BackgroundAs a respiratory team we provide annual reviews for local patients prescribed home oxygen. The aim of these reviews is to optimise oxygen benefit, reduce risk of harm, and address gaps in value-based interventions. We developed and introduced a Home Oxygen Review Proforma to support this approach. The aim of this study was to evaluate the impact of this proforma as an enabler of high-value COPD interventions and patient safety.MethodsAll 2019 Home Oxygen Review Proformas completed for patients with COPD were analysed for: demographics, spirometry, oxygen saturations on air (SpO2) and carbon monoxide (CO) readings; and actions taken following review: value-based interventions (influenza vaccination, tobacco dependence treatment, referral to pulmonary rehabilitation (PR)) and ‘oxygen alerts’ (Patient Specific Protocols (‘PSPs’)) for patients with raised serum bicarbonate.Results52/55 (26M;26F) patients with COPD prescribed oxygen were reviewed at home. Mean age was 73 (range 52–89) years. Mean (SD) FEV1 was 0.71 (0.37) L; n=52, FVC 1.59 (0.77) L; n=51 and SpO2 87(5)%; n=50. Smoking status was confirmed with CO testing; 43/50 (86%) normal (0–4 ppm); none with CO>10ppm (smoking). 7/50 (14%) were ‘possibly smoking’ (5–9ppm) with no evidence of smoking in home, hence monitored. 39/52 (75%) patients were up-to-date with influenza vaccination; 9/52 (17%) were referred for vaccination; 4 declined vaccination offer. 40/52 (77%) had previously completed PR; 7/52 (13%) were referred for PR; 3 declined referral; 2 did not meet criteria. 46/52 had serum bicarbonate measured: raised in 27/46 (59%); 19 had ‘PSP’ already and 7 (26%) were referred for new ‘PSP’ to prevent oxygen poisoning.DiscussionThis Home Oxygen Review Proforma for patients with COPD using home oxygen was an enabler of increased safety; specifically CO validation of smoking status, and serum bicarbonate identifying nearly 60% of patient as at risk of oxygen poisoning. While the majority of patients reviewed had received value-based interventions, it was also an effective way to identify gaps;17% had missed out on, and were referred for: influenza vaccination, 13% referred for PR and 26% for a ‘PSP’. This proforma is now used for all home oxygen reviews across two CCGs.

BackgroundAll Hospital Trusts in England are expected to offer influenza vaccination to eligible inpatients during Winter 2020–21. There is currently no data on which to model need and uptake of this approach by clinicians and patients. In 2018 addressing vaccination status was added to the COPD ‘Bundle’ used in our hospital, electronic influenza vaccine prescription was introduced following NICE guidance recommending offering vaccination to eligible inpatients and checking vaccination status and offering to appropriate patients was included in respiratory ward reviews.AimTo evaluate the uptake and characteristics of inpatients offered and accepting influenza vaccination over Winter 2018–19 and 2019–20 in one Acute Trust.MethodsData on inpatient influenza vaccine prescriptions between October-March 2018–19 and 2019–20 was obtained from our electronic prescribing system. Electronic records of each admission were reviewed and analysed for patient demographics, reason for admission, indication for vaccination, ward and mortality at June 2020.ResultsSee table 1 for results. 159 inpatient vaccinations were administered over 2 years. Mean (range) age was 62 (18–94) years and mortality at 1+ year was 28%. 114 (72%) were on our 23-bed respiratory ward. By year 2, 32% (28/88) vaccines were administered on other wards. 2/3 vaccines were for patients with COPD or asthma.DiscussionOur data suggests that offering influenza vaccination to inpatients is a feasible and sustainable intervention for which there is patient demand. Approximately 2 vaccinations/week were administered on a 23-bed respiratory ward. Inpatients were also vaccinated on other wards; with >60% increase on elderly-care wards in year 2. This was largely due to prescribing by trainees who had completed a respiratory rotation and continued to offer vaccination in subsequent roles. The high snap-shot mortality at June 2020 (28% 1 year+) is a reminder of the high risk of death for inpatients eligible for influenza vaccination. Our findings suggest that clinicians want to offer vaccination and that there are groups of unvaccinated inpatients who take up the offer of influenza vaccination. In the era of COVID-19, it is particularly important this population is vaccinated. Face-to-face contact during admission is an opportunity we should be using to do this.

BackgroundTobacco dependence is a significant cause of morbidity and mortality in patients with respiratory disease for which there is evidence-based treatment. This includes behaviour change support (BCS), nicotine replacement therapy (NRT) and varenicline. We have previously reported a 41% 6-month quit rate for a cohort of smokers admitted with respiratory disease treated with varenicline.1AimThe aim of this study was to evaluate 5-year outcomes for a cohort of respiratory ward inpatients started on varenicline, with BCS and NRT, during hospital admission.MethodsWe retrospectively reviewed the electronic records (Hospital/General Practice access) for 44 respiratory inpatients1 prescribed varenicline August 2012 to January 2014 for demographics, diagnoses, spirometry, smoking history, admissions and death. Patients not seen recently had telephone follow-up; death certificates were reviewed for hospital deaths. Primary outcomes were death, current smoking status (clinician/patient reported) and admissions/bed-days since index admission.ResultsData was available for 39/44 patients (89%); table 1 shows patient characteristics and outcomes. Eighteen (46%) patients died within 5 years of index admission with mean age at death 67 years; 16/18 (89%) patients who died had COPD and 78% (14/18) remained tobacco dependent. Cause of death for 3/4 (75%) patients, where certificate available, was a smoking-related cause. Six of 21 (29%) patients alive at 5 years were ex-smokers. Over 5 years from index admission ex-smokers had a lower but non-significant number of admissions and bed-days compared to smokers; mean admissions 2.0 v 3.1 and bed-days 16 v 25.ConclusionsThis group of patients who were tobacco dependent and admitted with respiratory disease had a very high 5-year mortality at almost 50% and mean age of death was only 67 years. Quit rate at 5 years in those still alive was 29%; down from 41% at 6-months.1 Over 5 years continuing smokers had an average of three further admissions and 25 days in hospital. Yet nationally fewer than one in two inpatients are offered treatment for tobacco dependence. This study highlights the importance of clinical teams treating tobacco dependence as a relapsing-remitting long-term condition at every contact point.ReferenceAinley, et al. Thorax 2014;69(Suppl 2):A199.

Introduction Tobacco Dependence (TD) is a long-term condition with evidence-based clinically effective treatment; skilled behaviour change conversations in combination with prescribed medication (nicotine replacement therapy (NRT)/varenicline). Historically diagnosing and treating TD has not been included in health care professional (HCP) training. Objectives The aim of this study was to assess hospital-based HCPs needs in an inner city Acute Trust in diagnosing/treating TD in inpatients and evaluate whether tailored training can address these needs. Methods TD diagnosis/treatment training was designed for trainee doctors, pharmacists and the respiratory MDT (including consultants, nurse specialists and physiotherapists) based on national guidance. An annual cycle of 1–2 hour training was delivered by three clinicians trained and experienced in behaviour change (motivational interviewing (MI)) and TD prescribing. HCP training needs and impact of training were evaluated using scaled 0–10 'importance' and 'confidence' questions based on MI principles. Changes following training were evaluated using paired t-tests. Results 168 HCPs attended one of eight 1–2 hr TD diagnosis/treatment training sessions between Sept 2017 and March 2019. Importance of HCPs being able to diagnose/treat TD HCPs (n=72) across professions identified it as important to: ask patients about smoking mean (range) 8.1/10 (4–10); advise patients how best to stop smoking 8.1/10 (4–10); and that patients in hospital should be prescribed NRT 8.0/10 (4–10). Need to increase HCP confidence in diagnosing/treating TD Before training HCPs confidence in diagnosing TD was mean 7.9/10 (n=101); mean confidence in discussing TD treatment was 5.7/10 (n=116) and mean confidence in prescribing TD medication was 5.1 (n=56). Impact of training in increasing HCP confidence in diagnosing/treating TD Confidence in diagnosing TD, discussing TD treatment and in prescribing TD medication all increased very significantly with 1–2 hours of clinician-led training p<0.0001. See table 1 for full results. Conclusions This study shows that HCPs want to be able to diagnose and treat tobacco dependence but without training are not confident to do this. One-off training, delivered by clinician-peers, who are experienced and trained in diagnosing and treating tobacco dependence, and in motivational interviewing, is one way to effectively increase HCP confidence in diagnosing, discussing and treating tobacco dependence.

Introduction and objectives The London Ambulance Service(LAS) uses Patient Specific Protocols(PSPs) as directives for a range of conditions. Since 20061 we have worked with LAS using PSPs to prevent oxygen(O2) toxicity during ambulance transfer in patients at risk of type 2 respiratory failure. PSPs are now 'flagged' on our records which may also influence hospital oxygen prescribing. The aim of this study was to evaluate PSP effectiveness in influencing appropriate O2 prescribing during both ambulance transfer and hospital stay. Methods Data from 50 patients identified as at risk of oxygen toxicity(disease severity and/or raised bicarbonate) who had PSPs initiated sequentially pre-May 2017 were reviewed for; initiation bicarbonate, ED attendances, prescription and delivery of O2 in ambulance/ED/wards, and death in the subsequent year. Results Hospital records were reviewed for 43/50 (86%) patients with PSPs. Patient characteristics are shown in table 1. In the year post-PSP 20/43 (46.5%) had ≥1 hospital attendance (overall 44 attendances); there were 2 deaths(not O2-related). LAS data were available for 34/44 (77%) attendances. 30/34 (88.2%) were appropriately oxygenated during ambulance transfer. 4/34 (11.8%) had saturations above target range; of these, 2/4 had immediate action taken. In ED 34/34 (100%) patients had documented alert of O2 sensitivity and 34/40 (85%) had appropriate oxygenation. 5/40 (12.5%) had saturations above target range and 1/40 (2.5%) saturations below range; of these, 4/6 had corrective action taken to restore saturations towards target range. 21/34 (61.8%) had specified O2 prescription in ED. On ward transfer, 34/36 (94%) had saturations in range; 1/36 (2.7%) above target range, with corrective action not taken and 1/36 (2.7%) below target, with corrective action taken. 32/34 (94.1%) had ward O2 prescriptions. Conclusions PSPs continue to be an effective mechanism for ensuring safe oxygenation during ambulance transfer of at risk patients. Patients were identified appropriately for PSP; almost half were admitted in the subsequent year. Having a PSP flagged on their records also enabled safe O2 prescription and delivery from arrival in ED through to inpatient wards. While PSPs are an agreed Londonwide Ambulance tool to prevent oxygen toxicity, their impact on patient safety appears to be far wider reaching than ambulance transfer. Reference Stern, et al. Thorax2008;63(Suppl VII):A131–2.

Introduction and objectives Evidence-based tobacco dependence (TD) treatment is recommended for all smokers admitted to hospital. TD remains a significant driver of respiratory admissions in national audits contributing to 37% COPD admissions and 27% asthma admissions.1 2 The aim of this study was to define the burden of TD on a respiratory ward and identify what resources are needed to treat this long-term condition (LTC) more effectively. Methods Electronic records of all patients identified as 'smokers' on discharge from a respiratory ward were reviewed for demographics, admission diagnosis, spirometry, smoking history, co-morbidities, medications, cessation support and TD medication (TDM; nicotine replacement therapy (NRT) and/or varenicline) from 1/8/17 to 31/1/18. Results 78 (47 M; 31 F) patients, mean age 54 (range 19–82) years with TD were discharged over 184 days from a 21–23 bed respiratory ward. 21/78 (27%) were admitted with asthma, 16 (20%) COPD, 11 (14%) pneumonia, 6 (8%) lung cancer and 4 (5%) pneumothorax. Mean (SD) FEV1 was 1.52 (0.85)L and FVC 2.45 (0.99)L; n=53. Mean (range) number of co-morbidities was 4.5 (1–12) and mean (range) number of medications was 7.7 (0–20). 26/78 (33%) had serious mental illness, including alcohol dependence. 62/78 (79%) received very brief advice (VBA), 61/78 (78%) saw a smoking cessation specialist (SCS) on the ward and/or had SCS outpatient follow-up arranged. 63/78 (81%) were prescribed one or more TDM (figure 1). Conclusions TD is a common LTC on an inner city respiratory ward; one patient with TD was discharged almost every other day and of note asthma was the commonest respiratory diagnosis. Delivering TD treatment in hospital is challenging; one in 5 did not receive documented VBA and 1 in 5 were not prescribed any NRT, even though we have established treatment pathways. This patient group has high prevalence of multi-morbidities and poly-pharmacy and one third had serious mental illness. Effective TD treatment is therefore likely to require access to highly skilled smoking cessation specialists as well as clinical teams who have been trained in smoking cessation, want to treat tobacco dependence, and are confident to prescribe TDM. References www.rcplondon.ac.uk/projects/outputs/copd-who-cares-matters-clinical-audit-2014 www.brit-thoracic.org.uk/document-library/audit-and-quality-improvement/audit-reports/bts-adult-asthma-report-2016/

Introduction Smoking is a significant cause of respiratory disease and risk factor for chronic obstructive pulmonary disease (COPD) and asthma admissions. 70% of smokers admitted to hospital want to quit and quit smoking interventions during acute admission are NICE recommended.1 Many patients with respiratory disease are highly nicotine-dependent and varenicline is an effective treatment1,2 but is not routinely initiated during admission. Method We retrospectively reviewed the notes of all patients prescribed varenicline during in-patient stay on the respiratory ward over 18 months (August 2012–January 2014). Baseline data included demographics, disease details (diagnosis, spirometry) and smoking history (tobacco/cannabis use, pack/joint-years). The primary outcomes were carbon monoxide (CO) validated quit rates at 4-weeks and self-reported quit rates at 6-months and 1-year. All patients were seen on the ward by a smoking cessation advisor and after discharge as per NICE guidance.1 Nicotine withdrawal during varenicline initiation was treated with standard combination nicotine replacement therapy.1 Results 44 patients (17M:27F) were prescribed varenicline during admission. Mean (range) age was 61 (23–81) years with median (range) 50 (8–180) pack-years. 8/44 (18%) also smoked cannabis. 29 (66%) had COPD, 7 (16%) asthma, and 8 (18%) had both. Mean (SD) FEV1 was 1.18 (0.52)L (n = 40) with FEV1%predicted 47 (21)% (n = 26). 7 patients (16%) died; all from smoking-related diseases, within 18 months of admission with mean (range) age at death 71 (61–78) years. 2 were lost to follow-up. CO-validated 4-week quit rate was 48% (21/44). Self-reported 6-month and 1-year quit rates were 41% (18/44) and 20% (9/44) respectively. Only 4/44 (9%) stopped varenicline early due to side-effects (nausea/headache). Conclusion Varenicline was safe and well-tolerated when initiated in hospital. The 4-week 48% quit rate for these ‘sick’ smokers was almost as high as the 52% national target for ‘well’ smokers. Self-reported 6-month quit rates were almost as good as the best published rates with intensive support in COPD (41% cf 49%).2 Varenicline should be used as a treatment for smokers admitted with respiratory disease.1 References NICE PH guidance 48. Smoking cessation in secondary care. 2013 Jiménez Ruiz et al. Nicotine and Tobacco Research. 2012;14(9):1035-1039

Introduction There is increasing evidence that cannabis smoking, combined with tobacco, increases the risk of emphysema and bullous lung disease (BLF Report 2012). The aim of this retrospective case study was to determine the prevalence of tobacco and/or cannabis smoking amongst patients < 50 years with radiologically-diagnosed emphysema, pneumothorax or bullous lung disease, and to assess the quality of smoking documentation. Methods A list of all high-resolution computerised tomography (HRCT) scans over 2 years (Jan2010-Dec2012), of patients ≤50 years at scan date was generated from the radiology database. All scans were reviewed by a Consultant Thoracic Radiologist to confirm accuracy of initial reports. Case notes of all patients with radiological emphysema, pneumothorax or bullous lung disease were reviewed for tobacco and cannabis smoking histories to examine the relationship with abnormalities. Results 361 HRCTs were performed over 2 years in ≤50 year olds. 91/361 (25.2%) scans were reported as emphysema, pneumothorax or bullae. 85/91 notes were available for analysis and 62/85 (73%) had full smoking histories recorded; 7/85(8.2%) tobacco smoking history not recorded and 22/85(25.9%) cannabis smoking history not recorded. 27/48 (56%) current tobacco smokers with an abnormal HRCT also smoke cannabis. There were no cannabis-only smokers and only 6/62 (9.7%) were never-smokers (tobacco&cannabis). 56/62 (90%) abnormal HRCTs were in ex/current tobacco smokers and 27/62 (44%) were in current tobacco&cannabis smokers. There was a higher prevalence of pneumothoraces and bullae with a cannabis and tobacco smoking history than for tobacco alone but this was not statistically significant different (chi-squared STATA) (Table1). Conclusion More than half of tobacco smokers with abnormal HRCTs also had a history of previous and current cannabis smoking. Despite these findings 25% of patients with abnormal HRCTs had no documentation regarding cannabis smoking. This population of ≤50 years olds with abnormal HRCTs did not smoke cannabis without tobacco. While not statistically significant, bullae and pneumothoraces were more frequently observed in patients who smoked tobacco with cannabis compared to tobacco alone. Larger studies are needed to further understand the additive effect of cannabis smoking to tobacco-induced lung damage. These studies will require systematic recording of both tobacco and cannabis smoking histories.

Introduction and Objectives National audits show oxygen prescribing is not consistently safe, despite BTS Emergency Oxygen Guidelines. We previouslyidentified that medical students were unable to safely prescribe oxygen at final MBBS examinations.1 A compulsory e-Learning module was introduced to address this unmet educational need. We assessed the impact of this intervention in 2013. Methods An Oxygen Prescribing Final MBBS OSCE station was used in 2012 and 2013. In 2013 candidates (350) completed a new compulsory oxygen e-Learning module. Candidates in 2012 (227) had not. In 2013 the exam prescription chart also included an oxygen prescription section. Each year, candidates were presented with one of two clinical scenarios. Scenario 1: 72-year-old patient with COPD, and Scenario 2: 72-year-old hypoxic patient without respiratory disease. Oxygen prescriptions were assessed against BTS standards across a number of domains. They were classified as 9safe/unsafe9 and 9perfect/imperfect9 by a respiratory nurse specialist. Results Some improvements were seen in both scenarios (See Table 1), particularly prescription of the correct target saturation range. In 2012 40% (42/105) prescribed correct range for the non-COPD scenario; in 2013 this was 98% (154/156). Conclusions Introducing an oxygen e-Learning module and BTS-recommended oxygen prescription section resulted in improved competence and safety of oxygen prescribing with significant improvement in correct target saturation ranges. However, students still have gaps in equipment knowledge and a high proportion did not prescribe oxygen safely for a patient without respiratory disease. The e-Learning module was undertaken by students at a point close to examinations; moving this earlier in the year may lead to better engagement and improve the understanding of oxygen prescribing in non-COPD patients, emphasised in the module. Safer prescribing is enabled by oxygen prescription sections with target range saturation choices but equipment education is also needed. Adverse consequences of incorrect oxygen use continue to cause patients harm. Ensuring undergraduates have the practical knowledge and skills to prescribe oxygen safely is essential. Reference D Hammersley, A Connor, C Ward, et al. Competence in, and safety of, oxygen prescribing by medical students taking Final MBBS as assessed by Objective Structured Clinical Examination. Thorax 2012; 67(Suppl 2):A168

Introduction Post-discharge pulmonary rehabilitation (PR) within 7–10 days after discharge from hospital admission for acute exacerbation of COPD (AECOPD) has been shown not only to result in the well-described benefits of PR (reduced breathlessness, improved exercise performance and health-related quality of life), but also to reduce emergency department attendances over a 3 month period. We report the outcomes of a locally-provided post-exacerbation PR (PEPR) pilot study for patients admitted to hospital with AECOPD, and compares outcomes and subsequent 90-day re-admission rates with published RCT data showing re-admission reduction from 33 to 7%1. Methods Patients were recruited during AECOPD admission to start PR within 10 days of discharge from hospital. Taxi transport was offered to all patients.Outcome measures chosen were change in: 6-Minute Walking Test (6MWT), Hospital Anxiety and Depression Score (HADS), Chronic Respiratory Disease Questionnaire (CRDQ), and 90-day re-admission rates. Results 43 patients were offered PEPR, 32 started and 21/32 (66% of starters, 49% of all referrals) completed the course (>11/16 sessions). Mean (range) age was 67(40–86) years and mean (SD) %predicted FEV1 32(15)%. Median time (range) between discharge from hospital and starting PEPR was 8(0–17) days. There were clinically significant improvements in 6MWT median (range) 27%(-40- + 233) and CRDQ dyspnoea domain 0.79(-0.60– + 3.00). There was no clear effect on 90-day re-admission rate: 45% patients who started PEPR were re-admitted v 58% who were offered but declined PEPR. Local 90-day re-admission rate for all 2012 AECOPD admissions was 39%. Conclusion This study failedto replicate published reductions in re-admission rates in a patient population that was more severe than the comparison study, mean%predicted FEV1 32% v 52%1. Value of PEPR programmes in reducing AECOPD re-admission rates needs further investigation across disease severity spectrum. An additional area that would benefit from further investigation is completion rate for PEPR2; completion rate from referral for PEPR at 49% compares to 43% for our standard PR programme. References Seymour et al. Outpatient pulmonary rehabilitation following acute exacerbations of COPD. Thorax 2010;65:423–428 National Institute of Health Research, HTA no 13/24 ‘does starting PR early following AECOPD improve adherence and outcomes compared to starting rehabilitation later?’

Introduction and Objectives National audits show oxygen prescribing is still not consistently safe and appropriate, despite the 2008 BTS Emergency Oxygen Guidelines. The aim of this study was to assess whether medical students taking Final MBBS examinations are able to prescribe oxygen safely and appropriately. Methods A 2012 medical school Final MBBS Objective Structured Clinical Examination station assessed oxygen prescribing. Candidates were presented with one of two clinical scenarios requiring an oxygen prescription on a drug chart; Scenario 1: 72-year-old patient with COPD, and Scenario 2: 72-year-old hypoxic patient without respiratory disease. Prescriptions from 227 out of 363 students taking MBBS were retrospectively assessed against BTS standards using the criteria; correct target saturation range, oxygen flow, device and frequency of delivery. The remaining prescriptions were not available for analysis. Prescriptions were classified as ‘safe/unsafe’ and ‘perfect (met all standards)/imperfect’ by a respiratory nurse specialist. Results 66/122 (54%) of candidates wrote the correct saturation range for the COPD scenario, compared with 42/105 (40%) for scenario 2. Oxygen flows were correct in 74/122 (60.6%) of COPD and 4/105 (3.8%) of scenario 2 prescriptions. The flow was appropriate for the device in 91.2% (207/227) and prescriptions specified ‘continuous’ oxygen in 60.8% (138/227). 59/122 (48.4%) prescriptions for COPD were safe and 26/122 (21.3%) ‘perfect’ compared with 19/105 (18.1%) safe and 0/105 (0%) perfect prescriptions for the hypoxic patient without respiratory disease. 185/363 (51%) students passed this station with overall year pass rate for finals 96% (349/363). Conclusions This study demonstrates an important unmet need in undergraduate education as competence in, and safety of, oxygen prescribing by otherwise successful MBBS candidates was poor. Of the prescriptions available for analysis, only half used appropriate target saturations. Half of prescriptions for COPD scenario were safe but only one in five met all BTS standards. No prescriptions for hypoxia without respiratory disease met all standards and one in five was safe. We believe that this reflects the undergraduate teaching focus on oxygen in COPD. We recommend introducing a compulsory undergraduate e-learning module on oxygen delivery and prescribing as newly-qualified doctors need to be able to prescribe oxygen safely.

Chronic obstructive pulmonary disease (COPD) is a common cause of acute medical hospital admission, and the prevalence of undiagnosed COPD in the community is high. The impact of undiagnosed COPD on presentation to secondary care services is not currently known. We therefore set out to characterise patients at first admission with an acute exacerbation of COPD, and to identify potential areas for improvement in earlier diagnosis and further management. A retrospective case review of patients first admitted to a district teaching hospital with an acute exacerbation of COPD over a 1-year period was carried out. Forty-one patients with a first admission with an acute exacerbation of COPD were identified, 14 (34%) of whom had not been previously diagnosed and were diagnosed with COPD as a result of the admission. At presentation, this group of patients had severe disease, with mean (SD) FEV 1 1.02 (0.32) L, and a respiratory acidosis in eight (20%) patients, even though this was their first admission for an acute exacerbation of COPD. Missed potential opportunities to intervene in community and inpatient management were identified, including earlier diagnosis, pre-hospital corticosteroid therapy, inpatient respiratory team input, provision of smoking cessation advice and consideration of pulmonary rehabilitation. Patients with a first hospital admission with an acute exacerbation of COPD frequently have severe disease at presentation. Despite having severe disease, a diagnosis of COPD had not been made in the community prior to admission in one-third of patients. Future work should be directed at earlier identification of patients who are symptomatic from COPD and ensuring that the interventions of proven benefit in COPD are systematically offered to patients in both primary and secondary care.

Long-term oxygen therapy (LTOT), the provision of oxygen for continuous use at home for patients with chronic hypoxemia, is regarded by clinicians as an essential component of the management of severe chronic obstructive pulmonary disease (COPD).1–3 It is the only treatment, other than stopping smoking4 that has been clearly proven to alter outcome in COPD.1–3 The evidence that LTOT improves survival comes from two landmark clinical trials in patients with severe COPD and chronic hypoxemia (PaO2 at or below 7.3 kPa [55 mmHg]) published nearly 30 years ago. The UKMedical Research Council (MRC) trial2 randomized 87 patients to 15 h of supplemental oxygen therapy or no oxygen, whereas the US Nocturnal Oxygen Therapy Trial (NOTT)3 randomized 203 patients to 24 h of oxygen or to 12 h of oxygen therapy. In the MRC study, 3-year mortality with oxygen was 45% compared to 67% without oxygen2; in the NOTT study, 19-month mortality was almost halved in the continuous oxygen group when compared to the 12-h oxygen group.3 Pooling the results demonstrated a dose–response effect with greatest survival for patients in the 24-h oxygen group (NOTT), then the 15-h group (MRC), followed by the 12-h group (NOTT), with the worst survival in the group who did not receive oxygen (MRC control group).2,3 Although there are no studies demonstrating improved survival with LTOT in other chronic respiratory diseases associated with chronic hypoxemia, in clinical practice, the results from the MRC and NOTT studies are extrapolated to other patient groups, and LTOT is offered to the majority of patients with chronic hypoxemia, including patients with interstitial lung disease5 and cystic fibrosis.6 LTOT is usually recommended for at least 15 h daily, including overnight, as chronic hypoxemia worsens during sleep. In many countries, including the UK, LTOT is delivered in the home by nasal cannulae, with oxygen supplied by an oxygen concentrator, rather than by oxygen cylinders. However, patients often have difficulty achieving the recommended 15 h of LTOT; of 930 patients with COPD on LTOT in France, only 45% used 15 h or more7, and in a study of 176 patients in London, only 61% used 16 h or more.8 From the clinician’s perspective, starting a patient on LTOT requires explanation of the reasons for recommending oxygen and teaching a patient how to use the equipment appropriately and safely. However, for the patient, there are also physical, psychological, and emotional implications of starting to use oxygen. These are important to identify as it is well-recognized that understanding and addressing patient beliefs and concerns about their treatment is an important way to improve adherence.9,10 This includes clinicians explicitly addressing the common belief that many patients (and some health professionals) have that oxygen is being provided as a treatment for breathlessness. At the outset, clinicians need to communicate clearly that there is no evidence that LTOT improves breathlessness and that it is not being recommended as a treatment for their breathlessness, rather as an evidence-based treatment to improve survival. There is also increasing evidence that shared agendas, including shared treatment aims, between clinicians and patients improve selfmanagement in long-term conditions.11,12 The article by Cullen and Stiffler13 therefore provides much needed data on the experiences of patients using LTOT. The authors use data from four qualitative studies, mostly in patients with COPD, to identify the common themes from patients’ experiences of using LTOT. Because of the shortage of published qualitative studies on Chronic Respiratory Disease 2009; 6: 131–132

Background: There is evidence that platelet activation occurs in allergic inflammation and asthma, but little is known about the role platelets play in airway inflammation associated with asthma. Objectives: In the present study, we have investigated the kinetics of platelet activation following allergen provocation of allergic asthmatics to determine the dynamics of platelet activation relative to changes in lung function and changes in airway inflammation. Methods: Changes in platelet count and haematocrit from baseline were measured during the early asthmatic response (EAR), late asthmatic response (LAR; or at corresponding time points) and at 24 h were compared between allergen- and saline-challenged groups. A subgroup of allergen-challenged asthmatics, a group of 7 challenged asthmatics and 7 controls were bronchoscoped, and BAL fluid was collected and analysed for levels of histamine and eosinophil cationic protein. Results: There was a fall in circulating platelet count, but not haematocrit after allergen challenge when compared with saline during the LAR or at 24 h. At 24 h FEV1 had returned to within 20% of baseline in all subjects, although the thrombocytopaenia and airway inflammation persisted. Conclusions: Our results suggest that persistent thrombocytopaenia accompanies allergen exposure and persists beyond changes in airway obstruction at a time when airway inflammation is present. Our results provide further evidence that platelets may be involved in allergic disease.

The management of a young woman with congenital kyphoscoliosis, who developed symptomatic nocturnal hypoventilation during the third trimester of pregnancy, is described. Nasal intermittent positive pressure ventilation (NIPPV) was safely and effectively used to correct nocturnal hypoxaemia and hypercapnia from the 30th-36th week of gestation, when a healthy boy was delivered by Caesarean section. Following delivery, the mother no longer required NIPPV and returned to her prepregnancy level of activity.

BACKGROUND--Leukotrienes are inflammatory mediators implicated in the pathogenesis of asthma. The capacity of inflammatory cells within the airways to generate leukotrienes may be altered in asthma. This hypothesis was tested using bronchoalveolar lavage (BAL) to sample cells within the airways from atopic asthmatic and normal subjects, and by measuring their capacity to generate leukotriene B4 (LTB4) and leukotriene C4 (LTC4) in response to A23187, a potent stimulus of leukotriene generation. METHODS--Bronchoalveolar lavage was performed in 12 mild asymptomatic atopic asthmatic patients and 12 normal subjects. Mixed BAL cell aliquots (approximately 80% alveolar macrophages) were incubated with 0-20 microM A23187 for 10 minutes and with 4 microM A23187 for 0-30 minutes, and leukotrienes were measured by radioimmunoassay and high performance liquid chromatography. RESULTS--Mixed BAL cells from asthmatic subjects generated less LTB4 than cells from normal subjects in dose response and time course experiments (area under the curve 81.5 (0.0-228.5) ng.min.10(-6) cells in asthmatic subjects and 197.9 (13.9-935.6) ng.min.10(-6) cells in normal subjects. There were no differences in LTC4 generation between BAL cells from asthmatic and normal subjects. CONCLUSIONS--Generation of LTB4 by BAL cells from atopic asthmatic subjects in response to A23187 was reduced. As the alveolar macrophage is the major source of LTB4 in BAL cells, these results probably reflect reduced generation of LTB4 by alveolar macrophages from asthmatic patients. This may be a consequence of monocyte migration into the lung, or altered alveolar macrophage function in asthma, or both.

Bronchoalveolar lavage (BAL) fluid is a variable mixture of instilled and lung fluid, which makes interpretation of solute concentrations difficult. We describe the use of inulin as a marker of dilution of BAL in human subjects. BAL, using saline containing 0.1 mM inulin, was safely performed in 13 subjects with mild asthma and 11 normal subjects. The dilution factor (DF: inulin concentration in BAL fluid/inulin concentration in instilled fluid) was measured spectrophotometrically, and it was used to calculate the volume of lung fluid in BAL fluid. There was no significant difference between the median (range) DF of 0.931 (0.825 to 0.952) in asthmatics and 0.907 (0.768 to 0.985) in control subjects (p = 0.77). There was wide individual variation in, but no significant difference between, the lung fluid volume of 8.1 ml (5.4 to 22.2) in asthmatics and 12.3 ml (1.9 to 30.6) in control subjects (p = 0.56), thus validating comparisons of concentrations per ml of BAL fluid. Alternatively, concentrations can be compared per ml of lung fluid. Inulin fulfilled the requirements for a marker of dilution of BAL, enabling the validation and standardization of comparisons of solute concentrations in BAL fluid.

Nasal intermittent positive-pressure ventilation (NIPPV) has been used for domiciliary ventilatory support, and to avoid intubation for acute respiratory failure in patients with chronic airflow limitation (CAL). Its role in weaning patients from assisted ventilation in intensive care has not been defined. We have used NIPPV to wean 14 patients with respiratory disease who were referred either because of predicted difficulty in weaning or failure to wean using standard techniques. Twelve patients were ventilated for acute respiratory failure; eight patients had CAL and four had chest wall or neuromuscular disease. Two further patients with chest disease were difficult to wean following surgery. Weaning was successful in 13 patients. NIPPV corrected hypoxia, reduced hypercapnia and was well tolerated. Weaning from NIPPV was achieved in all patients with CAL, although three patients with chest wall disease later required domiciliary ventilatory support. All but one of the patients survived to leave hospital. NIPPV may have an important role in weaning from assisted ventilation, particularly in patients with underlying chronic respiratory disease. This preliminary report needs to be followed by a controlled study comparing NIPPV with established weaning methods.