0.48, p = <0.01, and r = 0.5, p = 0.01), respectively. Conclusions Subjective measures of cough and cough reflex sensitivity are statistically related to time spent coughing in patients with COPD, but with low-to-moderate levels of correlation. These measures have insufficient predictive value to substitute for objective time spent coughing; however, in conjunction with the CQLQ, they may provide a qualitative dimension to the assessment of cough. The relationships between objective cough rates, cough reflex sensitivity, subjective estimates of cough frequency, and cough-related quality of life in patients with COPD are poorly understood. Twenty-six patients with stable COPD who complained of cough (76.9% men; mean ± SD age, 68.7 ± 6.9 years; mean FEV1, 54.2 ± 12.0% of predicted; median smoking history, 42.4 pack-years [range, 13 to 135 pack-years]). Subjects performed a cough challenge test, ambulatory daytime and overnight sound recordings, scored the severity of cough (0 to 5 score and visual analog scale) for each recording period, and completed a cough-specific quality of life questionnaire (CQLQ). Coughs were counted manually and quantified in terms of cough seconds per hour (cs/h): the number of seconds within the recording that contain cough. Overall median time spent coughing was 7.5 cs/h (range, 2.7 to 23.1 cs/h; daytime median, 12.4 cs/h [range, 3.3 to 40.4 cs/h]; overnight, 1.9 cs/h [0.0 to 19.0 cs/h]) [p = <0.01]. Median log concentration of citric acid eliciting five coughs (C5) was − 0.9 mol/L (range, − 1.5 to 0.0 mol/L). Day time but not overnight time spent coughing was significantly correlated with log C5 (log C5 r = − 0.49, p = 0.02, and r = − 0.20, p = 0.37, respectively). Subjective cough scores and visual analog scales were moderately associated with objective time spent coughing: daytime (r = 0.37, p = 0.03, and r = 0.41, p = 0.03) and overnight (r = 0.48, p = <0.01, and r = 0.5, p = 0.01), respectively. Subjective measures of cough and cough reflex sensitivity are statistically related to time spent coughing in patients with COPD, but with low-to-moderate levels of correlation. These measures have insufficient predictive value to substitute for objective time spent coughing; however, in conjunction with the CQLQ, they may provide a qualitative dimension to the assessment of cough.

Manual cough counting is time-consuming and laborious; however it is the standard to which automated cough monitoring devices must be compared. We have compared manual cough counting from video recordings with manual cough counting from digital audio recordings.

Background Little is known of the language healthcare professionals use to describe cough sounds. We aimed to examine how they describe cough sounds and to assess whether these descriptions suggested they appreciate the basic sound qualities (as assessed by acoustic analysis) and the underlying diagnosis of the patient coughing. Methods 53 health professionals from two large respiratory tertiary referral centres were recruited; 22 doctors and 31 staff from professions allied to medicine. Participants listened to 9 sequences of spontaneous cough sounds from common respiratory diseases. For each cough they selected patient gender, the most appropriate descriptors and a diagnosis. Cluster analysis was performed to assess which cough sounds attracted similar descriptions. Results Gender was correctly identified in 93% of cases. The presence or absence of mucus was correct in 76.1% and wheeze in 39.3% of cases. However, identifying clinical diagnosis from cough was poor at 34.0%. Cluster analysis showed coughs with the same acoustics properties rather than the same diagnoses attracted the same descriptions. Conclusion These results suggest that healthcare professionals can recognise some of the qualities of cough sounds but are poor at making diagnoses from them. It remains to be seen whether in the future cough sound acoustics will provide useful clinical information and whether their study will lead to the development of useful new outcome measures in cough monitoring.

ObjectiveTo assess the effectiveness of two grading systems used to predict surgical outcome in nonapneic snorers.Study DesignA prospective observational study. Prior to undergoing palatal surgery, 20 patients completed a sleep nasendoscopic examination involving sequential steady‐state sedation with intravenous propofol. Using a combination of acoustic parameters of snoring sound as an objective outcome measurement, and the answers to a specifically designed questionnaire as a subjective outcome measurement, the effectiveness of each grading system in predicting surgical outcome was examined.ResultsDepending on the outcome measurement used, sensitivity in predicting success of surgery for snoring varied from 16.7% to 50.0% and specificity from 38.5% to 62.5% for the Pringle and Croft system, while sensitivity varied from 91.7% to 100% and specificity from 30.8% to 31.5% for the Camilleri system.ConclusionSleep nasendoscopy using these classifications cannot be recommended as a reliable predictor of surgical outcome in nonapneic snorers.EBM rating: C‐4

BACKGROUND The relationships between objective cough rates, cough reflex sensitivity, subjective estimates of cough frequency, and cough-related quality of life in patients with COPD are poorly understood. SUBJECTS Twenty-six patients with stable COPD who complained of cough (76.9% men; mean +/- SD age, 68.7 +/- 6.9 years; mean FEV(1), 54.2 +/- 12.0% of predicted; median smoking history, 42.4 pack-years [range, 13 to 135 pack-years]). METHODS Subjects performed a cough challenge test, ambulatory daytime and overnight sound recordings, scored the severity of cough (0 to 5 score and visual analog scale) for each recording period, and completed a cough-specific quality of life questionnaire (CQLQ). Coughs were counted manually and quantified in terms of cough seconds per hour (cs/h): the number of seconds within the recording that contain cough. RESULTS Overall median time spent coughing was 7.5 cs/h (range, 2.7 to 23.1 cs/h; daytime median, 12.4 cs/h [range, 3.3 to 40.4 cs/h]; overnight, 1.9 cs/h [0.0 to 19.0 cs/h]) [p = <0.01]. Median log concentration of citric acid eliciting five coughs (C5) was - 0.9 mol/L (range, - 1.5 to 0.0 mol/L). Day time but not overnight time spent coughing was significantly correlated with log C5 (log C5 r = - 0.49, p = 0.02, and r = - 0.20, p = 0.37, respectively). Subjective cough scores and visual analog scales were moderately associated with objective time spent coughing: daytime (r = 0.37, p = 0.03, and r = 0.41, p = 0.03) and overnight (r = 0.48, p = <0.01, and r = 0.5, p = 0.01), respectively. CONCLUSIONS Subjective measures of cough and cough reflex sensitivity are statistically related to time spent coughing in patients with COPD, but with low-to-moderate levels of correlation. These measures have insufficient predictive value to substitute for objective time spent coughing; however, in conjunction with the CQLQ, they may provide a qualitative dimension to the assessment of cough.

The frequent use of inhaled corticosteroids (ICSs), especially at higher doses, has been accompanied by concern about both systemic and local side effects. The systemic complications of ICSs have been extensively studied and are well-documented in the literature. There are comparatively few studies reporting on the local complications of ICSs. Compared with systemic side effects, the local side effects of ICSs are considered to constitute infrequent and minor problems. However, while not usually serious, these local side effects are of clinical importance. They may hamper compliance with therapy and the symptoms produced may mimic more sinister pathology. This review considers the prevalence of local side effects, their clinical features, the potential causes, the role of inhaler devices, and current measures that have been suggested to avoid the problem.

Short-burst domiciliary oxygen therapy is prescribed for symptomatic relief of breathlessness in patients with many respiratory disorders. 52 patients (54% male;median age 72yrs) prescribed domiciliary short burst oxygen therapy were interviewed by means of a questionnaire. The underlying diagnoses was COPD in 67%(35/52) cases, Interstitial Lung Disease 13%(7/52), Ca.Bronchus (8%,4/52), Asthma (8%,4/52), Bronchiectasis (2%,1/52) and 1 patient with no definitive diagnosis. 44% (23/52) of patients estimated their exercise tolerance as10 yards, 23%(12/52) 20 yards, 25%(13/52) up to 50 yards and 8%(4/52) up to 100 yards. The time spent using oxygen therapy each day was less than 15 minutes in 29%(15/52), up to one hour in 42%(22/52), up to 4 hours in 15%(8/52), and 6 hours or more in 13%(7/52). 45(87%) patients reported symptomatic benefit of the oxygen therapy, 33%(17/52) of patients reporting "I could not manage without it", 6%(3/52) that therapy helped "A tremendous amount" and 48%(25/52) reported it had helped "Quite a lot". However 13%(7/52) felt it had helped "Very little" or "Not at all". Thirty-nine patients(75%) believed that oxygen therapy had helped prevent emergency hospital admission and 25%(13/52) of the sample had no admissions to hospital over the last one year. However 56%(29/52) had been admitted up to 5 times and 19%(10/52) had more than 5 admissions in the last one year. The results of this study show that large numbers of patients report symptomatic benefit from short burst oxygen therapy with the majority suggesting it prevented emergency hospital admission. However, further studies are needed to determine whether this perceived benefit is indeed real and whether it translates into improved clinical outcomes.

Regular nebulised bronchodilator therapy in the home is commonly prescribed for patients with chronic obstructive pulmonary disease (COPD). If this therapy is administered inappropriately it exposes patients to potential side effects and has considerable financial cost to the health service. In a recent large audit in Liverpool we found that many patients with mild to moderate disease have obtained nebulisers from a variety of different sources including hospitals, primary care physicians, relatives and even the small advertisements of local papers.1 In this review the current rationale and recommendations for domiciliary nebulised bronchodilator therapy for patients with COPD are discussed. In 1997, the British Thoracic Society published guidelines concerning the supply, use and maintenance of nebuliser-compressor systems for chronic therapy in the patient's home.2 It was recommended that in the management of patients with COPD, such treatment should be reserved for only the minority in whom bronchodilator therapy, when effectively administered at a high dose from a handheld inhaler device, fails to provide adequate symptomatic relief. These guidelines also state that nebuliser provision should be made only after a full assessment by either a respiratory physician or trained hospital specialist or general practitioner.