key: cord-0007036-yb1645b3
authors: nan
title: Irish Thoracic Society Annual Scientific Meeting: 21(st), 22(nd)and 23(rd)November 2019 – The Galmont Hotel, Galway
date: 2019-11-22
journal: Ir J Med Sci
DOI: 10.1007/s11845-019-02123-3
sha: 1a250fd1f5a21abf6ac7fac25d87e7fa9c3791c9
doc_id: 7036
cord_uid: yb1645b3

nan

Severe Asthma is a subset of difficult-to-treat asthma. Difficult-to-treat asthma is defined as asthma that is uncontrolled despite GINA Step 4 or 5 treatment, or that requires such treatment to maintain good symptom control and reduce the risk of exacerbations 1 . According to the most recent GINA Guidelines (2019) 3.7% of patients with asthma have severe asthma. Despite the rather small percentage of patients with severe asthma, they disproportionally incur 40-50% of all asthma related costs 2 . Anti IL5 therapy is now an established therapy for the treatment of uncontrolled severe asthma. Currently 8 patients are receiving Mepolizumab therapy in Connolly Hospital, Blanchardstown. The aim of the study was to look at the real-life outcomes from Mepolizumab in our patient population. Before commencing anti IL5 therapy 90% of the patients were on long term oral corticosteroids (OCS). Response to therapy was evaluated using the Asthma Control Questionnaire 7 (ACQ7), Asthma Control Test (ACT), St. Georges Respiratory Questionnaire (SGRQ), Hospital and Anxiety Depression Scale (HADS), steroid reduction and exacerbation rates. To date, 50 % of patients have had a minimal clinical important difference (MCID) improvement in ACQ7 scores. 50% of our study population have discontinued OCS and 50% have had a reduction in their steroid dose. SGRQ has shown MCID improvements in 63% of patients. There has been a 75% reduction in exacerbation rates. Measurement of fractional nitric oxide concentration in exhaled breath (FENO) is a method of measuring airway inflammation and assessing airways disease. In recent years, the Global Initiative Guide for Asthma (GINA) recommends the use of FENO as a tool for asthma management, combined with symptom assessment questionnaires and spirometry. We preformed a retrospective study aiming to explore the utilisation and utility of FENO in our clinic. Many of the patients had multiple measurements of FENO, we selected patients attending our clinic between January 2018 and May 2019, who had at least 4 FENO measurements. We analysed changes in FENO and FEV1 over time in 83patients (1 st , between 1-12months and last FENO measurements). This showed the Introduction Assessing responsiveness to inhaled corticosteroid (ICS) therapy is complicated by poor adherence rates, making it difficult to distinguish refractory patients from those who are non-adherent. As a result there is a significant risk of inappropriate prescription of high-dose ICS, with an associated increase in side-effects. Personalised dosing of ICS therapy is required to achieve the optimal trade-off between asthma control and side effects. Methods Using electronic monitoring of inhaler adherence and PEFR, we developed a statistical method to quantify responsiveness to treatment and determine the optimal dose for an individual asthma patient. Results We estimated personal threshold dosages for a cohort of 200 severe asthma patients. We quantify the personal level of treatment received using the time-above-threshold metric (Greene et al. 2018), and find that it is highly predictive of asthma control and exacerbations. The distribution of personalised dosages ( Fig.  1) shows that the majority of patients in our cohort are over-prescribed ICS. However many remained uncontrolled due to poor adherence. In addition a significant minority of patients (approx 15%) are truly refractory to ICS treatment. Patients who experienced frequent exacerbations had significantly higher threshold doses than those who did not exacerbate (p<0.001), suggesting that exacerbations were associated with steroid-resistance.

1. Greene, Garrett, et al. "A novel statistical method for assessing effective adherence to medication and calculating optimal drug dosages." PloS one 13.4 (2018): e0195663. This work was funded by the Health Research Board. The authors declare no conflict of interest. Uncontrolled asthma is characterized by poor symptom control and exacerbations requiring oral corticosteroids. Patients are deemed refractory to treatment if they remain uncontrolled despite; adherence to guideline directed therapy and treatment of contributing factors 1 . We hypothesize that using INCA™ technology we can distinguish between patients who are truly refractory to treatment and require type 2 targeted biologic treatments versus those who are not. We report the outcome of two patients with uncontrolled asthma who were both candidates for step-up therapy. They were recruited into a multicentre, prospective, randomized controlled study of uncontrolled asthma (INCASUN). They were both randomized; one received INCA™ directed inhaler education and medication adjustment according to objective adherence. The second was blinded to what the INCA™ technology was recording, received standard care and medication adjustment as per the GINA guidelines. On completion of the study both patients remained uncontrolled despite optimizing treatment, resulting in both being referred for step-up therapy. The INCA™ data was unblinded for the standard care patient and revealed suboptimal adherence negating the need for step-up therapy. Without an objective measure of adherence it is difficult to determine patients who are truly refractory to treatment. INCA™ technology assists clinicians in identifying patients who require stepup therapy while also preventing inappropriate prescribing where adherence is the real issue. 1 The Department of Respiratory Medicine, Cork University Hospital, Wilton, Cork. 2 The HRB funded CRF, University College Cork, Cork.

Eosinophils are associated with higher exacerbation frequency and increased asthma severity. In clinical trials, targeting Interleukin-5 is a useful therapeutic strategy for patients with severe eosinophilic asthma 1,2 . 26 patients have been commenced on Reslizumab in our institution since early 2017. Safety and clinical efficacy parameters were recorded at regular intervals. Mean ACQ-6 score at the start of treatment was 3.5. The average number of exacerbations in the year preceding treatment was 8.3 per person. 30% of patients had been admitted to hospital at least once over the 12 months preceding therapy. 54% of our patients were on long term oral steroid. Our data showed sustained improvement of Asthma control (Mean improvement in ACQ-6 was 1.7 at 1 year, and 2.0 at 2 years, P =0.0001). Of the patients on long term systemic steroids, 34% discontinued steroids completely, with a mean reduction of prednisolone dose of 5.2 mg at 1 year. There was a 79% reduction in the annual exacerbation frequency at 1 year, and 88% at 2 years (P = < 0.0001). Our real-world data show that initial improvements observed with Reslizumab are maintained at 2 years. References:

1. Corren, J., Weinstein, S., Janka, L., Zangrilli, J., & Garin, M. NSAID-exacerbated respiratory disease (N-ERD) is a clinical syndrome comprised of hypersensitivity to non-steroidal anti-inflammatories (NSAIDs), nasal polyposis and Asthma. [1] One day protocol for aspirin desensitisation using 90 minute aspirin administration intervals has been shown to be a safe and effective treatment. [2] Our aim was to develop & trial a protocol that both diagnoses and treats patients with suspected N-ERD by performing an aspirin challenge and subsequent desensitisation on the same day using 45 minute intervals. Desensitization was defined as tolerating a repeated administration of at least the provocative aspirin dose and at least 1 subsequent dose, bringing the final aspirin dose ingested during the in-clinic desensitization to 300mg. We recruited six patients from respiratory outpatients who met clinical criteria for N-ERD. Patients were challenged and desensitised on a single day. They were then discharged on aspirin 300mg and followed up at one week. Symptoms were assessed and quantified using a N-ERD scoring tool. Of the six patients, five had a positive challenge. Three of these patients had a clear improvement in symptoms while the other two had no improvement. There were no major adverse events. In summary, one day protocol for aspirin challenge and desensitisation for patients with suspected N-ERD using 45 minute intervals is safe and effective. References:

Severe eosinophilic asthma is characterized by persistent symptoms, decreased lung function and increased risk of asthma exacerbations. Anti-IL5 therapies have recently provided a new mechanism to manage such patients. We performed a retrospective study to assess the efficacy of anti-IL5 treatment in a severe asthma clinic. Cases of eosinophilic asthma treated with anti-IL5 therapy from December 2018 -July 2019 in the Mercy University Hospital, Cork were assessed. Eight patients commenced anti-IL5 treatment (1 male and 7 females) with ages ranging from 25 to 78 years.

In the 3 months prior to commencing treatment, the mean number of asthma exacerbations was 1.63 compared to 0.25 three months after commencement of anti-IL5 treatment (p=0.008). Prior to treatment, the mean dose of maintenance oral steroids was 8.75 mg compared to 1.88 mg three months after commencement of anti-IL5 therapy. The level of peripheral blood eosinophils pretreatment was 0.788 x 10 9 /L compared to 0.121 x 10 9 /L three months post treatment (p=0.001). Consistent with internationally published data, anti-IL5 therapy was highly effective in reducing exacerbations and oral steroid maintenance therapy in our patients with severe eosinophilic asthma. Asthma is a heterogeneous group of conditions that results in recurrent episodes of reversible airway obstruction. It presents with varying clinical severity from mild, occasional symptoms to frequent severe exacerbations which can be fatal. Ireland has the fourth highest prevalence of the disease worldwide. In a small percentage of patients eosinophils play a significant role in the pathogenesis and severity of asthma. Mepolizumab (Nucala®) targets IL-5, the main cytokine responsible for the growth, differentiation, recruitment, activation, and survival of eosinophils. Inhibition of IL-5 signaling reduces the production and survival of eosinophils which in turn reduces the severity of asthma symptoms and the number of exacerbations in patients with severe refractory eosinophilic asthma which remains uncontrolled despite maximum therapy. November 2018 saw the first patients commence Mepolizumab in the Mater Misericordiae University Hospital at a dedicated nurse-led new biologics clinic. Initial recorded outcomes for these first patients showed a reduction in exacerbations, reduced/discontinued oral corticosteroid requirements and improvements in symptom control and PEFR recordings. These improvements have been sustained ten months after the first dose.

Asthma often coexists with other atopic conditions such as allergic rhinitis and dermatitis. Dupilumab is a fully human monoclonal antibody that binds to the α-subunit of the IL-4 receptor and blocks both IL-4 and IL-13 signaling 1 . It is currently licensed for use in moderate-severe dermatitis however, early phase III studies have also proven its effectiveness in asthma 2 . This study aims to highlight that, dupilumab prescribed for dermatitis in 2 patients in our institution, had a positive effect on their asthma symptoms in terms of exacerbation frequency, asthma control and FEV 1 .

Patients' exacerbation frequency, ACQ7 scores and FEV 1 before and after dupilumab were collected. The exacerbation frequency, ACQ7 scores and FEV 1 of both patients improved significantly with dupilumab. In patient A, the FEV 1 improved from an average of 63.5% predicted to 79% predicted, ACQ7 improved from 3.1 to 1 with no exacerbations since commencement of dupilumab. In patient B, the FEV 1 improved from 59% predicted to 66% predicted, ACQ7 improved from 3.7 to 2.4 and again there has been no exacerbations since starting dupilumab. Our results suggest that dupilumab may have a rule to play in managing asthma. References Asthma affects up to 334 million people worldwide and has been increasing in prevalence over the past three decades. Ireland has one of the highest rates of asthma in the world, it is estimated that 890,000 people will experience asthma at some point in their lives 1 .

Research shows that health education in asthma reduces healthcare utilisation by up to two thirds, this in combination with guided self-management strategies and essential skills increases asthma control and reduces risk 2 . Despite this it is estimated that up to 60% of people in Ireland with asthma are uncontrolled 1 .

Self-management combines biological, psychological and social intervention techniques with a goal of maximal function 3 . It is the day to day tasks and home management strategies an individual must undertake to control or reduce the impact of disease on physical health status, guided by and in collaboration with healthcare providers 4 . Effective asthma self-management relies on the patient's confidence to accurately interpret their symptoms and follow through with the appropriate self-management strategy. Self-efficacy is a modifiable factor with the most influence on people's behaviour, adopting and sustaining health behaviour changes and improving health outcomes. I propose to examine self-efficacy among adults with asthma, following a nurse led educational intervention using enhanced bio feedback of treatment use.

1.14 Easing the Economic Burden of Asthma -Assessing the need for and impact of a Universal Asthma Self-Management Programme in Ireland Sandra Redmond, Salutem Insights Ltd

The Asthma Society of Ireland's 2019 Easing the Economic Burden of Asthma report set out for the first time a comprehensive evaluation of the economic cost to the State of Ireland's asthma clinical programme and presented estimated cost savings that could be achieved by introducing a universal selfmanagement programme. While data is available to calculate estimates on the direct and indirect cost of asthma to the State, prevalence and mortality data are inconsistent and outdated. New market research was therefore conducted as part of this study, which suggests a 1-in-5 (890,000 people) lifetime prevalence rate and 1-in-13 (380,000) annual prevalence rate. Alarmingly, Eurostat figures show that Ireland had the poorest asthma mortality outcome across 14 European countries in 2015 -74 peopleand one of the highest asthma hospitalisation rates in 2016. The report found the total estimated economic cost to the State in 2017 at €472 million. This equates to a cost of €1,242 per person with asthma. The direct cost of asthma care accounted for 57% of total costs, with indirect costs accounting for the remaining 43%.Secondary care represented the largest proportion of direct costs at €160 million.

Based on comparative analysis of other jurisdictions, the introduction of a universal self-management programme could provide for direct cost savings for Ireland of up to €68 million a year and indirect cost savings of up to €102 million a year. Most importantly, two thirds of asthma deaths and 50% of hospitalisations could be avoided.

1.15 Acute asthma admissions are characterised by excessive intravenous steroid prescribing with little use of peak flow. Acute asthma (AA) requiring hospitalisation is associated with increased risk for death (UK National Review Asthma Deaths 2014). Aim: to determine quality of care in AA admissions to Beaumont Hospital (BH). HIPE data determined length of stay (LOS), discharging specialty and mortality 2017-2018. An audit proforma evaluated quality of care across 32 parameters; best practice determined using national and local asthma care pathways. 122 patients were admitted with AA, average LOS 5.5 days, 53% under a Respiratory Consultant. There was 1 asthma death. 23 random AA episodes were audited. PEFR, n=15 (65%) and PEFR flow sheet, n= 3 (13%) recording was poor. All had steroids prescribed, n=18 (78%) intravenous for median (range) of 2 (0.5-3) days. Antibiotics prescribed in n=18 (78%), only n=8/18 (44%) indicated. While n=15 (65%) had respiratory evaluation only n=4 (17%) were admitted to the respiratory ward. Conclusion: Acute asthma management failed to meet multiple best practice guidelines. We propose the introduction of an advanced nurse practitioner-led service to improve acute asthma care. Ireland has 4th highest prevalence of asthma in the world, impacting on 10% of Irish adult population. A sub-set of asthma is eosinophilic asthma, which causes severe disease with poor control and prognosis. Mepolizumab is Interleukin 5 (IL-5) receptor inhibitor which are expressed on eosinophil's surface, thus controls eosinophil production and survival. It has recently been approved in Ireland for the use under HSE care.

Aim of the study was to see the interim progress of the patients while being on Mepolizumab in terms of reduction in steroid use, reduction in exacerbations of asthma & visits to GP/hospital and improvement of quality of life. This is observational retrospective study at SLK for patients on Mepolizumab and have completed at least 3 months of treatment. Data was gathered through questionnaire recording various aspects. In this study 5 patients were included who had at least 3 months of treatment with Mepolizumab. 60% of the population under study was male with average age of 45years ranging from 20years to 69years. 4 people have completed 6months of treatment while 1 patient had 3 months of treatment. On Mepolizumab Average dose of steroid reduced from 130mg/week to 31.5mg /week ( 71.9% ), number of visits to GP / Hospital with exacerbation of asthma reduced from 36 to 12 visits (33%), average ACQ-7 score improved from 6.22 to 0.96 & Asthma quality of life questionnaire (AQLQ ) score on average improved from 3.808 to 6.04. Population in general tolerated treatment well, with fewer exacerbations. Mepolizumab has shown to improve the quality of life and at the same time reduced the dependence on steroids. This is an experience of small population but as the funding increases, we would see more patients taking benefit from this IL-5 receptor inhibitor for eosinophilic asthma. In clinical trials Mepolizumab treatment in severe asthma has been shown to reduce exacerbation frequency, with significant improvement in lung function and asthma symptoms.

6 patients were commenced on Mepolizumab in Cork University Hospital in September 2018. Clinical efficacy parameters were collected prior to commencing Mepolizumab and at regular intervals. Patients were reviewed at each infusion by the clinical nurse specialist. Inhaler adherence, any exacerbations and change of medications were discussed at each infusion. There was a significant reduction of exacerbations frequency leading to GP visits and rescue systemic steroids (43 GP visits in the year proceeding therapy compared to 7 visits at 1 year, with 84% reduction, mean reduction -7.6, p= 0.014). There was 80% reduction of events leading to hospitalisation but this did not reach significance (p=0.08). While improvement in asthma control noted (mean reduction in ACQ-6 was -1.6 at 1 year, p=0.09), improvement wasn't statistically significant.

No improvement of lung function was noted at 1 year of treatment. Treatment was generally well tolerated, Mepolizumab discontinued in one patient after one dose upon patient request. Treatment interrupted in 1 patient due to transient elevation of creatinine kinase, and recommenced on an 8 weekly regime with no adverse effect. T Alkawadri [1] , KD Thornbury [1] , MA Hollywood [1] , L McGarvey [2] , F Lundy [2] , G Litherland [3] & GP Sergeant [1] [ [1] . The pre-junctional M 2 Rs are auto-inhibitory [1] , but the role of the post junctional M 2 Rs is unclear. The purpose of this study was to investigate the contribution of M 2 Rs to cholinergic-mediated contractions of ASM and to examine if these responses could be modulated by β-AR agonists. We used isometric tension recording to examine the effects of M 2 R and β-AR modulators on murine ASM contraction induced by electric field stimulation (EFS) and the cholinergic agonist carbachol (CCh). ASM contractions induced by EFS at 20Hz were enhanced by the selective M 2 R antagonist methoctramine, whereas those induced at 2Hz were inhibited (IC 50 =22nM, n=8). However, these inhibitory effects were not observed when the cholinesterase inhibitor neostigmine was present. The β 1 -AR agonist denopamine also inhibited contractions evoked by 2Hz EFS (IC 50 =1.4μM, n=12), but not those induced at 20Hz. Methoctramine inhibited contractions induced by low concentrations of CCh (30-300nM), but not those induced by higher concentrations (1-10μM 

The effect of inhibiting TMEM16A on carbachol-induced contractions in murine primary bronchial smooth muscle R Dwivedi [1] , RJ Large [1] , E Bradley [1] , G Litherland [2] , MA Hollywood [1] , GP Sergeant [1] & KD Thornbury [1] [ Large-conductance, Ca 2+ activated potassium (BK) channels are widely expressed in airway smooth muscle and epithelia. The biophysical and pharmacological properties of BK channels are modulated by auxiliary β and subunits [1] . We recently demonstrated [2] that LINGO1, a structurally similar protein to subunits modulated BK channels, by shifting their activation negatively and inducing inactivation. The purpose of this study was to examine which residues in the LINGO1 protein induced inactivation. HEK cells were transiently transfected with either BK⍺ or BK⍺:LINGO1 and currents from excised patches were studied under voltage clamp using the patch clamp technique, before and during application of synthetic LINGO1 peptides. BK⍺:LINGO1 currents inactivated rapidly. This effect was abolished in LINGO1 mutants lacking the last eight residues of the C-terminus and mimicked by a synthetic peptide identical to the terminal 8 residues of LINGO1 (IC 50 , 308 ± 60 nM, n=7). When charged residues in this peptide were substituted with alanine, the peptide affinity was reduced. A K618A substituted peptide also reduced affinity (IC 50 32 ± 4 μM, n=6, p<0.05) but failed to inactivate. When all 3 positively charged residues were changed to alanine, 100 μM of this peptide failed to inactivate or reduce BK current amplitude significantly.

receptors (1) , however the exact cellular pathways that underlie this effect remain unclear. In human coronary artery smooth muscle PGE 2 induces relaxation via activation of large-conductance Ca 2+ -activated K + channels (BK channels) (2 The data suggest a potential regulatory role for PAR2 in lung autophagy; modulation of receptor activity may therefore represent a novel potential therapeutic mechanism to alleviate the premature lung ageing seen in COPD. We have previously identified the cardiac sodium current, Na V 1.5, in rabbit airway smooth muscle [1] and reported preliminary evidence for a similar current in mouse bronchial smooth muscle cells (mBSMC). However, the mBSMC current was 1000-fold more sensitive to TTX, a Na V pore blocker, than rabbit Na V 1.5. The present study aims to further characterise the mBSMC current. Patch-clamp experiments established that the mBSMC current was sensitive to PF-05089771 (IC 50 =8.1nM, n=6), a Na V 1.7-selective blocker, and moderately sensitive to ICA-121431 (IC 50 =304nM, n=13) a Na V 1.1/ 1.3 blocker. However, the latter corresponds to reported sensitivity of Na V 1.2 to ICA-121431, not Na V 1.1 or 1.3 [2] . In mouse bronchial rings, veratridine (10μM), a Na V agonist, increased the frequency of phasic contractions induced by combined U-46619 (1μM) and PGE 2 (100nM). The veratridine effect was reversed by TTX (100 nM), but not PF-05089771, or ICA-121431. To further investigate this anomaly, patch-clamp experiments examined the effects of all 3 blockers on sustained Na V currents induced by veratridine. TTX reversed the veratridineinduced current, however PF-05089771 and ICA-121431 (allosteric, rather than pore, blockers) were unable to do so.

In conclusion, the current in mBSMC may be a combination of Na V 1. We examined participants enrolled in the Irish National AATD Registry to compare the lung health of those diagnosed with severe AATD due to pulmonary symptoms ("lung-index") (n=86) to those diagnosed due to family screening (n=75 Alpha1-antitrypsin deficiency (AATD) is the only common monogenic cause of COPD. The highly prevalent MZ genotype does not cause COPD in never-smokers, but increases the risk significantly among smokers. The ZZ genotype is associated with COPD, even among never-smokers. SZ-AATD, an intermediary of the MZ and ZZ genotypes, is considered high-risk despite insufficient evidence. We hypothesise that the effect of SZ-AATD is more akin to MZ-AATD than ZZ. This cross sectional study examined the baseline characteristics of MZ (n=161), SZ (n=109) and ZZ (n=204) participants in the National AATD Registry to compare lung physiology by genotype using generalised mixed models to adjust for confounders and stratify by never/ever smoking. Analyses were performed in RStudio Version 1. Cancer. In a further 95 patients (4%) other non lung cancer malignancies were diagnosed. Most of these were lung secondaries from breast, melanoma, urinary tract and colorectal tumours. In many of these cases the primary tumour was unknown at time of referral or remote (>5 years since diagnosis). Synchronous early stage tumours of breast and colon were also detected, usually on CT-PET at time of staging. In these cases treatment of both with curative intent often followed. Other thoracic malignancies found included thymoma and lymphoma.

While the principle role of the rapid access clinics is to ensure patients with a new diagnosis of lung cancer are seen and diagnosed in timely and standardised manner, these clinics also provide further value to patients in identifying other malignancies and providing expertise in diagnostic and Multidisciplinary care. Initially, 116 patients were identified, however 39 were excluded due to lack of data, leaving 77 patients to be included in the study (mean age = 66, female = 43%). Factors that had prognostic significance following univariate analysis were age, disease extent, gender, albumin, neutrophil to lymphocyte ratio, and urea. Disease extent, age at diagnosis and NLR were found to be independent prognostic indicators following multivariate Cox regression analysis.

In conclusion age and extensive stage were, as expected, associated with poor prognosis. The association of NLR with poor prognosis requires further investigation in the era of immunotherapy for lung cancer. The NCCP guidelines have standard referral forms to document important clinical features. This audit was done to assess if patients are being informed regarding a possible diagnosis of Lung cancer by the referring physician prior to attending a rapid access lung clinic and whether the referring physicians were using a method of referral other than the standard NCCP proforma. The NICE guidelines state "Explain to patients who are being referred with suspected cancer, reassure them, as appropriate, that most people referred will not have a diagnosis of cancer, and discuss alternative diagnoses with them." NICE guidelines recommend using a local referral proforma. Data was collected over 4 weeks for rapid access lung cancer clinic. Out of 25 patients, 84% (n=21) were aware of the referral to a rapid access lung cancer clinic. 56% (N=14) of the referral were on the standard NCCP referral form. 44% of referrals were not on the standard NCCP proforma but on short clinical letters which may lead to variable characteristics of information available. We need to make it more widely known to the GPs and other hospital based doctors that patients should be told of the referral for a possible diagnosis of lung cancer. The NCCP referral form be used to ensure continuity of information.

3.17 Rapid access lung cancer clinic de-ferral letter audit: The NCCP has guidance on how patients should be referred to and when they should be seen in the rapid access lung cancer clinic (RALC). It was suspected that a number of referrals with an abnormal x-ray may not need to be seen, provided that the clinical picture was in keeping with an acute infection which would only require antibiotic and a follow-up chest radiograph. During triage of referral letters we have carefully selected cases which would meet the above criteria and write a letter to GP advising them to repeat a chest radiograph and if the abnormality was still present to re-refer to the RALC. We performed a retrospective review of the deferral letters (n=30) we sent in response to the initial G.P referral letter. 12 (40%) were re-referred after repeat imaging showed persistent change, 9(30%) were not re-referred after repeat imaging showed resolution of original abnormality and 9(30%) were not re-referred and the recommeneded repeat imaging was not performed. In the context of national deficits in survivorship care, this project aims to develop a program of care in University Hospital Limerick for patients post lung cancer. We also aim to identify the needs of this patient group and the impact of interventions on patient outcomes. Most survivors of lung cancer have undergone invasive treatment (surgery, radiation therapy, and/or chemotherapy) and carry a higher co morbidity burden than survivors of other cancers. Overall QOL and HRQOL suffer during the treatment phase, with the potential for long-term decline. Physical and mental components of HRQOL seem to be most at risk for decline ( University Hospital Kerry is a 300 bed hospital providing acute healthcare to a large area in the South West of Ireland. Without a resident respiratory specialist, treating type 2 respiratory failure, interpreting arterial blood gases and initiating patients on noninvasive ventilation (NIV) are common management challenges which non-consultant hospital doctors (NCHDs) often face. This study aims to assess if NCHDs have the appropriate level of knowledge to manage these complex patients and whether they are confident in doing so. A comprehensive questionnaire comprising of multiple choice questions assessed NCHDs' basic knowledge of NIV and its prescription. Likert scales were used to assess how confident NCHDs are prescribing and commencing NIV.

Over 50% of NCHDs (n= 21) completed the survey. Sixty-one percent of NCHDs felt either neutral or unconfident regarding commencing NIV. Six doctors were unable to list any contraindications to NIV, and seven doctors were able to list three or more contraindications. Only 28% of NCHDs received education regarding non-invasive ventilation within the last year.

Following the results of this study an education day to improve understanding is being organised. An NIV working group has been set up to develop a NIV pathway.

Jehangir Khan, SpR and Sean Brady Intern to Dr Reardon

Aim: Oxygen is a vital for the survival of human beings and when it comes to the hospital setting as it is lifesaving drug if given in correct dosage. Research data broadly show that that oxygen administration practices are often not compliant with prescribed standards (3) Objectives:

The main objective of this study is to assess the practices of oxygen prescription and to establish concrete guidelines on local basis for its prescription and follow up. Introduction: Oxygen is needed at cellular level for the correction of hypoxia and basic cellular mechanism (2) However On the other side, oxygen may be harmful with mechanism such as paradoxical effect of oxygen in decreasing coronary artery blood flow and increasing coronary vascular resistance. (1) Methodology: Cross-Sectional study, we went through all patients chart and drug kardexes to see how many patients are on oxygen and then we studied those patients based on the following parameters (Gender, Age group, Diagnosis, Smoking status, Mode of oxygen delivery, Prescription on drug kardexes, Parameters written on NEWS chart, Were the parameters matching the patient's own parameters and application of oxygen port.

Conclusion: Based on this study, a significant percentage of the inpatients were on oxygen (13.3%). In our study most of the patients were females (55%). Smoking history also shed light on trends of smoking in Wexford catchment area evident by our study population as 70% were exsmokers, 5% were active smokers, and 25% were never smokers. In 100% of cases the patients were getting oxygen via nasal prongs Discussion: We suggest that patients on oxygen should be evaluated on a continual basis and de-escalated whenever possible to minimize the strain on resources and to optimize patient care. This was a quality improvement project set out to ensure that all patients on a respiratory ward were prescribed the correct oxygen saturations targets on their drug kardex on admission to hospital. This was carried out after our survey of newly qualified junior doctors in the hospital demonstrated that 32% would not feel confident in choosing correct oxygen saturations for inpatients, particularly in an out of hours environment.

We carried out education sessions for staff and displayed reminder posters to ensure that oxygen was prescribed on the drug kardex. In addition, we asked our nursing colleagues to incorporate this into their daily handover. Finally, we provided alert cards/bracelets for any patient at risk of hypercapnic respiratory failure. Prior to our change, only 63% of patients had oxygen targets prescribed. 37% did not, including 2 patients at risk of hypercapnic respiratory failure. None of the at risk patients had alert cards/bracelets. One month following our changes, 83% of patients had oxygen targets prescribed. 100% patients at risk of hypercapnic respiratory failure had correct oxygen targets prescribed and had alert cards/ bracelets. This is an ongoing project and is being introduced to other wards in the hospital. Long term oxygen therapy (LTOT) offers survival benefit and improvement in physiological indices in hypoxemic COPD patients (1) . Underprescription of LTOT is an independent risk factor for hospital admission with COPD exacerbation (2) . A dedicated physiotherapy led oxygen clinic (0.5WTE) was set up in response to growing outpatient waiting lists for respiratory patients needing oxygen assessment.

Over 6 months, 148 patients were assessed. Of these patients, stability in relation to their oxygen usage was confirmed (N=58), or they received appropriate intervention (n=90). This included a change in oxygen prescription (n=48), education on correct oxygen use (n=22), commencement of oxygen (n=14), unfit/needing medical review (n=4) and removal of oxygen (n=2). Furthermore, 38 of these received additional interventions or were referred appropriately to pulmonary rehabilitation (n=29), community physiotherapy (n=3), ataxia clinic (n=1), women's health physiotherapy (n=1) or prescribed a gait aid (n=4). The above findings highlight the need for dedicated oxygen clinics to ensure timely access, optimal intervention, and appropriate follow-up for respiratory patients requiring oxygen. Physiotherapists have the required skillset to excel in the delivery of oxygen assessment, taking into account other aspects of the patients' presentation, ensuring a holistic approach to management and recognition for additional interventions. In this study we sought to evaluate blood gas analysis use in the ED at our institution. It has been argued that venous blood gas analysis (VBG) is an acceptable replacement for arterial blood gas (ABG) in the Emergency Department setting. There are no guidelines as to when a VBG is acceptable in place of an ABG. We performed a retrospective chart review of patients presenting with an exacerbation of a known respiratory condition requiring acute medical admission. This study assessed 23 admissions. Oxygen saturations were less than 95 % on admission in 52 % of patients. ED staff performed an ABG on 13 % of patients and VBG on 69.5 %. In 56.5% of patients, only the medical team on call performed an ABG. In 81.25 % of ABG results, supplementary oxygen status was documented. 57.5 % of ABGs showed an elevated A-a gradient. ABG and VBG comparison showed an average discrepancy of 0.05 in pH.

There is no pattern to arterial blood gas sampling in patients admitted with respiratory compromise to our institution. There is a need for clear guidelines for performing ABG in the ED for patients with a known respiratory condition. A two week service evaluation was carried out in June 2019 to gather 'snap-shot' information on the role of physiotherapists in treating deteriorating patients, particularly those on NIV (n = 27). Results were evaluated using Microsoft Excel. In a subgroup where EWS was recorded (n = 13), first responder physiotherapy interventions facilitated in reducing the number of patients with high risk Early Warning Scores (EWS > 9) from 46% (n = 6) to 23% (n = 3). Interventions performed by physiotherapists to stabilise these deteriorating patients can be seen in Figure 1 . Physiotherapists were instrumental in identifying the need for and initiating NIV as well as playing a key role in the overall respiratory management. Figure 1 .

Physiotherapists, led by Clinical Specialist Respiratory Physiotherapists, are a key first responder for acutely ill respiratory patients. They recognise and prevent further deterioration as their skills impact on the stabilisation of the deteriorating patient's Early Warning Score. The use of High Flow Nasal Therapy as a means of lung targeted aerosol delivery is commonly used. Applied gas flow rates may impact the respirable mass of drug delivered to patients. Here, we compare the dose delivered with continuous nebulisation therapy during simulated adult breathing across two gas flow rates. Salbutamol (1mg/mL) was administered at a rate of 12mL/hr using a syringe pump (CNTS, Aerogen, Ireland This study indicates that gas flow rates have a significant effect on volumetric dose delivery during continuous nebulisation. Lower gas flow rates were seen to facilitate a higher dose, however, these low flows may be of limited use clinically.

All authors are employees of Aerogen. Physiotherapists prescribed HFNC in 50% of cases and 90% of patients receiving HFNC were treated by a physiotherapist. Secretion retention/ humidification was the most common indication for prescription (40%) while the use of HFNC for hypercapnic respiratory failure was observed in 10% of patients ( Figure 1 ). Figure 1 : Clinical indication for prescription of HFNC HFNC is predominantly utilised in line with local policy. The need for education in the management of hypercapnic respiratory failure was noted. An association with physiotherapists and patient receiving HFNC was observed.

Department of Respiratory Medicine, Mercy University Hospital, Co Cork

The use of Bi-Level Positive Airway Pressure (BiPAP) has been shown to be an effective treatment option for people with Type 2 respiratory Failure. The primary aim of this study was to determine if patients with T2RF were correctly diagnosed and treated with BiPAP as per hospital protocol. The secondary aim was to create and implement an NIV Hospital Pathway. A retrospective review of BiPAP usage on inpatients in a public hospital over a month period was carried out. 11 cases were identified and analysed.

64% patients were commenced on BiPAP by the medical teams, with 82% commenced early into their admission in ED. COPD was the most common underlying diagnosis (91%). 82% of patients met all 4 criteria for commencing BiPAP and no patients had any absolute contraindications. Only 54.5% of patients had ceiling of care documented. 18% of patients had too many ABGs performed and 45.5% of patients did not have 3rd or 4th ABG carried out as per protocol. 82% had their settings changed appropriately. 91% were reviewed in 24hours by the respiratory department. 91% of patients had appropriate skin protection and 100% had good mask fit.

The findings led to the creation and implementation of an NIV Hospital Pathway to aid staff with the commencement and monitoring of BiPAP.

The Predictors of one-year mortality in COPD patients using home mechanical ventilation (HMV)

Introduction: Chronic obstructive pulmonary disease (COPD) is a progressive and disabling disease. Non-invasive mechanical ventilation (NIV) is given acutely to COPD patient who have an acute respiratory failure. However, in terms of Home mechanical ventilation (HMV), there is still controversial discussions. In this study, we want to investigate the predictors of 1-year mortality in COPD patients using HMV.

Method: The data of 24 patients, who have COPD and getting home ventilation in the county Mayo, were collected using records of the patients. Arterial blood gases, lung function tests, death, NIV settings and comorbidities were collected.

Results: The 1-year mortality of COPD only group was n=26 (25%) while only 2 died in the COPD with sleep related disorder group (p 0,005). BMI was found to be significantly different between the two groups (p 0,001). Also, GOLD stage was found to be significantly different between the two groups (p 0,001). Whether COPD is accompanied with sleep related disorder or not and FVC predicted% were found to be predictors of mortality. Discussion: BMI in COPD patients is not a predictive measure of mortality but fat-free-mass was found to be so in another study. The relation between the diagnoses of sleep related disorder and mortality can misunderstand since the severity of COPD and the sleep related disorder varies. FVC predicted % is a predictor of mortality in this study which, to our knowledge, was not found to be so in other studies. Chronic Obstructive Pulmonary Disease (COPD) is a progressive respiratory condition defined by airway inflammation and partially reversible airflow obstruction. Non-invasive ventilation (NIV) with bi-level positive airway pressure is the assumed standard of care in the management of acute hypercapnic respiratory failure (AHRF) secondary to Acute exacerbation of COPD (AE-COPD). The national standard of in-hospital mortality for COPD patients is 15% (1). We reviewed the patients admitted with AE-COPD requiring NIV (ie: acidotic with a ph < 7.35 and pCO2 > 6.3kPa). We included all adult patients admitted to hospital with AHRF secondary to AE-COPD. We defined AHRF by an admitting ph < 7.35 and a baseline partial pressure of carbon dioxide (PaCO2) greater than 6.3kPa. The primary outcome measure was mortality during the hospital episode of respiratory failure. Early intervention of NIV for acidotic respiratory failure reduced inhospital mortality and the need for invasive ventilation in the Intensive care unit (ICU). In-hospital mortality in Portiuncula Hospital reduced from 33% to 14.8% with the successful set-up of a designated ward based NIV service. The purpose of this study was to explore the guidelines for returning to driving for a patient who is oxygen dependent. Patients suffering from ILD (interstitial lung disease), IPF (idiopathic pulmonary fibrosis) and COPD (chronic obstructive pulmonary disease) are referred to occupational therapy for assistance with return to activities of daily living. Many of these people are young, still working, and in many cases, driving. For some of these patients, the use of oxygen is a short term measure while they await a lung transplant, for others it's a long term prescription, but regardless of duration of oxygen prescription, many of these patients need to return to driving for their jobs, social interactions, and quality of life. This study looked at the guidance available for return to driving while oxygen dependent.

During this study we reviewed the literature of 5 journal databases, we completed, a review of driver guidelines in Ireland and the UK, we contacted the Irish oxygen supply companies, and we also contacted Irish insurance companies. The HSE currently spend circa €25million per annum on respiratory therapies. Under the auspices of the Primary Care Directorate, the National Service Improvement Programme for Community Funded Schemes (CFS) was established. The programme intends to ensure that eligible patients have equity of access to essential respiratory therapy equipment and services regardless of geographical location.

The programme intends to improve the quality and sustainability of the CFS through the establishment of national standards, equity of access, value for money, functional processes and a management system that ensures compliance with standards and objectives. All work streams of the respiratory section of the CFS were examined. Details of staffing, output documentation and possible implications for practice were reviewed. Process of structuring a national tender for all community based respiratory products was detailed. Tender evaluation groups were split into 3 product categories, general respiratory, sleep and laryngectomy/tracheostomy. Tenders for general respiratory include oxygen equipment, ventilation, nebulisers and airway clearance. Standardised operating procedures will streamline access to equipment and associated services. For the first time since the establishment of the HSE Ireland will have a national contract for all community based respiratory products. The work of the CFS programme has been well received to date. Approximately, 14% of patients presenting to emergency departments and 10-20% of patients subsequently admitted to hospitals show primary respiratory problems.1 This audit highlights the importance of respiratory inputs in the diagnoses and management of hospital inpatients.

In this cross-sectional study, one hundred seventy-seven patients were consulted among 5,482 inpatients (3.2%), from January 2019 to April 2019. Respiratory diagnosis was found to have newly arisen after admission in one third of the total cases requiring consultation. The common causes of consultation included: lung mass/nodules (22%), COPD (21%), pleural effusions (15%), pneumonia (13%) and asthma (6%). The contributions of the respiratory consultation to the diagnostic and management processes were determined. Forty-four patients (25.9%) needed respiratory interventions (bronchoscopy, thoracentesis and chest drain). New respiratory diagnoses were made (where no diagnosis had existed before) in 24.8% of patients, and an incorrect diagnosis was corrected in 21.4% of the cases. Contributions to the differential diagnosis and management plans were made in 8% and 40% of cases, respectively. The prospective consultation time was collected for 109 (61%) initial visits, with a mean consultation time of 39 minutes, including procedure time.

This study finds that inpatient respiratory consultations lead to significant improvements in patient diagnoses and management plans. The Rapid Access Lung Cancer Clinic (RALC) allows access to rapid diagnostics and expedites the assessment of patients with clinical suspicion for lung cancer based on symptoms and/or abnormal chest xray. This results in many non-cancer pathologies being identified through clinic and we aimed to further evaluate this. We reviewed our institution's lung cancer database and identified all patients who attended the RALC from 2012 to 2018. We reviewed the CT imaging findings of these patients and separated those with lung cancer from others. 2372 patients attended the RALC for the first time in this period of whom 92% had CT thorax arranged as part of their evaluation. 866 patients (36%) were diagnosed with Lung Cancer, all had an abnormal CT scan. Of the remainder, 193 patients had chest xray only and 1290 (87%) underwent CT imaging with a number of alternative non-lung cancer findings (figure 1); 55% of these had their CT scan post first RALC attendance. 82% of patients with pulmonary nodules entered nodule surveillance. A rapid triage using 'CT first' can identify patients with nonmalignant disease facilitating re-direction from the RALC to more appropriate follow up services. These findings warrant close consideration when devising future national lung cancer policy. Hyper-reactivity, inflammation and hyperplasia/hypertrophy of airway smooth muscle (ASM) limit airflow and are key features of chronic obstructive pulmonary disease (COPD). Proteinase activated receptor 2 (PAR2) is a critical modulator of inflammatory responses in respiratory disease such as asthma, yet is reported to promote ASM relaxation. However, the role of ASM PAR2 in COPD is not well understood1.

Our aim was to determine the presence and role of PAR2 in murine lung and ASM subjected to oxidative stress using both immunohistochemistry (IHC) and wire myography. PAR2 was detected using APR-32 antibody (Alomone, Israel) on both murine airway and lung tissue, with clean isotype. Oxidative stress increased trypsin-induced ASM relaxation in both bronchial and tracheal tissue. This was PAR2 dependent, as relaxation was significantly reduced in PAR2-/-compared with WT tracheal (mean ± SEM; WT 53.4±13.4 % vs. PAR2-/-2.5±0.8 %; p=0.02; n=3-4) and bronchial tissue (WT 56±13.3 % vs. PAR2-/-2.3± 0.9 %; p=0.02; n=3-4).

In conclusion, this study confirms a functional PAR2 role in murine airway tissue; importantly, the role of PAR2 in mediating ASM relaxation appears to be enhanced in oxidative environments such as found in COPD. This may have important implications for future potential therapies. We focused our analysis on 83 NSCLC samples. Overall αdiversity showed that advanced stage (IIIb-VI) lower airway samples were more similar to buccal samples than local stage (I-IIIa), p<0.0001. In addition, worse 6-month and 1-year survival was associated with more similar αdiversity between lower airway and buccal samples ( Figure 1A-D) . Utilizing DMM two clusters were identified, Supraglottic-Predominant-Taxa (SPT) and Background-Predominant-Taxa (BPT). There was a significant increase in percentage of SPT in advance stage compared to local stage (p<0.008) Kaplan-Meir survival analysis shows worse survival in those with NSCLC who were clustered into the SPT group compared to BPT (p=0.0003, Figure 1E ). With RNAseq, differentially expressed genes between advanced stage vs. local stage and 6-month vs. 1year survival were not as pronounced as SPT vs. BPT ( Figure 1F ) suggesting that globally, transcriptomic changes between different stage and NSCLC survival were difficult to detect as compared to when airway microbiome were differentiated. In lung cancer, dysbiosis within the lower airway microenvironment, possibly by micro-aspiration, is associated with a worse 6-month and 1year survival. This change is also associated with transcriptome changes in the local environment. Overall 283 (52.6%) patients were identified as having definite HHT (based on the presence of 3 or more Curacao criteria). Internationallypublished data suggest a prevalence of 15-35% for pAVMs and 10-23% for cAVMs in patients with HHT, which would suggest prevalence of cAVM's in this cohort is slightly lower. 

It has been widely acknowledged that lung function exhibits diurnal variation, notably in spirometric tests routinely used to aid the diagnosis and monitoring of respiratory diseases. We hypothesise that during an exacerbation diurnal variation changes, as physiological changes alter the reversibility of airway obstruction, likely due to a combination of bronchoconstriction, mucus production and local inflammation. Longitudinal asthma patient data from the INCA-1 randomised control trial (n=218) was analysed to assess the amplitude and timing of patients' objectively measured peak expiratory flow (PEF) diurnal variation using a non-linear least-squares estimation model. Logistic regression was performed on the ability of diurnal variation (expressed as percentage of personal best PEF) to predict physician diagnosed exacerbations (OR 1.052; 95% CI [1.027, 1.059]). In practice, this translates to an increase in diurnal variation of 10% of a patient's personal best increasing the odds ratio of an exacerbation occurring to 1.66 (1.05210). Currently, there are no reliable early predictors of exacerbations employed as an early detection system. An ensemble of predictors would likely be required to create such a system, of which diurnal variation is likely a useful component. This would provide clinical utility as earlier and more efficacious treatment timing can improve exacerbation outcomes.

7.6 T2-low asthma is over represented in current literature and is likely due to suppression of biomarkers by inhaled therapy V Brennan, G Greene, EMacHale, R Costello Beaumont Hospital, RCSI

In recent years patients with asthma have been dichotomised by the degree of their type 2 (T2) airways inflammation into 'T2-high' and 'T2-low' phenotypes. It is well established that corticosteroids suppress T2 inflammation and monitored adherence can result in a patients T2 markers changing from "high" to "low". Published data reports the incidence of T2-low asthma to be 50% of asthma is T2-low yet despite this, T2-low asthma remains poorly understood and is currently defined by the lack of T2-high biomarkers, namely FeNO & blood or sputum eosinophilia. We prospectively analysed a cohort of symptomatically uncontrolled asthmatics recruited from respiratory clinics over a period of 8 months, longitudinally monitoring FeNO & blood eosinophil count and other potential markers of T2 inflammation. Adherence was monitored using an electronic device. Of our 103 patients, 41(39.8%) patients classified as T2-low at recruitment however, by the end of the study, only 19 (18.4%) had persistently T2-low biomarkers. Having low T2 Biomarkers is strongly associated with good adherence (OR 3.88 per unit change in adherence -95% CI 1.13 -13.4) & conversely having high T2 Biomarkers is strongly associated with poor adherence (OR 9.81 per unit change in adherence -95% CI 1.5 -64.8) These findings suggest that the reported statistic 50% of asthmatics being "T2low" is a significant overestimation and that a substantial proportion of "T2low" asthmatics are "T2-high" with suppressed biomarkers due to adherence. The respiratory microbiome is altered in asthmatics. Alterations in the microbiome of the skin and gut have been implicated in the development of asthma. It is not yet known how these three communities interact with each other or how they react to treatments. We aim to assess whether airway physiology and the bacterial density of the oropharynx, lung, skin and gut change significantly after an asthmatic is exposed to an antibiotic. Airway physiology was assessed and skin swabs, throat swabs, faecal samples, and lung brush samples were obtained in thirteen asthmatic patients. Subjects were asked to take an antibiotic for 10 days. Repeated skin, throat, and faecal samples were collected at regular intervals and airway physiology was repeated. Biological samples underwent qPCR assessment. Data were analysed using a combination of paired T-test and repeated measure ANOVA. There were no significant differences in airway physiology post exposure to antibiotic. Bacterial counts in faecal samples (n=37), skin swabs (n=52), throat swabs (n=49) and lung brushes, (n=88) did not change significantly over the study period. Airway physiology and the bacterial density of faeces, skin, throat, and lung samples do not change meaningfully after an asthmatic patient is exposed to an antibiotic. The effects of Ivacafator on cystic fibrosis transmembrane conductance regulator (CFTR) activity in patients with cystic fibrosis and G551D-CFTR mutations have been well described clinically. However, little is known about Ivacaftor's relationship with lung inflammation in children.

From the SHIELD CF database we analysed five preschool subjects with G551D-CFTR mutations before and after commencing Ivacaftor (cases). Comparing these results with five age-matched F508del-CFTR mutations not on disease modifying medications (controls). Inflammation was assessed by neutrophil elastase activity (NE), inter-leukin-8 (IL-8) and cell counts. Log10IL-8 change over time between groups demonstrated a tread towards reduced IL-8 levels in those using ivacaftor compared to controls (P=0.0395). NE detection was equivocal between groups. TCC demonstrated a downwards trend in cases compared to an upward trend in controls, ANC trended upwards in both groups. This study demonstrates a trend towards a reduction in lung inflammation in paediatric subjects with G551D-CFTR mutations after commencing Ivacaftor. Lung inflammation trended upwards in subjects with F508del-CFTR mutations over the same time period. Recruitment will continue to better assess this relationship. Bronchoalveolar lavage (BAL) of six lobes during bronchoscopy in children has been reported to be safe and confer a higher microbiological yield, however, descriptions of sampling protocols and safety reporting have been suboptimal. Regional variability in CF lung disease is described but incompletely understood. This ongoing prospective case-control study of pre-school children with CF compares standardised six lobe (case) against traditional two lobe (control) BAL using 2x1ml/kg/lobe. Safety is compared between case and control groups using 12 intra/post-operative parameters and intraprocedural pulse oximetry. Marginal efficacy is determined by comparing the microbiological culture and PCR yield from pooled lavages in the cases. Twelve cases and six controls have been enrolled (mean age 3.06 vs 4yrs). No significant differences in safety outcomes was demonstrated between cohorts (P-value 0.098-0.99). Mean oxyhaemoglobin saturations and 4% desaturation indices were comparable between cases (N=11) and controls (N=4). Case microbiological yield demonstrated equivalent culture growths ( Figure 1 ). Data so far has not noted a significant difference in viral or P. Aeruginosa PCR.

No safety concerns have yet been noted. Microbiological yield of 2 v 6 lobe pooled lavage is equivalent based on current recruitment. The study is continuing to recruit subjects. Childhood interstitial lung disease (chILD) is a rare condition with an estimated prevalence of <1 per 100,000.1 Here we report two cases that presented to our centre in the last 3 months. The first case presented to the hospital at seven months of age with an acute history of cough and a history of faltering growth and laboured breathing since birth. He had had an uncomplicated neonatal course. He was initially diagnosed clinically with bronchiolitis (negative viral respiratory panel). His symptoms persisted and he underwent further investigations including CT Thorax which showed diffuse ground glass opacification.

The second patient presented to the hospital at 4 months of age with a history of intermittent laboured breathing and faltering growth. He had also had an uncomplicated neonatal course. He required oxygen during his admission. He had a CT thorax which showed ground glass opacification posteriorly and medially in the upper lobes and in the lower lobes medially and within the lingula. Both patients had negative respiratory viral panels, normal echocardiograms, and sweat tests. They were discharged on home oxygen. Mologic Laboratories, Bedford, UK. 7 School of Medicine, Trinity College Dublin BACKGROUND: Lung inflammation and subsequent lung injury are a major component of the morbidity and mortality associated with CF. Biomarkers of lung injury can be found in urine. The analysis of biomarkers in urine represents a promising noninvasive approach to predicting lung injury, particularly in children. In a previous phase of this study, we have demonstrated differences in biomarker levels in the urine of children with CF compared to controls. The longitudinal variability of urine biomarkers in children is unknown. AIMS: To determine the natural longitudinal variability of urinary biomarker levels in children with CF and healthy controls. METHODS: Urine samples were collected weekly for 12 weeks at home, from children with CF and healthy controls. Sampling was increased to every two days when the children with CF unwell -defined as the presence of a new cough. The levels of 26 different biomarkers were determined in the urine samples of 18 children (18 CF, 4 control), by ELISA. The intraindividual (CVi) coefficient of variations of different biomarkers were first calculated for each of the 18 children. The interindividual (CVg) was then measured between the CF and control groups. RESULTS: The CVi was high across all the measured biomarkers, with the highest average being Matrix Metalloprotease-8 (MMP8) at 154.6% and the lowest being Tissue inhibitor of metalloprotease-2 (TIMP2) at 46.8%. There was no significant difference between the the CVi of the control and CF groups for any biomarker or between the CVi of those in the CF group when stable or unwell. The CVg was, on average, higher in the group with CF versus the control group. CONCLUSION: Biological variation indices show that urine biomarkers are highly very variable longitudinally in children with and without CF. Variability between individuals was however more pronounced in the CF group. Further work will focus analysis of grouped biomarkers and on longitudinal relationship to outcomes. Guidelines on the management of children with neuromuscular disorders (NMD) recommend the use of augmented cough techniques in patients with ineffective cough (including children >12 years with cough peak flows (CPF) <270 litres/min)1. We aimed to assess the use of these techniques in our patient population. We performed a retrospective chart review from June 2018 to June 2019. Pulmonary function testing (PFT) including CPF measurements and respiratory physiotherapy assessments including use of cough augmentation techniques were recorded and analysed using Microsoft Excel. Ninety-six children with NMD attend the multidisciplinary (MDT) respiratory clinic at our institution. Thirty-eight were >12 years and had attempted PFT including CPF in the previous year. Thirty of 38 (79%) were using cough augmentation techniques with 27/30 using MI-E and 3 using manual breath-stacking methods. All patients had documented clinical impression of weak cough. Twenty-one of the 30 patients (70%) had performed CPF (mean 206 litres/min, range 90 -378 litres/min) and 27/30 (90%) performed forced vital capacity (mean 1.92 litres, range 0.61 -3.97 litres). Our review demonstrates a high proportion of patients >12 years using assisted cough techniques particularly MI-E. The support of a MDT including respiratory physiotherapy and pulmonary physiology testing facilitates adherence to international standards. Reference Vitamin E (Vit E) levels appear to have increased in cystic fibrosis (CF) patients attending Children's Health Ireland (CHI) at Temple Street (TS). Cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapy has a definite positive impact on nutritional status but the reasons behind this are not clearly understood. The objective of this study was to investigate a link between modulator treatment and Vit E serum levels. Vit E levels of CF patients were recorded retrospectively from the Clinical Portal System at CHI at TS from the years 2017 (n=92), 2018 (n=98) and 2019 (n=75).

A significant number of patients had high Vit E levels with 24/75 recorded in 2019. 12/ 24 are on modulator therapy. However, 9/12 had high levels of Vit E prior to commencing on modulators and thus an association cannot be made at this time. Interestingly this study shows a shift in serum levels away from treating deficiency towards managing excess. This is in stark contrast to practice over the past decade where dieticians sought to correct deficient serum levels of fat soluble vitamins through supplementation and diet. Newly licenced Vitamin A, D, E & K supplements have higher levels of fat soluble vitamins than current preparations and based on our recent finding may no longer be clinically indicated. Introduction: Asthma is an extremely common paediatric condition presenting to emergency departments1. Severe episodes are potentially life threatening; requiring effective, rapid treatment2. Aims: (1) To assess adherence to asthma treatment guidelines (2) To assess if asthma action plans were issued on discharge.

A retrospective analysis of asthma admission rates to ICU over a ten-year period (2008-2018). Data was extracted from charts and analysed using SPSS 24. Results: 44 admissions (>2 years of age) were admitted; mean age 5.61 years (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) . The mean length of ICU stay was 1.09 days. Nine cases were first diagnosis. One patient transferred to a tertiary centre. Nine had a recent hospital admission or out-patient visit. Compliance to treatment and parental smoking was not documented in 64% and 86%. 32 had evidence of a discharge asthma action plan. Ten patients under 2 years of age were diagnosed with asthma. Results: Fifteen children taking Ivacaftor (mean age of commencement 6.2 years) were pancreatic insufficient prior to commencing Ivacaftor (FE <200μg/g). At follow up, nine were found to be pancreatic sufficient (FE 200->500μg/g) and three had mild pancreatic insufficiency (FE >100-200μg/g). Of the nine children with restored pancreatic sufficiency (ranging in age from 2-6), all discontinued, and have remained off, PERT without abdominal symptoms or weight loss after a minimum follow up period of 3 months. In a further 2 children aged 8 and 9 at commencement, FE has increased from <15 to 190 and 195 respectively after a period of 7 years. Conclusion: Restoration of exocrine pancreatic sufficiency and successful clinical withdrawal of PERT is possible in children with CF on Ivacaftor. Longitudinal follow up and monitoring will be required to evaluate the natural history of exocrine pancreatic function of these children. Height tracked in all infants and body mass index at 2, 3, 4 and 5 years (n=7) was 50th or above. In those infants where "top-ups" of formula milk were introduced all (n=6) had ceased BF within 3 weeks. Reasons for ceasing BF included:

• "supply dried up"(n=4)

• "less stress"(n=2)

• "easier to dose enzymes with" (n=1). Good weaning practices are observed which is positive and largely these babies are thriving and maintaining optimal nutritional status throughout early childhood. It is worrying that "top-ups" of formula may significantly impact BF. Resources are being made more BF-focused to reflect increasing BF rates and we continue to offer close weight monitoring to reassure both the team and family that growth remains optimal during BF.

A. Walsh (1) Anxiety and depression are major public health issues affecting 6.3% and 4.8% of the Irish population. Asthma affects 12.5% of the population. Anxiety and depression rates are significantly higher amongst asthma sufferers and these conditions may adversely affect asthma control. [1] Treatment of anxiety and depression may improve asthma control. [2] We performed a retrospective chart review to identify the prevalence of anxiety and depression amongst asthma patients including rates of prescription of anxiolytic and antidepressant medications. A total of 99 patients were included in this study. Of these 59.6% were female (n=59) and the mean age was 51.35 years. A history of depression and anxiety were documented in 16% (n=16) and 7% (n=7) respectively. Two patients had a dual diagnosis of both conditions. Rates of antidepressant and anxiolytic medications were 10% (n=10) and 6% (n=6) respectively. The most commonly prescribed class of drug was SSRI (n=10), followed by benzodiazepine (n=4) and olanzapine (n=2).

Our cohort had lower rates of anxiety and depression than previous studies in asthma patients. However, rates of depression in our cohort are higher than the national average. There is a need for further research evaluating the effect of anxiety and depression on asthma control and severity.

9.2 Patient selected goals in asthma, the evidence behind them and how to apply them: the relationship between physician and patient desired outcomes, how they relate to asthma severity, and a proposed methodology for their implementation Poor adherence a well-documented barrier to successful control in difficult to treat asthma (1), which may be due to the discordance between patient and clinician treatment goals (2) . In this study patients taking part in two RCTs were asked to select treatment goals to reflect successful treatment from a patient's perpective. These goals were categorised as: disease-specific, knowledge-based, and functional (pertaining to activities of daily life). While current practice focusses on disease-specific goals for the longterm management of asthma, as outlined by GINA, almost half of patient-selected goals were functional as opposed to disease-specific. Indeed, goal achievement was found to be significantly higher in diseasespecific rather than functional-based goals (odds ration 1.667, 95% C.I: 1.1-2.52). This indicates that while current management strategies address disease-specific goals, patients often fail to achieve their funcational goals. This may result in a perceived failure of treatment impacting patient engagement. Furthermore, the relationship between lung function and goal category selection is not mirrored by commonly used asthma questionnaires in these data (eg. ACT). Patients with a lower FEV1/FVC ratio on spirometry were significantly more likely to choose disease-specific goals (odds ratio 1.09, 95% C Diagnosis of asthma often relies on clinical history and examination. Guidelines now incorporate physiological measurements of reversible airflow limitation in order to establish the diagnosis. We hypothesise that when diagnostic criteria involving documentation of objective reversible airflow obstruction are applied to a cohort of physician-diagnosed asthmatics, asthma will be over-diagnosed.

Patients attending a single respiratory centre with the diagnosis of asthma were invited to attend. Clinical history and examination was documented and patients underwent spirometry with reversibility. In those who did not demonstrate airway reversibility on spirometry, bronchial challenge testing was undertaken. 71 patients participated. 44 (61.9%) were considered asthmatic based on history, examination, and documentation of either reversibility on spirometry or positive bronchial challenge test results. Of the non-asthmatic cohort (n=27, 38.1%) , the most common cause for symptoms were sinusitis (n=15) and gastroesophageal reflux disease (n=10). Less common causes included vocal cord paradox and hyperventilation. This study demonstrates the difficulties which arise when assigning a diagnosis of asthma to a symptomatic patient. We believe that careful assessment of airway physiology should be a cornerstone of the diagnostic process in the case of this disease. Smoking cessation interventions (SCI) are recommended to be integrated into the routine care 7of patients with COPD who smoke 1 .

A retrospective review of medical records was conducted to clarify whether SCIs are an integral part of the routine care of patients with COPD who attended St. Michaels Hospital. The audit included 100 episodes of care from 4 different departments. The questionnaires developed using the Tobacco cessation guidelines for COPD 1 found that 91% of patients were asked about their smoking status, 95% of all identified smokers were advised and were assessed for their interest in quitting and 80% of them received more than one intervention offered (40% of smokers were offered assistance with pharmacological support, 42.5% were offered behaviour support and further follow up). It was also found that a considerable amount of smokers had declined the offer for assistance (10% has declined pharmacological support and 25% for behaviour support). The overall result indicated that SCIs are an integral part of caring for patients with COPD in St. Michaels hospital. However, there is more room for improvement in all areas of interventions. Appropriate identification of smokers and initiating motivational advice that is personalised and specific to patients with COPD could increase their chance of adopting SCIs. Alpha-1 antitrypsin deficiency (AATD) is a hereditary condition that causes lung, liver and skin disease with the ZZ phenotype resulting in severe deficiency. The highly prevalent MZ phenotype (1/25 of the Irish population) causes a moderate deficiency which interacts with smoking to increase the risk of COPD ten-fold compared to usual smokers (1). We examined the relationship between a diagnosis of MZ-AATD and patient smoking habits. We attempted to contact 154 MZ on the National AATD Registry achieving 91 responses (59.1%). A custom questionnaire was designed and responses were captured using survey software (QuestionPro®). Among ever-smoking respondents (n=49, 57% female) mean tobacco consumption was 22.57 (SD ± 14.4) pack-years, with a mean GOLD airflow obstruction of 1.59 and only 8 (16.3%) individuals reporting active-smoking. Importantly, 60% of those quitting after a diagnosis of MZ-AATD did so within 6 months, while the 6 month quit rate was 12% for those who reported quitting after a diagnosis of COPD. Our data demonstrates significantly lower active smoking in ever-smoking MZs versus typical COPD cohorts (2) . There are an estimated 50,000 MZ smokers in Ireland. Identifying smoking MZs may help to improve cessation rates in this high-risk cohort and reduce their long-term morbidity. Benefits for nurse-led service provision by advanced nurse practitioners (ANPs) are well substantiated in international literature. Central to the role of Respiratory ANPs is patient-centred care and preference which encompasses empowerment, self-management and health promotion opportunities. In addition, a requirement of the role is to proactively seek feedback from persons receiving such care. 1 The purpose of the survey was to elicit patients' satisfaction with the quality of care received by Respiratory ANPs across 5 hospital sites in Ireland in order to evaluate current service provision as perceived by the patient. A non-experimental, descriptive design was used. One hundred sixty two clients who were reviewed by a Respiratory ANP in a hospital setting over a 6-month period were invited to participate in the survey. Data were collected by means of an adapted validated self-administered questionnaire 2 . Eighty six clients chose to participate, yielding response rate of 53%. Data were analysed using Excel statistical functions. The majority of respondents (N≥80) strongly agreed that the ANPs were interested and thorough, provided health education including inhaler technique and medicines management and allowed sufficient time for discussion. All respondents indicated that they would like to see the ANP again for a similar health need. Recommendation: Emphasis should be placed on avoidance to particular aeroallergens in asthmatic patients and environmental Interventions are recommended to to these particular patients.

9.13 Pedometers a useful adjunct in Pulmonary Rehabilitation?

Physiotherapy, Respiratory Integrated Care, Sligo/Leitrim Pulmonary Rehabilitation (PR) is a high value treatment for COPD management; however the benefits of PR decrease over time. In the absence of maintenance therapy, health benefits from PR are seen up to 12-18 months after completing PR1, which has led to interest in strategies to maintain the health gains achieved through PR.

In Sligo we decided to use pedometers as a strategy to encourage physical activity during the PR programme and once PR was completed. 18 participants were provided with a pedometer at the start of the PR programme and were encouraged to record the amount of steps achieved at the end of each day. Each week they were given step targets to aim towards. At the end of the PR programme, a questionnaire was administered to each of the 18 participants. 94.4% of participants (n=17) stated that the pedometer did encourage them to exercise, 88.9%(n=16) of participants stated that they would continue to use the pedometer after the classes have finished. 100% of participants stated that they would recommend use of the pedometer in future classes. Pedometers may have a role as an adjunct in Pulmonary Rehabilitation. Immediately post PR, pedometers appear to be favourable and utilised with this cohort however further follow up evaluation is required to see if participants are still using their pedometers at 6 months and 12 months post completing PR. As research is increasingly acknowledged within the competencies of specialist nursing roles, it is a challenge to balance the research role with clinical demands. In Naas General Hospital (NGH), nurses from six different specialities came together to discuss the need for psychological support for their patients with chronic illness. The objective of the research was to assess the levels of depression in patients with chronic illness and to develop a set of recommendations to provide support for these patients. Working with the Trinity Centre for Practice and Healthcare Innovation (TCPHI) partnership model, the research group commenced a descriptive, exploratory quantitative study in July 2018. Participants were patients with a chronic illness and were recruited from the relevant outpatient clinics (respiratory, cardiac, diabetes, rheumatology, stroke and dermatology). Patients completed a cross-sectional survey which included a validated self-related health question, generic demographics, illness-specific variables and the Patient Health Questionnaire (PHQ9)1. The PHQ9 questionnaire can used as a screening tool for depression in at-risk populations -e.g. those with chronic illness.

This has been the first nursing inter-departmental study of its kind in the hospital and has been instrumental in sharing knowledge and experiences across specialities. To date, data on 152 patients has identified that 22% of all patients (and 30% COPD patient cohort) screened in NGH with a chronic illness had scores equating to a potentially moderate or severe level of depression. Initially, an algorithm was developed based on existing RAU outreach criteria. This enabled the ED Staff/ ANP to identify appropriate patients for ANP facilitated ED discharge. If suitable, the patients' full episode of care (assessment, diagnostics, prescribing and discharge) was managed by the ANP. From January -June 2019, 30 patients were referred to the ANP for rapid assessment and ED discharge. 80% (n=24) of this group were accepted for ANP review with a further 67% (n=20) discharged directly by the ANP All patients (n=20) discharged by the ANP had a completed GP discharge summary and ANP follow up within 4-8 weeks. In the 3 months post ED discharge, 25% (n=5) of the ANP discharges re-attended ED compared to 30% (n=3) of the patients discharged through the traditional pathway. The benefits of pulmonary rehabilitation (PR) are widely known and published1, 2. Patients often report finding PR to be of significant benefit but outcome measures do not always reflect this. Is it that the outcome measures do not capture the entire benefit of rehabilitation or do we need to improve our service in order to get better outcomes? This audit was undertaken to investigate patient satisfaction with PR in St Michael's Hospital. Satisfaction questionnaires were given out to all patients who completed the rehab between August 2018 and March 2019. Of the 45 questionnaires given out, 42 were returned (93%). The results highlighted overall strong satisfaction with the course and with staff. Most patients either strongly liked (>60%) or liked (>30%) the course, in addition to finding it improved breathlessness (69%), fitness (83.3%) and anxiety levels (59.5%). However, it also identified patients need for further education on topics such as breathlessness, environmental triggers and targeting anxiety and depression.

Future PR courses should aim to improve the education provided. Extra effort should also be made to ensure the room is less crowded and well aerated Chronic Obstructive Lung Disease (COPD) is associated with enormous adverse socioeconomic and personal implications. Self-management is advocated for optimal disease management. "SingStrong" is a pilot community singing intervention co-led by a respiratory physiotherapist and community singing instructor designed to use targeted singing exercises and techniques to support optimal disease management. Eighty-five participants were recruited from COPD support groups in Limerick, Nenagh and Ennis. Pre and post-intervention (n=75) testing included physical endurance (Six Minute Walk Test), questionnaires (COPD Assessment Test, Hospital Anxiety and Depression Scale), and spirometry to establish disease presence and severity. Participants completed 8 one-hourly group singing classes at local centres. Participants were provided with a compact disk to practice breathing and singing technique and encouraged to use it daily. Focus groups with 21 participants were also conducted to establish participant experience post intervention. Focus group feedback was unanimously positive, reporting improvements in physical endurance, breathing capacity and enjoyment of the intervention. Quantitative data analysis is underway, but suggests significant improvements in endurance and lung capacity in many participants. Questionnaire-based outcomes appear largely unchanged. "SingStrong" is a low-cost, highly effective and enjoyable intervention for persons with COPD. Further research will investigate exacerbation frequency and cost-effectiveness, with national roll-out planned.

Cunneen, S., Baily-Scanlan, M., Cribbin, E., Scallan, C., Barker, E.

Tallaght University Hospital, Dublin

The mean length of stay (LOS) for patients admitted to TUH with an AECOPD was 10.88 days in 2018. A CSP post was established to reduce the LOS and improve quality of care for these patients who may not otherwise encounter a respiratory specialist during their inpatient stay. Patients were seen on the first weekday of their admission to assess their needs, treat if appropriate and establish a discharge destination. They were tracked until medically stable and if appropriate were discharged home or to Peamount Healthcare Respiratory Unit (PHRU).

124 patients were screened and 48 were accelerated to home (n=25) and to PHRU (n=23). Improvements were made in mean LOS e.g. 8.43 days in March 2019 in comparison to 10.94 days in March 2018. The mean LOS of medically stable patients after review by the CSP was 1.33 days whereas the mean wait for a Respiratory Registrar review for patients under general take was 4.6 days. The quality of care that patients received was enhanced by the CSP as shown below. These patients had early access to a respiratory specialist that improved their quality of care and accelerated their discharge. The CSP is also perfectly positioned to provide access to the wide-range of follow-up services that these patients require (e.g. pulmonary rehabilitation, airway clearance, oxygen clinic etc.). 

Frailty is a syndrome with poor physiological reserve which is a poor prognostic indicator in COPD. Levels of frailty in people with COPD who are supplemental oxygen users are not well known. Ireland has the highest hospitalisation rate for exacerbations of chronic obstructive pulmonary disease (COPD) among selected Organization for Economic Cooperation and Development (OECD) countries 1 . As part of the national COPD collaborative project, we aimed to reduce the length of stay (LOS) of patients presenting with acute exacerbations of COPD (AECOPD); to improve access to the respiratory specialist service and to introduce a COPD Bundle of care to the emergency department. As part of the National COPD Improvement Collaborative project, a team was established in Naas General Hospital and weekly meetings were held. Process mapping was used, and baseline data gathered to understand the complexities of our current system. Subsequently, SMART aims and driver diagrams were developed, change ideas were generated and tested using the PDSA cycle ( Figure 1) . A respiratory nurse attended the emergency department to screen for patients attending with AECOPD and a COPD management bundle was introduced at the point of triage. By introducing early respiratory review there was a reduction in LOS from 8 days to 5 days. Time from patient registration to review by respiratory specialist improved by 2 days. Furthermore, introduction of COPD bundle ensured that every patient attending with AECOPD received standardised care. COPD is a major burden for Irish Emergency Departments (ED). Long waits to be seen by a clinician, high admission rates and sub-optimal care impair the delivery of services and patient wellbeing. 1 In September 2018 we introduced a nurse practitioner (NP) service for patients presenting with exacerbations of COPD to our ED. Patients are screened by the triage nurse using eligibility criteria. If a patient meets the criteria, the NP is contacted and promptly comes to assess the patient. The NP independently assesses, diagnoses, treats and refers the patient for admission or discharge. To date, 86 patients have been assessed. For those with exacerbations of COPD (52), 80% were discharged home. The 30 day ED re-presentation rate was 17% (9) with 2 of these patients requiring hospital admission. The median length of ED stay for these patients was 2.5 hours. A reduction of 18% has been seen in the hospital admission rate for COPD when compared to the same period last year. With strict management protocols and good mentorship, nurse practitioners can effectively and independently manage this group of patients. Respiratory nurse practitioners can enhance patient flow, improve high admission rates and standardise care for patients with exacerbations of COPD within the ED. consultant-led respiratory teams in 19 hospitals attempting to reduce variation in the treatment of acute exacerbations of COPD (AECOPD) at presentation, admission and discharge stages. The Collaborative aims to facilitate the development of participating teams' QI skills and to empower them to generate improvement specific to their own hospital/patients' needs through adherence to evidence-based standards of care and the implementation of care bundles. QI theory and methodology is taught at five face-to-face national "Learning Sessions (LS)" with hospital site visits between each LS. Evaluation focuses on assessment of monthly patient data (22 measures) submitted by each team relating to the acute care journey of patients presenting with AECOPD. Run charts will be used and data will be cohorted for analysis according to the focus of each team's project(s). A survey will be administered at the final LS (September 2019) to explore whether team members feel they have effectively learned QI methodology and whether this knowledge allowed them to improve patient care in their hospital. Impact on patient care will be qualitatively analysed. Ireland has an estimated 500,000 people with COPD and is currently the main reason for presentations to emergency departments in Ireland. Evidence shows COPD patients have poor MA. Outreach services/care is becoming more popular in the management of COPD in Ireland. A systematic review was completed on all available research on COPD patients whose MA was studied in the community with a vast online database search yielding 8 articles. Due to heterogeneity, a narrative synthesis was used to review the articles (4 randomised control trials and 4 pre-and-post intervention studies). Of the 8 studies, 2 were deemed non-valid, but were included due to the lack of available articles. All studies measured MA as either a primary or secondary outcome and this SR demonstrated the ability to improve MA from outreach programmes. This SR determined MA has the potential to be improved from an outreach programme but requires more high-quality research in the area to develop a standardised plan for outreach programmes on MA. The aim of this study was to achieve and sustain 80% of patients having their inhaler technique checked and for 100% of patients to receive a selfmanagement plan and discharge bundle by January 31 st 2019. Our initial audit results showed inconsistent assessment of patient's inhaler technique and a lack of discharge planning and self-management plan, 10% and 0% respectively. The inhaler technique checklist from the National Asthma Council Australia was amended to include all inhalers licenced for COPD management in Ireland. Following education, physiotherapists began assessing inhaler technique as part of their in-patient treatment. A new self-management plan and discharge bundle was developed based on a review of national and international resources, multi-disciplinary team (MDT) discussion and patient consultation. Inhaler technique and the use of the discharge bundle and selfmanagement plan improved from 10% to 100% and 0% to 100% respectively by January 2019. Sustainability has varied depending on annual leave, staffing resources and time. There is evidence for the importance of correct inhaler technique and the use of self-management plans and discharge bundles (Molimard et al. This quality improvement initiative focused on i) improving early access to assessment for patients admitted to Mayo University Hospital (MUH) with AECOPD by both a Respiratory Nurse and Physiotherapy and ii) standardisation of treatment. All AECOPD patients will have a Respiratory Nurse and Respiratory Physiotherapy assessment within 24 hours of admission between Sunday to Thursday and will have an intervention bundle completed prior to discharge. The Respiratory Nurse and Respiratory Physiotherapist pro-actively attended ED and AMAU daily to ensure all AECOPD patients would receive standardised respiratory interventions. The patients then received a standardised intervention bundle based on BTS 2016 and GOLD 2019 guidelines. The primary outcome was to reduce the amount of time to first respiratory assessment to <24hrs. This was achieved for 8/11 months (73%), with reduced staffing and weekend admissions being the main reasons for failing to achieve this every month. Evidence of prescription review with patient improved from 0% to 89% in August 2019. Completion of the intervention bundle improved from 10% to 89%. Follow up phone call within 72hours improved from 0% t0 100%. Evidence of provision of the self-management plan improved from 0% to 44%. Early respiratory assessment for patients admitted with acute exacerbations of COPD (AECOPD) resulted in an improvement in quality and consistency of care delivered in line with best practice. A COPD support group was established in 2007 following on from completion of pulmonary rehab program. Its aim was to facilitate and support ongoing education, self-management and exercise for COPD patients in the North west After completion of a pulmonary rehab programme, the necessity of a regular review/engagement with hospital MDT staff was identified by all patients on their post pulmonary rehab evaluation. As an objective to meet the needs of the COPD patients, the inaugural COPD/Respiratory Support group was commenced in JULY 2007. The BENBULBEN COPD Support group has been successfully running since, with regular monthly meetings and weekly exercise classes. As A facilitator for Our local COPD/Respiratory Support group, I support the patients by phone, facilitate the speakers for the monthly meetings and give advice when required. On our 10year anniversary we retrospectively reviewed all original members admission to hospital rates for 2006/7and 20016/2017. We then reviewed all Spirometry for 2007 and compared to 2017and further reviewed in 2019. The benefit of the COPD support group was evaluated very positively, with all patients having fewer admission to hospital. Variability in lung function was static or had improved for most patients.

The benefits of a COPD support group are patient centred, cost effective and beneficial to all. Empowering our patients with regular MDT education updates, social engagement and self management prevents hospital admissions and maintains lung function. The aim of this project was to improve and standardise the treatment pathway for patients admitted to hospital with COPD, from admission to discharge. Patients with COPD, who attended the Emergency Department (ED), were to be reviewed by the respiratory ANP, where appropriate, and initiate a management pathway. If the patient was deemed suitable for discharge, COPD Outreach would provide appropriate follow-up care. If the patient was to be admitted, the patients were to be reviewed within 24-48 hours by a respiratory CNS to optimise COPD treatment, initiate a discharge bundle, provide education, check inhaler technique and ensure adequate follow-up was put in place. On discharge, the patient would link in with COPD Outreach. Since September 2018, 86 patients have been reviewed in ED by an ANP, 80% of patients with COPD were discharged home. There has also been an 18% reduction in admission rates. Since November 2018, 115 of admitted cases were reviewed by the CNS, 65% of all COPD admissions. These results confirm the effectiveness of implementing a standardised pathway for the treatment of patients with COPD.

Utilizing care bundles during acute COPD exacerbations results in fewer complications, reduced length of stay and readmissions. Gaps were identified in COPD management such as no care bundles / standardised tools, lack of confirmed diagnosis, inhaler technique not routinely checked, and suboptimal respiratory follow-up. Nenagh Hospital implemented a Discharge Bundle, to address these gaps. Stakeholders were identified, including the local COPD support group. Monthly meetings were arranged. Process mapping, SMART aims, and PDSA's followed. Training sessions completed for staff. A draft bundle was trialled and amended based on feedback. Monthly audits completed and analysed. 50% of patients admitted now have a discharge bundle. Spirometry results are now accessible and a shared access folder is available across sites. Training provided enhanced staff knowledge of inhaler devices for prescription and review. Referrals to the respiratory team increased from 20% to 100%. Setting out to implement a Discharge Bundle allowed us to identify gaps in the COPD service. The process required multidisciplinary input to establish the care bundle. We did not achieve 100% of our goals, but our successes to date demonstrate positive outcomes. The aim was to develop an evidence based admission bundle that would standardise assessment, aid clinical decision making and ensure optimum care for all patients. The goal for this project was to improve the overall care for patients presenting with AECOPD and allow an evidence-based approach in their management .We looked at the DECAF assessment tool, which is a simple and effective predictor of mortality in patients hospitalised with AECOPD and which also proved beneficial to clinicians to more accurately predict patient outcomes and levels of care (Steer et al. 2012). The components of the Admission Care Bundle were developed following a review of current best practice guidelines including BTS. 100% of patients presenting with AECOPD to Ennis MAU are assessed using the pathway & outcomes have improved as a result. Spirometry results are now available on a shared database. The DECAF tool has assisted clinical decision making, allowing clinicians to contemplate safe discharge The AECOPD Intervention Bundle has ensured appropriate management of all patients presenting with suspected or known COPD. Early introduction of COPD outreach would significantly benefit patients with a low DECAF score in the community. The development of a Nurse Led Clinic would ensure early follow-up of higher risk patients. We have indentified the need to now develop a discharge bundle to further improve patient management.

Steer, J., Gibson, J. and Bourke, S. (2012) The DECAF Score: predicting hospital mortality in exacerbations of chronic obstructive pulmonary disease. Thorax

The implementation of a COPD management intervention bundle with a DECAF assessment to improve care of acute exacerbation of COPD Cullinan, M., Ryan, P., Watkins, S., Julian, N., Dr. Peirce Respiratory Department, University Hospital Limerick Group, Limerick Introduction/Aim: Admissions of COPD exacerbations within the University Hospital Limerick group are not standardised and there is a lack of evidence based knowledge. A COPD admission intervention bundle was implemented with the aim of improving care and reducing readmissions for patients admitted to the AMAU with acute exacerbations of COPD. The goal for this project was to improve the overall care for COPD exacerbating patients and to standardise treatment for this group of patients. Evidence based care has been shown to improve quality of life, reduce length of stay and on occasions avoid hospital admission. The admission bundle allowed for a more streamlined approach of the standardised treatment for this patient group. Results: The care bundle was implemented in the AMAU department with the overall care of AECOPD patients being improved. Spirometry results are available on a shared database for all respiratory patients. Conclusion: The COPD management intervention bundle and DECAF assessment tool has significantly proven the importance of standardised care. A designated team to capture all AECOPD patients presenting to ED/AMAU throughout the hospital group would reduce admissions, exacerbations and improve quality of care. Viral, bacterial, allergic and inflammatory pathways are implicated in the pathophysiology of CF exacerbations. We hypothesise that subtypes of CF exacerbation exist that predict clinical outcomes. This prospective cohort study recruited 72 patients at onset of a CF exacerbation. Three exacerbation categories were proposed: pauciinflammatory (CRP <5mg/L), viral (CRP ≥ 5mg/L and viral infection) and bacterial (CRP ≥ 5mg/L and no viral infection). Clinical data (FEV 1 , IV antibiotic duration) and biologic samples (serum CRP, plasma biomarkers, sputum ± nasal viral PCR) were collected at exacerbation onset. Chi-square, ordinal logistic regression and linear regression were used to test for trends between phenotypes. The most prevalent category was "pauci-inflammatory" (40.58%) followed by "bacterial" (36.23%) and "viral" (23.19%). Baseline microbiological status and exacerbation history did not differ between phenotypes. Significant differences between phenotypes were present in IL-6, IL-8, IL-10 and IgG. Relative drop in FEV 1 The prevalence of concomitant asthma in CF has been estimated at 14-19%. Little information is available on CF patients' inhaler technique or adherence,making it difficult to determine the effectiveness of inhaled medications in CF. In this cross-sectional study a chart review of 173 CF patients attending Cork University Hospital was performed.Inhaler technique and adherence were assessed in a subset of patients using validated technique scoring sheets and a validated self-reported adherence questionnaire. 34.9% had an elevated total IgE level.Reversibility was documented in 13.9%. 64.1% were prescribed a Short-Acting B 2 -Agonist,43.2% of which were prescribed as part of inhaled antibiotic regimens.52% were prescribed an Inhaled Corticosteroid/Long-Acting B 2 -Agonist combination and 15% were prescribed a Long-Acting Anti-Cholinergic. 83.3% demonstrated suboptimal technique(score<100%),the mean total score being 74.2%.Patients scored worst in the "Additional Steps" category(mean=59.4%).96.8% previously received education on inhaler technique. 70.3% reported adherence rates of 81%-100%.The most common barrier to adherence was remembering to take a dose(29.4%). Analyses of total IgE and PFT results suggest a prevalence of the asthmatic phenotype of 13.9-34.9%,which is higher than previous studies. Remembering to take doses and the "Additional Steps" category were identified as key barriers to optimal inhaler adherence and technique. Future focus on these barriers may prove beneficial. Physical activity (PA) is a well-established therapeutic modality for improving long-term health in cystic fibrosis (CF). Healthcare professionals (HCPs) play a significant role in promoting PA behaviours. Limited research exists regarding Irish HCPs' knowledge and practice of PA promotion for people with CF. There is also a lack of research identifying the barriers experienced by CF-HCPs when promoting PA. The present study identified Irish HCPs' knowledge and practice in prescribing PA for CF and the barriers preventing such prescription. 48 HCPs (physiotherapists n=24, other n=24) from six CF-centers in Ireland, and members of the national physiotherapy clinical interest group, completed a 30-item online survey. 70% of CF-HCPs agreed that recommending PAwas part of their professional role, with three-quarters reportedly discussing PA at every patient visit. Almost all physiotherapists (95%) reported having sufficient knowledge regarding PA prescription, compared to 17% of other CF-HCPs. Interestingly, 81% of physiotherapists and 96% of other CF-HCPs reported receiving no formal undergraduate training in relation to exercise prescription for CF populations. The perceived deficiency among a high proportion of CF-HCPs, in relation to undergraduate education of CF-specific exercise prescription, is surprising and needs to be addressed, particularly with the high prevalence of CF in Ireland. RATIONALE: Cystic fibrosis (CF) pulmonary disease is characterized by chronic infection with Pseudomonas aeruginosa and sustained neutrophildominant inflammation. The lack of effective anti-inflammatory therapies for people with CF (PWCF) represents a significant challenge. OBJECTIVES: To identify altered immunometabolism in the CF neutrophil, and investigate the feasibility of specific inhibition of the NLR family, pyrin domain-containing protein 3 (NLRP3) inflammasome as a CF anti-inflammatory strategy in vivo. METHODS: Key markers of increased aerobic glycolysis, known as a Warburg effect, including cytosolic pyruvate kinase M2 (PKM2), phosphorylated PKM2, succinate, HIF-1α, lactate and the interleukin (IL)-1β precursor pro-IL-1β, as well as caspase-1 activity and processing of pro-IL-1β to IL-1β by the NLRP3 inflammasome, were measured in neutrophils from blood and airway secretions from healthy controls (n=12), PWCF (n=16) and PWCF post-double-lung transplant (n=6). The effects of specific inhibition of NLRP3 on airway inflammation and bacterial clearance were subsequently assessed in vivo. MAIN RESULTS: CF neutrophils display increased aerobic glycolysis in the systemic circulation. This effect is driven by low-level endotoxaemia, unaffected by CFTR modulation, and resolves post-transplant. The increased pro-IL-1β produced is processed to its mature active form in the lipopolysaccharide-rich CF lung by the NLRP3 inflammasome via caspase-1. Specific NLRP3 inhibition in vivo with MCC950 inhibited IL-1β in the lungs of CF mice (P<0.0001), resulting in significantly reduced airway inflammation and improved Pseudomonas clearance (P<0.0001). CONCLUSIONS: CF neutrophil immunometabolism is altered in response to inflammation. NLRP3 inflammasome inhibition may have an anti-inflammatory and anti-infective role in CF. Objectives: Recent clinical trials have supported the efficacy of Lumacaftor-Ivacaftor (Orkambi). We aimed to evaluate real world clinical effectiveness over 12 months Methods: Thirty-one standard clinic patients with a PhelF508del homozygous mutation were assessed at baseline, 3, 6, 9 and 12 months' post initiation of treatment. Changes in 1)clinical parameters including ppFEV 1 , BMI, IV antibiotic usage, number of hospital admissions 2)surrogate markers of CFTR modulation-sweat chloride, 3)disease/quality of life-related symptoms questionnaires 4)plasma/sputum inflammatory mediators were measured. Results: Significant and sustained improvement in lung function(ppFEV 1 ↑4.8%-p<0.001), BMI (↑0.9kg/m2-p<0.001), sweat chloride(↓17.6 mmol/l-p<0.001), IV antibiotic usage(↓84%-p<0.001) and hospitalisations(↓87%-p<0.01) at 1 year was noted. Improvements in quality of life were demonstrated; CFQ-R respiratory domain(+7 points-p<0.001), CFQ-R digestive domain(+6.6 points-p<0.05). Improvements in patient reported outcomes included; FACIT fatigue score(↑5.6-p<0.001) and sino-nasal-outcome-test(↓2.9-p=0.001). A significant change in sleep quality was not observed Plasma IL-1β(p<0.001), plasma TNF-α(p<0.01) and sputum IL-1β(p=0.001) were also reduced. Conclusion: Our real world cohort supports recent clinical trials with improvements in lung function, BMI, CFQR respiratory domain and exacerbation reduction. Our study additionally highlights improvements in sweat chloride, CFQR digestive domain and an important patient reported outcome of fatigue reduction. In addition to the standard quarterly review, patients often contact the CF Multidisciplinary Team (MDT) via phone to express health-related concerns which may require a phone evaluation before organizing an unscheduled appointment. Current resources are often heavily affected by the sporadic nature of these interactions. Furthermore, data from the European CF registry predicts that there will be a 75% increase in the adult CF population by 2025 which will further impact these limited resources 1 . For this reason, creating a system which could collect and report the patient's status so that the MDT can take timely and appropriate action would optimize the existing process. A series of meetings was held with members of the MDT and UCC Computer Science Department to develop an appropriate series of clinical questions. Two scoring systems were developed to evaluate the patient's condition and the change between their current and baseline conditions. Assessment and triage of patients will be partly based on these scores. The system has been developed for web and interacts with the patient via speech. A prototype has been developed and undergone technical evaluation. The front-end 3D avatar interface is currently in development before undergoing pilot testing and review with patients. The prevalence of pulmonary arterial hypertension (PAH) among the pretransplant Cystic Fibrosis (CF) population has become a rising concern in recent years. Reported prevalence in the literature ranges from 26.0%-63.2% between international centres. 1, 2 Here for the first time; we examine the prevalence of PAH in an Irish pre-transplant CF single-centre cohort. This study retrospectively examines the pre-transplant trans-thoracic echocardiogram (TTE), right heart catheterisation (where applicable) and spirometry results for all patients in the HSE South Adult CF Service undergoing lung-transplant assessment from 2009-2019. TTE results were scrutinised for evidence of increased right-heart pressures (raised RVSP, right-ventricular dilation, inter-ventricular septal flattening, right-atrial dilation, tricuspid regurgitation). Concomitant spirometry results were collated. A cohort of 20 patients underwent transplant work-up from 2009-2019. Figure 1 summarises their outcomes. 60% of included patients demonstrated evidence of increased right-heart pressures. The results suggest poorer outcomes within this group. Spirometric results showed a mean FEV1 0.95L(27.2% predicted). The data presented demonstrates a high prevalence of 60% for mildmoderate PAH among this Irish pre-transplant CF single-centre population with severe obstructive lung disease. This single-centre data supports the need for further interrogation of the national pre-transplant CF population to establish the true overall prevalence and clinical significance of PAH. Following the narrative analysis of the data in the 7 articles, it is evident that pain is a common problem affecting both paediatric and adult CF patients. Pain has a negative effect on the quality of life of these patients and is linked to higher incidences of depression and anxiety. It also negatively affects patient's treatment regimens and day to day life. There is limited research into this subject and therefore there is a need for further research. 

All had reduced DLCO (35% -60% Predicted), 88% had a reduced TLC.

In this group, all had increased P0.1 and 83% had a reduced PI Max. 50% had a reduced PE Max and 38% had a reduced MVV. 43% had a reduced distance on 6MWT, 29% had significant desaturations on 6MWT, and 25% had a Borg Score of 4 or higher, none had significant differences between Sitting and Supine FVC.

This study suggests that a significant percentage of IPF patients have some impairment in respiratory muscle function. All these patients, as a result of these findings, are fast-tracked into the pulmonary rehabilitation program. *These authors contributed equally to this work Pirfenidone and Nintedanib are oral anti-fibrotic agents(OAF) which have been shown to slow the rate of decline in lung function in Idiopathic pulmonary fibrosis (IPF). Randomised controlled trials reported adverse events (AE) and have shown discontinuation rates of 14-33%. However post approval 'real world' datasets describe much higher discontinuation rates and allow for better understanding of side effects and tolerability. We retrospectively assessed the tolerability of OAF in our patient cohort to assess possible associations with patient clinical or diagnostic factors. We identified 67 patients with a diagnosis of IPF who had been prescribed an OAF. The overall discontinuation rate was 57%. This was the cumulative rate over a 4year period. We excluded patients who underwent lung transplantation from this analysis. Some interesting patient factors which may predict discontinuation of OAF therapy were identified. For example we found an interesting association between pre-treatment gastroesophageal reflux disease (GORD) and OAF discontinuation. A total of 14 (63%) of patients who discontinued OAF had a diagnosis of GORD prior to initiation of OAF. Eleven (78%) of these patients were taking Pirfenidone. In our experience OAF are less well tolerated in practice then described in clinical trials, with patient specific factors requiring consideration pre-treatment. The management and outcome of patients with pulmonary fibrosis (ILD) has improved in recent years. The aim of this study was to review all patients attending this District General Hospital (DGH) and identify the morbidity of the population locally with ILD. A data base of all patients attending this DGH was established by Spring 2019. Age at diagnosis, sex, radiological sub type of fibrosis, the use of anti fibrotic agents and requirement for oxygen was all recorded. There are 127 patients with a diagnosis of ILD attending this DGH in June 2019., 71 male. Age at diagnosis varied from 47-92, mean 77. Duration of follow up has varied from months to 13 years. 109 patients have been discussed at an ILD Xray meeting, 69 have been classified as having UIP, 16 connective tissue related fibrosis. 41 patients are on oxygen, 29 of these are on ambulatory oxygen, 11 are on long term oxygen therapy (LTOT). Twenty-five patients are on anti-fibrotic drugs as per NICE guidelines. This study shows that the patients with ILD are very diverse in both age and disability. This information will help us plan future care of these patients more effectively. We will be able to identify those patients who require more regular and intensive follow up. A specialised interstitial lung disease clinic was established in Beaumont hospital in April 2018. Since then approximately 104 new patients have been seen in this clinic. All patients attending the service were discussed at a specialised multidisciplinary meeting. Of these, 60 were identified as having idiopathic pulmonary fibrosis (IPF). The cohort was predominantly male, with 38 men and 22 women attending the service, and median age of 74.5 years. Over half of those who were diagnosed with IPF were ex-smokers, with an average 25 pack-year history. A radiological diagnosis of definite Usual Interstitial Pneumonia was confirmed in 39 patients, with 6 patients having undergoing lung biopsy to attain a diagnosis.

A total of nine patients were identified to have a significant family history of interstitial lung disease (ILD), with a further patient having an identified genetic mutation associated with ILD. This represented 17% of the patient cohort, directly reflecting proportions of familial ILD in preliminary work from the ITS National Registry of IPF. Documentation of treatments offered to patients, including referral for transplant, palliative care referrals, and consideration of anti-fibrotic therapy were obtained. A breakdown of anti-fibrotic treatment, steroid or other immunotherapy use, and their tolerability was recorded. (Chart 1, below).

12.6 Physical activity in people with idiopathic pulmonary fibrosis: A cross sectional study The aim of this study was to explore physical activity (PA) levels and the associated self-efficacy as well as the barriers and facilitators to PA in a cohort of people with idiopathic pulmonary fibrosis (IPF).

All IPF patients at Cork University Hospital were screened for eligibility. Questionnaires were circulated to eligible participants by post. PA was assessed with the international physical activity questionnaire (IPAQ), self-efficacy with Marcus self-efficacy and a questionnaire was developed to explore participants' barriers and facilitators to PA. Information on a patient's demographics, 6 minute-walk-test (6MWT) and pulmonary function tests (PFTs) were recorded. Descriptive statistics were used Thirty-one participants consented. Patient demographics, PFTs, 6MWT and smoking history are summarized in Table 1 . IPAQ (median(IQR)): 3123(1036.5-6441.1) MET minutes/week. Marcus self-efficacy (mean(SD)): 2.1(0.8). The most common barriers were breathlessness 95%, lack of energy/too tired 64% and activity induced coughing 54%. The most common facilitators were pacing oneself 93%, motivation from benefits of PA 82% and access to a space for engaging in PA at own pace 79%. Participants in the current study reported higher levels of PA, compared to other IPF cohorts 1 . This research provides novel information on PA selfefficacy and the barriers and facilitators to PA in IPF. Patients commencing antifibrotic therapy for interstitial lung disease (ILD) require monitoring with pulmonary function testing (PFTs), liver function testing (LFTs) and clinical review as per Irish Thoracic Society guidelines. We investigated whether clinical follow up at Sligo University Hospital met these standards. Recommendations included the above investigations be carried out at treatment commencement and at 6 weeks. Inclusion criteria included patients with ILD amenable to antifibrotic treatment and who were started on medication, without attendance at another respiratory service. Patients with ILD were discussed at our local multi-disciplinary meeting (MDM) with consultant radiologist input, with selected patients further discussed at tertiary hospital MDM. Of the 27 patients discussed, 22% (n=6) were started on antifibrotic treatment. We carried out an online chart review to identify baseline and 6 weekly clinical review, PFTs and LFTs. At therapy commencement, 33% of patients had PFTs, 83% had LFTs and 100% of patients were clinically reviewed. At the recommended six weeks, 17% had PFTs, 50% had LFTs and 33% had clinical review. To fulfil audit aims, a specialized multi-disciplinary team is advised with Respiratory Consultant, ILD Specialist Nurse and Specialist Respiratory Physiotherapist reviewing patients at a dedicated to ILD clinic with access to required investigations. 

Farrell A 1 , Higgins H 1 , Aherne P 2 , Sweeney P 2 , Brady C 2 , O'Connor TM 1. The incidence of sarcoidosis in patients with testicular cancer is higher than in the general population (1) . The aim of this study was to determine the incidence of sarcoidosis in patients with testicular cancer in a tertiary referral centre in Ireland between 2005 and 2018. A retrospective review was carried out to identify male patients with a diagnosis of testicular cancer and sarcoidosis seen in a tertiary referral centre in Ireland between 2005 and 2018. 12 cases were identified. The average age of diagnosis of testicular cancer was 36 years. Nine patients had stage one disease, 1 had stage two and 2 had stage three at diagnosis. All underwent surgical resection (orchidectomy). In 75% (9/12), the histological subtype was pure seminoma. All cases of sarcoidosis were diagnosed after diagnosis of testicular cancer. Six patients had tissue confirmation of sarcoidosis, the remainder were diagnosed following MDT discussion. 11 patients had Siltzbach stage one sarcoidosis at presentation and 1 patient had stage two sarcoidosis. The estimated cumulative incidence of sarcoidosis amongst patients with testicular cancer was 6185.6 per 100,000 patients. The observed incidence of sarcoidosis showed an over 200 fold increase in patients with testicular tumours compared with general population in Ireland. Sarcoidosis is a multisystem granulomatous disorder with a high prevalence in the Irish population. Diagnosis is made with transbronchial/ endobronchial biopsy (parenchymal lung disease) or EBUS (lymph node predominant disease), with a hallmark of noncaseating granulomata. However it is recommended Immunoglobulin levels are checked, to exclude a diagnosis of Combined Variable Immunodeficiency (CVID).The purpose of this study was to assess compliance to testing immunoglobulin levels in patients made with a diagnosis of sarcoidosis. We reviewed the charts and blood results of 34 consecutive patients who had been diagnosed with sarcoidosis over a four year period. All 34 were confirmed as having non-caseating granulomata at either EBUS or parenchymal lung biopsy. 13 patients (38%) did not have immunoglobulin levels checked at diagnosis. For follow up, 2 of these patients had emigrated, and of the remaining 11 patients, 1 patient had an abnormal immunoglobulin profile and was diagnosed with CVID. He was male, aged 26, had suffered from intermittent chest infections and had been referred with dyspnoea and parenchymal lung changes on chest xray. This study highlights the importance of routinely checking immunoglobulin levels to assess for CVID in patients diagnosed with a granulomatous lung disease. Isolated pauciimmune pulmonary capillaritis (IPPC) is a rare cause of p u l m o n a r y c a p i l l a r i t i s a n d r e s u l t a n t d i f f u s e a l v e o l a r haemorrhage(DAH). IPPC is defined by the absence of serological or histological evidence of systemic disease.(1) Due to its rarity there are no RCTs for treatment. Management has centred on immunosuppression with corticosteroids and steroid sparing agents like cyclophosphamide. There is no known rescue therapy for patients unresponsive to above mainstay treatments. (2) We present two cases of IPPC which have maintained remission with rituximab therapy following recurrent DAH on standard immunosuppression. These cases suggest that rituximab can be considered as an alternative therapy for refractory IPPC. The failure rates of pleurodesis approaches 40% resulting in pleural fluid reaccumilation and dyspnoea 1 . Identifying patients in whom pleurodesis may fail is desirable. The objective of this study was to assess the relationship of specific ultrasound characteristics, namely pleural and diaphragmatic thickness, with the outcome of pleurodesis. A prospective study was conducted of 38 consecutive patients with malignancy and recurrent symptomatic malignant pleural effusions. 26 to mass effect 1 . Tracheobronchial stent insertion is a common intervention for the management of airway compromise. Adequate respiratory function can usually be supported with jet ventilation. However, in some patients with severe TBM, airway collapse can limit the ability to oxygenate and ventilate patients undergoing complex tracheobronchial intervention. Veno-venous extra-corporeal membrane oxygenation (VV-ECMO) has been considered as an adjunct to surgery in a subset of patients who cannot be adequately supported with conventional mechanical ventilation 2 .

samples ( Figure 1K ), similar to measuring these SCFAs by mass spectrometry. In addition, taxa associated with these KOs in RNA are known upper airway commensals ( Figure 1M ). 16S rRNA gene sequencing does not provide accurate functional information in the lower airway microbiome. The addition of RNA metatranscriptomic characterization of the lower airway microbiota is feasible and provides functional insights that are consistent with metabolomic signatures identified in a dysbiotic signature. The addition of this technology to standard microbiome investigations may provide important insight into the interaction between microbiome and host. Patients who survive a hyper-inflammatory stage of sepsis can progress to the late stage characterised by immunosuppression believed to be due, in part, to monocytic cell paralysis and T-cell exhaustion.

Our lab group have shown that Mesenchymal Stem Cells (MSCs) are effective in combating bacterial pneumonia for early stage sepsis (1) and we aimed to develop an in vivo and in vitro prolonged sepsis model to subsequently investigate if MSCs restore immune cell homeostasis in late sepsis. We established an in vivo model of prolonged sepsis by administering intratracheal K. pneumonia cultures to CD rats. MSCs were administered after two days and immune cell and cytokine profiles of the blood and BAL analysed after a further three days. An endotoxin tolerant cell culture was established using immune cell lines and isolated white cells from blood and Bronchoalveolar lavage (BAL) exposed to increasing levels of endotoxin in vitro.

MSCs have the ability to restore immune homeostasis in vivo and in vitro as demonstrated by a restoration of functionality in cells isolated from treated animal models ( Figure 1 ) and also in cells induced to become tolerant ex vivo. MSCs could comparatively restore their function, and conditioned media was as effective as co-culture in vitro. 

Non-invasive ventilation in acute exacerbations of chronic obstructive pulmonary disease: long term survival and predictors of in-hospital outcome

References: 1. Smith GB , et al. A review, and performance evaluation, of single-parameter "track and trigger" systems

Impact of Depression and Anxiety on Quality of Life, Health Behaviors, and Asthma Control Among Adults in the United States with Asthma

Chronic Obstructive Pulmonary Disease in over 16's: diagnosis and management. 29/04/2019

Respiratory Assessment Unit, St. James's Hospital, Dublin 8. 3. Physiotherapy Department

Future trends in cystic fibrosis demography in 34 European countries

Dublin Identification and optimisation of potential risk factors that predict poor survival can aid clinical decision making, facilitate improved patient selection and ultimately improve outcomes. We wish to describe the Irish experience of co-morbidities post-transplant for cystic fibrosis and investigate potential pre-transplant factors that could impact on long term survival. We performed a retrospective review of all 61 patients who received a lung transplant for cystic fibrosis between 2008-2017 at our centre. A t-test was used for comparison of mean values. The overall 5-year survival post-transplant is 73.8%. The mean age at transplant is 29.8 years (range 17.8-59.9) with a male predominance (69%). 64% were homozygous ΔF508 genotype

Of the 48 patients who remain under review, chronic kidney disease is common with 54% of patients having an eGFR <60ml/min. The prevalence of diabetes increased from 38% at listing to 71% at follow-up

Pulmonary hypertension is a mild comorbidity in end-stage cystic fibrosis patients

Prevalence of pulmonary hypertension in end-stage cystic fibrosis and correlation with survival. The Journal of Heart and Lung Transplantation

What is the impact of pain on the quality of life for patients with Cystic Fibrosis? A systematic review MetaAnalyses: The PRISMA Statement

Interstitial Lung Disease

Respiratory Muscle Function in Interstitial Lung Fibrosis (IPF)

Population Estimates fo r S o u th e rn He al t h a n d S o ci al Ca re Tr u st

Video-Assisted Thoracoscopic Surgery Lobectomy versus Open Lobectomy in Patients with Clinical Stage I Non-Small Cell Lung Cancer: A Meta-Analysis

Thoracotomy Is Better than Thoracoscopic Lobectomy in the Lymph Node Dissection of Lung Cancer: A Systematic Review and Meta-Analysis

Accessed 4

Based on ultrasound measurement of pleural thickness, we found a highly statistically significant difference between both groups. Group I (successful pleurodesis) had a mean pleural thickness of 9.5 mm as compared to Group II (failed pleurodesis), who had a mean of 15 mm. (p<0.001)

We conclude that ultrasound findings of pleural nodularity accompanied by thickening of the parietal costal pleura represent significant predictors of pleurodesis failure

Respiratory support with venovenous extracorporeal membrane oxygenation during stent placement for palliation of critical airway obstruction: case series analysis

Investigation of a unilateral pleural effusion in adults: British Thoracic Society Pleural Disease Guideline

A Single Center Review of Pleural Fluid Samples

Institute of Biomedical and Environmental Health Research, Health and Acknowledgement: This study was funded by the EU under the Interreg VA Programme, managed by the Special EU programmes body (SEUPB) References: Thus, we retrospectively reviewed cases of three cases of patients with severe airway obstruction (ASA grade IV) undergoing "awake ECMO" (May-September 2018) at centres of excellence for thoracic surgery in Ireland. We report a successful series of cases of tracheobronchial stent insertion requiring the use VV-ECMO to provide adequate respiratory support during bronchoscopy. References

Authors' comments: This study identifies a new anti-inflammatory therapeutic strategy for cystic fibrosis (CF). We show for the first time that alterations in CF neutrophil immunometabolism drive pro-inflammatory cytokine release by these cells, an effect that correlates closely with clinical outcomes and can be abrogated by a specific small molecule inhibitor of the NLRP3 inflammasome. The data show that these immunometabolic changes stem from chronic inflammation rather than an intrinsic CFTR defect and as such may occur even in the presence of effective CFTR modulation. The aim of this study was explore how idiopathic pulmonary fibrosis (IPF) patients are catered for within pulmonary rehabilitation (PR) services. A study specific online survey was developed. The survey was circulated to 27 PR sites in Ireland. Descriptive statistics were used for quantitative data and open ended questions were analysed using thematic analysis. The survey was completed by n=18 sites. All sites include IPF patients, n=1 site provides PR specifically for interstitial lung disease (ILD). The mean (SD) number of participants per cohort: 9.4(2.5); n=6 COPD patients per cohort. N=5 reported adapting their assessment of quality of life for IPF. All sites reported tailoring the exercise component to the individual regardless of condition, common themes for the adaptation for the IPF cohort were increased monitoring of saturations and provision of supplemental oxygen. Four sites reported providing IPF specific education, common themes identified were oxygen therapy and advanced care planning. A further three sites reported providing IPF education for disease management as appropriate. All sites reported including IPF patients in their PR programmes. There is a varied approach to the management of IPF in PR. Further research is required to develop IPF specific PR guidelines to achieve optimal management.

Ottewill C 1 Preliminary data from the ITS National Registry of Idiopathic Pulmonary Fibrosis (IPF) suggests that in Ireland 17% of patients with IPF have a family history of fibrosis (familial-pulmonary-fibrosis). However, little is known about these patients' clinical presentation or progression and there is no data available on what type of mutations are prevalent in Ireland. We hypothesise that understanding the types of clinical presentation and progression which characterise familial-pulmonary-fibrosis may improve diagnosis and reduce clinical risk to patients. Telomerase and surfactant related mutations, [1] and genetic syndromes including Hermansky-Pudlack syndrome are associated with familialpulmonary-fibrosis [2] . Since establishing a specialised interstitial lung disease service in 2018 in Beaumont Hospital, 10 (17%) of 60 patients with IPF have a documented family history of pulmonary-fibrosis, including one with an identified genetic cause for his pulmonary fibrosis. Of these 10 patients, 6 were men and with a median age of 71 years. All had radiological imaging consistent with UIP (usual interstitial pneumonia), with three patients having undergone lung biopsies. Seven identified patients were ex-smokers. The average DLCO for these patients at referral was 30%, compared to 50% in the overall sporadic-IPF cohort. All were offered anti-fibrotic therapy and 3 were referred for lung transplant assessment. References: Idiopathic pulmonary fibrosis (IPF) is a chronic progressive lung disease with significant mortality and it is essential to understand the natural progression of this condition. The project aimed to describe the clinical characteristics of an Irish IPF population. Data was retrieved from St. Vincent's University Hospital ILD registry for 87 IPF patients enrolled from 2009-2017 and 202 patient/ physician encounters in the ILD clinic were assessed prospectively. Mean age of diagnosis was 69 years and the prominent symptoms were dyspnoea (72%, n=52) and cough (60%, n=43). 37% of all patients had undergone lung biopsy, however, this decreased from 39% prior to 2013 to 30% between 2013-2017. The annual rates of decline for FVC and DLCO were 114ml±157ml and 7%±7.7%, respectively. Of 202 physician encounters, 49% (n=99) did not document cough as a queried symptom or its absence. Leicester cough questionnaire demonstrated that cough was not particularly impactful on quality of life in this population (mean LCQ 16/21). IPF is a progressive lung disease, cough is a common presenting symptom, however in this group it appears to be poorly correlated with quality of life. To better understand the importance of cough, it is important to address it in all consultations. Robotic lobectomy is increasingly used to reduced post-operative pain while allowing flexibility in intra-operative technique. We reviewed the single surgeon experience of robotic Anatomical lung resection. All patients had lymph node dissection and Ro resection. This represents the learning curve in Robotic surgery for the surgeon. We assessed the duration of operation, duration of chest drain and duration of stay. We analysed time trends and relationships between the factors. 43 patients underwent anatomical lobectomy and lymph node dissection; Patients who had conversion to open thoracotomy were excluded. There was a wide distribution in the operative duration and the length of stay. While there was general trend with time towards shorter operations and length of stay statistical trends were obscured by outliers. In the second half of the series many patients were discharged on the second post-operative day. There were no in-hospital deaths and no major morbidity. Our study shows the learning curve for a new technique for anatomical lung resection. While there is improvement over time there is still wide variability in post op stay mainly due to airleak. For patients who have minimal airleak they are discharged earlier and with significantly less pain.

13.5 Establishing a nurse-led long-term indwelling pleural catheter service: from insertion to discharge Long-term indwelling pleural catheter (IPC) insertion for palliation of patients with malignant pleural effusions had previously been carried out by the Thoracic surgical team. The demand quickly increased having clearly demonstrated good symptom control of both pain and breathlessness for this population. In addition to increasing demand these patients required ongoing clinical review and outpatient support. We determined that this need would be most appropriately implemented and delivered by a nurse-led service. The Thoracic ANP underwent training for insertion of IPCs, this included attainment of both theoretical and practical skills supported by a thoracic consultant surgeon. It was deemed necessary to complete a competency based programme which included wetlab training, observation and supervised insertion technique (over 20 cases). Currently the majority of IPC insertion for the East of Ireland is undertaken in our thoracic department, and since January 2018 86% of these are independently performed by the thoracic ANP. This has facilitated a day case procedure, reducing length of stay from 5 days to 4 hours. There have been no intra-procedure adverse events. It is a safe and cost saving initiative which has facilitated streamlining of peri and post procedural care for this population. Alpha 1 antitrypsin disease (AATD) is a genetic codominant condition and commonly causes severe lower lobe emphysema [1] . AATD is the 4th most common indication for lung transplantation [2] , however less invasive procedures like video assisted thoracoscopic (VAT) lung volume reduction surgery (LVRS) are alternatives to transplant, especially since the National Emphysema Treatment trial. Due to the rare nature of this condition, few case reports exist on the Irish cohort. Therefore, we conducted a retrospective case review on three patients between 2016-2019 who underwent VAT LVRS at centres of excellence for thoracic surgery in Ireland. This paper reports on 3 patients with AATD who underwent LVRS, discussing preoperative and postoperative parameters such as pulmonary function tests and CT imaging. Improvements in post-operative PFTs were demonstrated in all patients (Table 1) . AATD induced COPD is a complex condition but LVRS is emerging as an additional option to medical therapy and transplantation for patients with end-stage emphysema. The above case series provides additional reporting of LVRS for a rare case of lung disease postoperative results were in keeping with NETT's conclusion that LVRS improves exercise capacity versus medical treatment alone for those with end stage emphysema. Tumour Necrosis Factor-alpha (TNF-α) blockade use has revolutionised the treatment of a host of auto-immune conditions world-wide. These include diseases such as inflammatory bowel disease, rheumatoid arthritis, seronegative spodylarthropathies, and psoriasis among other conditions. TNFα blockade however has been shown to be associated with an increased risk of tuberculosis (TB) infection. Tuberculous disease associated with TNFα inhibition is often complex and more often disseminated involving multi-organs including the central nervous system. Furthermore, withdrawal of TNFα blockade following TB diagnosis may lead to worsening symptoms due to the now commonly called 'paradoxical reactions' as the immune system reconstitutes.Within the wide scope of our TB specialty experience to date in St. James's Hospital (Ireland's Largest TB Specialist Tertiary Centre), we have been observing a concerning increase in TB and more worryingly drug resistant TB. Several of our cases of TNFα associated TB have been either drugresistant or, alarmingly, multi-drug resistant TB. And for the first time we can report this in Irish-born national patients, without exposure by travel.To better understand the extent of this alarming problem and in future efforts to put strategies in place to eliminate or prevent its potential complications, we set out to perform a small observational study of multi-fold analysis. The aim of which is to:1. Report the incidence of anti-TNF-α associated TB cases on a national level in the last decade.

Stratify numerically on an annual basis the prescribed use, indication and expenditure of commonly used biologic agents in the last 10 years. These include Humira as a prime example and all the other TNF-α blockers as a collective group.3. Speculate on potential strategies to halt progression and prevent recurrence of this alarming 'TB Rising'. In order to gain access to verifiable data on a national level, we sought expert's input and insight from the following specialties: Public Health, Therapeutics and Clinical Pharmacology, and our distinct multidisciplinary TB team in St. James's University Hospital.14.6 An audit of the practices of treating Community acquired Pneumonia in Wexford General Hospital, Republic of Ireland

Wexford General Hospital Introduction: As community acquired pneumonia (CAP) is such a common problem in the acute hospital setting, we wanted to look at how we are managing it in WGH.There are clear guidelines available to all NCHDs and consultants on the UHW &SE Hospitals Antimicrobial Guidelines app.These guidelines have been developed to guide investigation and management of CAP in this area.We looked at whether these guidelines are being followed in daily practice. Objectives: To assess diagnosis, investigation and management of patients diagnosed with community acquired pneumonia (CAP) in Wexford General Hospital.Looking particularly at antibiotic prescription as per CURB-65 score.This could find areas of our practice where we could improve how we treat this common condition. Methodology: Reviewed the charts of patients admitted to Wexford General Hospital after attending the Emergency Department. Patients admitted between 01/12/ 2018 -14/12/2018 and who had diagnosis of pneumonia on HIPE system.We looked at patient notes, online lab system and online radiology system to assess how patients were managed. Results: Based on CURB -65 Score 20 % of the patients were of mild severity, 50 % moderate severity and 30 % of them had severe pneumonia. Overall CURB 65 score was documented in only 30 % of the cases. In 33 % of the cases antibiotics were prescribed based on guidelines while in rest of 77 % either it was incorrectly prescribed or there was no record of it in the clinical notes. Only half 50 % of the patients were investigated per HSE standard guidelines .Of those investigations none has legionella antibodies checked. Only two patients has pneumococcal antigen checked and was positive in 100% of the cases.60% who had a diagnosis of pneumonia had radiological evidence of pneumonia.40 % who had a diagnosis of pneumonia had clinical and biochemical evidence of pneumonia without radiological findings. Of those patients who had radiological evidence of pneumonia, 60 % of them had follow up CXR booked to ensure resolution.

This was a small sample size of 20 patients admitted through the ED with a diagnosis of pneumonia. When audited against the UHW &SE Hospitals Antimicrobial Guidelines we found the following.CURB-65 score was documented in 30% of cases. Microbiology investigations appropriate to the CURB-65 score were undertaken in 30% of cases. Antibiotics as per these guidelines were prescribed in 30% of cases. References: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/ pneumonia-adults/ 14.7 An audit of the care pathway of seasonal influenza patients in University Hospital Galway compared to guidelines of best practice Seasonal influenza is associated with an increased morbidity and mortality in high-risk patient groups. In the Emergency Department (ED), the care pathway of suspected influenza patients can be complicated by the fact that 72 hours may elapse before the results of the gold standard test (reverse-transcription polymerase chain reaction) becomes available. Thus, we conducted a survey to assess NCHDs attitude towards diagnosing influenza and beginning treatment with oseltamivir. Additionally, we directly compared anonymised data collected from patients admitted via the UCHG ED with a suspected influenza diagnosis to the data of patients diagnosed with non-influenza related LRTIs. The results showed that most medical NCHDs are reluctant to ask for an influenza swab in apprehension of untimely patient management. In the dataset, the average LOS and time to ward of patients with suspected influenza is delayed compared to other respiratory illnesses. Point of care (POC) diagnostic are equally specific to RT-PCR tests. Additionally, the pre-test probability can be increased via a clinical decision guideline questionnaire. Therefore, we propose the introduction POC diagnostic tests and an integrated care pathway for patients with clinically suspected influenza. Dedicated influenza wards may be the next step forward in improving bed management of seasonal influenza patients. Conflicts of Interest: The authors have no conflicts of interest to declare. Empyema is a pathology of the pleural space in which purulent material accumulates in pleural space. It is often associated with pneumonia but can also be a ramification of lung carcinoma and immunosuppression status. Although radiological imaging is used to form a preliminary diagnosis, its true predictive value remains questionable. Microbiological and histopathological records of 43 patients undergoing decortication were included in this review. Only patients who were diagnosed with late stages of empyema and underwent decortication surgery were included in this study. The material obtained for the data was from Broncho-alveolar lavage, pleural fluid, and decorticated material (pleural/ lung tissue). The sample consisted of 43 patients-23 males and 20 females. For microbiology, 4.88% of BAL samples, 7.69% of tissue fluid samples, and 7.32% of pleural fluid samples were positive. For cytology/histopathology, 0.00% of BAL samples, and 5.41% of pleural fluid samples and 7.32% of tissue samples were positive.We recommend that, for the study and analysis of the microbiological samples, a myriad of all 3 different modalities of diagnosis is essential. However, tissue sampling is the preferred modality of diagnosis for cytology/histopathology owing to its ability to detecte positive cases that cannot otherwise be detected.14.9 A case series of yellow nail syndrome and a potential novel biomarker Micro-aspiration commonly occurs in health and its prevalence is increased in many lung diseases. A dysbiotic signature identified by enrichment with oral microbes is associated with increased inflammation and distinct metabolic profile in the lung microenvironment. 16S rRNA gene sequencing is commonly used for taxonomic annotation and inferred functional capacity. However, it is desirable to actually measure the function of these bacteria. We therefore took an approach that combines marker gene amplification, whole genome shotgun sequencing (WGS), RNA sequencing (RNA) and measured metabolites. Upper (UA), lower airway (BAL), and background (BKG) samples were obtained via bronchoscopy from 19 healthy subjects. 16S rRNA gene sequencing was used to assess the microbiota and identify dysbiosis among lower airway samples. In parallel, functional microbial signatures were identified via WGS metagenome and RNA metatrascriptome sequencing. Dirichlet Multinomial Modelling identified two clusters from the 16S data where: 12 BAL samples clustered with BKG samples and were characterized as BAL.BPT (enriched with background characteristic taxa such as Acinetobacter, Pseudomonadales) and 7 clustered with most UA samples and were characterized as BAL.SPT (enriched with oral commensals such as Veillonella and Streptococcus). Using Gene-Set-Enrichment Analysis (GSEA), there is very little overlap between the three sequencing methods for taxonomic annotation ( Figure 1A-F) . For functional annotation, in samples clustered to BAL.SPT, with WGS, most upregulated pathways are associated with Ribosome while with RNA a number of pathways are upregulated including lipid metabolism and fatty acid metabolism. Comparing the differentially expressed pathways for BAL.SPT samples, between the three sequencing methods, some pathways share directionality and significance ( Figure 1H ,J,L). For example, fatty acid biosynthesis is significantly upregulated in all three sequencing methods. Short chain fatty acids (SCFAs) were therefore measured. UA and BAL samples had significantly higher levels of acetate and propionate when compared to BKG samples. However, only with RNA, KOs associated to these SCFAs are significantly elevated in both UA and BAL Influenza and pneumococcal vaccines are recommended for patients with chronic lung disease as protective measures against influenza and pneumococcal pneumonia respectively. The purpose of this study was to evaluate documentation status of vaccine uptake in newly referred patients, and to review the actual uptake in these referred patients. Seventy three consecutive referrals were included in this study (54 female, mean age 64). Patients were predominantly smokers (59 of the 73 patients-81%). All patients had been referred due to dyspnoea, cough, or recurrent respiratory tract infections. Vaccine status was recorded in 58 of the 73 patients (79%). Of these 58 patients, 42 (72%) had received the influenza vaccine, and 23 had received the pneumococcal vaccine (40%). Vaccine status in 15 patients was undetermined. This study highlights the importance of adequate documentation of vaccine status in newly referred patients. It also highlights a lack of uptake of vaccines in patients with chronic lung disease symptoms prior to being seen in a respiratory clinic. Reasons given were lack of awareness of the need for vaccination, preferring to wait to be seen in clinic prior to receiving the vaccines, and fear of actually developing influenza or pneumonia from the vaccines.14.13 Air pollutants in urban and semi-rural locations Air pollution represents the greatest environmental threat to the global population, particularly for vulnerable groups e.g. patients with chronic obstructive pulmonary disease. Control of airborne xenobiotics within Britain is addressed by air monitoring strategies which identify pollutant levels. However, these do not provide a comprehensive overview of the pollution profile within an area. This study investigated metal composition within particulates, to enable source apportionment of contaminants, and detection of elements most influential to health impact. Inductively Coupled Plasma Mass Spectroscopy was used to analyse air samples obtained from urban and semi-rural locations. Metal contaminants identified in the environmental studies are then investigated in parallel cell culture studies on lung epithelial cells, to assess their effect on cell viability and cytokine release. Beryllium, iron and zinc were detected in samples derived from the urban site; sodium, potassium and magnesium as well as zinc and iron were detected from the semi-rural site. Cell cultures studies on these identified pollutants are now ongoing.Results from the environmental studies suggest rural pollutants likely originate from anthropogenic sources, whereas semi-rural pollutants may additionally derive from biogenic sources. Identifying the impact of these pollutants on cell function may help develop targeted approaches to improving air quality.14.14 A review of bronchial washings as an adjunct to bronchoscopy in testing for mycobacterial infection in University Hospital Limerick (UHL) Bronchial washings are an adjunct to bronchoscopy in the diagnosis of various pulmonary diseases, including primary or metastatic lung cancer and, infectious and non-infectious inflammatory lung disease. They may increase the diagnostic yield for this procedure. Bronchial washings testing for mycobacteria are routinely performed for all bronchoscopy cases in University Hospital Limerick (UHL). This is a review of the results of all bronchoscopies with bronchial washings performed over a six-month period, January to June 2019 that were tested for mycobacteria where there was a very low suspicion for mycobacterial infection in most cases. We assessed if acid-alcohol fast bacilli were seen on direct microscopy and if mycobacterium species were isolated on culture. A total of 598 bronchoscopies were performed in this period. 566 bronchoscopies with bronchial washings/bronchoalveolar lavage samples were received in the lab testing for mycobacterium. Two cultured mycobacterium tuberculosis but the suspicion was intermediate and high respectively in these cases. Six cultured atypical mycobacteria that didn't require treatment. See table. This review demonstrates that when there is a low suspicion for mycobacterial infection the additional yield in testing bronchial washings is negligible. Therefore, routine assessment of bronchial washings for mycobacteria is not indicated. 

The Alpha One FoundationThe Asthma Society of Ireland COPD Support Ireland

The Irish Lung Fibrosis AssociationThe Sleep Disorders Support Foundation