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Background Patients that have chronic respiratory disease (CRD) and breathing pattern disorders (BPD) have a higher prevalence of anxiety and depression than the general population. These patients have worse respiratory health outcomes and in addition, their psychological problems are often left undiagnosed and untreated. Little is known about how anxiety and depression varies between CRD and BPD. Methods This prospective study involved screening patients attending secondary and tertiary respiratory clinics over an eight-week period. Patients were asked to complete the Hospital Anxiety and Depression Scale (HADS), Short Form-12 (SF-12) and St. George’s Respiratory Questionnaire (SGRQ). Demographical data and spirometry were also collected. Our primary outcome measure was the difference in these scores between patients with CRD (asthma, bronchiectasis and chronic obstructive pulmonary disease) compared to BPD (vocal cord dysfunction and dysfunctional breathing). Results 43 patients (21 with CRD and 22 with BPD) completed questionnaires; mean (SD) age 55 (17) yrs, 32 female. The overall prevalence of borderline anxiety was 17% and clinically significant anxiety 37%. The overall prevalence of borderline depression was 15% and clinically significant depression 29%. Of the patients with CRD, 29% had anxiety and 29% depression. In the BPD cohort, anxiety and depression were found in 45% and 30% of patients respectively. The difference between these groups was not statistically significant (anx: P = 0 .42; dep P = 0 .19). Independent predictors for anxiety and depression were higher SGRQ (anx: P = 0 .001; dep: P < 0 .0001), lower SF-12 Mental (anx: P < 0 .0001; dep: P < 0 .0001) and Physical (anx: P = 0 .042; dep: P = 0 .0027) Health Composite Scores, and lower FEV 1 % predicted (anx: P = 0 .0043; dep: P = 0 .016). Conclusions Anxiety and depression are present in a significant numbers of individuals in both CRD and BPD, with no difference between these groups, so efforts should be made to screen for psychological problems in patients with both CRD and BPD. Worse respiratory function and more symptoms are important contributing factors to patients’ risk of anxiety and depression.

Introduction There is strong emerging evidence on the devastating effect of anthropogenic climate change on lung health. In England, the NHS accounts for 30% of the public sector carbon footprint, with patient travel being accountable for 8% of overall travel (17%). The climate change act (2008) resulted in the government and NHS committing to an 80% reduction in carbon emissions by 2050. Methods There are many studies detailed the benefit of telemonitoring in reducing carbon footprint within NHS services. Within the Lancashire and South Cumbria Long Term Ventilation Service (LSCLTVS) we have invested in a ventilator remote monitoring system (EncoreAnywhereTM). Over a 3 month time period we analysed the telephone consultations of all 138 patients under the care of the LSCLTVS (80 patients on remote monitoring systems). Patients or carers that called reporting deterioration in a clinical condition that could not be rectified over the telephone were identified. The normal intervention that would follow would be a visit from the GP or community respiratory team, hospital admission, clinic visit or home visit from the ventilation team. A ventilator review was indicated in 29 patients which would normally necessitate either a clinic visit to Royal Preston Hospital or a consultation at home. However as these patients had remote ventilator monitoring we were able to review data and make changes remotely. Results In a 3 month time period 29 return journeys were prevented through the use of remote monitoring. This equated to 1029.3 km (623 miles), 249 kgCO2e (0.24 t CO2e)*saved over 28 hours in commuting time and £255 in mileage costs (40 p per mile). It also had a positive impact on patient experience and no hospital admissions or clinic visits were necessary after remote consultation. 62% (n = 18) patients required use of rescue packs including antibiotics and mucolytics as well as remote ventilator changes. *Emission factors from DEFRA 2012 show for an average petrol car the value is 0.24234 kg CO2e per km Discussion The use of remote monitoring within the LSCLTVS has reduced the carbon footprint of the service on average 6.6 kg CO2e per patient. Patients also reported improved satisfaction and compliance.

Background and aim Many patients presenting to our complex breathlessness service appear to have breathing pattern disorders (BPDs). When suspected clinically, they are referred to a specialist respiratory physiotherapist for assessment and treatment. Here we describe the prevalence of identifiable breathing patterns and their clinical characteristics Methodology We performed a retrospective review of our clinical database including patients seen for initial physiotherapy assessment between December 2015 and June 2016. Patients underwent a standardised diagnostic assessment (clinical history, physiotherapy assessment, lung function and Nijmegan questionnaire). Results Data from 43 patients with confirmed BPD were included, 77% female, mean age 58 yrs. Relevant respiratory comorbidities included chronic cough (33%), asthma (30%) and vocal cord dysfunction (30%), with no comorbidity in 23%. Other associated conditions included musculoskeletal conditions (47%), chronic pain (44%), obesity (44%), nasal blockage (42%) and anxiety (31%). Four categories of breathing patterns were identified: thoracic dominant (58%), irregular/crescendo (51%), forced abdominal expiration (30%), and thoraco-abdominal asynchrony (2%). More than one BPD was seen in 35% of patients; only forced abdominal expiration and thoracic dominant didn’t co-exist. Conversely all pattern types could be found in isolation, although irregular/crescendo was more likely to co-exist with another pattern type. Conclusion Four separate breathing pattern types were identified, in isolation or in combination. Although anxiety was fairly common, many other associated disease and conditions were seen, especially relating to biomechanical factors. This preliminary data may enable clinicians to identify breathing pattern types, lead to the development of targeted treatment options and promote screening of particular conditions associated with BPD.

Introduction Home mechanical ventilation (HMV) is a recognised evidence-based intervention for patients in chronic respiratory failure (CRF). However there is a paucity of evidence on the adherence to this treatment. This study examined the adherence of HMV and evaluated the clinical outcomes associated with adherence in a variety of patient populations – namely neuromuscular disease, chest wall disease, obesity hypoventilation syndrome and chronic obstructive pulmonary disease (COPD). Methods A retrospective study was carried out between May to June 2016. Adherence data was downloaded through remote monitoring. Primary outcomes included changes in blood gases at 3 and 6 months, and hospital admissions 12 months pre- and post-ventilation. Qualitative outcomes were obtained through a questionnaire conducted via telephone interviews. Results 62 patients were included in this study. Patients undertaking remote monitoring of HMV demonstrated an adherence rate of 90.3%, defined as more than 4 hours of ventilator use/night (mean [SD] = 7h 17min [2h 53min]). No significant difference in adherence was found between patients of different aetiologies. The blood gases improved significantly at 3 months compared to baseline (p Conclusion This study has demonstrated that contrary to existing evidence, the adherence to HMV was extremely good across all diseases. Remote monitoring may play a role in this increased adherence. Although HMV contributed to improvements in blood gases at 3 months, there was a universal trend for these parameters to return to baseline at 6 months in all disease states despite good adherence. Our data therefore suggests that early follow-up is essential to detect deterioration and support the need for palliation. Nevertheless HMV remains an effective treatment to reduce hospital admissions and improve quality of life, if patients are adherent to the intervention.

Background Severe asthma comprises 5% of all asthma, but over 50% of the asthma healthcare burden. With multi-disciplinary team (MDT) working there is potential to improve patient outcomes and reduce healthcare costs. In 2013 NHS England produced service specifications for severe asthma aiming to develop a limited number of high volume specialist centres. In the North West we have developed a networked approach to specialised severe asthma services; the first Operation Delivery Network for a chronic disease. Representatives from 11 NHS Trusts and a central hub undertake a monthly virtual MDT meeting, with physicians, nurses, physiotherapists, clinical psychologists, speech and language therapists, allergists, pathologists and radiologists represented. All patients being considered for specialised treatments undergo MDT discussion for consensus approval of treatment. Aim To summarise the experience and case-mix encountered during the first 18 months of operation of our regional virtual severe asthma MDT Methods We reviewed all cases discussed at the MDT between January 2015 and June 2016. Cases were submitted online via nhs.net accounts, and data entered into a central database managed by two MDT coordinators for MDT discussion. Results During this period 17 meetings were held, with 208 case-submissions representing 185 patients, mean (SD) 12 (7) discussions per meeting. Indications for case submission included proposals for use of omalizumab, bronchial thermoplasty (BT), and steroid-sparing therapies, and for the discussion of patients with complex clinical issues, often managed across multiple sites. Omalizumab was approved in 81% of cases submitted, and BT in 39%, with more of the latter requiring multiple discussions (30% versus 2%) The most common reasons for non-approval of omalizumab were insufficient steroid requirement, poor adherence, and lack of allergy to a perennial allergen. Thermoplasty was not approved or listed for re-discussion for a variety of reasons, including 10 (43%) that required further investigation. Conclusion We describe our early experience of a multi-site virtual severe asthma MDT meeting facilitating expert care across a wide geographical area. This ensures governance in the use of novel and expensive severe asthma therapies, strengthens regional collaborations and ultimately aims to provide better patient care.

Introduction The Airways Service at Royal Preston Hospital receives tertiary referrals from across the UK. When a diagnosis of vocal cord dysfunction (VCD) or chronic cough is made and speech and language therapy (SLT) required, patients undergo weekly therapy (minimum four sessions), which some may struggle to attend due to pre-existing commitments and/or travel time. As SLT typically does not require ‘hands-on’ therapy we felt that Skype™ videoconferencing may be a useful mode of treatment delivery. We present our initial experience of this service. Methods A six-month pilot was completed whereby patients were offered SLT over Skype. Prior to therapy all patients were seen by the respiratory consultant and speech and language therapist for assessment and flexible laryngoscopy. Patients required confidential webcam access and proficiency. Symptom questionnaires were completed pre and post therapy (for VCD the 12 item VCDQ; for chronic cough the 19-item LCQ), and patient satisfaction questionnaires and flexible laryngoscopy performed post therapy. Results Eleven people have completed SLT over Skype™ to date, and all demonstrated improvement in symptoms following therapy. Patients with VCD showed a decrease in score on the VCDQ from median (range) 48 (12–53) pre therapy to 40 (7–42) post therapy [minimal clinical important difference (MCID) 5]. Patients with chronic cough showed an increase on the LCQ from median (range) 6.4 (4.6–8.2) pre therapy to 12.2 (10–14.6) post therapy (MCID 1.3). Improvements in laryngeal tension and sensitivity were noted in all cases. All patients gave positive feedback in their patient satisfaction questionnaire scoring “very satisfied” or greater. On three occasions Skype connection problems delayed sessions by a few days. Conclusions Virtual consultations provide the opportunity to treat patients in a more time efficient and practical way, and improvements in patient-reported symptoms and laryngeal appearances were similar to those of patients attending therapy sessions in chest clinic. This data gives support to pursue formalised tariffs for a specialised telehealth service. We feel that Skype should continue as a regular therapy option for patients and other members of the multi-disciplinary team (MDT) should consider this method of therapy delivery.

Introduction Vocal cord dysfunction (VCD) typically involves abnormal vocal cord movement during inspiration. The recognised gold standard for diagnosis is fibreoptic laryngoscopy (FOL) during a symptomatic attack. Despite this there are no reported VCD FOL assessment scales to facilitate agreement in presentation, disease severity and treatment monitoring. Our VCD tertiary airways clinic receives over 300 referrals a year. We run a weekly diagnostic FOL list and identified the need for a VCD FOL classification for optimal care. Aims To gain consensus for a VCD FOL appearance scale and identify its interrater reliability. Methods An expert consensus group was convened comprising two respiratory consultant physicians and two respiratory speech and language therapists (SLTs). All have significant experience in VCD FOL interpretation. The group met, discussed and agreed on the VCD FOL appearance scale (Table 1). Two assessment teams were identified, each comprising a respiratory physician and a respiratory SLT. Each team rated patients, referred for FOL with a clinical suspicion of VCD, in three consecutive diagnostic FOL lists. All procedures were recorded and then blindly re-rated during playback by the other assessment team. Results Eighteen patients received ratings; the mean (range) age was 51(19–80) and 78% were female. The assessing teams agreed on the rating for seven patients. For nine patients there was disagreement but adjacent classifications. Interrater agreement was performed using a weighted kappa (1 = complete agreement in classification; 0.5 = disagreement but adjacent classifications; 0 = disagreement and non-adjacent classifications). There was moderate agreement between the teams; 0.44 with a 95% confidence interval of 0.18–0.70. There was no bias between the assessment teams, as each had mean ratings for all patients of 2.4. Conclusions The VCD FOL appearance scale is a promising clinical assessment tool for the VCD population. We expected further interrater agreement; interestingly the majority of disagreement would not have changed management as classification still yielded a positive diagnosis. The differential maybe attributed to whether ratings were performed live or in playback, and this should be investigated. With further development, standardisation of application and robust validation it will be a useful assessment to direct appropriate management and facilitate accurate and consistent diagnosis.

Introduction Heliox21 reduces the work of breathing in patients with extra-thoracic airway obstruction, is not curative or intended to replace other treatments. In our specialist service we have significant numbers of patients whom have history of regular hospitalisations, relating to poorly controlled vocal cord dysfunction (VCD). The gold standard for treatment is respiratory speech and language therapy (rSLT). We increasingly value Heliox21 as an early adjunct to rSLT in severe patients who are establishing management strategies. Aims To assess the impact of Heliox21 on patient admission rate and self-reported experience, for patients with severe VCD. Methods We retrospectively reviewed the rSLT caseload from June–December 2014. All patients with endoscopically confirmed VCD, greater than five VCD related hospitalisations prior to the commencement of VCD treatment and who were prescribed Heliox21 for use in the community were included. We requested hospital admission data (from patient’s GP and secondary care physicians) between June 2013–June 2015, and reviewed medical and rSLT notes for demographic information/co-morbidity data/opinions of Heliox21. Results Five patients met the inclusion criteria, three were available for analysis; one male and two female (aged 23,43,57 years). All had treated co-morbidities of asthma (BTS step 5) and reflux. One patient had treated nasal disease. Six-months prior to community Heliox21 administration the mean (range) number of hospital admissions was 11 (8–13); after instigation, during the same follow-up period, this reduced by 81% (2 admissions) and two patients had no hospitalisations. In all patients rSLT occurred simultaneously. Patient opinions included, ‘heliox gives me time to start my therapy and means I don’t ring 999 straight away,’ and, ‘heliox stops me from going to A&E all the time.’ Two patients, who had completed rSLT, had Heliox21 removed as it was no longer needed. Conclusions Heliox21 has a positive impact on reducing VCD hospital admissions and is a low cost short-term solution (£160 set-up, £8.50 month). This retrospective review has limitations; the impact of rSLT alone on admission rates needs to be compared. Further investigation is needed to examine the worth of Heliox21 as an initial adjunct to rSLT, with consideration of how to prevent reliance.

Introduction Our specialist service manages patients with vocal cord dysfunction (VCD), chronic cough (CC) and dysfunctional breathing (DB), and referrals have grown exponentially since we introduced this novel multi-disciplinary (MDT) model in 2006. The team comprises two severe asthma specialist physicians, two respiratory speech and language therapists (rSLT), a severe asthma nurse specialist, respiratory physiotherapist and clinical psychologist. Aims To describe the clinical characteristics of those referred and assess utilisation of the multi-disciplinary structure. Methods Patient demographics and clinical data were retrospectively collated from clinical records of patients referred between January and December 2014. Results The service received 249 referrals. Excluding patients still in treatment or who failed to attend initial assessment, 141 complete data sets were available for analysis: 71% female; mean (range) age 55 (18–79) years. Assessment requests were for VCD (71%), CC (28%) or both (1%) and over half were from NW severe asthma centres or extra-regional specialist centres. The majority of referrals were from hospital consultants (72%), with the remainder from GPs (17%) and AHPs (11%). For VCD there was 73% agreement between the clinical suspicion on referral and nasendoscopic assessment. Approximately half had evidence of co-existent reflux (52%) and a third (29%) had nasal disease. The majority were seen by more than one member of the MDT team; all by a specialist physician and a rSLT, 43% by respiratory physiotherapy, and 7% clinical psychology. In the VCD cohort 64% had a previous asthma diagnosis and this was confirmed in the majority (93%) – 49(82%) were ≥Step 3 on BTS/SIGN guidelines; 43% were additionally referred for DB assessment; 78 flow volume loops were available and 31 (40%) were suggestive of extra thoracic inspiratory airway obstruction. Sixty-seven patients (48%) received rSLT management [median (range) 4(1–8) sessions] with a further 16(11%) scheduled to receive it post medical intervention. Of those who completed treatment, 63% had clinically improved presentation on discharge nasendoscopy. Conclusions A large proportion of patients referred to a specialist service for patients with complex breathlessness require multi-disciplinary intervention. There is a significant incidence of VCD and DB in patients with severe complex asthma. Of those receiving rSLT interventions, outcome was extremely effective at reducing symptoms.

Introduction Pulmonary rehabilitation (PR) programs use multidisciplinary teams to optimise physical and social functioning of patients with chronic respiratory impairment. Such patients demonstrate an increased prevalence of oropharyngeal dysphagia as a consequence of impaired co-ordination between respiration and swallowing function. Often patients will not be aware of the warning signs of dysphagia and unfortunately will not be seen by a speech and language therapist until they are admitted to hospital. We report the outcomes of a pilot scheme whereby such patients underwent education, assessment and treatment for dysphagia as part of their PR programme.. Methods The pilot scheme ran between June 2013 and May 2014. Intervention consisted of: (1) a one hour group education session on the signs, symptoms and risks of dysphagia; (2) screening for oropharyngeal dysphagia; and (3) individual outpatient management in Airways Clinic. The majority of patients attending the education sessions had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD). Results The education programme was delivered to 72 patients, and resulted in a significant improvement in dysphagia knowledge. The average score pre education was 3/11 and post education was 8/11. Fourteen patients (19%) exhibited or reported symptoms of dysphagia. Of these two patients were overtly aspirating and required food/fluid modification and seven patient’s required instrumental assessment in the form of fibre endoscopic evaluation of swallowing (FEES). During FEES, three patients showed penetration of food/ fluids and were at risk of silent aspiration. These patients attended for further SLT where diet/ fluids were modified, posture was assessed and dysphagia therapy was introduced. Conclusions Dysphagia education and management of patients in PR can contribute the early identification, patient awareness and self-management of dysphagia. We have confirmed that undiagnosed but clinically important dysphagia is present in patients undergoing PR. We are investigating whether improved dysphagia knowledge and early identification of dysphagia symptoms leads to reduced exacerbations and improved quality of life.

Background Laryngopharyngeal reflux (LPR) is implicated in inducing laryngeal hyper-responsiveness which is a unifying feature underlying chronic cough and vocal cord dysfunction. A lack of response to standard anti-reflux therapy in patients with LPR may be due to persistence of non-acid-reflux and pepsin causing ongoing laryngeal epithelial inflammation. We investigated: (a) the prevalence of pepsin reflux in respiratory patients requiring nasendoscopy for the investigation of upper airway symptoms; (b) the performance of commonly used clinical LPR-diagnostic tools in predicting the presence of salivary pepsin. Methods Subjects had symptoms and signs of laryngeal inflammation quantified using, the Reflux Symptom Index (RSI) and Reflux Finding Score (RFS). Salivary pepsin was measured with a lateral flow device using monoclonal antibody labelling (Peptest, RDBiomed). Patients with severe signs of laryngeal inflammation were referred for impedance-pH oesophageal studies to assess for objective evidence of reflux. Results Of the 78 subjects recruited, 76% were female, mean age 55 (range 17–82). Ten were undergoing investigation for chronic cough, and 68 for possible vocal cord dysfunction (confirmed in 45). 30 had concomitant asthma, and 42 were prescribed anti-reflux treatment. 87% had a high RSI, and 51% a high RFS. Pepsin was detected in the saliva of 49/78 subjects (63%), and prevalence did not vary significantly between treatment group. There was a weak correlation between the RFS and pepsin concentration (r=0.28, p=0.01) and the positive and negative predictive values for pepsin detection for those with a high RFS were 63% and 69% respectively. To date all 8 patients tested have had significant proximal reflux on impedance study, of which 6 had a positive pepsin assay. Conclusion Salivary pepsin was frequently present in patients with upper airway symptoms, but only weakly related to clinical findings of reflux, suggesting a high prevalence of LPR that is not associated with typical laryngeal findings. The significance of such sub-clinical reflux remains to be seen however the use of pepsin assay in patients with upper airway symptoms may be most valuable in directing diagnosis in milder cases where symptoms and signs lack specificity and the condition may otherwise be missed.

Background Vocal Cord Dysfunction (VCD) is typically reported to affect young females and has been associated with a psychiatric history. We run a multidisciplinary-based service for VCD patients with input from specialist speech and language therapy, physiotherapy and psychology. We investigated the demographics of our patient cohort with VCD, its association with anxiety and depression and whether this affected treatment response. Methods All patients referred for specialist speech and language therapy at the Royal Preston Hospital Airways Clinic between June 2006 and May 2011 with VCD confirmed by endoscopy were included. During routine clinical care data were collected including demographic details and comorbidities. Patients were also asked to complete the Hospital Anxiety and Depression (HAD) questionnaire. Subjective symptomatic improvement was recorded at patient follow-up visits. Results A total of 95 patients were eligible for study inclusion: 73.7% were female with a median age of 53 (17–83) years while men were older at 59 (37–80) years. Medical comorbidities included asthma (56.8%), reflux (47.4%), chronic cough (17.9%), nasal disease (16.8%) and neurological disease (12.6%). A history of confirmed psychiatric disease was noted in 38.9%. In 43 patients who completed HAD scores, moderate or severe anxiety was found in 41.8% and depression in 23.3%. Response to treatment was excellent (67% showing clinical improvement) and this was independent of medical or psychological comorbidity. Conclusions Our data suggest that VCD affects a wide range of patients, in terms of age, gender, comorbidities and HAD scores which do not impact on treatment response, as a result of the multidisciplinary approach and this success is comparable to most asthma therapies when patient compliance and education are accounted for. It challenges many previously held concepts and supports a multidisciplinary approach to treating VCD.