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BackgroundContinuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been used to manage hypoxaemic respiratory failure secondary to coronavirus disease 2019 (COVID-19) pneumonia. Limited data are available for patients treated with noninvasive respiratory support outside of the intensive care setting.MethodsIn this single-centre observational study we observed the characteristics, physiological observations, laboratory tests and outcomes of all consecutive patients with COVID-19 pneumonia between April 2020 and March 2021 treated with noninvasive respiratory support outside of the intensive care setting.ResultsWe report the outcomes of 140 patients (mean±sd age: 71.2±11.1, 65% male (n=91)) treated with CPAP/HFNO outside of the intensive care setting. Overall mortality was 59% and was higher in those deemed unsuitable for mechanical ventilation (72%). The mean age of survivors was significantly lower than those who died (66.1 versus 74.4 years, pversus 4, pConclusionsCPAP and HFNO delivered outside of the intensive care setting are viable treatment options for patients with hypoxaemic respiratory failure secondary to COVID-19 pneumonia, including those considered unsuitable for invasive mechanical ventilation. This provides an opportunity to safeguard intensive care capacity for COVID-19 patients requiring invasive mechanical ventilation.

Coronavirus disease 19 (COVID-19) poses the greatest public health threat in 100 years, with cases rising rapidly in many countries around the world. We report a case of a 78-year-old female who exhibited a biphasic course of COVID-19; showing initial clinical improvement followed by deterioration before making a full recovery. The patient was managed with prolonged continuous positive airway pressure (CPAP) and supportive care. In total, 24 days of treatment with CPAP was administered. We emphasize the role of CPAP in the management of severely hypoxemic patients who are inappropriate for mechanical ventilation and describe the role of adequate nutrition and hydration for such patients.

Cough is an important symptom of asthma. The objective assessment of chronic cough has been enhanced by the development of ambulatory cough monitoring systems. Mepolizumab has been demonstrated to reduce exacerbations in eosinophilic asthmatics long-term. We evaluate the utility of objective cough count as an outcome measure in severe eosinophilic asthma treated with mepolizumab. Consecutive, consenting patients initiated on treatment with mepolizumab had a 24-h cough count recorded at baseline; this was repeated at 1, 3 and 6 months. Asthma control questionnaire (ACQ) scores and exacerbation frequency were also recorded. The mean 24-h cough count in 11 subjects (8 females, mean age 53.6 years) was 172.4 at baseline; at 1, 3 and 6 months following initiation of treatment this decreased to 101.4, 92 and 70.8, respectively (p

P211 Table 1Displaying baseline characteristics, physiological observations, laboratory tests, and outcomes of all patients treated with CPAP and comparing these observations between those treated inside and outside of the ICU All Patients (n=187) ICU (n=90) Non-ICU (n=97) p-value Age - Mean (SD) 66.1 (12.7) 61.2 (13.9) 70.9 (11.8)

There has been a significant reduction in all-cause and exacerbation-related #asthma and #COPD admissions during the #COVID19 pandemic. Patients also report a subjective decline in disease control and describe a negative impact on their mental health. https://bit.ly/2Kv0O0H.

Cystic fibrosis (CF) is a life-limiting autosomal recessive disease caused by dysfunction of the cystic fibrosis transmembrane conductance regulator (CFTR) ion channel. Management of CF has traditionally relied upon managing complications of CFTR protein dysfunction and this has led to a steady improvement in survival of CF patients. However, the landscape of CF care has changed substantially over the last decade with the discovery of CFTR modulators that aim to increase or potentially restore the function of the disease-causing CFTR protein. This narrative review summarizes the development of CFTR therapies so far with emphasis on tezacaftor/ivacaftor combination therapy. We have also summarized the Phase II results of triple combination therapy which promises an effective CFTR modulator therapy for more than 90% of CF patients.

Chronic obstructive pulmonary disease (COPD) often goes unrecognised resulting in people living with the disease without a diagnosis. We investigated the characteristics, symptom burden and flow of participants in a community COPD screening initiative. Screening was undertaken during four events over 2-weeks. Participants completed symptom questionnaires and FEV-1/FEV-6 measurement. Patients with FEV-1

Respiratory viral infections are a significant cause of morbidity in asthma [1]. Patients with severe asthma were assumed to be at greater risk from novel coronavirus-2 (COVID-19) infection. In the global response to the COVID-19 pandemic, multiple countries enacted social containment policies. In the UK a countrywide lockdown occurred in March 2020, with stringent self-isolation (“shielding”) advice for high-risk patients, including people with severe asthma.

Asthma and Chronic Obstructive Pulmonary Disease (COPD) patients are considered at increased risk of dying from COVID-19 and were therefore subject to UK government shielding advice. While this may have protected against respiratory viruses; adverse effects, including reduced physical activity, social isolation, and increasing anxiety have been recognised consequences [3]. Airways disease management is multidisciplinary and there may also be pervasive deleterious effects due to suspension of clinical services including out-patient clinics, smoking cessation support, and pulmonary rehabilitation (PR) [4]. A recent national survey found that up to 23% of patients with lung conditions have experienced worsening symptoms during the pandemic [5].

Introduction Severe asthma patients were assumed to be at greater risk of morbidity from infection with the novel severe acute respiratory syndrome coronavirus (COVID-19), hence, in the UK, were advised to shield. Community data on COVID-19 infection in severe asthmatics is lacking. We assessed the burden of shielding, the impact of COVID-19 and the effect of asthma medication on the UK severe asthma population. Methods Adults previously consented to inclusion in the UK Severe Asthma Registry (UKSAR) across 14 centres were contacted in June 2020 to collect data on potential COVID-19 infection, asthma control and shielding. Electronic records, where available, were reviewed for confirmation. Data was combined with clinical data from the UKSAR. Univariate and multivariate logistic regression analyses were performed to identify risk factors for COVID-19 infection. Results 1365 patients were included. 1268 (93%) were advised to shield, 1131 (89%) patients who received shielding advice followed it. Men (OR 0.4, p=0.045) and those in non-shielding households (OR 0.27, p=0.001) were less likely to follow shielding advice. 544 (47%) of patients advised to shield reported worsening of mental health; females (OR 1.59, p=0.001) and those with history of anxiety or depression (OR 2.12 p=0.001) were at greater risk. 97 (7.1%) patients had suspected/confirmed COVID-19 infection, 19 (1.39%) PCR/serology confirmed infection, 13(0.95%) were hospitalised and 2 patients (0.15%) died (table 1). 918 (67%) were on biologic therapy, 515 (37%) maintenance oral corticosteroid (mOCS). Multivariate analysis showed neither biologic therapy (OR 0.73, p=0.165) nor mOCS (OR 1.18, p=0.427) increased the risk of COVID-19 infection. Patients on biologics were less likely to require an acute course of corticosteroids for asthma symptoms (OR 0.6, p=0.002) while patients on mOCS were more likely (OR 1.96 p≤0.001). Inhaled corticosteroids (ICS) were not associated with COVID-19 infection, including high dose (2000 mcg BDP equivalent) (OR 0.64, p=0.234). Hospitalised patients were on lower median doses of ICS vs non-hospitalised patients (1000 vs 2000 mcg BDP equivalent, p=0.002). Conclusion Hospitalisation and death occurred in small numbers in our severe asthma population. From this observational data, biologic agents for asthma were not associated with increased risk of COVID-19 infection or hospitalisation.

Introduction The National Review of Asthma Deaths England identified inadequate routine asthma care in over two thirds of patients and frequent sort-acting beta agonist (SABA) use was a marker of adverse outcomes. Correct inhaler technique and a personalised asthma action plan have been suggested as positive interventions. Novel biologic therapies are licensed for the management of severe eosinophilic asthma and improve outcomes for patients. We undertook a pilot outreach programme of multidisciplinary specialist asthma clinics in primary care. We present the key findings of this programme. Methods We undertook 7 clinics in 3 general practices between June and October 2019. Patients to be seen in these clinics were identified in primary care; suggested criteria were frequent SABA use (≥6 per year), recurrent courses of prednisolone or poor symptoms control. Each consultation encompassed asthma specialist nurse and consultant review in 3 stages: 1. spirometry, FeNO, symptom and QoL questionnaires, and prior asthma treatment review; 2. respiratory physician review; and 3. action plan and inhaler technique training. A standard dataset was collected, which included documentation of highest eosinophil levels in the preceding 12 months as well as exacerbations requiring prednisolone. Results 52 asthma patients participated in the programme (Table 1). 77% reported having had an asthma review in the past year with 67% reporting having had inhaler technique assessed and 21% having an asthma action plan. 58% had an eosinophil count (eos) recorded within the past year of whom 36% had eos ≥300cells/µL. Those with eos >300 cells/µL had numerically lower lung function and higher SABA and OCS use. 6 (12%) participants met NICE eos and exacerbation requirements for biologic therapy; however, none were on optimal therapy. Conclusion Despite being identified as having poor asthma control, patients may not have had simple interventions such as inhaler technique assessment done and may be unknown to specialist services. A proportion of these patients may be eligible for biologic treatment if they fail to improve on otherwise optimal therapy. A community outreach service may help in the identification and management of severe asthma patients.

Introduction: Despite advances in treatment, people are still dying from asthma. Only one third of patients in the National Review of Asthma Deaths England received adequate routine asthma care. Because frequent SABA use is associated with adverse outcomes including death, we used this to identify participants in a pilot outreach programme of multidisciplinary specialist asthma clinics in primary care. Here we present the key findings of this programme. Methods: We undertook 7 clinics in 3 general practices between June and October 2019. Each consultation comprised asthma nurse and consultant review in 3 stages: 1. spirometry, FeNO, symptom and QoL questionnaires, and prior asthma treatment review; 2. respiratory physician review; and 3. action plan and inhaler technique training. A standard dataset was collected. Results: Baseline characteristics for the 52 participants are presented in table 1. 4 (8%) were known to specialist asthma services and 21% of participants reported already having an asthma action plan. 58% had an eosinophil count (eos) recorded within the past year of whom 36% had eos ≥300cells/µL. 6 (12%) participants met NICE eos and exacerbation requirements for biologic therapy but none were on optimal therapy. Conclusion: Our experience suggests that there are many asthma patients in primary care that have suboptimal control, are unknown to specialist services, and may be eligible for biologic treatment if they fail to improve on otherwise optimal therapy.

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.

FENO suppression testing is practical and feasible during assessment for biologics in severe asthma. Patients with significant FENO suppression were less likely to be recommended biologics but saw similar reductions in exacerbation frequency.http://bit.ly/35oSoxP

Background and Objectives: Cough is a major symptom in cystic fibrosis. Ivacaftor is a novel drug which targets the G551D mutation and has been demonstrated to improve lung function and weight in the long term. It also improves symptoms of extra-oesophageal reflux. We wanted to evaluate the effect of ivacaftor on cough in cystic fibrosis. Methods: In two patients with cystic fibrosis the Hull Airway Reflux Questionnaire (HARQ) was completed and objective cough counts were measured prior to and within 4 weeks after initiation of treatment with ivacaftor. Spirometry was also undertaken and weight checked at these time frames. Results: In the first patient the HARQ score decreased from 29 to 11 and objective cough counts from 29 to 9 cough events per hour. Similarly in the second patient the HARQ score decreased from 13 to 9 and objective cough count from 76 to 5 cough events per hour. There was no significant change in spirometric parameters or weight. Conclusion: We have observed early subjective and objective improvement in cough measures on treatment with ivacaftor. We suggest that this improvement could be attributed to improvement of gastro-intestinal function and that cough metrics could be used as early and accurate end points of drug efficacy.

Aims: In this retrospective study we assess the diagnostic yield of computed tomography pulmonary angiogram (CTPA) and the incidence of alterative and incidental diagnoses. Methods: The results of all CTPA scans performed in our trust over a period of 18 months were reviewed and all diagnoses noted. Data collected was descriptively analysed. Results: A total of 1138 scans were performed (56.5% men, mean age 59 years). A diagnosis of pulmonary embolism (PE) was made in 20.2%, an alternative aetiology for presenting symptoms in 26.4% and incidental findings in 19.5%. The commonest alternative diagnosis was pneumonia (9.5%). Conclusions: Significant numbers of CTPA yield unexpected findings, which may provide an explanation for the clinical presentation. Furthermore substantial numbers of incidental pathologies are also diagnosed which may lead to inappropriate resource utilization and increased patient anxiety.

Aims Cough is an important symptom in asthma. The objective assessment of chronic cough has been enhanced by the development of validated ambulatory cough monitoring systems and this form of assessment may represent the best global objective synthesis, compared to other forms of objective and subjective assessment of cough. Mepolizumab is a novel drug which binds to and inactivates interleukin-5 and has been demonstrated to reduce exacerbations in eosinophilic asthmatics in the long term. We postulated that objective measurement of cough could potentially act as a rapidly responsive, objective and clinically relevant endpoint for establishing the effectiveness of this class of drugs. Methods Consecutive consenting patients being initiated on treatment with mepolizumab had a 24 hour cough count recorded at baseline, a day prior to initiation of therapy. This was repeated 1, 3 and 6 months later. Cough recording was done using the validated Hull Automated Cough Counter. Asthma control was assessed via the asthma control questionnaire (ACQ). Demographic data is presented descriptively. Paired t-test was used to look for analysis and missing values were imputed from preceding data. Results Eleven subjects (8 females) with a mean age of 53.6 years had a baseline cough count recorded. Mean 24 hour cough count was 172.4 at baseline. At 1, 3 and 6 months following initiation of treatment the 24 hour cough count fell to a mean of 101.4, 92 and 70.8 respectively (figure 1). Area under the curve of cough counts on treatment was significantly improved over baseline (p Conclusion We demonstrate clear improvement in objective cough count at one month following initiation of treatment with mepolizumab, which is sustained over 6 months, in patients with uncontrolled eosinophilic asthma. Objective cough measurement could be used as an early, precise and clinically relevant endpoint in both the assessment of response to therapy as well as future drugs development.

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: Suppression of FeNO following a week of directly observed inhaled corticosteroid (ICS) therapy can provide objective evidence of non-adherence. We report the effect of demonstrating this on long-term clinical outcomes. Methods: Consecutive patients adherent to prescribed therapy based on clinical assessment, with FeNO levels greater than 45 ppb on two occasions and meeting criteria for biological therapy trials, underwent supervised directly observed ICS therapy over 8 days. In this, patients existing ICS/LABA inhalers were changed to once daily fluticasone / vilanterol (Relvar 184/22). Inhaled therapy technique was taught by and taken under direct supervision of a specialist nurse; in person or remotely via Skype. FeNO, spirometry and the Asthma Control Questionnaire -7 (ACQ-7) were recorded on the first and last days. Those identified as non-adherent (≥42% FeNO suppression at day-8) were appropriately educated. Initiation of biological therapy at 6 months or more of follow up is presented. Results: Of 46 (males 23, mean age 49) subjects 19 (males 7, mean age 41) were identified as non-adherent. Of these 19 subjects, 14 did not need to progress to biological therapies. FeNO levels significantly decreased from baseline to day 8 (p Conclusion: Combining once-daily ICS with remote access technology, FeNO suppression is a feasible objective test in routine clinical practice and demonstrating non-adherence may lead to sustained improvement in asthma control.

Gastro-oesophageal reflux disease may present with extra-oesophageal symptoms. A wide assortment of questionnaires is available to use for the evaluation of different dimensions of the classical symptoms of gastro-oesophageal reflux disease. In contrast, there are very few validated questionnaires available which evaluate extra-oesophageal symptoms. In this review specific questionnaires which evaluate variously termed laryngopharyngeal, supra-oesophageal or airway reflux are described and discussed.

Asia is one of the most diverse and dynamic continents. Due to recent rapid industrialisation and urbanisation, morbidity patterns are likely to be diverse in Asian populations. Chronic cough is a disease condition resulting from host-environmental interactions, and is associated with a high global epidemiological burden. However, the underlying epidemiology remains unclear, particularly in Asia. We performed a literature search to identify peer-reviewed articles on chronic cough in community-based adult Asian populations that have been published between January 2000 and June 2015. In this review, we aim to examine the epidemiological characteristics and determinants of chronic cough in several geographical areas of Asia.

Background Obstructive sleep apnoea syndrome is a common condition for which continuous positive airways pressure (CPAP) is the standard treatment. The condition affects a population of which a substantial proportion will be travelling. Methods We use a questionnaire survey of CPAP users to gain understanding regarding the behaviours, attitudes and problems surrounding travel with CPAP machines during travel and while abroad. All CPAP patients on our database at a UK district general hospital reviewed over a period of 4 years were sent a postal questionnaire. Results A response rate of 53% was achieved giving data on 588 trips. In the last 2 years, 63.7% of respondents had travelled; reasons for not travelling were CPAP related in only five cases. Travellers took their CPAP machines on 81% of trips. A similar proportion of patients took their CPAP machines regardless of the mode of travel, destination or length of holiday. Problems with checking in the CPAP machine were encountered in 4% of trips, all as part of air travel. Just over a third of patients faced problems either with the power cord, adapter or transport of the CPAP machine. Of those taking overnight flights, half did not sleep and none used their CPAP machines in flight. CPAP usage while away did not differ to usage at home. Conclusions This is the first report to describe in some detail CPAP machine use and associated problems in travel and while away. The data may aid the targeting of brief interventions in CPAP clinics as well as helping to standardize the process of check-in in order to help travellers with CPAP machines.

Introduction Measurement of fractional exhaled nitric oxide (FeNO) is an easy to perform non-invasive test and surrogate marker of eosinophilic airway inflammation. It has been suggested that suppression of FeNO following a week of directly observed inhaled corticosteroid (ICS) therapy provides objective evidence of non-adherence. Though guidelines for the prescription of novel steroid sparing agents recommend this strategy as part of evaluation, it has not been rigorously evaluated in routine clinical practice. We report the outcomes of using this strategy as part of standard clinical care in our centre. Methods Consecutive consenting patients with FeNO levels greater than 45 ppb on two occasions who were adherent to prescribed therapy on the basis of clinical history, and meeting criteria for initiation of biological therapy undertook directly observed ICS therapy – supervised (DOTS) over 8 days. In this, patients existing ICS/LABA combination inhalers were changed to once daily fluticasone/vilanterol (Relvar 184/22). Inhaler technique was taught by a specialist nurse and inhaled therapy taken under direct supervision (in person or remotely via Skype). FeNO, spirometry, eosinophil count and the Asthma Control Questionnaire −7 (ACQ-7) were recorded on the first and last days. FeNO was also recorded on day 4. Data are presented as mean ±SD. Results Sixteen subjects (7 males, age 43±18 years) completed assessments (1 did not have day 4 FeNO value). All but one had ≥80% prescription pick-up rates checked with GP records. FeNO levels decreased from 121±63 ppb to 71±36 ppb at day 4 and 66±43 ppb at day 8 (p Conclusion Combining the use of once a day therapy with remote assessment using appropriate technology, FeNO suppression is a feasible objective test of adherence in the routine clinical setting. Despite appropriate refill collection rates over half of subjects were identified as non-adherent to inhaled therapy. Although these individuals did not commence biological therapy, improvements have been sustained. We recommend routine use of this assessment in severe asthma services.

Background Chronic Obstructive Pulmonary Disease (COPD) is a smoking related lung disease characterised by airflow obstruction on spirometry. COPD patients are prone to acute exacerbations, frequently leading to health care utilisation. There are over 7500 people in Hull with COPD and it is estimated over 6000 patients are living with the condition without a diagnosis. Early identification of COPD with targeted smoking cessation and early initiation of treatment has potential to improve outcomes. We describe the early Results of a COPD screening initiative in Hull. Methods A collaborative screening program was developed involving the acute hospital trust, community services, clinical commissioning group and city council. The initiative was supported by British Lung Foundation, branded under their ‘Love Your Lungs’ campaign. Screening was undertaken over 4 days in public venues in areas with high smoking prevalence. Individuals completed symptom and lifestyle questionnaires and FEV-1/FEV-6 assessment. Symptomatic individuals with FEV-1 ≤80% predicted and/or FEV-1/FEV-6 ratio Results 253 individuals were screened (41% male, 25% current smokers). 67/253 screened positive and 60 were given a one-stop clinic appointment. Individuals not offered appointments either declined or lived outside the area. 31/60 individuals attended their appointment, 6/60 are awaiting review and 23/60 either cancelled or did not attend (DNA). 17/31 clinic attenders were diagnosed with COPD and 13/31 received an alternative diagnosis in addition to or instead of COPD. 57/60 were discharged for on-going care under their GP and 3/60 remain under specialist follow-up. The characteristics of screen positive individuals are presented in Table 1. Conclusions In this unselected screening program, the COPD diagnosis rate was 7% and would likely have been higher if all screen positive individuals had attended a one-stop clinic. This compares favourably with diagnosis rates in targeted COPD case finding trials reported previously. Engaging current smokers proved challenging with high DNA rates in this group. Further research is required to assess whether early COPD diagnosis through screening alters smoking behaviour or disease outcomes.

Aims The examination of cough reflex sensitivity through inhalational challenge can be utilized to demonstrate pharmacological end points. Here we compare the effect of butamirate, dextromethorphan and placebo on capsaicin-induced cough in healthy volunteers.

Detection of salivary pepsin (Peptest) may be a useful adjunct in the diagnosis of airway refluxhttp://ow.ly/T7B0l

Giant bullous emphysema is an uncommon condition characterised by large asymmetric bullae with upper lobe predominance. This condition is most frequent in young male smokers. Patients usually present with progressive breathlessness which is secondary to enlargement of the bullae leading to compression of the lung parenchyma. Large asymmetrical bullae may appear as a unilateral hyperlucency on a plain chest radiograph, and may mimic the appearances of pneumothorax. A computed tomography scan is needed to delineate the lung pathology. We describe two cases with this condition that presented acutely and discuss the management of bullous emphysema.

Investigations completed in a 77-year-old ex-smoker presenting with weight loss showed raised CA 19-9 levels. The findings of chest radiograph, abdominal computed tomography (CT) and gastrointestinal endoscopic examinations were all normal. On follow-up, the patient developed left upper lobe collapse on chest radiograph with increasing CA 19-9 levels. Chest CT findings suggested the presence of a left upper lobe tumour. The results of a biopsy of the left upper lobe nodule seen on bronchoscopy suggested a diagnosis of amyloidosis; however, this was not the only diagnosis. The left upper lobe mass comprised a neuroendocrine tumour with amyloid deposition just beneath the bronchial epithelium and focally between the nests of the tumour cells. We report and discuss this uncommon association and presentation.

Reports from individual centres suggest a preponderance of females with chronic cough. Females also have heightened cough reflex sensitivity. Here we have reviewed the age and sex of unselected referrals to 11 cough clinics. To investigate the cause of any observed sex dimorphism, functional magnetic resonance imaging of putative cough centres was analysed in normal volunteers.The demographic profile of consecutive patients presenting with chronic cough was evaluated. Cough challenge with capsaicin was undertaken in normal volunteers to construct a concentration-response curve. Subsequent functional magnetic resonance imaging during repeated inhalation of sub-tussive concentrations of capsaicin observed areas of activation within the brain and differences in the sexes identified.Of the 10 032 patients presenting with chronic cough, two-thirds (6591) were female (mean age 55 years). The patient profile was largely uniform across centres. The most common age for presentation was 60–69 years. The maximum tolerable dose of inhaled capsaicin was lower in females; however, a significantly greater activation of the somatosensory cortex was observed.Patients presenting with chronic cough from diverse racial and geographic backgrounds have a strikingly homogeneous demographic profile, suggesting a distinct clinical entity. The preponderance of females may be explained by sex-related differences in the central processing of cough sensation.

Background and objective: Gastro-oesophageal reflux has been implicated in the pathogenesis of chronic cough. Guidelines on management suggest a therapeutic trial of anti-reflux medication. Esomeprazole is a proton pump inhibitor licensed for the long-term treatment of acid reflux in adults and we compared the effects of esomeprazole and placebo on patients with chronic cough. Methods: This was a prospective, single-centre, randomized, double-blind, placebo-controlled, parallel group study conducted over 8 weeks. Fifty adult non-smokers with chronic cough and normal spirometry were randomized. Patients completed cough-related quality-of-life and symptom questionnaires and subjective scores of cough frequency and severity at the beginning and end of the study. They also kept a daily diary of symptom scores. Citric acid cough challenge and laryngoscopic examination were performed at baseline and the end of the study. The primary outcome was improvement in cough score. Results: There were no differences in cough scores in the placebo and treatment arms of the study although some significant improvements were noted when compared to baseline. In the cough diary scores there was a trend towards greater improvement in the treatment arm in patients with dyspepsia. Conclusions: Esomeprazole did not have a clinically important effect greater than placebo in patients with cough. It suggests a marked placebo effect in the treatment of cough.

Introduction and Objectives: Lactate dehydrogenase (LDH) is found in almost all tissues of the body and five different isoenzymes are known (LDH-1 to LDH-5). LDH can be elevated in many pathological conditions. We have observed serum LDH to be increased in patients with chronic cough. We wanted to confirm this finding, study the reproducibility and determine the origin of the LDH. Methods: Patients prospectively seen at the Hull Cough Clinic had total and specific LDH isoenzyme levels in serum determined. A subgroup of patients also had a serum creatine phosphokinase (CK) measured. Patients completed cough symptom scores and the Hull Airway Reflux Questionnaire (HARQ). Spirometry was performed. Results: Eighty-three patients were included. Forty-two percent had LDH values above the reference range and 78% had LDH values in the fourth quartile of the reference range or above. This increase in LDH was predominantly because of a rise in isoenzymes 4 and 5. The increase in LDH was found to be reproducible at 8 weeks. Ten percent had CK values above the normal range. There was no correlation observed between LDH values and the cough scores, HARQ scores or lung function. Conclusion: Serum LDH levels are elevated in a substantial proportion of patients with chronic cough. This rise is likely to be due to airway inflammation known to be associated with chronic cough. Please cite this paper as: Faruqi S, Wilmot R, Wright C and Morice AH. Serum LDH in chronic cough: a potential marker of airway inflammation. Clin Respir J 2012; 6: 81–87.

Background and objective: The assessment of chronic cough has been improved by the development of objective ambulatory cough monitoring systems and subjective quality of life questionnaires. Experimental induction of cough is a useful tool in the assessment of the cough reflex. We wanted to assess the reproducibility of and association between these measurements. Methods: This was a prospective observational study in patients with chronic cough of greater than 6 months' duration. All patients had an initial 24-h cough recording. They also completed a Leicester Cough Questionnaire, a Symptom Assessment Score, a Visual Analogue Score for cough and had a capsaicin cough challenge performed. They were reviewed at 8 weeks when all assessments were repeated. Results: Twenty-five patients (15 women) with a mean age of 54 years were included in the study. The median cough count at the second visit (302) was significantly lower compared to the first visit (381, P

We have previously suggested that oesophageal dysfunction may underlie a number of otherwise unexplained respiratory symptoms particularly chronic cough. However on conventional testing of oesophageal function using pH and impedance techniques few patients are abnormal. We have compared patients with unexplained respiratory symptoms with a control group with dyspepsia and heartburn using High Resolution Oesophageal Manometry. 121 patients were studied, 61 with respiratory complaints and 60 with primarily gastrointestinal symptoms. Respiratory patients consisted of 38 females, combined mean age of 56, range (18 – 81) and a matched group of GI patients, 39 female, mean age 57, range (19 – 81). The majority of the respiratory patients had chronic cough, 11 primarily breathlessness.11 had asthma and in two patients CT demonstrated bronchiectasis. HROM revealed a significantly greater degree of peristaltic dysfunction in the respiratory group with over half (57%) demonstrating either failed or weak contraction (GORD 42%). Acid reflux was more common in GORD (44%) versus respiratory (39%). Mean DeMeester score was 22.6 versus 16.1, time below pH 4 8.5% versus 4.5%) p = 0.05. Whilst resting lower oesophageal sphincter pressure was similar but there was a significant difference between groups in the LOS contraction on inspiration. The respiratory patients increased LOS pressure to 46 mmHg versus 33 in the GORD group. Thus respiratory patients with unexplained symptoms have greater propensity for oesophageal dysfunction than a group thought to have overt oesophageal disease. This does not seem to be related to excessive acid exposure. The increase in the compensatory LOS contraction remains to be explained.

Snakebite is an important medical emergency. Anti-snake venom along with supportive care is the only specific treatment. However, many people put their faith in non-registered medical practitioners. Where medical aid is available, lack of trained health personnel jeopardizes the situation. This retrospective study, the first of its kind, was aimed at studying the pre-hospital treatment as well as the behavior of patients bitten by snakes and referred to the Postgraduate Institute of Medical Education and Research, Chandigarh, India. A total of 88 cases that occurred between January 1997 and December 2001 were studied. Seventy patients received treatment prior to admission (the majority was treated by non-registered medical practitioners, registered medical practitioners, and MBBS doctors). The various treatment modalities used were: anti-snake venom (ASV), tourniquet, incision and drainage (I&D), tetanus toxoid, injections, and tablets. Non-registered medical practitioners still preferred tourniquet and I&D. The patients who were referred within 24 hours stayed less time in the hospital and spent less money on the treatment compared to those who were referred after 24 hours. Non-registered medical practitioners and inadequately trained health staff are often the first contact of snakebite victims. Their traditional and unscientific methods of treatment lead to unnecessary morbidity and increased treatment cost. It is therefore necessary to train these people adequately so that proper treatment can be instituted at the earliest.

Sitaxentan, a highly-selective endothelin receptor antagonist (ETRA) and bosentan a non-selective ETRA are both approved for the treatment of idiopathic pulmonary arterial hypertension (iPAH). Sildenafil is a phosphodiesterase-5 (PDE-5) inhibitor used in the treatment of iPAH. Tadalafil is a long acting PDE-5 inhibitor largely unexplored for the treatment of iPAH. Following failure of monotherapy combination therapy with an ETRA and a PDE-5 inhibitor is often used, a frequently used combination being bosentan with sildenafil. We report our clinical experience in three patients with iPAH treated with a combination of sitaxentan and tadalafil, who previously discontinued bosentan. There was sustained symptomatic and haemodynamic improvement in all three patients treated with the combination. No adverse effect related to the combination treatment was noted. Sitaxentan and tadalafil, both being once a day treatments, can also possibly increase compliance.

Pneumomediastinum is a rare complication of an acute exacerbation of asthma. We describe a 28-year-old female who was admitted to hospital with acute severe exacerbation of asthma and developed a spontaneous pneumomediastinum (SPM) with associated subcutaneous emphysema. She was successfully managed conservatively. On follow up there was resolution of the subcutaneous emphysema and the pneumomediastinum, clinically and radiologically. SPM although usually a self-limiting condition, can occasionally be life threatening. Therefore, it is important to raise the awareness of this potential complication of asthma.

We report the case of a 58-year-old female who presented with productive cough, weight loss, pulmonary nodular infiltrates and cavitations. She had a positive anti-neutrophil cytoplasmic antibodies (ANCA) test. A diagnosis of vasculitis was considered and a video-assisted thoracoscopic biopsy of the lung nodules was organised. However, prior to the biopsy, the sputum results revealed the presence of acid-fast bacilli, which were identified as Mycobacterium avium complex. A repeat ANCA assay was positive for atypical ANCA with negative proteinase-3 and myeloperoxidase titres. The patient was treated with rifampicin, ethambutol and clarithromycin with clinical and radiological improvement. The objective of this report is to highlight a rare association between positive ANCA titres and a non-tuberculous mycobacterial infection as a misdiagnosis and treatment of this patient with immunosuppressive therapy might have led to serious consequences.

Background The pathogenesis of chronic cough is not well understood and treatment options are limited. In this study we sought to explore the current understanding and management of chronic cough across an international group of specialists. Methods This was an international study of cross sectional qualitative design. In depth interviews were carried out with “Respiratory Specialists” experienced in treating treating Chronic Obstructive Pulmonary Disease (COPD), idiopathic pulmonary fibrosis (IPF), idiopathic chronic cough (ICC) and/or lung cancer patients and with “Disease Experts” in the field of Chronic Cough. Participants in the study were recruited from the USA, UK, Germany, Ireland, Australia and Japan. Interviews with specialists were held at research facilities and with DEs over the telephone. These were preceded by the specialists completing case records of patients recently seen. All interviews were conducted by native speaking trained moderators using a semi-structured interview guide script. This was designed to elicit the definition of chronic cough, explore the unmet needs for each disease state, define therapy goals, identify patient phenotypes and give an overview of the treatment pathway. Results 76 specialists and 10 experts took part in the study. Over two thirds (70%) of respondents defined chronic cough as “cough lasting more than 8/12 weeks” (range 2 weeks to 2 years). Physicians emphasised three interdependent aspects of clinical assessment: impact on quality of life, type of cough (productive versus non-productive) and the underlying pathology. Specialists emphasised treating the underlying cause rather than the cough, this being most prominent in Japan. Experts as a group focussed on chronic cough independently. Evaluation of the respiratory system, GI tract and upper airway (ENT) for establishing an underlying cause was recommended. Type of cough (productive vs non-productive) and impact on quality of life influenced treatment initiation. 33% of patients with ICC were prescribed anti-tussives. With associated diagnoses of COPD, IPF or lung cancer the emphasis was on treating the underlying condition. Alternatives to pharmacological treatments were frequently considered. Conclusion There is significant international variation in our understanding and management of chronic cough. Further work is required to bring forth clear guidance and effective medicines for these patients.

Background and aims Chronic cough is a common symptom the aetiology of which can be challenging to diagnose. Diagnostic protocols for chronic cough have required the use of specialist investigations which are not always easily available. We wanted to determine whether patients with chronic cough can be successfully managed using a clinical algorithm. Methods 112 consecutive patients with chronic cough were prospectively recruited into this study. They were assessed by history, physical examination, chest radiograph, spirometry and reversibility to nebulised salbutamol. A clinical diagnosis was made and the patient had an 8-week trial of appropriate therapy. Further therapeutic trials were carried out depending on response to treatment and the possible differential diagnoses. Investigations were carried out in cases of failed clinical trials and to exclude specific pathology. The “clinical arm” comprised patients managed on the basis of clinical assessment and without any investigations. The “investigative arm” comprised those who needed further investigations. Results 81 (72%) were managed in the clinical arm. Of these 74 (66%) were discharged following response to therapy. 31 (28%) patients were converted to the investigative arm after failure of diagnosis in the clinical protocol. The commonest causes of cough were gastroesophageal reflux, asthma and chronic rhinitis. 51 (45.5%) patients responded to therapy based on diagnosis at initial assessment while a further 23 (20.5%) patients responded to sequential clinical trials for the commonest causes of cough. Cough severity score improved by a mean of 3.6 points on a numeric response score (from 0–10, p Conclusion It is possible to manage a majority of chronic cough patients successfully using a protocol based on presenting symptoms and therapeutic trials for the common causes of cough.

Purpose Recent evidence suggests a global burden of chronic cough in general populations. However, the definitions vary greatly among epidemiological studies, and none have been validated for clinical relevance. We aimed to examine previous epidemiological definitions in detail and explore the operational characteristics. Methods A systematic review was conducted for epidemiological surveys that reported the prevalence of chronic cough in general adult populations during the years 1980 to 2013. A literature search was performed on Pubmed and Embase without language restriction. Epidemiological definitions for chronic cough were classified according to their components, such as cutoff duration. Meta-analyses were performed for the male-to-female ratio of chronic cough prevalence to explore operational characteristics of epidemiological definitions. Results A total of 70 studies were included in the systematic review. The most common epidemiological definition was identified as 'cough ≥3 months' duration without specification of phlegm (n=50); however, it conflicted with the cutoff duration in current clinical guidelines (cough ≥8 weeks). Meta-analyses were performed for the male-to-female ratio of chronic cough among 28 studies that reported sex-specific prevalence using the most common definition. The pooled male-to-female odds ratio was 1.26 (95% confidence interval 0.92-1.73) with significant heterogeneity (I2=96%, P

A 58 year old man was brought to the emergency department with acute confusion after being found unconscious on his floor at home. He had a background of alcohol misuse with alcoholic liver disease. He was not taking any regular medications. On examination he smelt of alcohol and was tachycardic at 96 bpm with BP 110/70. The patient’s Glasgow Coma Score was 14, being drowsy but responsive with bilateral lower zone crepitations on auscultation of the chest. Neurological examination revealed generalized reduced muscle bulk but no focal deficits.