Introduction: Oxygen therapy is a key component in the management of advanced respiratory disease. Traditionally, long-term oxygen therapy (LTOT) assessment required multiple hospital attendances to establish and titrate. The COVID-19 pandemic required transfer of this to the community. We evaluated our nurse-led domiciliary LTOT assessment using the iSTAT (Abbot, USA) point of care capillary blood analyser. Methods: Retrospective analysis of a North Glasgow respiratory patient database was performed between 2021 and 2023. 98 patients who required LTOT were assessed. We assessed baseline demographics, functional class, waiting times and reviewed patient feedback of the service. We assessed the most common referral source and the outcomes of the referrals. Results: 98 patients required domiciliary assessment, 64 were female. Median age was 72-years (IQR: 65-78). The majority of patients had a primary diagnosis of COPD (n=80). All patients were MRC grade 4 (n=11) or 5 (n=87). The median time from referral to assessment was 10 days (IQR: 4-14[BH1]). The main referral source was secondary care. Oxygen therapy was avoided in 43%, commenced in 18% and titrated at 33%. No adverse events occurred. Patient feedback demonstrated logistical, psychological and physical benefits. Conclusion: In this functionally limited, vulnerable group, we have successfully transitioned to community-based model of oxygen assessment. The service was found to be safe, effective, and beneficial to patients. Further cost analysis is merited to ensure this is a cost effective and sustainable model of care.

Pulmonary rehabilitation has been shown to be a safe intervention in those with interstitial lung disease, leading to improved quality of life in those with functional limitation. Traditionally, patients would attend a local rehabilitation class for up to eight weeks. The Covid-19 pandemic led to the development of a home exercise programme to minimise face-to-face contact. The efficacy of an 8 week remotely supervised rehabilitation programme between November 2021 and February 2022 was evaluated. This was a combination of aerobic and resistance training at home, the intensity of which was based on the reported fitness of the individual. A 6MWT and quality of life score were performed before and after training. This was compared to an 8-week in-person supervised programme, where patients attended thrice weekly. 6MWTs and QoL scores were performed before and after exercise training. 79 patients were enrolled in the HEP, of which 42 completed. Mean age was 68.9 years, with mean FEV1 75.6% and BMI 29. Pre rehabilitation mean 6MWT for HEP was 223.6m and post 254.4m (p=<0.01). QOL improved with a reduction in mean BORG from 2.3 to 2 (p=0.19). No adverse events were reported. In the supervised group, 556 completed, with mean age of 74years. Mean FEV1% 61.6 and BMI 27.7. Mean pre-training 6MWT 203.4m, post 256.3m (p=<0.01) and BORG pre 2.71, post 2.1 (p=0.19). Whilst HEP was shown to be safe and effective, supervised rehabilitation was shown to be more effective in this population. Supervised training has the added benefit of peer support, and health provider interventions, such as smoking cessation and lifestyle advice. HEP should be reserved for those unable to perform a supervised programme.

OBJECTIVE:Group II pulmonary hypertension (PH) can be challenging to distinguish from Group I PH without proceeding to right heart catheterisation (RHC). The diagnostic accuracy of the H2FPEF and OPTICS scores was investigated in Scotland.METHODS:Patients were included in the study if they were referred to the Scottish Pulmonary Vascular Unit between 2016 and 2020 and subsequently diagnosed with Group II PH or Group I PH which was either idiopathic, heritable or pulmonary veno-occlusive disease. The established cut offs for the H2FPEF and for the OPTICS scores were applied retrospectively to predict the presence of Group II PH. The diagnosis from the scores were compared with the MDT consensus diagnosis following RHC.RESULTS:107 patients with Group I PH and 86 patients with Group II PH were included. Retrospective application of the OPTICS score demonstrated that pretest scoring would detect 28% of cases with Group II PH yet at the cost of misdiagnosing 4% of patients with Group I as Group II PH (specificity 0.96). The H2FPEF score had a far greater sensitivity (0.70) yet reduced specificity (0.91), leading to misdiagnosis of 9% of Group I PH cases.CONCLUSION:While the specificity of these scores was high, the lack of perfect specificity limits their utility as it results in missed patients with Group I PH. As a consequence, they cannot replace RHC as the means of diagnosing the aetiology of PH in their current form. The scores may still be used to support clinical judgement or to indicate the advisability for further provocative testing at RHC.

Background Ventricular septal flattening reflects RV pressure overload in pulmonary arterial hypertension. Eccentricity index (EI) and pulmonary artery distensibility (PAD) correlate with pulmonary artery pressure. We assessed the utility of these using cardiac magnetic resonance (CMR) to assess for pulmonary hypertension (PH) in patients with chronic thromboembolic disease. This may allow non-invasive differentiation between patients who have chronic thromboembolic pulmonary hypertension (CTEPH) and those with pulmonary vascular obstructions without PH at rest, known as chronic thromboembolic pulmonary disease (CTEPD). Methods Twenty patients without resting pulmonary hypertension, including ten with chronic thromboembolic disease, and thirty patients with CTEPH were identified from a database at the Scottish Pulmonary Vascular Unit. CMR and right heart catheter had been performed within 96 h of each other. Short-axis views at the level of papillary muscles were used to assess the EI at end-systole and diastole. Pulmonary artery distensibility was calculated using velocity-encoded images attained perpendicular to the main trunk. Results Eccentricity index at end-systole and end-diastole were higher in CTEPH compared to controls (1.3 ± 0.5 vs. 1.0 ± 0.01; p ≤ 0.01 and (1.22 ± 0.2 vs. 0.98 ± 0.01; p ≤ 0.01, respectively) and compared to those with CTED. PAD was significantly lower in CTEPH compared to controls (0.13 ± 0.1 vs. 0.46 ± 0.23; p ≤ 0.01) and compared to CTED. End-systolic EI and end-diastolic EI correlated with pulmonary vascular hemodynamic indices and exercise variables, including mean pulmonary arterial pressure (R0.74 and 0.75, respectively), cardiac output (R-value −0.4 and −0.4, respectively) NTproBNP (R-value 0.3 and 0.3, respectively) and 6-min walk distance (R-value −0.7 and −0.8 respectively). Pulmonary artery distensibility also correlated with 6-min walk distance (R-value 0.8). Conclusion Eccentricity index and pulmonary artery distensibility can detect the presence of pulmonary hypertension in chronic thromboembolic disease and differentiate between CTEPH and CTED subgroups. These measures support the use of non-invasive tests including CMR for the detection pulmonary hypertension and may reduce the requirement for right heart catheterization.

Background : Since the emergence of Severe Acute Respiratory Syndrome Coronavirus 2(SARS-CoV-2) in late December 2019, there has been increasing recognition of the pro-thrombotic risk this virus can cause as part of Coronavirus disease 2019 (Covid-19). Aims : To assess if the rate of PTE was increased in those with COVID-19 in both critical care and ward patients. To assess the effect of right heart strain or requirement for critical care on mortality. Methods : We reviewed all computed tomography pulmonary angiograms (CTPA) performed in Scotland between 23 rd March and 31 st May 2020 (1st wave) and identified those inpatients with COVID-19 using either classical radiological appearances, or positive COVID-19 polymerase chain reaction swab. 3401 CTPAs were reviewed. 192 were positive for PTE in patients with evidence of COVID-19 either real-time polymerase chain reaction (RT-PCR) swab positive for SARS-CoV-2 [ n = 104] or having radiological changes consistent with COVID-19 [ n = 88]). The total number of hospital admissions in Scotland between 23 rd March 2020 and 31 st May 2020 with COVID-19 was 5195. The incidence of PTE during this time was 3.7% in all patients admitted to all hospitals in Scotland with COVID-19 during this period. 475 hospitalised patients were managed in critical care (both level 2 and level 3 care), in whom the incidence of PTE was 6% ( n = 29). 4720 patients required ward based care alone and the incidence of PTE was 3.5% ( n = 163). This compares to the national pre-Covid rate of 1%. There was increased risk of death with right heart strain (25/52 vs 128/140[ P < 0.01]) and in critical care (15/29 vs 146/163[ P < 0.01]). Conclusions : In this national study, we have demonstrated an increased risk of pulmonary thromboembolism in both critical care and ward based environments.

Objectives To assess for increase in pulmonary thromboembolism (PTE) in hospitalised patients with COVID-19, in both critical care and ward environments. Setting We reviewed all CT pulmonary angiograms (CTPA) performed in Scotland between 23 March 2020 and 31 May 2020 and identified those with COVID-19 using either classical radiological appearances or positive COVID-19 PCR swab. Participants All hospitalised patients in Scotland with COVID-19 between 23 March 2020 and 31 May 2020 who underwent a CTPA. Primary outcome measure To assess if the rate of PTE was increased in those with COVID-19 compared with previously published figures of hospitalised patients. Secondary outcome measures To assess the effect of right heart strain or requirement for critical care on mortality. Results 3401 CTPAs were reviewed. 192 were positive for PTE in patients with evidence of COVID-19 either real-time PCR swab positive for SARS-CoV-2 (n=104) or having radiological changes consistent with COVID-19 (n=88). The total number of hospital admissions in Scotland between 23rd March 2020 and 31st May 2020 with COVID-19 was 5195. The incidence of PTE during this time was 3.7% in all patients admitted to all hospitals in Scotland with COVID-19 during this period. 475 hospitalised patients were managed in critical care (both level 2 and level 3 care), in whom the incidence of PTE was 6% (n=29). 4720 patients did not require admission to critical care, in whom the incidence of PTE was 3.5% (n=163). There was increased risk of death with right heart strain (25/52 vs 128/140 (p<0.01)) and in critical care (15/29 vs 146/163 (p<0.01)). Conclusions We have demonstrated an increased risk of PTE in critical care and ward-based environments. Further studies are required to establish effective prophylactic anticoagulation in this group.

Neural respiratory drive (NRD) has been studied in respiratory disease by measuring diaphragmatic EMG signals. In these conditions, it has shown use as a non-invasive marker of disease severity. Studies have demonstrated that parasternal EMG can be used instead of diaphragmatic EMG, providing a simpler method of recording data. We wanted to investigate if neural drive is raised in patients with pulmonary hypertension to assess its feasibility as a marker of disease severity. EMG readings were acquired and analysed by measuring signals to parasternal muscles using PowerLab software. Neural respiratory drive was calculated by measuring the average of one minute of RMS of EMG signals during tidal breathing at rest and comparing that to the maximal signal achieved during volitional sniff manoeuvre. This gives a percentage value that is known as neural respiratory drive. Previous studies of NRD have shown healthy subject measurements of 9.0 ± 3.4 and COPD patient measurements of 27.9 ± 9.9. We recruited 48 patients who were attending for diagnostic investigations for presumed pulmonary hypertension. Results were compared to measurements from diagnostic right heart catheterisation. Six patients did not have pulmonary hypertension. Forty two patients had mPAP ≥ 25mmHg. Overall, NRD was 17.0 ± 8.7. There was no significant difference between different PH groups (Group 1, 16.1; Group 2, 17.6; Group 3, 18.6; Group 4, 16.2). Our research shows that measuring NRD in pulmonary hypertension patients is feasible and shows raised respiratory drive (p-value <0.0001). Its use as a non-invasive marker of disease in PH and as a method of assessing response to treatment are worthy of further research.

[No abstract. Showing first paragraph of article]Pulmonary hypertension (PH) associated with hypoxia and lung disease, first identified as Group 3 in the 2008 Dana Point classification of PH, is the second most common form of PH and is associated with increased morbidity and mortality. The most common lung diseases resulting in PH are chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and obstructive sleep apnoea (OSA) but is also associated with other diseases, such as cysticfibrosis and high altitude exposure. Those with PH in the setting of obstructive or restrictive lung disease have worse outcomes, but it is not clear if the PH causes increased mortality or whether it is a marker for the severe end of the lung disease spectrum. Patients with Group 3 disease have a worse outcome than Group 1 IPAH. Those patients with Group 1 disease pulmonary arterial hypertension (PAH) but with minor associated lung disease also suffer from worse outcomes.

Socioeconomic factors have been shown to have an adverse impact on survival in some respiratory diseases. Studies from the USA and China have suggested worse survival in idiopathic pulmonary arterial hypertension in low socioeconomic groups. We looked at the effect of deprivation on the outcomes in patients with connective tissue disease-associated pulmonary hypertension (CTDPH) and chronic thromboembolic pulmonary hypertension (CTEPH) in a retrospective observational study. Data were obtained from 232 patients with CTDPH and 263 with CTEPH who were under the care of the Scottish Pulmonary Vascular Unit, Glasgow, UK. We used Cox proportional hazards regression to assess for a relationship between deprivation and survival. We found no difference in survival across deprivation quintiles in the CTDPH (p=0.26) or CTEPH cohorts (p=0.18). We constructed multivariate models using enrolment time, age, sex and body mass index, with no significant change in findings. There was no difference between expected and observed population distribution of CTDPH (p=0.98) and CTEPH (p=0.36). Whilst there was no difference in presenting functional class in the CTDPH group, the CTEPH patients in more deprived quintiles presented in a worse functional class (p=0.032). There was no difference between quintiles of CTEPH patients who had distal or proximal disease (p=0.75), or who underwent surgery (p=0.5). Increased social deprivation is not associated with worse survival in patients with CTDPH and CTEPH managed in the Scottish National Health Service. Whilst there is no evidence of referral barriers in CTDPH, this may not be the case in CTEPH, as lower deprivation was associated with worse functional class at presentation.

Introduction: Exercise rehabilitation is effective and safe in patients with pre-capillary pulmonary hypertension (PH). It has been shown to improve exercise capacity and quality of life but there is limited information available on changes in cardiac function. We assessed the effect of exercise on cardiac function, measured by cardiac MRI (CMR), in a prospective study in the Scottish Pulmonary Vascular Unit. Methods: 26 patients with stable, optimally treated PH, were recruited to a two-phase rehabilitation trial: Phase 1: 3 weeks of supervised inpatient aerobic and resistance exercise Phase 2: 12 weeks of remotely supervised exercise, based on inpatient regime. CMR was obtained at baseline and 15 weeks. Image analysis was performed using Circle Cardiovascular Imaging, version 5.1. Results: Mean age 53 years, majority female (19/26). 62% Idiopathic Pulmonary Arterial Hypertension, 23% Connective Tissue Disease related PH, 8% Heritable, 8% Chronic Thromboembolic PH. Table 1 shows changes in cardiac indices. Conclusion: Exercise rehabilitation in pre-capillary PH led to significant improvements in cardiac output, stroke volume and right ventricular ejection fraction (EF). Small numbers limited results. Further work is required to assess long term benefits.

Introduction Accurate prognostication is difficult in malignant pleural mesothelioma (MPM). We developed a set of robust computational models to quantify the prognostic value of routinely available clinical data, which form the basis of published MPM prognostic models. Methods Data regarding 269 patients with MPM were allocated to balanced training (n=169) and validation sets (n=100). Prognostic signatures (minimal length best performing multivariate trained models) were generated by least absolute shrinkage and selection operator regression for overall survival (OS), OS <6 months and OS <12 months. OS prediction was quantified using Somers D-XY statistic, which varies from 0 to 1, with increasing concordance between observed and predicted outcomes. 6-month survival and 12-month survival were described by area under the curve (AUC) scores. Results Median OS was 270 (IQR 140-450) days. The primary OS model assigned high weights to four predictors: age, performance status, white cell count and serum albumin, and after cross-validation performed significantly better than would be expected by chance (mean D(XY)0.332 (+/- 0.019)). However, validation set D-XY was only 0.221 (0.0935-0.346), equating to a 22% improvement in survival prediction than would be expected by chance. The 6-month and 12-month OS signatures included the same four predictors, in addition to epithelioid histology plus platelets and epithelioid histology plus C-reactive protein (mean AUC 0.758 (+/- 0.022) and 0.737 (+/- 0.012), respectively). The <6-month OS model demonstrated 74% sensitivity and 68% specificity. The <12-month OS model demonstrated 63% sensitivity and 79% specificity. Model content and performance were generally comparable with previous studies. Conclusions The prognostic value of the basic clinical information contained in these, and previously published models, is fundamentally of limited value in accurately predicting MPM prognosis. The methods described are suitable for expansion using emerging predictors, including tumour genomics and volumetric staging.

Background: In patients attending for diagnostic pleural fluid aspiration, blood-staining of the pleural fluid withdrawn is commonly taken to be a predictor of underlying pleural malignancy. We assessed the diagnostic performance blood-stained pleural fluid in the detection of malignant pleural disease (MPD). Methods: A retrospective review of consecutive local anaesthetic throacoscopies (LATs) performed in the Southern General Hospital between July 2010 and January 2015 was conducted. Data was collated from electronic case records and LAT reports. Results: 110 LATs were performed, of which 95% (n=104) had pleural fluid removed. Median volume of fluid removed was 1650 (IQR 900 –2700) mls. In 59% (n=65) the fluid was straw-coloured, 32% (n=35) blood-stained, 1% (n=1) chylous, 1% (n=1) frank blood, 1% (n=1) pus and 1% (n=1) turbid in appearance. The diagnostic accuracy of the appearance of blood-stained pleural fluid at LAT for predicting MPD is summarized in Table 1. Conclusions: Blood-staining of pleural fluid appears inaccurate in differentiating benign from malignant pleural disease in a selected LAT population. We plan to reassess its utility in a less selected cohort with suspected MPD prospectively recruited to the DIAPHRAGM study.