TYPE: Abstract TOPIC: Education, Research, and Quality Improvement PURPOSE: Virtual Clinic (VC) is a norm since the COVID-19 and there have been rapid developements to switch hospital services virtually. Our quality improvement project (QIP) predates COVID-19 hence the main aim of QIP was to establish a modern way of following up investigation after discharge and avoid non-clinical hospital or general pracitioner (GP) contact. METHODS: We screened the discharges from the respiratory ward. We reviewed the discharge summaries for February 2019 to look at the numbers that required any investigation post-discharge that could have been followed up virtually. We identified several patients and proceeded to set up a VC to be run by the respiratory trainees. VC referral form with strict citeria was configured and we did several teachings of the medical/nursing staff on the respiratory ward. We ran the pilot VC for March-April 2019. RESULTS: In our preliminary assessment, we had 19 investigations in February 2019 which were suitable for VC follow up. We received 45 VC referrals for for follow up in March/April 2019. These referrals were related to 28 individuals who would have otherwise required face to face clinic or GP follow up. CONCLUSIONS: Due to promising results, VC is now established as a formal clinic in our Trust and has taken a significant role of following up elegible COVID-19 and non-COVID-19 patients. CLINICAL IMPLICATIONS: The project exhibits evolutiornary methods to safely follow up patients whom otherwise would have required a specialist or GP clinic appointment. An established VC at the advent of COVID-19 gave us a head start over many other hospitals when establishing our services virtually. DISCLOSURE: Nothing to declare. KEYWORD: virtual clinic

Pleural infection is among the most common causes of pleural disease and is defined as bacterial invasion of the pleural space. MIST2 trial has been a single large multi-centre trial that has demonstrated a clear advantage in radiographic clearance of infection in the combination tissue plasminogen activator (tPA) and DNase arm in comparison to tPA, DNAse or placebo treatments individually. In our large district general hospital, we applied the selction criteria and treatment protocols used in the MIST2 trial to develop our own experience. Between August 2018 and August 2020, we selected 8 patients who were admitted with pleural infection based on the MIST2 trial criteria. The mean age of the patients was 61 years. Out of the 8 patients, 5 patients had 2 or more co-morbidities. We had an equal distribution of 4 males and 4 females. The chest radiographs were reviewed by 3 experienced respiratory physicians. The mean percentage area of pleural opacity on chest (CXR) at the time of admission was 70% and the mean C-rective protein (CRP) at the time of admission was 263. Only two patients had positive pleural fluid cultures. The pleural fluid pH was always less than 7.2. Out of 8 patients, 6 had the combination of tPA and DNase and 2 patients only received tPA. Mean improvement in pleural opacity after intercostal drain insertion was 14%. Mean improvement in pleural opacity after fibrinolytic use was 41%. The mean pleural opacity was 16% and the mean CRP was 105 on discharge. All the patients were alive at the time of discharge and 20 days after discharge. Only one patient had complication of pain. Our results were very encouraging and has improved our confidence in use of combination fibrinolytics.

BACKGROUND:Programmed death-ligand 1 (PD-L1) expression on cancer cells is a clinically important biomarker to select patients with non-small cell lung cancer (NSCLC) for treatment with programmed death-1/PD-L1 inhibitors. Clinical trials of immunotherapy in patients with NSCLC have required histologic evidence for PD-L1 testing; in clinical practice, cytologic samples commonly are acquired in patients with advanced disease. RESEARCH QUESTION:This study aims to investigate whether endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) samples are adequate for PD-L1 testing in NSCLC. STUDY DESIGN AND METHODS:This study investigates the sampling adequacy of EBUS-TBNA for PD-L1 testing when compared with other methods. Furthermore, the relationship between clinicopathologic characteristics and PD-L1 expression in the study population have been examined. Five hundred seventy-seven NSCLC specimens were analyzed from consecutive patients with NSCLC across six centers in the United Kingdom and one center in the United States between January 2015 and December 2016. RESULTS:In the EBUS-TBNA group (189 specimens), the overall percentage of patients with successful PD-L1 testing was 94.7%. There was no significant difference in sampling adequacy with other methods of tissue acquisition. Older patients had higher failure rates of PD-L1 testing (OR, 1.06; P = .008). In multivariate analysis, advanced N-stage (P = .048) and presence of brain metastasis (P < .001) were associated with high PD-L1 expression. INTERPRETATION:This large multicenter study shows that EBUS-TBNA provides samples adequate for PD-L1 testing and that advanced N stage and the presence of brain metastasis are associated with high PD-L1 expression.

Background: General Medical Council survey (GMC, National Training Surveys 2018: Initial findings report) states that a quarter of medical trainees and over a fifth of trainers have reported burnout due to various reasons. Respiratory medicine is one of the more intense specialties in terms of workload and patient acuity. Aim: We aimed to study professional fulfilment (PF) and burnout among UK RP. Methods: 16-question survey, PF Index (PFI) as a validated tool (Trokel M, Bohman B et al. Academic Psychiatry 2018;42(1):11-24), was designed using Google Forms and sent to 14 deaneries across UK. Data was collected on RPs’ job role, age group, gender, job plan (i.e. general medicine (GIM) on-call commitment) and opinion on the leading causes of burnout. Results: 110 RP completed the survey. 43 (76.8%) consultants and 44 (91.7%) trainee registrars (TR) lacked professional fulfillment. 27 (48.2%) consultants and 26 (54.2%) TR were found to have burnout. All non-training registrars (n=6) were deficient of PF and had burnout. Participants rated Rota Gaps as the leading cause for burnout, while GIM on-call commitment and lack of respect from administrators were voted 2nd and 3rd respectively. Conclusion: Prevalence of burnout and scarcity of PF is much more profound among RP when comparing with similar studies in general medicine. Interestingly most of this is related to mandatory contribution to GIM on-calls than respiratory medicine and pose a threat to recruitment and retention. Ongoing rota gaps is a grave concern especially in wake of Brexit. We recommend running this survey on a wider forum to get thorough results and to take remedies against the leading causes.

Management of primary spontaneous pneumothorax (PSP) depends on the symptoms and size of lung collapse. The British Thoracic Society recommends needle aspiration (NA) for all PSP requiring intervention, followed by intercostal drain (ICD) if NA fails. We compared the role of NA versus ICD as the first step in PSP with 'complete lung collapse'.This was a retrospective observational study of 877 consecutive pneumothorax episodes at University Hospitals of North Midlands, Stoke on Trent, UK. Chest X-ray (CXR) at presentation was reviewed to identify PSP with complete lung collapse. The primary outcome measure was successful lung re-inflation after initial intervention.Two-hundred and sixty-six PSP patients were identified; 69 had complete lung collapse on CXR of which 35 had NA and 34 had ICD. The ICD group had a significantly better immediate success compared with the NA group (62% versus 11%, odds ratio (OR) = 12.5, p<0.0001; after adjustment for potential confounders, OR increased to 26.4, p=0.0001) although long-term outcomes were comparable.There should be clear consensus on definition and management of complete lung collapse. PSP with complete lung collapse could be managed as a separate subgroup where ICD placement is considered to be the first intervention.

Background Work related burnout is a rising concern among healthcare providers. GMC survey states that a quarter of trainees and over a fifth of trainers have reported burnout due to various reasons. Respiratory medicine is one of the more intense specialties in terms of workload and patient acuity. To date, respiratory physicians’ (RP) wellbeing has not been probed as a specialty. Aim We aimed to study professional fulfilment and burnout among UK respiratory physicians. Methods 16-question survey, Professional Fulfillment Index (PFI), designed using Google Forms was sent to 14 deaneries across UK. Data was collected on RPs’ job role, age group, gender, job plan (ie general medicine (GIM) on-call commitment) and opinion on the top causes for burnout. Results 110 RP completed the survey. 43 (76.8%) consultants and 44 (91.7%) training registrars (TR) lacked professional fulfillment. While 27 (48.2%) consultants and 26 (54.2%) RT were found to have burnout. All trust grade registrars (n=6) were deficient of professional fulfillment and had burnout. Participants rated Rota Gaps as the leading cause for burnout, while GIM on-call commitment and lack of respect from administrators were voted 2nd and 3rd respectively. Conclusion Prevalence of burnout is much more profound among RP when comparing similar studies in general medicine. Also, scarcity of professional fulfillment is another concern. We recommend running this survey on a wider forum to improve the results and to take remedies against at-least the top causes.

BACKGROUND Chronic obstructive pulmonary disease (COPD) is a respiratory condition causing accumulation of mucus in the airways, cough, and breathlessness; the disease is progressive and is the fourth most common cause of death worldwide. Current treatment strategies for COPD are multi-modal and aim to reduce morbidity and mortality and increase patients' quality of life by slowing disease progression and preventing exacerbations. Fixed-dose combinations (FDCs) of a long-acting beta2-agonist (LABA) plus a long-acting muscarinic antagonist (LAMA) delivered via a single inhaler are approved by regulatory authorities in the USA, Europe, and Japan for the treatment of COPD. Several LABA/LAMA FDCs are available and recent meta-analyses have clarified their utility versus their mono-components in COPD. Evaluation of the efficacy and safety of once-daily LABA/LAMA FDCs versus placebo will facilitate the comparison of different FDCs in future network meta-analyses. OBJECTIVES We assessed the evidence for once-daily LABA/LAMA combinations (delivered in a single inhaler) versus placebo on clinically meaningful outcomes in patients with stable COPD. SEARCH METHODS We identified trials from Cochrane Airways' Specialised Register (CASR) and also conducted a search of the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch). We searched CASR and trial registries from their inception to 3 December 2018; we imposed no restriction on language of publication. SELECTION CRITERIA We included parallel-group and cross-over randomised controlled trials (RCTs) comparing once-daily LABA/LAMA FDC versus placebo. We included studies reported as full-text, those published as abstract only, and unpublished data. We excluded very short-term trials with a duration of less than 3 weeks. We included adults (≥ 40 years old) with a diagnosis of stable COPD. We included studies that allowed participants to continue using their ICS during the trial as long as the ICS was not part of the randomised treatment. DATA COLLECTION AND ANALYSIS Two review authors independently screened the search results to determine included studies, extracted data on prespecified outcomes of interest, and assessed the risk of bias of included studies; we resolved disagreements by discussion with a third review author. Where possible, we used a random-effects model to meta-analyse extracted data. We rated all outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) system and presented results in 'Summary of findings' tables. MAIN RESULTS We identified and included 22 RCTs randomly assigning 8641 people with COPD to either once-daily LABA/LAMA FDC (6252 participants) or placebo (3819 participants); nine studies had a cross-over design. Studies had a duration of between three and 52 weeks (median 12 weeks). The mean age of participants across the included studies ranged from 59 to 65 years and in 21 of 22 studies, participants had GOLD stage II or III COPD. Concomitant inhaled corticosteroid (ICS) use was permitted in all of the included studies (where stated); across the included studies, between 28% to 58% of participants were using ICS at baseline. Six studies evaluated the once-daily combination of IND/GLY (110/50 μg), seven studies evaluated TIO/OLO (2.5/5 or 5/5 μg), eight studies evaluated UMEC/VI (62.5/5, 125/25 or 500/25 μg) and one study evaluated ACD/FOR (200/6, 200/12 or 200/18 μg); all LABA/LAMA combinations were compared with placebo.The risk of bias was generally considered to be low or unknown (insufficient detail provided), with only one study per domain considered to have a high risk of bias except for the domain 'other bias' which was determined to be at high risk of bias in four studies (in three studies, disease severity was greater at baseline in participants receiving LABA/LAMA compared with participants receiving placebo, which would be expected to shift the treatment effect in favour of placebo).Compared to the placebo, the pooled results for the primary outcomes for the once-daily LABA/LAMA arm were as follows: all-cause mortality, OR 1.88 (95% CI 0.81 to 4.36, low-certainty evidence); all-cause serious adverse events (SAEs), OR 1.06 (95% CI 0.88 to 1.28, high-certainty evidence); acute exacerbations of COPD (AECOPD), OR 0.53 (95% CI 0.36 to 0.78, moderate-certainty evidence); adjusted St George's Respiratory Questionnaire (SGRQ) score, MD -4.08 (95% CI -4.80 to -3.36, high-certainty evidence); proportion of SGRQ responders, OR 1.75 (95% CI 1.54 to 1.99). Compared with placebo, the pooled results for the secondary outcomes for the once-daily LABA/LAMA arm were as follows: adjusted trough forced expiratory volume in one second (FEV1), MD 0.20 L (95% CI 0.19 to 0.21, moderate-certainty evidence); adjusted peak FEV1, MD 0.31 L (95% CI 0.29 to 0.32, moderate-certainty evidence); and all-cause AEs, OR 0.95 (95% CI 0.86 to 1.04; high-certainty evidence). No studies reported data for the 6-minute walk test. The results were generally consistent across subgroups for different LABA/LAMA combinations and doses. AUTHORS' CONCLUSIONS Compared with placebo, once-daily LABA/LAMA (either IND/GLY, UMEC/VI or TIO/OLO) via a combination inhaler is associated with a clinically significant improvement in lung function and health-related quality of life in patients with mild-to-moderate COPD; UMEC/VI appears to reduce the rate of exacerbations in this population. These conclusions are supported by moderate or high certainty evidence based on studies with an observation period of up to one year.

Background: Seldinger chest drains (SCD) are safe, less invasive and better tolerated compared to large bore chest drains (LBCD) via blunt dissection. Respiratory Medicine (RM) specialty trainees (ST) curriculum in UK recommends ‘experience of LBCD and competence in SCD. LBCD are rife with the popularity of Thoracoscopy and are arguably safer in complex cases in experienced hands. There is limited data on training, access to teaching and competency in LBCD by RM STs. Aim: We aimed to study UK based RM STs experience with LBCD. Methods: 15-question survey designed using SurveyMonkey was sent to RM STs in 14 deaneries across UK. Data was collected on STs’ deanery, training year, competence in SCD and LBCD, access to training and experience in placing, securing and removing LBCD, availability of thoracic surgery (TS) and treatment delays incurred due to lack of training in LBCD or TS non-availability. Results: 147 STs completed the survey. 143 STs (97.3%) were competent in SCD but only 22 STs (14.9%) were competent in LBCD. 29 STs (19.7%) were competent in securing LBCD and 52 STs (35.3%) were competent in removing LBCD. 84 STs (57.1%) did not receive any formal training in LBCD and 129 STs (87.7%) felt they were not getting sufficient experience in LBCD. 77 STs (52.3%) remarked that patients had faced treatment delays due to lack of physician LBCD expertise and/or TS non-availability. Conclusion: LBCD are becoming commonplace but experience has declined in RM STs leading to treatment delays. An overwhelming majority of RM STs in UK believe they should be getting more experience in LBCD.RM training curriculum may need revision to accomodate these views to improve training of STs.

We present a case of bilateral haemotympanum (HT) during endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBNA). A 64 year-old-man underwent EBUS-TBNA for mediastinal lymph nodes (LN) staging. Medical history included emphysema and angina. Medication included aspirin until the day before procedure. Full blood count and clotting screen were normal. He received sedation (5 mg midazolam, 1000 mcg alfentanil) and topical anaesthesia (16 mL 1% lignocaine) but coughed excessively throughout the procedure. Left hilar LN was the only area sampled. Spontaneous bleeding ensued from both ears towards the end of the procedure. Patient remained haemodynamically stable. The procedure was aborted and otolaryngology consult sought. Otoscopy showed bilateral haematoma from anterior ear canal with normal tympanic membranes and no hearing loss. Nasendoscopy revealed erythematous ostium of both Eustachian tubes. Bleeding stopped spontaneously and patient required no further imaging or treatment. We report this case to increase awareness of this very rare complication resulting from excessive coughing during EBUS-TBNA.

Introduction: Hemotympanum (HT) refers to bleeding in middle ear cavity with intact tympanic membrane (TM). It is rarely associated with barotrauma in scuba drivers. We present a rare case of HT post EBUS-TBNA. Case report: 64 year-old-man had EBUS-TBNA for mediastinal staging of left upper lobe mass. Past medical history included emphysema and angina. He did not take anticoagulants or antiplatelets other than Aspirin. Recent full blood count and clotting screen were normal. He had maximal conscious sedation (5mg Midazolam, 1mg Alfentanil) and adequate topical anesthesia (16ml 1% Lignocaine). Despite this, he coughed excessively throughout. Left hilar lymph node was the only area sampled. Spontaneous bleeding was noted from both ears although patient remained hemodynamically stable. Procedure was aborted and otolaryngology consult sought. Otoscopy showed bilateral hematoma from anterior ear canal with normal TM and no hearing loss. Nasendoscopy revealed erythematous ostium of both Eustachian tubes. Bleeding stopped spontaneously and patient required no further imaging or treatment. He was discharged home after a period of observation, to otolaryngology follow up at his local hospital. EBUS-TBNA histology confirmed Adenocarcinoma and patient underwent surgical resection. After thorough examination and case review, the etiology of HT was thought to be due to barotrauma caused by abrupt rise in middle ear pressure due to excessive coughing. Conclusion: HT after bronchoscopy is a rare self-limiting condition and has only been reported once in the literature. There is minor risk of HT after bronchoscopy with excessive coughing due to upsurge in middle ear pressure.

Introduction: Latent Tuberculosis (LTB) is an infection caused by Mycobacterium Tuberculosis which is usually treated with Rifampicin/Isoniazid. We explored the unreported complication of neutropenia resulting from treatment of LTB and its long term consequences. Methods: We conducted a retrospective observational study of 270 patients presenting to LTB clinic between Jan 2012 and Dec 2016. Patient’s blood tests were searched for values of neutrophils <1.60x10⁹/L. Further data was collected from clinic/discharge letters and GP surgery. Results: 20 became neutropenic during their treatment with transient neutropenia of <1.60x10⁹/L. 5 patients developed significant neutropenia of <1.0x10⁹/L. These patients had no admissions to hospital during the time of their treatments and had no adverse consequences. 4 of these patients had their regime altered to Isoniazid only with complete resolution of their neutropenia. One patient developed persistent neutropenia and was diagnosed with a combination of medication induced and benign ethnic neutropenia. Interestingly, there were only 16 patients whose Liver functions (LFTs) were deranged significantly, (ALT>twice upper limit) hence more patients having neutropenia than significantly deranged LFTs. All patients’ LFTs improved after completion of treatment. Conclusions: Mild neutropenia secondary to Rifampicin treatment is under-reported and is higher than significantly deranged LFTs. Clinicians should be aware of this potential complication and should alter patients’ management accordingly. However, it is not necessary to stop the chemotherapy immediately, because the neutrophil count recovers spontaneously and patients should still be treated with careful monitoring.

To the Editor: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is generally a safe procedure with very rare complications including bleeding, pneumothorax, pneumomediastinum, mediastinitis, and respiratory failure. We report a rare, unrecognized complication of EBUS-TBNA that, once recognized, is treatable by prompt action. A 74-year-old gentleman recently diagnosed with left upper lobe squamous cell carcinoma underwent elective EBUS-TBNA for sampling of subcarinal lymph node, and thus staging the malignancy. Past medical history included chronic obstructive pulmonary disease (COPD), bronchiectasis, rheumatoid arthritis, and hypertension. The oropharynx was sprayed with a topical local anesthetic (50 mg of Lidocaine) and he was sedated with Propofol and Remifentanyl. An BF-UC260FW Olympus EBUS-TBNA scope was passed through oral cavity via a mouth guard (medgic medical devices, disposable bite block). The patient had persistent cough during the procedure. Four samples were taken from station 7 lymph nodes and the procedure was stopped thereafter. Total duration of procedure was 22 minutes. Overall, the procedure was uneventful and the mouth guard was removed. The patient woke up 20 minutes after the procedure in the recovery suite. He complained of jaw pain, inability to close his mouth and could not talk secondary to incomplete mouth closure. He was seen by the Oral and Maxillofacial surgery team and clinical diagnosis of bilateral anterior temporomandibular joint (TMJ) dislocation was made. As he was still under the effect of sedation, manual relocation of mandible was performed, which led to immediate relief of symptoms. Dislocation of TMJ is a common complication associated with endotraheal intubation and anesthesia and has rarely been described secondary to gastroscopy, bronchoscopy, trans-esophageal echocardiogram, otolaryngology, and dentistry procedures.1–8 However, to the best of our knowledge TMJ dislocation has never been reported secondary to EBUS-TBNA. Several factors have been identified as potential sources for increasing the risk of jaw dislocation which include previous joint dislocation, prolonged procedure time, increased age, and relaxation of the musculature caused by sedating medications.1–3 When patients suffer from TMJ dislocation, they will often be unable to close their mouth and have drooling and garbled speech along with pain.5 The diagnosis of TMJ dislocation is based upon clinical examination. Delayed reduction increases the risk of development of muscular spasms making the reduction of the dislocation more challenging.6 Although Propofol and Remifentanyl was used for sedation in our patient, jaw dislocation has been reported with use of midazolam alone.8 EBUS-TBNA often requires deeper sedation and prolonged intubation compared with conventional flexible bronchoscopy. While jaw dislocation is a very rare complication of EBUS-TBNA, it is important for bronchoscopists to be aware of this possibility, recognize it in the recovery area and seek urgent treatment. Patients with a history of TMJ subluxation are at a high risk for this complication during any bronchoscopic procedure. Early recognition of this unusual complication of EBUS-TBNA enables prompt, effective treatment, and reduces further morbidity. Usman Maqsood, MRCP (UK) Janet Mills, BSc (Hons) Mohammed Munavvar, MD DNB, FRCP(Lon) FRCP (Edin)Lancashire Teaching Hospitals NHS Trust Preston, United Kingdom

We describe a case of near-fatal asthma, treated successfully by initiation of extracorporeal membrane oxygenation (ECMO). A 29-year-old woman, known asthmatic on steroid inhalers, inhaled/nebulised bronchodilators, long-term oral prednisolone, theophylline and montelukast, presented with acute shortness of breath. She deteriorated following initial treatment with nebulised bronchodilators and magnesium sulfate requiring intubation and mechanical ventilation. Severe bronchospasm ensued following mechanical ventilation and peak airway pressures remained at 55 cm H2O with intrinsic positive end expiratory pressure(PEEP) of 14 cm H2O. Despite treatment with sedation, paralysis, intravenous salbutamol and inhaled sevoflurane, her condition deteriorated. She was commenced on mobile ECMO by the retrieval team. While on ECMO, her CO2 normalised within 48 hours. She was extubated within 72 hours of initiating ECMO and was discharged to the ward next day. We reiterate that ECMO should be considered sooner for status asthmatics not responding to maximal pharmacological therapy and ventilatory support to prevent ongoing lung injury and mortality.

Rationale Recent data have demonstrated the superiority of Pembroluzimab over chemotherapy for patients with advanced NSCLC and high (≥50% expression) of PD-L1.1 This has resulted in NICE approving Pembroluzimab as a first line treatment option for patients with advanced NSCLC in June 2017. The original trial however excluded patients with PD-L1 testing on EBUS samples. We therefore conducted a large, multicentre study to clarify whether specimens obtained by EBUS-TBNA were suitable for testing PD-L1 in patients with NSCLC. Methods NSCLC samples acquired by EBUS-TBNA (29.4%), percutaneous biopsy (31.2%), endobronchial biopsy (13.8%), surgical (21.4%) or other techniques (4.1%) were recorded from 435 consecutive patients with known or suspected lung cancer across 5 centres in England between January 2015 and December 2016. Results PD-L1 assessment (using the 22 C3 assay in all cases) was possible in 92.2% of patients undergoing EBUS and there was no difference in success of PD-L1 testing according to modality of tissue acquisition (p=0.18). The frequency of complications from EBUS-TBNA was similar to endobronchial or percutaneous techniques but lower than surgical procedures (5.0% vs 13.8%; p=0.03). PD-L1 expression in the cohort was high (≥50%) in 28.5%, weak (≥1%–50%) in 28.2%, whilst 43.3% of patients were PD-L1 negative. The only statistically significant predictor for PD-L1 expression in multivariate analysis was the presence of brain metastasis at diagnosis (OR 2.02; CI 1.04–3.90). 47 patients (11.4%) were treated with immunotherapy and the response rate was 16.2%. All patients that responded to immunotherapy had high (≥50%) expression of PD-L1. Conclusions This large multicentre study demonstrates for the first time that samples obtained by EBUS-TBNA in routine practice are suitable for PD-L1 testing in patients with NSCLC. The presence of brain metastases at diagnosis predicts high PD-L1 expression in this cohort and this new finding should be tested in future clinical trials. Reference Reck M, Rodrguez-Abreu D, Robinson AG, et al. Pembrolizumab versus Chemotherapy for PD-L1Positive NonSmall-Cell Lung Cancer. N Engl J Med 2016;375(19):1823-33. doi:10.1056/NEJMoa1606774

Tracheobronchial foreign body (TFB) aspiration is a common occurrence in children compared with adults. Long-standing cases of TFB aspiration during childhood presenting in an adult have rarely been reported. We report the unique case of an endobronchial Playmobil traffic cone that went undetected for 40 years and presented as a suspected bronchogenic carcinoma. This was subsequently removed successfully with flexible bronchoscopy. To our knowledge this is the first case of a TFB that was overlooked this length of time.

Introduction Small, asymptomatic pneumothoraces may be managed as outpatients. Several studies show that small-bore catheters and Heimlich valves may be used in the treatment of pneumothoraces. A systematic review of the literature1 showed successful outpatient management of pneumothorax. Despite good evidence to support ambulatory approach, there has been slow development of this service across the UK. We wished to assess the number of potential primary spontaneous pneumothorax patients that could be managed as outpatients in a large teaching hospital. Methods Hospital attendances of pneumothorax at a large teaching hospital between 2012–2015 were reviewed. Type of pneumothorax was characterised: primary spontaneous (PSP), secondary spontaneous (SSP), iatrogenic (IP) and traumatic/post-operative. The data for PSP was then correlated against the data retrieved from the systematic review of outpatient pneumothorax management.1 Results Total number of pneumothorax episodes were 877; PSP 266, SSP 229, IP 41 and traumatic/post-operative 341. Average length of stay (LOS) for all episodes of pneumothorax was 12.39 days. LOS for PSP was 6.9 days. Total number of hospital admissions for PSP (266/3 =) 88.7 patients/year. Extrapolated from systematic review1: Successful outpatient PSP management (88.7*78% =) 77.1 patients/year. Potential bed days saved for PSP: (77.1*6.9 =) 532 beds/year. Conclusions Studies show both spontaneous and iatrogenic pneumothorax may be managed safely as outpatients. Dedicated pleural services will result in correct stratification of patients requiring appropriate interventions. Ambulatory chest drains could be used and inserted by professionals trained in their use. Advantages to patients: reduced need for hospital admission, greater patient autonomy, improved patient experience, no need to carry chest drain bottle, reduced likelihood of accidental dislodgement of chest drain, reduced time to discharge. Advantages to trust: admission avoidance, early discharge, reduced costs, reduced complications from chest drain insertions, reduced hospital associated complications, optimised patient care with increased patient satisfaction. Although we would not advocate the use of ambulatory pneumothorax devices in trauma patients, there is scope to establish whether they can be used post procedural (e.g. pneumothorax following pacemaker insertion). Reference Brims FJ, Maskell NA. Ambulatory treatment in the management of pneumothorax: a systematic review of the literature. Thorax 2013;68(7):664–9.

INTRODUCTION: Approximately 2-4% of all patients hospitalized for acute asthma require invasive mechanical ventilation. 7% of these will not survive (Krishnan, V. et al. Am J Respir Crit Care Med 2006; 174:633). We describe a case of near fatal Asthma who survived successfully by the initiation of ECMO. CASE PRESENTATION: A 29-year-old female, known asthmatic on steroid inhalers, inhaled/nebulised bronchodilators, long term Prednisolone, Theophylline and Montelukast presented with acute shortness of breath. Following initial treatment with nebulised bronchodilators and Magnesium Sulphate, there was rapid deterioration requiring intubation and mechanical ventilation. Severe bronchospasm ensued following mechanical ventilation. Peak airways pressures remained at 55cm H2O with intrinsic PEEP of 14. Despite treatment with sedation, paralysis, IV salbutamol and inhaled sevoflurane, her condition deteriorated so she was transferred for ECMO. Whilst on ECMO her CO2 normalised within 48 hours. She was extubated within 72 hours of initiating ECMO and was discharged to the ward next day. CONCLUSION: ECMO should be considered sooner for status asthmatics not responding to maximal pharmacological therapy and ventilatory support to prevent ongoing lung injury and mortality.