OBJECTIVES:This study examines clinically confirmed long-COVID symptoms and diagnosis among individuals with COVID in England, aiming to understand prevalence and associated risk factors using electronic health records. To further understand long COVID, the study also explored differences in risks and symptom profiles in three subgroups: hospitalised, non-hospitalised, and untreated COVID cases. METHODS:A population-based longitudinal cohort study was conducted using data from 1,554,040 individuals with confirmed SARS-CoV-2 infection via Clinical Practice Research Datalink. Descriptive statistics explored the prevalence of long COVID symptoms 12 weeks post-infection, and Cox regression models analysed the associated risk factors. Sensitivity analysis was conducted to test the impact of right-censoring data. RESULTS:During an average 400-day follow-up, 7.4% of individuals with COVID had at least one long-COVID symptom after acute phase, yet only 0.5% had long-COVID diagnostic codes. The most common long-COVID symptoms included cough (17.7%), back pain (15.2%), stomach-ache (11.2%), headache (11.1%), and sore throat (10.0%). The same trend was observed in all three subgroups. Risk factors associated with long-COVID symptoms were female sex, non-white ethnicity, obesity, and pre-existing medical conditions like anxiety, depression, type II diabetes, and somatic symptom disorders. CONCLUSIONS:This study is the first to investigate the prevalence and risk factors of clinically confirmed long-COVID in the general population. The findings could help clinicians identify higher risk individuals for timely intervention and allow decision-makers to more efficiently allocate resources for managing long-COVID.

Introduction and Objectives SARS-CoV-2 has reemphasised the importance of respiratory virus infections (RVIs). UNIVERSAL aims to characterise the impact of a broad range of RVIs. We hypothesise that analysis of a prospective cohort of hospitalised adults with RVI will allow determination of clinical and biological profiles associated with virus type and disease severity. Methods Excluding co-infection, we recruited 313 hospitalised, symptomatic adults, with PCR evidence of RVI. Clinical characteristics were collected prospectively. We compared admission total/differential white cell count (WCC), CRP and supplementary O2-requirement. Multiple logistic regression (MLR) was utilised to calculate the OR and 95%CI associated with oxygen requirement for all viruses. Adjustments included: Age>65, smoking status, Charlson co-morbidity score (CCS), COPD, asthma, hypertension, diabetes, obesity, congestive heart failure, pneumococcal/covid/influenza-vaccination status, white cell differentials and CRP. Results Table-1 displays patient characteristics by virus group. Overall, 62.9% of participants required supplemental-O2 on admission. There was no significant difference in admission-O2 requirement between virus groups (p=0.651). Lymphocyte count <1.0*109/L(p=0.018) and CRP>55 mg/L(p<0.001) were associated with admission-O2 requirement SARS-CoV-2 positive patients (median age-72) were significantly older than Rhino/enterovirus (RhV/EV) (median age-64, p=0.006), and influenza positive patients (median age-64, p=0.001).Furthermore, SARS-CoV-2 patients (median CCS-10) were significantly more comorbid than the RhV/EV (median CCS-4, p=0.043) and influenza patients(median CCS-4, p=0.001). For all viruses, median WCC was 10.3*109/L. WCC differential median values included: neutrophils (8.0*109/L), lymphocyte count (1.0*109/L), eosinophil count (0.0*109/L) Median CRP was 55 mg/L and there was no significant CRP difference between the viruses(p=0.389). SARS-CoV-2 WCC (median-8.8*109/L) was significantly lower when compared to RhV/EV (median-11.7*109/L, p=0.003) and influenza (median-8.9*109/L, p=0.041).Neutrophils were significantly lower in SARS-CoV-2 (median-7.2) than in RhV/EV(median-8.9*109/L, p=0.030).Additionally, lymphocytes were significantly lower in SARS-CoV-2(median-0.9*109/L) compared to RhV/EV(median-1.3 p=0.002). Eosinophil count in RhV/EV (median-0.1 IQR:0.0–0.3) was significantly higher than in influenza (median-0.0*109/L, p<0.001) and SARS-CoV-2(median-0.0*109/L p=0.043). MLR revealed lymphocytes <1.0*109/L (OR 1.838 CI:1.05–3.26) and CRP >55 mg/L (OR-2.58 CI:1.45–4.67) were independent risk factors for admission supplemental-O2 requirement. Conclusion Common RVIs including RhV cause considerable morbidity. Lymphopenia and CRP>55 mg/L were associated with more severe disease in adults admitted with RVI. More precise characterisation of biomarkers associated with severity is an essential prerequisite to novel therapeutics development. Please refer to page A286 for declarations of interest related to this abstract.

ObjectivesConfirming adherence to therapy is recommended prior to escalating treatment regime in patients with asthma. This is usually based on patient report and prescription pick up rates. We report the utility of using ‘smart’ inhaler technology to objectively address adherence with inhaled therapy among patients with mild to moderate asthma.MethodsConsecutive consenting patients (age ≥ 18) adherent to therapy based on clinical assessment had their LABA/ICS combination inhaler/s switched over to budesonide/formoterol turbohaler (Symbicort) with sensor. A proportion of the patient advised to use Symbicort as maintenance and reliever therapy (MART) while others to use it as Non-MART. This commercially available treatment comes with a sensor that connects via Bluetooth to an app, which records every time the inhaler is used. Inhaler technique and the use of the app was taught by a specialist nurse and asthma metrics recorded. At 4 weeks, adherence data was reviewed; asthma control was reviewed; and ongoing follow up arranged.ResultsOf the 26 patients (mean age 51, 16 females), 73% recorded dose concordance > 50%. There is a greater concordance in MART group in which 89% of patients recorded concordance > 50% whilst only 65% in non-MART group achieve the same level of concordance. Results depicted in table 1.Conclusion‘Smart’ inhalers used in routine clinical practice may help in achieving better asthma control both by identifying sub-optimal adherence, which can then be addressed. However, smart inhaler use alone does not guarantee adherence and role of clinicians in monitoring concordance data and providing suitable education remains very important.

Objectives: Both use of “smart” inhalers as well as suppression of FeNO can provide objective evidence of non-adherence. We report the effect of this combination on clinical outcomes in severe asthma. Methods: Consecutive consenting patients with FeNO levels ≥ 45 ppb on 2 occasions and meeting criteria for biologics were included. Baseline high-dose ICS/LABA/LAMA combination/s inhalers were switched to mometasone/indacaterol/glycopyrronium (Enerzair® Breezhaler®). This inhaler comes with a sensor that connects via Bluetooth to an app, which records every time the inhaler is used. Inhaler technique and the use of the app were taught, FeNO checked recorded at baseline. At 4 weeks adherence data and asthma control was reviewed; FeNO levels checked; a decision made whether to proceed to biologics; and follow up arranged. Those identified as non-adherent (< 85% inhaler use and / or ≥42% FeNO suppression) were educated on compliance. Results: In the 24 patients (median age 52 [19-81], 15 female) included, median FeNO level decreased from 81 to 45.5 ppb (p<0.01). 14 patients did not proceed to biologics (Table 1). Conclusion: Utilisation of smart inhalers together with FeNO suppression is feasible objective measure. FeNO suppression in conjunction with good adherence and improved asthma control suggests that objective monitoring may lead to better asthma control.

Introduction: Acute exacerbations of COPD (AECOPD) are clinically significant events and very personal experiences. Patients’ (and their carers9) experiences, expectations and understanding affect their response to symptoms, impacting healthcare professionals’ recognition and management of AECOPD. Aim: To improve understanding of how people with COPD and their carers feel about AECOPD, including their experiences, expectations and understanding about these events. Methods: Semi-structured interviews were completed remotely in a multicentre, qualitative study with COPD patients and their carers. Interviews were transcribed and thematic analysis performed with reference to exacerbation tendency (Group 1: ≥1 severe and/or ≥2 moderate AECOPD in the past year; Group 2: ≤1 moderate and 0 severe AECOPD in the past year). Results: 40 COPD patients participated in this study (21 Female; mean [SD] age 69 [8.1] yrs and CAT 21.9 [9.5]). 23/40 participants were in Group 1 and 17/40 in Group 2. People’s experiences of AECOPD are set in the context of living with COPD day-to-day. Patients’ ‘Breathing Space’ (Figure) shapes how they respond when their symptoms worsen. This framework enabled granular classification of patients with COPD beyond exacerbation history and symptom burden. Conclusions: The Breathing Space concept may provide a useful framework to identify needs and tailor COPD management appropriately.

Introduction: Acute exacerbations of COPD (AECOPD) are significant events. Patients’ (and their carers9) experiences and understanding of these events affect their response to symptom changes and likelihood of reporting such episodes of COPD worsening. Aim: To explore the language used by COPD patients and their carers to describe AECOPD including the meaning and relevance of the term ‘exacerbation’ to them. Methods: A multicentre, qualitative, semi-structured interview study. Interviews with patients/carers were completed remotely. Participants were asked what the term exacerbation meant to them and to describe an exacerbation in their own words. Demographic data are presented as mean [SD] unless stated. Results: 40 COPD patients were interviewed (52.5% female; age 69 [8.1] yrs, COPD duration 11.3 [8.3] yrs, CAT score 21.9 [9.5], median [range] number of exacerbations in the past year 1.5 [0-9]). Participants found the word exacerbation difficult to say, very few reported using it and half stated the word means nothing to them. Most people used terms associated with symptom worsening to describe exacerbations although none used the word ‘worsening’. Flare-up was a commonly used term. The words/phrases used by patients and carers are presented (figure). Conclusions: The term exacerbation has little meaning to patients and healthcare professionals should consider alternative language when communicating with patients and their carers.

Objective: Confirming adherence to therapy is recommended before escalating to biological therapy in severe asthma. This is usually based on patient report and prescription pick up rates. We report the utility of using “smart” inhaler technology to objectively address inhaled therapy in severe asthma patients who meet criteria for biologics. Methods: Consecutive consenting patients meeting criteria for biologics had their existing high-dose ICS/LABA//LAMA combination inhaler/s switched to mometasone/indacaterol/glycopyrronium (Enerzair® Breezhaler®). This inhaler comes with a sensor that connects via Bluetooth to an app, which records every inhaler use. Inhaler technique and the use of the app were taught, exhaled nitric oxide levels (FeNO) checked and ACQ-6 recorded at baseline. At 4 weeks adherence data and asthma control was reviewed; FeNO checked; a decision made whether to proceed to biologics; and follow up arranged. Results: Of the 46 patients (median age 49 [19-81], 15 male), 23 proceeded to biological treatment (Figure 1). Median FeNO and ACQ-6 score at baseline were 54 ppb and 3.08; and at 4 weeks were 38.5 ppb and 1.8 respectively. All patients had better asthma control at median follow up of 6 months. Summary: “Smart” inhalers may help in achieving better asthma control both by identifying sub-optimal adherence as well as due to ongoing monitoring of therapy.

Background: Globally, SABA represents most inhaler use and associated greenhouse gas (GHG) emissions. GINA recommends ICS/formoterol as the preferred reliever for patients with asthma. To date, the environmental impact of ICS/formoterol MART and maintenance (Mx)+SABA regimens has not been quantified. Aim: To model GHG emissions of MART vs Mx+SABA regimens. Methods: Total number of GINA step 3−5 patients prescribed ICS/LABA+/−SABA therapy in the UK was based on the SABa use IN Asthma (SABINA) I real-world study (Bloom C.I., et al. Adv Ther 2020;37:4190−4208). Market share data were used to estimate the number of ICS/LABA and SABA inhalers prescribed/year. The CO2 equivalent (CO2e)/device/year was derived from Janson et al (Thorax 2020;75:82−84). Exacerbation rates managed by primary and secondary care were estimated from SABINA and the CO2e impact of resource use aggregated. Results: Total CO2e/year for managing GINA 3−5 patients with inhaled therapies was 585,527 tonnes, 97% of which was driven by Mx+SABA use. DPI MART had the lowest carbon footprint (7 kg/patient/year assuming 6 inhalers/year) compared with pMDI MART (116 kg/patient/year) and Mx+SABA regimens (DPI: 119 kg/patient/year; pMDI: 242 kg/patient/year) (Figure). Conclusion: DPI MART has lower GHG emissions vs pMDI MART and Mx+SABA.

Background Acute exacerbations of COPD (AECOPD) are clinically significant events. Patients' experiences, expectations and understanding affect their recognition of and response to AECOPD. Aim To understand i) how COPD patients recognise AECOPD and ii) how they subsequently react. Methods Semi-structured interviews were completed remotely in a multicentre qualitative study. Interviews were transcribed and analysed thematically. Data presented as mean [SD] unless stated. Results 40 COPD patients were interviewed (21 female; age 69 [8.1] yrs, COPD duration 11.3 [8.3] yrs, median [range] number of exacerbations in the past year 1.5 [0–9]). Three themes were identified: Theme 1: Recognition of AECOPD onset Most patients felt able to recognise AECOPD onset (increased breathlessness, fatigue, cough, coloured sputum), however some became suddenly overwhelmed. Theme 2: Response to AECOPD onset Patients' responses to AECOPD onset depended on their experience and the outcome of past help-seeking. Those previously taught breathlessness self-management typically used a stepwise approach, including non-pharmacological techniques and inhalers. If felt necessary, they would take a 'rescue pack' (antibiotics and/or steroids) or contact their GP for advice and/or medication. Those attending the hospital did so after GP contact or based on previous advice. Those not previously taught breathlessness self-management described over-reliance on inhaled medication and either i) frequent 'rescue pack' use or ii) direct presentation to the hospital. Theme 3: The role of 'rescue packs' 28/40 patients reported 'rescue pack' use. Many patients were knowledgeable about when to take a 'rescue pack' which provided them with a sense of control and security when access to clinicians was limited. However, some relied on repeated 'rescue pack' use without clinical review and experienced overall declining health. Conclusion Most patients were able to recognise AECOPD onset and their subsequent behaviour related to responses to previous help-seeking. Some were empowered by access to 'rescue packs'. For others, limited access to clinicians and lack of self-management education may have contributed to over-reliance on 'rescue packs' and/or direct hospital presentation. It is important that all patients are guided on how to appropriately respond to AECOPD onset; when to use 'rescue packs' (if provided); and when to seek clinical review. Please refer to page A214 for declarations of interest related to this abstract.

Introduction We previously reported the outcome of a retrospective evaluation of asthma care for patients attending three emergency departments (ED) in England. 1 We demonstrated that components of the BTS Asthma Care Bundle were completed in less than a third of patients attending the ED with an acute exacerbation. We now report prospective data from two of the participating trusts following implementation of interventions designed to improve asthma care for patients attending the ED. Methods Setting: Two NHS hospital trusts in England over a six-month period. Design: Prospective evaluation of asthma care for patients attending the ED with asthma exacerbation. Intervention: Both trusts implemented electronic systems to identify asthma patients attending ED. All patients were contacted by an asthma nurse by telephone following their attendance. In Trust 1, contacted patients were invited to attend a specialist nurse-led clinic within 2 working days of ED attendance. In Trust 2, a specialist nurse-led telephone consultation was undertaken and patients were triaged for follow-up using a standard protocol. Data collection: A standard dataset was collected for each patient event, including demographics and delivery of asthma care with reference to the BTS asthma Care Bundle. Data analysis: Data are presented descriptively. Results This study includes 120 patient events (26% male, 17–81 years). Significant improvements in asthma care were observed in both trusts. Attendance in nurse-led clinics in Trust 1 led to completion of care elements set-out in the BTS asthma bundle in almost all patients. Follow-up arrangements improved in both Trusts. Data are presented in Table 1. Conclusion Electronic systems can be used to identify patients attending ED with asthma exacerbations for review by specialist asthma services. Elements of asthma care described in the BTS bundle are infrequently performed in the ED. Early specialist nurse-led clinic review can address this. Identifying patients and arranging review in specialist nurse-led clinics offer a way of providing optimal asthma care for patients discharged from ED.

To evaluate whether patients who receive systematic adherence phone calls from an Adherence Support (AS) program achieve better medication adherence than a matched control group of patients. This AS program is a HealthForward service provided on behalf of Green Shield Canada (GSC) and implemented as an enhanced service which focuses on adherence support for GSC plan members. During the identification period (October 2015 through September 2016), GSC pharmacy claims data from the following two cohorts were compared - A) Patients who received adherence support through the AS program (intervention group); B) Patients who did not participate in the AS program (control group). Medication adherence was measured by modified medication possession ratio (mMPR). The final claims data for analysis consisted of 79 AS program patients who were able to be matched with 331 control patients. The top 3 (out of 11) disease conditions amongst these patients were rheumatoid arthritis, Crohns/ulcerative colitis, and psoriasis. AS program patients demonstrated higher medication adherence than control patients after matching the cohorts on 4 variables - drug, disease condition, gender, and age group (mMPR: 95.2% vs. 93.8%; p=0.002). The percentage of patients who met the mMPR threshold of 90% was also higher in the AS program patients compared to control patients (73.8% vs. 49.2%; p=0.004). The analysis demonstrates that AS program patients' benefit from enhanced medication adherence. Further research is needed to understand whether this difference in adherence is clinically meaningful.

Introduction The UK National Review of Asthma Deaths (NRAD) found that 21% of patients had attended an emergency department (ED) due to asthma at least once in the year before their death. National guidelines have set out a series of recommendations to improve outcomes following admission with an asthma exacerbation. The following five elements of care now form the basis of the British Thoracic Society (BTS) Asthma Care Bundle: (1) inhaler technique assessment; (2) medication review; (3) written action plan; (4) consideration of trigger factors; and (5) arrangement of follow-up (within two working days in the community and two weeks with a specialist). Three NHS hospital trusts present baseline (interim) data, both as an assessment against the current care bundle elements and to allow the trusts to undertake a targeted approach of addressing internal processes to improve patient outcomes. Methods Setting: Three NHS hospital trusts in England over a six-month period. Design: A retrospective review of asthma care and subsequent discharge follow-up arrangements for patients attending ED with an asthma exacerbation. Participants were identified using electronic systems and eligibility confirmed by case note review. Data collection: Patient demographics and clinical measurements were recorded according to local requirements/protocols. Data analysis: Descriptive interim data are presented to date. Results The review included 319 eligible patients/admission events. Participant demographics and data on the asthma care received in the ED are summarised in table 1. Interim data from all three trusts showed only 46 (14.4%) records of inhaler technique assessment, the existence/provision of 36 (15.7%) personalised asthma action plans and 103 (32.3%) recorded instances of follow-up with the General Practitioner (GP) being arranged/recommended. No discharge follow-up GP events were recorded. Conclusion Four years after NRAD, it appears that their recommendations and elements of the relevant BTS Care Bundle seems to only be undertaken in a small proportion of patients attending ED with asthma exacerbation. It is likely that a range of barriers exist preventing guideline and care bundle implementation in this setting. This highlights the need for asthma services to work with EDs, acute and primary care colleagues/providers to develop flexible and scalable solutions.

Objectives In this study we explored the effectiveness of treatment with montelukast 10 mg as compared with prednisolone in chronic cough patients with an associated elevated FeNO (The fraction of exhaled nitric oxide in breath) – a marker of eosinophilic inflammation. Methods 50 non-asthmatic patients with chronic cough were recruited sequentially from a specialist cough clinic. 30 patients with high FeNO (≥30 ppb) were randomised to either two weeks prednisolone 20 mg or two weeks montelukast 10 mg followed by montelukast 10 mg for the subsequent two weeks in both arms. A control group of 20 patients with low FeNO (≤20 ppb) were enrolled who received four weeks montelukast. 24 hours cough counting at baseline after 2 and 4 weeks treatment was the primary endpoint. Subjective measures of cough, the Leicester Cough Questionnaire (LCQ), and Hull Airways Reflux Questionnaire (HARQ) were also administered. Results At baseline the average FeNO value in both high FeNO treatment groups was similar (around 60±30 ppb). At the end of the study there was a significant fall in FeNO of approximately 30% in both high FeNO treatment groups (p < 0.005). In the low FeNO group there was no significant change during the study (12±5 ppb). Therapy reduced the number of coughs in 24 hours by approximately 50% in both low and high FeNO groups (p<0.005). HARQ and LCQ scores also improved significantly (p<0.005) in all treatment groups. Conclusions The hypothesis that FeNO could be used as a marker of eosinophilic inflammation in chronic cough was supported by our observation at baseline in the high FeNO group of eosinophilia in both blood and sputum. However, baseline FeNO did not predict overall treatment response. Perhaps the most surprising aspect of our study is the dramatic response in the low FeNO group to montelukast. The fact that montelukast appears to be equally effective in the low FeNO group suggest the either the current markers of eosinophilic lung disease are insufficiently sensitive to pick up low levels of leukotriene activation in the low FeNO group, or that montelukast has its antitussive activity by an alternative mechanism. Abstarct S33 Figure 1 Measurements of FeNO, 24hr cough count, HARQ and LCQ in three treatment groups in three visits. Horizontal bars represent mean and SEM value.

Introduction Clinical trials of pirfenidone and nintedanib have shown similar reduced rates of lung function decline in patients with idiopathic pulmonary fibrosis (IPF). In 2013 NICE approved pirfenidone for use in IPF patients with forced vital capacity (FVC) between 50% and 80% predicted. More recently, nintedanib has been available on an individual patient supply program (IPSP). Aims Reporting early experience of nintedanib in two tertiary referral centres, focussing on characterising the treated population, assessing the indications for use, and evaluating adverse effects. Method All IPF patients attending two tertiary referral centre ILD clinics who were commenced on nintedanib as part of the IPSP were included. Data were collected retrospectively from clinical records and local clinical databases. Data are presented as mean (range). Results 75 patients (mean age 70.8 years (50–85), 76% male). The FVC was 79.2% predicted (35% - 123%) and transfer factor (DLCO) 45.8% predicted (13% - 74%) prior to commencing treatment. 54% of patients were prescribed nintedanib because they did not meet FVC criteria for pirfenidone (FVC >80% in 41% of patients and FVC <50% in 13%). Other indications included refusal of pirfenidone due to the side effect profile (15%) or adverse effects requiring pirfenidone discontinuation (13%). 39 patients (52%) experienced adverse effects on nintedanib, the most common being diarrhoea (25%), nausea (13%), abnormal liver function tests (8%) and lethargy (11%). Adverse effects required nintedanib to be discontinued in 7 (9%) patients (diarrhoea (n = 3), abnormal LFTs (n = 2) and patient choice (n = 2)), dose reduction in 13 (17%) patients, and temporarily stopped and restarted in 9 (12%) patients. Conclusion Nintedanib is a relatively new medication and although there are modest numbers in this review only 9% had to discontinue treatment. Diarrhoea is the most quoted side effect from trial data (63% of patients in INPULSIS-2), but in our observational data only one quarter suffered diarrhoea and only 3 patients stopping due to this. Although the data is from early experience the discontinuation rate is favourable compared with published and local data on pirfenidone (drop out rate 15%). This needs continued review to further evaluate drug tolerability and real world efficacy.